SUBSTANCE ABUSE AND THE ELDERLY

1
SUBSTANCE ABUSE AND THE ELDERLY

• A GERIATRICIANS PERSPECTIVE

2
OBJECTIVES

• Demographics of the aging population especially
  in relation to the boomers
• A short course in the physiology of aging with
  the focus on how it influences abuse problems in
  the elderly
• A look at the prevalence of substance abuse in
  the geriatric population
• Examine risk factors and special dynamics of the
  boomer cohort
• Look at the reasons the diagnosis of substance
  abuse is so often low on the differential list

3
DEMOGRAPHICS
4
PRESENT POPULATION

• 77 million Americans are over the age of 50
• 41.9 are 50 64
• 18.4 are 65 74
• 12.4 are 74 84
• 4.2 are 85
• At age 50, Americans can, on the average live
  another 30 years
• People who are now 75 can expect to live another
  11 years
• People who are now 65 can expect to live till 90

5
FUTURE POPULATION

• By 2030, 70 million people will be over the age
  of 65
• This will be about 20 of the population
• More than 6 million will be over 85
• The oldest old make up the fastest growing
  segment of the population

6
GOOD NEWS/ BAD NEWS IN HEALTH

• People are living longer
• Women live longer, but the gap between women and
  men is decreasing
• Racial differences in life expectancy are
  decreasing
• Smoking rates have decreased in the past two
  decades by 23 in women and 36 in men
• The percentage of Medicare beneficiaries
  receiving preventative services has increased
  markedly
• More Americans are reporting some efforts to
  increase exercise this has especially been seen
  in those over the age of 75

7

• Changes in drinking patterns have not changed
  yet
• Greater numbers of older American are reporting
  their health status as excellent or very good
  especially those in the 65-74 year old age range
  42

8
SOCIAL SUPPORT SYSTEMS

• As people age, the social support system becomes
  more important
• But the longer people live, the more likely they
  are to live alone
• Especially if they are female
• ½ of all females in the 75-84 and 58 of females
  older than 85 lived alone in 1999
• 1/3 of people providing support to the elderly
  are adult children
• During the baby bust of the 60s, there was a
  marked increase of females not having children
• This means that people now in their 60s are much
  less likely to have a social support system with
  adult children to help
• And those with adult children are less likely to
  have them living in the same general area

9
A SHORT LESSON IN THE PHYSIOLOGY OF AGING IN
RELATION TO SUBSTANCE ABUSE
10
FAT STORES

• Increased fat stores and overall decrease in body
  water content
• Decreased muscle mass
• Increased peak alcohol level at lower doses
• Long acting benzos get stored in the fat and stay
  around a lot longer
• Lower doses of short acting benzos attain higher
  peak levels more quickly

11
LIVER FUNCTION

• Blood flow through the liver decreases and the
  metabolic capacity decreases with age
• Acute ETOH abuse impairs liver function
• Chronic ETOH abuse may actually increase liver
  enzyme induction and increase metabolism of some
  drugs (until the liver becomes really damaged)
• Drug clearance may fluctuate because of this
  especially in binge drinking.
• With drugs like warfarin or anticonvulsants,
  this can have catastrophic consequences
• Or the mixture of sedatives and ETOH chronic
  drinkers have decreased effect of say temazepam
  and binge drinkers will have increased effect
  when they drink

12
IMMUNE FUNCTION

• Decreased immune function as we age
• ETOH itself in large doses is an
  immunosuppressant
• This increases problems with infection and poorer
  outcomes when an infection occurs
• ETOH, benzos, opioids all decrease the level
  conciousness, thus increasing risk of aspiration
• Increased risk of HIV one of the fastest
  growing segments of population is the elderly (?
  Thanks to viagra et al?)

