Substance Use Disorders

in Geriatric Patients

Marilyn White-Campbell

Geriatric Addiction Specialist

Community Responsive Behavior Team

St Josephs Health Care Guelph/ CMHA

OBJECTIVES

1) To review the unique needs of Older Adults with Substance Use Disorder.

2) To discuss best practice in Geriatric Addictions.

3)To enhance your knowledge in the care of geriatric patients who have

addictions

4) To provide local and provincial resources to support older adults with SUD

Why is Addiction different in the

Geriatric Population?

Additional care is required when applying DSM-V TR diagnostic criteria to older Adults

significant problems with even low amounts of alcohol intake

tolerance and withdrawal need not be present

Physiological aging changes include proportion of body fluids (reduced) & metabolism (slower)

NB prolongation of neurological consequences

Geriatric Addictions. What's the

difference?

High rates of mental health problems in older people (including a high prevalence of cognitive disorders) result in frequent, complex psychiatric comorbidity accompanying substance use disorders

Older people may show complex patterns and combinations of substance use (e.g. alcohol plus inappropriate use of prescribed medications)

Mortality rates linked to drug and alcohol use are higher in older people compared with younger people

Our invisible addicts First Report of the Older Persons’ Substance Misuse

Working Group of the Royal College of Psychiatrists Report CRP 165 2011

SUD in Geriatric MENTAL HEALTH

The prevalence of SUD (1999-2009) in a geriatric inpatient population (1,788

admission) admitted over a ten-year period was 11.7%. Most commonly

abused substance = alcohol totaling 73.3% of the identified substance use

disorders. Other SUDs were also found including sedative-hypnotics, opiates,

cannabis, and tobacco.

The prevalence of other SUDs was as follows: sedative-hypnotic

abuse/dependence 11%, opiate abuse/dependence 2.9%, cannabis abuse 1%,

tobacco use disorder 1.4%

(Dombrowski et al, 2016)

Addiction can be categorized as Geriatric

Syndromes

Geriatric syndromes speak to the multifactorial

etiology/multiple organ systems which contribute

to common geriatric problems e.g. falls- can

result from Musculoskeletal, Cardiac,

Medications, Sensory issues…

Addictions may be present and a precipitating

factor in many geriatric presentations

Why is Addiction different in the

Geriatric Population?

Alcohol not broken down by the liver goes to the

rest of the body, including the brain.

Alcohol can affect parts of the brain that control

movement, speech, judgment, and memory.

These effects lead to the familiar signs of

intoxication : difficulty walking, slurred speech,

memory lapses, and impulsive behavior.

Long-term heavy drinking can shrink the frontal

lobes of the brain, which impairs thinking

Alcohol use disorders=Health

Problems

• Increased drinking puts older adults at increased risk of wide range of devastating diseases Coronary Artery Disease, Hypertension, Stroke,

Osteoporosis, and Liver Problems

• Being under the influence of alcohol can affect balance and can increase the risk of falls in older adults

• Heavy drinking can cause problems related to self neglect, such as nutrition and poor hygiene

• Most LTCH (Long Term Care Home) Residents with Addictions were described as residents with behaviors

CASE STUDY Female 58 years old

Formerly homeless now living in LTHC

Long term history of alcohol and marijuana use currently abstinent for 18

months

Wheel chair bound incontinent of urine

Stage four wounds to coccyx and feet

Prescribed multiple opiates to manage pain

2 pack a day smoker

Refusing wound care stating it is too painful

Misses am opiates regularly as she leaves the floor to smoke outside

Returns to the floor demanding pain medications is yelling and screaming

at staff to get her pills.

What do you think the issues are here?

SURVEY

1. Alcohol addiction

2. Marijuana dependent

3. Opiate addiction

4. Nicotine Addiction

5. Benzodiazepines

6. Mental Health

7. Pain

8. Mobility

Opiates and Older Adults

Drug seeking behaviour

Is the older adult Crushing

snorting, cooking injecting?

Buying from the street or

dealer?

