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Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1998. (Treatment Improvement Protocol (TIP) Series, No. 26.)

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Substance Abuse Among Older Adults.

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Chapter 3 - Use and Abuse of Psychoactive Prescription Drugs and Over-the-Counter Medications

Adults age 65 and older consume more prescribed and over-the-counter medications than any other age group in the United States. Although older adults constituted less than 13 percent of the population in 1991, they received 25 to 30 percent of all prescriptions (Woods and Winger, 1995; Ray et al., 1993; Sheahan et al., 1989) and experienced more than half of all reported adverse drug reactions leading to hospitalization (Chastain, 1992). Some 80 to 86 percent of older adults over age 65 reportedly suffer from one or more chronic diseases or conditions(Administration on Aging and Staff of the U. S. Senate Special Committee on Aging, 1991; U. S. Bureau of the Census, 1996), and an estimated 83 percent of adults over 65 take at least one prescription drug (Hazelden Foundation, 1991; Ray et al., 1993). In fact, 30 percent of those over 65 take eight or more prescription drugs daily (Sheahan et al., 1989).

A large share of prescriptions for older adults are for psychoactive, mood-changing drugs that carry the potential for misuse, abuse, or dependency. In 1983, one-fourth of community-dwelling older adults used psychotherapeutic drugs on a regular basis for sleep disorders or chronic pain as well as for anxiety and labile mood (Finlayson, 1995b). Approximately 25 to 28 percent of older adults reported use of a psychoactive drug within the last year, and 20 percent used a tranquilizer daily. Indeed, 27 percent of all tranquilizer prescriptions and 38 percent of hypnotic prescriptions in 1991 were written for older adults. Moreover, older adults are apparently more likely to continue use of psychoactive drugs for longer periods than their younger counterparts (Sheahan et al., 1995; Woods and Winger, 1995).

This chapter focuses on the most commonly prescribed abusable psychoactive medications for older adults - benzodiazepines, antidepressants, and opiate/opioid analgesics. Also covered are risk factors that make older adults more vulnerable to misuse and abuse of these substances; adverse effects associated with consumption of psychoactive medications; and uses for, effects of, and alternatives to different categories of prescription drugs.

Evolution of Psychoactive Prescribing

Since their introduction in the late 1950s, benzodiazepines have become the most widely prescribed anxiolytics and hypnotics in medical practice. Their growing use throughout the 1960s prompted many to ask whether the United States was becoming an overmedicated society in which people would take a pill for any physical or emotional pain rather than exert some simple self-control. Some researchers feared that use of prescribed psychoactive drugs for a vast array of conditions would inexorably lead to irresponsible recreational use or physiological dependence on licit or illicit substances. Others thought that prevalence of associated psychosocial problems would rise along with the prescription drug use (Balter, 1973; Manheimer et al., 1973; Cooperstock and Parnell, 1982).

Yet studies of older populations conducted over the past 20 years have generally found that most adults who take psychoactive medications do not intend to abuse them. The drugs usually are obtained with an appropriate prescription from a primary care physician for a specific health-related purpose and are primarily used in conjunction with a physical condition or to alleviate symptoms of emotional stress (Piland, 1979; Guttmann, 1977; Cooperstock and Parnell, 1982). In fact, there has been a steady improvement in prescribing practices and safe and appropriate medication use in the last 25 years.

Misuse and abuse of prescriptions have dwindled over that time for several reasons: (1) safer drugs with fewer undesirable side effects are constantly being developed by pharmaceutical companies, especially for common health and mental health problems; (2) ever-changing Federal and State regulations seek to protect consumers from hazardous substances and to restrict undesirable provider practices; (3) guidelines and protocols recommending best practices are being developed and disseminated to health care providers; (4) more physicians are receiving training relevant to the care of older patients (from geriatric research, education, and clinical centers); and (5) consumers are being educated by their physicians and other health care providers, pharmacists, and various media sources regarding the dangers of drug interactions and the importance of medication compliance for positive therapeutic outcomes.

