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JOURNAL OF DUAL DIAGNOSIS, 8(1), 74–84, 2012 Copyright C© Taylor & Francis Group, LLC ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2012.648439

CLINICAL FORUM

Substance Abuse and Co-occurring Psychiatric Disorders in Older Adults: A Clinical Case and Review of the Relevant Literature

Joanna Marie Salmon, PhD, MBA,1,2 and Brent Forester, MD, MSc2,3

Substance misuse is predicted to become an increasing problem in the older adult population. Individuals with psychiatric symptoms are at increased risk for a co-occurring substance use disorder, further complicating accurate diagnosis and effective treatment. The abuse of substances, including alcohol and prescribed or illicit drugs, can have deleterious effects on an individual’s emotional, physical and cognitive well-being. These effects may be exacerbated by age and, therefore, potential substance misuse should be screened for as rigorously in older patients as in younger adults. Despite research into patterns and consequences of alcohol and prescription drug misuse in older populations, there are limited data on the use of other illicit substances. Most treatment protocols have been developed in younger populations, but basic premises have been extrapolated and revised to suit older adults. (Journal of Dual Diagnosis, 8:74–84, 2012)

The goal of this article is to use a clinical case to introduce a formal review of the literature related to substance use and psychiatric illness in older adults. Prevalence rates of psychi- atric disorders, substance abuse, and co-occurring disorders in older adults are reviewed, and the cognitive ramifications of substance abuse are discussed. Treatment options are outlined with suggestions for future studies.

CASE PRESENTATION

Mrs. Smith was a 79-year-old divorced woman, living inde- pendently, who was referred by her primary care physician for persistent depression in the context of increasing pain and physical disability due to arthritis in her knees and back. Mrs. Smith had a history of recurrent depression, dating back to her mid-30s after the birth of her third child. During the initial psychiatric evaluation, she was tearful and described initial insomnia, depressed mood, impaired motivation to socialize

1Neuropsychology Department, McLean Hospital, Belmont, Massachu- setts, USA

2Department of Psychiatry, Harvard Medical School, Boston, Massachu- setts, USA

3Mood Disorders Division, Geriatric Psychiatry Research Program, McLean Hospital, Belmont, Massachusetts, USA

Address correspondence to Brent Forester, Mood Disorders Division, Geriatric Psychiatry Research Program, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA. E-mail: [email protected]

with friends, and thoughts that life was not worth living. She denied any symptoms of hallucinations, delusions, or discrete panic attacks but noted anxiety manifesting as gastrointestinal distress that bothered her mostly on awakening. Her medical history was significant for arthritis, type II diabetes mellitus, and hypertension. Her medications included metoprolol, gly- buride, and sertraline 150 mg in the morning. Although she had begun to socialize with a few friends since starting ser- traline 8 weeks prior, she still experienced interrupted sleep, poor appetite (with an approximate 15-pound weight loss in 3 months) and morning anxiety. Her Montreal Cognitive As- sessment (MoCa© Dr. Z. Nasreddine, 2003–2011) score was 27/30 with deficits on trails B and delayed recall (missed 2 words out of 5 after a delay but recalled them with category cues). Although Mrs. Smith had a history of two prior alco- hol detoxification admissions, the last of which occurred 30 years earlier, she denied urges to drink and was not attend- ing Alcoholics Anonymous (AA) meetings. After a complete medical evaluation ruled out new intercurrent medical illness and lab testing demonstrated normal thyroid-stimulating hor- mone, B12, and folate levels, she was started on mirtazapine at bedtime to augment sertraline with the goal of improving residual symptoms of insomnia, poor appetite, and anxiety.

Four weeks later she returned for follow-up. She had discon- tinued mirtazapine after a few days due to morning lethargy. In the meantime, her primary care physician had prescribed lorazepam 0.5 mg at bedtime to help with initial insomnia. She also noted that she was now drinking two glasses of wine

Substance Abuse and Co-occurring Disorders in Older Adults 75

at night to help her to relax, sleep better, feel more comfortable around her two friends, and improve her appetite. Mrs. Smith denied that her alcohol consumption was interfering with her daily activities, physical health, or emotional stability. She was not interested in cutting back on the wine consumption and had not told any family members that she was drinking again. Motivational interviewing techniques were used to as- sess her readiness to reduce her alcohol consumption and seek treatment.

Subsequent to a missed appointment, the patient’s daughter called stating that her mother had been admitted to the hospital after passing out at home with a blood sugar level of 300. She was found in her apartment with dozens of empty wine bottles and evidence that she had not been adherent to her medication regimen. After a brief medical inpatient stay, she was admitted to a geriatric psychiatry unit for treatment of alcohol dependence and depression. Mrs. Smith was alert and oriented but angry that she was in the hospital and minimized the likelihood that her recent medical admission was related to alcohol.

Questions

1. What triggered the relapse of alcohol use after 30 years of sobriety?

2. What role did recurrent depression and anxiety play in her alcohol relapse?

3. What evidenced-based treatments should be recom- mended to help improve the likelihood of a successful treatment and recovery program for Mrs. Smith?

