Physical Effects of Substance Use in Older People. Peter Crome University College London

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1 Physical Effects of Substance Use in Older People Peter Crome University College London

2 What s different about older people? Image Age discrimination services Cohort effects Survival effects Physiological changes metabolism of alcohol frailty, weakness Restrictions to independence Multiple morbidity physical and mental Medication appropriate and inappropriate evidence free zone Atypical presentations Geriatric giants Financial Personal Loss, retirement MCA 19 November 2014

3 Changes in Older People What Goes Dementia Up Long standing illness and limitation in activities Mobility difficulties Pain and discomfort Excess winter mortality

4 The Bible s View of Ageing The days of our years are threescore years and ten; and if by reason of strength they be fourscore years, yet is their strength labour and sorrow; for it is soon cut off, and we fly away. Psalms 90:10

5 The cohort effect ז כ ר י מוֹת עוֹל ם בּ ינוּ שׁ נוֹת דּ ר ו ד ר שׁ אַל אָב י ו י גּ ד ז ק נ י ו י אמ רוּ ל : Zechor yemot olam binu shnot dor-vador she'al avicha veyagedcha zekeneycha veyomru lach. Remember the days of old; consider the generations long past. Deuteronomy 32:7

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8 Multiple Morbidity Claudius: When sorrows come, they come not single spies but in battalions. Shakespeare Hamlet (1602).

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10 Geriatric Giants of Bernard Isaacs Immobility Instability Incontinence Intellectual deterioration Plus some new giants Iatrogenesis Sarcopaenia Frailty

11 Geriatric Giants of Bernard Isaacs Common Multiple causes Difficult to treat Long term treatment May lead to further deterioration if not managed

12 Geriatric Giants and Alcohol Falls Osteoporosis: More likely to fracture Balance Co-ordination Judgement Risk Taking Autonomic neuropathy Peripheral neuropathy Cardiac disease Myopathy

13 Frailty predictors Fried model Frailty Characteristic Unintentional weight loss Weakness, fatigue Poor endurance Low activity levels Slowness Measure* Baseline; >10lbs lost in prior year Grip strength adjusted for BMI/gender Self reported exhaustion K cals/week Walking time by gender/height Frailty defined as a clinical syndrome in which three or more of the above criteria is present *Cardiovascular Health Study Measures

14 Hip Fracture and Benzodiazepines Even at modest doses, treatment with benzodiazepines appears to increase the risk of hip fracture. Patients appear to be particularly vulnerable immediately after initiating therapy and after more than 1 month of continuous use. Benzodiazepines with shorter half-lives appear to be no safer than longer half-life agents. Wang et al 2001

15 Physical Effects of Alcohol (Barclay et al. APT : ) Liver Fatty liver, hepatitis, cirrhosis, Gastro-intestinal tract Varices, pancreatitis Cardiovascular system Hypertension, stroke, cardiomyopathy, arrhythmias Respiratory system Aspiration pneumonia, sleep apnoea Nervous system Neuropathy, seizures,

16 Physical Effects of Alcohol (Barclay et al. APT : ) Endocrine system Musculo-skeletal system Skin Blood Urinary system Cancer

17 Older At-Risk Patients: Subject Characteristics (Moore et al 2011) Characteristic Percentage Age 68.4 years Male 71 College degree 46 Living with spouse or partner 74 Excellent or very good health 52 Good health 37 Able to do strenuous activities 75 Heavy work 83

18 Older At-Risk* Patients: Symptoms (Moore et al 2011)* by CARET Symptom Percentage Sleeping problems 38.5 Gastrointestinal symptoms 24.1 Memory problems 22.5 Feeling sad or blue 16.8 Tripping, falling, or having accidents 17.8

19 Older At-Risk Patients: Co-morbidity (Moore et al 2011) Co-morbid condition Percentage Hypertension 30.6 Depression 12.4 Gout 7.6 Diabetes 5.2 Ulcer disease 4.1 Liver condition 3.5 Pancreatitis 0.6

20 Older At-Risk Patients: Medications (Moore et al 2011) Type of medication Anti-hypertensive 31.7 Ulcer medication 18.2 NSAID 17.9 Anti-platelet 17.3 Non-prescription drugs medications for allergies Percentage 12.7 Antidepressants 11.9 Sedatives 10.1 Opioids 6.7 Nitrates 4.3 Warfarin 4.4 Seizure medication 0.6

21 Physical and Mental Health in Older Alcohol- Dependent Inpatients (van den Berg et al 2014) Characteristic Early Onset Late Onset Very Late Onset Age Age of onset of alcohol dependence Chronic physical conditions Cognitive problems Spends free time alone

22 Physical Health in Methadone Users (%) (n=140) Health Problem Overall sample Men Women Arthritis Hypertension Heart condition Lung disease Stomach ulcers Cirrhosis Hepatitis C Diabetes Current smokers Rosen et al (2008). Am J Geriat Psychiat 16:

23 Physical Health in Methadone Users Rosen et al The Prevalence of Mental and Physical Health Disorders Among Older Methadone Patients. Am J Geriat Psychiatry :

24 Health Status in Older Heroin Users 50% abnormal liver function 94% tested positive for Hep C, 86% for Hep B, 3.8% for syphilis and 27% for TB Perceived themselves as having worse physical functioning, worse emotional well being, less energy and worse general health when compared to the general population Hser et al (2004)

25 How it was How it will be? DV. 67 year old woman with decreasing mobility and worry about excess alcohol use. Old age psychiatry do not do alcohol General psychiatry do not do older people Alcohol people do not see people at home and only see those who can climb the stairs to their office!