13
NEUROLOGIC CHANGES OF THE ELDERLY

• The brain atrophies significantly
• Blood flow to the brain decreases by 20
• There is significant cellular loss
• Proprioception decreases with age
• All of this will be worsened by ETOH and other
  psychoactive drugs
• Studies show that the benzos increase cognitive
  decline especially the long acting
• ETOH can give global cognitive impairment
• Peripheral neuropathy with ETOH abuse and vitamin
  deficiency

14
ETOH AND THE ELDERLY
15

• HX VT was 82 yo that was found down in the
  parking lot of a local restaurant. He was
  nonresponsive to verbal stimuli but responsive to
  pain. He had eaten at this restaurant every
  night since his wife died 3 years before
• Past Hx HBP, nonsmoker, has a drink every day
• Social hx retired beer salesman, widower, one
  child in town
• Hospital Course Taken to ULH ER. Noted to have
  bruising and abrasion on occipital region. ETOH
  level was 0.08. CT scan showed intracerebral
  bleed. Stormy course with prolonged delirium and
  pneumonia. Finally DCed to SNF

16
COMMUNITY DWELLING ELDERLY60 AND ABOVE

• 62 drink ETOH
• Heavy drinking in 13 of males and 2 of females
• Overall 6 of elderly were considered to be heavy
  drinkers
• In this study heavy drinking was defined as
  greater than two standard drinks in a day
• A standard drink is 1. 5 ounces of distilled
  spirits, 12 oz. of beer or 5 oz of wine
• This study lowered the standard def of heavy
  drinking because of the elderly lowered tolerance

17
HOSPITAL AND NURSING HOME

• 13 of elderly trauma patients had blood ETOH
  levels greater than 0.1
• 23 of elderly Psychiatry patients have history
  of ETOH abuse
• 10 -21 of elderly patients admitted to inpatient
  med/surg abuse ETOH (may be higher)
• In a recent study, 49 of patients in a nursing
  home met criteria for lifetime ETOH abuse or
  dependence

18
RISK FACTORS FOR ETOH ABUSE IN ELDERLY

• Males
• Major life changes or losses
• Especially retirement or death of a spouse
• Substance abuse earlier in life
• Comorbid psyche disorders
• Positive family history
• Abuse of nicotine
• Use/abuse of psychoactive drugs

19
LATE ONSET VS EARLY ONSETEARLY ONSET

• 2/3 of elderly alcoholics
• Usually start in the 20s- 30s or even earlier
• High percentage estranged from family
• Often in socioeconomic decline
• More likely to have chronic alcohol related
  medical problems
• Usually more comorbid psyche disorders

20
LATE ONSET

• 1/3 of elderly alcoholics
• Usually get into problems after 40 50
• Generally have achieved higher level of education
  and income
• A stressor often triggers the problem
• Usually fewer medical problems related to the
  ETOH
• Social support system is usually better
• Usually more amenable to treatment
• But also more likely to be overlooked

21
OTHER SUBSTANCE USE IN THE ELDERLY

• Including marijuana, cocaine, heroin,
  hallucinogens, and illicit use of prescription
  drugs
• Is really not known in the community setting
• The older population is less likely to report
  problems than the younger age groups
• Physicians underrecognize the problem ( but more
  about that later)
• In 2005, 0.5 of adults 65 and older reported
  illicit drug use
• In 2006 it was 0.7
• However, patients in the 50 54 age group
  doubled their reporting from 3.4 to 6.0 from
  2002 to 2006

22
IN THE ER SETTING

• A 2001 study published in Addiction
• 23.7 used benzos
• 14.4 used opioids
• 9.6 used barbituates
• 19.8 used stimulants like cocaine and meth

23
PRESCRIPTION DRUG USE

• Prescription drug use in the elderly is much
  greater
• Multiple doctors and often no captain of the
  ship
• Older people take a lot of psychoactive drugs
  and more so in women up to four times greater
  misuse
• Women are more likely to become dependent if they
  are widowed, less educated, lower income, poor
  health, and have reduced social support

24
ADVERSE EFFECTS OF DRUG USE/ABUSE

• Most studies do not necessarily distinguish
  between use, abuse, and dependence
• An association between falls and benzos has been
  repeatedly shown
• Fractures seem to be much more common in those
  who use opioids
• Elderly who use benzos chronically are more
  likely to develop Mobility disability and
  disability in their ADLS
• Long term benzo use is related to early cognitive
  decline
• Increased risk of urinary retention, MVAs, and
  pressure ulcers with sedative /hypnotics in the
  LTC settings

