Transcript Substance Use Problems and Older Adults

Never Too Old:
Substance Use Problems and
Older Adults
The University of Texas at Austin
June 2009
Acknowledgements
Development of this presentation was made possible through a Gero Innovations Grant from the CSWE
Gero-Ed Center’s Master’s Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.
Never Too Old:
Substance Use Problems and Older Adults*
 Incidence and Prevalence
 Risk Factors
 Prescription Drugs
 Screening
 Diagnosis
 Dementia, Delirium, and Psychiatric Comorbidity
 Culture
 Intervention
 References
* Disclaimer: This presentation does not constitute legal, medical, or
psychiatric advice.
How Many Older Adults Are Affected
by Alcohol and Drug Problems?
 15% of men and 12% of women aged
60+ seen in primary care settings drank
more than NIAAA recommended limits
(Adams, Barry, & Fleming, 1996)
 As many as 17% misuse alcohol or
prescription drugs (in addition to
tobacco, these are the major
problems) (Blow, 1998)
Drug Use Among Adults
Aged 50 and Older
 Between 1999-2001:
 1.6 million adults reported some illicit drug use
 719,ooo adults reported marijuana use
 911,ooo adults reported using prescription
psychotherapeutics for non-medical purposes
 It is projected that by 2020:
 3.5 million adults will report illicit drug use (113% inc.)
 3.3 million adults will report marijuana use (355% inc.)
 2.7 million adults will report use of prescription
psychotherapeutics for non-medical purposes (193%
inc.)
(Colliver, Compton, Gfroerer, & Condon, 2006)
Ethnic Population Comparison
(Office of Applied Studies, 2005)
As the Life Cycle Turns:
Substance Abuse Risks Across Stages
• Youth: genetic predisposition, temperament,
nonconformist/antisocial behavior
(delinquency/aggression), adults’ example, high-risk
living environment, peer pressure, media, gender,
ethnicity
• Young Adult: intimate relationships, sex, college, early
family stressors
• Middle Age: achieving life goals, later family stressors
• Older Adult: empty nest, loneliness/lack of social
support, changing roles, losses, health problems,
metabolism, prescription drug use
(See, for example, National Institute on Alcohol Abuse and
Alcoholism, 2000)
Important Considerations
 Drinking and illicit drug use decline with age, but problems
can occur at lower doses.
 Younger age cohorts more likely to drink and become
dependent than older cohorts, but problems will increase as
baby boomers age.
 Gender gap has decreased but men still have more alcohol
problems; women, however, more likely to begin heavy
drinking later in life.
 Older people are largest users of Rx drugs, and women
prescribed more psychoactive Rx drugs than men.
 Most older adults do not intend to abuse Rx drugs (less
nontherapeutic use than younger people).
(Blow, 1998; Center for Substance Abuse Prevention, 2002; National
Institute on Alcohol Abuse and Alcoholism, 2000)
Alcohol Metabolism and Aging
Tolerance to alcohol decreases because:
 Lean body mass decreases (as body
water decreases, alcohol concentration
increases)
 Gastric alcohol dehydrogenase decreases
(slows alcohol pharmacokinetics,
increases alcohol that enters
bloodstream)
 Increased alcohol sensitivity/decreased
tolerance
(Blow, 1998; Fingerhood, 2000)
Misuse/abuse of prescription drugs has
declined because:
 Safer drugs with fewer side effects
 Stricter federal and state regulations
 Health care providers given best practice
guidelines
 Physicians better educated to treat older
patients
 Consumers better educated
(Blow, 1998)

But Prescription Drug Problems Still
Occur Because…
Older adults:
 Misunderstand directions for use or purpose of
meds
 Forget to take meds
 Take too much by accident or to get greater
effect

Prescribing practices need improvement:
 Drugs’ effects among older adults not
understood
 Multiple drugs prescribed by multiple physicians
 Insufficient diagnosis for prescribing
 Meds prescribed for too long
 Insufficient monitoring of effects and compliance
(Blow, 1998)
Examples of Medication Issues
 Many medications and street drugs interact
with alcohol
(e.g., additive effects with
sedative/hypnotics/benzodiazepines)
 Some drugs may cause delirium:
Sedative/hypnotics (e.g., benzodiazepines)
Analgesics (narcotics)
Drugs with anticholinergic effects* (e.g.,
disopyramide used for arrhythmia) (Alagiakrishnan
& Wiens, 2004)
*These drugs block the action of acetylcholine, a neurotransmitter
that helps nerve cells communicate.
