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Grandma and Grandpa Under the Influence

Grandma and Grandpa Under the Influence. Stephen M. Scheinthal, D.O., FACN Associate Professor, Psychiatry Chief Geriatric Behavioral Health UMDNJ-SOM Stratford, NJ. Golden Years!. If you don’t ask…. 78 yo female CC: “I feel lonely.”

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Grandma and Grandpa Under the Influence

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  1. Grandma and Grandpa Under the Influence Stephen M. Scheinthal, D.O., FACN Associate Professor, Psychiatry Chief Geriatric Behavioral Health UMDNJ-SOM Stratford, NJ

  2. Golden Years!

  3. If you don’t ask… • 78 yo female • CC: “I feel lonely.” • Hx: Depression, Anxiety, Insomnia, HTN, DJD, Hyperlipidemia. • Social: Lives alone, divorced (ex still alive), 3 kids, 12 grandkids. • Retired secretary

  4. If you don’t ask ... • Presents to ED with hallucinations • Medical workup negative • UA neg • UDS • Cannabis • Opiates • “You never asked!”

  5. Quick Facts • 1 to 15 % of community older adults drinking problems • 12% report binge drinking • 2% report using an illicit drug • Marijuana most common 1% • Prescription drug abuse 0.7% • Cocaine 0.2% Bartels SJ, Blow FC, Brockman LM, Van Citters AD, Substance abuse and Mental Health Among Older Americans: The State of the Knowledge and Future Directions, SAMHSA 2005.

  6. Substance Use and the Older Adult • Use a high number of prescription drugs • Poor health outcomes • Higher health care utilization • Increased complexity • Increased disability • Compromised quality of life • Increased caregiver stress • Increased mortality • Increased suicide risk

  7. Growing Problem Differ from their younger counterparts Don’t look to get high Biggest Problems: Alcohol Misuse Medication Misuse Combined these effect approximately 20% of older adults Blow FC, Bartels SJ, Brockman LM, etal. Evidence Base Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults, SAMHSA 2005.

  8. Who Uses Alcohol More? • Older Men? • Older Women?

  9. Men tend to drink alcohol more.

  10. Women tend to use pills more.

  11. Older Adults are uniquely at risk • Rates of illegal drug use is low • Higher number of prescription drugs • Higher number of over the counter medications • High risk of interaction between alcohol and prescription drugs, especially psychoactive drugs • Benzodiazepines • Barbiturates • Antidepressants

  12. Alcohol Misuse 20-30% of people 75-85 years old have experienced drinking problems National Institute on Alcohol Abuse and Alcoholism 2007.

  13. Alcohol Misuse - Theories • Social Learning Theory Social Activities with friends and families associated with alcohol use is a predictor of excessive use. • In older adults • Activities and events with alcohol for social reasons is associated more alcohol consumption • Family and friends who drink are associated with higher and more frequent and heavier alcohol use Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.

  14. Alcohol Misuse Theories • Stress and Coping Theory • Problematic life stressors lead to use • Coping Based Alcohol use • Self Medicate to decrease depression and anxiety • Older Adults • Site personal reasons for drinking • Grief • Anxiety • Pain Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.

  15. Alcohol Misuse Theories • Social Control Theory • Social bonds, family, friends and religion help to regulate patient toward socially appropriate behavior • When bonds are weak or absent, will engage in risky behaviors such as excessive drinking • Financial resources may be associated with increase purchasing of alcohol. • Older Adults • Financial resources may be associated with increase use. Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.

  16. Alcohol Misuse Theories • Baseline Alcohol Consumption/ Life History • Correlates with use in old age • Alcohol use stays stable in late life • Efficacy of AA in older adults not clear. Moos RH, Schutte, KK, Brennan PL, etal. Late-lige and life history predictors of older adults’ high-risk alcohol consumption and drinking problems. Drug and Alcohol Dependence 108, pp 13-20, 2010.

  17. Alcohol Misuse • CAGE • Lifelong measure • Not high validity in the elderly • MAST-G and SMAST-G • More specific to the geriatric population • ARPS (Alcohol Related Problems Survey) • More sensitive than MASTS or CAGE Blow FC, Bartels SJ, Brockman LM, etal. Evidence Base Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults, SAMHSA 2005.