More specifically, benzodiazepines with a lower addiction potential and fewer adverse interactions with other medications have replaced many of the older barbiturates, bromides, meprobamate, and neuroleptics for management of anxiety, especially acute situational anxiety, generalized anxiety disorder, and associated transient insomnia. Similarly, in the 1960s, the benzodiazepine flurazepam (Dalmane) replaced many of the barbiturates and nonbarbiturates routinely used for sleep disorders and insomnia complaints. Displaced drugs included such barbiturates as pentobarbital (Nembutal), secobarbital (Seconal), and the combination aprobarbital and secobarbital (Tuinal), as well as the nonbarbiturates chloral hydrate, ethchlorvynol (Placidyl), and glutethimide (Doriden) (Fouts and Rachow, 1994; Finlayson, 1995b; Rickels and Schweizer, 1993). Sales reports and pharmacy prescription audits reflect the overall decline in the numbers of stimulant and barbiturate prescriptions, with minor tranquilizers and/or sedatives exceeding other classes since the 1980s (Cooperstock and Parnell, 1982). Prescriptions for the popular anxiolytic benzodiazepines have more recently shifted from diazepam (Valium) to the shorter acting compounds, particularly alprazolam (Xanax) and lorazepam (Ativan), and from the earlier long-acting benzodiazepine hypnotic, flurazepam, to the shorter acting triazolam (Halcion) and temazepam (Restoril). Overall, sales of benzodiazepine anxiolytics have decreased, whereas use of benzodiazepines as sleep-inducing hypnotics has increased or remained stable (Winger, 1993; Woods and Winger, 1995).

In 1996, the top 10 drugs prescribed in nursing homes included two selective serotonin reuptake inhibitors (SSRIs), sertraline (Zoloft) and fluoxetine (Prozac), as well as the nonbenzodiazepine anxiolytic, buspirone (BuSpar). This represents a decrease from 1970, when 8 of the top 10 nursing home prescriptions were for psychoactive drugs (Prentice, 1979). Furthermore, chronic pain from such conditions as arthritis is more frequently treated now with nonsteroidal anti-inflammatory agents rather than with opiate-containing drugs such as acetaminophen with codeine (Finlayson, 1995b). Yet even though fewer prescriptions for psychoactive drugs are being written for older adults, many patients prescribed these drugs still misuse and abuse them, and some health care providers continue to exhibit poor judgment in their prescribing and monitoring practices.

Patterns of Use

The drug-taking patterns of psychoactive prescription drug users can be described as a continuum that ranges from appropriate use for medical or psychiatric indications through misuse by the patient or the prescribing health care practitioner to persistent abuse and dependence as defined by the American Psychiatric Association's criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) (see Figure 3-1). Because older adults are less likely to use psychoactive medications nontherapeutically, problems with drugs generally fall into the misuse category and are unintentional. For example, older patients are more likely to misunderstand directions for appropriate use - a problem that is compounded by the multiple prescriptions they receive, often from multiple physicians unaware of a colleague's treatments. In these circumstances, overdose, additive effects, and adverse reactions from combining drugs are more likely to occur. Unintentional misuse can, however, progress into abuse if an older adult continues to use a medication nontherapeutically for the desirable effects it provides, much as an abuser of any drug does.

Adults can become physiologically dependent on psychoactive medications without meeting dependence criteria. Tolerance and physical dependence can develop when some psychoactive medications (e.g., benzodiazepines, opioids) are taken regularly at the therapeutically appropriate dose for relatively brief periods. An abstinence syndrome or withdrawal effects may occur if the drug is stopped precipitously. This type of iatrogenically induced physiological dependence is not usually accompanied by any tendency on the part of the patient to escalate dosage during or after medically supervised withdrawal, to experience cravings after discontinuation, or to subsequently continue use or addictive behavior (Woods and Winger, 1995; Portenoy, 1993). In other words, adults can become dependent on psychoactive medications without realizing it.

Risk Factors for Misuse And Abuse of Psychoactive Drugs

A variety of factors influence the use and potential for misuse or abuse of psychoactive prescription drugs and over-the-counter medications by older adults. The aging process, with its physiological changes, accumulating physical health problems, and other psychosocial stressors, makes prescription drug use both more likely and more risky. The most consistently documented correlates of psychoactive prescription drug use are old age, poor physical health, and female gender (Cooperstock and Parnell, 1982; Sheahan et al., 1989; Finlayson, 1995b).

Among older women, use of psychoactive drugs is correlated with middle- and late-life divorce, widowhood, less education, poorer health and chronic somatic problems, higher stress, lower income, and more depression and anxiety (Gomberg, 1995; Closser and Blow, 1993). Major losses of economic and social supports, factors related to the provider and health care system, and previous or coexisting drug, alcohol, or mental health problems also seem to increase vulnerability for misusing or abusing prescribed medications.

