Substance Abuse in the Elderly: What Every Clinician Should Know Courtney Ghormley, PhD Geriatric Neuropsychology Central Arkansas Veterans Healthcare System

Disclosure of Interest Dr Ghormley has NO disclosures Robinson, A., Spenser, B., & White (1988)

Objectives Report on the process of addiction and the prevalence of substance abuse in the elderly. Discuss the importance of assessing for substance abuse and approaching patients about this health issue

Population Statistics US residents age 65 and over: 38.9 million Persons reaching age 65 have an average life expectancy of an additional 18.6 years (19.8 years for females and 17.1 years for males). United States Census Bureau -

Population Statistics The population 65 and over will increase from 35 million in 2000 to 40 million in 2010 (a 15% increase) and then to 55 million in 2020 (a 36% increase for that decade). The 85+ population is projected to increase from 4.2 million in 2000 to 5.7 million in 2010 (a 36% increase) and then to 6.6 million in 2020 (a 15% increase for that decade). Administration on Aging –

Statistics Breakdown by State

Alcohol Consumption NIAAA recommends that people age 65+ limit to 1 standard drink per day or 7 standard drinks per week with no more than 3 drinks per occasion – 12 ozs. of beer – 4-5 ozs. of wine – 1 ½ oz. liquor Naegle (2012)

Substance Disorders Diagnostic and Statistical Manual of Mental Disorders (4 th edition, text revision, DSM-IV-TR, 2000) – DSM-IV identifies 11 classes of substances Substance Use Disorders – Substance Abuse – Substance Dependence Substance-Induced Disorders DSM-IV-TR (2000)

Substance Abuse Maladaptive substance use leads to significant problems in 1 of 4 domains: – Legal – Interpersonal – Work or school – Hazardous behaviors Problems occur repeatedly within a 12-month period. In contrast to substance dependence, there is no withdrawal, tolerance, or compulsive use. DMS-IV-TR (2000)

Substance Dependence Persistent substance use resulting in impairment in 3 or more cognitive, behavioral, or physiological symptoms that include: – Persistent or unsuccessful attempts to cut down – Tolerance – Withdrawal – Curtailment of social, occupational, or recreational activities to use or obtain the substance DMS-IV-TR (2000)

Substance-Induced Disorders Substance intoxication Substance withdrawal Substance-induced persisting dementia Substance-induced persisting amnestic disorder Substance-induced psychotic, mood, or anxiety disorders Substance-induced sexual dysfunction Substance-induced sleep disorder Robinson, A., Spenser, B., & White (1988)

Increased Risk in the Elderly Largest consumers of prescribed medication – Receive 30% of all prescribed medication and 40% of benzodiazepine prescriptions Age-related changes in physiology cause drugs to be more potent Poor understanding of medication effects and interactions Inadequate education and misunderstanding of proper use Decreased cognitive abilities Robinson, A., Spenser, B., & White (1988)

Medical Treatment in the Elderly Average person age 65+: – 8-12 prescription medications – 1-3 over-the-counter medications / supplements Beers List for medications in the elderly Anticholinergic Effects – dry mouth, constipation, drowsiness, flushing / overheating, confusion / memory loss, blurred vision

Prevalence Rates in the Elderly Substance use disorders in the elderly – 1 year prevalence rate of alcohol abuse Males = 22.1% vs. Males 65+ = 1.2% Females = 9.8% vs. Females 65+ = 0.3% 20% of older adults had a substance abuse disorder during their lifetime 19% are “at risk” drinkers 23% report binge drinking Notably, alcohol abuse is significantly more prevalent in elderly hospitalized patients, with incidence as high as 50% – 1 year prevalence rate for illegal drug use Age 18 to 29 = 4.0% vs. Age 65+ = less then 1/10 of 1.0% Naegle (2012); Snyder et al. (2009)

Reasons for Decreased Rates “Maturing out” theory – Maturation – Increased mortality among those who abuse Decreased detection in the elderly population – Inadequate or inappropriate diagnostic criteria – Abuse of prescription medications – Late-life onset of substance abuse Snyder et al. (2009)

“Maturing In” Theory Increased risk in an otherwise low-risk population: – Unique and novel challenges of life – Depression – Pain – Increased access to prescription medications – Increased potency secondary to age-related physiological changes – Older adults less likely to perceive it as a problem or to seek treatment Lin et al. (2011); Snyder et al. (2009); Wu & Blazer (2011)

Detection in the Elderly Elderly less likely to meet full DSM-IV criteria for dependence Limited assessment measures focused on elderly population Increased stigma Clinicians simply do not ask

Consequences for the Elderly Sleep problems and insomnia Depression GI problems Increased confusion Increased risk of delirium Risk of falls Head trauma Stroke Alcohol-induced dementia Overdose and death Snyder et al. (2009); Naegle (2012)

If you don’t ask, they won’t tell!

Assessment How much? GET SPECIFIC! How often? Use screening measures Social context and circumstances – Coping with low mood, loneliness, grief, pain, or sleep problems Prior experience with treatment and interest in resuming if needed

Alcohol Screening Measures Short Michigan Alcohol Screening Test – Geriatric Version (SMAST-G) – 10-item, self-report measure – Score of 2 or more indicates alcohol problems – Good specificity (78%) and sensitivity (94%) Johnson-Greene, et al. (2009); St. John, et al. (2009)

Alcohol Screening Measures – Sample items (SMAST-G) : Does alcohol sometimes make it hard for you to remember parts of the day or night? Have you ever increased your drinking after experiencing a loss in your life? When you feel lonely, does having a drink help? o/aging_mind/Aging_AppB5_MAST-G.pdf Robinson, A., Spenser, B., & White (1988)

Alcohol Screening Measures CAGE Questionnaire – Screening for alcohol dependence – 4 Qs, 2 “yes” responses suggests alcohol problems Have you ever felt you should C ut down? Does other’s criticism of your drinking A nnoy you? Have you ever felt G uilty about drinking? Have you ever had an “ E ye Opener” to steady your nerves or get rid of a hangover?

Benzodiazepines Elderly receive about 40% of Benzo prescriptions Even low doses can impair cognition Two key questions: – Have you tried to stop taking this medication? – Over past 12 mos., have you noticed a decrease in the effect of this medication? – 97% sensitivity and 94% specificity to detect benzo dependence Voyer et al. (2010)

How to Talk to Your Patients Let them know you are concerned Educate about the “recommended” daily consumption Educate about the negative impact of substance abuse Encourage them to cut down Provide non-judgmental support and always leave the door open – Motivational Interviewing Techniques Make appropriate referrals for treatment if needed

Summary Substance abuse is a growing problem in the elderly Elders are at increased risk for co-morbidity and mortality Clinicians should be engaging their elderly patients about this topic on a regular basis Talk to your patients and use screening measures when appropriate

Questions? Courtney O. Ghormley, PhD Geriatric Neuropsychologist Central Arkansas Veterans Healthcare System North Little Rock, AR