Transcript Alcohol and Drug Use Disorders in Older Adults

Alcohol and Drug Use
Disorders in Older Adults
Burns M. Brady, MD, FASAM, ABFP, FAAFP
Older Adults
Definition ---- range
50 years and older
Four generations
GI generation 1901 – 1924 (boot straps)
Current largest group
Silent generation 1925 – 1945 (better living through chemistry)
of older adults
Baby boomer generation 1946 – 1964 (tune in turn on drop out)
X generation 1965 – 1984 (thirteenth generation)
Social and cultural effects on each generation
Social and cultural effects on the significant adults who birthed and reared
each generation
Alcohol – The Domesticated
“recreational beverage of choice”
“Adjunct to better digestion, lipid control, low risk
tranquilizers, and sleep inducer. Initial drug for ED and
premature issues of sexual performance”
Drugs – Illegal or Prescribed or OTC
None are perceived as recreational by the vast majority of
older adults. Yet 30% of drugs (prescription and OTC) are
consumed by adults 60 and older (10% of population).
I.
ALCOHOL
Pharmacological Properties
A. Absorption – water soluble
older adults – less extracellular fluid and higher body fat.
Therefore h blood levels per amount consumed than
younger adults.
B. Oxidization – liver – by ADH (alcohol dehydrogenase)
Slow and constant. Therefore a definite limit must be
placed on amount consumed per unit of time or face
significant consequences, i.e.
1. binge drinking, all effects in older adults (falls –
cognition, all physical effects)
2. Gastric secretions
10% - 40% alcohol – generally ok
40% and higher – erosive gastritis
3. Change in ratio of nicotinamide adenine
dinucleotide (NAD) to its reduced form (NADH).
This h lipid synthesis by the liver with an h of fatty
tissue in the liver.
Accumulation of fat with protein initially usually
causes no problem but eventually cannot be reversed
and cirrhosis occurs.
Alcoholic fatty liver and cirrhosis are diseases of
middle and late life. (exceptions – those with poor
nutrition and greater than severe amount consumed)
4. Osteomalacia – 2o to i hepatic
metabolism of Vitamin D to its more active form
5. Cardiomyopathies – direct toxic effect of alcohol
6. Erosive gastritis – lesions in stomach – bleeding
anemia
7. i folic acid and B12 absorption and thiamine
resultant neuropathies resultant anemias –
MCV h with macrocytic anemias
8. Nutritional requirements – older adults require
more protein. Chronic alcoholism in this
population exhibits muscle wasting hypo
protenemia and edema with greater severity than
in the younger patient.
9. Interaction of aging – alcohol – dementia
Intelligence – relatively un-affected
Deficits – clusters – involving memory and
information
In contrast with Alzheimers Disease, those with
alcoholic dementia who abstain may exhibit stable
or improved memory and motor performance
Alcoholic Amnestic Dementia
(Wernicke – Korsakoff disease)
Etiology – thiamine deficiency and/or direct toxic
effect on brain tissue (widespread neuronal)
chronic end stage
10. Sleep problems.
The older adult with alcohol use problems will
reverse this. With abstinence major
consideration is sleep Rx with combination
sedative hypnotics and some other
medications.
ALCOHOL
II.
Diagnostic Workup
A. Center for Substance Abuse Treatment’s Panel on substance abuse
among older adults recommends that every 50 year old (and older)
person should be screened for alcohol and prescription drug use
disorders as a part of any routine physical examination. All questions
should be normalized as a routine and necessary part of every
history and physical exam.
B. NIAAA recommendation (1995) – no more than one drink per day
and a maximum of two drinks on any drinking occasion
C. Self report may be unreliable 2o
1. Medical issues
2. cognitive compromise
3. minimize or deny
D. Collateral info critical – may not be totally reliable but
absolutely necessary. Source – anyone involved with the
patient frequently and closely.
