Transcript Substance Use Disorders in Geriatric Patients

SUBSTANCE USE DISORDERS IN
GERIATRIC PATIENTS
Steven H. Madonick, M.D.
Yale University School of Medicine
New Haven, CT
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Substance Use Disorders (SUDs) in Geriatric
Patients Are Often Overlooked
• Substance users stereotyped as young
• Physicians miss substance use
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Geriatric Patients with SUDs are Often
Evaluated by Physicians
• Frequent evaluation an opportunity to screen
• Higher rates of SUDs in medical facilities
• Substance use complicates medical illnesses
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Subjects to be Covered in this Lecture:
• Increased substance use effects in geriatric
patients
• Description of SUDs in geriatric patients
• Screening for SUDs in geriatric patients
• Treatment and rehabilitation strategies in
geriatric patients
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Increased Substance Use Effects in Geriatric
Patients
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Increased BAC because:
• Decreased lean body mass
• Decreased total body water
• Decreased gastric alcohol
dehydrogenase
Alcohol and drugs more intoxicating in
geriatric patients
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Description of Alcohol Use Disorders in
Geriatric Patients: Prevalence
• 16% Men > 2 drinks per day, 15% Women >
1 drink per day
• Up to 31% men, 21% women > 3 drinks daily
in retirement communities
• Up to 21% alcohol dependence in medical
patients
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Alcohol Use Disorders (AUDs):
Early Onset (< Age 60)
• About 2/3 of geriatric AUDs
• Greater financial, legal and social problems
than later onset
• Heavier drinkers than later onset patients
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AUDs: Late Onset ( > Age 60)
• About 1/3 of geriatric AUDs
• Aging social drinkers more intoxicated with
same dose
• Cognitive disorder in heavy drinkers
• Social drinkers who increase drinking after
losses
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I. Medical Complications of Alcohol in
Geriatric Patients
• Cirrhosis: 60% 1 year death rate > age 60
vs. 7% in younger patients
• Heart Effects
• Women more susceptible
• Alcoholic women 4 X coronary artery disease vs. nonalcoholic women
• Atrial fibrillation common, “holiday heart” increases risk
• Increased stroke risk
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II. Medical Complications
• Increase in cancers of liver, esophagus,
nasopharnx and colon
• Thrombocyopenia, macrocytosis
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III. Medical Complications
• Neurologic
• Increased dementia, Wernicke’s
encephalopathy, Korsakoff’s psychosis
• Psychiatric
• Alcohol-induced mood disorder
• Pseudodementia from mood disorder
• Suicide
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Other SUDs
• Less data than AUDs
• Low prevalence of illicit drug use
• Few IV drug users survive
• Reduced access to illicit substances
• High prevalence of prescription drug use disorders
• 25% using psychotropic medications
• This includes benzodiazepines and opioids
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Importance of Physician Screening
• Medical complications
• Doctors in an important position to intervene
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DSM-IV Criteria for Substance Dependence
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Maladaptive pattern and 3 or more of the following in a 12
month period:
Tolerance (often reduced in geriatric patients).
Withdrawal (often delayed, with mental status changes in
geriatric patients).
Greater amount of use or longer duration than expected.
Unsuccessful efforts to reduce use.
Large amount of time obtaining, using and recovering from use.
Important activities reduced or given up.
Continued substance use despite its aggravation of physical or
psychological problem.
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DSM-IV Criteria for Substance Abuse
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Maladaptive use and 1 of the following in 12
month period:
Failure to fulfill obligations at work school or
home.
Recurrent use when physically hazardous.
Recurrent related legal problems.
Continued use despite recurrent social or legal
problems.
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State Markers that Suggest Alcoholism
• Gamma-glutamyl transferase (GGT): Sensitivity of
70% to 80% if 6-8 drinks per day consumed
• Mean corpuscular volume (MCV) greater than 90
cubic microns consistent with alcohol dependence
• Carbohydrate deficient transferrin (CDT): Social
over 14 units/liter and alcohol dependence over
20-30 units/liter
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Questionnaires that Raise Suspicion of
Alcohol Abuse or Dependence
• MAST-G is unique in that it is specific to
geriatric alcohol use disorders.
• AUDIT is comprehensive.
• CAGE and TWEAK are quick but have
limited sensitivity and specificity.
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Screening for SUDs other than AUDs
• Methods less developed than for AUDs
• Signs for concern (not specific) include:
• doctor shopping
• drug-seeking behavior
• decreased motivation
• trouble sleeping
• poor self care
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Treatment of SUDs
• Identification
• Intervention
• Detoxification
• Rehabilitation
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Identification
Doctor’s office, clinic and hospital
extremely important sites for identification
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Intervention in Geriatric patients
• Involve adult family members.
• Denial by family and peers.
• Reduced mobility.
• Losses and social isolation.
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Brief Intervention
• Two to three 10-15 minute counseling
sessions
• Identify problem, consequences and
formulate treatment plan.
• Non-confrontational and supportive.
• Tailored to individual needs and goals.
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I. Alcohol Detoxification Concerns in
Geriatric Patients
• Confusion (rather than tremor) early
withdrawal sign
• Duration of withdrawal/hallucinosis increased
• Rule out DTs in confused elderly
• Replace electrolytes and nutrients
• Short acting benzodiazepines (lorazepam)
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II. Alcohol Detoxification Concerns in
Geriatric Patients
• Severe withdrawal or medical illness
managed inpatient
• Otherwise outpatient with family support
• Monitor symptomatology with Clinical Institute
Withdrawal Assessment for Alcohol (CIWAs)
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General Overview of Alcohol
Detoxification
• Supportive treatment
• Benzodiazepine taper
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Opioid Detox
• Supportive Treatment
• Medication
• Clonidine
• Methadone taper
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I. Rehabilitation Strategies for Geriatric
Patients
• Psychotherapy
• Individual for substance use and social
needs from losses and isolation
• Group, family and network therapy for
damage to family and peer relationships
from substance use.
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II. Rehabilitation Strategies for Geriatric
Patients
• Optimized by age-specific treatment
• Must fill the time formerly spent using
substances
• Senior centers often have alcoholics
anonymous (AA) groups and support
socialization
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Pharmacotherapy in Rehabilitation:
A Limited Role
• Naltrexone reduces alcohol reinforcing effects
but does not clearly promote abstinence,
monitor liver transaminases
• Disulfiram problematic with potential drug
interactions and co-morbid medical conditions
• Acamprosate may modestly increase
abstinence rates but GI upset, FDA approval
pending
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Summary
• Physicians have a strategic role in detection
• Geriatric patients have vulnerability to medical
complications of substance use
• There are clinical tools and strategies for detecting
SUDs in this population
• Effective biopsychosocial treatment and rehabilitation
benefit from physician input and family support
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