INTRODUCTION

Perhaps a result of generational stereotypes or “ageism,” the topic of substance misuse, abuse, and dependence rarely con- jures thoughts of our elderly population. However, ignoring or failing to identify substance misuse in older adults leaves patients vulnerable to psychiatric, physical, and cognitive de- cline. Although substance misuse in the elderly has histori- cally been under-researched compared to the investigation of substance abuse in younger populations, clinical research is beginning to elucidate the consequences of unrecognized sub- stance abuse or dependence in an aging population.

The Older Adult

An elderly or “older” adult is often defined as anyone older than 65. In the United States in 2009, this group constituted over 39 million individuals, or 12.9% of the population (Administration on Aging, 2009). Gender differences exist, and older women outnumber older men at 22.7 million older women to 16.8 million older men (Administration on Aging, 2009). Strikingly, the population of individuals aged 64 and

older is estimated to increase to 55 million by 2020 and 72.1 million by 2030. Complications that occur with increasing fre- quency as people age, such as medical comorbidity, cognitive impairment, and frailty, all contribute to the potential adverse interactions between substance misuse and an aging brain.

A Growing Problem

Rates of substance misuse tend to decline as people age. This reduction with aging has been hypothesized to be the result of individuals “maturing out” of drug use, as well as substance abusers simply not living as long (Winick, 1962; Moos, Bren- nan, & Mertens, 1994). However, research conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA; 2000) has indicated that birth cohorts with high rates of illicit drug use in their youth demonstrate higher rates of use in older age, as well as increased related medical com- plications. Moreover, these rates are predicted to be on the rise. Data from the National Household Survey on Drug Use predicted that, as baby boomers age, substance abuse treat- ment rates for older adults (defined in this survey as aged 50 and older) may increase by as much as 70% (Gfroerer, Penne, Pemberton, & Folsom, 2003). Some predict that substance abuse among older adults will become an increasing problem and that current diagnostic criteria, which have only been val- idated on younger adults, may be underestimating these rates (Patterson & Jeste, 1999).

Age at Onset

Older adult substance abusers can be categorized into two groups: early-onset or late-onset abusers (Benshoff, Harrawood, & Koch, 2003). Early-onset abusers, individuals who experienced substance abuse before the age of 65, tend to have a higher incidence of psychiatric and medical comorbid- ity than their late-onset counterparts (Jung, 1994). In addition, it is estimated that early-onset substance abusers make up two-thirds of all geriatric alcoholics. Late-onset substance abusers are often thought to have developed these behaviors subsequent to a negative life situation associated with the losses that commonly occur with aging: changes in living situation, loss of friends/spouse, retirement, social isolation, etc. (Rigler, 2000; Norton, 1998). These individuals are found to typically experience fewer physical and mental health problems than early-onset abusers (Brennan & Moos, 1996).

PREVALENCE RATES

Prevalence of Substance Use Disorders in Older Adults (See Table 1)

Alcohol is the most commonly used recreational drug in older adults (Breslow & Smothers, 2004). Blazer and Wu (2009)

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76 J. M. Salmon and B. Forester

TABLE 1 Prevalence of Substance Use Disorders in Older Adults

Age 55 + Age 60 + Age 65 +

12-month prevalence of DSM-IV/WMH-CIDI any substance disorder, 2007a

0.3%

Any illicit drug use in the past year, 2006–2008b

1.2%

Marijuana use in the past year, 2006–2008b

0.4%

Nonmedical use of prescription drugs in the past year, 2006–2008b

0.8%

12-month prevalence of DSM-IV/WMH-CIDI alcohol abuse with/without dependence, 2007a

0.3%

Adults reporting past month heavy alcohol use, 2000c

1.5%

Benzodiazepine use in a community settingd

10%–41.6%

aSource: National Comorbidity Survey Replication (NCS-R), updated data as of July 19, 2007.

bSource: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2009).

cSource: Substance Abuse and Mental Health Services Administration (2001).

dSource: Madhusoodanan & Bogunovic (2004).

conducted a secondary analysis of the 2005 and 2006 National Survey on Drug Use and Health, which included data collected from 10,953 respondents aged 50 years and older. Alcohol use in the past year was endorsed by 66% of male respondents and 55% of female respondents. For respondents aged 65 and older, 13% of men and 8% of women reported at-risk alcohol use, and more than 14% of men and 3% of women reported binge drinking.

Although there is generally a dearth of literature regarding patterns of illicit drug use and abuse in older adults, recent sur- veys have indicated that abuse of illicit drugs among this group is on the rise (Schlaerth, Splawn, Ong, & Smith, 2004). Ben- shoff et al. (2003) argue that “as aging individuals are thought to be among the least likely to use illicit drugs, little informa- tion is known about incidence or prevalence or about the effects of these drugs on the elderly population.” In fact, Levin and Kruger (2000) have deemed substance abuse in older adults as an “invisible epidemic” that is largely ignored or downplayed by caregivers and/or mistaken for dementia or depression.

A 2009 study by SAMHSA yielded some sobering conclu- sions regarding substance use among older adults (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009). This study revealed dramatic increases in illicit drug use in adults 50 and older, including a concern- ing incidence of nonmedical use of prescription drugs among women aged 60 to 64. An earlier 2005 SAMHSA study in- vestigated substance abuse treatment among older adults by substance type. Overall, alcohol was the most frequently re-

ported primary substance of abuse in all admissions of persons aged 50 or older, but the highest proportions of admissions in which alcohol was the primary substance were among those aged 65 to 69 and 70 or older. Opiates were the second most commonly reported primary substance of abuse, noted most frequently by individuals aged 50 to 54 and 55 to 59 (22% and 19%, respectively). Similarly, individuals in these two age groups also had the highest proportions of older adult admis- sions for cocaine, marijuana, and stimulants.

