Mental Health Issues and Addiction in Older Adults - PowerPoint Presentation

1. Mental Health Issues and Addiction in Older Adults Sharon A. Matthew LPC,CCS,ACRPS,CSAT, CMAT

2. ObjectivesTo educate on the myths about mental health in older adults Statistics on prevalence of mental health disorders in adultsTo understand common problems addressed in treatment with older adultsTo understand generational differences To understand how addiction causes complications in older adults

3. Myths and Realities about Older AdultsMythPretty much alikeAlone and LonelySick, frail, dependentRealityVery DiverseMost maintain close relationships Most live independently

4. Myths and realities cont.Cognitively impairedMost are depressed Rigid with old age Cognitively intactLower rates of depression than YAPersonality fairly consistent throughout life

5. Health Professionals StruggleI’d rather be dead than oldWhat does she have to live for?(a life not worth livingIt must be depressing (working with old people)Ageism- Negative attitudes toward aging

6. Mental Health Issues in Late LifePrevalence of Mental disorders in All Adults vs Older AdultsAll Adults Older Adults32.4% have MD 15.5% MD19.1% Anxiety 9% Anxiety 6.8% Major Depression 2.9% Major Dep.13.4% SUD 5.9% SUD

7. Common Problems Addressed in Therapy with Older AdultsLife transitions (onset of medical problems, Caring for a loved one, Retirement, Moving, Financial problems)Disputes/Conflicts (Family, siblings, institutions)Grief and lossSocial Isolation

8. Generational DifferencesSilent generation (traditionalists-1925-1945) Don’t air your dirty laundry (don’t like talk therapy)They are dedicated, willing to sacrifice, duty before pleasure, loyalty, family focused

9. Generational Differences Cont.Boomers ( 1946-1964)Act like they don’t care what people think, but they do They are into personal growthLoyal to their children and believe anything is possible

10. Successful Treatment of Mental Disorders in Late Life Psychotropic medications (most respond well to these medications, start slow, go slow)Evidenced based Psychotherapy (CBT, DBT, CPT, Problem Solving, Reminisce Therapy, Interpersonal Psychotherapy Mindfulness)Dance/ Movement Therapy

11. Addiction and Older AdultsFastest growing population in need of specialized careTreatment components necessary for a well rounded approachThe importance of staying connected

12. Substances UsedAlcohol most prevalent however, opiates, benzodiazapines, cocaine and marijuana also being used. 1/3 of prescription drugs consumed by older adults and 2/3 of over the counter medications consumed by Older adults Boomer and Older adults living with multiple chronic disorders, including the disease of addiction

13. Treating Older Adults Successful Integrated ModelPhysical, Emotional, Spiritual , Medical, recreational, Nutritional, Social and also Systemic (Caregivers)Population that demands dignity and respectThey are diverse, complex, changing , clinically challenging, unique individuals, rewarding to serve

14. What WorksEducation about the diseaseAppropriate medicationsBeing with peers of their same mindsetMindfulness, Wellness, getting moving, Dance Movement, music

15. What Works ( Cont.)DBT, CBT, 12 step recovery, massage, acupuncture, coping skills to deal with emotional pain, loneliness, loss, chronic pain medical monitoring, having fun in recovery

16. Super Aging Physical Super Ager (Exercise, good food, sleep)Cognitive Super Ager (Learn new tasks, do puzzles, etc)

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18. Edith Wilma Connor holds the Guinness World Record for oldest female weightlifter. She’s 84

19. ReferencesMay 2017. What does it take to be a super-ager?. Harvard Health Publishing. National Registry of Evidenced-Based Programs and Practices: SAMSHA http://www.nrepp.samhsa.govAugust 2016. NIH National Institute on Drug Abuse Prescription Drugs, Older Adults.

20. References (Cont.)2017. Treatment of Depression in older adults evidence-based practices( EBP). Center for Mental Health Services.

21. Medical Considerations for Addiction Treatment of Older AdultsMing R. Wang, MD, FASAMAmerican Board of Preventive Medicine; Addiction Medicine CertifiedDiplomate of the American Board of Addiction MedicineDiplomate of the American Board of AnesthesiologyCaron Treatment CentersWernersville, Pennsylvania

22. ASAM Disclosure of Relevant Financial RelationshipsContent of ActivityDate of ActivityNameCommercial InterestsRelevant Financial Relationships:what was receivedRelevant Financial Relationships: for what roleNo Relevant Financial Relationships With Any Commercial InterestsMing R. Wang, MDX

23. Treating Older AdultsSuccessful Integrated Model Physical, Emotional, Spiritual, Medical, Recreational, Nutritional, Social and Systemic (Caregiver)

24. Physical Signs and Symptoms Complicated by Addiction Sleep complicationsIsolationHealth complicationsDecline in ADL’sUnexplained burns/bruisesFall riskMedication complications Disease concept: chronic progressive characterized by denial Memory loss, dementia, deliriumMalnutritionIncontinenceDecline in social interactionVision problemsCognitive decline Hearing problems.