E. General health questions (review pharmacological properties
in this presentation) - falls, bruises, cuts, nausea, vomiting,
abdominal pain, amnesia (blackouts), neuropathics (stocking –
glove)
F. Psychiatric questions – anxiety, depression, delusions, and
hallucinations, paranoid ideation, suicidal ideation
G. Screening tests
1. CAGE – not as reliable in (OA)
2. MAST geriatric version
H. Genetic and adolescent/adult onset of alcohol use and/or
disorder in past drinking history
1. Any significant history in kin – especially first degree
relatives
2. Type two (2) highly heritable – adolescent
Type One (1) milieu limited – adult
Mayo Clinic study 41% >65
I. Laboratory evaluation – EKG, chest x-ray, SMA24, amylase,
lipase, CBC, urine, magnesium, B12, folic acid, thiamine, stools
occult blood.
Cognitive testing – usually at least (if possible) 2 weeks
abstinence.
Screening simple
1. Person, place, time, situation
2. Abstract thinking rolling stone
Screening detailed – neuropsychiatric evaluation
ALCOHOL
III. Treatment
A. Detoxification
Hospitalization – full protocol with thiamine, mg SO4, appropriate
fluid control and medical detox (usually long acting benzodiazepine
or phenobarb). Length of detox variable at control of physician in
charge
Full and frequent communication with family and appropriate
significant others from admission to final placement
(recommendation). This is critical whether hospitalizations and
detox is felt necessary or not
B. Individual or agency doing the evaluation should be experienced in
gerontology or know the resources (available) who are
C. Intervention
The full spectrum of this resource will be available from
preceding statement B
D. Rehabilitation
1. Short term
2. Long term
initial Rx
3. Outpatient
considerations
4. Residential
All directed to educating the patient about his/her
disease in the safest and most effective environment
(know your resources)
5. Long-term Rx
12 step recovery model of alcoholics anonymous is the
mainstay: Critical this be in concert with knowledgeable
medical, psychiatric, community, family coordination.
5. (cont’d) References:
“Not as Prescribed” author Harry Hartounian, MD
“Textbook of Geriatric Psychiatry” 3rd edition
Dan G. Blazer, MD, PhD
David Steffens, MD, MHS
Ewald W. Gusse, MD
American Psychiatric Publishing, Inc.
6. Special attention will be required for certain patients, ie,
significant cognitively impaired,
significant physical limitations
(specific case management) considerations
DRUGS
I.
Illegal (illicit)
A. The use of illicit drugs, i.e., cannabis, cocaine, meth, MDMA
(ecstasy), etc. are generally not considered a common
problem in the older adult. (less that 1%)
THC is the exception.
One should always suspect illicit drug use in the presence
of alcohol use disorder and/or atypical psychiatric symptoms
in the older adult
DRUGS
II. Prescription
A. 25% of older adults use psychoactive prescription drugs and are at
risk for development of drug use disorder
1. cardiac meds
2. antihistamines
3. antidepressants
4. antianxiety
5. hypnotics (Ambien)
6. narcotics (Ultram)
7. mood stabilizers
If you are the patient discuss this with your physician. If you are the
caregiver of an older patient do the same.
B. 50% (estimated) of nursing home patients receive psycotropic
meds, i.e., benzos, hypnotics, analgesics.
C. 20% of older adults admitted to a med-surg hospital have a
drug use disorder
D. Three patterns of use/misuse
overuse
underuse
erratic use
The potential of above significantly increased by the older
adult with mental and/or psychiatric compromised mental
capacity.
DRUGS
III. Over-the-counter
A. 65% of older age adults use OTC drugs routinely
B. Sensitivity to all drugs is increased in older adults (fat soluble)
C. Many OTC drugs with CNS activity were originally script drugs.
When placed OTC the recommended dosage was significantly
decreased. In the older age adult – with and without
compromised mentation – this frequently is not known or
considered, i.e., arthritis meds, antihistamines, pain (Tylenol),
etc.
DRUGS
IV. Treatment
A. Review treatment of alcohol use disorder
B. Special consideration
Benzodiazepines
low dose
withdrawal
high dose
syndromes
References:
David Smith, MD
Donald Wesson, MD