The Science of Addiction in Older Adults

Transcription

1 The Science of Addiction in Older Adults Byron Bair,M.D. Professor Geriatric Internal Medicine & Geriatric Psychiatry University of Utah School of Medicine

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3 SAMHSA National Older Adult Mental Health Awareness Day: its about time First held 18 May, 2018

4 The Science of Addiction in Older Adults Latin: scienctia = knowledge What do we know? Data base for geriatrics is Very limited Studies exclude those with comorbidities Extrapolations from younger populations are problematic We need to know much more Detection & Evaluation is critical

5 Outline Context Demographics Evaluation Substance Abuse / Misuse polypharmacy abuse / addiction

6 Context: Older Adults` Definition of aging? Cellular Physiological Birthdays Other? Aging Groups Young Old: Middle Old: Old Old: 85+

7 Context: Older Adults Age & intervention outcomes Age not an independent predictor Outcomes CABG in age 90+ Underlying illness + premorbid function status = best predictors Targets of treatment Comfort, Function, Quality of Life, Dignity Frailty + homeostenosis + functional reserve Still functional BUT closer to the edge

8 Context: Older Adults Life expectancy calculators birth female years + 5 years years male years + 4 years +2.2 years Age 65+ in US (2010 census) Largest numeric demographic group Largest percentage population Fastest growing

9 Context: Older Adults 1 symptom set = 1 illness vs. 1 symptom set = multi illnesses / syndromes Multidimensionality of contributors to health and function Social & Psychosocial Groups cs. Dyad Environmental Structure, support / supervision, stimuli, safety, stress Economic Costs of care impacts care seeking Cognitive Dementia, delirium, depression / psychiatric, damaged brain, developmental delay, deficient education Functional Vision, hearing, mobility

10 Context: Older Adults Physiological changes Organ systems Heart: < CO; stiffing major vessels, < atrial kick; < max HR Lungs: > residual volume; < compliance; < elastic recoil Pharmacodynamics Absorption GI; not significant Distribution Water soluble; decrease volume distribution Lipid soluble; increased volume distribution Metabolism Liver; < oxidation reduction; stays same glucoronidation Elimination Kidney» GFR calculations: Cockcroft-Gault: (140-age) x IBW (kg)/plasma creat. X 72 (x.85 females)

11 Context Older Adults Medical Conditions Average 2 chronic medical conditions age 65+ Sensory deficits: vision + hearing Cognition / depression / anxiety / psychosis Malnutrition Fall risk & mobility Urinary incontinence Polypharmacy: Average 4 RX medications and 4 OTC preparations age 65+ Functional status Environmental status Patient Goals

12 Purpose: Evaluation detect factors contributing to the current problem improve: function, comfort, dignity, quality of life It is common for multiple processes to be occurring simultaneously in older adults Recognize role of Geriatric frailty aging = reduced reserve capacity increased propensity for small insults to result in disability

13 Homeostenosis

14 Polypharmacy Average number medications age 65+ = 4 RX + 4 OTC = 8 Medicare discharge medications to skilled nursing facility = 14 Prospective study Average number of medications post d/c acute Med/Surg. floor = 12 Average number of medication discrepancies within 72 hours = 20 Independent risk for: ADE Hip fracture & falls Medical adherence Inappropriate Medications leading to adverse outcomes including hospitalization: Beers Criteria American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel JAGS 63:2227, 2015 CDC study of ER visits leading to hospitalization: warfarin (17%), insulin 13%), digoxin (3%) not on Beer s list Ann Int Med 2007 Screening Tool of Older Person s Prescriptions (STOPP) Fit For The Aged (FORTA) HCFA CMS: target; digoxin, Ca channel blockers, ACE inhibitors, H2 blockers, NSAIDs, benzodiazepines, antipsychotics, antidepressants

