SUBSTANCE ABUSE AND THE ELDERLY
A GERIATRICIAN’S PERSPECTIVE
OBJECTIVES
•
•
•
•
•
Demographics of the aging population especially in relation to the
“boomers”
A short course in the physiology of aging with the focus on how it influences
abuse problems in the elderly
A look at the prevalence of substance abuse in the geriatric population
Examine risk factors and special dynamics of the “boomer” cohort
Look at the reasons the diagnosis of substance abuse is so often low on the
differential list
DEMOGRAPHICS
PRESENT POPULATION
77 million Americans are over the age of 50
41.9 are 50 – 64
18.4 are 65 – 74
12.4 are 74 – 84
4.2 are 85+
At age 50, Americans can, on the average live another 30 years
People who are now 75 can expect to live another 11 years
People who are now 65 can expect to live till 90
FUTURE POPULATION
By 2030, 70 million people will be over the age of 65
This will be about 20% of the population
More than 6 million will be over 85
The oldest old make up the fastest growing segment of the population
GOOD NEWS/ BAD NEWS IN HEALTH
• People are living longer
• Women live longer, but the gap between women and men is
decreasing
• Racial differences in life expectancy are decreasing
• Smoking rates have decreased in the past two decades – by 23% in
women and 36% in men
• The percentage of Medicare beneficiaries receiving preventative
services has increased markedly
• More Americans are reporting some efforts to increase exercise –
this has especially been seen in those over the age of 75
• Changes in drinking patterns have not changed – yet
• Greater numbers of older American are reporting their
health status as excellent or very good – especially
those in the 65-74 year old age range – 42%
SOCIAL SUPPORT SYSTEMS
•
•
•
•
•
•
•
•
As people age, the social support system becomes more important
But the longer people live, the more likely they are to live alone
Especially if they are female
½ of all females in the 75-84 and 58% of females older than 85 lived
alone in 1999
1/3 of people providing support to the elderly are adult children
During the “baby bust” of the 60’s, there was a marked increase of
females not having children
This means that people now in their 60’s are much less likely to
have a social support system with adult children to help
And those with adult children are less likely to have them living in
the same general area
A SHORT LESSON IN THE PHYSIOLOGY OF AGING
IN RELATION TO SUBSTANCE ABUSE
FAT STORES
•
•
•
•
•
Increased fat stores and overall decrease in body water content
Decreased muscle mass
Increased peak alcohol level at lower doses
Long acting benzos get stored in the fat and stay around a lot longer
Lower doses of short acting benzos attain higher peak levels more
quickly
LIVER FUNCTION
• Blood flow through the liver decreases and the metabolic capacity
decreases with age
• Acute ETOH abuse impairs liver function
• Chronic ETOH abuse may actually increase liver enzyme induction
and increase metabolism of some drugs (until the liver becomes
really damaged)
• Drug clearance may fluctuate because of this – especially in binge
drinking.
• With drugs like warfarin or anticonvulsants, this can have
catastrophic consequences
• Or the mixture of sedatives and ETOH – chronic drinkers have
decreased effect of say temazepam and binge drinkers will have
increased effect when they drink
IMMUNE FUNCTION
• Decreased immune function as we age
• ETOH itself in large doses is an immunosuppressant
• This increases problems with infection and poorer outcomes when
an infection occurs
• ETOH, benzos, opioids all decrease the level conciousness, thus
increasing risk of aspiration
• Increased risk of HIV – one of the fastest growing segments of
population is the elderly (? Thanks to viagra et al?)