One-quarter of the prescription drugs sold in the United States are used by the elderly, and the prevalence of abuse may be as high as 11% (Culberson & Ziska, 2008). Polyphar- macy, common in patients older than 65, increases the risk of dangerous drug interactions. Common prescriptions of poten- tial abuse are used to treat anxiety, pain, and insomnia and include benzodiazepines, opiate analgesics, and skeletal mus- cle relaxants (Rogers, Wiese, & Rabheru, 2008). Estimates of benzodiazepine use in community settings range between 10% and 41.6% (Madhusoodanan & Bogunovic, 2004). Finlayson and Davis (1994) reviewed the medical records of 100 elderly patients admitted to the Mayo Inpatient Addiction Program between 1974 and 1993 who were dependent on prescription drugs and calculated the frequency of abuse by type of pre- scription drug abuse. Benzodiazepines (80%) and opioid anal- gesics (49%) were found to be the most commonly abused. Similarly, Jinks and Raschko (1990) evaluated 1,668 geriatric outpatients and identified rates of prescription drug misuse at 5%. Of prescription drug abusers, 92% were found to have per- sistently abused for at least the past 5 years. In this study, the top four abused prescription agents were diazepam, codeine, meprobamate, and flurazepam. Interestingly, there also was a 60% correlation between prescription drug abuse and previous or active alcoholism.

Prevalence of Psychiatric Illness in Older Adults (See Table 2)

Psychiatric illness is not uncommon among older adults. Such disorders may develop in reaction to late-life stressors and/or underlying biological and neurochemical changes associated with the aging brain. Alternatively, individuals may continue to struggle with more long-standing mental illness in their older years. Depression, sleep disturbance, and anxiety are the most common psychiatric symptoms in the older adult population, and anxiety and dementia are the most common diagnoses given to this group (Blazer & Stephans, 2009).

Several studies have attempted to ascertain current estimates of psychiatric disorders in late life. Both Gum, King-Kallimanis, and Kohn (2009) and Byers, Yaffe, Covin- sky, Friedman, and Bruce (2010) evaluated the data from the National Comorbidity Survey Replication, a representative national sample of community-dwelling adults in the United States. Of note, rates of psychiatric disorders were lower for older adults (65 years and older) than for younger age groups.

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Substance Abuse and Co-occurring Disorders in Older Adults 77

TABLE 2 Prevalence of Mood and Anxiety, Substance Use, and Co-occurring

Substance Use Disorders in Older Adults

Prevalence Prevalence Prevalence of co-occurring of mood of anxiety substance use

Age group disordersa disordersa disordersa,b

55–64 7.6% 16.6% 4.8%–13.5% 65–74 3.6% 8.9% 1.7%–7.3% 75–84 1.8% 6.0% 0.9%–4.4% 85 + 2.4% 8.1% No data

aAdapted from Byers et al. (2010). bPrigerson et al. (2001).

Similar patterns were noted for any lifetime disorders, 46.4% in those aged 18 to 44, 43.7% in those aged 45 to 64, and 20.9% among those 65 years and older (Gum et al., 2009). Further- more, the following factors were associated with an anxiety disorder that lasted more than 12 months: being female, having lower education level, being unmarried, and/or having three or more chronic conditions. Byers et al. (2010) concluded that, “the prevalence rates of mood and anxiety disorders in late life tend to decline with age, but remain very common, especially in women.” Prigerson, Desai, and Rosenheck’s (2001) cross-sectional survey of a representative national sample drawn from 91,753 individuals receiving treatment through the Department of Veterans Affairs mental health programs suggests that, although the rates of co-occurring disorders are lower in older versus younger populations, older adults with both substance abuse and psychiatric disorders tend to access mental health care at high rates.

Prevalence of Co-occurring Substance Use and Psychiatric Disorders in Older Adults

In general, there is a paucity of research and scholarly arti- cles investigating co-occurring substance use and psychiatric disorders in the elderly. Bartels, Blow, Van Citters, and Brock- mann (2006) conducted a review of the available literature and reported that the rates of psychiatric illness in older adults with substance use disorders ranged from 21% to 66%, with rates being higher for individuals surveyed in inpatient settings and with more severe mental illness. In addition, this review high- lighted the positive correlation between psychiatric illness and substance abuse. In a study of 1,668 geriatric outpatients, rates of alcohol abuse were identified at 9.6% (Jinks & Raschko, 1990). Despite these substantial prevalence rates, co-occurring disorders among older adults are often undetected or ignored by health and social workers (Jinks & Raschko, 1990).