15 Components of Functional Status Activities of Daily Living (ADL) Bathing Dressing Toileting Transferring Continence Self feeding Deficits present in 10% of community dwelling elderly 20% have difficulty but able to preform Common post hospitalization: pre discharge OT /PT evaluation Inability requires increased caregiver assistance Indicator of higher level of care: assisted living, ECF

16 Katz index of independence in activities of daily living ADLs 6 points: High (patient independent) 0 points: Low (patient very dependent) Activities Independence Dependence Points (1 or 0) Points (1) NO supervision, direction, or personal assistance Bathing POINTS: Dressing POINTS: Toileting POINTS: Transferring POINTS: Continence POINTS: Feeding POINTS: Total points: (1 point) Bathes self completely or needs help in bathing only a single part of the body, such as the back, genital area, or disabled extremity. (1 point) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes. (1 point) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help. (1 point) Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable. (1 point) Exercises complete self-control over urination and defecation. (1 point) Gets food from plate into mouth without help. Preparation of food may be done by another person. Points (0) WITH supervision, direction, personal assistance, or total care (0 points) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing. (0 points) Needs help with dressing self or needs to be completely dressed. (0 points) Needs help transferring to the toilet and cleaning self or uses bedpan or commode. (0 points) Needs help in moving from bed to chair or requires a complete transfer. (0 points) Is partially or totally incontinent of bowel or bladder. (0 points) Needs partial or total help with feeding or requires parenteral feeding.

17 Components of Functional Status Instrumental Activities of Daily Living (IADL) Use telephone Shopping Doing housework Doing laundry Preparing meals Driving Taking medications Managing money 17% of older adults dependent in at least 1 IADL Progressive loss = increase assistance at home

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19 Components of Functional Status Advanced Activities of Daily Living (AADL) Occupational Recreational Travel activities Use of IADL, ADL, pre visit tools

20 Task No help needed Help needed Who helps? Feeding yourself Getting from bed to chair Getting to the toilet Getting dressed Bathing or showering Walking across the room (includes using cane or walker) Using the telephone Taking your medicines Preparing meals Managing money (like keeping track of expenses or paying bills) Moderately strenuous housework such as doing the laundry Shopping for personal items like toiletries or medicines Shopping for groceries Driving Climbing a flight of stairs Getting to places beyond walking distance (eg, by bus, taxi, or car)

21 Environment Assessment Office visit Order home OT or RN evaluation from home services Post discharge from hospital OT & PT pre discharge evaluation Consider post acute rehab transition Factors: IADLs, ADLs Living environment Family / significant other assistance Community involvement Advanced care planning Pre-visit evaluation information collection

22 Environment Assessment: support Adult day /health care Meals on wheels Senior transportation services Community centers Religious program VA & State Office VA Home Aids Area Agency Aging: National Council on Aging services: :

23 Environment Assessment: Living Options Finances and resources Assess individual needs before suggesting living environment Supervision Independent vs dependent Structure Self vs external Stimuli Conducive vs chaotic Stress Self + others Safety Home, weapons, medications, driving

24 Environment Assessment: Living Options Residential Independent Living IADL + ADL independent Assisted Living ADL independent Variety of services for some ADLs Skilled Nursing Facility Post acute care Medicare 20 days post 3 midnights in hospital 100%; days covered 80% Skilled need: rehab, wound care, IVs, tube management etc. Long term care

25 SUD In Older Adults Unrecognized Untreated

26 Substance Use Disorder Geriatrics Data base & research limited Cohort effects Great Depression vs. Woodstock Illicit Drugs: life time history = 2.88% men, 0.66% women Cocaine / Heroine: 13% active users in those with history, age % VA older adult treatment program Over the counter / Non prescription: Alcohol: occasional use = 50% Tobacco: community dwelling = 15.2% (65-75) 8.4% (75+) Prescription Misuse Common: 72 hours post discharge = average 20 discrepancies / patient Sedatives: benadryl, benzodiazepines Analgesics: narcotics Utah rank 22 nd for overdose deaths in US

27 Addiction / Substance Use Disorder Male > 65 Female > 65 ETOH 3.1 %.5 % Benzo 1.6 % 1.6% Narcotics 2.3% 2.1% Illegal > 1% or??