NEUROLOGIC CHANGES OF THE ELDERLY
•
•
•
•
•
•
The brain atrophies significantly
Blood flow to the brain decreases by 20%
There is significant cellular loss
Proprioception decreases with age
All of this will be worsened by ETOH and other psychoactive drugs
Studies show that the benzos increase cognitive decline – especially
the long acting
• ETOH can give global cognitive impairment
• Peripheral neuropathy with ETOH abuse and vitamin deficiency
ETOH AND THE ELDERLY
• HX : VT was 82 yo that was found down in the parking lot of a local
restaurant. He was nonresponsive to verbal stimuli but responsive
to pain. He had eaten at this restaurant every night since his wife
died 3 years before
• Past Hx: HBP, nonsmoker, “has a drink every day”
• Social hx: retired beer salesman, widower, one child in town
• Hospital Course: Taken to ULH ER. Noted to have bruising and
abrasion on occipital region. ETOH level was 0.08. CT scan
showed intracerebral bleed. Stormy course with prolonged delirium
and pneumonia. Finally DCed to SNF
COMMUNITY DWELLING ELDERLY
60 AND ABOVE
•
•
•
•
62% drink ETOH
Heavy drinking in 13% of males and 2% of females
Overall 6% of elderly were considered to be heavy drinkers
In this study heavy drinking was defined as greater than two
standard drinks in a day
• A standard drink is 1. 5 ounces of distilled spirits, 12 oz. of beer or 5
oz of wine
• This study lowered the standard def of heavy drinking because of
the elderly lowered tolerance
HOSPITAL AND NURSING HOME
• 13% of elderly trauma patients had blood ETOH levels greater than
0.1
• 23% of elderly Psychiatry patients have history of ETOH abuse
• 10 -21% of elderly patients admitted to inpatient med/surg abuse
ETOH (may be higher)
• In a recent study, 49% of patients in a nursing home met criteria for
lifetime ETOH abuse or dependence
RISK FACTORS FOR ETOH ABUSE IN ELDERLY
•
•
•
•
•
•
•
•
Males
Major life changes or losses
Especially retirement or death of a spouse
Substance abuse earlier in life
Comorbid psyche disorders
Positive family history
Abuse of nicotine
Use/abuse of psychoactive drugs
LATE ONSET VS EARLY ONSET
EARLY ONSET
•
•
•
•
•
•
2/3 of elderly alcoholics
Usually start in the 20’s- 30’s or even earlier
High percentage estranged from family
Often in socioeconomic decline
More likely to have chronic alcohol related medical problems
Usually more comorbid psyche disorders
LATE ONSET
•
•
•
•
•
•
•
•
1/3 of elderly alcoholics
Usually get into problems after 40 – 50
Generally have achieved higher level of education and income
A stressor often triggers the problem
Usually fewer medical problems related to the ETOH
Social support system is usually better
Usually more amenable to treatment
But also more likely to be overlooked
OTHER SUBSTANCE USE IN THE ELDERLY
• Including marijuana, cocaine, heroin, hallucinogens, and illicit use of
prescription drugs
• Is really not known in the community setting
• The older population is less likely to report problems than the
younger age groups
• Physicians underrecognize the problem ( but more about that later)
• In 2005, 0.5% of adults 65 and older reported illicit drug use
• In 2006 it was 0.7%
• However, patients in the 50 – 54 age group doubled their reporting
from 3.4 to 6.0% from 2002 to 2006
IN THE ER SETTING
•
•
•
•
•
A 2001 study published in Addiction
23.7% used benzos
14.4 used opioids
9.6% used barbituates
19.8% used stimulants like cocaine and meth
PRESCRIPTION DRUG USE
• Prescription drug use in the elderly is much greater
• Multiple doctors and often no “captain of the ship”
• Older people take a lot of psychoactive drugs – and more so in
women – up to four times greater misuse
• Women are more likely to become dependent if they are widowed,
less educated, lower income, poor health, and have reduced social
support
ADVERSE EFFECTS OF DRUG USE/ABUSE
Most studies do not necessarily distinguish between use, abuse, and
dependence
• An association between falls and benzos has been repeatedly
shown
• Fractures seem to be much more common in those who use opioids
• Elderly who use benzos chronically are more likely to develop
“Mobility” disability and disability in their ADLS
• Long term benzo use is related to early cognitive decline
• Increased risk of urinary retention, MVAs, and pressure ulcers with
sedative /hypnotics in the LTC settings
THE STORY OF MW
• HX: 75 yo female admitted to LTCF after right total knee
replacement.
