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1 ADDICTIONS 2 OBJECTIVES Know and understand: • The extent of the problem of substance abuse among older adults • How to identify substance abuse problems • The risks and benefits of substance use • Strategies for treating substance abuse problems found in older patients 3 TO P I C S C O V E R E D • Definitions of Substance Abuse • Magnitude of the Problem • Risks and Benefits of Substance Use • Identifying Substance Abuse Disorders • Treatment S U B S TA N C E A B U S E I N O L D E R A D U LT S • In older adults, negative health consequences of alcohol, psychoactive medications, illicit drugs, and nicotine have been demonstrated at consumption levels previously thought of as light to moderate • Older adults are particularly vulnerable to the cognitive and physical effects of these substances • Treatment leads to reductions in substance use and improvement in general health 4 5 S U B S TA N C E D E P E N D E N C E • Any use that imparts significant disability and warrants treatment • Older problem drinkers are identified less often by clinicians and are less often referred for treatment than are their younger counterparts Many older people drink at home alone Many disorders caused or affected by substance misuse are common disorders in late life 6 AT- R I S K U S E • Any use of a substance at a quantity or frequency greater than a recommended level For instance, the recommended upper limit of alcohol consumption for older adults: No more than 1 standard drink per day No more than 2 episodes of binge drinking (≥4 drinks/day) in a 3-month period • Any drinking while on certain medications • Any drinking with certain medical problems 7 PROBLEM USE AND LOW-RISK USE • Problem substance use—consumption of any amount of an abusable substance that results in at least one problem For example, use of benzodiazepines by a patient who has an unsteady gait • Low-risk or moderate use—that which falls within the recommended guidelines for consumption and is not associated with problems 8 ABSTINENCE • Person consumed no alcohol in the previous year • Obtain history of past use • Determine reason for abstinence: Recent illness Lifelong pattern Previous history of abuse May require preventive monitoring Patient may be at risk of mental health problems ILLICIT DRUG USE AMONG O L D E R A D U LT S A study in the general population found that 2.88% of older men and 0.66% of older women had a lifetime history of illicit drug use A more recent study of older adult veterans found 25% had a primary drug problem or concurrent drug and alcohol problems 9 O L D E R A D U LT S O F T E N TA K E A B U S A B L E M E D I C AT I O N S 100% 80% 60% Do not use Use 40% 20% 0% Analgesic CNS medication Benzodiazepine 10 I N A P P R O P R I AT E U S E O F M E D I C AT I O N S ( 1 o f 2 ) • Many medications used by older people have the potential to induce: Tolerance or withdrawal syndromes Harmful medical consequences such as cognitive changes, kidney disease, falls, and liver disease • Often misused: sedatives, hypnotics, analgesics, diet aids, decongestants, and a wide variety of OTC medications 11 I N A P P R O P R I AT E U S E O F M E D I C AT I O N S ( 2 o f 2 ) • Monitor medication use carefully • Avoid prescribing: Potentially hazardous combinations of drugs Medications with a high risk of adverse effects Ineffective or unnecessary medications • Reevaluate use every 3–6 months 12 13 USE OF ALCOHOL BY OLDER ADULTS Studies have reported a range of: • 2% to 4% for alcohol abuse • 3% to 9% for heavy drinking • 10% to 22% for daily drinking • 31% to 58% for abstinence Alcohol abuse Heavy drinking Daily drinking Abstinence 0% 20% 40% 60% 80% 100% C U LT U R A L A N D D E M O G R A P H I C FA C TO R S I N S U B S TA N C E U S E • The prevalence of alcohol-related problems is much higher for older men than for older women Among younger adults, more women are presenting for treatment Similar patterns are seen with illicit drug use, except that benzodiazepines are much more commonly used by older women than by older men • Conclusions are less clear from the few studies addressing the effect of ethnicity Risk factors more relevant than ethnicity are increased leisure time and higher disposable income 14 P R E VA L A N C E I N CLINICAL SETTINGS • Prevalence rates of alcohol problems in hospital populations are substantially higher than for community dwellers • High prevalence rates for problems