substance abuse
o Which brain pathways are affected by drugs of abuse?
All three brain pathways are affected - however, our dopamine & serotonin pathways are GREATLY affected
Measuring of instrument's accuracy in identifying individuals who do not have an alcohol problem (True negative/ False positive)
specificity
clinical laboratory testing
-poor sensitivity and specificity; for identifying problem drinkers -Gamma-glutamyl transferase -mean corpuscular volume -carbohydrate-deficient transferrin
chronic abuse of some drugs may?
-exacerbate normal age changes
drinkers that tend to reduce or terminate drinking?
-heavy drinkers
increased body fat, decreased lean body mass and total body water content reduced leads to what when mixed with alcohol?
-increased BAC
moderate alcohol consumption in elderly associated with
-increased risk of strokes caused by bleeding -impaired driving; falls -the potential interaction with drugs they are taking
potential comorbidities with alcohol use
-interference with metabolizing medications -increased side-effects from medication -sleep disorders -psychiatric conditions (depression, anxiety) -increased risk of suicide -dementia -depression
what is the major disadvantage of the AUDIT screening?
-it must be administered in writing
drinkers that maintain a stable pattern?
-light/moderate drinkers
why are limits for older women lower than those for older men when it comes to alcohol use?
-lower BMI; more fat
less use of illicit drugs; more unintentional misuse of drugs due to
-memory loss or misunderstanding of dosing instructions
implications for older adult drinkers:
-moderate levels of consumption can be more risky -more consequences from maintaining consumption -increased consumption may quickly result in consequences
what is considered binge drinking for adults 65+?
-more than 2 drinks on any drinking day
takes into consideration that peopleare in various stages of change?
-motivational interviewing
the most common substance use problems/disorders in older adulthood are?
-nicotine -alcohol -psychoactive prescription drugs -other illegal drugs: marijuana, cocaine, narcotics
adults age 65 and older should follow these drinking guidelines:
-no more than 1 drink each day -never more than 2 drinks on any drinking day (binge drinking)
alcohol decreases the effects of
-oral hypoglycemic; anticoagulatns; anticonvulsants
How can we use the TTM of behavior change?
Gauge our patient's readiness to change Devise appropriate interventions Help put an end to frustrating education sessions that fail to bring positive results
substance abuse arises from old age as a coping mechanism, to deal with these issues (unique to older adults)
- Loss (people, vocation, status) Social Isolation & loneliness • Boredom Major financial problems Changes in housing Family concerns Complex medical problems • Pain associated with chronic illness • Depression Use of multiple medications Sensory deficits Reduced mobility Cognitive impairment or
screens should be chosen based on?
-# of items -methods of administration -substances covered -accuracy by age group, gender, pregnancy status, ethnic group
standard drink size: beer? spirits: whiskey, gin, vodka? wine? sherry? liquer or aprertitif?
-12 oz -1.5 oz -5 oz -4 oz -4 oz
alcohol interacts with what percentage of prescription drugs?
-50%;; note: acetaminophen taken regularly and combined with alcohol may lead to liver failure
every person age ___ and older should be screened for alcohol and prescription drug use/abuse as part of regular physical examination
-60; brown bag approach
12 multiple choice questions; screening for at-risk drinking, abuse, and dependence?
-AUDIT (Alcohol Use Disorders Identification Test)
most accurate screening test for at-risk and problematic drinking?
-AUDIT: accurate for individuals of many different nations and cultures
CAGE screening for abuse and dependence on alcohol
-Cut down? -Annoyed? -guilty -eye opener 1 yes = positive
decreased gastric acidity and drinking alcohol puts elderly at prone to?
-GI ulceration and bleeding
elder specific alcohol screening and assessment tools?
-MAST-Geriatric version; SMAST-G
10 yes/no items; covers alcohol only; validated for ages 55-81
-SMAST-G
no alcohol in the previous year?
-abstinence
why are older adults more vulnerable to adverse alcohol effects?
-age-related changes: higher BAC from a given dose; more impairment at a given BAC
a chronic, relapsing, mental disease
-alcohol abuse
use, double the consequences; repetition; loss of control, preoccupation, compulsivity, physical dependence
-alcohol dependence:
what systems are affected in the brain by drug abuse?
-altered neurotransmission of dopaminergic, serotonergic, and glutmatergic systems
Potential S/S of alcohol problems in older adults:
-anxiety, blackouts, dizziness -depression; disorientation -mood swings -falls, bruises, burns -family problems; financial problems -HAs; incontinence -increased tolerance to alcohol -legal difficulties -memory loss -new problems in decision-making -poor hygiene -seizures, idiopathic; sleep problems; social isolation; unusual response to medications These signs and symptoms are not uncommonly observed when working with older adults and may not be related to alcohol/medication misuse, but may be related to other problems seen in later life. (practitioners and family attribute these s/s to aging)
types of drugs with significant alcohol interactions?