• PAST HX: multiple failed backs surgeries, DM, RA, , Chronic
cellulitis of lower extremity, has Morphine intrathecal pump
allergies to multiple drugs including codeine, demerol, oxycodone,
sulfa, and quinolones
• SOCIAL HX: retired RN and nursing home administrator. Lives at
home with demented husband
MED LIST
•
•
•
•
•
•
•
•
•
•
•
•
Intrathecal pain pump
Xanax 1mg in am 0.5 at noon, and 2mg at hs
Lortab 10-500 q 4 hours prn pain
Arthrotec
Nexium
Synthroid
Lipitor
Niferex
Lasix
Potassium supplement
Starlix
Plus 20 other routine and prn meds
NH COURSE
• The first day the patient seemed pleasant and comfortable. She
started to participate in physical therapy but complained of a lot of
pain. On day #2,one of the nurses noticed that the patient’s
“demented” husband had driven over to the NH and was giving the
patient some medication. When the patient was confronted about
this, she stated that she was still in a lot of pain and needed more
medicine. The husband had brought over Percocet 10 as well as
flexeril. The patient was examined by the physician and the wound
looked very good. She was advised to tell the nurses that she was
having pain and not to bring medicine from home. The same thing
happened on day #3. Again she was advised this was against the
NH policy. Again she was examined to r/o other problems. Two
hours later she requested to be transferred back to the hospital.
WHY DO MDs AND HEALTH CARE WORKERS HAVE PROBLEM
DIAGNOSING SUBSTANCE ABUSE IN THE ELDERLY?
Faulty assumptions and myths ie the alcoholic as a bum
Denial by the abuser, family and MD
May be fewer social signs of problem like losing a job or legal
difficulties
Substance abuse problems may be overshadowed by the other
medical problems
The physical and/or cognitive decline caused by chronic substance
may be thought of as the “ravages of aging”
Substance abuse problems are the “Great Masquerader”
OTHER REASONS FROM THE PATIENTS
•
•
•
•
•
Increased denial (not necessarily just the elderly with this)
Decreased private insurance payment for mental health treatment
Multiple comorbidities including other psyche issues
Increased use of legal psychotropic drugs
Lack of good population based studies in the elderly
SO WHY ARE THE “BOOMERS” DIFFERENT THAN
OTHER AGING POPULATION COHORTS?
• Higher population
• The dynamics of the “Me” generation – rightly or wrongly are
accused of being more self centred and used to having things their
way
• Higher risk of substance abuse in this cohort than in others
previously
• Certainly more accepting of “Sex, Drugs, and Rock and Roll”
PROJECTED DRUG USE IN THE AGING “BOOMERS”
•
•
•
•
From 1999 to 2020 in people 50 and above
Marijuana use from 1% to 2.9% - 719,000 to 3.3 million
Use of any illicit drug from 2.2% to 3.1% - 1.6 to 3.5 million
Non medical use of psychotropic drugs from 1.2% to 2.4% 911,000 to 2.7 million
• Collier, James P et al, Annals of Epidemiology Vol 14 #4 April 2006
pg 257-265
AND WHAT ABOUT CHRONIC PAIN?