related to drinking are becoming more common in retirement communities • Data from a Veterans Affairs nursing home demonstrated that 35% of the patients interviewed had a lifetime diagnosis of alcohol abuse 15 BENEFITS OF ALCOHOL CONSUMPTION • Moderate alcohol consumption among otherwise healthy older adults has been promoted as having beneficial effects: Reduced cardiovascular disease Relaxation and reduced social anxiety • Recommending drinking to people who currently do not drink is not advocated 16 R I S K S A S S O C I AT E D W I T H S U B S TA N C E A B U S E • Excess physical disability • Mental health problems • Social and relationship problems • Economic problems 17 18 EXCESS PHYSICAL DISABILITY F R O M S U B S TA N C E A B U S E ( 1 o f 2 ) • Consumption > 1 drink/day: Increased risk of stroke caused by bleeding Impaired driving skills Increased rate of injuries such as falls, fractures • The risk of breast cancer in women who consume 3–9 drinks/week is ~50% over that of women who have <3 drinks/week 19 EXCESS PHYSICAL DISABILITY F R O M S U B S TA N C E A B U S E ( 2 o f 2 ) • Greatest risk: Older adults who have an average of >4 drinks/day or a diagnosis of alcohol dependence • Most common physical problems associated with alcohol dependence: Alcoholic liver disease Chronic obstructive pulmonary disease Peptic ulcer disease Psoriasis • Unexplained multisystem disease probe closely for alcohol use INTERACTIONS BETWEEN A L C O H O L A N D M E D I C AT I O N S Potential harmful interactions occur between alcohol and both prescription and OTC medications: • Special concern: psychoactive medications such as benzodiazepines and antidepressants • Alcohol is also known to interfere with the metabolism of many medications, including digoxin and warfarin 20 21 M E N TA L H E A LT H P R O B L E M S • Older adults with alcohol abuse/dependence are nearly 3 times more likely to have a lifetime diagnosis of another mental disorder • Alcoholism has been implicated in: Mood disorders Suicide Dementia Anxiety disorders Sleep disturbances • Comorbid depression and alcohol use: abstinence better depression outcomes A L C O H O L - R E L AT E D D E M E N T I A (1 of 2) • Patients with alcohol-related dementia who become abstinent do not show a progression in cognitive impairment comparable to that of people with Alzheimer’s disease • Alcoholism is known to lead to a syndrome of dementia independently Interesting new hypotheses implicate glutamatergic toxicity, but the mechanisms are not well understood 22 A L C O H O L - R E L AT E D D E M E N T I A (2 of 2) • Criteria for alcohol-related dementia: Clinically evident dementia ≥60 days after last drink History of significant use for at least 5 years, ie, ≥35 drinks/week for men and ≥28/week for women Occurrence of this period of significant use within 3 years of the onset of cognitive deficits • Supporting clinical features: End-organ damage Cognitive stabilization or improvement after abstinence Evidence of cerebellar atrophy in brain imaging 23 IDENTIFYING S U B S TA N C E U S E D I S O R D E R S • Clinical examination is the most valuable tool • Screening instruments help increase the sensitivity and efficiency of the diagnosis • Laboratory testing: Any combination of macrocytic anemia, thrombocytopenia, and elevated γ-glutamyl transferase further screening 24 25 THE AUDIT-C • Q1: How often did you have a drink containing alcohol in the past year? • Q2: How many drinks did you have on a typical day when you were drinking in the past year? • Q3: How often did you have 6 or more drinks on one occasion in the past year? • AUDIT-C is a highly sensitive screen for at-risk drinking and alcohol dependence and is preferred over the CAGE questionnaire (next slide) 26 THE CAGE QUESTIONNAIRE C Have you ever tried to Cut down on your drinking? A Have you ever gotten Annoyed at someone for criticizing your drinking? G Do you ever feel Guilty about your drinking? E Have you ever had an Eye-opener to steady your nerves or get rid of a hangover? A positive answer to one or more questions suggests problem drinking. CAGE is highly sensitive for alcohol dependence but not for at-risk drinking. T R E AT M E N T E N G A G E M E N T A N D T R E AT M E N T O P T I O N S ( 1 o f 2 ) • The most important aspect of treating an older adult who is misusing a substance is to engage the patient in the intervention • The spectrum of interventions: Prevention and education for people who are