28 Substance Use in Older Adults: ETOH Prevalence use disorder / dependence 1.2 % men & 0.3% women (DSM-IV National Longitudinal Alcohol Epidemiologic Survey) Heavy Drinking 15-20% men & 8-10% women Occasional use = 50% Regular use =40% Primary Care = 4-10% ETOH dependent ER = 14% Hospital = 10-21% 2/3 early onset, others onset after age 65

29 Diagnosis: ETOH Age 65+ Recommended Limit for age 65 or older: 1 drink = 1 ounce of ETOH no more than 1 drink per day or 7 drinks per week no more than 4 drinks on any drinking day

30 Substance Use: ETOH Risk Factors Single Well educated Male Living alone Prior history when young Vulnerabilities Decreased volume of distribution H2O soluble Decreased activity of alcohol dehydrogenase with age Chronic illness + medications = increased medication side-effects Consequences Liver disease Cancer: head, neck esophagus, lung, breast Myopathy, peripheral neuropathy, cerebellar (falls), osteoporosis Impaired cognition: judgment, brain function (dementia, delirium etc) Psychiatric: depression, anxiety, personality changes, suicide

31 Suicide Utah ranks 5 th in US for suicides

32 Suicide Risk Factors Personal or environmental characteristics that increase the risk of suicide: Misuse / abuse of alcohol or drugs Mental disorders; depression / anxiety Access to lethal means Knowing someone who died by suicide / family member Social isolation Chronic disease and disability in self or significant other Lack of access to behavioral health care

33 Suicide Protective Factors Personal or environmental characteristics that help protect people from suicide Effective behavioral health care Connectedness to individuals, family, community, and social institutions Life skills (problem solving, coping skills, ability to adapt to change) Self-esteem and a sense of purpose or meaning in life Cultural, religious, or personal beliefs that discourage suicide

34 Prior to Suicide: 75% see an M.D. within 1 month of attempt 30-50% see an M.D. within 1 week of attempt Common Concomitant Illness: CHF, COPD

35 Suicidal Clues In Older Adults Direct Verbalization I want to kill myself Indirect Verbalization I m a burden increased somatic complaints Behavioral non-compliance sudden purchase of gun / change will death of significant other

36 DSM 5 Diagnosis Substance use Disorder: replaces substance abuse / dependence A pattern of substance use leading to significant impairment / distress, with at least two of the following within a 12-month period: substance taken in larger amounts / longer period than intended persistent desire / unsuccessful efforts to cut down or control use Great effort to obtain the substance, use the substance, or recover from its effects. Craving, or a strong desire or urge to use the substance Recurrent use and failure to fulfill role obligations at work, school, or home Continued use despite having recurrent social or interpersonal problems due to use Important social, occupational, or recreational activities given up /reduced to use Recurrent use in situations in which it is physically hazardous Continued use despite persistent / recurrent physical / psychological problems caused or exacerbated by the substance Tolerance Withdrawal

37 DSM 5 Diagnosis Substance use Disorder: replaces substance abuse / dependence Severity specified based on the number of symptoms present: Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms

38 Detection Substance Abuse: ETOH Ageist beliefs: why treat now Nonspecific symptoms: falls, sleep problems, irritability Screening CAGE (Cut down, Anger, Guilt, Eye opener) MAST-G (Michigan Alcoholism Screen Test-geriatric) All require current drinking history

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40 Treatments for SUD Older Adults Now SUD has been identified Treatment options: Detoxification Outpatient programs In patient programs Medications Treatment Goals: Improve function, comfort, quality of life, & dignity

41 Summary Geriatric presentations are different than other populations due to the effects of aging Multidimensional evaluation is critical Specifically Look for or consider: Substance abuse / misuse Delirium & complicating medical issues Depression

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