Research supports a strong link between substance abuse and depression. A chart audit of 101 individuals aged 60 and older discharged from three psychiatric hospitals indicated that depression was the leading psychiatric diagnosis (Blixen,

McDougall, & Suen, 1997). Older adults with depression are three to four times more likely to have alcohol-related prob- lems than are older adults who are not depressed (Devanand, 2002), and approximately one-third of patients with major de- pressive disorder also have substance use disorders (Davis, Uezato, Newell, & Frazier, 2008). Importantly, this comor- bidity is associated with a higher risk of suicide and greater social/functional impairment (Davis et al., 2008). Notably, sui- cide attempts prior to hospitalization were found to be more common among elders in a co-occurring disorders group than in a group with only a psychiatric disorder diagnosis (Blixen et al., 2007). Likewise, the co-occurrence of alcohol use dis- orders and depression are associated with poorer mental and physical health outcomes in older adults, but depressive symp- toms among older adults often are overlooked or misdiagnosed (Blow, Serras, & Barry, 2007).

The rates of lifetime substance abuse are also high among individuals who have bipolar disorder. Among 392 patients hospitalized with bipolar disorder, 48.5% also had alcohol abuse problems and 43.9% had problems with drug abuse (Cassidy, Ahearn, & Carroll, 2001). Although these rates did decrease with age, substance abuse was still present at “clin- ically important” rates in older adults. Bolton, Robinson, and Sareen (2009) found that almost one-quarter of adults with mood disorders (24.1%) used alcohol or drugs to relieve symp- toms, and men were more than twice as likely as women to engage in self-medication.

PHYSIOLOGIC AND PHARMACOKINETIC INTERACTIONS

Older adults are at higher risk for drug interactions given the elevated prevalence rates of medical comorbidity and high rates of associated prescription medication use. Furthermore, the physiological and metabolic changes that occur during the process of normal aging may increase sensitivity and de- crease tolerance to alcohol and drugs (Crandall, 1991; Ondus, Hujer, Mann, & Mion, 1999). Specifically, with increasing age, the half-lives of drugs and alcohol are lengthened due to decreased renal excretion, reduced hepatic clearance and lowered gastrointestinal absorption (Crandall, 1991). Changes in body muscle mass can also affect concentrations of lipid soluble drugs and sensitivity to alcohol (Crandall, 1991; On- dus et al., 1999). As a result of these changes, older adults can be more sensitive to drug-related side effects including anticholinergic toxicity. In addition, older adults often require lower doses of prescription medications to achieve therapeu- tic efficacy while experiencing a heightened vulnerability to delirium due to an age-related narrowing of the therapeutic index for many prescription medications. As a consequence of these factors, even low amounts of abused substances such as alcohol and prescribed/illicit drugs can have an exaggerated effect in the older adult. Mrs. Smith’s alcohol relapse at the age of 79 had direct adverse consequences on her mood and

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anxiety state, whereas 2 glasses of wine per night may not have demonstrated adverse consequences on mood or cogni- tion 30 years ago when Mrs. Smith was last drinking alcohol regularly.

It is especially important to assess for the presence of sub- stance misuse in older adults given the risk of possible interac- tions with prescribed medications (Rigler, 2000). Medication and alcohol interaction can include both pharmacokinetic in- teractions (i.e., alcohol affects the metabolism of medications) and pharmacodynamic interactions (i.e., alcohol enhances the effects of medications; Weathermon & Crabb, 1999). Alco- hol can have harmful interactions with numerous drug classes, including anesthetics, antibiotics, anticoagulants, antidepres- sants, antidiabetic medications, antihistamines, antipsychotic medications, antiseizure medications, antiulcer medications, cardiovascular medications, narcotic pain relievers, non- narcotic pain relievers, sedatives, and hypnotics (see Table 3). For elderly individuals with co-occurring disorders, there is particular concern for interactions with antidepressant and anti-anxiety medications (Holder, 1992). Alcohol increases the sedative effect of selective serotonin reuptake inhibitors, tricyclic antidepressants, and benzodiazepines, which may increase the risk of household and/or automotive accidents (Lieber, 1992). For individuals taking a monoamine oxidase inhibitor, beer and wine consumption can produce a dangerous rise in blood pressure (Lieber, 1992). Similarly, the combina- tion of alcohol and lorazepam may result in depressed cardiac and pulmonary function (Hollister, 1990). Mrs. Smith’s relapse

TABLE 3 Alcohol and Medication Interactions

Medication Interaction

Analgesics Aspirin: increases gastric emptying, leading to faster alcohol absorption

Ibuprofen: hepatotoxicity Antihistamines (e.g.,

diphenhydramine), opioids (e.g., codeine), and benzodiazepines (e.g., lorazepam)

Alcohol enhances the effects of these agents on the central nervous system including sedation, decreased motor skills, and impaired cognition

Warfarin Acute alcohol ingestion decreases warfarin metabolism leading to increased anticoagulation; chronic alcohol consumption enhances warfarin metabolism leading to reduced anticoagulation

Diabetes medications Alcohol increases the risk of hypoglycemia when taken with these agents

H2 antagonists (e.g., cimetidine) Inhibit alcohol metabolism leading to higher blood alcohol levels

NSAIDs (e.g., ibuprofen) Alcohol increases the risk of gastrointestinal bleeding

TCAs (tricyclic antidepressants such as nortriptyline)

Alcohol increases the risk of sedation and orthostatic hypotension

Source: Weathermon and Crabb (1999).

on alcohol was partly a consequence of lorazepam use lowering the alcohol relapse threshold. Furthermore, alcohol use likely altered the metabolism of the centrally acting psychotropic medications, mirtazapine and sertraline, possibly limiting their therapeutic efficacy. Finally, dysregulation of glucose control and elevated blood pressure was possibly related to an inter- action between alcohol and the antihypertensive medication, metoprolol, and the oral hypoglycemic, glyburide.

