Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds

Alcohol and substance misuse in older adults

With the "Baby Boom" cohort reaching the age of 65 years, the older adult population is growing and will continue to grow at a rapid rate. There is a substantial and growing number of older adults who misuse alcohol, psychoactive prescription drugs, and/or other substances. The emerging literature on the cohort of aging adults indicates that they are continuing to use alcohol and psychoactive prescription medications at a higher rate than previous generations. The development and refinement of techniques to address these problems and provide early intervention services is going to be crucial to meeting the needs of this growing population. This chapter provides background on the extent of the problem, guidelines for alcohol and psychoactive medication use, and methods for screening and providing early interventions to improve the lives of older adults who misuse alcohol and/or psychoactive medications and drugs.

Psychoactive drug abuse in older adults

BACKGROUND

Misuse and abuse of legal and illegal drugs constitute a growing problem among older adults.

OBJECTIVE

This article reviews the prevalence, risks and protective factors, and screening and diagnosis of drug abuse in older adults. Treatment concerns and the consequences of drug problems are examined briefly.

METHODS

MEDLINE and PsychInfo were searched using the terms substance-related disorders, drug-use disorders, abuse, dependency, opioid-related disorders, stimulant-related disorders, cocaine-related disorders, marijuana-related disorders, and withdrawal syndrome. The review included articles published in English between January 1, 1990, and May 31, 2006.

RESULTS

Despite a wealth of information on the epidemiology and treatment of alcohol abuse in older adults, few comparable data are available on drug abuse in this population. The evidence suggests that although illegal drug use is relatively rare among older adults compared with younger adults and adolescents, there is a growing problem of the misuse and abuse of prescription drugs with abuse potential. It is estimated that up to 11% of older women misuse prescription drugs and that nonmedical use of prescription drugs among all adults aged > or =50 years will increase to 2.7 million by the year 2020. Factors associated with drug abuse in older adults include female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential. No validated screening or assessment instruments are available for identifying or diagnosing drug abuse in the older population. Special approaches may be necessary when treating substance-use disorders in older adults with multiple comorbidities and/or functional impairment, and the least intensive approaches should be considered first.

CONCLUSIONS

Psychoactive medications with abuse potential are used by at least 1 in 4 older adults, and such use is likely to grow as the population ages. The treatment of disorders of prescription drug use in older adults may involve family and caretakers, and should take into account the unique physical, emotional, and cognitive factors of aging. Further research is needed on the epidemiologic, health services, and treatment aspects of drug abuse in older adults, as well as the development of appropriate screening and diagnostic tools.

[Substance abuse in middle and old age -- general abuse]

The problems of drug-addicted middle- and older-aged people have been disregarded for a long time. However, results show a risky consumption of illegal drugs in the 18- to 59-year-old German population. The following paper will analyse the substance abuse of alcohol, sedatives, cannabis, stimulants, cocaine, opiates and other drugs not described more closely (all of which lead to health problems) using the Interdisciplinary Longitudinal Study of Adulthood (ILSE). Data collection is based on two cohorts (1930-1932 and 1950-1952) at two measurement points (1. MMP: N = 1006, 2. MMP: N = 900) in centres of investigation in Heidelberg and Leipzig. The "Substance Abuse Section" of the Structured Clinical Interview for DSM-III-R (SCID) was used for the evaluation. The abuse of alcohol can be registered as the focal point. Men consume more alcohol, while women tend to take sedatives, stimulants, opiates and other substances more often. The East-West comparison shows the importance of accessibility. At both measurement points, abuse of more substance groups was determined in the Heidelberg centre. As for as the abuse rates are concerned, a reduction of all the substance groups can be registered for the second measurement point.

Nonalcohol-related use disorders in geropsychiatric patients

The authors determined the prevalence and demographic features of drug use disorders in a database of 565 veteran geropsychiatric inpatients. Twenty-four patients (4%) were diagnosed with nonalcoholic substance use disorders, including 18 (3%) with prescription drug use disorders and 6 (1%) with illegal drug use disorders. The patients diagnosed with prescription drug use disorders were predominantly Caucasian, whereas those diagnosed with illegal substance use disorders were predominantly African American. No other significant demographic differences were noted. Nonalcohol substance use disorders represent an unappreciated problem in psychiatrically hospitalized older adults, with illegal substance use disorders making up a larger than expected proportion of this group.

