Dr. Micheal Weaver, VCU presented on Older Adults and Addiction on Friday, March 23rd for the Farley Professional Lecture Series.
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Wmsbg 2012 Older Adults Addic
1. Farley Lecture Series
March 23, 2012
Older Adults and Addiction
Michael Weaver, MD
Division of General Medicine and
Division of Addiction Psychiatry
Virginia Commonwealth University
School of Medicine
2. Objectives
Addiction in Older Adults
Screening and Brief Intervention
Addiction Treatment with Older Adults
Conclusions
Practice Cases
3. What percentage of older adults
(over age 65) are affected by
alcohol and prescription drug
abuse?
A. 5
B. 7
C. 10
D. 17
E. 25
4. Prevalence reduced with age
Rates of illicit drug use
drop among older
cohorts
Addiction problems
resolved
– Treatment when young
– Too old to hustle
Die earlier
Cohort effect
– Current older adult
cohort didn‘t have ‗crack‘ Alcohol and prescription
in their youth drug misuse still affect 17%
of older adults
5. The Age Wave is cresting
First ‗Baby Boomers‘
just turned 65
This generation used
illicit drugs in youth
Continue to use their
drugs into older
adulthood
Different from
previous generations
6. Alcohol abuse in older adults
Community
– Heavy use 3-25%
– Abuse 3-10%
Primary Care clinics
(>1 drink/day)
– 12% of women
– 15% of men
Hospitalized
– 18-44%
Liberto 1992; Saunders 1991
7. Why is it under-diagnosed?
Selection Bias Under-recognized
– Surveys miss nursing – Alcoholism recognized in
homes only a third of
– Poorer recall hospitalized older adults
Ageism Symptoms of AUD may
– ―Granny‘s cocktails mimic symptoms of
make her happy‖ other disorders
– ―He won‘t be around – Depression, dementia
much longer anyway‖ – Diabetes
Graham 1986; Curtis, et al 1989
8. Sensitivity to alcohol with age
Older adults more
sensitive to alcohol
– Reduced total body
water
Higher concentrations
– Reduced metabolism
in GI tract
Amount with little
effect in youth causes
intoxication in older
adults
Smith 1995
9. Drinking Guidelines
Over age 65 years:
– 1 standard drink/day
for men
– Less for women
– No more than 2
drinks on any one
occasion
– No more than 7
drinks per week
NIAAA 2005
10. Psychiatric Co-Morbidity
Higher risk for May present with
substance use among complex clinical histories
those with psychiatric and symptoms
– Diagnosis challenging
disorders – Intoxication and
– Depression or anxiety withdrawal symptoms may
disorders be mistaken for other
psychiatric or medical
– Other psychiatric symptoms
comorbidities Contact with health care
– Personality disorders system is opportunity to
Dual diagnosis intervene
– Substance use Earlier detection and
disorder + another intervention prevents
major psychiatric problems
disorder
11. Gender differences
Older men more likely
to have alcohol-
related problems
Women develop
problems later in life
– More vulnerable to social
pressure
– Higher remission rates (all
age groups)
Myers, et al 1984; Wilsnack 1985;
Fillmore 1987
12. Late-onset alcoholism
Makes up a third of older adults with drinking
problems
Alcohol use associated with life losses
– career loss due to retirement
– death of spouse, change in own health status
Not stereotypical alcoholic—too healthy
Milder & more amenable to treatment, especially
brief intervention
Hurt, et al 1988; Atkinson & Ganzini
1994
13. Alcohol effects on older adults
Rate of hospitalizations
of older persons for
alcoholism is ~1%
– Same rate of
hospitalization as for
myocardial infarction
Alcohol-related
dementia
Highest rate of
completed suicide
Adverse reactions when
combined with
prescription or OTC
meds
Callahan & Tierney 1995; Brennan &
Moos 1996
14. Some Prescriptions with
Potential for Abuse
More common
among Older
Adults
– Sedative-
hypnotics
– Opioids
16. Sedative misuse/abuse
Self-medicate hurts,
losses, affect changes
Older patients
prescribed more
benzodiazepines than
any other age group
Butalbital (Fiorinal)
contributes to
medication rebound
headaches
17. Other Sleeping Pills
Bind to BZ receptor Behavioral
subtypes pharmacological profile
– Zolpidem (Ambien) similar to
benzodiazepines
– Zalaplon (Sonata)
– Drug liking, good effects,
– Eszopiclone monetary street value
(Lunesta) Recommended for short-
term use, many taken
long-term
May cause hazardous
confusion & falls
18. Risky prescriptions: Sedatives
Problematic for
– Alcohol abuse
– Sedative misuse
Benzodiazepines
– Valium, Xanax, Ativan,
Librium, etc.