NEUROBIOLOGICAL CONSEQUENCES

Alcohol, Neurobiological Sequelae, and Cognitive Impairment

While some studies have supported the neuroprotective effects of mild to moderate alcohol consumption, studies of users of a significant amount of alcohol have documented the increased risk of cognitive impairment associated with heavy drinking (Ganguli, Vanderbilt, Saxton, Shen, & Dodge, 2005; Peters, Peters, Warner, Beckett, & Bulpitt, 2008; Anstey, Mack, & Cherbuin, 2009; Panza et al., 2008; Xu et al., 2009; Letenneur, 2004).

Although half of the estimated 20 million alcoholics in the United Stated appear to be free of cognitive impairment, the remaining 10 million do manifest alcohol-related neuropsy- chological weaknesses (Oscar-Berman & Marinkovic, 2003). The risk of cognitive impairment varies between individuals and the effects on the brain are influenced by a wide range of variables (Parsons, 1996). The effects of long-term alcohol abuse are probably best viewed as existing on a spectrum of severity. A distinct neuropathological basis for alcohol-related dementia has not been established (Oslin, Atkinson, & Smith, 1998).

The rates of alcohol-related dementia in late life differ de- pending on the diagnostic criteria used and the nature of the population studied; however, there is general consensus that alcohol contributes to the acquisition of cognitive deficits in late life. Evidence for this notion has been supported by epi- demiological data. For instance, among participants older than 55 in the Epidemiologic Catchment Area study in the USA, the prevalence of alcohol use disorders was 1.5 times greater among people with mild and severe cognitive impairment than those with no impairment (George, Landerman, Blazer, & Anthony, 1991).

One theory proposes that alcoholism results in premature aging, which was deduced by the finding that the brains of alcoholics are similar to the brains of chronologically older nonalcoholics. However, it also has been suggested that the effects of alcoholism are disproportionately expressed in older adults (Oscar-Berman & Schendan, 2000).

Brain regions that appear to be particularly vulnerable to alcohol-related damage include the cerebral cortex and sub- cortical regions such as the limbic system, thalamus, hy- pothalamus, basal forebrain, and cerebellum (Oscar-Berman

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Substance Abuse and Co-occurring Disorders in Older Adults 79

& Marinkovic, 2003). Imaging studies have demonstrated de- creased cortical and subcortical volume thought to be the result of neurotoxicity associated with heavy alcohol consumption (Lisman, 1990). The frontal lobe systems appear to be partic- ularly vulnerable to alcohol-related damage, which becomes more prominent with age (Oscar-Berman & Schendan, 2000). Furthermore, given the “emotional flattening” often evidenced by alcoholics, investigators have begun to hypothesize that the right hemisphere is more vulnerable to alcohol-related dam- age (Oscar-Berman & Schendan, 2000). Research also has in- dicated that gamma-aminobutyric acid, glutamate, dopamine, acetylcholine, and serotonin systems are especially sensitive to alcohol use (Oscar-Berman & Marinkovic, 2003).

A wealth of research has supported the risk of cognitive decline associated with excessive alcohol consumption. The cognitive effects of alcohol can include acute intoxication, withdrawal syndrome, and more chronic impairment. With- drawal states may be prolonged in older adults and hospital- ization is commonly recommended (Kraemer, Mayo-Smith, & Calkins, 1997). Hospitalization was medically necessary in the case of Mrs. Smith to safely complete alcohol detoxification while managing the medical comorbidities of hypertension and diabetes and assessing for an exacerbation of cognitive dysfunction.

There is a wide spectrum of chronic cognitive effects that may occur as a result of long-term alcohol abuse. Most se- vere cases can result in Wernicke-Korsakoff syndrome, which is the result of thiamine deficiency secondary to malnutrition and decreased absorption related to moderate to heavy alco- hol use (Thompson & Marshall, 2006). Although this damage may be reversible if treated with thiamine supplements in its earlier stages (Wernicke’s encephalopathy), a more prolonged thiamine deficiency often results in permanent brain damage to the hypothalamus, diencephalon, and brain stem. This type of cognitive damage manifests as a Korsakoff’s dementia, char- acterized by a dense and persistent amnestic state. Although susceptibility to Wernicke-Korsakoff syndrome is always a risk for moderate to heavy alcohol abusers, thiamine supplementa- tion in common foods (e.g., white bread) appears to decrease susceptibility to this condition (Connelly & Price, 1996).

Individuals also may experience dementia secondary to alcohol abuse, which can vary from mild to severe in its presentation. Individuals with alcohol-related dementia have demonstrated neuropsychological weaknesses on measures of complex visual-spatial skills, psychomotor speed, executive functioning, and memory (Schmidt et al., 2005; Grant & Adams, 1996). Importantly, for a diagnosis of alcohol-related dementia to be made, the individuals should be abstinent from alcohol for at least 60 days (Oslin et al., 1998).

