Substance Abuse in the Elderly: What Every Clinician

Should Know

Courtney Ghormley, PhDGeriatric 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 - http://www.census.gov/

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 – www.aoa.gov

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 (4th 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 18-24 = 22.1% vs. Males 65+ = 1.2% • Females 18-24 = 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?

http://www.ssc.wisc.edu/wlsresearch/pilot/P01R01_info/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 Cut down?• Does other’s criticism of your drinking Annoy you?• Have you ever felt Guilty about drinking?• Have you ever had an “Eye 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, PhDGeriatric Neuropsychologist

Central Arkansas Veterans Healthcare System

North Little Rock, AR

Courtney.ghormley@va.gov501-257-3234