  18. Medication Misuse

  19. Medication Misuse • High use of prescription drugs (2 – 6) • High use of over the counter medications (2-3) • Combined alcohol and prescription drug use may affect 20% of older adults. Bartels SJ, Blow FC, Brockman LM, VanCitters AD, Substance Abuse and Mental Health Among Older Americans: The State of the Knowledge and Future Directions, SAMHSA, 2005

  20. Medication Misuse • Over use • Underuse • Irregular use • Prescribing Cascades

  21. Medication Misuse • Prescribing Cascades • Treating side effects of one drug with another • Common Cascades • ACHEI – Benzodiazepines/antipsychotics/sedatives • Antipsychotics – Benzodiazepines/stimulants • SSRI – Benzodiazepines/antipsychotics/sedatives

  22. Medication Misuse • Vulnerable population • Lonely • Decreased mobility • Impaired sensory function • Chronic pain • Poor physical health • Poor financial status • Poor social support

  23. Medication Misuse • Drug-Drug Interactions • Falls • Depression • Cognitive issues • Hepatic disease • Cardiac disease • Sleep problems

  24. Medication Misuse • Alcohol-Drug Interactions • Falls • Cognitive problems • Delirium • Depression • Increased medical co-morbidities

  25. Medication Misuse • Other interactions of concern: • Barbiturates • Antidepressants • Benzodiazepines • Benzodiazepines and sedatives are associated with a 36% mortality rate in the older adult. Barclay L, Lie D, Medication for Insomnia or Anxiety Linked to Increase in Mortality Risk, Canadian Journal of Psychaitry 55, 137-146 2010.

  26. New onset agitation • 75 yo female • Hx of Depression, Dementia, HTN, DJD, UTI’s • Living in Nursing Home for 2 years • New onset agitation • Medication reconciliation – negative • Medical workup - negative

  27. New onset agitation • Nursing expresses concern: • Agitation only occurs 2 hours after daughter leaves • Request is to get a UDS

  28. Surprise!!! • UDS – Positive Cocaine • Met with daughter: “my mother needed a pick me up.”

  29. Narcotic Use

  30. Narcotic Abuse • Much of the problem is unknown • Younger patients use to get high • Older patients usually do not do the same • Most older substance users are chronic and long time using • Unusual for an older adult to start using narcotics.

  31. Narcotic Use • Marijuana most common drug used • Estimated to be 1% of the older population • Cocaine • Estimated to be 0.2% of the older population • Study in Miami of 800 hospitalized older adults 22% of the admission from ‘04 to ‘07 were positive for cocaine. Chait R, Fahmy S. Caceres J, Letter to the Editor, Journal of the American Geriatric Society, 52 (2) 2010

  32. Narcotic Use • Heroin • Scant data • Older users who started after their kids were raised • Never injected heroin • Never shared needles • Do not report loosing control over their usage Boeri MW, Sterk CE, et al., Reconceptualizing Early and Late Onset: A Life Course Analysis of Older Heroin Users. The Gerontologist 48 (5) 2008.

  33. Next Steps • More research on this topic is critcal • Much of the data and impact is unknown • Problem is much likely larger and more serious • Significant health problem for older adults

  34. What can you do? • Talk to spouse or caregiver • Look out for: • Falls • Confusion • Doctor shopping • Increased medical service utilization • A home visit nurse can be your eyes and ears • Pay attention to what is in the recycling bucket

  35. What can you do? • 12 step program, AA, NA. • Data does not support that these work in the older patient • Universal prevention • Preventative education discussing risks • www.samhsa.gov

  36. What can you do? The Surgeon General’s Report on Mental Health, Administration of Aging Report on Older Adults’ and the Center for Substance Abuse Treatment:; Crafted a recommended treatment protocol

  37. What can you do next? • The Treatment Improvement Protocol for Older Adults (TIP) • Age specific treatement to build or rebuild self esteem • Coping with depression, loneliness and loss • Rebuilding the patient’s support network • Pace of treatment should be appropriate for the patient • Staff should be interested and experienced with the elderly. • Links with medical services, aging services and referrals for follow-up care and case management.

  38. Doctor please, some more of these Outside the door, she took four more What a drag it is getting old Jagger M, Richards K, 1965

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