In summary, cognition can be negatively affected by alcohol consumption, even in small to moderate amounts. Even with sustained abstinence from alcohol, evidence supports persis- tent cognitive vulnerabilities and an increased susceptibility to a mixed dementia (Oslin & Cary, 2003). However, there is evidence that some individuals do demonstrate improved cog-

nitive functioning after extended periods of abstinence (Oslin et al., 1998).

Alcoholism, Depression, and Brain Changes

The common co-occurrence of alcoholism and depression has long been established, although the exact relationship between these disorders remains unclear (Lynskey, 1998; Bakouras, Bakola, Bakola, Kotrotsiou, & Skyllakos, 2003; Davidson, 1995). A unidirectional cause and effect relation- ship is unlikely, and associations among pathophysiologi- cal, structural, and metabolic changes as well as socioeco- nomic/environmental factors have been considered. Pietraszek proposed that lower levels of serotonin found in the blood fol- lowing consumption of alcohol may contribute to depression (Pietraszek et al., 1991). A recent study conducted by Kelley and Danzter (2011), based on preclinical rodent models and humans, suggests a physiological link between alcoholism and mood disorders. Evidence suggests that changes to the immune system related to the increased production of toll-like receptor 4, a protein that induces resistance to chronic alcohol inges- tion, produces inflammation-induced depressive-like behav- iors in mice, and new findings have extended these concepts to humans.

As cognitive changes can be seen with chronic alcohol abuse, and depressive symptoms are common with dementia, it can be postulated that co-occurring mood disorders may be related to underlying changes in cerebral integrity (see Table 4). Imaging studies have suggested that brain atrophy as- sociated with chronic alcohol consumption tends to manifest most significantly in the frontal and temporal lobes (Carde- nas, Studholme, Gazdzinkski, Durazzo, & Meyerhoff, 2007). These overlap with the brain regions (frontostriatal and corti- colimbic networks) implicated in studies of individuals with depression (Goldstein & Volkow, 2002). For example, imaging studies have identified hypometabolism of the orbital-frontal prefrontal cortex and anterior temporal cortex in depressed pa- tients (Mayberg, 1994; Mayberg et al., 1999). Feldstein Ewing, Filbey, Chandler, and Hutchinson (2009) investigated the co- occurrence of depressive and anxiety symptoms and neuronal responses to alcohol and found that depressive symptoms were positively correlated with activation during the alcohol cue in the insula, cingulate, ventral tegmentum, striatum, and thala- mus. Likewise, anxiety symptoms were positively correlated with activation during the alcohol cue in the striatum, thala- mus, insula, and inferior, midfrontal, and cingulate gyri.

Cognition and Prescription or Illicit Drug Misuse

Substances such as opioids, benzodiazepines, and medica- tions with anticholinergic properties present a risk of cognitive impairment ranging from confusion to delirium to demen- tia (Rogers et al., 2008). Opioids are commonly prescribed

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TABLE 4 Effects of Alcohol, Depression, and Anxiety on Regional Brain Structure

and Function

Clinical syndrome Associated neuroimaging findings

Chronic alcohol consumption

Frontal and temporal lobe atrophya

Hypometabolism in the right visual cortex,e fusiform gyrus,e left dorsolateral prefrontal cortex,e

cerebellum,e frontal lobe,e,f and parietal cortexf

Major depression Frontostriatal and corticolimbic involvementb

Hypometabolism in the orbital-frontal prefrontal cortex and anterior temporal cortexc

Anxiety symptoms Activation of striatum, thalamus, insula, and inferior, midfrontal, and cingulate gyri in the presence of alcohol cuesd

Depressive symptoms Activation of insula, cingulate, ventral tegmentum, striatum, and thalamus in the presence of alcohol cuesd

aCardenas et al. (2007). bGoldstein and Volkow (2002). cMayberg (1994); Mayberg et al. (1999). dFeldstein Ewing et al. (2009). 2Wilson (2007). fTapert et al. (2001).

in the geriatric population and can have a significant po- tential for misuse (Rogers et al., 2008). Importantly, both acute and chronic opioid use may have cognitive effects. Neuropsychological vulnerabilities may include decreased at- tention/concentration, reduced memory, slowed psychomo- tor speed, executive dysfunction, and decreased visual-spatial skills (Gruber, Silveri, & Yurgelun-Todd, 2007).

Benzodiazepines are often used to treat anxiety and insom- nia. With advancing age, elderly individuals are more sensitive to the potential side effects of benzodiazepines (Bogunovic & Greenfield, 2004). This class of drugs can have significant effects on cognitive functioning in the geriatric population (Fick et al., 2003). Confusion and disorientation may also be seen as a result of withdrawal when benzodiazepines are stopped abruptly (Schweizer, Case, & Rickels, 1989). On neu- ropsychological tests, weaknesses can be seen on measures of memory, concentration, response inhibition, and motor coor- dination (Gray, Lai, & Larson, 1999, Lader, 1987; Salzman et al., 1992). These cognitive weaknesses often improve after discontinuation of benzodiazepines (Salzman et al., 1992).

The cognitive effects of marijuana and other illicit sub- stance use in the older adult population have not been well stud- ied. Studies in younger adult populations have demonstrated the presence of decreased attention and short-term memory in habitual marijuana users (Lundqvist, 2005).

Both lorazepam and alcohol were likely contributing to cognitive side effects in the case of Mrs. Smith.