Other substances

Chronic Pain Management

Older adults may be

undertreated for pain

Methadone Maintenance

Buephenorephine most

appropriate for seniors

Canadian Guideline for Safe and Effective

Use of Opioids for Chronic Non-Cancer Pain —

Part B: Recommendations for Practice,

Version 5.5 April 30 2010

Withdrawal considerations

what do we need to address?

Survey

alcohol

Marijuana

Opiates

Nicotine

Benzodiazepines

Options for palliative care

Pain management

opiate Replacement therapy

Benzodiazepines for anticipatory pain during wound care

Nicotine replacement Therapy

Spray Vs Patch

WITHDRAWAL

MANAGEMENT FOR

GERIATRIC PATIENTS IS

DIFFERENT

Nicotine Spray

Use of spray is helpful (particularly with cognitively impaired)

Used to manage the withdrawal of nicotine

Used to decrease agitation behaviors around smoking

Response time from administration 2 minutes

16

Opioid Withdrawal Half-Life Affects Time Course

Begins day 1-2, with in 10 hours of last dose

Peaks day 2-3, Begins resolving day 5-7 longer for older adults

Acute Signs and Symptoms

Nausea, vomiting, diarrhea

anxiety, dysphoria, insomnia

knees and back worst

Runny nose, goose bumps

Withdrawal and Instability can cause

Delirium

DSM-5 diagnostic criteria :

Disturbance of consciousness - reduced ability to focus, sustain, or shift

attention.

Change in cognition that is not better accounted for by a preexisting,

established, or evolving dementia.

The disturbance develops over a short period (usually hours to days) and

tends to fluctuate during the course of the day.

Evidence from the history, physical examination, or laboratory findings is

present that indicates the disturbance is caused by a direct physiologic

consequence of a general medical condition, an intoxicating substance,

medication use, or more than one cause.

DELIRIUM TREMENS

Immediate Hospitalization

Should not rely on history to identify risk

Worsening disorientation, sweating, tremors, (CIWA sx’s)

DT is potentially fatal and can occur in a 3-5 day with special

attention to the first 48 hours

History (Delirium) Because delirious patients often are confused and unable to

provide accurate information, getting a detailed history from family, caregivers, and nursing staff is particularly important.

Delirium is mistaken for dementia or depression, especially when patients are quiet or withdrawn. Health professionals can do Mini-Mental Status Exam (MMSE),[15] depression assessment screening using DSM-5 criteria,[1] or the Geriatric Depression Scale (GDS).

They can also assess for suicidal and homicidal risk if necessary

Delirium always should be suspected when (a new onset) or an acute or subacute deterioration in behavior, cognition, or function occurs. Patients may have visual hallucinations or persecutory delusions as well as grandiose delusions.

Some patients with delirium also may become suicidal or homicidal. Therefore, they should not be left unattended or alone.

.

Tools (Delirium)

Diagnostic instruments are the Delirium Symptom Interview (DSI) and the

Confusion Assessment Method (CAM).

Delirium symptom severity can be assessed by the Delirium Rating Scale (DRS)

and the Memorial Delirium Assessment Scale (MDAS).

Alcohol withdrawal in older Adults

More prolonged withdrawal and higher risk of delirium

daytime sleepiness

weakness

high blood pressure

FALLS

Some older Adults may not be suitable for outpatient

Withdrawal:

lack of adequate social support

significant withdrawal symptoms

comorbid physical & mental illness

complicated withdrawal (seizures, delirium cognitive impairment )

KINDLING EFFECT OF WITHDRAWAL

Increasing severity of withdrawal following repeated withdrawal episodes

Increasing risk of seizures on withdrawal with increasing number of

withdrawal episodes

Progressive brain damage excitatory neurotransmitters with each

withdrawal episode

May lead to permanent brain damage (dementia)

Prompt treatment with benzodiazepines to prevent seizures may prevent

further damage

Thiamine

Dementia and substance use

23

Reversibility in Alcohol Related

Dementia

In contrast to other common causes of dementia, it has been suggested that

the decline in cognitive or physical functioning in alcohol-related

dementia is relatively non-progressive in abstinent ex-drinkers, or even

partially reversible; this is supported by imaging studies.