abstinent or low-risk drinkers Minimal advice or brief structured interventions for atrisk or problem drinkers Formalized alcoholism treatment for drinkers who meet criteria for abuse or dependence 27 T R E AT M E N T E N G A G E M E N T A N D T R E AT M E N T O P T I O N S ( 2 o f 2 ) • The array of formal treatment options: Psychotherapy Education Rehabilitative and residential care Psychopharmacologic agents • Older adults engaged in treatment have been shown to have very robust improvement, especially in comparison with younger cohorts 28 29 B R I E F I N T E RV E N T I O N S • Low-intensity, brief interventions are cost-effective, practical approaches to at-risk and problem drinking • 2 randomized, controlled trials of advice protocols in primary care settings showed that: Older adults can be engaged in brief intervention protocols The protocols are acceptable to this population There was a substantial reduction in drinking among the at-risk drinkers receiving the interventions compared with a control group 30 O U T PAT I E N T M A N A G E M E N T • For older adults, peer-specific group activities are superior to mixed-age group activities • Outpatient rehabilitation usually needs to address issues of time management Abstinence reduces the time spent in maintaining the substance-use disorder Management of this time, which is often the greater part of a patient’s day, is critical to the prognosis • Commend patients for cutting down on use as well as for stopping—especially with medications such as benzodiazepines 31 A L C O H O L W I T H D R AWA L • Early symptoms: tachycardia, diaphoresis, tremulousness, and hypertension • May progress to overt delirium, psychosis, seizures • Interventions: Oral benzodiazepine is the most common intervention IV lorazepam (off-label), followed by oral taper, is the most expedient intervention Carbamazepine (off-label) evidence suggest this is as effective as a benzodiazepine 32 I N PAT I E N T D E TO X I F I C AT I O N • Consider for patients with severe dependency, withdrawal potential, or significant medical or psychiatric comorbidity • To achieve detoxification: Place the patient on the minimum amount of drug that suppresses withdrawal symptoms Decrease dosage by 10% every 3 half-lives Provide supportive counseling via groups, psychosocial support, and 12-step programs 33 PHARMACOTHERAPY (1 of 2) • The use of medications to support abstinence may be of benefit, but it is not well studied Small-scale studies have demonstrated that naltrexone is well tolerated and efficacious in older patients SSRIs and other antidepressants are not effective at reducing alcohol use in younger persons but can be effective in treating depression in some with both alcohol addition and depressive disorder • Comorbid medical and psychiatric disorders must be identified and properly treated 34 PHARMACOTHERAPY (2 of 2) Some of the general principles used in treating younger patients can be applied: • Benzodiazepines are important in the treatment of alcohol detoxification, but they have no clinical place in maintaining long-term abstinence • Disulfiram may benefit well-motivated patients, but cardiac and hepatic disease limits its use by the older person • Older patients can be initiated and maintained on methadone following the same principles of use as in younger patients E S TA B L I S H I N G A B S T I N E N C E FROM NICOTINE 35 • Pharmacologic substitution with either nicotine gum or patch is followed by a gradual decrease in dosage • In several trials, antidepressants improved rates of continued abstinence, but only bupropion is FDAapproved for this purpose • Varenicline is also FDA-approved but there is a black-box warning because of neuropsychiatric symptoms, such as depression and suicidality. • Psychotherapy plus pharmacotherapy is better than pharmacotherapy alone Slide 36 GAMBLING • Older adults who engaged in problematic and compulsive gambling behaviors earlier in life often continue this pattern of destructive behavior • Ask about problematic gambling during history taking Screen for alcohol abuse, smoking, other substance abuse • Refer to community resources and 12-step programs 37 S U M M A RY ( 1 o f 3 ) • Older adults are particularly vulnerable to the effects of alcohol, psychoactive medications, illicit drugs, and nicotine • Misuse of prescription and OTC medications is common among older adults • The clinical examination is the most valuable tool in identifying substance-use