David Bienenfeld, M.D. Wright State University Department of Psychiatry

Transcription

1 David Bienenfeld, M.D. Wright State University Department of Psychiatry 1

2 Describe the epidemiologic patterns of substance abuse over age and time List the metabolic changes that influence the effect of alcohol and rugs in late life List clinical features of presentations of substance abusing elderly in clinical practice Outline treatment strategies for alcohol withdrawal and substance abuse maintenance. 2

3 I. Alcohol A. Epidemiology B. Metabolic changes C. Consequences 1. Medical 2. CNS / psychiatric D. Clinical recognition E. Threatment 1. Withdrawal 2. Maintenance II. Drug abuse / dependence A. Epidemiology B. Treatment 3

4 % using in past month Age 2006 National Survey on Drug Use and Health (SAMHSA 2007) 4

5 per cent * * * p< National Survey on Drug Use and Health (SAMHSA 2008) 5

6 Premature mortality Increased morbidity Institutionalization Social isolation Underrecognition Cohort effects Substitute gratifications 6

7 Changes in body composition 7

8 per cent yo 80 yo Fat Water Age 8

9 Changes in body composition Diminished hepatic metabolism 9

10 Peak BAC (mg/dl) after 22.5g EtOH/m 2 body surface area Age Hartford JT, Samorajski T. J Amer Geriatr Soc

11 Changes in body composition Diminished hepatic metabolism Increased permeability of blood-brain barrier Increased sensitivity of brain cells 11

12 Drug interactions Warfarin Anticonvulsants Benzodiazepines OTCs See attached table of drug-alcohol interactions 12

13 Elderly use 30% of all Rx Elderly use 30% of all OTC meds Average use for persons > prescription drugs over-the-counter medicine Conry, Geriatric Times

14 Drug interactions Warfarin Anticonvulsants Benzodiazepines OTCs Falls GI disease Hepatic disease Immunosuppression Nutritional deficiencies Malignancies 14

15 Delirium Intoxication Withdrawal Wernicke encephalopathy Korsakoff syndrome Alcohol-related dementia Insomnia Depression 15

16 Alzheimer disease Vascular dementia Other dementias Neurotoxicity Malnutrition COGNITIVE DECLINE Temporary emotional relief ALCOHOL INGESTION Anxiety, depression 16

17 15 33% begin after 40 y.o. Early onset Late onset : = 1:4 : = 1:3 More frequent use, greater quantities More likely to have used treatment programs, including AA More physical consequences More legal, financial problems Onset follows retirement, bereavement Less self-critical of drinking, greater denial More social support Liberto JG, Oslin DW. Int J Addic,

18 Anxiety Auto accidents Blackouts Disoreintation Falls, bruises, burns Family problems Financial problems Headache New onset seizures Incontinence Increased tolerance Legal difficulties Memory loss Poor hygiene Poor nutrition Sleep problems Social isolation 18

19 High index of suspicion History, pattern, amounts Family history Screening instruments CAGE MAST-G, SMAST-G 19

20 Spouses Children Public agencies Police Charitable institutions Health care professionals 20

21 Higher risk of Delirium Falls Dependency for ADLs Discharge to extended care facility Longer lasting Confusion Hospital stays 21

22 Inpatient preferred Benzodiazepines Low dose Short acting Antipsychotics Metabolic support Vitamins Electrolytes 22

23 Disulfiram NO Naltrexone??? Outpatient, community-based programs Completion rates Involve family 23

24 24

25 3.5 Percent (number in millions) 0.7 Wu LT, Blazer DG. J Aging & Health

26 per cent Satre DD, Sterling SA, et al. Am J Geriatric Psych

27 Arndt SA, Clayton R, Schultz SK Am J Geriatric Psych

28 Arndt SA, Clayton R, Schultz SK Am J Geriatric Psych

29 Arndt SA, Clayton R, Schultz SK Am J Geriatric Psych

30 Arndt SA, Clayton R, Schultz SK Am J Geriatric Psych

31 Better motivation and cooperation than younger individuals Involve family, PCP 12-step groups: AA > NA Al-Anon for families Driving 31

32 Home page drop down: Resources > Department Manuals > Geriatric Psychiatry Handout of this presentation Quiz Drug-alcohol interactions MAST-G SMAST-G 32