Addictions in the Older Adult Alcohol, Drugs, Gambling - PowerPoint PPT Presentation

1 / 47
About This Presentation
Title:

Addictions in the Older Adult Alcohol, Drugs, Gambling

Description:

Addictions in the Older Adult Alcohol, Drugs, Gambling Michelle Gibson, MD, CCFP, COE Queen s University, Geriatric Medicine Specialized Geriatric Services – PowerPoint PPT presentation

Number of Views:226
Avg rating:3.0/5.0
Slides: 48
Provided by: its1251
Category:

less

Transcript and Presenter's Notes

Title: Addictions in the Older Adult Alcohol, Drugs, Gambling


1
Addictions in the Older AdultAlcohol, Drugs,
Gambling
  • Michelle Gibson, MD, CCFP, COE
  • Queens University, Geriatric Medicine
  • Specialized Geriatric Services

2
Objectives
  • Participants will be able to
  • Recognize addiction in older adults
  • Discuss management strategies

3
What are your challenges?
4
Outline
  • Case presentations
  • Review of diagnostic criteria
  • Alcohol
  • Drugs
  • Gambling
  • General approach to management

5
Mr. S.H.
  • 83 y.o. man, admitted to acute care with falls,
    weakness
  • Diagnosed with acute renal failure secondary to
    dehydration diarrhea
  • Admits to consuming 10 drinks (2 oz.) of scotch
    per day
  • Rehydrated, given a walker, sent home.

6
Mr. S.H.
  • Medical History
  • COPD (smokes 1 pack per day)
  • CVA 1999 (mild)
  • HTN
  • Dyslipidemia
  • Venous insufficiency edema
  • Alcoholic liver disease
  • Left hip fracture 1990

7
Mr. S.H. Day Hospital
  • Still having falls very vague history
  • Quit smoking! But not taking any meds
  • Initial bloodwork
  • Serum ethanol 56.7 mmol/L (_at_1300!)
  • Hb 137 MCV 106
  • GGT 315
  • AST 115

8
If you were seeing him
  • What would your approach be?

9
Mrs. MD
  • 79 year old woman being admitted to LTC
  • Dementia, chronic pain from spinal stenosis,
    falls, nerves
  • Was misusing meds at home according to home
    care.
  • Husband has cognitive issues, med issues, also
    awaiting LTC.

10
Mrs. MD selected meds
  • Diazepam 5mg tid
  • Lorazepam 2mg po qhs
  • Meperidine 50mg po q4h prn
  • Allergic to codeine, morphine, oxycodone,
    hydromorphone, amitriptyline, gabapentin,
    pregabalin

11
Mrs. MD
  • Pain history all over, all the time
  • Cannot articulate more than this.
  • Demerol is the only thing that helps.
  • I cant cope without my nerve pills and my
    sleeping pill.

12
Whats your approach?
13
Addiction
  • Primary, chronic disease characterized by
    impaired control over the use of a psychoactive
    substance and/or behaviour.
  • Bio/Psycho/Social/Spiritual
  • Progressive, relapsing, fatal.
  • www.csam.org/non_member/definitions/

14
Substance Abuse
  • Maladaptive pattern, significant impairment or
    distress, and 1 or more of
  • Failure to fulfill role at work, school or home
  • Physically hazardous
  • Substance-related legal problems
  • Persistent or recurrent social or interpersonal
    problems
  • Has never met criteria for Dependence

15
Substance Dependence
  • Maladaptive pattern, significant impairment or
    distress, and 3 or more of
  • Tolerance
  • Withdrawal
  • Larger amounts than intended
  • Unsuccessful efforts to cut down
  • Significant amount of time spent on substance
  • Reduced activities 2o to substance
  • Persistent use despite problems

16
The Pickle Line
  • All cucumbers can become pickles, but
  • Once a pickle, you can never become a cucumber
    again...

17
Alcohol
18
Epidemiology - Alcohol
  • Alcohol use decreases after age 60
  • Problem drinking as high as 14
  • CSHA 8.9 alcohol abuse
  • High prevalence in hospitalized elderly (21 in
    one study)
  • Incidence rates for abuse/dependence decline with
    age up to 60
  • Increase after age 60, especially in men 75

19
Patterns of alcoholism
  • Early onset vs. late onset
  • Age 60 is arbitrary cut-off
  • 2/3 in early onset group
  • Somehow avoided usual complications - allowing
    them to get to later life

20
Late-onset alcoholism
  • Usually arises in former drinkers
  • Women as a greater proportion
  • Three common patterns
  • Onset of cognitive / functional impairment in
    functional alcoholics
  • Increased sensitivity to effects of alcohol
  • New problem as a result of a stressor

21
Geriatric Presentations
  • Confusion
  • Falls and functional decline
  • Polypharmacy
  • Urinary incontinence
  • High fluid intake
  • Diuretic effect of alcohol