-anxiolytics & sedatives/hypnotics (benzodiazepines) anticonvulsants: phenytoin; psychotropics; antidepressants; barbiturates diphenhydramine; hydroxyzine (other sedatives) -opioids: morphine; codeine; hydrocodone; meperidine;
what percentage of elderly are on risky drugs?
-baby boomers
what is the number one most abused drug by elders? what is # 2?
-benzodiazepines; analgesics
drugs that can cause severe problems if mixed with alcohol?
-benzos; barbiturates; antidepressants
prevention messages should be
-brief; relevant information; culturally appropriate; reinforcing
decreased metabolism of alcohol and higher blood levels for a longer time
-decreased alcohol dehydrogenase
alcohol interferes with metabolism of certain drugs such as?
-digoxin and warfarin
highly susceptible to cognitive, physical, and functional decline; also at an increased risk for injury
-elders who drink excessively
why might older women be at greater risk for alcohol problems?
-potential loneliness and depression from outliving spouse, or other losses physiologically at greater risk as they age -lower than normal alcohol recommendations screening and brief intervention are useful
transtheoretical model of behavioral change
-precontemplation -contemplation -preparation -action -maintenance
screen results and actions: -abstinence or low-risk drinker: -at-risk drinker or drug user with otherwise negative screen -positive screen for abuse or dependence
-prevention message -brief intervention -brief assessment
when assessing alcohol consumption, we are assessing?
-quantity, frequency, and binge drinking
these rates appear to decline with age
-rates of alcoholism
what are goals of brief interventions?
-reduce alcohol consumption -facilitate treatment entry
what slows down the metabolism of alcohol in elderly?
-reduced kdiney and liver function
spectrum of interventions for older adults with alcohol problems
1) prevention/education; 2) brief advice; 3) brief interventions; 4) pre-treatment interventions; and 5) formal specialized treatment e.g., an individual who is currently abstinent (but has had problems related to alcohol at mid-life) may benefit from prevention/education to encourage continued abstinence; if they start drinking again at some point in the future, brief interventions and even formal treatment may be needed
The essential components of alcohol brief interventions include:
1) screening; 2) feedback on the screening results; 3) a motivational approach to facilitate change; 4) the use of strategies for change; 5) a negotiated behavioral agreement ('contract'); and 6) follow-up.
spectrum of drinking among older adults
1. abstainers (haven't used alcohol or drugs within the last year) 2. low risk drinkers 3. at-risk and problem drinkers 4. alcohol abuse or dependence
what ratio of older Americans have MH/SU conditions?
1/5: mental health/substance use; depressive disorders and dementia are most prevalent
o Patient is currently making a health-behavior change(s), or has made one within the last 6 months
Action
depression and alcoholism
Depressed persons who are alcohol dependent have been shown to have a more complicated clinical course of depression with an increased risk of suicide and more social dysfunction than non-depressed alcoholics
o 24-72 hrs after last drink; continues for up to 10 days o MEDICAL EMERGENCY! Confusion Disorientation Hallucination Hyperthermia HTN o Treatment: Scheduled dose OR PRN short-acting Benzos
Delirium tremens
NIAAA Clinician's Guide
Do you sometimes drink beer, wine, or other alcoholic beverages? How many times in the past year have you had.... 5 or more drinks in a day? (men) 4 or more drinks in a day? (women)
includes quantity/frequency, binge, CAGE, and perceptions of a past or present problem with alcohol (Fleming & Barry, 1991). This scale embeds alcohol questions in a health context with three other health behaviors -- exercise, nutrition, and smoking (and depression)
Health Screening Survey
this type of treatment is preferred when the patient is suffering the effects of poor nutrition, poor overall health status, a history of DT's or seizures, or cognitive problems; also needed when there are no obvious community support systems for the patient (i.e., family, caretakers, services for aging).
Inpatient treatment
do the stages of the TTM have to be sequential?
NO: • A person MAY rotate through them many times before successfully changing his/her own health-behavior stage 6 (termination) but not used in clinical applications
OARS: motivational interviewing
O - Open questions (can't be answered with yes/no) A - Affirming (patient's character/values, things they have done well) R - Reflecting ("sounds like..." guess at feeling, meaning, affect) S - Summarize ("what I hear you saying is...and we talked about... and the plan is..."
support groups and group treatment programs for elderly
Older patients tend to be more faithful than younger patients in attending support group meetings and in completing specialized treatment programs. They, however, tend to be uncomfortable with the high noise level, rough language, and cigarette smoke in larger groups. Hearing and visual impairment affect the types of specialized and self-help groups that provide the most comfort.
