Feature Article
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Misadventures With Drugs and Alcohol in the Older Patient: Alcohol Use, Misuse, and Abuse in Older Persons Prescription Drug Use, Misuse, and Abuse In Older Persons
Kenneth E. Schmader, associate professor of Medicine-Geriatrics, Duke University and Durham VA Medical Centers, Durham, NC, noted that older adults use a large number of drugs, and they often take those associated with misuse and abuse, particularly central nervous system (CNS) agents. Therefore, this population is very vulnerable to adverse effects from these drugs, such as delirium, falls, undernutrition, functional decline, and failure to thrive. Dr. Schmader organized his presentation around a 73-year-old female patient of his who illustrates a number of these principles.
The patient had a long history of chronic insomnia and what were thought to be chronic muscle tension headaches. She had undergone several work-ups and was brought into the office by her family because of weight loss, decreased energy, and depression. She was on multiple medicines and a combination of aspirin 325 mg/butalbital 50 mg/caffeine 40 mg for her headaches. She did not want it discontinued and said she took it 2-4 times per day along with 2-3 cups of coffee. The patient noticed that when she dropped the dosage of the drug, her headaches would rebound. She also took lorazepam 0.5 mg, alendronate, and a multivitamin. No disease per se was found to be causing her symptoms: low energy, poor appetite, irritability, decreased physical activity, lack of fulfilling roles in her family. “So, the question becomes, ‘Is this woman abusing this drug?’” asked Dr. Schmader, referring to the aspirin 325 mg/butalbital 50 mg/caffeine 40 mg.
To help answer the question, Dr. Schmader discussed what a medical professional should be aware of with regard to misuse and abuse. “If you have a patient who is part of a spouse pair, you’d better know the other spouse’s drug list, because they may be borrowing from each other.” He explained that “some of these misuse behaviors can slip over the line to the point where it becomes harmful, and then we start thinking about abuse—that is, a maladaptive pattern of use that can cause harmful effects. I think, in my patient, there’s some misuse and abuse going on. When she tried to decrease the aspirin 325 mg/ butalbital 50 mg/caffeine 40 mg combination tablet, there were some withdrawal symptoms as well.”
Dr. Schmader next discussed what not-so-obvious drug types are associated with prescription drug misuse and abuse. “Maybe you’ve seen laxative abuse, in which patients take huge amounts of laxatives, and eventually their bowels become incredibly hard to control without the laxatives,” he said. He also mentioned problems with the overuse of antibiotics, particularly for viral bronchitis and other resistant organisms; use of diuretics, which have dehydrating effects, for persons with edema; and cognitive effects from antihistamines. “I want to point out that abuse and misuse aren’t associated necessarily with just CNS drugs, and this needs to be better studied,” he added.
“What’s the prevalence in elderly populations of prescription drug misuse and abuse?” the speaker asked. “We really don’t know. There are no population-based studies of this phenomenon; it’s incredibly hard to study. A few observational studies and retrospective case series in the literature, despite their methodological weaknesses, make some very good points.”
A case series from the Elderly Services of Spokane, Washington, in the Spokane Community Mental Health Center looked at over 1600 case management records and found 50 elderly patients who were referred for prescription drug abuse. The misused classes were sedative hypnotics, antianxiety agents, and analgesics. “The top four at that time (1990) were diazepam, codeine, meprobamate, and flurazepam, and I think that, except for meprobamate, those drugs are still being misused,” added Dr. Schmader. Duration of misuse over 5 years was seen in 92% of the patients. In addition, a 60% correlation was seen of codependency with alcoholism and alcohol dependence.
A retrospective case review from the Mayo Clinic inpatient addiction program found 100 elderly patients admitted between 1974 and 1993 with prescription drug abuse, the majority of whom were women. Results showed that a majority of the patients abused opioids and many had codependencies on other prescription drugs. “Sometimes they were both sedative hypnotics, and sometimes both stimulants and sedative hypnotics,” the presenter noted.