Geriatric substance use disorders

AUDs are increasingly recognized as common problems among older adults. The magnitude of this problem is likely to increase over ensuing decades as baby boomers reach retirement age with drinking habits that are significantly different from current cohorts of older adults. Barriers to detection are numerous and include nonspecificity of alcohol-related presentations, patient denial, and clinicians' unwillingness to recognize that patients can and do develop alcohol problems in later life. Despite the limitations of current screening and diagnostic instruments, the authors recommend use of the CAGE as a formal screening tool for older patients because of its brevity, demonstrated efficacy, and convenience. In patients who answer affirmatively to any CAGE question, diagnostic certainty can be increased by use of follow-up questions or referral to an alcohol treatment specialist. Referral of patients with established alcohol abuse or dependence is essential for definitive treatment, and successful outcomes can be expected and are gratifying once achieved. In patients with less severe AUDs, brief interventions with frequent follow-up are recommended. Age-specific screening and diagnostic instruments for older AUD patients, once fully developed and validated, will facilitate identification. Much less is known about other substance use disorders in older adults. Psychoactive drug use is not uncommon in this patient population and may result in adverse health outcomes. Treatment interventions proposed for AUDs are advocated for older adults found to have other substance use disorders as well and are likely to yield improved outcomes. Future investigations that better define the epidemiology, detection, and treatment of other substance use disorders in older populations are clearly warranted at this time.

Factors associated with suboptimal analgesic use in community-dwelling elderly

OBJECTIVE

To examine patterns and factors associated with overall and suboptimal analgesic use among community-dwelling elderly.

DESIGN

Cross-sectional survey.

SETTING

Five-county urban and rural region in Piedmont, NC.

PARTICIPANTS

A stratified random sample from the Duke Established Populations for Epidemiologic Studies of the Elderly of 3973 participants aged 65 years or older.

MAIN OUTCOME MEASURES

Use of any analgesic medication, suboptimal analgesic use (taking 2 or more analgesics from the same class, using 3 or more analgesics concurrently, or use of an analgesic that has a major interaction with another drug).

RESULTS

Analgesics were used by 60.4% of the participants. Use was more likely for those who had physical functional impairment, a history of cardiovascular disease, one or more health visits in the previous year, or were female. Use was less likely for older participants and for African-Americans with adequate financial status. Suboptimal use occurred in 9.2% of analgesic users. Therapeutic duplication was more likely in those who were depressed, needed help with basic activities of daily living, or used alcohol, and was less likely in those with adequate financial status. Multiple analgesic use was more likely in those who were depressed, had impaired physical functional status, had one or more health visits in the previous year, were African-American (of either sex), or were white women. Only two persons had a potential major analgesic-drug interaction.

CONCLUSIONS

Suboptimal analgesic use is common in community-dwelling elderly, and its risk in consistently increased in those who are depressed or have impaired physical functional status.

Alcohol and drug misuse in the nursing home

The misuse of alcohol or drugs is a common and frequently neglected problem among nursing home residents. The misuse of prescription medications is particularly prevalent, but tobacco, alcohol, and illicit drugs are all subject of misuse by nursing home residents. This article reviews the epidemiologic and clinical aspects of substance misuse in nursing homes, including alcohol, illicit drugs, tobacco, and pyscho-active medications. Regulations regarding the prescription of psycho-active drugs in nursing homes is also discussed.

The elderly and the use of illicit drugs: sociological and epidemiological considerations

Debates over the prevalence of elderly illicit drug addicts in the population divert our attention from this group as a viable study population. Due to their decelerated lifestyle, low crime rates, and our attitudes toward the elderly as nonstreet drug users, they are likely to remain hidden from the public eye. This paper reviews past trends in drug misuse among the elderly, the lifestyle of those addicted to drugs, the complications associated with drug misuse and aging, and the problems that the elderly face with traditional treatment programs. Given our aging society, is the study of elderly street addicts and users an important area of concern?