25
THE STORY OF MW

• HX 75 yo female admitted to LTCF after right
  total knee replacement.
• PAST HX multiple failed backs surgeries, DM, RA,
  , Chronic cellulitis of lower extremity, has
  Morphine intrathecal pump allergies to multiple
  drugs including codeine, demerol, oxycodone,
  sulfa, and quinolones
• SOCIAL HX retired RN and nursing home
  administrator. Lives at home with demented
  husband

26
MED LIST

• Intrathecal pain pump
• Xanax 1mg in am 0.5 at noon, and 2mg at hs
• Lortab 10-500 q 4 hours prn pain
• Arthrotec
• Nexium
• Synthroid
• Lipitor
• Niferex
• Lasix
• Potassium supplement
• Starlix
• Plus 20 other routine and prn meds

27
NH COURSE

• The first day the patient seemed pleasant and
  comfortable. She started to participate in
  physical therapy but complained of a lot of pain.
  On day 2,one of the nurses noticed that the
  patients demented husband had driven over to
  the NH and was giving the patient some
  medication. When the patient was confronted
  about this, she stated that she was still in a
  lot of pain and needed more medicine. The
  husband had brought over Percocet 10 as well as
  flexeril. The patient was examined by the
  physician and the wound looked very good. She
  was advised to tell the nurses that she was
  having pain and not to bring medicine from home.
  The same thing happened on day 3. Again she
  was advised this was against the NH policy.
  Again she was examined to r/o other problems.
  Two hours later she requested to be transferred
  back to the hospital.

28
WHY DO MDs AND HEALTH CARE WORKERS HAVE PROBLEM
DIAGNOSING SUBSTANCE ABUSE IN THE ELDERLY?

• Faulty assumptions and myths ie the alcoholic as
  a bum
• Denial by the abuser, family and MD
• May be fewer social signs of problem like losing
  a job or legal difficulties
• Substance abuse problems may be overshadowed by
  the other medical problems
• The physical and/or cognitive decline caused by
  chronic substance may be thought of as the
  ravages of aging
• Substance abuse problems are the Great
  Masquerader

29
OTHER REASONS FROM THE PATIENTS

• Increased denial (not necessarily just the
  elderly with this)
• Decreased private insurance payment for mental
  health treatment
• Multiple comorbidities including other psyche
  issues
• Increased use of legal psychotropic drugs
• Lack of good population based studies in the
  elderly

30
SO WHY ARE THE BOOMERS DIFFERENT THAN OTHER
AGING POPULATION COHORTS?

• Higher population
• The dynamics of the Me generation rightly or
  wrongly are accused of being more self centred
  and used to having things their way
• Higher risk of substance abuse in this cohort
  than in others previously
• Certainly more accepting of Sex, Drugs, and Rock
  and Roll

31
PROJECTED DRUG USE IN THE AGING BOOMERS

• From 1999 to 2020 in people 50 and above
• Marijuana use from 1 to 2.9 - 719,000 to 3.3
  million
• Use of any illicit drug from 2.2 to 3.1 - 1.6
  to 3.5 million
• Non medical use of psychotropic drugs from 1.2
  to 2.4 - 911,000 to 2.7 million
• Collier, James P et al, Annals of Epidemiology
  Vol 14 4 April 2006 pg 257-265

32
AND WHAT ABOUT CHRONIC PAIN?

• Very common in the elderly
• 25 50 in the community dwelling
• 40 80 in the nursing home setting
• 1/5 65 yo and older take analgesics several times
  a week
• Of these, 3/5 take prescription pain meds
• Chronic pain causes all sorts of complications
  like depression, decreased socialization, sleep
  disturbance, and impaired mobility

