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ARTURO G. LERNER, MD Dual Disorders Ward Lev- Hasharon Mental Health Center Netanya, Israel

ADDICTION MEDICINE WITH EMPHASIS ON PSYCHOACTIVE SUBSTANCES School of Continuing Medical Education Sackler School of Medicine, Tel Aviv University Substance Use Disorders in the Elderly: C linical Aspects 25 May 2010. ARTURO G. LERNER, MD Dual Disorders Ward

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ARTURO G. LERNER, MD Dual Disorders Ward Lev- Hasharon Mental Health Center Netanya, Israel

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  1. ADDICTION MEDICINE WITH EMPHASIS ON PSYCHOACTIVE SUBSTANCESSchool of Continuing Medical Education Sackler School of Medicine, Tel Aviv UniversitySubstance Use Disorders in the Elderly: Clinical Aspects25 May 2010 ARTURO G. LERNER, MD Dual Disorders Ward Lev- Hasharon Mental Health Center Netanya, Israel artura@lev-hasharon.co.il Cellular 050-6267912 Fax: 09-8980313

  2. Substance Use Disorders in the Elderly Definitions • Geriatrics is a subspecialty of medicine that focuses on health care of the elderly. • Psychiatry of the Elderly is a subspecialty of psychiatry that focuses on mental health care of the elderly. • Gerontology (from the Greek geron meaning "old man" and iatros meaning "healer) is the study of the aging process itself. • Aging is the accumulation of changes in an organism or object over time. It means a multidimensional process of physical, psychological, and social change. • Disease is an abnormal condition of an organism that impairs bodily functions, associated with specific symptoms and signs. • Old age consists of ages nearing or surpassing the average life span (life expectancy) of human beings, and thus the end of the human life cycle. • Life expectancy is the expected (in the statistical sense) number of years of life remaining at a given age.

  3. Substance Use Disorders in the Elderly Polypharmacy • Elderly people are subjected to polypharmacy. • Elderly people might have multiple medical disorders. • Elderly people might use many herbs & OTCs. • Some adult physicians just prescribe medications to their specialty without reviewing other medications used by the elder patient. • This polypharmacy may result in many drug interactions and may cause some drug adverse reactions. • Medications are excreted mostly by the kidneys or the liver, either of which maybe impaired in the elderly.

  4. Substance Use Disorders in the Elderly Types of users • Opportunistic Use: rare • Experimental Use: rare • Recreational Use: rare • Misuse or Prescription use disorder: seen in practice • Abuse: rare • Dependence to legal substances : seen in practice

  5. Substance Use Disorders in the Elderly Clinical aspects • Elderly with past or present history of psychiatric disorders • Elderly with past or present history of substance use disorders • Elderly with past or present history of physical disorders • Elderly with past or present history of multiple disorders

  6. Substance Use Disorders in the Elderly Clinical aspects Elderly with past or present history of psychiatric disorders • Frequent use: prescription use disorder (misuse) • Benzodiazepines • Sleeping medications • Anticholinergic medications

  7. Substance Use Disorders in the Elderly Clinical aspects Elderly with past or present history of substance use disorders • Frequent use: legal, illegal and prescription use disorder (misuse) • Alcohol • Cannabis (less frequent in Israel) • Opioids • Benzodiazepines • Sleeping medications

  8. Substance Use Disorders in the Elderly Clinical aspects Elderly with past or present history of physical disorder • Frequent use: prescription use disorder (misuse) • “Pain killers” • Benzodiazepines • Sleeping medications • Polypharmacy

  9. Substance Use Disorders in the Elderly Prescription use disorders ICD 10: F55 Dependence to Non Psychoactive Substances F55.0: Antidepressants F55.1: Laxatives F55.2: Analgesics F55.3: Antacids F55.4: Vitamins F55.5: Steroids and hormones F55.6: Specific herbal or folk remedies F55.7: Other substances that do not produce dependence F55.8: Unspecified

  10. Substance Use Disorders in the Elderly Cessation-substance syndromes • From therapeutic doses: Discontinuation syndrome • From non therapeutic doses: relapse, rebound and withdrawal syndrome

  11. Substance Use Disorders in the Elderly Elderly at risk Potentially addictive medications • Overmedication of any kind • Polypharmacy of any kind • Anticholinergics • Barbiturates • Benzodiazepines • Opioids