IDENTIFICATION AND ASSESSMENT

Clinicians may be resistant to actively challenge substance use habits in older adults due to an ageist “they are old, let them enjoy life” viewpoint (Bleechum, 2002). Unfortunately, older patients with substance use problems often do not receive thorough assessments, especially when the clinician is older as well (Pennington, Butler, & Eagger, 2000). An increased focus on successful identification and subsequent interven- tion is warranted, as some older problem drinkers reduce their consumption when encouraged to do so by their physician. Fink, Elliott, Tsai, and Beck (2005), in a study involving 23 physicians and 665 patients aged 65 and older (21% harmful drinkers, 26% hazardous drinkers), found that older primary care patients can effectively reduce their alcohol consumption and other drinking risks when given personalized information about their drinking and health. Patients reported that the in- tervention significantly reduced harmful drinking at follow-up from an expected 21% in usual care, to 16%.

Denial or downplay of substance use is common and can make accurate diagnosis and treatment more difficult (Bleechum, 2002). Rigler (2000) argues for clinicians to “maintain a high index of suspicion and a non-judgmental attitude” when caring for older patients with problems related to alcohol use, and she warns that older patients may be reticent to accept substance abuse treatment because of a “perceived negative stigma.”

Assessment of co-occurring disorders may be enhanced with the administration of screening measures that ascertain the quantity and frequency of substance use as well as the level of risk that this behavior poses. In addition to a thorough clinical interview, the clinician may consider using screen- ing instruments such as the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G), a 24-item screening mea- sure developed by Blow et al. (1992) specifically for geriatric populations. The MAST-G was found to have a sensitivity of 94.9%, a specificity of 77.8%, a positive predictive value of 89.4%, and a negative predictive value of 88.6% (Litchenberg, 1999). The outcomes of subsequent studies have continued to support the validity of the MAST-G in older adults (Hirata, Almeida, Funari, & Klein, 2001). The short version of this test, the S-MAST-G, consists of 10 items, appears to be an ac- ceptable alternative to the full version, and is clearly superior to measures used in younger adults (Litchenberg, 1999). Some clinicians may prefer to use the CAGE Screening Instrument or the Alcohol Use Disorders Identification Test; however, these have not been specifically validated for the geriatric popula- tion (Culberson & Ziska, 2008). Some studies have indicated that the CAGE and MAST-G test different aspects of alcohol use patterns and, therefore, recommend using both measures to capture more aspects of unsafe drinking (Moore, Seeman, Morgenstern, Beck, & Reuben, 2002). Whenever possible, collateral information obtained from caregivers and/or family members can prove invaluable, as they may provide a more

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Substance Abuse and Co-occurring Disorders in Older Adults 81

objective estimate of the patient’s substance use habits. In ad- dition, the functional consequences and cognitive impairment related to substance use must be considered. It is important to remember that, given changes in the metabolism of sub- stances of abuse, older adults may meet criteria for a substance use/dependence disorder despite relative small quantities of consumption. In the case of Mrs. Smith, direct questioning of alcohol use and collateral information from her daughter allowed for a prompt recognition of alcohol relapse.

TREATMENT

There are few empirically derived principles to guide treatment of co-occurring disorders in the elderly. As a result, much of what is recommended and practiced is based on interventions that have been validated in younger populations.

The need for detoxification and the potential for serious withdrawal symptoms should be carefully evaluated. While detoxification is sometimes offered on an outpatient basis, el- derly patients are more likely to require hospitalization due to medical complications, such as autonomic instability or, as seen with Mrs. Smith, metabolic changes or disorders. In general, the choice of treatment will depend on the severity of the condition, the degree of risk, and the level of func- tional impairment. Treatment settings may vary from hospital- ization to outpatient psychotherapy depending on the nature and severity of the abuse. Recommendations with regard to specific therapeutic modalities, for the most part, must be ex- trapolated from studies in younger populations. Motivational interviewing techniques have been validated in younger adult populations as an effective method to ascertain an individ- ual’s readiness to change and to enhance motivation toward change (Miller & Rollnick, 2002). Cognitive-behavioral ther- apy is also widely used in the treatment of substance abuse (Kranzler & Rosenthal, 2003). Initial studies of brief physician advice have shown promise in older adults (Fleming, Man- well, Barry, Adams, & Stauffacher, 1999). Tiet and Mausbach (2007) reviewed this literature and found that existing effica- cious treatments for reducing psychiatric symptoms also tend to be effective in patients with co-occurring disorders and that existing efficacious treatments for reducing substance use also decrease substance use in patients with dual diagnoses. Nor- ton (1998) recommended that interventions be tailored toward the older individual and delivered in treatment groups with similarly aged cohorts to increase comfort and adherence.

The treatment of co-occurring disorders in individuals with more serious mental illness presents added and unique chal- lenges. Again, this literature, although extensive for younger adult populations, is almost nonexistent for older adult pop- ulations. Bartels et al. (2006) have suggested that treatment of co-occurring disorders among individuals with severe men- tal illness is best delivered by a multidisciplinary team that serves to enhance the cohesiveness of care and reduce conflicts between clinicians. Furthermore, these authors suggest that

both disorders be treated as “primary” and that a combination of psychotherapeutic modalities, including effective outreach and case management, motivational techniques, psychother- apy and psychopharmacology, be mobilized. These recom- mendations are supported by numerous studies, which have demonstrated better outcomes for programs that provide an integrated approach to the treatment of co-occurring disorders and severe mental illness (Bartels et al.. 2004, Drake et al., 2001, Minkoff, 1989).

