1. Addictions in the Older AdultAlcohol, Drugs, Gambling Michelle Gibson, MD, CCFP, COE Queen’s University, Geriatric Medicine Specialized Geriatric Services

2. Objectives • Participants will be able to: • Recognize addiction in older adults • Discuss management strategies

3. What are your challenges?

4. Outline • Case presentations • Review of diagnostic criteria • Alcohol • Drugs • Gambling • General approach to management

5. Mr. S.H. • 83 y.o. man, admitted to acute care with falls, weakness • Diagnosed with acute renal failure secondary to dehydration & diarrhea • Admits to consuming 10 drinks (2 oz.) of scotch per day • Rehydrated, given a walker, sent home.

6. Mr. S.H. • Medical History • COPD (smokes 1 pack per day) • CVA 1999 (“mild”) • HTN • Dyslipidemia • Venous insufficiency & edema • Alcoholic liver disease • Left hip fracture 1990

7. Mr. S.H. – Day Hospital • Still having falls – very vague history • Quit smoking! But not taking any meds • Initial bloodwork • Serum ethanol: 56.7 mmol/L (@1300!) • Hb 137; MCV 106 • GGT 315 • AST 115

8. If you were seeing him • What would your approach be?

9. Mrs. MD • 79 year old woman being admitted to LTC • Dementia, chronic pain from spinal stenosis, falls, “nerves” • Was “misusing” meds at home according to home care. • Husband has cognitive issues, med issues, also awaiting LTC.

10. Mrs. MD – selected meds • Diazepam 5mg tid • Lorazepam 2mg po qhs • Meperidine 50mg po q4h prn • “Allergic” to: codeine, morphine, oxycodone, hydromorphone, amitriptyline, gabapentin, pregabalin

11. Mrs. MD • Pain history: “all over, all the time” • Cannot articulate more than this. • “Demerol is the only thing that helps”. • “I can’t cope without my nerve pills and my sleeping pill.”

12. What’s your approach?

13. Addiction • Primary, chronic disease characterized by impaired control over the use of a psychoactive substance and/or behaviour. • Bio/Psycho/Social/Spiritual • Progressive, relapsing, fatal. • www.csam.org/non_member/definitions/

14. Substance Abuse • Maladaptive pattern, significant impairment or distress, and 1 or more of • Failure to fulfill role at work, school or home • Physically hazardous • Substance-related legal problems • Persistent or recurrent social or interpersonal problems • Has never met criteria for Dependence

15. Substance Dependence • Maladaptive pattern, significant impairment or distress, and 3 or more of • Tolerance • Withdrawal • Larger amounts than intended • Unsuccessful efforts to cut down • Significant amount of time spent on substance • Reduced activities 2o to substance • Persistent use despite problems

16. The Pickle Line • All cucumbers can become pickles, but… • Once a pickle, you can never become a cucumber again...

17. Alcohol

18. Epidemiology - Alcohol • Alcohol use decreases after age 60 • “Problem drinking” as high as 14% • CSHA – 8.9% alcohol abuse • High prevalence in hospitalized elderly (21% in one study) • Incidence rates for abuse/dependence decline with age up to 60 • Increase after age 60, especially in men 75+

19. Patterns of “alcoholism” • Early onset vs. late onset • Age 60 is arbitrary cut-off • 2/3 in early onset group • Somehow avoided usual complications - allowing them to get to later life

20. Late-onset “alcoholism” • Usually arises in former drinkers • Women as a greater proportion • Three common patterns • Onset of cognitive / functional impairment in “functional” alcoholics • Increased sensitivity to effects of alcohol • New problem as a result of a stressor

21. Geriatric Presentations • “Confusion” • Falls and functional decline • Polypharmacy • Urinary incontinence – • High fluid intake • Diuretic effect of alcohol

22. Physiological Changes Decreased Lean Body Mass Decreased Total Body Water Decreased gastric EtOH Dehydrogenase Increased Serum EtOH for a given dose

23. Alcohol-related Dementia? • Heavy alcohol consumption associated with cerebral atrophy • May be reversible – “dementia” and atrophy • Alcohol and other dementias • “functional” alcoholic developing problems 2odementia • “stable” dementia worsening 2o alcohol

