The Treatment of Addiciton in Older Adults

Transcription

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

2 Basic Demographics Aging population age 65 or older: 130%+ per year Life expectancy birth: years at age 85: 6-8 more years Unique features of aging physiology changes disease presentation

3 Unique Features of Aging Pharmacodynamic changes of age increased receptor sensitivity opioids, benzodiazapines decreased receptor sensitivity beta blockers, beta agonists Pharmacokenetic changes of age absorption: little clinical effect distribution: lipid vs water soluble metabolism: phase I vs phase II excretion: Kidneys, bowels, tears, saliva, sweat

4 Diagnosis in DSM-5 Substance use disorder, replaced substance abuse / dependence: A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period: The substance is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control use of the substance. A great deal of time is spent in activities necessary 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 resulting in a failure to fulfill major role obligations at work, school, or home. Continued use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by its effects. Important social, occupational, or recreational activities are given up or reduced because of use. Recurrent use in situations in which it is physically hazardous. Continued use despite persistent or recurrent physical or psychological problems caused or exacerbated by the substance. Tolerance. Withdrawal. Current severity can be specified in the diagnosis based on the number of symptoms present: Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms

5 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% Alcohol SUD: 3% -0.5% (M/F) bimodal distribution Tobacco: community dwelling = 15.2% (65-75) 8.4% (75+) Prescription Sedatives: benzodiazepines; 2% Analgesics: narcotics; 2% Utah rank 22 nd for overdose deaths in US

6 Treatment Outcomes for Older Adults Review of randomized controlled trials 25 studies met criteria Limited: 15 or less participants Tracking: pre post tests Results Higher treatment exposure: Older adults do better than younger patients Older adults have a heterogeneous response to treatment Need randomized controlled trials of evidenced-based practices, including Motivational Interviewing, cognitive behavioral therapy, and medications (naltrexone) A Review of Existing Treatments for Substance Abuse Among the Elderly and Recommendations for Future Directions February 18, 2013 Alexis Kuerbis1 and Paul Sacco2 1Research Foundation for Mental Hygiene, Inc, and Columbia University Medical Center. 2University of Maryland, School of Social Work

7 Older Adults 5 Years after treatment Compared to young and middle age adults Older adults are: Less likely to be drug dependent at baseline Longer retention in treatment Less likely to be encouraged to take drugs / ETOH 12% higher abstinence last 30 days (52%) Older women had highest rates of abstinence ETOH only = no differences in age groups

8 Medical Conditions: Older Adults Sensory Deficits Check or refer for evaluation of: Vision hearing Malnutrition Follow weights: un-intended weight loss > 5lb within 1 month or 10 lb. in 3 months = high risk morbidity / mortality Cognition & Behavior Polypharmacy Depression Functional impairment Environmental status Prognosis & Life Expectancy Patient Goals Frailty

9 Frailty Functional Capacity Disability Time

10 Treatment Models chronic/relapsing substance use disorders (SUD) in the United States episodic treatment vs. continuing care Conceptualize as a chronic disease Serial patient assessments & monitoring modification of patients level of care over time based on: phase of illness clinical status co-occurring conditions treatment needs/preferences

11 Substance Use Disorders Treatment provided via a continuum of care multiple tiers of clinical services that vary by: Setting types of treatment intensity of services Standard levels of care include: Inpatient Residential partial hospital intensive outpatient outpatient care

12 Treatment Considerations The patient s clinical status and risk of relapse are monitored systematically and longitudinally As the patient s addiction waxes and wanes over time (ie, experiences periods of abstinence, relapse, or fluctuations in risk of relapse), the intensiveness and types of treatment are adjusted along with the level of care at which treatment is delivered

13 ASAM Dimensional Approach Dimension 1 Acute intoxication and withdrawal potential. Manage intoxication / withdrawal Dimension 2 Medical conditions and complications Treat acute / chronic medical issues that complicate SUD treatment Dimension 3 Emotional, behavioral, or cognitive conditions emotional, behavioral, or cognitive problems part of the addiction Dimension 4 Readiness to change Ready to stop or reduce use of substances/addictive behaviors Dimension 5 Relapse, continued use or continued problem potential Need relapse prevention interventions, groups, structure etc. Potential benefit of medications (psychotropic and addiction)? Dimension 6 Recovery environment Structure, Supervision, Stimuli, Safety, Stress

14 Matching patient substance use disorder treatment needs to levels care using ASAM criteria

15 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

16 Evaluation History: changes; acute vs chronic IADL s: independent, assist, dependent use telephone, shopping, food preparation, housekeeping, laundry, transportation, finances, medication ADL s: independent, assist, dependent bathing, dressing toileting, transfers, continence, feeding Detect: common changes from baseline new or exacerbation of illness: self /spouse death in family psycho-social, environmental, economic vision, hearing, constipation, fluid intake

17 Evaluation Physical Exam vital signs: weight, height, orthostatic BP, HR, RR, Temp. geriatric functional exam: get-up-and-go, ROM sensory: hearing, sight neurological gait, reflexes screening exams: PHQ9, GAD7, MOCA, PTSD etc.

