copyright alcohol medical scholars program1 substance use disorders in geriatric patients steven h....

Copyright Alcohol Medical Scholars Program 1

SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTS

Steven H. Madonick, M.D.Yale University School of Medicine

New Haven, CT


Substance Use Disorders (SUDs) in Geriatric Patients Are Often Overlooked

• Substance users stereotyped as young

• Physicians miss substance use


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


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


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


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


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


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


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


II. Medical Complications

• Increase in cancers of liver, esophagus, nasopharnx and colon

• Thrombocyopenia, macrocytosis


III. Medical Complications

• Neurologic • Increased dementia, Wernicke’s

encephalopathy, Korsakoff’s psychosis

• Psychiatric• Alcohol-induced mood disorder• Pseudodementia from mood disorder• Suicide


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


Importance of Physician Screening

• Medical complications

• Doctors in an important position to intervene


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.


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.


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


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.


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


Treatment of SUDs

• Identification

• Intervention

• Detoxification

• Rehabilitation


Identification

Doctor’s office, clinic and hospital

extremely important sites for identification


Intervention in Geriatric patients

• Involve adult family members.

• Denial by family and peers.

• Reduced mobility.

• Losses and social isolation.


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.


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)


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)


General Overview of Alcohol Detoxification

• Supportive treatment

• Benzodiazepine taper


Opioid Detox

• Supportive Treatment

• Medication• Clonidine• Methadone taper


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.


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


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


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 program1 substance use disorders in geriatric patients steven h....

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