(Slide 1) SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTS

Steven H. Madonick, M.D.

Yale University School of Medicine

New Haven, CT

I. Introduction: Important reasons to teach medical students about the diagnosis and treatment of Substance Use Disorders (SUDs) in geriatric patients (patients over age 60).

(Slide 2) A. SUDs in geriatric patients often not recognized (1).

1. Stereotypes often prevent the consideration of substance use as a cause of disability in the elderly.

a. Substance users are often portrayed in the media as young men or women.

b. Thus, substance intoxication or withdrawal are often mistaken for health problems or dementia more commonly associated with the elderly.

2. Physicians are less likely to diagnose SUDs in geriatric patients compared to other patients (2)

3. High utilization of medical services by geriatric patients provides a unique opportunity to better screen these patients for SUDs.

(Slide 3) B. SUDs are common in medical settings and often result in substantial morbidity, disability and mortality (3).

1. High rates of SUDs in geriatric patients presenting for medical treatment are an important opportunity for intervention (4, 5, 6)

2. SUDs cause/complicate geriatric medical disorders

(7).

3. With high rates of medical disorders and medications, geriatric patients may have more complications when SUDs develop.

(Slide 4) C. This lecture will cover the following subjects:

1. Morbidity from substance use that is specific to elderly patients.

2. Description of SUDs that are common in geriatric patients.

3. Approaches for physicians to improve their diagnosis of SUDs.

4. Comprehensive biopsychosocial treatment and rehabilitation strategies in elderly patients with SUDs.

Main Point: Doctors can make a big difference in screening, prevention, diagnosis and treatment because of their training and their strategic position in the healthcare system that is heavily used by older people.

II. Medical morbidity specific to geriatric patients with SUDs

A. Physiologic changes with aging increase problems even with low amounts of substance use (8).

(Slide 5) 1. Decreased lean body mass and total body water increase blood alcohol concentration (BAC).

2. Age-related decrease in gastric alcohol dehydrogenase (first step in alcohol metabolism) increases BAC.

3. Liver oxidation decreases with age, increases BAC.

4. Sensitivity of brain to depressants and opioids increases with age so substances more sedating.

5. Alcohol metabolism affected by common prescription medications and their use (such as benzodiazepines).

6. Alcohol metabolism reduced by medical conditions (such as liver disease).

B. Alcohol intoxication and withdrawal may complicate health problems

1. Increased blood pressure

2. Increase pulse

3. Psychological distress and discomfort

C. Medication interactions in SUDs in geriatric patients

1. > 4 medications taken by geriatric patients (9).

2. Interactions between medications and other substances

a. Benzodiazepines and perhaps alcohol may induce or inhibit liver enzymes. (10)

b. May alter blood levels and effectiveness of meds

Major Point: Many of the above consequences are avoidable or reversible with abstinence.

III. Description of SUDs in geriatric patients

A. Alcohol use disorders in geriatric patients

(Slide 6) 1. Prevalence.

a. Men > Women, 16% men over 65 consumed > 2 drinks per day, 15% females consumed > 1 drink per day (11).

b. Quite variable data on daily drinking in retirement communities: 8% daily drinking in Wisconsin retirement community but 31% men, 21% Women > 3 drinks per day in California retirement community.

Say, “this does not mean they are alcohol dependent, but still is a cause for concern.”

c. Consistently high rates of alcohol use disorders in medical settings: alcoholism in 21% geriatric inpatients, 14% geriatric emergency room patients, 8.6% prevalence of alcohol dependence in geriatric outpatients (12, 13, 14, 15).

2. Patterns of alcohol use disorders.

(Slide 7) a. Early Onset (before age 60) includes two thirds of geriatric patients with alcohol use disorders who avoid severe complications of alcohol use disorders and reach advanced age (16).

i. More likely to be isolated.

ii. Legal, financial and vocational problems.

iii. Heavier drinking compared to later onset.

(Slide 8) b. Late Onset (after age 60) in one third (17)

i. Heavy social drinkers no longer function normally due to a cognitive disorder.

ii. Social drinkers who become more vulnerable to the effects of the same dose of alcohol with aging.

iii. Social drinkers who increase their frequency of drinking after retirement or a loss of structure in their life (due to loss of spouse, job, health, physical mobility, change in living situation, etc.).

c. Demographics of Early Onset and Late Onset groups similar except that women are higher % of late onset.