REDS: motivational interviewing
R - Roll with Resistance - introduce change strategies E - Express Empathy - often, accurately, with effective reflection D - Develop Discrepancy - between patient's goals and behavior S - Support Self-Efficacy - express confidence in patient's abilities
barriers to seeking alcoholism treatment for older adults
Resistance to asking for help (often embarrassed) Disdain of labels (alcoholic, old) Lack of transportation No significant others to assist in motivation to seek help Providers less likely to refer older adults Gaps in substance abuse, aging, and mental health services
screening and assessment for older adults: recommendations
Screen or re-screen if certain physical symptoms are present or if the older person is undergoing major life changes or transitions Ask direct questions about concerns Preface questions with link to medical conditions or health concerns Do not use stigmatizing terms (e.g. alcoholic)
chronic relapsing brain disease; it is treatable and approachable, like treating diabetes and hypertension; not curable
Substance Use Disorder
a person may rotate through these stages many times before successfully changing his/her own health-behavior
TTM
use; consequences; repetition, but no loss of control, preoccupation, compulsivity, physical dependence
alcohol abuse:
medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite problems, physiological symptoms such as tolerance and withdrawal
alcohol dependence
alcohol use that has resulted in adverse medical, psychological or social consequences; or substantially increases the likelihood of such problems
at-risk and problem use
can have consequences, but not always; no repitition
at-risk use of alcohol
first generation indoctrinated with "quick-fix" culture (prescription drugs)
baby boomers
group of elderly with much higher rates of illicit drug use due to history of youth drug use
baby boomers
Time-limited (5 minutes to 5 brief sessions) and targets a specific health behavior (e.g., at-risk drinking)
brief interventions
in what stage of the TTM should nurses use motivational interviewing techniques to highlight benefits of making change, while minimizing perceived barriers to it?
contemplation stage
o Patient is READY to change, and has plans to make a change within the next 6 months
contemplation: pros and cons are balanced
plays a role in pleasure, motivation, motor function, and saliency of stimuli
dopamine
in its extreme form, drug misuse can lead to
drug abuse
Factors such as previous or coexisting drug, alcohol, or mental health problems, old age, and being of the female gender also increase vulnerability for misusing prescribed medications
facts on drug misuse
neurotransmitter that regulates learning and memory? regulates mood, sleep?
glutamate serotonin
________ are especially helpful in reducing shame and improving social network
groups
Drinking patterns that do not meet traditional abuse definitions can lead to
higher BAC, chronic illness, poor nutrition and poly-pharmacy in older patients
alcohol use within guidelines and not associated with problems
low-risk use
o Patient strives to prevent relapse and is more confident in his/her own ability to continue the health-behavior change
maintenance
implications for 2020 projections
major public health concern; urgent need to expand availability of SUD treatment for older adults; substance abuse services should be integrated into primary care; need to increase skills of health care professionals to provide the services
the CAGE does not have high validity with
older adults; if used, should be part of a larger questionnaire (Health Screening Survey)
o Patient will MAKE health-behavior changes within the next month, and has prepared an action plan for this
planning: pros outweighing cons; this persists throughout the rest of the TTM stages
o Patient isn't ready to make a health-behavior change, and has no plans to make one in the next 6 months
pre-contemplation: cons outweigh benefits
o Refers to the individual's internal confidence o Allows this person to believe that he/she can cope with high-risk situations, without relapsing into previous poor behaviors
self-efficacy; add TTM now
Measure of instrument's accuracy in detecting individuals who do have an alcohol problem (True positive/ False negative)
sensitivity
substance abuse and elderly
substance abuse problems among elderly individuals more typically occur from misuse of over-the-counter and prescription drugs. overuse, underuse, or irregular use
2 yes/no questions (1 yes = positive); covers alcohol and drug use; screens for abuse and dependence
two-item conjoint screen; almost like CAGE, but covers alcohol and drug use
Epidemiologic studies have clearly demonstrated that comorbidity between alcohol use and psychiatric symptoms is common in ____________ age groups
younger
o 10-72 hrs after last drink N/V Diaphoresis Hallucinations Tremors Seizures
• Major Withdrawal:
o 6-12 hrs after last drink Tremor Anxiety N/V Insomnia Tachycardia Increased B/P
• Minor Withdrawal (Withdrawal Tremulousness):