Goldman MS. Cognitive impairment in chronic alcoholics. Am Psychol

1983; 38: 1045–54.

Is Alcohol induced dementia

progressive?

Evidence suggests that alcohol-related dementia is less progressive than Alzheimer’s disease and even potentially partially reversible.

Anti-Craving Medications

FEATURES

Reduce urges to have a drink

Reduce pleasurability with drink (reducing

likelihood of a second or beyond)

MARKERS

Contribute to decreased days drinking

Contribute to increased days without relapse

Anti- Craving Medications

Medications you should be abstinent (no drinking) on for 48 hours before starting

Campral (Acamprosate)

Revia (Naltrexone)… there is increasing evidence for its use even without abstinence

Medications you must be abstinent on for 24 hours before starting

Antabuse (Disulfiram) NOT RECCOMENDED IN ELDERLY

Medications you can start on right away

Gabapentin

Topamax (Topiramate)

Baclofen

*Naltrexone

Naltrexone (Revia)

Well tolerated

Safety:

No major liver side effects if the patient “sampled” alcohol Only half as likely to relapse

Compliance/Adherence:

Older patients more likely than younger to take Naltrexone

regularly(Oslin, 2002);less likely to relapse than younger;

better attendance at therapy sessions than younger patients taking naltrexone

NB Older adults appear to respond well to a medically oriented

program that is supportive and individualised

Key Facts

Substance Use disorders in Older Adults is complex/ different treatment

approaches are needed

Withdrawal in older adults takes longer and there is a higher risk for

Delirium

Pharmacotherapy for addictions in older adults can be successful in

helping to reduce the harm of the substance

Older adults with SUD can be supported to safely withdraw from substances

and improve cognition and mobility.

Key Facts

For older adults, consequences of substance use and withdrawal are often more immediate and intense than in the general adult population

Questions need to be appropriate for the life stage and the context and sequence of questioning are important.

Going beyond substance use to assess mental health and cognitive status can provide a context for the information gathered and clarify the treatment plan.

Resources Provincial Drug and Alcohol Helpline

1-800-565-8603

DART information on beds and treatment availability

CAMH

416 535 5801 press 2 Access CAMH

8:30 to 4:30 (Not a crisis service)

Addiction services press 4

Addiction Medicine Clinic press 4

Emergency department ( not detox ) call through main switchboard ask for ED

Addictions Clinical Consultation services 1888 720 2227 pharmacy social work and addiction medicine

porticonetwork.ca

CAMH powered knowledge exchange Opiate tapering procedures videos etc.

STOP study Nicotine dependence ( stop on the road program )

nicotinedependanceclinic.com 416 535 8501 77400

21 day residential treatment wait time for distance clients is about 3 months call 416 538 8501 ext37062

RESOURCES

National Initiative for the Care of the Elderly addiction tools

http://www.nicenet.ca/cart-nice/gallery.aspx?pg=135&gp=57&ret=gallery

four tools including two physician pocket guides for addiction older adults

Waterloo Wellington Frailty E Modules provides e learning with test and e

certificate issued at conclusion

http://www.regionalhealthprogramsww.com/frailtymodules/

• Alcohol, delirium dementia , depression, pain, medication review, falls

• Behavioral Supports Ontario Older Adult Substance Use collaborative

• http://brainxchange.ca/Public/Communities.aspx#SubstanceUse

Provincial Resources

Monthly OTN Geriatric Addiction Rounds

First Tuesday of the Month noon to 1:30

First 45 minutes is educational presentation with Q& A

Last 30 minutes is closed session for case based consultation with Addiction

Medicine

Contact mwhitecampbell@cmnhaww.ca or darmstrong@cmha.ca to register

Marilyn White-Campbell

mwhitecampbell@reconnect.on.ca

mwhitecampbell@cmhaww.ca