Mental Health Issues and Addiction in Older Adults

1. Mental Health Issues and Addiction in Older Adults Sharon A. Matthew LPC,CCS,ACRPS,CSAT, CMAT

2. Objectives • To educate on the myths about mental health in older adults • Statistics on prevalence of mental health disorders in adults • To understand common problems addressed in treatment with older adults • To understand generational differences • To understand how addiction causes complications in older adults

3. Myths and Realities about Older Adults Myth • Pretty much alike • Alone and Lonely • Sick, frail, dependent Reality • Very Diverse • Most maintain close relationships • Most live independently

4. Myths and realities cont. • Cognitively impaired • Most are depressed • Rigid with old age • Cognitively intact • Lower rates of depression than YA • Personality fairly consistent throughout life

5. Health Professionals Struggle • I’d rather be dead than old • What does she have to live for?(a life not worth living • It must be depressing (working with old people) • Ageism- Negative attitudes toward aging

6. Mental Health Issues in Late Life Prevalence of Mental disorders in All Adults vs Older Adults All Adults Older Adults 32.4% have MD 15.5% MD 19.1% Anxiety 9% Anxiety 6.8% Major Depression 2.9% Major Dep. 13.4% SUD 5.9% SUD

7. Common Problems Addressed in Therapy with Older Adults • Life transitions (onset of medical problems, Caring for a loved one, Retirement, Moving, Financial problems) • Disputes/Conflicts (Family, siblings, institutions) • Grief and loss • Social Isolation

8. Generational Differences Silent generation (traditionalists-1925-1945) Don’t air your dirty laundry (don’t like talk therapy) They are dedicated, willing to sacrifice, duty before pleasure, loyalty, family focused

9. Generational Differences Cont. Boomers ( 1946-1964) Act like they don’t care what people think, but they do They are into personal growth Loyal to their children and believe anything is possible

10. Successful Treatment of Mental Disorders in Late Life • Psychotropic medications (most respond well to these medications, start slow, go slow) • Evidenced based Psychotherapy (CBT, DBT, CPT, Problem Solving, Reminisce Therapy, Interpersonal Psychotherapy • Mindfulness) • Dance/ Movement Therapy

11. Addiction and Older Adults Fastest growing population in need of specialized care Treatment components necessary for a well rounded approach The importance of staying connected

12. Substances Used • Alcohol most prevalent however, opiates, benzodiazapines, cocaine and marijuana also being used. • 1/3 of prescription drugs consumed by older adults and 2/3 of over the counter medications consumed by Older adults • Boomer and Older adults living with multiple chronic disorders, including the disease of addiction

13. Treating Older Adults Successful Integrated Model • Physical, Emotional, Spiritual , Medical, recreational, Nutritional, Social and also Systemic (Caregivers) • Population that demands dignity and respect • They are diverse, complex, changing , clinically challenging, unique individuals, rewarding to serve

14. What Works Education about the disease Appropriate medications Being with peers of their same mindset Mindfulness, Wellness, getting moving, Dance Movement, music

15. What Works ( Cont.) DBT, CBT, 12 step recovery, massage, acupuncture, coping skills to deal with emotional pain, loneliness, loss, chronic pain medical monitoring, having fun in recovery

16. Super Aging • Physical Super Ager (Exercise, good food, sleep) • Cognitive Super Ager (Learn new tasks, do puzzles, etc)

18. Edith Wilma Connor holds the Guinness World Record for oldest female weightlifter. She’s 84

19. References May 2017. What does it take to be a super-ager?. Harvard Health Publishing. National Registry of Evidenced-Based Programs and Practices: SAMSHA http://www.nrepp.samhsa.gov August 2016. NIH National Institute on Drug Abuse Prescription Drugs, Older Adults.

20. References (Cont.) 2017. Treatment of Depression in older adults evidence-based practices ( EBP). Center for Mental Health Services.

21. Medical Considerations for Addiction Treatment of Older Adults Ming R. Wang, MD, FASAM American Board of Preventive Medicine; Addiction Medicine Certified Diplomate of the American Board of Addiction Medicine Diplomate of the American Board of Anesthesiology Caron Treatment Centers Wernersville, Pennsylvania

22. ASAM Disclosure of Relevant Financial RelationshipsContent of ActivityDate of Activity

23. Treating Older AdultsSuccessful Integrated Model • Physical, Emotional, Spiritual, Medical, Recreational, Nutritional, Social and Systemic (Caregiver)

24. Physical Signs and Symptoms Complicated by Addiction • Sleep complications • Isolation • Health complications • Decline in ADL’s • Unexplained burns/bruises • Fall risk • Medication complications • Disease concept: chronic progressive characterized by denial • Memory loss, dementia, delirium • Malnutrition • Incontinence • Decline in social interaction • Vision problems • Cognitive decline • Hearing problems.