Several studies have addressed pharmacotherapy ap- proaches for older adults with co-occurring substance use dis- orders. The use of medications to improve abstinence from al- cohol in older adults has received some attention. Naltrexone is an opiate antagonist that reduces cravings for alcohol and is in- tended to be prescribed as adjunctive treatment to psychosocial support in order to reduce the risk of alcohol relapse. Naltrex- one 50 mg/d was found to be safe in a 12-week randomized controlled trial in 44 older veterans with alcohol dependence, but no differences were identified between the naltrexone and placebo groups in number of participants who relapsed or re- mained abstinent (Oslin, Liberto, O’Brien, Krois, & Norbeck, 1997). Disulfiram should generally not be prescribed to el- derly people because of the increased risk of delirium and other serious adverse effects due to physical comorbidities (e.g., cardiac issues) and polypharmacy (Dunne, 1994; Dufour & Fuller, 1995; Schonfeld & Dupree, 1995). Acamprosate is a gaminobutyric acid analogue that is thought to act by reduc- ing glutamate excitotoxicity while enhancing inhibitory neu- rotransmission. Acamprosate may be safer and more effective in those with liver dysfunction (Dar, 2006). A meta-analysis of younger adult studies of acamprosate showed a 13% im- provement in 12-month continuous abstinence rates (Mann, Lehert, & Morgan, 2004). There are no known pharmacoki- netic studies of buprenorphine/naloxone in older adults with opioid dependence, and the use of buprenorphine/naloxone in the elderly is cautioned due to increased risk of respiratory suppression and sedation.

FOLLOW-UP TO CASE OF MRS. SMITH

After a 2-week inpatient psychiatry admission, Mrs. Smith was discharged home to follow-up in a geriatric partial hos- pital program. She attended AA meetings daily. Her antide- pressant medication was changed to include a combination of duloxetine and trazadone, and her medications for diabetes and hypertension were resumed. With the assistance of AA meet- ings, individual therapy, and antidepressant medication, she gradually gained more insight into the triggers to her alcohol relapse and the adverse medical effects of alcohol. In retro- spect, she noted that once she began to take lorazepam for insomnia, her urges to drink escalated and she began to drink wine on social occasions. She did not have the insight to rec- ognize the escalation in her alcohol consumption or the impact on her physical and emotional health. Although Mrs. Smith is

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82 J. M. Salmon and B. Forester

still ambivalent about sobriety, her mood has improved, and she is planning to begin community volunteer work and to remain in the AA program and secure a sponsor.

SUMMARY AND RECOMMENDATIONS

Although the rates of substance misuse and psychiatric illness do tend to decline with age, proper evaluation and assessment of these disorders will likely become increasingly important with the aging baby boomer generation. While some principles derived from studies of younger adults can be translated to the treatment of older adults with co-occurring disorders, this pop- ulation does present unique challenges related to the increased prevalence of medical comorbidities and risk of cognitive im- pairment as well as generational differences in the way older patients interact with clinicians.

Given the comorbidity of substance abuse and psychiatric illness, it is important that older adults who present with psy- chiatric symptoms be fully assessed for the presence of a co-occurring substance misuse problem. Appropriate treat- ments are likely to be multifaceted, with an emphasis both on relieving psychological distress while concurrently reduc- ing substance use. Furthermore, treatment is likely to be most beneficial when individual treatments are combined with peer support modalities. Although older adults may be hesitant to seek help for and to initially discuss emotional and/or sub- stance misuse issues, research has indicated that psychoedu- cation by the clinician does indeed encourage these individuals toward change.

Because research on substance abuse has tended to focus on younger populations, issues facing older adults need to be better understood in order to adequately meet the needs of this growing population. Further study of the older adult population with substance use disorders and co-occurring illness is sorely needed. These efforts should include the study of mechanisms to routinely integrate screening into general medical settings, an increased understanding of the neurobiology of substance use disorders in older adults with medical and cognitive co- morbidities, and specific treatment interventions that are both safe and effective for the older adult population. Research is also needed to clarify whether there are vulnerabilities specific to older adults that place them at increased risk for substance abuse. Such data would assist outreach efforts to better tar- get prevention methods to certain segments of this population. Psychoeducational techniques that are effective in assisting caregivers in substance abuse identification need to be devel- oped. Finally, there is a current lack of data to support specific psychotherapeutic and pharmacotherapeutic techniques that are most effective for an older adult cohort. The development of an evidence base to support clearer recommendations for both specific psychotherapy modalities and effective and safe pharmacotherapy approaches will greatly benefit older adults with co-occurring disorders.

ACKNOWLEDGMENTS

The authors would like to acknowledge the input and advice of Dr. Olivera Bogunovic in the preparation of this manuscript. No financial support was received, nor were grants received. This article has not yet been presented at a meeting.

DISCLOSURES

Drs. Salmon and Forester have no conflicts of interest related to the content of this article to disclose.

NOTE

The case presented in this forum is an actual case altered to protect the individual’s identity.

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