•
•
•
•
•
•
Very common in the elderly
25 – 50% in the community dwelling
40 – 80% in the nursing home setting
1/5 65 yo and older take analgesics several times a week
Of these, 3/5 take prescription pain meds
Chronic pain causes all sorts of complications like depression,
decreased socialization, sleep disturbance, and impaired mobility
SUGGESTED GUIDELINES FOR LONG TERM OPIOID
USE
• Patients considered for long term opioid use should have a well
defined source of pain
• Patients with ill-defined MS syndromes are poor candidates for
opioid use
• Many patients, if not all, need psychosocial assessment
• Patients with current or previous history of substance careful psyche
assessment and close followup
• All patients with chronic opioids should have a regular assessment
of pain and functional status
NSAIDS AND COX 2 INHIBITOR
•
•
•
•
Increased risk of kidney and liver problems
Increased risk of GI bleed
Increased risk of fluid and Na retention
Drug – drug interactions
OTHER MEASURES
• Acetaminophen
• Physical therapy
• Nonpharmacologic methods
SUMMARY POINTS
• The “Boomers” are coming
• The absolute numbers of elderly with substance abuse problems will
be going up
• These disorders are underreported and misdiagnosed for a number
of reasons
• There are a lot of research opportunities concerning these disorders
in the elderly. Especially in relation to long term care living
arrangements.
• Comorbidities and drug interactions are very common in the elderly
• Substance abuse is associated with cognitive decline
Winkel, Vicki and Byron Bair Substance use disorders in older adults
Clinical Geriatrics Jul, 2008 ppg 25-29
Rigler, Sally Alcoholism in the elderly American Family Physician Vol
61#6 March 15, 2000
Oslin, David Evidence based treatment of geriatric substance abuse
Psychiatric Clinics of North America Vol 28 issue 4 dec 2005 noted
on MD Consult
Christensen, Helen et al Prevalence, risk factors and gtreatment for
substance abuse in older adults Current Opinion in Psychiatry
Vol19(6) Nov 2006 ppg 587-592
Finfgeld-Cornett, Deborah Treatment of substance misuse in older
women Journal of Gerontological Nursing Vol 30(8) Aug 2004 ppg
30-37
• Enoch, Mary Anne and David Goldman Problem drinking and
alcoholism: diagnosis and treatment American Family Physician
feb 1. 2002
• Hasin, Deborah et al Prevalence, correlates, disability, and
comorbidity of DSM-IV alcohol abuse and dependence in the United
States: results from the National Epidemiologic survry on alcohol
and related conditions Archives of General Psychiatry vol64(7) July
2007 ppg 830-842
• Mcgrath A et al Substance misuse in the older generation
Postgraduate Medical Journal Vol 81(954) April 2005 ppg 228-231
• McInnes, Elizabeth and Janet Powell Drug and alcohol referrals:
are elderly substance abuse diagnoses and referrals being missed?
British Medical Journal Vol 308(6926) Feb12, 1994 ppg 444-446
• Colliver, James et al Projecting drug use among aging baby
boomers in 2020 Annals of Epidemiology Vol 16 issue 4 April 2006
ppg 257-265
• Patterson, Thomas et al The potential impact of the baby boom
generation on substance abuse among elderly persons Psychiatric
Services 50:1184-1188 Sept 1999
• Schmader, Kenneth and Alison Moore Prescription use, misuse,and
abuse in older persons Annals of Long term care vol 11 issue 8 Aug
2003 ppg 37-42
• Joseph CL Alcohol and drug misuse in the nursing home Int Journal
of Addiction Nov-Dec 1995 30 (13-14) 1953-84
• Klein,WC and C Jess One last pleasure? Alcohol use among
elderly people in nursing homes health Soc Work 2002 Aug 27(3)
ppg 193 -203
• O’Connell, Henry et al Alcohol use disorders in elderly people –
redefining an age old problem in old age British Medical Journal
Vol 327(7416) Sept 20 2003 ppg 664-667
• Paterniti, Sabrina et al Long term benzodiazepine use and cognitive
decline in the elderly: the epidemiology of vascular aging study
Journal of Clinical Psychopharmacology vol 22(3) June 2002 ppg
285-293
• Menninger, John Assessment and treatment of alcoholism and
substance related disorders in the elderly Bulletin of the Menninger
Clinic vol 66 no 2 spring 2002 ppg 166-183