25. Older adults more vulnerable to effects of alcohol and medications • Increased risks of comorbid diseases • Increased risks of harmful drug interactions, injuries, depression, cognitive issues, liver and cardiovascular diseases • Increased fall risks leading to bone fractures, internal bleeding and head injury • Poor cognition interfere with ability to recall use history • Withdrawal management challenges

26. At risk drinking and problem drinking are the largest classes of substance use problems in older adults • At risk drinking defined by ≥ 3 drinks per day and ≥ 7 drinks per week in healthy men/women older than 65 y/o • At risk drinking increases the potential for developing problems and complications • Late onset problems may develop due to stressors related to older age (e.g., retirement, loss of income, loss of partner)

27. National Survey on Drug Use and Health (NSDUH, 2002-2003); age 50+, 12.2% were heavy drinkers, 3.2% were binge drinkers, and 1.8% used illicit drugs • Most elderly patients with alcohol problems go unidentified by health care personnel • Few elderly patients seek help

28. Adults > 65 y/o comprise 13% of the population and 36% of all prescription medications used in the United States • 25% of older adults use psychoactive medications with abuse potential • Greatest concerns are opioids and benzodiazepines • Misuse and abuse of prescription drugs by older adults not typically done for euphoria • Most abused medications are obtained by prescription • Estimated nonmedical use of prescription drugs will increase to ~2.7 million by 2020 in 50+ age group

29. Pharmacodynamics vs. Pharmacokinetics

30. Pharmacokinetic Implications • First Pass Metabolism Aging associated with reduction in first-pass metabolism due to reduction in liver mass and blood flow • Drug Distribution Age related changes in body composition leads to ↓ volume of distribution for water soluble drugs (polar) leading to ↑ serum levels in the elderly Volume of distribution ↑ for fat soluble drugs (non polar) leading to ↑ T (diazepam)

31. Protein Binding Acidic compounds (diazepam, Dilantin, warfarin, salicylic acid) bind primarily to albumin Basic compounds (propranolol) bind to α1-acid glycoprotein Albumin reduced in malnutrition or acute illness and α1 glycoprotein increased in acute illness. Main factor determining drug effect, however, is free fraction of drugs Initial and transient effect of protein binding on free [plasma] is quickly balanced by clearance, therefore, clinical relevance may be limited

32. Drug Clearance Reduction in renal function in elderly, especially GFR, affects clearance of many water soluble abx, diuretics, digoxin, water soluble β blockers, NSAIDS and Lithium Clinical importance is dependent on potential toxicity of the drug Strong implications in drugs with narrow therapeutic window (digoxin, Lithium, aminoglycoside abx)

33. Cardiac Dysfunction Age related dysfunction leading to ↓ HR and ↑ SVR with associated ↑ noradrenaline and serum creatinine excreted drugs clearance reduced Biotransformation of drugs reduced (pro drug activation, ie. Enalapril) due to hepatic congestion

34. drug clearance by liver depends on capacity of liver to extract drug from liver blood flow and amount of hepatic blood flow Clearance by liver depends on blood flow and extraction ratio [E] [E] is dependent on metabolizing capacity of the liver ↑ [E] then clearance is rate-limited by perfusion ↓ [E] then changes in liver blood flow produces little changes in CL Reduction in liver blood flow in aging will mostly effect drugs with high [E]

35. Drugs with low [E], clearance is independent of liver blood flow (warfarin, Dilantin) Drugs with high [E], clearance is rapid and dependent on liver blood flow (morphine, propranolol, NTG, verapamil) Reduction in renal function may affect metabolized drugs by decrease of P450 activity due to reduced gene expression

36. Pharmacodynamic Implications • Magnitude of drug effect depends on number of receptors in target organ, ability of cells to respond to receptor occupation and counterregulatory processes that preserve original fx. • Increase in drug sensitivity has to be assumed with response to a given serum concentration is enhanced. • Age related changes in pharmacodynamics may occur at receptor or signal-transduction level or homeostatic mechanism may be attenuated. • β-adrenoceptors downregulated in elderly by ↑ serum noradrenaline levels. • Number of dopaminergic neurons and dopamine D2 receptors decreased.

37. Progressive reduction in homeostatic mechanisms requiring more time to regain original steady-state due to reduced counterregulatory measures (drug effects are attenuated less in elderly). • Age related changes in GABAᴬ receptor complex may result in high sensitivity to benzodiazepines and alcohol leading to impairment of short term memory, confusion, ataxia and cognitive disturbances. • Extrapyramidal symptoms in response to dopaminergic blockade by drugs increased due to age related reduction in dopamine content.

38. Co-occurring Medical Considerations • Central Nervous System (CNS) • Cardiovascular • Pulmonary • Musculoskeletal • Renal • Gastrointestinal

40. Prefrontal area – higher executive functions, judgment, acting with appropriate decorum. Reward AreaLimbic System dopamine glutamate Oh WOW!!! amygdala

41. CNS • Increased cortical CSF in gray and white matter • Number of synapses decreases • Frontal lobes and cerebellar gray matter particularly sensitive to alcohol induced damage • Volume deficits in anterior hippocampus resulting in memory loss and possible Korsakoff syndrome • Reduced brain glucose metabolism resulting in disruption of neuronal integrity • Low frontal lobe perfusion resulting in cognitive and emotional changes

42. Heavy drinking results in neuronal loss • Overactivation of NMDA receptors (up regulation) by glutamate may lead to cell death • Activation of microglia and astrocytes in brain tissue promoting aberrant signaling of neuroimmune system leading to dysfunctional frontal circuits • Exact mechanisms underlying ethanol-induced neurotoxicity not well understood

43. Sedative/hypnotics/opioids increases risk of falls • Sedative/hypnotics may produce antegrade amnesia impairing learning of new information • Acute toxicity includes sedation, psychomotor impairment, and memory problems • Tolerance develops to most cognitive effects but not all sedatives produce the same type or severity of impairment