Substance Use/Abuse in the Geriatric Population Alan L. Schneider, MD DFAPA DABAM Medical Director, Western Region Aetna Behavioral Health Associate Professor of Psychiatry, UCLA School of Medicine Alcohol Use in the Elderly A national cohort study of 4800 adults >64 y/o showed that 10% were binge drinkers in last 30 days. Binge drinking defined at 5 or more drinks for men, or 4 or more for women, in one sitting. Alcohol consumption in senior associated with cognitive decline and increasing risk of hypertension, stroke, and osteoporosis. In surveys, self reported binge drinkers tend to be younger than nonbinge drinkers by ~4 years, and often men vs. women 64 vs 45%. Alcohol Use in the Elderly Binge drinking in the elderly is underreported and underestimated. Elderly adults predominantly hide their habit from family or facilities where they reside. Alcohol consumption creates secondary morbidity through falls, interaction with prescription drugs, or failure to keep up usual health routines. 1
Alcohol Use in the Elderly Binge drinkers are often veterans, low income (<25K/year), less likely to be college educated, and higher rates of smoking (24%). Surprisingly, in one analysis binge drinkers had lower incidence of CAD, etiology unclear. Alcohol Use in the Elderly On any average day there are almost 8 million older adults who drank alcohol, 150,000+ who used marijuana, and 5 6000 who used cocaine. These are undoubtedly low estimates based on phone interviews. We do know that of the 16000 ER admissions >age 65, there were per day at least 50 related to ETOH use and as many as 10 12 related to heroin or other opiates. 290 ER visits/day involve nonmedical use of pharmaceuticals combined with ETOH. Alcohol Use in the Elderly Substance use is emerging as a primary public health issue in not just the young, but in the older population. In 2014 there were almost 1,000,000 >65 with an alcohol use disorder, and almost 200K with an illicit drug use disorder. It is estimated that by 2020 this will rise to 5.7 million. This substance use problem will obviously further impact other chronic health conditions. 2
Protective Effects of Alcohol For the past 35 years the association btw moderate alcohol intake and cognitive function has been investigated in almost 80 studies. Most show an association between light moderate alcohol consumption and better cognitive function, and reduced risk of Alzheimer s and vascular dementia. However the jury s still out. Some contend that happy people with many friends have the most opportunity for social drinking. They re better educated, don t live alone, and have less depression, have lower overall risk for dementia. Improved vascular function in alcohol drinkers could account for lower vascular dementia rates. Protective Effects of Alcohol Of the studies done to date, most overall participants consume <2 drinks per day, almost 50% drank wine only, 30% drank beer only, and the remainder drank a mixture of those and straight liquor. No association was found between alcohol consumption, smoking, mild cognitive impairment, or Apo E4 status. In adults 75 or older, consumption of 20 29 gms per day of alcohol was associated with reduced overall dementia of 29%. Screening the Elderly for Alcohol Abuse As a routine part of the health check every practitioner should screen an elderly person >60 for alcohol/substance misuse. Specific tools include the AUDIT or CAGE. Concurrent screen with a monumental status or MOCA also recommended. As part of the screen tolerance levels for daily use should be adjusted down from those of the general adult population (1.5 drinks/day for men, 1 drink/day for women). 3
Red Flags for Alcohol Misuse in the Elderly Doing badly at home but functioning seemingly well at the hospital. Unexplained variations in health presentation. Inconsistencies and contradictions in presentations in the patient s history. Unexplained falls, injuries, episodes of incontinence, cognitive problems, or poor self care. Malnutrition. Sleep disturbances, anxiety, depression, mood swings. Legal, financial, family problems. Requiring early refills. Alcohol/Substance Use in the Elderly Several data sets are kept each year to study this problem. SAMHSA (Substance Abuse and Mental Health Services Administration). NSDUH (National Survey on Drug Use and Health) TEDS (Treatment Episode Data Set) DAWN (Drug Abuse Warning Network) How are the Elderly Referred for Treatment? Self or family referred: ~60%. Criminal justice system: 10 15%. Health care provider: 5 10%. Community organization: 5%. Alcohol or drug abuse providers: 5% 4
