SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTS Steven H. Madonick, M.D. Yale University School of Medicine New Haven, CT

1. SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTSSteven H. Madonick, M.D.Yale University School of MedicineNew Haven, CT Copyright Alcohol Medical Scholars Program

2. Substance Use Disorders (SUDs) in Geriatric Patients Are Often Overlooked • Substance users stereotyped as young • Physicians miss substance use Copyright Alcohol Medical Scholars Program

3. Geriatric Patients with SUDs are Often Evaluated by Physicians • Frequent evaluation an opportunity to screen • Higher rates of SUDs in medical facilities • Substance use complicates medical illnesses Copyright Alcohol Medical Scholars Program

4. Subjects to be Covered in this Lecture: • Increased substance use effects in geriatric patients • Description of SUDs in geriatric patients • Screening for SUDs in geriatric patients • Treatment and rehabilitation strategies in geriatric patients Copyright Alcohol Medical Scholars Program

5. Increased Substance Use Effects in Geriatric Patients • Increased BAC because: • Decreased lean body mass • Decreased total body water • Decreased gastric alcohol dehydrogenase • Alcohol and drugs more intoxicating in geriatric patients Copyright Alcohol Medical Scholars Program

6. Description of Alcohol Use Disorders in Geriatric Patients: Prevalence • 16% Men > 2 drinks per day, 15% Women > 1 drink per day • Up to 31% men, 21% women > 3 drinks daily in retirement communities • Up to 21% alcohol dependence in medical patients Copyright Alcohol Medical Scholars Program

7. Alcohol Use Disorders (AUDs): Early Onset (< Age 60) • About 2/3 of geriatric AUDs • Greater financial, legal and social problems than later onset • Heavier drinkers than later onset patients Copyright Alcohol Medical Scholars Program

8. AUDs: Late Onset ( > Age 60) • About 1/3 of geriatric AUDs • Aging social drinkers more intoxicated with same dose • Cognitive disorder in heavy drinkers • Social drinkers who increase drinking after losses Copyright Alcohol Medical Scholars Program

9. I. Medical Complications of Alcohol in Geriatric Patients • Cirrhosis: 60% 1 year death rate > age 60 vs. 7% in younger patients • Heart Effects • Women more susceptible • Alcoholic women 4 X coronary artery disease vs. non-alcoholic women • Atrial fibrillation common, “holiday heart” increases risk • Increased stroke risk Copyright Alcohol Medical Scholars Program

10. II. Medical Complications • Increase in cancers of liver, esophagus, nasopharnx and colon • Thrombocyopenia, macrocytosis Copyright Alcohol Medical Scholars Program

11. III. Medical Complications • Neurologic • Increased dementia, Wernicke’s encephalopathy, Korsakoff’s psychosis • Psychiatric • Alcohol-induced mood disorder • Pseudodementia from mood disorder • Suicide Copyright Alcohol Medical Scholars Program

12. Other SUDs • Less data than AUDs • Low prevalence of illicit drug use • Few IV drug users survive • Reduced access to illicit substances • High prevalence of prescription drug use disorders • 25% using psychotropic medications • This includes benzodiazepines and opioids Copyright Alcohol Medical Scholars Program

13. Importance of Physician Screening • Medical complications • Doctors in an important position to intervene Copyright Alcohol Medical Scholars Program

14. DSM-IV Criteria for Substance Dependence Maladaptive pattern and 3 or more of the following in a 12 month period: • Tolerance (often reduced in geriatric patients). • Withdrawal (often delayed, with mental status changes in geriatric patients). • Greater amount of use or longer duration than expected. • Unsuccessful efforts to reduce use. • Large amount of time obtaining, using and recovering from use. • Important activities reduced or given up. • Continued substance use despite its aggravation of physical or psychological problem. Copyright Alcohol Medical Scholars Program

