MEDICATION ABUSE IN OLDER ADULTS Clifford Milo Singer, MD Adjunct Professor, University of Maine, Orono ME Chief, Division of Geriatric Mental Health and Neuropsychiatry The Acadia Hospital and Eastern Maine Medical Center, Bangor ME 1
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Overview Prevalence Predisposing Factors Precipitating Factors Perpetuating Factors Consequences Specific Medications Interventions 3
Predisposing Factors Social isolation Multiple chronic diseases Highest risk conditions: depression, anxiety, insomnia, pain Polypharmacy Seniors prescribed 3X s more medication Previous history of substance dependence or abuse 4
Precipitating Factors Acute illness Many begin using high risk drugs while in hospital Bereavement Lower reserve function Functional decline and reduced independence Stress resulting in anxiety and insomnia 5
Perpetuating Factors Lack of appropriate diagnosis and treatment of underlying condition Abrupt discontinuation by patient or physician can result in severe withdrawal or rebound symptoms reinforces dependency End-of-dose symptom rebound strengthens conditioned dependency Social isolation or family collusion may delay detection 6
Older vs. Younger Adults Benzodiazepines and analgesics: the most common medications misused and abused by all adults Older adults more likely to be treating chronic diseases and suffer medical rather than psychosocial consequences Older adults more likely to uniintentionally misuse rather than abuse Younger adults much more likely to escalate into addiction and criminal behavior 7
Consequences Falls Confusion Renal failure (NSAIDs) Apathy and depression Obstipation (Opioid analgesics) Gastrointestinal bleeding (NSAIDs) Hospitalization for adverse drug reactions 8
Benzodiazepines BZD are the most commonly prescribed medications for anxiety and insomnia Frequently prescribed for depression and agitation associated with dementia Often started in hospital Dependency risk high; addiction risk low Withdrawal: anxiety, insomnia, agitation, restlessness, tremor, hypereflexia/clonus, tachycardia, delirium, myoclonus, seizures 9
Common BZD Antianxiety Hypnotic Anticonvulsant diazepam/valium lorazepam/ativan flurazepam/ Dalmane triazelam/halcion clonazepam/ Klonapin oxazepam/serax tamazepam/restoril chlordiazepoxide/ Librium lorazepate/ Tranxene zolpidem (BZRA)/ Ambien eszopiclone (BZRA)/ Lunesta zalipon (BZRA)/ Sonata 10
Risks of BZD Falls Apathy Fatigue Confusion Slow reflexes Slow cognitive processing Increased motor vehicle accidents Worsened sleep-disordered breathing 11
Epidemiology of BZD Dependence Older adults, 13% of the population, receive 27% of BZD prescribed for anxiety and 38% of BZD prescribed for insomnia Risk factors: female, anxiety disorders, multiple chronic conditions, high utilizers of medical services Of those referred for treatment of BZD abuse, 36% had old age onset of BZD use, 66% were depressed 12
Prescribing Protocol Ensure Appropriate Indication Anxiety or insomnia with concomitant employment of primary treatment plan such as SSRI, CBT, sleep hygiene measures Improved comfort and function Ensure Safe Pattern of use No dose escalation or multiple prescribers No mixing with alcohol Assess Tolerability No confusion or ataxia 13
Inappropriate Prescribing Primary treatment for depression Anxiety associated with delirium Agitation associated with dementia? Sleep fragmentation associated with sleep disordered breathing Anxiety associated with severe COPD Long-acting BZD leading to carry-over Dose equivalent > 2-3 mg/day lorazepam 14
Benzodiazapine Metabolism Age increases risk: Aging into Toxicity Lower Risk of falls & confusion/higher risk of severe withdrawal Phase II Hepatic Metabolism: glucoronide conjugation with 1/2 life < 8 hours lorazepam, tamazepam, oxazepam Higher Risk of falls & confusion/lower risk of severe withdrawal Phase I Hepatic Metabolism: oxidation with active metabolites and 1/2 life > 8 hours flurazepam, diazepam, chlordiazepoxide, clonazepam 15
Treatment of BZD Dependence Patient education Rapid taper, 12.5-25% of dose per week Slow taper, 25% of dose per month Final 25-50% of dose may be needed for prolonged maintenance Helpful strategies: Treat underlying condition (depression, anxiety disorder, insomnia with other class of drug) Transition to longer 1/2-life drug More frequent administration of lower amounts 16
Narcotic Dependency Doubled incidence in last 10 years > 55 yrs. Young addicts grown old is common pattern Often unrecognized because of multiple providers Diversion by selling or theft by family occurs, may not be rare Addiction behavior is rare in older adults without a history of substance abuse 17
Opioid Pharmacology Older adults are more sensitive to analgesic effects Tolerance can develop quickly High risk of respiratory depression, sedation, confusion, constipation, impaction, ataxia and falls Long-acting drugs (eg fentanyl and methadone) have greater risk 18
Detection Requests for large number of low mg Detailed knowledge of and preference for specific drug Lack of objective evidence of comfort or functional gains but intense investment in medication Multiple providers, complaints about providers 19
Risk Reduction Scheduled dosing initially (not prn) to avoid pain-relief cycle. Goal is to avoid pain peaks. Education about the tolerance and risks. Employing non-narcotic pain strategies: antidepressants, anticonvulsants, topical, injections, acupuncture, PT, CBT, relaxation techniques/meditation 20
Pharmacology Considerations Opioids to avoid: Demerol, Darvon Long acting drugs risk daytime sedation, confusion, accumulation, but provide smoother analgesic effect. Methadone, fentanyl, MS Contin, Oxycontin Short acting drugs may be safer but lead to peaks and valleys of pain that can reinforce dependency and addiction. Morphine, oxycodone, hydrocodone, hydromorphone 21
Other Drugs That Are Misused or Abused NSAIDs Stimulants Laxatives Diphenhydramine Muscle relaxants Anticholinergics 22
High Risk Drugs Beers Criteria: Arch Intern Med 2003; 163:2716-2724 1991: Mark Beers MD published list of high risk drugs for frail seniors Periodically updated by consensus panel Useful to refer when concerned about appropriate prescribing. 23
References Prescription drug misuse/abuse in the elderly. Geriatrics 2008 Sept; 63(9):22-31. Risk factors associated with problem use of prescription drugs. Am J Pub Health 2004 Feb; 94(2):266-268. Geriatric Substance Abuse Fact Sheet: www.gmhfonline.org/gmhf/consumer/factsh eets/substnabuse_factsheet.html 24