07/22/16

The Not-So-Golden Years

© lisafx | stockfresh.com

© lisafx | stockfresh.com

Dr. Stephen Barnes wrote a thoughtful article on the so-called golden years of adulthood. In case you’re wondering when (or if) you reach said span of time, he said it begins with retirement and ends with the beginning of “age-imposed physical, emotional, and cognitive limitations; roughly between the ages of 65 and 80+. This can be a time of self-fulfillment, with many positive outcomes related to aging. Of course there are some variables to consider: do you have good physical and psychological health; do you have adequate financial resources; do you now have fewer family and career responsibilities.  If you do, then there are opportunities for “self-fulfillment, purposeful engagement, and completion.” However, there is another perspective on the golden years for us to consider—that of Dr Seuss:

The Golden Years have come at last.

I cannot see.

I cannot pee.

I cannot chew.

I cannot screw.

My memory shrinks.

My hearing stinks.

No sense of smell.

I look like hell.

My body is drooping.

I have trouble pooping.

The Golden Years have come at last.

The Golden Years … can kiss my ass.

There was a study done by Gray et al. published in JAMA Internal Medicine for March of 2015 that caught some media attention. It looked at the cumulative use of anticholinergics and dementia. This class of drugs blocks a neurotransmitter called acetylcholine (ACh), which is found throughout the body. Dr. Sandra Steingard noted: “It is involved in gut motility, visual acuity, heart rate, and secretions. In the brain, its activity is linked to memory and movements.” There are a wide variety of drugs with an anticholinergic effect, from antihistamines like Chlor-Trimeton, Unisom (diphenhydramine), Vistaril and Benedryl to antidepressants like Paxil, antipsychotics like Seroquel and Zyprexa, and even Detrol (oxybutinin).

Anticholinergics often cause dry mouth, constipation, rapid pulse, urinary retention, blurred vision and impaired memory. Notice how they correspond to four of Seuss’ complaints. Dr. Steingard also commented on the Gray et al. study and said there were two major findings of the study. “The first is that total exposure to anticholinergic drugs increases the risk of developing dementia. But of further concern, these effects were seen even if the drugs had been stopped years before the onset of dementia.” The study found a dose response risk for developing dementia—a greater exposure to anticholinergics meant a greater risk.

Steingard thought the study was carefully done. Her one complaint was it didn’t have a very complete list of anticholinergic drugs. She provided a link to a chart on AgingBrainCare.org with a more complete listing. As a psychiatrist, she thought the study had particular implications for psychiatry since many psychiatric drugs have anticholinergic effects. Several antipsychotics were in the most severe category.

Many people are now being exposed to psychiatric drugs at very young ages, and are taking them for many years. “We need to use these drugs with caution. Dose matters. Length of time a person is on them matters. Polypharmacy matters.”

The Gray et al. study concluded that there was an increased risk for dementia in people with higher use of anticholinergics. The findings suggested that someone taking even one such drug for more than three years “would have a greater risk for dementia.”

Prescribers should be aware of this potential association when considering anticholinergics for their older patients and should consider alternatives when possible. For conditions with no therapeutic alternatives, prescribers should use the lowest effective dose and discontinue therapy if ineffective. These findings also have public health implications for the education of older adults about potential safety risks because some anticholinergics are available as over-the-counter products. Given the devastating consequences of dementia, informing older adults about this potentially modifiable risk would allow them to choose alternative products and collaborate with their health care professionals to minimize overall anticholinergic use.

Another area of concern within the so-called golden years is substance abuse. Ironically, the initial step into the golden years via retirement is seen as a contributing factor into senior substance abuse. Paul Gaita, writing for The Fix, indicated several aspects of retirement could lead to greater drug and alcohol use among seniors. The circumstances leading to retirement as well as the economic and social nature of retirement are two possible features. A substance abuse counselor added: “In retirement, there can be depression, divorce, death of a spouse, moving from a big residence into a small residence.”

There are issues of loneliness, anxiety and boredom to consider. Then there is the reality of the increased likelihood of medical issues and the death of family or friends who are older. And don’t forget changes in body metabolism. The liver slows down as does kidney filtration. Both of these factors lead to alcohol and drugs staying active in the body for longer periods of time. Then there are medical issues like menopause, limited mobility, sleeping problems and chronic pain.

SAMHSA publishes a free volume in its Treatment Improvement Protocol (TIP) Series entitled: “Substance Abuse Among Older Adults” (TIP 26). It contains chapters on alcohol use and abuse, prescription and over-the-counter drug use and abuse, referral and treatment approaches, as well as appendixes of assessment tools. Here I will highlight the Executive Summary and chapter 1, “Substance Abuse Among Older Adults: An Invisible Epidemic.”

TIP 26 also noted that physiological change and changes in kinds of responsibilities and activities pursued are factors in substance abuse with older adults. Individuals 65 and over consume more prescribed and over-the-counter medications than any other age group in the U.S. Concerns with benzodiazepine use and sleep aides were noted. Limited use of both drug classes was given. Antihistimines and anticholinergics were highlighted as well.