Opiates in the Elderly Compared to alcohol, few studies examine illicit drug use in the elderly. Major studies done have examined opioids and benzodiazepines (tranquilizers), where prevalence rates for nonmedical use appear to be tranquilizers ~1% of the population, opioids ~1%, and amphetamines ~1/2% of the population. HOWEVER, that doesn t tell much of the story. Nonmedical use of prescription opiates Vicodin, Percocet, etc. have an increasingly higher percentage of use in the geriatric population in the last 10 years. It s estimated that 81% of older adults with a prescription opioid use disorder have another substance use disorder. Opiates in the Elderly The axiom is substance use disorders beget other substance use disorders. Interestingly the suggestion is that in the elderly the most common substance use disorder next to alcohol is marijuana, with a rate on the low end approaching 5%. Risks of Opiate Use in the Elderly Oversedation Constipation Cognitive impairment Respiratory depression Bone demineralization Death in combination with other sedating agents 5
Sedatives in the Elderly Benzodiazepine class and so called Z drugs are widely prescribed for anxiety or insomnia. Barbiturates are no longer used. Sedatives are controlled substances due to their potential for abuse and misuse. Psychological dependence is high in all age groups. Often overlooked in the elderly who are not seen as typical abusers. Sedatives in the Elderly In younger individuals, sedatives are more abused for euphoric effects. In older individuals more often abused for anti anxiety effect. Dependency on hypnotic aspect very common. Work via GABA A receptor complex agonism primarily by binding nonselectively to the BZ1 and BZ2 receptors Sedatives in the Elderly Some benzodiazepines: directly conjugated via glucuronyl transferase and excreted. Oxazepam Serax Lorazepam Ativan Temazepam Restoril Some require cytochrome metabolism with multiple active metabolites and long ½ lives: Diazepam Valium Chlordiazepoxide Librium 6
Sedatives in the Elderly BZ1 specific drugs that are selective: Zolpidem, eszopiclone: shorter duration of action and ½ life, and have no effect on sleep architecture, HOWEVER can cause: Hallucinations and psychosis Bizarre and complex behavioral effects Contribute to overdose Up to 33% of elderly patients are now prescribed a sedativehypnotic by their physicians. Sedatives in the Elderly The classic sedative dependent patient: Elderly Female Perceived poor health status Often perceived poor physical health is associated with long term sedative use Long term sedative use associated with increasing falls and injury Sedatives in the Elderly Misuse and abuse has grown with time Admissions for BZD abuse has tripled from 22,400 in 1998 to 60,200 in 2008, to what s anticipated to be 100,000 in 2018 Exaggeration of symptoms in anxiety/insomnia often leads to long term use of BZD s or Z drugs Chemical coping is a challenging behavior for all treaters and is the boundary between physical and mental distress. 7
Special Focus in the Elderly Elderly pts differ markedly from their younger, middle aged cohorts. Average # concurrent drugs has tripled. # coexistent medical problems is 6 9. Body fat changes volume of distribution of drugs changes. Hepatic and renal function decreased in many patients, consequently ½ life of drugs is increased and protein binding of drugs goes down, so free drug component goes up. Drug: drug interactions become more significant. Special Focus in the Elderly Resiliency in falls, injuries, and drug interactions is markedly less. Resiliency in post hospitalization recovery is markedly less. Propensity for post hospitalization/post op delirium is markedly higher leads to higher incidence of death after one year. Propensity for unintentional death due to drug overdoseundiscovered high. Propensity for substance abuse related suicide in the face of chronic illness high. How Can We Address the Problem? Safe prescribing of controlled substances. Provide screening instruments to assess risks related to opiates or ETOH. History related to previous addiction, especially polysubstance use, is the single biggest predictor. Even single substance abuse (tobacco) lends a higher risk of medication/substance abuse. History of childhood sexual abuse, legal 8
How Can We Address the Problem? Take from childhood sexual abuse on fro prior slide Obtaining prescriptions from friends/family. Doctor shopping. All of the above indicate risk factors that arise in multiple treater's offices, not just physicians. Now the PDMP program in CA can be used frequently to assess for multiple prescribers and early refills. Pharmacies also tend to call physicians more frequently to alert them. How Can We Address the Problem? It takes a village As seen from prior slides, the physician cannot be relied upon for primary source of identification and referral for substance abusing elder. Often 1 st indication of ETOH, sedative hypnotic, or opiate withdrawal is seen in a hospital setting for a totally different condition where the pt doesn t acknowledge using any of these substances. What Can You Do? Make routine screening part of your usual work up in your office or facility in which you work. Use motivation interviewing to produce a harm reduction strategy. Refer out to substance abuse specialists rather than generalists, who are often ill acquainted with treating substance abuse problems in young adults or the elderly. Don t be afraid to ask about any substance. You re never too old to use crack cocaine or heroin. 9