Addictions in the Older Adult Alcohol, Drugs, Gambling

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Addictions in the Older AdultAlcohol, Drugs,
Gambling

• Michelle Gibson, MD, CCFP, COE
• Queens University, Geriatric Medicine
• Specialized Geriatric Services

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Objectives

• Participants will be able to
• Recognize addiction in older adults
• Discuss management strategies

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What are your challenges?
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Outline

• Case presentations
• Review of diagnostic criteria
• Alcohol
• Drugs
• Gambling
• General approach to management

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Mr. S.H.

• 83 y.o. man, admitted to acute care with falls,
  weakness
• Diagnosed with acute renal failure secondary to
  dehydration diarrhea
• Admits to consuming 10 drinks (2 oz.) of scotch
  per day
• Rehydrated, given a walker, sent home.

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Mr. S.H.

• Medical History
• COPD (smokes 1 pack per day)
• CVA 1999 (mild)
• HTN
• Dyslipidemia
• Venous insufficiency edema
• Alcoholic liver disease
• Left hip fracture 1990

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Mr. S.H. Day Hospital

• Still having falls very vague history
• Quit smoking! But not taking any meds
• Initial bloodwork
• Serum ethanol 56.7 mmol/L (_at_1300!)
• Hb 137 MCV 106
• GGT 315
• AST 115

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If you were seeing him

• What would your approach be?

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Mrs. MD

• 79 year old woman being admitted to LTC
• Dementia, chronic pain from spinal stenosis,
  falls, nerves
• Was misusing meds at home according to home
  care.
• Husband has cognitive issues, med issues, also
  awaiting LTC.

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Mrs. MD selected meds

• Diazepam 5mg tid
• Lorazepam 2mg po qhs
• Meperidine 50mg po q4h prn
• Allergic to codeine, morphine, oxycodone,
  hydromorphone, amitriptyline, gabapentin,
  pregabalin

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Mrs. MD

• Pain history all over, all the time
• Cannot articulate more than this.
• Demerol is the only thing that helps.
• I cant cope without my nerve pills and my
  sleeping pill.

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Whats your approach?
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Addiction

• Primary, chronic disease characterized by
  impaired control over the use of a psychoactive
  substance and/or behaviour.
• Bio/Psycho/Social/Spiritual
• Progressive, relapsing, fatal.
• www.csam.org/non_member/definitions/

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Substance Abuse

• Maladaptive pattern, significant impairment or
  distress, and 1 or more of
• Failure to fulfill role at work, school or home
• Physically hazardous
• Substance-related legal problems
• Persistent or recurrent social or interpersonal
  problems
• Has never met criteria for Dependence

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Substance Dependence

• Maladaptive pattern, significant impairment or
  distress, and 3 or more of
• Tolerance
• Withdrawal
• Larger amounts than intended
• Unsuccessful efforts to cut down
• Significant amount of time spent on substance
• Reduced activities 2o to substance
• Persistent use despite problems

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The Pickle Line

• All cucumbers can become pickles, but
• Once a pickle, you can never become a cucumber
  again...

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Alcohol
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Epidemiology - Alcohol

• Alcohol use decreases after age 60
• Problem drinking as high as 14
• CSHA 8.9 alcohol abuse
• High prevalence in hospitalized elderly (21 in
  one study)
• Incidence rates for abuse/dependence decline with
  age up to 60
• Increase after age 60, especially in men 75

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Patterns of alcoholism

• Early onset vs. late onset
• Age 60 is arbitrary cut-off
• 2/3 in early onset group
• Somehow avoided usual complications - allowing
  them to get to later life

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Late-onset alcoholism

• Usually arises in former drinkers
• Women as a greater proportion
• Three common patterns
• Onset of cognitive / functional impairment in
  functional alcoholics
• Increased sensitivity to effects of alcohol
• New problem as a result of a stressor

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Geriatric Presentations

• Confusion
• Falls and functional decline
• Polypharmacy
• Urinary incontinence
• High fluid intake
• Diuretic effect of alcohol

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Physiological Changes
Decreased Lean Body Mass
Decreased Total Body Water
Decreased gastric EtOH Dehydrogenase
Increased Serum EtOH for a given dose
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Alcohol-related Dementia?