“I’m sure you’ve heard from your patients that they don’t want to become ‘addicted’ with regard to opiates,” Dr. Schmader continued. “It’s useful to remind them that most elderly patients don’t become addicted if they don’t abuse opiates. However, there are a small number of elderly people who will abuse opiates, even in a criminal or illicit way. The way to look for these people is to look for a history of chemical dependency and substance abuse, including alcoholism, and history of psychopathology that might put them at risk for that, including personality disorders, severe mood, and anxiety disorders.”
The speaker gave a list of warning signs of prescription drug abuse compiled by a number of experts. It included cognitive impairment, delirium, personality change, altered mood, unexpected complaints about chronic pain that don’t seem normal, seizures, thinking about withdrawal, tremor, restlessness, agitation, sleep complaints, and withdrawal from family, friends, and normal activities. “This list shows the typical medical and functional things that might be associated with prescription drug abuse and misuse—anorexia, poor eating, malnutrition, frequent falls, functional decline, poor hygiene, and traffic accidents,” he stated. “The problem with this is that everything listed could be due to dementia, depression, or some other process. I think these warning signs are nonspecific, but I think it reminds us to keep adverse drug effects and even prescription drug abuse in a differential diagnosis of just about any geriatric syndrome.”
Some signs of drug-related behavior to look for, according to Dr. Schmader, include continuous requests for refills, particularly when the condition for which the prescription was originally made is no longer an issue; complaints about other physicians who refuse to write prescriptions for preferred drugs; and self-medication, which may be with over-the-counter drugs that give the patient the same effect they like from a prescription agent.
The speaker then discussed useful approaches for communicating the suspected or identified abuse to the patient and/or family members. “The first step is to describe the impact the drug is having on the patient’s health or functional status, making the drug the enemy, not necessarily their behaviors,” he explained. “Then you can follow up with some good news, such as saying, ‘This is treatable, and if we get rid of this drug or at least reduce it, you’re going to stay out of the nursing home.’ You can also address a fear they have expressed and tell them they’re not going to have, for example, a hip fracture.” Three responses typically accompany this process. “Some patients kind of know they have a problem and they’re willing to change,” Dr. Schmader continued. “The second group is the skeptics, who aren’t sure you’re right and not sure there is a problem, but they’re willing to consider it. If you continue with them over time with interventions, they probably will change. Brief interventions are often effective with the first two groups. The third group, which probably is the lion’s share a lot of times, are the ones who deny there is a problem. They look you straight in the face and say, ‘I don’t have a problem with this drug.’ They’re not willing to change, and they need more sophisticated interventions.”
Dr. Schmader’s example patient was a skeptic. “She didn’t believe it but had family breathing down her neck, so she said, ‘okay, I’m willing to consider this and maybe go along with your treatment plan over time.’ What’s incredibly useful is to include the patient in the treatment decisions, including family members and friends. However, if you want to involve the patient and the intervention involves family members, it’s best to get those who are on the same page with you.”
The Substance Abuse and Mental Health Services Administration convened a number of experts a few years ago and came up with the Treatment Improvement Protocol Series (TIPS) on substance abuse among older adults (http://hstat.nlm.nih.gov/hq/Hquest/ screenDownload/s/52941). “They recommend least intensive options first, which is called brief intervention,” Dr. Schmader stated. “The largest part of brief intervention involves a physician who firmly says to the patient in a nonjudgmental way, ‘I really think there’s a problem with this drug, and we need to work out ways to treat it.’ It can also include patient education, contracting, and goal setting.”
If the less intensive approaches do not work, many specialized treatment approaches are available but require a specialty referral. “Deciding in which cases these treatments should occur is also a difficult issue, depending on how sick the patient is, what the health care system is like that you work in, and what they’ll reimburse.”
TIPS include a list of situations that are signs that should enable a clinician to determine whether a patient should be hospitalized. Hospitalization should be considered for medical safety and removal of continuing access to abused drugs. An example is a case in which a drug has been prescribed at a very high dose and has high potential for adverse symptoms and/or suicidal ideation. Patients with major psychopathology such as major depression or psychosis, those with unstable comorbid conditions, and the “mixed addiction patient” who is also using alcohol are candidates for hospitalization.
