1. Copyright Alcohol Medical Scholars Program1 SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTS Steven H. Madonick, M.D. Yale University School of Medicine New Haven, CT

2. Copyright Alcohol Medical Scholars Program2 Substance Use Disorders (SUDs) in Geriatric Patients Are Often Overlooked Substance users stereotyped as young Physicians miss substance use

3. Copyright Alcohol Medical Scholars Program3 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

4. Copyright Alcohol Medical Scholars Program4 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

5. Copyright Alcohol Medical Scholars Program5 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

6. Copyright Alcohol Medical Scholars Program6 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

7. Copyright Alcohol Medical Scholars Program7 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

8. Copyright Alcohol Medical Scholars Program8 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

9. Copyright Alcohol Medical Scholars Program9 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

10. Copyright Alcohol Medical Scholars Program10 II. Medical Complications Increase in cancers of liver, esophagus, nasopharnx and colon Thrombocyopenia, macrocytosis

11. Copyright Alcohol Medical Scholars Program11 III. Medical Complications Neurologic Increased dementia, Wernicke’s encephalopathy, Korsakoff’s psychosis Psychiatric Alcohol-induced mood disorder Pseudodementia from mood disorder Suicide

12. Copyright Alcohol Medical Scholars Program12 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

13. Copyright Alcohol Medical Scholars Program13 Importance of Physician Screening Medical complications Doctors in an important position to intervene

14. Copyright Alcohol Medical Scholars Program14 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.

15. Copyright Alcohol Medical Scholars Program15 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.

16. Copyright Alcohol Medical Scholars Program16 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

17. Copyright Alcohol Medical Scholars Program17 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.

18. Copyright Alcohol Medical Scholars Program18 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

19. Copyright Alcohol Medical Scholars Program19 Treatment of SUDs Identification Intervention Detoxification Rehabilitation

20. Copyright Alcohol Medical Scholars Program20 Identification Doctor’s office, clinic and hospital extremely important sites for identification

21. Copyright Alcohol Medical Scholars Program21 Intervention in Geriatric patients Involve adult family members. Denial by family and peers. Reduced mobility. Losses and social isolation.

22. Copyright Alcohol Medical Scholars Program22 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.

23. Copyright Alcohol Medical Scholars Program23 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)

24. Copyright Alcohol Medical Scholars Program24 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)

25. Copyright Alcohol Medical Scholars Program25 General Overview of Alcohol Detoxification Supportive treatment Benzodiazepine taper

26. Copyright Alcohol Medical Scholars Program26 Opioid Detox Supportive Treatment Medication Clonidine Methadone taper

27. Copyright Alcohol Medical Scholars Program27 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.

28. Copyright Alcohol Medical Scholars Program28 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

29. Copyright Alcohol Medical Scholars Program29 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

30. Copyright Alcohol Medical Scholars Program30 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