disorders • Cognitive impairment from chronic alcoholism in the older adult may improve with sustained abstinence 38 SUMMARY (2 of 3) • Older adults involved in treatment have very robust improvement, especially compared with younger cohorts • In randomized, controlled trials, brief counseling interventions were efficacious in substantially reducing problem drinking • Clinicians should be vigilant for signs of alcohol withdrawal in older people hospitalized for elective surgery or a condition unrelated to substance abuse 39 S U M M A RY ( 3 o f 3 ) • Addiction treatment is not “one size fits all.” There are many options—use them. • Compliance with treatment is important. The next contact is the most important part of the session. • Treatment is not a “carve out” available only in select settings 40 CASE 1 (1 of 4) • An 82-year-old woman comes to the office to establish care. She is accompanied by her daughter, who is concerned that her mother’s use of diazepam is related to recent falls and problems with balance. • History includes osteoporosis and knee osteoarthritis. Medications include alendronate, calcium, acetaminophen, and diazepam. • The patient has been taking diazepam for many years, usually 10 mg q8h. She acknowledges having felt stressed during much of her life but says she is not anxious or depressed now. 41 CASE 1 (2 of 4) • On examination, vital signs are stable, and there are no orthostatic changes in blood pressure. There is some bruising on her elbows and hips, and osteoarthritic changes are noted in both knees. • There is no evidence of delirium or cognitive impairment. • Her gait is somewhat slow, and she needs to take a couple of steps to make a 180-degree turn. She describes some bilateral knee pain when she rises. She can remain in semi-tandem stance for <10 sec and cannot perform a tandem stance. 42 CASE 1 (3 of 4) Which of the following is the most appropriate first step in addressing the patient’s benzodiazepine use? A. Refer patient to residential treatment program. B. Refer patient for psychiatry consultation. C. Recommend gradual taper of the benzodiazepine dosage. D. Recommend switch to a shorter-acting benzodiazepine. 43 CASE 1 (4 of 4) Which of the following is the most appropriate first step in addressing the patient’s benzodiazepine use? A. Refer patient to residential treatment program. B. Refer patient for psychiatry consultation. C. Recommend gradual taper of the benzodiazepine dosage. D. Recommend switch to a shorter-acting benzodiazepine. 44 CASE 2 (1 of 2) A 73-year-old man comes to the office for a routine physical examination. He is in good health and takes no medications. He drinks alcohol daily but has no history of an alcohol use disorder. Which one of the following is within the daily limit for this patient? A. One 1.5-oz glass of whiskey B. One 8-oz glass of wine C. Two 12-oz beers D. One 4-oz glass of sherry 45 CASE 2 (2 of 2) A 73-year-old man comes to the office for a routine physical examination. He is in good health and takes no medications. He drinks alcohol daily but has no history of an alcohol use disorder. Which one of the following is within the daily limit for this patient? A. One 1.5-oz glass of whiskey B. One 8-oz glass of wine C. Two 12-oz beers D. One 4-oz glass of sherry 46 CASE 3 (1 of 3) • An 80-year-old previously independent man is evaluated because of lethargy with periods of severe agitation. Two days ago he had elective knee replacement, during which he lost ~500 mL of blood. • History includes hypertension controlled with hydrochlorothiazide. He drinks alcohol socially. • On examination, the patient is distracted and disoriented and picks at his clothing. Temperature is 37°C (98.7°F), BP is 170/84 mmHg, heart rate is 110 bpm and regular, and respiratory rate is 14 breaths per minute. The surgical site is clean and dry, and lab results are unremarkable. 47 CASE 3 (2 of 3) Which one of the following is the most likely cause of this patient’s agitation? A. B. C. D. Alcohol withdrawal syndrome Hypertensive encephalopathy Blood loss Underlying dementia 48 CASE 3 (3 of 3) Which one of the following is the most likely cause of this patient’s agitation? A. B. C. D. Alcohol withdrawal syndrome Hypertensive encephalopathy Blood loss Underlying dementia 49 GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by David W. Oslin, MD and Donovan Maust, MD and questions by Alison Moore, MD Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society