Mental Health and Aging

Alcohol, Tobacco, and Drug Use in the Elderly: A Public Health Issue

David W. Oslin, MD
University of Pennsylvania, School of Medicine and Philadelphia, VAMC
October 2, 2002

What is the Extent of the Issues?
In the Community
Epidemiology of Addiction in Late Life

How Much Alcohol is Too Much in Late Life?

Drinking no more than an average of 7 drinks per week
No episodes of binge drinking (4 + drinks in one day)
No drinking while taking certain medications or in patients with certain illnesses

What is a Drink? The Ill Effects of Drinking in Late Life

Decreased quality of life.
Compounds medical and psychiatric problems.
Excessive health care costs.
Family burden.
Decrease productivity.
Trauma - falls and MVAs

What's the Harm in a Few Drinks?

Epidemiologic data suggests moderate drinking can be beneficial for
- Heart disease
- Possibly preventing neurocognitive disorders
- Social aspects
Potential confounds
Sample selection (fit elders with healthy lifestyles)
Surrogate for something else (nutrition, exercise)
No clinical trials data

The Spectrum of Interventions: Barriers to Recognition and Treatment

Patient factors
Health professional factors
Healthcare system factors
Society factors
Treatment factors

Brief Intervention

Definition: Time-limited (5 minutes to 5 brief sessions) and targets a specific health behavior
Goals: Facilitate treatment entry and Reduce alcohol consumption

Brief Interventions in Primary Care: Specialty Addiction Services

Compliance with treatment is greater in older adults compared to younger adults
Age specific programming (groups, focus, etc) appears to have an impact on outcome in 1 randomized study and several observational studies
Cognitive Behavioral Therapy has efficacy over vocational and relationship enhancement therapy

BRENDA: Young versus Old
Outcomes from Patient Focused Care
Naltrexone for use in Late Life

Comorbidity with Mental Health Problems

Concurrent alcohol use and depression may be more common in late life than in younger adults
Concurrent moderate or at-risk use may be a much greater problem than dependence
Fragmented care is particularly problematic in late life

Co-Occurring Drinking and Depression: Sequential versus concurrent care?

80% of younger patients with depression have resolution of symptoms within 6 weeks.
Typical recommendation - Treat alcohol first and then depression only after abstinence is achieved

The same or a different story in the elderly?

Less than 50% resolution of symptoms early in treatment
No relationship between clinical impression of primary vs. secondary depression and early response

Concurrent Treatment of Depression: Complicated by Alcohol Dependence

Current depressive syndrome
Current alcohol dependence
Age 55 and over
10 sessions of BRENDA
1/2 of subjects are randomly assigned to receive naltrexone 50 mg
All subjects receive sertraline 100 mg
Outcomes at 3, 6 and 12 months

Preliminary Results (N=52)

Age 63 (6.3)
Gender (% male) 86%
Race (% African-American) 40%
Initial HDRS total score 22.1 (5.4)
Average Drinks/Day 9.3 (9.3)

Treating alcoholism is necessary but not sufficient: What about moderate or abusive drinking (non-dependent drinking)

Most common pattern of drinking among those with depression
May be beneficial for heart disease
Safety concerns may be less with newer medications (SSRIs) than older meds (TCAs)

Response to Standard Depression Care

PROSPECT stud
- Remission of depression (men only)
- Non-drinkers - 41 %
- Moderate drinkers - 18.2%
PRISMe study (preliminary)
- Remission of depression (men only)
- Non-drinkers - 33.8 %
- Moderate drinkers - 6.3 %

Concurrent Reduction of Moderate Drinking and Treatment Depression

2666 patients received inpatient treatment for major depression
Assessed at entry into hospital and 3 months post discharge
Alcohol used defined as
Light (0-1 drink per week, n=2088)
Moderate (2-6 drinks per week, n=32)
Heavy (7 or more drinks per week, n=84)

Improvement in Mental Health: Alcohol Related Dementia

Longitudinal study of nursing home residents with Alcohol related dementia (n=16) or Alzheimer's Disease (n=26).
Subjects identified from consecutive nursing home admissions (n=212) evaluated for cognition, disability, addiction history
Subjects followed every 6 months for 2 years.

Disability and cognition: Is Sedative/Hypnotic Use a Co-Occurring Problem?

Association with falls
Association with memory impairment
Association with treatment of depression

How to Define Inappropriate Benzodiazepine Use

Chronic Use (>3 months)
Use of long-acting agents
Undocumented response
Lowest effective dose (harm reduction)

Sedative/Hypnotic Use: A Disappearing Problem?
Sedative/Hypnotic use by Race
Types of Sedative/Hypnotics Used
Relationship Between Benzodiazepine Use and Depression Treatment
Benzodiazepine Discontinuation
Improvement in Smoking Related Disability

Caveats About Treatment

Addiction treatment is not one size fits all. There are many options-use them.
Compliance with treatment is important and tends to be greater in older adults compared to younger adults. Continually support treatment.
Treatment is not a "carve out" available only in select settings.
While abstinence is often the goal, it is not the only goal.