B. Medical problems exaggerated in geriatric alcoholics (18).

(Slide 9) 1. Gastrointestinal disorders are more serious.

a. Cirrhosis 60% first year mortality over age 60 compared to 7% under age 60 (19).

b. Malabsorption impairs uptake of medications, vitamins, minerals.

2. Cardiovascular effects.

a. Alcohol-related cardiomyopathies are 20% to 30% of all cardiomyopathies (20).

b. Women more sensitive to effects of alcohol on heart (21).

c. Women alcoholics have 4X the rate of coronary artery disease.

d. Atrial fibrillation most common arrhythmia in older adults is also most common arrhythmia in alcoholics (holiday heart) (22).

e. 4X risk of stroke (23).

(Slide 10) 3. Alcohol, tobacco, increase cancers of liver, esophagus, nasopharnx, and colon (24, 25).

4. Toxic to bone marrow with decreased platelets and increased MCV.

5. Metabolic disturbances: hyponatremia, hypocalcemia, hypomagnesemia, hypophosphatemia, gout.

(Slide 11) 6. Neurologic Complications:

a. Dementia worsened by alcohol use(26).

i. Wernike’s Syndrome-thiamine deficiency causes confusion, ataxia, nystagmus and paralysis of extraocular muscles.

ii. Korsakoff’s Psychosis-thiamine deficiency causes poor memory with confabulation.

b. Falls, acute and chronic subdural hematomas complicated by increased osteoporosis from alcohol.

7. Psychiatric complications (27)

a. Major Depression with alcohol use confused with dementia and complicates its diagnosis.

b. Greatly increased risk for suicide.

C. SUDs other than alcohol in geriatric patients (28)

1. Less data about illicit drug use and medication use disorders.

(Slide 12) 2. Lower prevalence of illicit drug use disorders than the general population

a. Many heroin and cocaine abusers do not reach old age due to HIV disease, liver disease, vascular disease and trauma.

b. Reduced access to illicit drugs for geriatric patients.

3. Greater prevalence of prescription drug use disorders than the general population.

a. 25% using psychotropic drugs including benzodiazepines.

b. High use of pain medications including opioids.

Main Point: Substance use patterns and consequences in geriatric patients differ substantially from those in the general population.

(Silde 13) D. Reiterate to medical students the central importance of medical doctors in surveillance, detection, and diagnosis of substance use disorders in geriatric patients.

IV. Screening geriatric patients for SUDs at office.

(Slide 14) A. DSM-IV dependence: more reliable and valid. A maladaptive pattern of use associated with clinically significant impairment or distress with 3 of the following over the same 12 month period:

1. Tolerance (often reduced in geriatric patients).

2. Withdrawal.

3. Greater amount of use or longer duration of use than expected.

4. Unsuccessful efforts to reduce use.

5. Large amount of time obtaining, using and recovering from use.

6. Important activities reduced or given up.

7. Continued substance use despite its aggravation of physical or psychological problem.

(Slide 15) B. DSM-IV criteria: A maladaptive pattern of use associated with clinically significant impairment or distress involving 1 of the following over the same 12 month period:

1. Failure to fulfill obligations at work school or home.

2. Recurrent use when physically hazardous.

3. Recurrent use-related legal problems.

4. Continued use despite persistent or recurrent social or legal problems.

(Slide 16) C. Some state markers are useful for raising suspicion of an alcohol use disorder but are not diagnostic of alcoholism (29).

1. Gamma-glutamyl transferase (GGT): First liver enzyme to change because of actual induction by alcohol. Sensitivity 70% to 80% if regularly consume 6-8 drinks per day (SGOT and SGPT are elevated with hepatocyte damage).

2. Carbohydrate deficient transferrin (CDT): Protein for iron transportation, 80% specificity for social drinking if over 14 units/liter and for alcohol dependence over 20-30 units/liter

3. Mean corpuscular volume (MCV) of greater than 90 cubic microns.

(Slide 17) D. Some questionnares also raise suspicion of problem drinking or alcoholism, but only a diagnostic interview establishes true abuse or dependence.

1. MAST-G (30): Only questionnaire specific to geriatric patients. 24 questions about alcohol use, sensitivity=93.7%, specificity=78.1%.