15. DSM-IV Criteria for Substance Abuse Maladaptive use and 1 of the following in 12 month period: • Failure to fulfill obligations at work school or home. • Recurrent use when physically hazardous. • Recurrent related legal problems. • Continued use despite recurrent social or legal problems. Copyright Alcohol Medical Scholars Program

16. State Markers that Suggest Alcoholism • Gamma-glutamyl transferase (GGT): Sensitivity of 70% to 80% if 6-8 drinks per day consumed • Mean corpuscular volume (MCV) greater than 90 cubic microns consistent with alcohol dependence • Carbohydrate deficient transferrin (CDT): Social over 14 units/liter and alcohol dependence over 20-30 units/liter Copyright Alcohol Medical Scholars Program

17. Questionnaires that Raise Suspicion of Alcohol Abuse or Dependence • MAST-G is unique in that it is specific to geriatric alcohol use disorders. • AUDIT is comprehensive. • CAGE and TWEAK are quick but have limited sensitivity and specificity. Copyright Alcohol Medical Scholars Program

18. Screening for SUDs other than AUDs • Methods less developed than for AUDs • Signs for concern (not specific) include: • doctor shopping • drug-seeking behavior • decreased motivation • trouble sleeping • poor self care Copyright Alcohol Medical Scholars Program

19. Treatment of SUDs • Identification • Intervention • Detoxification • Rehabilitation Copyright Alcohol Medical Scholars Program

20. Identification Doctor’s office, clinic and hospital extremely important sites for identification Copyright Alcohol Medical Scholars Program

21. Intervention in Geriatric patients • Involve adult family members. • Denial by family and peers. • Reduced mobility. • Losses and social isolation. Copyright Alcohol Medical Scholars Program

22. Brief Intervention • Two to three 10-15 minute counseling sessions • Identify problem, consequences and formulate treatment plan. • Non-confrontational and supportive. • Tailored to individual needs and goals. Copyright Alcohol Medical Scholars Program

23. I. Alcohol Detoxification Concerns in Geriatric Patients • Confusion (rather than tremor) early withdrawal sign • Duration of withdrawal/hallucinosis increased • Rule out DTs in confused elderly • Replace electrolytes and nutrients • Short acting benzodiazepines (lorazepam) Copyright Alcohol Medical Scholars Program

24. II. Alcohol Detoxification Concerns in Geriatric Patients • Severe withdrawal or medical illness managed inpatient • Otherwise outpatient with family support • Monitor symptomatology with Clinical Institute Withdrawal Assessment for Alcohol (CIWAs) Copyright Alcohol Medical Scholars Program

25. General Overview of Alcohol Detoxification • Supportive treatment • Benzodiazepine taper Copyright Alcohol Medical Scholars Program

26. Opioid Detox • Supportive Treatment • Medication • Clonidine • Methadone taper Copyright Alcohol Medical Scholars Program

27. I. Rehabilitation Strategies for Geriatric Patients • Psychotherapy • Individual for substance use and social needs from losses and isolation • Group, family and network therapy for damage to family and peer relationships from substance use. Copyright Alcohol Medical Scholars Program

28. II. Rehabilitation Strategies for Geriatric Patients • Optimized by age-specific treatment • Must fill the time formerly spent using substances • Senior centers often have alcoholics anonymous (AA) groups and support socialization Copyright Alcohol Medical Scholars Program

29. Pharmacotherapy in Rehabilitation: A Limited Role • Naltrexone reduces alcohol reinforcing effects but does not clearly promote abstinence, monitor liver transaminases • Disulfiram problematic with potential drug interactions and co-morbid medical conditions • Acamprosate may modestly increase abstinence rates but GI upset, FDA approval pending Copyright Alcohol Medical Scholars Program

30. Summary • Physicians have a strategic role in detection • Geriatric patients have vulnerability to medical complications of substance use • There are clinical tools and strategies for detecting SUDs in this population • Effective biopsychosocial treatment and rehabilitation benefit from physician input and family support Copyright Alcohol Medical Scholars Program