Recommended Limits for Alcohol
Consumption Among Older Adults
 National Institute on Alcohol Abuse and
Alcoholism
 People aged 65 and older: no more
than one drink per day (NIAAA, 2000)
 TIP Consensus Panel
 Older men: No more than one drink
per day;
maximum of 2 drinks on any
occasion
 Older women: Somewhat lower limits
(Blow, 1998)
Standard drink = 12 oz. beer; shot (1.5 oz.)
hard liquor; 5 oz. wine; 4 oz. sherry, liqueur,
or aperitif
Examples of Warning Signs
 Preoccupation with
 Malnutrition/dehydr





prescription drugs
Unnecessary
requests for
prescription refills
Uses more than
prescribed
Minor traffic
accidents
Unexplained
bruises, burns, falls,
fractures, accidents
(Blow, 1998)





ation
Withdraws from
normal social
activities
Poor personal
hygiene/grooming
Empty containers
Hidden alcohol
Expulsion from
housing
Avoids activities if
Barriers to Problem Resolution
 Health care providers poorly educated about substance use disorders
 Symptoms mistaken for depression, dementia, etc.
 Medical appointments rushed
 Attitude that treatment won’t be effective (waste of time, resources)
 Older adults more likely to hide problem (shame)
 Families also ashamed (stigma)
 Professionals and family members attitude of “why not– life is short”
 Older adults less likely to seek treatment
 Desire to solve problems on their own
(Blow, 1998)
Ask Yourself These Questions:
If someone died of a cocaine overdose,
what would be your first thought about
their age?
If someone died of accidental overdose
due to combined effects of Rx
painkillers, benzodiazepines or antianxiety agents, and sleep aids, what
would be your first thought about their
age?
Now consider this:
A. Rock ‘n roll legend Ike Turner died of
accidental cocaine toxicity (overdose) in
January 2008 at age 76. Hypertensive
cardiovascular disease and pulmonary
emphysema were significant, contributing
factors.
B. Actor Heath Ledger died of an accidental
overdose of prescription drugs (painkillers,
anti-anxiety drugs, and sleeping pills) in
February 2008 at age 28.
Screening with the CAGE
 Have you ever felt you should Cut down on
your drinking?
 Have people Annoyed you by criticizing your
drinking?
 Have you ever felt bad or Guilty about your
drinking?
 Have you ever had a drink first thing in the
morning to steady your nerves or get rid of a
hangover (Eye opener)
(Ewing, 1984)
Michigan Alcoholism Screening TestGeriatric Version (MAST-G)
Sample of items:
 Does alcohol make you sleepy so that you
fall asleep in your chair?
 After a few drinks, have you sometimes
not eaten or been able to skip a meal
because you don’t feel hungry?
 Have you ever increased your drinking
after experiencing a loss in your life?
(Source: Blow et al., 1992)
© The Regents of the University of Michigan, 1991.The complete
instrument is reprinted with permission in Blow, 1998.
Health Screening Survey (HSS), Revised
Sample items:
 In the last three months, have you been drinking
alcoholic drinks at all (e.g., beer, wine, sherry,
vermouth, or hard liquor).
 In the last three months, have you felt guilty or bad
about:
a. Your weight
b. How much you smoke
c. How much you drink
d. How unfit you are
(Source: Fleming & Barry, 1991)
The complete instrument is reprinted with permission in Blow, 1998.