  12. Substance Use Disorders in the Elderly Diagnosis Behavioral patterns Potential prescription use disorder patient • Loss of control with medication • Medications decrease overall function • Wants medication despite persistence of adverse side effects • Does not follow treatment plan • No leftover medication; often loses medications or prescriptions • Is preoccupied with obtaining medication after desired effect achieved

  13. Substance Use Disorders in the Elderly Diagnosis Behavioral patterns Non prescription use disorder patient • Stable pattern of medication use • Medications improve overall function • Is concerned about side effects • Will follow treatment plan • Has leftover medication • Is no longer preoccupied with obtaining medication after desired effect achieved

  14. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Common alcohol associated clinical syndromes (non DSM) • Acute alcohol intoxication • Idiosyncratic alcohol intoxication • Blackouts • Uncomplicated alcohol withdrawal • Alcohol delirium • Delirium Tremens • Withdrawal seizures • Wernicke – Korsakoff syndrome • Alcohol hallucinosis • Alcohol fetal syndrome

  15. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Acute alcohol intoxication • Slurred speech • Incoordination • Unsteady gait • nystagmus • Impairment in attention or memory • Stupor

  16. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Acute effects of alcohol • Acute sedation • Sleep induction • Anticonvulsant effect • Muscle relaxating effects • Physical dependence

  17. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Idiosyncratic alcohol intoxication • Is a severe alcohol intoxication that develops rapidly after a person consumes a small amount of alcohol • Some persons might have a genetic deficit of alcohol dehydrogenase • Blackouts can follow the intoxication episode • In the elderly organic reasons should be ruled out • Perr In. Pathological intoxication and alcohol idiosyncratic intoxication Diagnostic and clinical aspects. J Forensic Sci. 1986 Jul;31 :806-11

  18. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Blackouts • A blackout is a phenomenon caused by the intake of alcohol or other substance in which long term memory creation is impaired or there is a complete inability to recall the past. Blackouts are frequently described as having effects similar to that of anterograde amnesia, where the subject literally does not remember what has happened in the recent past. • Alcohol appears to block the consolidation of new memories into old memories, a process that is thought to involve the hippocampus and related temporal lobe structures. • Blackouts can generally be divided into two categories, "en bloc" blackouts, and "fragmentary" blackouts. • “En bloc” blackouts are classified by the inability to later recall any memories from the intoxicated period. A person experiencing an “en bloc” blackout may not appear to be doing so, as he can carry on conversations or even manage to accomplish difficult tasks. • Fragmentary blackouts are characterized by the ability to recall certain events from an intoxicated period, yet be unaware that other memories are missing until reminded of the existence of these 'gaps' in memory. This phenomenon is also termed a brownout. Research indicates that fragmentary blackouts, or brownouts are far more common than en bloc blackouts. • PARKER, E.S.; BIRNBAUM, I.M.; AND NOBLE, E.P. Alcohol and memory: Storage and state dependency. Journal of Verbal Learning and Verbal Behaviour 15:691-702, 1976 • ACHESON, S.; STEIN, R.; AND SWARTZWELDER, H.S. Impairment of semantic and figural memory by acute ethanol: Age-dependent effects. Alcoholism: Clinical and Experimental Research 22:1437-1442, 1998

  19. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Uncomplicated alcohol withdrawal • Tremor • Autonomic hyperactivity (sweating or pulse rate greater than 100) • Insomnia • Nausea or vomiting • Transient visual, or auditory hallucinations or illusions • Psychomotor agitation • Anxiety • Grand mal seizures

  20. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Uncomplicated alcohol withdrawal • Alcohol withdrawal might begin 3 -24 hours ( instead 6 to 48 hours) • Peak within 12 – 24 ( instead 24 to 48 hours) • It gradually resolves within 7-14 days (instead 5 to 7 days after last drink) • Tremor may be the only sign • Slight delirium might be seen more frequently • If left untreated alcohol withdrawal might rapidly progress to seizures and delirium tremens despite mildness of syndrome

  21. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Suggested treatment • First line pharmacological agents • Benzodiazepines (BZ) for treatment and prevention • Second line pharmacological agents • Carbamazepine, valproic acid or any antiepiletic (in alcoholics under antiepileptic or BZ treatment medication should be increased) • Propanolol • Clonidine • Complex B vitamins • First and second line pharmacological agents are recommended to be administered together • American Society of Addiction Medicine. Guidelines: pharmacological management of alcohol withdrawal. JAMA, July 9, 1997 - Vol. 278, No. 2

