Transcript Reynolds GeriEM Lecture Title Here

Grandma and Grandpa
Under the Influence
Stephen M. Scheinthal, D.O., FACN
Associate Professor, Psychiatry
Chief Geriatric Behavioral Health
UMDNJ-SOM
Stratford, NJ
Golden Years!
If you don’t ask…
• 78 yo female
• CC: “I feel lonely.”
• Hx: Depression, Anxiety, Insomnia, HTN,
DJD, Hyperlipidemia.
• Social: Lives alone, divorced (ex still alive), 3
kids, 12 grandkids.
– Retired secretary
If you don’t ask ...
• Presents to ED with hallucinations
• Medical workup negative
– UA neg
• UDS
– Cannabis
– Opiates
• “You never asked!”
Quick Facts
• 1 to 15 % of community older adults drinking problems
• 12% report binge drinking
• 2% report using an illicit drug
– Marijuana most common 1%
– Prescription drug abuse 0.7%
– Cocaine 0.2%
Bartels SJ, Blow FC, Brockman LM, Van Citters AD, Substance abuse and Mental
Health Among Older Americans: The State of the Knowledge and Future
Directions, SAMHSA 2005.
Substance Use and the Older Adult
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Use a high number of prescription drugs
Poor health outcomes
Higher health care utilization
Increased complexity
Increased disability
Compromised quality of life
Increased caregiver stress
Increased mortality
Increased suicide risk
Growing Problem
Differ from their younger counterparts
Don’t look to get high
Biggest Problems:
Alcohol Misuse
Medication Misuse
Combined these effect approximately 20% of
older adults
Blow FC, Bartels SJ, Brockman LM, etal. Evidence Base Practices for
Preventing Substance Abuse and Mental Health Problems in Older Adults,
Who Uses Alcohol More?
• Older Men?
• Older Women?
Men tend to drink alcohol more.
Women tend to use pills more.
Older Adults are uniquely at risk
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Rates of illegal drug use is low
Higher number of prescription drugs
Higher number of over the counter medications
High risk of interaction between alcohol and
prescription drugs, especially psychoactive drugs
– Benzodiazepines
– Barbiturates
– Antidepressants
Alcohol Misuse
20-30% of people 75-85 years old have experienced drinking
problems
National Institute on Alcohol Abuse and Alcoholism 2007.
Alcohol Misuse - Theories
• Social Learning Theory
Social Activities with friends and families associated
with alcohol use is a predictor of excessive use.
• In older adults
• Activities and events with alcohol for social reasons is
associated more alcohol consumption
• Family and friends who drink are associated with higher and
more frequent and heavier alcohol use
Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and
drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.
Alcohol Misuse Theories
• Stress and Coping Theory
– Problematic life stressors lead to use
– Coping Based Alcohol use
– Self Medicate to decrease depression and anxiety
• Older Adults
– Site personal reasons for drinking
• Grief
• Anxiety
• Pain
Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and drinking
problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.
Alcohol Misuse Theories
• Social Control Theory
– Social bonds, family, friends and religion help to
regulate patient toward socially appropriate behavior
– When bonds are weak or absent, will engage in risky
behaviors such as excessive drinking
– Financial resources may be associated with increase
purchasing of alcohol.
• Older Adults
– Financial resources may be associated with increase
use.
Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and
drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.
Alcohol Misuse Theories
• Baseline Alcohol Consumption/ Life History
– Correlates with use in old age
– Alcohol use stays stable in late life
– Efficacy of AA in older adults not clear.
Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history
predictors of older adults’ high-risk alcohol consumption and drinking
problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.
Alcohol Misuse
• CAGE
– Lifelong measure
– Not high validity in the elderly
• MAST-G and SMAST-G
– More specific to the geriatric population
• ARPS (Alcohol Related Problems Survey)
– More sensitive than MASTS or CAGE
Blow FC, Bartels SJ, Brockman LM, etal. Evidence Base Practices for Preventing
Substance Abuse and Mental Health Problems in Older Adults, SAMHSA 2005.
