Managing medication and alcohol misuse by your older patients
Age-appropriate screening and in-office interventions are sufficient in many cases
Table 2
Spectrum of alcohol use disorders: Heavy drinking to dependence
| Term | Definition | Recommended intervention for patients age ≥65 |
|---|---|---|
| Heavy drinking | >1 drink/day | Brief alcohol intervention |
| Hazardous use | >3 drinks in 1 sitting or >7 drinks/week; places patient at risk for adverse consequences | Brief alcohol intervention |
| Harmful use | Greater than hazardous use, with evidence of negative physical or psychological consequences | Brief alcohol intervention |
| Abuse | Signs of increasing use or decreasing functioning, including engaging in fewer activities, preoccupation with substance, continued use despite adverse consequences | Brief interventions (advise to cut down, educate regarding deleterious effects, and consider referral to substance abuse specialist for evaluation) |
| Dependence | Clear interference with daily function (such as increased falls, otherwise unexplained cognitive impairment); unsuccessful quit attempts; continued use despite adverse consequences | Refer to substance abuse specialist for treatment, including detoxification and age-specific rehabilitation program |
Drug abuse or medication misuse. Illegal drug use is relatively rare in the geriatric population,8 although the rates in patients age 50 to 59 increased from 2.7% in 2002 to 5.0% in 2007.9 In part this may reflect a higher lifetime use of illicit drugs by the baby boomers compared with previous generations.
Evidence also suggests an increasing risk for misuse and abuse of prescription drugs. One factor associated with this risk is medical exposure to prescription drugs with abuse potential. Among older adults in the United States:
- 10% are taking sedative-hypnotic medications
- 15% have been prescribed an opioid-analgesic medication.10
Other factors associated with prescription medication misuse and abuse by older adults include female sex, social isolation, history of substance use or psychiatric disorder, polypharmacy, and chronic medical problems.11
Very few screening instruments detect illicit drug use or prescription medication abuse. To screen older patients, ask about the drugs they are using (prescription and nonprescription), ask about side effects, and look for behavioral signs of medication misuse ( Table 3 ).12,13
Laboratory tests for alcohol’s metabolic effects can identify biologic markers of alcohol use disorders. An elevated mean corpuscular volume (MCV) or gamma-glutamyl transpeptidase (GGT) above the upper normal value can indicate possible problem drinking, even without considering total alcohol intake. Normal lab values are the same for older and younger adults.
Evidence suggests a poor association between findings of the CAGE questionnaire and MCV and GGT tests. Di Bari et al14 reported that biologic markers help identify older drinkers with compromised health status independent of a positive CAGE. This suggests that using a combination of tools to screen for psychosocial and biologic consequences could be more accurate than a single instrument in identifying older individuals with alcohol use disorders.14 We often use a GGT and MCV, along with the CAGE and the AUDIT-5 or SMAST-G.
Tobacco use. Smoking rates decrease with age, but this trend may reflect early mortality among tobacco users. Nicotine dependence remains a significant public health issue among the 7% to 9% of adults age ≥65 who smoke.15 An estimated 70% of all smokers want to quit, and 46% make an attempt each year.11
The single most important step in addressing tobacco use and dependence is screening. After asking about tobacco use and assessing the patient’s willingness to quit, you can provide appropriate interventions.16
Table 3
Behavioral signs of medication misuse by elderly patients
| Excessive worry about whether the medications are working |
| Strong attachment to a particular psychoactive medication |
| Resisting cessation or decreased doses of a prescribed psychoactive drug |
| Excessive anxiety about the supply and timing of medications |
| Decline in hygiene or grooming |
| Daytime sleeping |
| Medical symptoms such as fatigue, weight loss, or insomnia |
| Psychiatric symptoms such as irritability, memory problems, or depression |
| Source: References 12,13 |
Treatment options
General treatment options to consider for older patients with SUDs include a brief outpatient intervention, referral to a substance abuse specialist or inpatient treatment, and appropriate pharmacotherapy ( Table 4 ).
Brief interventions vary from relatively unstructured interactions in a physician’s office to more formal therapy. Components of these interventions include expression of concern, assessment and feedback, and direct advice. For older patients with SUDs, psychosocial approaches can improve treatment outcomes. One useful example—designed for alcohol use disorders—is the BRENDA model ( Table 5 ). Any trained health care staff member can administer this model, which is standardized with a comprehensive manual.17