  22. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly • Alcohol delirium • confusion • disorientation • cognitive impairments • Alcohol delirium tremens – DT • Psychiatric emergency • Perceptual disturbances • Psychomotor agitation • insomnia • Fear and terror • Violence (not aggression) • High doses of BZ or haloperidol recommended • Physical restraint is forbidden • Lights should be kept turn on during night • Hoes MJ (1979) The significance of the serum levels of vitamin B-1 and magnesium in delirium tremens and alcoholism. J Clin Psychiatry; 40 :476-9 • ERWIN, WILLIAM E. MD; WILLIAMS, DIANNE B. PharmD; SPEIR, WILLIAM A. MD(1998) Delirium Tremens. Southern Medical Journa;l 91: 425-432

  23. Substance Use Disorders in the Elderly Management of alcohol use disorders in the elderly Withdrawal seizures • Generalized • Tonic-clonic • After first seizure there is an increased possibility to have more seizures • Status epilepticus is a rare condition • Seizures can be associated to head injuries, CNS infections, strokes, hypoglycemia, hyponatremia, hypomagnesemia • Nowadays seizures are not supposed to develop with adequate treatment • Management of seizures: BZ (diazepam IV)+ antiepileptic agent • Status epilepticus: neurologist consultation • Antiepileptic loading: carbamazepine and valproate • Schuckit M. A.; Tipp J. E.; Reich T. (1995)  Hesselbrock V. M.; Bucholz K. K.The histories of withdrawal convulsions and delirium tremens in 1648 alcohol dependent subjects. Addiction 90: 1335-1348

  24. Wernicke Encephalopathy Acute neurological disorder Ataxia (primarily gait) vestibular dysfunction confusion Ocular motility: abnormalities: horizontal nystagmus, lateral orbital palsy gaze palsy sluggish reaction to light Anisocoria Thiamine deficiency: poor nutritional habits or malabsortion syndrome Treatment: thiamine oral or IV Korsakoff Amnesia (anterograde) Psychosis Dementia Confabulation Alertness Responsiveness Cognitive impairments Treatment: thiamine oral (100- 300 mg/day) Mamillary bodies involvement suspected Substance Use Disorders in the Elderly

  25. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: short history • For centuries alcohol and opium were the recommended treatments • 1864- barbituric acid ( Adolf von Baeyer) • 1892-barbital (Josef von Mering) • 1903-barbital (Veronal) • 1912- phenobarbital (Luminal) • 1952-chlorpromazine • 1958-haloperidol • 1959- chlordiazepoxide • 1963- diazepam

  26. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: Indications • Sedation-Insomnia • Seizures-epilepsy • Muscle tension • Alcohol withdrawal • Depression • Substance induced psychotic agitation (except amphetamine) • Bipolar disorder (mania) • Anesthesia • Catatonia • Akathisia • Drug assisted interviewing • Hallucinogen persisting perception disorder

  27. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: side effects • Drowsiness • Ataxia • Confusion • Vertigo • Hypotension • Skin rushes • GI disturbances • Urinary retention • Blood disorders and jaundice

  28. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines:C/I • Acute pulmonary insufficiency • Respiratory depression • Myasthenia gravis

  29. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: S/P • Chronic renal or hepatic disease • Chronic pulmonary disease • Pregnancy and lactation • Avoid long term use (three weeks courses)

  30. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: way of administration • Oral • Intravenous • Intramuscular (midazolam,lorazepam) • Nasal (sniffing) • Smoking-chasing • Rectal suppositories or tubes (Diazepam Desitin rectal Tubes, 5-10 mg)

  31. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: Classifications Half-lives • Short action: < 6 HOURS • Intermediate action: > 6 HOURS < 20 HOURS • Long action: > 20 HOURS

  32. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines:Classification Half-lives Short action: < 6 HOURS • Triazolam (shortest half-life: 2-3 Hours) • Clorazepate (active metabolite: nordazepam long action) • Midazolam • Nitrazepam • Flunitrazepam • Brotizolam

  33. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines:Classifications Half-lives Intermediate action > 6 HOURS < 20 HOURS • Alprazolam • Lorazepam • Oxazepam • Chlordiazepoxide (metabolites:demethylchlordiazepoxide,nordazepam, demoxepam- 200 Hs)

  34. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines: Classifications Half lifes: Long action > 20 HOURS • Alprazolam XR • Clonazepam • Diazepam (metabolite:nordazepam- +10 days )