Medication Misuse
Medication Misuse
• High use of prescription drugs (2 – 6)
• High use of over the counter medications (2-3)
• Combined alcohol and prescription drug use
may affect 20% of older adults.
Bartels SJ, Blow FC, Brockman LM, VanCitters AD, Substance Abuse and Mental
Health Among Older Americans: The State of the Knowledge and Future
Directions, SAMHSA, 2005
Medication Misuse
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Over use
Underuse
Irregular use
Prescribing Cascades
Medication Misuse
• Prescribing Cascades
– Treating side effects of one drug with another
– Common Cascades
• ACHEI – Benzodiazepines/antipsychotics/sedatives
• Antipsychotics – Benzodiazepines/stimulants
• SSRI – Benzodiazepines/antipsychotics/sedatives
Medication Misuse
• Vulnerable population
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Lonely
Decreased mobility
Impaired sensory function
Chronic pain
Poor physical health
Poor financial status
Poor social support
Medication Misuse
• Drug-Drug Interactions
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Falls
Depression
Cognitive issues
Hepatic disease
Cardiac disease
Sleep problems
Medication Misuse
• Alcohol-Drug Interactions
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Falls
Cognitive problems
Delirium
Depression
Increased medical co-morbidities
Medication Misuse
• Other interactions of concern:
– Barbiturates
– Antidepressants
– Benzodiazepines
• Benzodiazepines and sedatives are associated
with a 36% mortality rate in the older adult.
Barclay L, Lie D, Medication for Insomnia or Anxiety Linked to Increase in
Mortality Risk, Canadian Journal of Psychaitry 55, 137-146 2010.
New onset agitation
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75 yo female
Hx of Depression, Dementia, HTN, DJD, UTI’s
Living in Nursing Home for 2 years
New onset agitation
Medication reconciliation – negative
Medical workup - negative
New onset agitation
• Nursing expresses concern:
– Agitation only occurs 2 hours after daughter leaves
– Request is to get a UDS
Surprise!!!
• UDS – Positive Cocaine
• Met with daughter:
“my mother needed a pick me up.”
Narcotic Use
Narcotic Abuse
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Much of the problem is unknown
Younger patients use to get high
Older patients usually do not do the same
Most older substance users are chronic and long
time using
• Unusual for an older adult to start using
narcotics.
Narcotic Use
• Marijuana most common drug used
– Estimated to be 1% of the older population
• Cocaine
– Estimated to be 0.2% of the older population
– Study in Miami of 800 hospitalized older adults
22% of the admission from ‘04 to ‘07 were positive for
cocaine.
Chait R, Fahmy S. Caceres J, Letter to the Editor, Journal of the American Geriatric
Society, 52 (2) 2010
Narcotic Use
• Heroin
– Scant data
– Older users who started after their kids were raised
• Never injected heroin
• Never shared needles
• Do not report loosing control over their usage
Boeri MW, Sterk CE, et al., Reconceptualizing Early and Late Onset: A Life Course
Analysis of Older Heroin Users. The Gerontologist 48 (5) 2008.
Next Steps
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More research on this topic is critcal
Much of the data and impact is unknown
Problem is much likely larger and more serious
Significant health problem for older adults
What can you do?
• Talk to spouse or caregiver
• Look out for:
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Falls
Confusion
Doctor shopping
Increased medical service utilization
• A home visit nurse can be your eyes and ears
• Pay attention to what is in the recycling bucket
What can you do?
• 12 step program, AA, NA.
– Data does not support that these work in the older
patient
• Universal prevention
• Preventative education discussing risks
• www.samhsa.gov
What can you do?
The Surgeon General’s Report on Mental Health,
Administration of Aging Report on Older Adults’
and the Center for Substance Abuse Treatment:;
Crafted a recommended treatment protocol
What can you do next?
• The Treatment Improvement Protocol for Older
Adults (TIP)
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Age specific treatement to build or rebuild self esteem
Coping with depression, loneliness and loss
Rebuilding the patient’s support network
Pace of treatment should be appropriate for the patient
Staff should be interested and experienced with the elderly.
Links with medical services, aging services and referrals for followup care and case management.
Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old
Jagger M, Richards K, 1965