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Substance Abuse and the Elderly

Substance Abuse and the Elderly. A Growing Epidemic. Margaret Brawner / Pfeiffer University / Charlotte, NC / 2014. Medical system “ill-prepared” for wave of older adult substance abusers comin. Adults 60+: substance abuse one of U.S. fastest growing health problems.

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Substance Abuse and the Elderly

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  1. Substance Abuse and the Elderly A Growing Epidemic Margaret Brawner / Pfeiffer University / Charlotte, NC / 2014

  2. Medical system “ill-prepared” for wave of older adult substance abuserscomin • Adults 60+: substance abuse one of U.S. fastest growing health problems. • Baby boomers retiring: 10,000 a day. • 85+ fastest-growing demographic. Medical system • Gerontologists in short supply. • Physicians receive little-to-no training • in addiction. • Few age-specific treatment programs. Image: www.edofdreams.com SAMHSA, 2012; Doweiko, 2014; Bartels and Blow, 2011

  3. ) “The lack of identifying and treating SUDs may ruin the last stage of life for countless older adults.” (SAMHSA, 2012)

  4. Alcohol: scope of the problem • 19 percent of older adults aged 50-64 are “at risk” drinkers (drinking more than the NIAAA recommendations of 1 per day) and 23 percent report binge drinking (4-5 drinks). (Naegle, 2012) • 2013: Center for Disease Control reports alcohol accounts for more than 21,000 deaths among adults 65 or older each year. (Doweiko, 2014) • An estimated 1 in 4 older adults may be adversely affected by combining alcohol and medication (especially CNS depressants.) Can cause unintentional addiction and death. Potentiation: 1 + 1 = 3.(Bartels and Blow, 2011)

  5. Patterns of older adult substance use disorders • Early-onset: • substance use disorders develop before age 65. • psychiatric and physical problems tend to be higher than late-onset (Bogunovic, 2012). • Late-onset: • substance abuse develops after stressful life • situation (death of partner, retirement.) • boredom and loneliness high risk factors. • Addiction can occur unintentionally (Bogunovic, 2012). Chronic pain is a high risk factor for both categories(Shallow, 2014). Prescription drug misuse often overlooked in elderly(Doweiko, 2014). The use of alcohol with pain pills is a common occurrence.(Neagle, 2012).

  6. Signs and symptoms of alcohol use disorders in elderly • Wanting to stay alone much of the time • Memory problems after having a drink • Loss of coordination (walking unsteadily, frequent falls) • Irritability, sadness, depression • Failing to bathe or keep clean • Having trouble concentrating • DSM-5 categories rarely apply to elderly (Doweiko, 2014; SAMHSA, 2003)

  7. Polling Question • What type of psychoactive medication is associated with the most emergency department visits related to prescription medication misuse among older adults? • Pain pills • Sedatives/tranquilizers • Anti-depressants (Bartels and Blow, 2011)

  8. Emergency department visits • Pain pills (43.5%) • Medications for anxiety or insomnia (31.8%) • Anti-depressants (8.6%) (Bartels and Blow, 2011)

  9. Most abused opioid medications • Oxycodone (OxyContin) • Oxycodone/acetaminophen (Percocet) • Hydrocodone (Vicodin) • (Prescription Drugs April 13, 2010)

  10. Opioids: scope of the problem • Overdose deaths overall involving opioid pain relievers (OPR), also known as opioid analgesics exceed deaths in U.S. involving heroin and cocaine combined. ( Bartels and Blow, 2011) • Opioids are the most frequently reported emergency department-related visits involving prescription misuse among older adults. (Bartels and Blow, 2011). • 2014 CBS News report: death rates from prescription opioid medications in the 45-64 age groups increased significantly in recent years. (Swallow, 2014; CDC, 2013))

  11. Death rates from prescription opioids Significant increases in 45-54 and 55-64 age groups Swallow, 2014; CDC, 2013

  12. Signs and symptoms of opioid abuse • Confusion • Depression • Delirium • Insomnia • Parkinson’s-like symptoms • Weakness or lethargy • Loss of appetite • Falls • Changes in speech; slurring (Bartels and Blow, 2011)

  13. Signs and symptoms of opioid abuse • Loss of motivation • Memory loss • Family or marital discord • New difficulty with activities of daily living (ADL) • Difficulty sleeping • Drug seeking behavior • Doctor shopping (Bartels and Blow, 2011)