Ideas for Improving Screening
 Teach health care providers, volunteers (Meals-on-Wheels), caretakers
to screen.
 Ask alcohol/drug questions with health questions (“I’m wondering if
alcohol may be the reason your diabetes isn’t responding as it
should.”).
 Be non-confrontational, supportive, and show respect, but address
denial and rationalization.
 Avoid stigmatizing terms like “alcoholic” or “drug abuser.”
 If older person cannot respond coherently, ask permission to speak
with collaterals (e.g., family, friends).
 Use “brown bag approach” (bring all meds, Rx, OTC, herbs).
 Use preferred language and be aware of cultural issues.
 Take good social histories.
(Blow, 1998)
Consensus Panel Recommendation:
“Every 60 year-old should be screened for
alcohol and prescription drug abuse as part of
his or her regular physical examination.”
Screen again if physical symptoms indicated or
older person undergoing major life changes.
(Blow, 1998)
Differential Diagnosis
 Obtain a medical history
 Obtain a family and social history
 Obtain a behavioral health, psychiatric history
 Obtain an alcohol and drug history
 Determine current medication/alcohol/other drug use
 Consider effects of all drugs being used
 Consider effects of chronic diseases
(Center for Substance Abuse Prevention, 2002; McNeece & DiNitto,
2005)
What are Substance Use Disorders?
Pattern of use leading to clinically significant impairment or distress
Abuse
Dependence
Obligations not met
Tolerance
Recurrent hazardous use
Withdrawal
Recurrent legal problems
Larger amounts over longer time
Continued use despite recurring Can’t cut down
problems
(One or more in 12-month
period)
More time using/recovering
Important activities reduced/given
up
Recurrent physical or
psychological problems
(American Psychiatric
Association, 2000)
(Three or more in 12-month period)
Substance Dependence
Specify:
Course Specifiers:
With physiological
Early full remission
dependence: tolerance
and/or withdrawal
present
Without physiological
dependence: neither
tolerance nor
withdrawal present
Early partial remission
Sustained full remission
Sustained partial remission
On agonist therapy
(medication)
(American Psychiatric
Association, 2000)
In a controlled environment
Applying DSM-IV Criteria to Older Adults
Tolerance
May not occur; small amounts
can be a problem
Withdrawal
Larger amounts/
longer time
May not occur in late onset
Cognitive impairment
impairs self monitoring
Can’t cut down
Same
Low levels can be problem
More time using/
giving up activities
Reduced activities may mask
detection
Continued use
despite problems
May not understand problems are
related to use even after medical
advice
(Barry, Blow & Oslin, 2002; Blow, 1998)
Alternative Classifications for
Older Adults
At Risk: Pattern of alcohol use not
causing problems yet but may bring
about adverse consequences
Problem Drinkers: Includes heavy
drinkers/hazardous consumers and
those who fit abuse and dependence
categories
(Blow, 1998)
What are Substance-Induced Disorders?
 Substance Intoxication
 Substance Withdrawal
 Substance Induced:
 Delirium
 Persisting Dementia
 Persisting Amnestic Disorder
 Psychotic Disorder
 Mood Disorder
 Anxiety Disorder
 Sexual Dysfunction
 Sleep Disorder
(American
Psychiatric
Association, 2000)
Eleven Drug Classes in DSM-IV-TR
1. Alcohol
7. Inhalants
2. Amphetamines
8. Nicotine
3. Caffeine
4. Cannabis
5. Cocaine
6. Hallucinogens
9. Opioids
10.Phencyclidine
(PCP)
11.Sedatives,
hypnotics, and
anxiolytics
(American Psychiatric Association, 2000)
Early vs. Late Onset Alcohol Problems
Early Onset (more intractable)
Late Onset (easier to treat)
2/3 of older alcoholics
1/3 of older alcoholics
Disorder begins before age 40,
Disorder begins later (after age
Social supports less likely
Former social drinkers or even
More likely to
More likely to
often in 20s or 30s
Drink to intoxication
Have previous treatment
Have legal, financial, other
problems
Have psychiatric comorbidity
(mood & thought disorders)
(Studies on early and late onset are
discussed in Blow, 1998; Fingerhood, 2000)
40, 50, or 60)
teetotalers
Enter treatment due to
crisis/recent loss/health
Be in better physical/
psychological health
Be depressed or lonely
Deny problem
Have social support
Late Onset: Three Scenarios
1. Longtime “functional” alcoholics develop
behavioral or cognitive impairment
unrelated to alcohol use; can no longer
function when drinking.