– Try anti-anxiety
antidepressants or
psychotherapy
Z-drugs (zolpidem, etc.)
– Sleep hygeine
– Side effects of other meds
– Ramelteon (Rozerem)
20. Opioid misuse/abuse
Use pain med to sleep, relax,
soften negative affect
Dose requirement reduced
with age
– Reduced GI absorption
– Reduced liver metabolism
– Change in receptor sensitivity
Short-acting are the most
easily & widely available
Defeat extended-release
mechanism
Problems
– Sedation, confusion
– Respiratory depression
22. Prescription drug abuse
in older adults
Reduced ability to
absorb & metabolize
meds with age
Increased chance of
toxicity or adverse
effects
Med-related delirium
or dementia wrongly
labeled as
Alzheimer‘s
23. Impact on
Healthcare Providers
Medication misuse causes adverse health
consequences for patient
Worsens prognosis of coexisting medical
and/or psychiatric conditions
Significant proportion of practice is dealing
with consequences of
unrecognized/untreated addiction
Leads to practitioner frustration
24. Screening for addiction
High level of suspicion
Non-judgmental
Caring
Free of hostility
History-taking can be
therapeutic
25. Why screen patients
for addiction?
Medical problems Financial difficulties
– Cardiovascular disease Legal problems
– Stroke Work-related issues
– Cancer
Interpersonal
Spread of disease problems
– HIV, HBV, HCV – Family issues
Mental health
– Depression
– Anxiety
– Sleep problems
26. Screening makes a difference
Patients reduce
alcohol and tobacco
use when this is
addressed by a
clinician
Research shows
benefits from
screening and brief
intervention for illicit
and prescription drug
abuse
27. Screening Tool for
Alcohol Abuse
CAGE Questions
– Cut down
– Annoyed
– Guilty
– Eye-opener
Affirmative response
to 1 or more is
positive test in older
adult
28. Screening in older adult
Collateral information
– Family
– Friends
– Senior center staff
Drivers
Volunteers
Ask in terms of
effects on health
problems
Medication
interactions
29. The 5 ―A‘s‖
ASK about alcohol and drug use
ADVISE all patients to quit
ASSESS willingness to change
ASSIST patients in quitting
ARRANGE for follow-up
30. ASK about alcohol and drug use
Have you ever used … When did it begin?
– Tobacco products How often?
– Caffeinated beverages How much?
– Alcohol When was the last
– OTC drugs of abuse use?
– Prescription drugs of
abuse
– Illicit drugs
31. Diagnosis of
Alcohol Abuse/Dependence
Continued substance use despite adverse
consequences
Use in larger amounts or for longer periods than
intended
Preoccupation with acquiring or using
Inability to cut down, stop, or stay stopped,
resulting in a relapse
Use of multiple substances of abuse
APA 2000
32. Brief Intervention
Motivate patients to
change problem
behavior
Multiple brief sessions
Bridge to treatment
or sufficient itself
Same impact as more
extensive counseling
Most cost effective
Weaver & Cotter 1998
33. Patient Behavior
Ambivalence
– Attracted to problem
behavior (substance
use)
Denial
– Unable to admit
problem to themselves
– Actively conceal
Common to many
chronic conditions
34. Motivation
Probability of certain
behaviors
State of readiness to
change
May fluctuate from one
situation to another
Clinician‘s goal is to
increase the patient‘s
intrinsic motivation
– change arises from within
rather than being imposed
from without
36. ADVISE all patients to quit
A strong recommendation to change substance
use is essential
"Based on the screening results, you are at
high risk of having or developing a
substance use disorder. It is medically in
your best interest to stop your use of [insert
specific drugs here].”