22
Physiological Changes
Decreased Lean Body Mass
Decreased Total Body Water
Decreased gastric EtOH Dehydrogenase
Increased Serum EtOH for a given dose
23
Alcohol-related Dementia?
  • Heavy alcohol consumption associated with
    cerebral atrophy
  • May be reversible dementia and atrophy
  • Alcohol and other dementias
  • functional alcoholic developing problems 2o
    dementia
  • stable dementia worsening 2o alcohol

24
Falls and functional decline
  • Impaired balance (acute and chronic)
  • Diuretic effect -gt orthostasis
  • Myopathy
  • Neuropathy
  • Higher rates of hip fractures
  • Cognitive impairment (acute and chronic)

25
Polypharmacy
  • As a result of medical problems secondary to
    alcohol
  • Selected common geriatric presentations
  • HTN
  • CVA
  • Osteoporosis
  • Psycho-social-psychiatric problems

26
Psycho-social-psychiatric
  • Frequent familial stresses/dysfunction
  • Coming to light because of increasing dependence
  • Depression often co-exists, hard to diagnose
  • Anxiety leads to benzodiazepines

27
Detecting Problem Drinking
  • Look harder with suggestive findings
  • Cognitive or self-care decline
  • Nonadherence appointments, treatment
  • Unstable or poorly controlled HTN
  • Recurrent accidents, falls
  • Frequent ER visits
  • GI problems

28
Detecting Problem Drinking
  • Look harder
  • Unexpected delirium
  • Estrangement from family
  • Laboratory abnormalities
  • CAGE use a cut off of 1
  • Cut Back Annoyed Guilt Eye opener

29
Standard Drinks
  • 12 oz. Beer
  • 5 oz. Wine
  • 1.5 oz. Liquor

30
Myths
  • Theyre housebound cant get EtOH
  • Family as unwitting providers
  • Taxis
  • Delivery services
  • Theyre old, of course theyre
  • Hypertensive
  • Demented
  • Falling, osteoporotic

31
Drugs
32
Benzodiazepines
  • Benzodiazepine use increases with age
  • Dose increases with age
  • 16 of inpatients in an addiction unit -
    sedatives or hypnotics
  • Women are prescribed sedatives 2.5 times more
    than men

33
Opioids
  • Not really studied
  • Abuse and dependence in the elderly certainly
    exists
  • Need to differentiate between untreated or
    undertreated pain and opioid misuse
  • Safe practice
  • Single provider, single pharmacy, contract

34
Other drugs
  • OTC
  • Marijuana others
  • Just about anything else
  • Stay tuned!

35
Gambling
36
Gambling epidemiology
  • 5 of those who gamble develop problems
  • 1 will develop serious problems
  • ?proportion of older adults
  • Pathological gambling is a DSM IV diagnosis
    disorder of impulse control

37
Screening?
  • South Oaks Gambling Screen
  • EIGHT
  • Appropriate in the elderly?
  • More likely case-finding
  • Problem gambling is associated with poor physical
    health think about it if the story doesnt make
    sense

38
Treatment
  • Detection
  • Detection
  • Detection
  • Assess severity
  • Engage the patient in a treatment plan
  • HOW?

39
Treatment
  • Simple strategy
  • Identify it as a problem
  • Connect it to the patients other problems
  • Provide strategies to cut back

40
Treatment
  • Depends on severity of problem
  • Older patients may need inpatient detoxification
  • May need inpatient alcohol/drug rehab with
    geriatric focus
  • Community programs
  • Addiction medicine specialists are often
    essential especially re medications

41
Mr. S.H.
  • Meeting arranged to discuss alcohol consumption
  • Reviewed the numbers serum alcohol, MCV, liver
    tests (speak in engineering terms)
  • Connected to his concerns
  • Poor balance falls
  • Fear of another stroke
  • Wanting to get his license back

42
Mr. S.H.
  • Contracted to have no alcohol prior to attending
    Day Hospital, and to reduce his consumption by
    25
  • After another fall, requested help to attempt
    abstaining entirely
  • Small doses of lorazepam prescribed

43
Mr. S.H.
  • After 3 days, no withdrawal symptoms, but then
    felt he couldnt commit to abstaining
  • Reached a common goal of 1 or 2 standard drinks
    per day
  • Continued education and support
  • Generally met his target

44
Mr. S.H.
  • No further admissions to acute care
  • Door left open to him for follow-up clinic he
    needed to initiate it
  • Died 2 years later

45
Mrs. MD
  • No changes at first
  • Discussion with patient and competent
    substitute decision maker about goals of care,
    acceptance of risk.
  • Decision to try to find other pain modalities
  • Psychiatry consult for mood/anxiety
  • May just live with the drugs?
  • No happy ending here.

46
Take Home Messages
  • Identification is key
  • Simple strategies work for many patients
  • Its never often not too late!
  • Balancing quality of life and goals of care is
    crucial.

47
Thank you
  • "I may be forgiven for saying, as a physician,
    that drinking deep is a bad practice, which I
    never follow, if I can help, and certainly do not
    recommend to another, least of all to any one who
    still feels the effects of yesterday's carouse."
  • Plato's Symposium
  • (gibson_at_queensu.ca)
Write a Comment
User Comments (0)
About PowerShow.com