Older persons appear to be more susceptible to adverse anticholinergic effects from antihistamines and are at increased risk for orthostatic hypotension and central nervous system depression or confusion. In addition, antihistamines and alcohol potentiate one another, further exacerbating the above conditions as well as any problems with balance. Because tolerance also develops within days or weeks, (bold the remaining) the Panel recommends that older persons who live alone do not take antihistamines.

Substance misuse among adults 60 an older is one of the fastest growing health problems in the country. Yet the situations is underestimated, underidentified and undertreated. “Until relatively recently, alcohol and prescription drug misuse, which affects up to 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature.” Diagnosis or identification can be difficult because symptoms of substance abuse in older adults will sometimes mimic symptoms of other medical and behavioral concerns such as diabetes, dementia and depression. Adding to this issue is that drug trials of new medications rarely include older adults. So even recognizing the presence of adverse drug reactions with older adults often doesn’t happen until enough adverse events accumulate after the drugs have been approved.

Alcohol abuse can accelerate the normal decline of physiological functioning that happens with aging. There is also the probability of an increased risk of injury, illness and socioeconomic decline. Increased benzodiazepine use with older adults also causes problems. The BMJ indicated that the mass of evidence suggested the benefits of benzodiazepines in older adults rarely outweigh their risks.

Benzodiazepine risks, whether short-term or chronic, include cognitive impairment, delirium, respiratory insufficiency, falls, fall-related injuries such as hip fractures, motor vehicle crashes, and death. Most patients are not warned of these risks before starting these medications. The main risk factor for chronic benzodiazepine use is any previous use, so an intended short-duration prescription of these habit-forming medication is likely to lead to their long-term use. Chronic benzodiazepine users are rarely prompted to discontinue, despite good evidence for the safety and tolerability of tapering protocols.

Ageism also contributes to the problem. “There is an unspoken but pervasive assumption that it’s not worth treating older adults for substance use disorders.” Behaviors that are seen as problematic in younger adults may not inspire the same urgency for treatment with older adults. Also, there can be an attitude that treatment for this population is a waste of health care resources. Attitudes like these are callous and based on misperceptions. For example, most older adults live independently. Only 4.6% of adults over 65 are in nursing homes or personal care facilities.

The reality is that misuse and abuse of alcohol and other drugs take a greater toll on affected older adults than on younger adults. In addition to the psychosocial issues that are unique to older adults, aging also ushers in biomedical changes that influence the effects that alcohol and drugs have on the body.

Health care and social service providers working with older Americans will mainly encounter abuse or misuse of alcohol or prescribed drugs. Although a smaller population, illicit drug users over 60 are increasing. This trend is at least partly due to aging baby boomer whose rates of illicit drug use have historically been higher than previous generations. The following chart from a NIDA report tracks past month use of illicit drugs among adults aged 50 to 64.

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Here is a more intimate and personal look at this issue. Patrick O’Neil, described coping with his 79 year-old mother’s recovery from hip surgery in “I Can’t Watch My Mom Detox.” Incidently, her HMO had been heavily prescribing Vicodin for seven years. Before the surgery. The medical team is considering detoxing her from her dependency on hydrocordone WHILE she’s recuperating from her hip surgery “for her own good.”

A doctor I’ve never met takes me aside and explains the process, how the patient will appear to be suffering but it’s for her own good.

I look at her skeptically. “So you’re going to detox my mom in the middle of her recovering from one of her most painful surgeries ever, because you’re having a knee-jerk reaction to your HMO being at fault for keeping her addicted?”

“It’s a little more complicated than that,” replies the doctor.

“Well, try and explain it then,” I say. “Because it looks exactly like that to me.”

O’Neil is himself a recovering heroin addict and author of his own journey through addiction in Gun, Needle, Spoon. So he really understands what his mother is going through. He suggests they not attempt a detox until after she’s healed from her surgery. It seems they finally agreed.

When I was growing up, my mom never had an obvious substance abuse problem. Even though her father was an alcoholic and addiction is thought to be hereditary, she never exhibited any outright addictive behaviors. And until recently, she hadn’t displayed the sort of desire to overmedicate that I had. Only with age, her retiring, my stepfather dying and close friends passing, she’d lost interest in life. These days she sits at home, alone. Her health, having never been great, is deteriorating even more. When her knee went out, she had it replaced and the doctor prescribed Vicodin. And suddenly, the same monster that lives in me was awakened in my mom and she took to them like they were the solution to all her problems.

“The Golden Years have come at last. The Golden Years … can kiss my ass.”

05/13/15

Sedating Seniors

© Vera Kuttelvaserova Stuchelova | 123RF.com

© Vera Kuttelvaserova Stuchelova | 123RF.com

In September of 2014, the British Medical Journal published an article titled: “Benzodiazepine use and risk of Alzheimer’s disease.” It received a good bit of public attention because of its conclusion that there was an increased risk of up to 51% of Alzheimer’s disease with the use of benzodiazepines —for as short a period of time as three months. There was concern expressed by Psychiatric News, which quoted Davangeere Devanand, the director of the geriatric psychiatry program at Columbia, who said: “These findings emphasize the importance of restricting the use of benzodiazepines in the elderly population.”