• Heavy alcohol consumption associated with
  cerebral atrophy
• May be reversible dementia and atrophy
• Alcohol and other dementias
• functional alcoholic developing problems 2o
  dementia
• stable dementia worsening 2o alcohol

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Falls and functional decline

• Impaired balance (acute and chronic)
• Diuretic effect -gt orthostasis
• Myopathy
• Neuropathy
• Higher rates of hip fractures
• Cognitive impairment (acute and chronic)

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Polypharmacy

• As a result of medical problems secondary to
  alcohol
• Selected common geriatric presentations
• HTN
• CVA
• Osteoporosis
• Psycho-social-psychiatric problems

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Psycho-social-psychiatric

• Frequent familial stresses/dysfunction
• Coming to light because of increasing dependence
• Depression often co-exists, hard to diagnose
• Anxiety leads to benzodiazepines

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Detecting Problem Drinking

• Look harder with suggestive findings
• Cognitive or self-care decline
• Nonadherence appointments, treatment
• Unstable or poorly controlled HTN
• Recurrent accidents, falls
• Frequent ER visits
• GI problems

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Detecting Problem Drinking

• Look harder
• Unexpected delirium
• Estrangement from family
• Laboratory abnormalities
• CAGE use a cut off of 1
• Cut Back Annoyed Guilt Eye opener

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Standard Drinks

• 12 oz. Beer
• 5 oz. Wine
• 1.5 oz. Liquor

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Myths

• Theyre housebound cant get EtOH
• Family as unwitting providers
• Taxis
• Delivery services
• Theyre old, of course theyre
• Hypertensive
• Demented
• Falling, osteoporotic

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Drugs
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Benzodiazepines

• Benzodiazepine use increases with age
• Dose increases with age
• 16 of inpatients in an addiction unit -
  sedatives or hypnotics
• Women are prescribed sedatives 2.5 times more
  than men

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Opioids

• Not really studied
• Abuse and dependence in the elderly certainly
  exists
• Need to differentiate between untreated or
  undertreated pain and opioid misuse
• Safe practice
• Single provider, single pharmacy, contract

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Other drugs

• OTC
• Marijuana others
• Just about anything else
• Stay tuned!

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Gambling
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Gambling epidemiology

• 5 of those who gamble develop problems
• 1 will develop serious problems
• ?proportion of older adults
• Pathological gambling is a DSM IV diagnosis
  disorder of impulse control

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Screening?

• South Oaks Gambling Screen
• EIGHT
• Appropriate in the elderly?
• More likely case-finding
• Problem gambling is associated with poor physical
  health think about it if the story doesnt make
  sense

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Treatment

• Detection
• Detection
• Detection
• Assess severity
• Engage the patient in a treatment plan
• HOW?

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Treatment

• Simple strategy
• Identify it as a problem
• Connect it to the patients other problems
• Provide strategies to cut back

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Treatment

• Depends on severity of problem
• Older patients may need inpatient detoxification
• May need inpatient alcohol/drug rehab with
  geriatric focus
• Community programs
• Addiction medicine specialists are often
  essential especially re medications

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Mr. S.H.

• Meeting arranged to discuss alcohol consumption
• Reviewed the numbers serum alcohol, MCV, liver
  tests (speak in engineering terms)
• Connected to his concerns
• Poor balance falls
• Fear of another stroke
• Wanting to get his license back

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Mr. S.H.

• Contracted to have no alcohol prior to attending
  Day Hospital, and to reduce his consumption by
  25
• After another fall, requested help to attempt
  abstaining entirely
• Small doses of lorazepam prescribed

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Mr. S.H.

• After 3 days, no withdrawal symptoms, but then
  felt he couldnt commit to abstaining
• Reached a common goal of 1 or 2 standard drinks
  per day
• Continued education and support
• Generally met his target

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Mr. S.H.

• No further admissions to acute care
• Door left open to him for follow-up clinic he
  needed to initiate it
• Died 2 years later

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Mrs. MD

• No changes at first
• Discussion with patient and competent
  substitute decision maker about goals of care,
  acceptance of risk.
• Decision to try to find other pain modalities
• Psychiatry consult for mood/anxiety
• May just live with the drugs?
• No happy ending here.

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Take Home Messages

• Identification is key
• Simple strategies work for many patients
• Its never often not too late!
• Balancing quality of life and goals of care is
  crucial.

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Thank you

• "I may be forgiven for saying, as a physician,
  that drinking deep is a bad practice, which I
  never follow, if I can help, and certainly do not
  recommend to another, least of all to any one who
  still feels the effects of yesterday's carouse."
• Plato's Symposium
• (gibson_at_queensu.ca)