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Substance Use Disorders in the Geriatric Patient

VIEWS: 90 PAGES: 30

									SUBSTANCE USE DISORDERS IN
    GERIATRIC PATIENTS

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




         Copyright Alcohol Medical Scholars Program   1
Substance Use Disorders (SUDs) in Geriatric
      Patients Are Often Overlooked




• Substance users stereotyped as young

• Physicians miss substance use




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   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



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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
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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

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  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

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       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



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        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
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    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



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          II. Medical Complications



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

• Thrombocyopenia, macrocytosis




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         III. Medical Complications

• Neurologic
     • Increased dementia, Wernicke’s
       encephalopathy, Korsakoff’s psychosis

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

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                       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

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     Importance of Physician Screening



• Medical complications

• Doctors in an important position to intervene




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    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.


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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.


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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

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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.


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 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
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             Treatment of SUDs

• Identification

• Intervention

• Detoxification

• Rehabilitation



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               Identification


Doctor’s office, clinic and hospital
extremely important sites for identification




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 Intervention in Geriatric patients


• Involve adult family members.

• Denial by family and peers.

• Reduced mobility.

• Losses and social isolation.


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         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.
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    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)



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    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)




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      General Overview of Alcohol
            Detoxification


• Supportive treatment

• Benzodiazepine taper




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                   Opioid Detox

• Supportive Treatment

• Medication
    • Clonidine
    • Methadone taper




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   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.




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  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




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     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
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                       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


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