Philip Hickey reviewed the article and noted where the study’s authors commented there findings were congruent with five previous studies. The authors also said their findings were of major importance for public health, particularly considering the widespread chronic use of benzodiazepines with older people. Guy Goodwin, a professor of psychiatry at Oxford, voiced a common assessment of the study, namely that it was more likely that the drugs were being given to people who were already ill. I’ve heard similar comments made by pharmaceutical researchers. This dismissal of the study’s results was despite the fact that the researchers specifically attempted to control for this factor. They said:

Our study was designed specifically to reduce the possibility of reverse causation bias and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.

To a certain extent, this is a rehashing of old news, as I’ve previously addressed the BMJ study in “What a Drag It Is Getting Old.” But the concern over the use of benzos with older people hasn’t gone away. There was an article published in the February 2015 issue of JAMA Psychiatry that looked at “Benzodiazepine Use in the United States.” The article first appeared online in December of 2014. You can watch a short YouTube video by the lead author summarizing the study’s results here.

The study found that about 1 in 20 (5%) people between the ages of 18 and 80 received a benzodiazepine prescription in 2008. However, the percentage increased with age, rising to 8.7% among individuals 65 to 80. Women were twice as likely as men to receive prescriptions in all age groups. Most of the prescriptions—two thirds—were written by non-psychiatrists. For adults 65 to 80, this was 9 out of 10. Thomas Insel, the director of the National Institute of Mental Health (NIMH), voiced the following concerns with the NIMH-funded study’s results:

These new data reveal worrisome patterns in the prescribing of benzodiazepines for older adults, and women in particular. . . . This analysis suggests that prescriptions for benzodiazepines in older Americans exceed what research suggests is appropriate and safe.

In a Psychiatric News Alert, one of the study’s authors was quoted as saying that it was alarming to find the highest rates of benzodiazepine use among the groups with the highest risks. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.” In an editorial written about the study in JAMA Psychiatry, the authors commented that there seems to be a societal addiction to using benzodiazepines with the elderly. They said these drugs should only be used for very short periods of time. With individuals susceptible to cognitive impairment or to falls and fractures, benzodiazepines should be avoided altogether.

The editorial authors also suggested that prescribing benzodiazepines should be restricted to psychiatrists. Their recommendation was based upon the perception that psychiatrists seemed prescribe them properly in the JAMA Psychiatry study. They further recommended that benzodiazepines be reclassified as a Schedule II Controlled Substance with limited-duration prescriptions and no refills. “Such barriers could help the public and prescribers think more about these risks before prescribing or using benzodiazepines.”

I don’t think limiting the prescription of benzodiazepines to psychiatrists is either practical or realistic. Despite the dangers reviewed here, restricting benzodiazepines, while permitting antidepressants, neuroleptics and mood stabilizers to be prescribed by all medical doctors is nonsensical. All these additional classes of drugs have their own serous side effects. Some are arguably more problematic than benzodiazepines. If only psychiatrists were permitted to prescribe benzos, then pharmaceutical companies would adjust their marketing strategies to concentrate on psychiatrists.

Reclassifying benzodiazepines as Schedule II Controlled Substance has more merit, but will be hard to accomplish. The process to reclassify any prescription drugs is complicated and difficult.

I’m also not convinced that all psychiatrists would be better monitors of benzodiazepine use/abuse. I know of one person whose primary care physician was reluctant to continue a long-term benzodiazepine prescription, but a psychiatrist wasn’t. I know of another individual who has been prescribed daily benzodiazepine use for sleep by a psychiatrist for over two years. My thought is that the more entrenched any medical doctor is within a biological view of psychiatric disorders, the more willing they are to prescribe benzodiazepines long-term.

Sadly, all these concerns with the use of benzodiazepines with the elderly were voiced and know twenty-five years ago. The journal Drug Safety published “Problems and Pitfalls in the Use of Benzodiazepines in the Elderly” by Wolfgang Kruse in its September issue for 1990. Dr. Kruse noted benzodiazepines were frequently prescribed for elderly patients; and that their use was more common with women. Prolonged use was likely for treating not only insomnia and anxiety in the elderly, but also a wide range of nonspecific symptoms. “Long term users are likely to have multiple concomitant physical and psychological health problems.”

He noted that long-term studies on unwanted effects were scarce, but there was some evidence that benzodiazepines were implicated in drug-associated hospital admissions. “There is suggestive evidence that benzodiazepines, especially compounds with long half-lives, may contribute to the falls which are a major health problem in old age.” Prophetically, he stated:

Problems in the use of benzodiazepines will arise if the available knowledge on altered pharmacokinetics and pharmacodynamics and principal guidelines for drug prescribing in the elderly are neglected. Poor prescribing habits are related mainly to inadequate clinical assessment, excessive prescribing and inadequate supervision of treatment. Unlimited repeat prescribing, particularly for the treatment of sleep disturbances, is seldom justified.