2. AUDIT (31) 10 questions about alcohol use on a 4 pt. scale.

3. CAGE (32, 33), 4 questions, and TWEAK, 5 questions, (37) are quick and easy but limited sensitivity and specificity.

(Slide 18) E. Screening methods for prescription medication and other SUDs less well defined include: doctor shopping, drug seeking behavior motivation loss, trouble sleeping, marital discord and difficulties with self-care.

V. Treatment and Rehabilitation strategies and their effectiveness in geriatric patients.

(Slide 19) A. Treatment is divided into overlapping topics of: identification /intervention/detoxification/rehabilitation.

(Slide 20) B. Re-emphasize: An extremely important place for the identification

of SUDs in geriatric patients is in the doctor’s office, clinic or hospital using the screening tools described along with appropriate diagnostic interviewing (34. 35, 36)

(Slide 21) C. Unique aspects of intervention in the geriatric patients involve:

1. Need to involve adult family members.

2. Denial by family and peers.

3. Reduced mobility.

4. Social isolation due to loss.

(Slide 22) D. Intervention and early rehabilitation may both benefit from fairly brief interventions (37).

1. Two to three 10-15 minute counseling sessions

2. Identify problem, consequences and formulate treatment plan.

3. Non-confrontational and supportive, tailored to individual needs and goals.

E. Detoxification.

(Slides 23, 24) 1. General overview of alcohol withdrawal symptoms:

a. Tremor

b. Anxiety

c. Autonomic excitement with increased pulse, blood pressure and temperature.

d. Seizures-rare < 5%.

e. Hallucinosis-rare.

f. Delirium-rare.

(Slide 25) 2. General overview of detox approaches for alcohol.

a. Supportive treatment.

b. Benzodiazepine taper.

3. Alcohol detox of geriatric patients (38).

a. Confusion rather than tremor is often the first sign of withdrawal.

b. Duration of withdrawal increases with age, including any associated hallucinosis.

c. Delirium tremens is in the differential diagnosis of any newly confused older person.

d. Older dependent drinkers without history severe withdrawal and co-morbid medical conditions may be managed at home with support of family members and the availability medical intervention.

f. Older dependent drinkers with severe withdrawal and/or co-morbid medical conditions are best monitored in the inpatient setting.

i. Replacement of electrolyte and nutritional deficits.

ii. Short acting benzodiazepines for withdrawal to avoid increased cognitive problems (lorazepam for patients with liver dysfunction; it does not rely on hepatic clearance).

iii. Monitor withdrawal symptomatology with Clinical Institute Withdrawal Assessment for Alcohol (CIWAs) (39).

4. Application of detox principles to the special case of opiod dependence.

(Slide 26) a. Supportive treatment

b. Medication treatment of withdrawal symptoms.

i. Clonidine alleviation of acute withdrawal symptoms.

ii. Methadone taper if possible.

(Slide 27) F. Rehabilitation strategies to support long-term abstinence in geriatric patients (40, 41).

1. Psychotherapy. (42).

a. Individual to address both social needs as well as cravings and triggers associated with drinking.

b. Group, family and network therapy to address potential damage to family and peer relationships from substance use.

(Slide 28) 2. Optimized by age-specific treatment

a. Must include ways to fill the time void formerly spent using.

b. Senior center involvement in rehabilitation supports new interests, peer support and socialization to fill the void left by abstinence.

c. Many senior centers have age-specific Alcoholics Anonymous (AA) groups on site.

(Slide 29) G. There is a limited role of pharmacotherapy in rehabilitation.

1. Naltrexone reduces reinforcing effects of alcohol but does not clearly promote abstinence, must follow liver transaminases (43).

2. Disulfiram problematic, no trials because of potential drug

interactions and exacerbation of co-morbid medical conditions (44).

3. Acamprosate (an NMDA-receptor antagonist) has been tested in Europe and may have a modest effect on retaining patients in treatment and increasing abstinence rates (45).

(Slide 30)

VI. Summary

A. Strategic role of the medical community in detecting substance use in geriatric patients.

B. This is important in view of the special vulnerability of geriatric patients to the most severe complications of substance use.

C. Clinical tools and strategies for detection of SUDs in geriatric patients.

D. Biopsychosocial treatment and rehabilitation strategies for SUDs in geriatric patients

1. Effective and facilitated by physician and family (support system) input.

2. More specific to alcohol use disorders than other SUDs.

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