Kevin W. O'Neil, MD, FACP, CMD and Chief Medical Officer of Internal Medicine and Geriatrics reviews how to navigate the intricacies of substance abuse in older adults.

1. Substance Abuse in
Older Adults
Kevin W. O’Neil MD, FACP, CMD
Internal Medicine and Geriatrics
Chief Medical Officer

2. Objectives
• Define the prevalence of alcohol and substance abuse
among older adults.
• Name two screening instruments for alcohol abuse in
older adults and one screening instrument for
prescription drug abuse.
• Name three recommendations of an expert panel of
SAMHSA (Substance Abuse and Mental Health Services
Administration) for treatment of substance abuse.

3. • Overall prevalence in older adults about 17%
• Reasons underreported:
– Symptoms mistaken for dementia, depression, etc.
– Older adults tend to hide substance abuse
– Relatives may be ashamed and hide it
Prevalence of Alcohol and Substance Abuse

4. • One drink =
– 12 oz. beer
– 4-6 oz. glass of wine
– 1 ½ oz. distilled spirit
• Heavy use:
– Men >2/day
– Women >1/day
Alcohol Use

5. Measurement Is Important

6. • 2.5 million older adults
• 21% of hospitalized adults over age 40
• Community Elderly
– Heavy Alcohol Use: 3-25%
– Alcohol Abuse: 2-9.6%
• Primary Care Outpatients
– 12% women
– 15% men
Prevalence of Alcohol Abuse (NIAAA)

7. • Early Onset
– Continuing
– 2/3 of older adults with alcohol abuse
• Late Onset
– Mostly previous users
– Increased use
– Or more vulnerable to EtOH effects
Onset

8. • People 65 and older consume more prescribed and
OTC medications than an other age group.
• Illicit drug problems rare in those not previously
addicts or alcoholics..
• Opiates: Abuse or dependence rare unless a history
of addiction.
• Approximate 4 addicted out of about 12,000
morphine prescriptions.
Drugs

10. • Chronic use: 1.8%
• Women > Men
• 17-23% of all prescriptions for older adults
• Chronic use >4 months not recommended
• Treatment of insomnia should be limited to 7 to 10 days
with frequent monitoring and reevaluation if the
prescribed drug will be used for more than 2 to 3
weeks. Intermittent dosing at the smallest possible
dose is preferred, and no more than a 30-day supply of
hypnotics should be prescribed.
Benzodiazepines Hypnotics

11. • Legal: not driving
• Marital: widowed
• Occupational: retired
• Tolerance and Withdrawal differ
Consequences of Substance Abuse

12. • Hypertension
• Cardiac arrhythmias
• Myocardial infarction
• Cardiomyopathy
• Hemorrhagic stroke
• Impaired immune function
• Liver disease
• GI disease
• Osteoporosis
• Psychiatric
• Falls/fractures
Health Consequences

13. • Drowsiness
• Delirium
• Forgetfulness
• Dependence and withdrawal
• 23% of adverse drug events in nursing homes
Adverse Effects

14. • Past history of alcohol use disorder (AUD)
• Male gender (2x female)
– 10% have history of AUD
– 43% of LTC veterans have history of AUD
• Loss of spouse
• Other losses
– Health, sensory, function, mobility
• Psychiatric disorder
• Nicotine, or other drug use disorder
Alcohol Use: Risk Factors

15. • Female gender
• Older age
• Poor health
• Widow
• Divorce
• Anxiety, depression, stress
Risk Factors: Drugs

16. • Cognitive impairment
• Tremors, seizures
• Irritability, mood changes, sleep disturbances
• Unexplained pain
• Poor hygiene, neglect
• Abnormal liver function tests
• GI complaints
• Malnutrition
• Urinary incontinence
• Gait disturbance, falls
• Slurred speech
Red Flags

17. • Patient feels threatened
• Assure confidentiality
• Use non-judgmental approach
• Don’t rush
• A medical approach is better: “The alcohol is
affecting your liver enzymes.”
• Build on problems and causal link with alcohol/drug
use
• You and the patient against their problems
Approach To Patient

18. • Talk to others to confirm story
– Spouse
– Other family
– Friends
• Obtain permission!
Collateral Information

19. • Alcohol
– CAGE
– MAST
– AUDIT
– Maximum in last year
• Other drugs
– Use despite consequences
Screening

20. • C: Have you ever felt the need to Cut Down?
• A: Have you ever been Annoyed at criticism of your
drinking?
• G: Have you ever felt Guilty about your drinking?
• E: Have you ever had a morning Eye-opener to get
going?
CAGE

21. 21
• Simple, self-scoring test
• Twenty-two questions
• Yes or No Answers
• Scoring:
• 0-2: No apparent problem
• 3-5: Early or middle problem drinker
• 6 or more: Problem drinker
MAST: Michigan Alcoholism Screening Test

22. AUDIT: Alcohol Use Disorders Identification Test
• Developed by the World Health Organization
• Clinician-administered and self-report version
• Ten questions
• First three questions deal with quantity and
frequency of use
• Geriatric primary care out-patients
• CAGE: 5% prevalence
• AUDIT: 18% prevalence

23. • Eight item questionnaire
• Obtains information from patients about lifetime use of
substances
• Current substances use associated problems over the last 3
months (tobacco products, alcohol, cannabis, cocaine,
amphetamine-type stimulants, sedatives, sleeping pills,
hallucinogens, inhalants, opioids, ‘other’ drugs)
• Can identify a range of problems associated with substance use:
– acute intoxication
– regular use
– dependent or ‘high risk’ use
– injecting behavior.
ASSIST: Alcohol, Smoking, and Substance Involvement
Screening Test

24. • Evidence-based practice used to identify, reduce,
and prevent problematic use, abuse, and
dependence on alcohol and illicit drugs.
• SBIRT model was incited by an Institute of Medicine
recommendation that called for community-based
screening for health risk behaviors, including
substance use.
SBIRT: Screening, Brief Intervention, and Referral to
Treatment
http://www.integration.samhsa.gov/clinical-practice/sbirt

25. • Dementia/Delirium
– MMSE
– SPMSQ
– Mini-Cog
– SLUMS
– CAM
• Functioning
– ADLs
– IADLs
Cognition/Function

26. • Feedback on alcohol/drug use and consequences
• Reasons for use
• Reasons to cut down/stop
– Health
– Mental capacity
– Independence
• Goals, written agreement
Brief Intervention

27. • Readiness for Change (Prochaska)
– Pre-Contemplation
– Contemplation
– Preparation
– Action
• Need to believe the benefits of change
Motivational Counseling

28. • Age-specific treatment and pace
• Focus on:
– Depression, losses
– Restoration of self-esteem and social supports
• Staff experienced with elders
• Links with services for elders
Treatment

29. “ Alone we can do so little;
together we can do so much.”
— Helen Keller
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