SUBSTANCE ABUSE AND THE ELDERLY

A GERIATRICIAN’S PERSPECTIVE

OBJECTIVES

• Demographics of the aging population especially in relation to the “boomers”

• A short course in the physiology of aging with the focus on how it influences abuse problems in the elderly

• A look at the prevalence of substance abuse in the geriatric population

• Examine risk factors and special dynamics of the “boomer” cohort

• Look at the reasons the diagnosis of substance abuse is so often low on the differential list

DEMOGRAPHICS

PRESENT POPULATION

77 million Americans are over the age of 50

41.9 are 50 – 64

18.4 are 65 – 74

12.4 are 74 – 84

4.2 are 85+

At age 50, Americans can, on the average live another 30 years

People who are now 75 can expect to live another 11 years

People who are now 65 can expect to live till 90

FUTURE POPULATION

By 2030, 70 million people will be over the age of 65

This will be about 20% of the population

More than 6 million will be over 85

The oldest old make up the fastest growing segment of the population

GOOD NEWS/ BAD NEWS IN HEALTH

• People are living longer• Women live longer, but the gap between women and men is

decreasing• Racial differences in life expectancy are decreasing• Smoking rates have decreased in the past two decades – by 23% in

women and 36% in men • The percentage of Medicare beneficiaries receiving preventative

services has increased markedly• More Americans are reporting some efforts to increase exercise –

this has especially been seen in those over the age of 75

• Changes in drinking patterns have not changed – yet• Greater numbers of older American are reporting their

health status as excellent or very good – especially those in the 65-74 year old age range – 42%

SOCIAL SUPPORT SYSTEMS

• As people age, the social support system becomes more important• But the longer people live, the more likely they are to live alone• Especially if they are female• ½ of all females in the 75-84 and 58% of females older than 85 lived

alone in 1999• 1/3 of people providing support to the elderly are adult children• During the “baby bust” of the 60’s, there was a marked increase of

females not having children• This means that people now in their 60’s are much less likely to

have a social support system with adult children to help• And those with adult children are less likely to have them living in

the same general area

A SHORT LESSON IN THE PHYSIOLOGY OF AGING IN RELATION TO SUBSTANCE ABUSE

FAT STORES

• Increased fat stores and overall decrease in body water content• Decreased muscle mass• Increased peak alcohol level at lower doses• Long acting benzos get stored in the fat and stay around a lot longer• Lower doses of short acting benzos attain higher peak levels more

quickly

LIVER FUNCTION

• Blood flow through the liver decreases and the metabolic capacity decreases with age

• Acute ETOH abuse impairs liver function• Chronic ETOH abuse may actually increase liver enzyme induction

and increase metabolism of some drugs (until the liver becomes really damaged)

• Drug clearance may fluctuate because of this – especially in binge drinking.

• With drugs like warfarin or anticonvulsants, this can have catastrophic consequences

• Or the mixture of sedatives and ETOH – chronic drinkers have decreased effect of say temazepam and binge drinkers will have increased effect when they drink

IMMUNE FUNCTION

• Decreased immune function as we age• ETOH itself in large doses is an immunosuppressant• This increases problems with infection and poorer outcomes when

an infection occurs• ETOH, benzos, opioids all decrease the level conciousness, thus

increasing risk of aspiration• Increased risk of HIV – one of the fastest growing segments of

population is the elderly (? Thanks to viagra et al?)

NEUROLOGIC CHANGES OF THE ELDERLY

• The brain atrophies significantly• Blood flow to the brain decreases by 20%• There is significant cellular loss• Proprioception decreases with age• All of this will be worsened by ETOH and other psychoactive drugs• Studies show that the benzos increase cognitive decline –

especially the long acting • ETOH can give global cognitive impairment• Peripheral neuropathy with ETOH abuse and vitamin deficiency

ETOH AND THE ELDERLY

• HX : VT was 82 yo that was found down in the parking lot of a local restaurant. He was nonresponsive to verbal stimuli but responsive to pain. He had eaten at this restaurant every night since his wife died 3 years before

• Past Hx: HBP, nonsmoker, “has a drink every day”

• Social hx: retired beer salesman, widower, one child in town

• Hospital Course: Taken to ULH ER. Noted to have bruising and abrasion on occipital region. ETOH level was 0.08. CT scan showed intracerebral bleed. Stormy course with prolonged delirium and pneumonia. Finally DCed to SNF

COMMUNITY DWELLING ELDERLY60 AND ABOVE

• 62% drink ETOH• Heavy drinking in 13% of males and 2% of females• Overall 6% of elderly were considered to be heavy drinkers• In this study heavy drinking was defined as greater than two

standard drinks in a day• A standard drink is 1. 5 ounces of distilled spirits, 12 oz. of beer or 5

oz of wine• This study lowered the standard def of heavy drinking because of

the elderly lowered tolerance

HOSPITAL AND NURSING HOME

• 13% of elderly trauma patients had blood ETOH levels greater than 0.1

• 23% of elderly Psychiatry patients have history of ETOH abuse• 10 -21% of elderly patients admitted to inpatient med/surg abuse