Dr. Schmader’s patient was eventually willing to change. “It wasn’t just tapering off of the drug but also treatment of her depression,” he noted. She was started on an antidepressant, exercise program, and a diet program. After several weeks, her symptoms improved dramatically. “She was not going to give up the drug, but she eventually got to the point where she was taking one or two pills a day and was down to one cup of coffee per day,” he added. “She felt like her headaches were controlled. So, we compromised; that’s fine. If we can stay at that level, we’re probably doing okay, and functionally she was.”
Alcohol Use, Misuse, and Abuse in Older Persons
“Half of people age 65 and older don’t drink at all,” began Alison A. Moore, MD, MPH, associate professor in the Division of Geriatric Medicine at UCLA. “Approximately 3% (2% men) would be considered either abusing or dependent on alcohol using Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria, and 22% would be considered ‘at-risk’ drinkers. Another quarter would be considered low-risk drinkers.”
“It’s important when you’re talking to your patients to make sure you’re talking about the same thing,” she continued. “A drink of alcohol contains 12 g of ethanol, which is contained in a 12-oz beer, 4-6 oz glass of wine, 3-4 oz of fortified wine (eg, sherry, port), and 1.5 oz, or a typical shot glass, of 80-proof liquor.”
Risk factors for alcohol abuse include male gender, family history of alcohol problems and social, psychological, and physical stressors. “Isolation, bereavement, retirement, insomnia, pain, depression, anxiety, loss of function, comorbidity, and polypharmacy all increase one’s risk for alcohol problems,” Dr. Moore explained.
Multiple federal agencies, including the U.S. Department of Health and Human Services, the National Institutes of Health (NIH), and the National Institute for Alcoholism and Alcohol Abuse within the NIH, recommend that men and women under age 65 have no more than two drinks per day and no more than one drink per day, respectively. “Furthermore, they say that when you reach age 65, men have to cut back to one drink per day,” the speaker noted. “These agencies recognize that things are different when you’re older. It’s really the interaction of alcohol with multiple comorbidities and multiple medications that is the big issue in the older population.”
As people age, the ratio of body fat to lean muscle mass increases, which causes an elevation of a given dose of alcohol. “If you give both a 30-year-old and an 80-year-old two drinks each, the 80-year-old will have a blood-alcohol level of three drinks,” Dr. Moore explained. In addition, for reasons that are not completely clear, older people have increased susceptibility to the psychomotor effects of alcohol, which may result in increased susceptibility to sedation, confusion, falls, and problems with coordination, according to the presenter. Varying amounts of frailty play a role in how alcohol affects the elderly population.
Dr. Moore discussed certain conditions that can be caused and, in most cases, worsened by alcohol use. “A person who has one drink per day and has gastritis, ulcers, or liver or pancreas problems is considered to be an at-risk drinker,” she noted, “as is somebody who has two or more drinks per day and has depression, gout, gastroesophageal reflux disease, breast cancer, insomnia, memory problems, or falls. Three or more drinks per day can worsen or cause hypertension. It can increase risk for hemorrhagic stroke, worsen problems with diabetes or make control more difficult, and can cause or worsen a whole host of gastrointestinal diseases and cancer of many varieties.
Interactions between alcohol and medications can increase drug metabolism, which is typically seen in people who regularly have 3-6 drinks per day. “These people rev up their P450 systems and so the drugs, including sedatives, warfarin, phenytoin, and propranolol, are less efficacious,” said Dr. Moore. “Conversely, you can get decreased drug metabolism in persons who don’t drink all week and then drink a six-pack on Friday and Saturday nights. If you take temazepam every night to sleep and then drink your six-pack on Friday, you might not wake up Saturday morning because you have an increased effect of the drug.” Alcohol can also interfere with the effectiveness of drugs. “If a patient is taking a drug for hypertension and has more than three drinks per day, his or her blood pressure may be raised by the alcohol, thereby interfering with the efficacy of the drug,” Dr. Moore stated.
“Alcohol effects in older persons are generally in the degree of organ injury or other adverse consequences rather than the type of injury,” continue the speaker. “You’ll see the effects at lower doses of consumption, and consequences are likely to be more severe because of the physiological changes and comorbidity with age.”