Recommend quitting before problems (or more
problems) develop
– Give specific medical reasons
– Medically supervised detoxification may be necessary
37. Elements of Brief Intervention
FRAMES
– Feedback
– Responsibility
– Advice
– Menu
– Empathy
– Self-efficacy
38. Feedback
Present information to
client
– Based on history,
exam, labs, etc.
Increase awareness
of adverse
consequences
Help make the case
for change in
drinking, med use, or
illicit substances
39. Responsibility
Client has the
ultimate responsibility
for change
Practitioner can‘t
force client to change
Client chooses goals,
not practitioner
– Should be realistic
– Clarify client‘s goals
– Develop discrepancy
40. Advice and Menu
Give clear,
concrete advice to
change
Give choices
(menu)
– 3 is ideal
– Making a choice is
first step to making
a change in
behavior
41. Empathy
Listen carefully
Clarify client‘s
meaning
Don‘t impose
practitioner‘s
values on client
42. Self-efficacy
Build up client‘s
belief in ability to
succeed
Be optimistic
Simple goals early
– Success breeds
success
– Increases self-
confidence
43. Types of treatment
Detoxification
12-Step groups
Outpatient counseling
– Cognitive-behavioral
– Case management
Intensive outpatient
Inpatient
Residential
44. 12-Step Groups
A.A., N.A., C.A.
Group format
Anonymous
No cost
No affiliations or
endorsement
Different groups have
different characteristics
– ―Gray A.A.‖ for Older
Adults
45. Which of the following
characteristics of attendees is
the best predictor of success in
Alcoholics Anonymous?
A. Male gender
B. Christian religious denomination
C. Frequency of meeting attendance
D. NO history of depression
46. Success with 12-Step
More groups=more
abstinence
No threshold, but at
least 2
meetings/week best
Not affected by
– Gender
– Religion
– Psychiatric diagnosis
– Novice
48. Treatment in older adults
Focus on coping
– Depression, loneliness
– Losses
Rebuild social support
network
– Socialization groups
– Alumnae meetings
More compliant
Outcomes as good or
better than younger
patients
49. Treatment works
Sustained remission
rates of up to 60%
– Better success than
treatment of
hypertension, diabetes
Every $1 spent on
treatment saves $7 in
costs to society
Lots of new research
50. Summary
Older adults more sensitive to effects of
alcohol and drugs than younger patients
Higher doses increase the risk of adverse
drug events
Substance abuse is under-diagnosed in
older adults
Screen for substance abuse in all older
patients, avoid stereotyping
51. Summary
Encourage older adults to keep a
medication list and discuss prescription,
OTC, supplement and alcohol use with
health care providers
Watch for signs of medication-related
problems (falls, confusion, etc).
Older adults respond well to treatment
for substance abuse with good
outcomes
54. References
Prochaska JO, DiClemente CC, Norcross JC: In search of
how people change: Applications to addictive behaviors.
American Psychologist 1992;47:1102
Miller WR, Rollnick S: Motivational Interviewing:
Preparing people to change addictive behavior. NY:
Guilford Press 1991
Weaver MF, Jarvis MAE, Schnoll SH: Role of the primary
care physician in problems of substance abuse. Archives
of Internal Medicine 1999;159:913
Bien TH, Miller WR, Tonigan JS: Brief interventions for
alcohol problems: a review. Addiction 1993;88:315
55. References
Substance Abuse and Mental Health Services
Administration (SAMHSA): Results from the National
Survey on Drug Use and Health: National Findings.
Office of Applied Studies, Rockville, MD: SAMHSA; 2008
American Psychiatric Association (APA): Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision. Washington, DC: APA 2000