Treatment approaches for older problem drinkers

Recent research suggests that older adults with alcohol problems often drink in response to loneliness, depression, and poor social support networks. Although a variety of approaches such as psychodynamic, Twelve Step, social support, behavioral, and cognitive-behavioral, have been suggested, only those studies involving behavioral and cognitive-behavioral interventions have provided empirical support for treatment effectiveness. Some research also suggests that age-specific group treatment produces better outcomes than when older adults are placed in treatment with younger alcoholics.

Practical functional assessment of elderly persons: a primary-care approach

OBJECTIVE

To describe simple, practical measures of physical and psychosocial function to detect problems and enhance the care of elderly patients.

DESIGN

We reviewed pertinent articles and current standard textbooks of geriatrics; the most useful findings are summarized, and tools that can be used for functional assessment of the geriatric population are presented.

RESULTS

Care of elderly patients necessitates a comprehensive review of key areas of function. Using only clinical judgment, physicians may overlook important clinical deficits common in older patients. Because of their length and complexity, many of the standard geriatric assessment tools are impractical for use by primary-care physicians. Certain simplified or condensed versions--such as the Functional Reach Test and the "Get Up and Go" Test--are efficient substitutes. In this article, we describe methods for practical identification of functional impairments, assessment of cognition and mood, evaluation of hearing and vision, and detection of problems with continence, nutrition, and social needs. Instruments for assessment of caregiver burden are also outlined.

CONCLUSION

Use of the assessment tools presented herein can assist primary-care physicians in comprehensive evaluation of function in older patients.

A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients

BACKGROUND

Although many studies describe benefits from the comprehensive assessment of elderly patients by an interdisciplinary team (comprehensive geriatric assessment), the most supportive evidence for the process has come from programs that rely on specialized inpatient units and long hospital stays. We examined whether an inpatient geriatric consultation service might also be beneficial in a trial involving four medical centers of a group-practice health maintenance organization (HMO).

METHODS

We conducted a randomized clinical trial with 2353 hospitalized patients 65 years of age or older in whom at least 1 of 13 screening criteria were present: stroke, immobility, impairment in any basic activity of daily living, malnutrition, incontinence, confusion or dementia, prolonged bed rest, recent falls, depression, social or family problems, an unplanned readmission to the hospital within three months of a previous hospital stay, a new fracture, and age of 80 years or older. Of the 1337 patients assigned to the experimental group, 1261 (94 percent) received a comprehensive geriatric assessment in the form of a consultation, with limited follow-up; the 1016 patients assigned to the control group received usual care. The functional and health status of the patients was measured at base line and 3 and 12 months later; survival was assessed at 12 months. Subgroups of patients who might be presumed to benefit from comprehensive assessment were also studied.

RESULTS

The survival rate at 12 months was 74 percent in the experimental group and 75 percent in the control group. At base line, 3 months, and 12 months the scores of the two groups on measures of functional and health status were similar. The analysis of 16 subgroups did not identify any with either clearly improved functional status or improved survival.

CONCLUSIONS

In this HMO, comprehensive geriatric assessment by a consultation team, with limited follow-up, did not improve the health or survival of hospitalized patients selected on the basis of screening criteria.

Practice guidelines in the addictions. Recent developments

Consensually established principles of clinical conduct, known variously as practice guidelines, standards, protocols, or algorithms, have proliferated throughout medicine over the past decade. Institutional and disciplinary efforts to develop and promulgate guidelines for the treatment of additive disorders have recently been initiated. We review guideline development activities of the American Psychiatric Association, American Psychological Association, American Society of Addiction Medicine, American Nurses Association, National Association of Social Workers, and Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration. Medical care performance and outcome assessments are discussed with attention to the role they can play in evaluating and refining guidelines. Potential effects of guidelines, salutary and deleterious, on clinical practice in the addictions are delineated.