Substance Abuse in the Elderly: The Boomers Change Things Again

Steven T. DeKosky, MD, FAAN, FACP, FANAProfessor of Neurology

Director, Alzheimer’s Disease Research CenterUniversity of Virginia School of Medicine

Charlottesville, VA USA

Recovery Centers of AmericaScientific Advisory Board Meeting Malibu Beach, CASeptember 30, 2013

Disclosures• Consultant/Advisory Boards : Consultant/Advisory Boards : – Elan/Wyeth, Genzyme, Lilly, Janssen, Merck, Elan/Wyeth, Genzyme, Lilly, Janssen, Merck,

Novartis, PfizerNovartis, Pfizer• Clinical Trials:Clinical Trials:– Baxter, Elan, Janssen, Novartis, PfizerBaxter, Elan, Janssen, Novartis, Pfizer

Signs of the Apocalypse• Cheech Marin is 67 years old• Tommy Chong is 75.

Demographics

• Over the next 35 years there will be significant increases in the US elderly population as the Boomers move into late life

• Substance abuse in this cohort is different from both the Greatest Generation cohort and the younger generation (Gen X)

• More alcohol and prescription medication abuse in the Boomer population

• Boomers have less illicit drug use, Cheech and Chong notwithstanding

Challenges• Majority of funded research has been focused on cocaine,

other narcotics, and illegal stimulant drugs

• Target population has been younger adult males

• Less direct applicability to the elderly population

• Many Boomers came of age in the 60s and early 70s and are more willing to take prescription drugs

• Questions about adequacy of screening methods for elderly (most screening tests devised for younger cohorts)

Medical and Psychiatric Issues

• Aging is a time of loss: friends, spouse, career, vigor, health

• Higher rates of depression• Use of stimulant medications• Multiple co-morbidities: systemic diseases,

increased frailty

Social Issues• In our mobile society, concerned children

and social supports may not be present• Children have moved away or elderly

have moved to retirement communities with loss of support systems and friends

• Families reluctant to bring up substance abuse issues if they note it

Medical Disease and Predilection for Substance Abuse

• Arthritis leads to chronic use/abuse of prescription pain medications

• Opiates and alcohol used for mood elevation in depressed elderly

• Sleep disruption due to arthritis and other pain leads to sleep medication abuse, other sedative/anxiolytic abuse

• OT sleep aids frequently have anticholinergic side effects andinterfere with cognition

Medical Disease and Predilection for Substance Abuse

• Geriatric depression and anxiety lead to prescription for benzodiazepines

• Busy physicians dealing with medical comorbidities may not be as vigilant concerning medication abuse

• Slowed metabolism increases half-life of medications and increases fatigue, slowed reaction times, increased driving risk, falls

Cognition and Substance Abuse

• Alcohol abuse may lead to irreversible cognitive decline

• Sedative/narcotic abuse and slowed metabolism may lead to cognitive impairment/incorrect diagnosis of dementia

• Amnestic mild cognitive impairment and dementia (most commonly Alzheimer disease) lead to confusion in dosing and potential overdosing of many medications

Dual Diagnoses• Geriatric depression may predispose to alcohol

abuse in late life as attempt at self-medication• Both diagnoses need to be treated• Altered cognition in one or both of these

disorders may lead to premature diagnosis of dementia, with decrease or cessation in therapeutic efforts

• Dementia diagnosis cannot be confirmed until both are treated

Conclusions• Growing need for effective screening methods

specific for geriatric population• Education programs for physicians, patients, and

families regarding use of psychoactive drugs and alcohol

• Research to address most effective treatment for (more frail) elderly for alcohol and drug abuse

• Best practices for diagnosis and treatment with appropriate referral for the medical comorbidities