24. Falls and functional decline • Impaired balance (acute and chronic) • Diuretic effect -> orthostasis • Myopathy • Neuropathy • Higher rates of hip fractures • Cognitive impairment (acute and chronic)

25. Polypharmacy • As a result of medical problems secondary to alcohol • Selected common geriatric presentations • HTN • CVA • Osteoporosis • Psycho-social-psychiatric problems

26. Psycho-social-psychiatric • Frequent familial stresses/dysfunction • Coming to light because of increasing dependence • Depression often co-exists, hard to diagnose • Anxiety leads to benzodiazepines

27. Detecting Problem Drinking • Look harder with suggestive findings: • Cognitive or self-care decline • Nonadherence – appointments, treatment • Unstable or poorly controlled HTN • Recurrent accidents, falls • Frequent ER visits • GI problems

28. Detecting Problem Drinking • Look harder • Unexpected delirium • Estrangement from family • Laboratory abnormalities • CAGE – use a cut off of 1 • Cut Back; Annoyed; Guilt; Eye opener

29. Standard Drinks • 12 oz. Beer • 5 oz. Wine • 1.5 oz. Liquor

30. Myths • They’re housebound – can’t get EtOH • Family as unwitting providers • Taxis • Delivery services • They’re old, of course they’re • Hypertensive • Demented • Falling, osteoporotic

31. Drugs

32. Benzodiazepines • Benzodiazepine use increases with age • Dose increases with age • 16% of inpatients in an addiction unit - “sedatives or hypnotics” • Women are prescribed sedatives 2.5 times more than men

33. Opioids • Not really studied • Abuse and dependence in the elderly certainly exists • Need to differentiate between untreated or undertreated pain and opioid misuse • Safe practice: • Single provider, single pharmacy, contract

34. Other drugs • OTC • Marijuana & others • Just about anything else • Stay tuned!

35. Gambling

36. Gambling epidemiology • 5% of those who gamble develop “problems” • 1% will develop serious problems • ?proportion of older adults • Pathological gambling is a DSM IV diagnosis – disorder of impulse control

37. Screening? • South Oaks Gambling Screen • EIGHT • Appropriate in the elderly? • More likely case-finding • Problem gambling is associated with poor physical health – think about it if the story doesn’t make sense

38. Treatment • Detection • Detection • Detection • Assess severity • Engage the patient in a treatment plan • HOW?

39. Treatment • Simple strategy • Identify it as a problem • Connect it to the patient’s other problems • Provide strategies to cut back

40. Treatment • Depends on severity of problem • Older patients may need inpatient detoxification • May need inpatient alcohol/drug rehab with geriatric focus • Community programs • Addiction medicine specialists are often essential – especially re: medications

41. Mr. S.H. • Meeting arranged to discuss alcohol consumption • Reviewed the numbers – serum alcohol, MCV, liver tests (speak in engineering terms…) • Connected to his concerns: • Poor balance & falls • Fear of another stroke • Wanting to get his license back

42. Mr. S.H. • Contracted to have no alcohol prior to attending Day Hospital, and to reduce his consumption by 25% • After another fall, requested help to attempt abstaining entirely • Small doses of lorazepam prescribed

43. Mr. S.H. • After 3 days, no withdrawal symptoms, but then felt he couldn’t commit to abstaining • Reached a common goal of 1 or 2 standard drinks per day • Continued education and support • Generally met his target

44. Mr. S.H. • No further admissions to acute care • Door left open to him for follow-up clinic – he needed to initiate it • Died 2 years later

45. Mrs. MD • No changes at first • Discussion with patient and *competent* substitute decision maker about goals of care, acceptance of risk. • Decision to try to find other pain modalities • Psychiatry consult for mood/anxiety • May just live with the drugs…? • No happy ending here.

46. Take Home Messages • Identification is key • Simple strategies work for many patients • It’s never often not too late! • Balancing quality of life and goals of care is crucial.

47. Thank you "…I may be forgiven for saying, as a physician, that drinking deep is a bad practice, which I never follow, if I can help, and certainly do not recommend to another, least of all to any one who still feels the effects of yesterday's carouse." Plato's Symposium (gibson@queensu.ca)