33
SUGGESTED GUIDELINES FOR LONG TERM OPIOID USE

• Patients considered for long term opioid use
  should have a well defined source of pain
• Patients with ill-defined MS syndromes are poor
  candidates for opioid use
• Many patients, if not all, need psychosocial
  assessment
• Patients with current or previous history of
  substance careful psyche assessment and close
  followup
• All patients with chronic opioids should have a
  regular assessment of pain and functional status

34
NSAIDS AND COX 2 INHIBITOR

• Increased risk of kidney and liver problems
• Increased risk of GI bleed
• Increased risk of fluid and Na retention
• Drug drug interactions

35
OTHER MEASURES

• Acetaminophen
• Physical therapy
• Nonpharmacologic methods

36
SUMMARY POINTS

• The Boomers are coming
• The absolute numbers of elderly with substance
  abuse problems will be going up
• These disorders are underreported and
  misdiagnosed for a number of reasons
• There are a lot of research opportunities
  concerning these disorders in the elderly.
  Especially in relation to long term care living
  arrangements.
• Comorbidities and drug interactions are very
  common in the elderly
• Substance abuse is associated with cognitive
  decline

37

• Winkel, Vicki and Byron Bair Substance use
  disorders in older adults Clinical Geriatrics
  Jul, 2008 ppg 25-29
• Rigler, Sally Alcoholism in the elderly American
  Family Physician Vol 616 March 15, 2000
• Oslin, David Evidence based treatment of
  geriatric substance abuse Psychiatric Clinics of
  North America Vol 28 issue 4 dec 2005 noted on
  MD Consult
• Christensen, Helen et al Prevalence, risk
  factors and gtreatment for substance abuse in
  older adults Current Opinion in Psychiatry
  Vol19(6) Nov 2006 ppg 587-592
• Finfgeld-Cornett, Deborah Treatment of substance
  misuse in older women Journal of Gerontological
  Nursing Vol 30(8) Aug 2004 ppg 30-37

38

• Enoch, Mary Anne and David Goldman Problem
  drinking and alcoholism diagnosis and treatment
  American Family Physician feb 1. 2002
• Hasin, Deborah et al Prevalence, correlates,
  disability, and comorbidity of DSM-IV alcohol
  abuse and dependence in the United States
  results from the National Epidemiologic survry on
  alcohol and related conditions Archives of
  General Psychiatry vol64(7) July 2007 ppg
  830-842
• Mcgrath A et al Substance misuse in the older
  generation Postgraduate Medical Journal Vol
  81(954) April 2005 ppg 228-231
• McInnes, Elizabeth and Janet Powell Drug and
  alcohol referrals are elderly substance abuse
  diagnoses and referrals being missed? British
  Medical Journal Vol 308(6926) Feb12, 1994 ppg
  444-446

39

• Colliver, James et al Projecting drug use among
  aging baby boomers in 2020 Annals of
  Epidemiology Vol 16 issue 4 April 2006 ppg
  257-265
• Patterson, Thomas et al The potential impact of
  the baby boom generation on substance abuse among
  elderly persons Psychiatric Services
  501184-1188 Sept 1999
• Schmader, Kenneth and Alison Moore Prescription
  use, misuse,and abuse in older persons Annals of
  Long term care vol 11 issue 8 Aug 2003 ppg 37-42
• Joseph CL Alcohol and drug misuse in the nursing
  home Int Journal of Addiction Nov-Dec 1995 30
  (13-14) 1953-84
• Klein,WC and C Jess One last pleasure? Alcohol
  use among elderly people in nursing homes health
  Soc Work 2002 Aug 27(3) ppg 193 -203

40

• OConnell, Henry et al Alcohol use disorders in
  elderly people redefining an age old problem in
  old age British Medical Journal Vol 327(7416)
  Sept 20 2003 ppg 664-667
• Paterniti, Sabrina et al Long term
  benzodiazepine use and cognitive decline in the
  elderly the epidemiology of vascular aging study
  Journal of Clinical Psychopharmacology vol
  22(3) June 2002 ppg 285-293
• Menninger, John Assessment and treatment of
  alcoholism and substance related disorders in the
  elderly Bulletin of the Menninger Clinic vol 66
  no 2 spring 2002 ppg 166-183