2. Social drinkers become more vulnerable to
alcohol even when drinking same
quantity/frequency.
3. Social drinkers increase quantity/frequency
due to recent stressors (spouse’s death,
retirement, disability).
(Fingerhood, 2000)
Dementia and Delirium
 Dementia: Marked loss in multiple
areas of intellectual/cognitive functioning
(e.g., memory, abstract thinking) that is
chronic, progressive, and usually
irreversible
 Delirium: Sudden or acute confusion
that can be life threatening but generally
reversible with medical treatment
(Blow, 1998; also see American Psychiatric Association, 2000)
Dementia
 Impaired short- & long-term memory, abstract
thinking, & judgment
 Language disorder
 Inability to carry out motor activities
 Constructional difficulties
 Personality change
 Mood disturbances
 Loss of self-care ability
(Blow, 1998; Center for Substance Abuse Prevention, 2002)
Delirium
 Inability to appreciate/respond to environment normally
 Clouding of consciousness
 Reduced wakefulness
 Disoriented to time/space
 Increased motor activity (e.g., restless, plucking, picking)
 Impaired attention, concentration, memory
 Anxiety, suspicion, agitation
 Misinterpretations, illusions, hallucinations
 Disrupted thinking, delusions, speech abnormalities
(Blow, 1998; Center for Substance Abuse Prevention, 2002)
Causes: Dementia
Most common causes: Alzheimer’s, vascular
dementia, alcohol-related
Metabolic toxic causes (e.g., organ system
failure, hypoglycemia)
Infectious causes (e.g., AIDS/HIV,
encephalitis)
Other causes include Parkinson’s, Lewy body
dementia
(Blow, 1998; Center for Substance Abuse Prevention, 2002)
Causes: Delirium
 Intracranial: infections (e.g., meningitis,
encephalitis), seizures, stroke, subdural
hematomas, tumors
 Extracranial: anesthesia, drug-drug or
alcohol-drug interactions, alcohol or
drug intoxication and withdrawal, hip
fracture, infections, dehydration,
malnutrition, diabetes, depression, etc.
(Blow, 1998; Center for Substance Abuse Prevention, 2002)
Wernicke-Korsakoff Syndrome
Loss of specific brain functions due to thiamine
deficiency; often associated with chronic
alcohol dependence
 Wernicke’s encephalopathy: Damage to nerves
in CNS (brain, spinal cord) and peripheral nervous
system (rest of body). Thiamine (vitamin B)
deficiency common in alcoholics; heavy use
prevents absorption.
 Korsakoff’s syndrome or psychosis: Develops
as Wernicke’s symptoms remit. Symptoms: vision
(double vision, eye movement abnormalities,
dropping eyelids); ataxia (unsteady, uncoordinated
walking); memory loss (may be profound), inability
to form new memories; confabulation (makes up
stories that may seem believable at first), and
hallucinations
(Medline Plus, 2006)
Substance Use Disorders Often
Comorbid with Psychiatric Disorders
 Mood Disorders
 But memory impairment in major depressive
episode may be mistaken for signs of
dementia
 Alcohol and other sedatives (depressant
drugs) may induce depression
 Anxiety Disorders
 Personality Disorders
 Potential for “self” medication
(See Blow, 1998; Center for Substance Abuse Prevention,2002)
Cultural Considerations
 In a given culture, what factors are believed
to cause alcohol/drug problems--genetics,
biology, psychology, culture, morality, choice,
curses?