18 Laboratory Blood work: Evaluation lytes, BUN/creatinine, Ca++, Mg++, albumen, (prealbumen), LFT s, CBC & diff., TSH, B12, folate, FTA, HIV Pulse oximetry EKG Imaging: Chest x-ray, CT without contrast? PVR Other: Other neuropsych. testing

19 Cognitive Function Cognition comprises all mental functions used to deal with the internal & external world

20 Selected Cognitive Functions Memory Attention Orientation Language Writing Calculation Praxis Initiation Abstraction Planning Visuospatial Sequencing Personality Judgement Insight Behavior

21 Dementia 7 D s of Cognitive Dysfunction Alzheimer's, Vascular, Mixed, Lewy Body, Frontotemporal Delirium Drugs +/- infections; acute vs subacute / chronic Damaged Brain Chemical (ETOH), traumatic, surgical Depression: Psychiatric disorders, mania, psychosis, PTSD, bereavement Developmental Delay Deficient Education Decision Making Capacity

22 Delirium: DSM V Criteria Disturbance of Consciousness Change in Cognition Acute Onset (hours - days) Result of General Medical Condition

23 Delirium: Etiology Common Endpoint for Many Illnesses: Infections: UTI, pneumonia MI Pain Dehydration Medications / drugs intoxicated or withdrawal

24 Delirium: Significance 50-80% of Hospitalized Elderly Listed as Discharge Diagnosis: 5-23% M.D. Recognition during course: < 1% Length of Stay: 2 x > controls Nursing Home D/C: 5 x > controls Inpatient Mortality: 8 x > controls

25 Evaluation: Delirium ANY acute change in mental status or behavior may signal a delirium Delirium requires prompt medical evaluation differing evaluations is suspicious for delirium TREAT UNDERLYING MEDICAL ILLNESS haloperidol & lorazepam may help tranquilize to allow evaluation and intervention but are not tx

26 Unrecognized Medical Issues 80% have at least 1 chronic medical condition An average of 8 different prescriptions, OTC, herbals New behavioral symptoms may reflect underlying comorbid disorders or new disorders layered on previous conditions 1 set of symptoms may reflect multiple interacting etiologies

27 Unrecognized Medical Issues Sleep disorders medications: diuretics, benzodiazepines, caffeine symptom of other illness: depression sleep apnea: 30-70% Pain, nutrition, hydration, HTN, CAD, Lipids, etc. Substance use disorders ETOH, benzodiazepines, opioids, other Polypharmacy: Prescription abuse? ADE s: 40-50% vs 2-10% in younger populations pharmacodynamic, pharmacokenitic changes of age

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29 Polypharmacy: Unintentional Prescription Abuse? Average person over the age of 65 80% have 2 or more chronic medical conditions 4.5 prescriptions 3.5 over the counter (OTC) medications? Herbals new prescriptions per year

30 Polypharmacy: Unintentional Prescription abuse In Older Adults? 596 unique admissions 15% readmission rate range of 2-6 admissions Reasons for readmission new clinical problem clinical failure other (scheduled test) Discharge medications: hour follow-up discrepancies: 20.2

31 Polypharmacy and ADE s 75% office visits include prescription 15% hospital admissions from ADE 50% of hospital stays are complicated by ADE Longer hospitalization = more medications

32 Treatment Tools Trust + Verify Random blood / urine tests Continuity of care & monitoring Substance Abuse Database

33 Pharmacological Interventions Restricted Prescription Drugs Utah Controlled Substance Database Access to providers + designee, pharmacy staff Exemptions: Prescriptions filled at federal facilities (military or VA); Prescriptions filled at pharmacies licensed by other states; or Controlled substances administered in an in-patient setting.

34 Environmental Interventions 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

35 Pharmacological Interventions ETOH Older Adults Few trials in older adults Inpatient supervised withdrawal Outpatient care 70% relapse after psychosocial treatments alone Psychosocial + Medication: older adults? Medications modulate effects of ETOH Naltrexone (ReVia, Depade); liver toxicity / opioids; available as depot Acamprosate (Campral): liver safe; opioids Disulfiram (Antabuse): highly motivated and compliant

36 Pharmacological Interventions Opioids Older Adults Structured & Experienced environment Agents: Geriatric studies limited Buprenorphine naloxone combo Methadone: overdose & cardiac toxicity Clonidine: symptomatic relief

37 Pharmacological Interventions Benzodiazepines Older Adults Structured environment Outpatient Gradual tapper under supervision Inpatient Unknown dose or unsafe environment

38 Utah Centers that Advertise Older 16 Centers Adult Treatment -rehab/elderly-persons-disorders/utah 70 Centers Advertisements vs. Reality

39 Additional Addition Information

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