Post on 31-Aug-2018
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