ETOH (may be higher)• In a recent study, 49% of patients in a nursing home met criteria for

lifetime ETOH abuse or dependence

RISK FACTORS FOR ETOH ABUSE IN ELDERLY

• Males • Major life changes or losses• Especially retirement or death of a spouse• Substance abuse earlier in life• Comorbid psyche disorders• Positive family history• Abuse of nicotine• Use/abuse of psychoactive drugs

LATE ONSET VS EARLY ONSETEARLY ONSET

• 2/3 of elderly alcoholics• Usually start in the 20’s- 30’s or even earlier• High percentage estranged from family• Often in socioeconomic decline• More likely to have chronic alcohol related medical problems• Usually more comorbid psyche disorders

LATE ONSET

• 1/3 of elderly alcoholics• Usually get into problems after 40 – 50• Generally have achieved higher level of education and income• A stressor often triggers the problem• Usually fewer medical problems related to the ETOH• Social support system is usually better• Usually more amenable to treatment• But also more likely to be overlooked

OTHER SUBSTANCE USE IN THE ELDERLY

• Including marijuana, cocaine, heroin, hallucinogens, and illicit use of prescription drugs

• Is really not known in the community setting• The older population is less likely to report problems than the

younger age groups• Physicians underrecognize the problem ( but more about that later)• In 2005, 0.5% of adults 65 and older reported illicit drug use• In 2006 it was 0.7%• However, patients in the 50 – 54 age group doubled their reporting

from 3.4 to 6.0% from 2002 to 2006

IN THE ER SETTING

• A 2001 study published in Addiction• 23.7% used benzos• 14.4 used opioids• 9.6% used barbituates• 19.8% used stimulants like cocaine and meth

PRESCRIPTION DRUG USE

• Prescription drug use in the elderly is much greater • Multiple doctors and often no “captain of the ship”• Older people take a lot of psychoactive drugs – and more so in

women – up to four times greater misuse • Women are more likely to become dependent if they are widowed,

less educated, lower income, poor health, and have reduced social support

ADVERSE EFFECTS OF DRUG USE/ABUSE

Most studies do not necessarily distinguish between use, abuse, and dependence

• An association between falls and benzos has been repeatedly shown

• Fractures seem to be much more common in those who use opioids• Elderly who use benzos chronically are more likely to develop

“Mobility” disability and disability in their ADLS• Long term benzo use is related to early cognitive decline• Increased risk of urinary retention, MVAs, and pressure ulcers with

sedative /hypnotics in the LTC settings

THE STORY OF MW

• HX: 75 yo female admitted to LTCF after right total knee replacement.

• PAST HX: multiple failed backs surgeries, DM, RA, , Chronic cellulitis of lower extremity, has Morphine intrathecal pump allergies to multiple drugs including codeine, demerol, oxycodone, sulfa, and quinolones

• SOCIAL HX: retired RN and nursing home administrator. Lives at home with demented husband

MED LIST

• Intrathecal pain pump• Xanax 1mg in am 0.5 at noon, and 2mg at hs• Lortab 10-500 q 4 hours prn pain• Arthrotec • Nexium • Synthroid• Lipitor• Niferex• Lasix • Potassium supplement• Starlix• Plus 20 other routine and prn meds

NH COURSE

• The first day the patient seemed pleasant and comfortable. She started to participate in physical therapy but complained of a lot of pain. On day #2,one of the nurses noticed that the patient’s “demented” husband had driven over to the NH and was giving the patient some medication. When the patient was confronted about this, she stated that she was still in a lot of pain and needed more medicine. The husband had brought over Percocet 10 as well as flexeril. The patient was examined by the physician and the wound looked very good. She was advised to tell the nurses that she was having pain and not to bring medicine from home. The same thing happened on day #3. Again she was advised this was against the NH policy. Again she was examined to r/o other problems. Two hours later she requested to be transferred back to the hospital.

WHY DO MDs AND HEALTH CARE WORKERS HAVE PROBLEM DIAGNOSING SUBSTANCE ABUSE IN THE ELDERLY?

Faulty assumptions and myths ie the alcoholic as a bum

Denial by the abuser, family and MD

May be fewer social signs of problem like losing a job or legal difficulties

Substance abuse problems may be overshadowed by the other medical problems

The physical and/or cognitive decline caused by chronic substance may be thought of as the “ravages of aging”

Substance abuse problems are the “Great Masquerader”

OTHER REASONS FROM THE PATIENTS

• Increased denial (not necessarily just the elderly with this)• Decreased private insurance payment for mental health treatment• Multiple comorbidities including other psyche issues• Increased use of legal psychotropic drugs• Lack of good population based studies in the elderly

SO WHY ARE THE “BOOMERS” DIFFERENT THAN OTHER AGING POPULATION COHORTS?