  14. Factors contributing to substance abuse • Chronic pain • Anxiety • Sleep problems • Lack of awareness of reduced ability to well-absorb and metabolize chemicals. • Lack of a support system • Disability. Older adults bound to their homes due to disability are at high risk for SUDs. • Depression. Alcohol and depression is the most common co-occurring disorder among older adults. • Isolation. Older adults are more likely to drink at home alone and see friends less often. (SAMHSA, 2012)

  15. Factors contributing to substance abuse • Grief (loss of spouse, job, ability to function.) • Trauma (elder abuse). • Boredom / loneliness. Particularly for late onset drinking. • Family history of alcoholism • Gender: men more at risk for alcohol abuse; women more at risk for psychoactive medication abuse. • Previous history of substance abuse • Cognitive impairment (SAMSHA, 2012)

  16. Protective Factors • Married • Supportive, safe living environment • Gerontologist trained in addiction supervising diverse medications • Adequate income to meet needs (medical expenses likely to far exceed those of younger adult) • Annual substance abuse screening including psycho-education. (SAMHSA recommends for 60+) • Wellness factors including eating, sleeping, exercise, spirituality. • Linkage to age-specific groups and activities • Access to transportation (SAMSHA, 2012)

  17. Barriers to identifying and treating older adults for substance abuse • Lack of awareness of chemical’s effects • SUDs often mimic symptoms of other disorders, making diagnosis difficult (Doweiko, 2014. • The 15-minute “managed care” appointment factor • Older adults living alone: an SUD may go undetected (Doweiko, 2014). • Denial may be particularly glaring in an older adult substance abuser, whose generation and culture may have adopted the Moral Model of addiction (Doweiko, 2014). • Familial shame (Doweiko, 2014).

  18. Barriers to identifying and treating older adults for substance abuse • DSM-5: the substance use disorder criteria rarely apply to older adult substance abusers (Doweiko, 2014). • Ageism: widespread assumption that treating older adults for substance use disorders a waste of time and health care resources (SAMHSA, 2012). • Lack of age-specific treatment programs (Doweiko, 2014)

  19. Special Treatment Needs • Elderly likely to present with: • - multiple medical conditions • - cognitive problems - mobility problems • - emotional issues (grief, loneliness, depression) • - sensory deficits (hearing/vision) • - lack of support system • Treatment for older adult requires more medical management than standard. • -- Detoxification can take up to 28 days. • -- Patients are likely taking multiple prescription medications. Antabuse not well-absorbed. Doweiko, 2014; SAMSHA,, 2012

  20. Engaging and retaining the older adult • SAMSHA 2012 Expert Panel and other addiction professionals recommend: • Supportive, non-confrontational approaches • Age-specific group treatment • Address emotional issues common to older adults (grief, depression) • Develop social support network • Setting: calm, low stimulation (Naegle, 2012) • Pace and content (slower pace; simplified content) • Staff trained in gerontology / pharmacology / addiction • Linkage (to social services, hospitals, activities, doctors) • SAMHSA recommends adults 60+ receive annual SUD screening. (SAMSHA, 2012; Steinhagen and Friedman, 2008)

  21. Engaging and retaining the older adult • Integrating substance abuse, health, mental health, and aging services to provide comprehensive, holistic care tailored to the needs of the older consumer who presents with co-occurring, multiple needs. • Specific, simple goals/objectives • Culturally sensitive • Offering services in home and community-based settings where older adults congregate. • Outreach services • Extended stay treatment (SAMSHA, 2012; Steinhagen and Friedman, 2008) Image: www.medindia.net

  22. Recommended screening tools • SMAST-G: The Short Michigan Alcoholism Screening Instrument – Geriatric Version (SMAST-G). Short-form tailored to the needs of older adults. If positive, use SBIRT (Neagle, 2012). • SBIRT is also an appropriate intervention for combinations of psychoactive medications and alcohol (a common occurrence) (Neagle, 2012). • CAGE-AID (detects alcohol and psychoactive drug use) (Neagle, 2012). • Opioid Risk Tool (up to 82 years old) (SAMSHA, 2012).

  23. SAMSHA, 2012

  24. Ages 17-82

  25. Questions and Answers ?

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