Substance Abuse in the Elderly: What Every Clinician Should Know

1. Substance Abuse in the Elderly: What Every Clinician Should Know Courtney Ghormley, PhD Geriatric Neuropsychology Central Arkansas Veterans Healthcare System

2. Disclosure of Interest • Dr Ghormley has NO disclosures Robinson, A., Spenser, B., & White (1988)

3. Objectives • Report on the process of addiction and the prevalence of substance abuse in the elderly. • Discuss the importance of assessing for substance abuse and approaching patients about this health issue

4. Population Statistics • US residents age 65 and over: 38.9 million • Persons reaching age 65 have an average life expectancy of an additional 18.6 years (19.8 years for females and 17.1 years for males). United States Census Bureau - http://www.census.gov/

5. Population Statistics • The population 65 and over will increase from 35 million in 2000 to 40 million in 2010 (a 15% increase) and then to 55 million in 2020 (a 36% increase for that decade) . • The 85+ population is projected to increase from 4.2 million in 2000 to 5.7 million in 2010 (a 36% increase) and then to 6.6 million in 2020 (a 15% increase for that decade). Administration on Aging – www.aoa.gov

6. Statistics Breakdown by State

7. Alcohol Consumption • NIAAA recommends that people age 65+ limit to 1 standard drink per day or 7 standard drinks per week with no more than 3 drinks per occasion • 12 ozs. of beer • 4-5 ozs. of wine • 1 ½ oz. liquor Naegle (2012)

8. Substance Disorders • Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision, DSM-IV-TR, 2000) • DSM-IV identifies 11 classes of substances • Substance Use Disorders • Substance Abuse • Substance Dependence • Substance-Induced Disorders DSM-IV-TR (2000)

9. Substance Abuse • Maladaptive substance use leads to significant problems in 1 of 4 domains: • Legal • Interpersonal • Work or school • Hazardous behaviors • Problems occur repeatedly within a 12-month period. • In contrast to substance dependence, there is no withdrawal, tolerance, or compulsive use. DMS-IV-TR (2000)

10. Substance Dependence • Persistent substance use resulting in impairment in 3 or more cognitive, behavioral, or physiological symptoms that include: • Persistent or unsuccessful attempts to cut down • Tolerance • Withdrawal • Curtailment of social, occupational, or recreational activities to use or obtain the substance DMS-IV-TR (2000)

11. Substance-Induced Disorders • Substance intoxication • Substance withdrawal • Substance-induced persisting dementia • Substance-induced persisting amnestic disorder • Substance-induced psychotic, mood, or anxiety disorders • Substance-induced sexual dysfunction • Substance-induced sleep disorder Robinson, A., Spenser, B., & White (1988)

12. Increased Risk in the Elderly • Largest consumers of prescribed medication • Receive 30% of all prescribed medication and 40% of benzodiazepine prescriptions • Age-related changes in physiology cause drugs to be more potent • Poor understanding of medication effects and interactions • Inadequate education and misunderstanding of proper use • Decreased cognitive abilities Robinson, A., Spenser, B., & White (1988)

13. Medical Treatment in the Elderly • Average person age 65+: • 8-12 prescription medications • 1-3 over-the-counter medications / supplements • Beers List for medications in the elderly • Anticholinergic Effects – dry mouth, constipation, drowsiness, flushing / overheating, confusion / memory loss, blurred vision

14. Prevalence Rates in the Elderly • Substance use disorders in the elderly • 1 year prevalence rate of alcohol abuse • Males 18-24 = 22.1% vs. Males 65+ = 1.2% • Females 18-24 = 9.8% vs. Females 65+ = 0.3% • 20% of older adults had a substance abuse disorder during their lifetime • 19% are “at risk” drinkers • 23% report binge drinking • Notably, alcohol abuse is significantly more prevalent in elderly hospitalized patients, with incidence as high as 50% • 1 year prevalence rate for illegal drug use • Age 18 to 29 = 4.0% vs. Age 65+ = less then 1/10 of 1.0% Naegle (2012); Snyder et al. (2009)

15. Reasons for Decreased Rates • “Maturing out” theory • Maturation • Increased mortality among those who abuse • Decreased detection in the elderly population • Inadequate or inappropriate diagnostic criteria • Abuse of prescription medications • Late-life onset of substance abuse Snyder et al. (2009)

16. “Maturing In” Theory • Increased risk in an otherwise low-risk population: • Unique and novel challenges of life • Depression • Pain • Increased access to prescription medications • Increased potency secondary to age-related physiological changes • Older adults less likely to perceive it as a problem or to seek treatment Lin et al. (2011);Snyder et al. (2009); Wu & Blazer (2011)

17. Detection in the Elderly • Elderly less likely to meet full DSM-IV criteria for dependence • Limited assessment measures focused on elderly population • Increased stigma • Clinicians simply do not ask

18. Consequences for the Elderly • Sleep problems and insomnia • Depression • GI problems • Increased confusion • Increased risk of delirium • Risk of falls • Head trauma • Stroke • Alcohol-induced dementia • Overdose and death Snyder et al. (2009); Naegle (2012)

19. If you don’t ask, they won’t tell!

20. Assessment • How much? GET SPECIFIC! • How often? • Use screening measures • Social context and circumstances • Coping with low mood, loneliness, grief, pain, or sleep problems • Prior experience with treatment and interest in resuming if needed

21. Alcohol Screening Measures • Short Michigan Alcohol Screening Test – Geriatric Version (SMAST-G) • 10-item, self-report measure • Score of 2 or more indicates alcohol problems • Good specificity (78%) and sensitivity (94%) Johnson-Greene, et al. (2009); St. John, et al. (2009)

22. Alcohol Screening Measures • Sample items (SMAST-G) : • Does alcohol sometimes make it hard for you to remember parts of the day or night? • Have you ever increased your drinking after experiencing a loss in your life? • When you feel lonely, does having a drink help? http://www.ssc.wisc.edu/wlsresearch/pilot/P01R01_info/aging_mind/Aging_AppB5_MAST-G.pdf Robinson, A., Spenser, B., & White (1988)

23. Alcohol Screening Measures • CAGE Questionnaire • Screening for alcohol dependence • 4 Qs, 2 “yes” responses suggests alcohol problems • Have you ever felt you should Cut down? • Does other’s criticism of your drinking Annoy you? • Have you ever felt Guilty about drinking? • Have you ever had an “Eye Opener” to steady your nerves or get rid of a hangover?

24. Benzodiazepines • Elderly receive about 40% of Benzo prescriptions • Even low doses can impair cognition • Two key questions: • Have you tried to stop taking this medication? • Over past 12 mos., have you noticed a decrease in the effect of this medication? • 97% sensitivity and 94% specificity to detect benzo dependence Voyer et al. (2010)

25. How to Talk to Your Patients • Let them know you are concerned • Educate about the “recommended” daily consumption • Educate about the negative impact of substance abuse • Encourage them to cut down • Provide non-judgmental support and always leave the door open • Motivational Interviewing Techniques • Make appropriate referrals for treatment if needed

26. Summary • Substance abuse is a growing problem in the elderly • Elders are at increased risk for co-morbidity and mortality • Clinicians should be engaging their elderly patients about this topic on a regular basis • Talk to your patients and use screening measures when appropriate

27. Courtney O. Ghormley, PhD Geriatric Neuropsychologist Central Arkansas Veterans Healthcare System North Little Rock, AR Courtney.ghormley@va.gov 501-257-3234 Questions?