25. Older adults more vulnerable to effects of alcohol and medicationsIncreased risks of comorbid diseasesIncreased risks of harmful drug interactions, injuries, depression, cognitive issues, liver and cardiovascular diseasesIncreased fall risks leading to bone fractures, internal bleeding and head injuryPoor cognition interfere with ability to recall use historyWithdrawal management challenges

26. At risk drinking and problem drinking are the largest classes of substance use problems in older adultsAt risk drinking defined by ≥ 3 drinks per day and ≥ 7 drinks per week in healthy men/women older than 65 y/oAt risk drinking increases the potential for developing problems and complicationsLate onset problems may develop due to stressors related to older age (e.g., retirement, loss of income, loss of partner)

27. National Survey on Drug Use and Health (NSDUH, 2002-2003); age 50+, 12.2% were heavy drinkers, 3.2% were binge drinkers, and 1.8% used illicit drugsMost elderly patients with alcohol problems go unidentified by health care personnelFew elderly patients seek help

28. Adults > 65 y/o comprise 13% of the population and 36% of all prescription medications used in the United States25% of older adults use psychoactive medications with abuse potentialGreatest concerns are opioids and benzodiazepinesMisuse and abuse of prescription drugs by older adults not typically done for euphoriaMost abused medications are obtained by prescriptionEstimated nonmedical use of prescription drugs will increase to ~2.7 million by 2020 in 50+ age group

29. Pharmacodynamics vs. Pharmacokinetics

30. Pharmacokinetic ImplicationsFirst Pass Metabolism Aging associated with reduction in first-pass metabolism due to reduction in liver mass and blood flowDrug Distribution Age related changes in body composition leads to ↓ volume of distribution for water soluble drugs (polar) leading to ↑ serum levels in the elderly Volume of distribution ↑ for fat soluble drugs (non polar) leading to ↑ T (diazepam)  

31. Protein Binding Acidic compounds (diazepam, Dilantin, warfarin, salicylic acid) bind primarily to albumin Basic compounds (propranolol) bind to α1-acid glycoprotein Albumin reduced in malnutrition or acute illness and α1 glycoprotein increased in acute illness. Main factor determining drug effect, however, is free fraction of drugs Initial and transient effect of protein binding on free [plasma] is quickly balanced by clearance, therefore, clinical relevance may be limited

32. Drug Clearance Reduction in renal function in elderly, especially GFR, affects clearance of many water soluble abx, diuretics, digoxin, water soluble β blockers, NSAIDS and Lithium Clinical importance is dependent on potential toxicity of the drug Strong implications in drugs with narrow therapeutic window (digoxin, Lithium, aminoglycoside abx)

33. Cardiac Dysfunction Age related dysfunction leading to ↓ HR and ↑ SVR with associated ↑ noradrenaline and serum creatinine excreted drugs clearance reduced Biotransformation of drugs reduced (pro drug activation, ie. Enalapril) due to hepatic congestion

34. drug clearance by liver depends on capacity of liver to extract drug from liver blood flow and amount of hepatic blood flow Clearance by liver depends on blood flow and extraction ratio [E] [E] is dependent on metabolizing capacity of the liver ↑ [E] then clearance is rate-limited by perfusion ↓ [E] then changes in liver blood flow produces little changes in CL Reduction in liver blood flow in aging will mostly effect drugs with high [E]

35. Drugs with low [E], clearance is independent of liver blood flow (warfarin, Dilantin) Drugs with high [E], clearance is rapid and dependent on liver blood flow (morphine, propranolol, NTG, verapamil) Reduction in renal function may affect metabolized drugs by decrease of P450 activity due to reduced gene expression

36. Pharmacodynamic ImplicationsMagnitude of drug effect depends on number of receptors in target organ, ability of cells to respond to receptor occupation and counterregulatory processes that preserve original fx.Increase in drug sensitivity has to be assumed with response to a given serum concentration is enhanced.Age related changes in pharmacodynamics may occur at receptor or signal-transduction level or homeostatic mechanism may be attenuated.β-adrenoceptors downregulated in elderly by ↑ serum noradrenaline levels.Number of dopaminergic neurons and dopamine D2 receptors decreased.

37. Progressive reduction in homeostatic mechanisms requiring more time to regain original steady-state due to reduced counterregulatory measures (drug effects are attenuated less in elderly).Age related changes in GABAᴬ receptor complex may result in high sensitivity to benzodiazepines and alcohol leading to impairment of short term memory, confusion, ataxia and cognitive disturbances.Extrapyramidal symptoms in response to dopaminergic blockade by drugs increased due to age related reduction in dopamine content.

38. Co-occurring Medical ConsiderationsCentral Nervous System (CNS)CardiovascularPulmonaryMusculoskeletalRenal Gastrointestinal

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40. Reward AreaLimbic SystemPrefrontal area – higher executive functions, judgment, acting with appropriate decorum.Oh WOW!!!dopamineglutamateamygdala

41. CNSIncreased cortical CSF in gray and white matterNumber of synapses decreasesFrontal lobes and cerebellar gray matter particularly sensitive to alcohol induced damageVolume deficits in anterior hippocampus resulting in memory loss and possible Korsakoff syndromeReduced brain glucose metabolism resulting in disruption of neuronal integrityLow frontal lobe perfusion resulting in cognitive and emotional changes

42. Heavy drinking results in neuronal lossOveractivation of NMDA receptors (up regulation) by glutamate may lead to cell deathActivation of microglia and astrocytes in brain tissue promoting aberrant signaling of neuroimmune system leading to dysfunctional frontal circuitsExact mechanisms underlying ethanol-induced neurotoxicity not well understood

43. Sedative/hypnotics/opioids increases risk of fallsSedative/hypnotics may produce antegrade amnesia impairing learning of new informationAcute toxicity includes sedation, psychomotor impairment, and memory problemsTolerance develops to most cognitive effects but not all sedatives produce the same type or severity of impairment