 How much stigma is attached to alcohol/drug
problems?
 What are cultural considerations for
screening, interventions, and treatment?
(See McNeece & DiNitto, 2005)
Example: Mexican Americans
Possible “causes”:
 Fatalism
 Moral weakness
 Culture-bound syndromes/illnesses (e.g., susto,
nervios)
Stigma:
 Greater for women
 Men entitled to drink but not irresponsibly
 More stigma attached to illicit drug use
(See, for example, Alvarez & Ruiz, 2001; Kail & DeLaRosa, 1999; McNeece &
DiNitto, 2005)
Example: Mexican Americans (cont.)
Screening/Intervention
 Acculturation/acculturative stress
 Language
 Values (personalismo, respeto, familismo, confianza,
dignidad, marianismo, fatalismo, machismo)
 Religion and clergy
 Health insurance (high rates of uninsured)
 Concrete services (meet basic needs)
 Fiestas and celebrations
 Folk medicine (curanderos/curanderas)
(Alvarez & Ruiz, 2001; Kail & DeLaRosa, 1999; McNeece & DiNitto, 2005)
Assess Stage of Change
 Precontemplation: lacks awareness of
problem; no intent to change
 Contemplation: aware of problem;
considers change
 Preparation: intends to change soon
 Action: successfully makes changes
 Maintenance: continues to change and
prevent relapse
(Connors, Donovan, & DiClemente, 2001; Prochaska,
DiClemente, & Norcross, 1992)
Elements of Brief Intervention
 Customized
feedback based on
screening and
assessment
 Where patient fits in
terms of drinking
norms for his/her
age group
 Discuss client’s
reasons for drinking
 Discuss
consequences of
heavy drinking
 Discuss reasons to




cut down or quit
Discuss sensible
drinking limits and
strategies for cutting
down or quitting
Drinking agreement
in form of a
prescription
Discuss how to cope
with risky situations
Summarize session
(Barry et al., 2002; Blow,
1998)
FRAMES Approach to Brief
Intervention
 Give feedback about personal risk from assessment
results
 Emphasize personal responsibility (patient’s choice
to reduce/stop drinking)
 Give clear advice about how to change drinking
 Provide a menu of change options
 Use an empathic counseling style (be warm,
reflective, understanding)
 Encourage client self-efficacy and optimism
 Establish a drinking goal
(Miller & Rollnick, 1991; Miller
& Sanchez, 1994)
Brief Intervention with
Older Adults
 Appreciate
the individual for meeting with you
 Identify health goals and other goals
 Summarize health habits
 Educate on standard drink and types of older drinkers
 Explore reasons older person drinks and reasons to cut
down or quit
 Develop a drinking agreement
 Plan for situations that may trigger drinking
(Center for Substance Abuse Prevention, 2002; Fleming, Manwell,
Barry, Adams, & Stauffacher, 1999)
Additional Treatment Approaches
 Detoxification
 Inpatient, day treatment/partial hospitalization,
extended outpatient treatment, case
management as needed
 Alcoholics Anonymous and other mutual-help
groups
 Community support programs or groups
(Blow, 1998; Vinton & Wambach, 2005)
Strategies for Improving Substance Use
Disorder Treatment for Older Adults
 Include older person as full partner in recovery
 Age-specific treatment that is supportive, nonconfrontational, builds self-esteem
 Focus on coping with depression, loneliness, loss
 Rebuild social support network
 Pace, content, environment appropriate for older
persons
 Staff experienced and interested in serving older adults
 Links with medical, social, institutional and other
services for older people
(Blow, 1998)
More Strategies
 Assure confidentiality to extent possible
 Include smoking cessation
 Provide transportation
 Hearing devices, large print materials
 Follow principles or work with older clients
 Address denial
 Motivate, inspire
 Provide hope and encouragement
(Blow, 1998)
Remember
It’s never too late to develop an alcohol or
drug problem.
It’s never too late (or too early) to
intervene.
AND
It’s never too late to recover.
References
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References (cont.)
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