Hospital and emergency room physicians fail to recognize 63-79% of elderly alcohol abusers, according to Dr. Moore. “One of the reasons for this is that the criteria used for the diagnosis of alcohol abuse/dependence using DSM-IV may be less pertinent in older people, such as failure to fulfill major obligations at work, school, or home and alcohol- related legal problems. For example, older people are much less likely to get into fights or to steal when they’re drunk.”
Other reasons for underdiagnosis are the lack of screening instruments, standard definitions of at-risk drinking, and the fact that clinical symptoms of alcohol use disorders can mimic, overlap, and exacerbate common medical and psychiatric conditions. “None of the definitions have incorporated the idea that medication and disease can be a problem with alcohol,” explained Dr. Moore. “And screening instruments developed to identify alcohol abuse and dependence, like the Michigan Alcohol and Screening Test (MAST), the CAGE (Cut down, Annoyed, Guilty, Eye opener) test, or the Alcohol Use Disorders Identification Test (AUDIT), have really been developed and validated in younger populations. There is one exception: the MAST-Geriatric version was developed specifically for an older population, but it also does not incorporate the idea of alcohol–medication and alcohol–disease interactions.” Other barriers include denial on the part of the patient and family, pessimism that treatment will work, and time constraints that do not allow the physician enough time to address the problem.
In an effort to come up with a measure that might identify older people who are at risk because of their alcohol and drugs or disease, Dr. Moore and colleagues developed a 32-item questionnaire called the Short Alcohol Related Problem Survey. “It simply asks people ‘How much do you drink?’ ‘How frequently do you drink?’ ‘Do you ever drink three or more drinks on an occasion, and how often is that?’ and asks them about diseases, medications, and symptoms that can be caused or worsened by alcohol,” said Dr. Moore. “It uses algorithms to really categorize patients into either at-risk or not at-risk drinkers. We’ve used different versions of this survey, and the one we’re using now has a sensitivity of 89% and specificity of 77%.”
“Governmental organizations suggest a four-step approach for screening alcohol misuse issues,” stated Dr. Moore. Step one is to ask about alcohol or prescription use. “Ask how often they typically drink and how much they have when they have a drink. Is it a can of beer, a tall boy, a shot, or a double shot?” she added. “Get specific with them. Also, we typically like to know if they ever drink more on certain occasions.” The CAGE is most commonly used because it is short and easy to remember, according to the speaker. The four items ask if the patient has tried to cut down the amount he or she drinks, if he or she has been annoyed by people asking about their drinking, if the patient has felt guilty about the amount he or she drinks, and if the patient has had an “eye-opener,” or drink first thing in the morning. “If you have one or two ‘yes’ answers, it’s a pretty high likelihood that a problem exists.”
Step two is to assess for alcohol-related problems. “You might want to ask questions like ‘Why do you drink?’ ‘Does it make you feel good?’ ‘Does it help you sleep?’ and ‘Is it just something you do because your friends do it?’” explained Dr. Moore. “Ask about the symptoms, the interactions of medications and comorbidity.”
Step three is to advise appropriate action. “You can recommend low-risk drinking limits for patients who are not alcohol-dependent,” Dr. Moore said. “You can ask them to set specific drinking goals, and you write a prescription out for that. You can provide educational materials, which are available at www.health.nih.gov. If they do have evidence of alcohol dependence, you need to refer them for additional diagnostic evaluation and treatment.”
Step four is to monitor the patient’s progress. “If you think the patient needs to make behavior changes, it’s important to support them in this,” continued the presenter. “And it’s important to provide regular follow-up. If they aren’t ready, just go with it and say ‘I understand you’re not ready,’ for those who are pessimistic, but try to address it periodically so they know that you still feel it’s an issue for them, without driving them away.”
Dr. Moore concluded by stating, “There is much more work to be done in this area. Very little work has been done, so there’s potential for a great deal of additional research.” Annals of Long-Term Care - ISSN: 1524-7929 - Volume 11 - Issue 08 - August 2003 |