  35. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Long half-life benzodiazepines Advantages over short half-life • Less frequent dosing • Less variation in plasma concentration • Less severe withdrawal syndrome Disadvantages over short half-life • Drug accumulation • Increased risk of daytime sedation • Daytime psychomotor impairment

  36. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Short half-life benzodiazepines Advantages over long half-life • No drug accumulation • Less daytime sedation Disadvantages over long half-life • More frequent dosing • Earlier and severe withdrawal syndrome

  37. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines cessation syndromes • Discontinuation syndrome (therapeutic doses) • Detoxification syndrome (non therapeutic doses)

  38. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepine withdrawal • Cessation of (or reduction in) sedative, hypnotic or anxiolytic use that has been heavy and prolonged. (1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) (2) increased hand tremor (3) insomnia (4) nausea or vomiting (5) transient visual, tactile, or auditory hallucinations or illusions (6) psychomotor agitation (7) anxiety (8) grand mal seizures (9) Death

  39. Substance Use Disorders in the ElderlyApproximate Therapeutic Equivalent Doses of Benzodiazepines Generic name Alprazolam Alprazolam XR Chlordiazepoxide Clonazepam Clorazepate Diazepam Lorazepam Oxazepam Triazolam Estazolam Flurazepam Prazepam Temazepam Quazepam Zolpidem Dose (mg) 1 1 25 1 15 10 2 30 0.25 1 30 80 20 15 10

  40. Substance Use Disorders in the Elderly Management of BZ use disorders in the elderly Benzodiazepines cessation syndrome Shifting to another longest action benzodiazepine • Less frequent dosing • Less variation in plasma concentration • Less severe withdrawal syndrome Adjunctive medication • Carbamazepine (immediate release), valporal • Clonidine • Rational use of antidepressants, low doses of first and second generations SDRB (serotonin dopamine receptor blockers) for sleep disorders Abrupt cessation is life threatening !!

  41. Substance Use Disorders in the Elderly Management of “pain killers” use disorders in the elderly (Mostly prescription use disorders) • Hydromorphone: Palladone SR, parenteral • Oxycodone: Percocet, Percodan, Oxycontin 10, 20,40,80 mg, Oxycod Syrup • Propoxyphene: Proxol, Rogaan, Algolysin • Morphine: MCR, MIR, Morphex CR 10,30, 60, 100, 200 mg • Fentanyl: Duragesic 25,50,75,100 mcg/Hs • Codeine: Cod-Acamol, Codical • Buphrenorphine: Nopan (0.2 mg), Subutex (2 and 8 mg) • Methadone: Adolan

  42. Pain Etiology: recognized Type of pain: acute, intermittent Severity of pain: severe with trigger Prior successful means of pain relief Successful treatment at Pain Clinics No craving for prescription No search for new medications No multiple consultations Family involved in treatment Pain + Potential Dependence Etiology: unrecognized Type of pain: chronic Severity of pain: severe without trigger Non prior successful means of pain relief Unsuccessful treatment at Pain Clinics Craving for prescriptions Search for new medications Multiple consultations No family involved in treatment Substance Use Disorders in the ElderlyPain disorders

  43. Aspirin Diclofenac Dipyron Etodolac Ibuprofen Ketoprofen Ketorolac Naproxen Tramadol Aspirin 500 Bayer Abitren, Dicoplast, Voltaren Optalgin Etopan Artofen, Advil , Nurofen Ketonal, Oruvail, Profenid Topadol Naproxi, Naxyn, Narocin Tramadex, Trabar, Tramal Substance Use Disorders in the ElderlyNon opioid analgesics

  44. Substance Use Disorders in the Elderly Basic guidelines for pharmacological treatment of pain • Start with an analgesic that is least likely to cause dependence (non opioids) • Use equivalent doses when changing an analgesic • Enhance opioid effect with: • Carbamazepine, valproic acid, lamotrigine • Chlorpromazine and perphenazine (small doses) • Haloperidol (small doses) • Clotiapine • Mianserin, Trazodone, Mirtazapine • TCAs • Duloxetine

  45. Substance Use Disorders in the Elderly Other references • Kaplan & Sadock’s, Synopsis of Psychiatry, Tenth Edition, 2007 • The Diagnostic and Statistical Manual of Mental Disorders, DSM IV TR, American Psychiatric Association, 2000 • The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), 1992 • Textbook of Substance Abuse Treatment, The American Psychiatric Publishing, Editors: Galanter & Kleber, Third edition, 2003 • Wikipedia articles • Erowid articles • NIDA

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