• Higher population• The dynamics of the “Me” generation – rightly or wrongly are

accused of being more self centred and used to having things their way

• Higher risk of substance abuse in this cohort than in others previously

• Certainly more accepting of “Sex, Drugs, and Rock and Roll”

PROJECTED DRUG USE IN THE AGING “BOOMERS”

• From 1999 to 2020 in people 50 and above• Marijuana use from 1% to 2.9% - 719,000 to 3.3 million• Use of any illicit drug from 2.2% to 3.1% - 1.6 to 3.5 million• Non medical use of psychotropic drugs from 1.2% to 2.4% -

911,000 to 2.7 million

• Collier, James P et al, Annals of Epidemiology Vol 14 #4 April 2006 pg 257-265

AND WHAT ABOUT CHRONIC PAIN?

• Very common in the elderly• 25 – 50% in the community dwelling• 40 – 80% in the nursing home setting• 1/5 65 yo and older take analgesics several times a week• Of these, 3/5 take prescription pain meds• Chronic pain causes all sorts of complications like depression,

decreased socialization, sleep disturbance, and impaired mobility

SUGGESTED GUIDELINES FOR LONG TERM OPIOID USE

• Patients considered for long term opioid use should have a well defined source of pain

• Patients with ill-defined MS syndromes are poor candidates for opioid use

• Many patients, if not all, need psychosocial assessment• Patients with current or previous history of substance careful psyche

assessment and close followup• All patients with chronic opioids should have a regular assessment

of pain and functional status

NSAIDS AND COX 2 INHIBITOR

• Increased risk of kidney and liver problems• Increased risk of GI bleed• Increased risk of fluid and Na retention• Drug – drug interactions

OTHER MEASURES

• Acetaminophen• Physical therapy• Nonpharmacologic methods

SUMMARY POINTS

• The “Boomers” are coming• The absolute numbers of elderly with substance abuse problems will

be going up• These disorders are underreported and misdiagnosed for a number

of reasons• There are a lot of research opportunities concerning these disorders

in the elderly. Especially in relation to long term care living arrangements.

• Comorbidities and drug interactions are very common in the elderly• Substance abuse is associated with cognitive decline

Winkel, Vicki and Byron Bair Substance use disorders in older adults Clinical Geriatrics Jul, 2008 ppg 25-29

Rigler, Sally Alcoholism in the elderly American Family Physician Vol 61#6 March 15, 2000

Oslin, David Evidence based treatment of geriatric substance abuse Psychiatric Clinics of North America Vol 28 issue 4 dec 2005 noted on MD Consult

Christensen, Helen et al Prevalence, risk factors and gtreatment for substance abuse in older adults Current Opinion in Psychiatry Vol19(6) Nov 2006 ppg 587-592

Finfgeld-Cornett, Deborah Treatment of substance misuse in older women Journal of Gerontological Nursing Vol 30(8) Aug 2004 ppg 30-37

• Enoch, Mary Anne and David Goldman Problem drinking and alcoholism: diagnosis and treatment American Family Physician feb 1. 2002

• Hasin, Deborah et al Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic survry on alcohol and related conditions Archives of General Psychiatry vol64(7) July 2007 ppg 830-842

• Mcgrath A et al Substance misuse in the older generation Postgraduate Medical Journal Vol 81(954) April 2005 ppg 228-231

• McInnes, Elizabeth and Janet Powell Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed? British Medical Journal Vol 308(6926) Feb12, 1994 ppg 444-446

• Colliver, James et al Projecting drug use among aging baby boomers in 2020 Annals of Epidemiology Vol 16 issue 4 April 2006 ppg 257-265

• Patterson, Thomas et al The potential impact of the baby boom generation on substance abuse among elderly persons Psychiatric Services 50:1184-1188 Sept 1999

• Schmader, Kenneth and Alison Moore Prescription use, misuse,and abuse in older persons Annals of Long term care vol 11 issue 8 Aug 2003 ppg 37-42

• Joseph CL Alcohol and drug misuse in the nursing home Int Journal of Addiction Nov-Dec 1995 30 (13-14) 1953-84

• Klein,WC and C Jess One last pleasure? Alcohol use among elderly people in nursing homes health Soc Work 2002 Aug 27(3) ppg 193 -203

• O’Connell, Henry et al Alcohol use disorders in elderly people – redefining an age old problem in old age British Medical Journal Vol 327(7416) Sept 20 2003 ppg 664-667

• Paterniti, Sabrina et al Long term benzodiazepine use and cognitive decline in the elderly: the epidemiology of vascular aging study Journal of Clinical Psychopharmacology vol 22(3) June 2002 ppg 285-293

• Menninger, John Assessment and treatment of alcoholism and substance related disorders in the elderly Bulletin of the Menninger Clinic vol 66 no 2 spring 2002 ppg 166-183