Data from the 1984 Epidemiological Catchment Area (ECA) survey (Regier et al., 1988) confirm that anxiety disorders are relatively prevalent in the general population of adults older than 65, with 7.3 percent of older respondents reporting an incidence within the past month. Older women are nearly twice as likely as older men to develop a diagnosable anxiety disorder. Bereavement precipitates anxiety in nearly one-fourth of survivors during the first 6 months following the death of a loved one and in nearly two-fifths of those left behind during the second 6-month period. Anxiety is also common after a severe traumatic event (Salzman, 1993a).

System and Environmental Influences

A variety of health care system-related and environmental factors also place older adult users of psychoactive prescription drugs at risk for misuse of these substances, serious adverse effects, or abuse and dependence. Potentially dangerous prescribing practices include ordering medications without adequate diagnoses or other documented indicators of symptoms, prescribing them for too long a time without appropriate medical monitoring of drug reactions and patient compliance with the prescribed regimen, selecting drugs known to have a high potential for side effects in older adults at the doses given, ordering drugs without knowing or reviewing whether they interact adversely with other medications the patient is taking, and failing to provide adequate and comprehensible instructions for patients regarding how and when to take medications and what side effects to expect and report. Drug misuse also includes failure to consider the influence of aging on the effects of drugs in the body (see Figure 3-2).

Figure 3-2: Effect of Aging on Response to Drug Effect.

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Figure 3-2: Effect of Aging on Response to Drug Effect.

Previous History of Substance Abuse or Psychiatric Disorder

Although most experts agree that nonmedical use or abuse of benzodiazepines is rare at any age and household surveys indicate that nonmedical use is declining (Salzman, 1993b; Barnas et al., 1992), some liability for abuse of the benzodiazepines does seem to exist in the following cohorts: (1) light-to-moderate alcohol drinkers who have been demonstrated to prefer diazepam over placebo and may be vulnerable to the reinforcing properties of these drugs; (2) adults with histories of sedative abuse, abuse of multiple drugs, and methadone-maintained clients; and (3) patients who have developed physiological dependence on benzodiazepines after long-term use and are experiencing acute withdrawal effects following abrupt discontinuation (Salzman, 1993b; Barnas et al., 1992).

However, continued craving for the medication does not seem to persist among adults who fit none of the categories above and who have successfully been withdrawn from benzodiazepines. By contrast, adults with histories of substance abuse prefer benzodiazepines to placebo. They also prefer, however, older anxiolytics and hypnotics such as methaqualone (Quaalude) or meprobamate (Miltown) to benzodiazepines (Winger, 1993; Woods and Winger, 1995). The benzodiazepines preferred by sedative abusers and methadone maintenance clients seem to be diazepam, lorazepam, and alprazolam (Woods and Winger, 1995). Unfortunately, little is known about the risk potential for these individuals in late life.

Data from the Mayo Clinic further suggest that psychiatric diagnoses may be a risk factor among older adults for abuse of and dependence on prescription drugs (Finlayson, 1995a). In this study, rates of mental disorder diagnosis in 100 older adults hospitalized for prescription drug dependence included the following disorders: mood (32 percent), organic mental (28 percent), personality (27 percent), somatoform (16 percent), and anxiety (12 percent). The patient group was predominantly female, and some patients had more than one mental disorder diagnosis. The patient group was identified as having considerable psychopathology by several other measures as well (Finlayson, 1995a). Although research on older drug addicts is rare, at least one study indicates that older patients with substance dependence disorders are more likely than younger drug addicts to have a dual diagnosis. In this investigation, only 15 percent of older drug-dependent patients had a substance abuse diagnosis without a coexisting psychiatric disorder compared with 64 percent of younger counterparts. These researchers concluded that older adults with a preexisting psychiatric disorder may be more at risk for concurrent prescription drug dependence (Solomon et al., 1993).

Adverse Effects

The chronic administration of psychoactive substances to older adults, even at therapeutic doses, has been associated with a variety of adverse central nervous system effects, including diminished psychomotor performance, impaired reaction time, loss of coordination, ataxia, falls, excessive daytime drowsiness, confusion, aggravation of emotional state, rage, and amnesia as well as the development of physiological dependence manifested by withdrawal effects when the drugs are suddenly discontinued (Fouts and Rachow, 1994). Psychoactive medications have been implicated in 23 percent of adverse drug reactions among nursing home residents (Joseph, 1995). Side effects from these drugs range from constipation, dry mouth, or urinary difficulty to such severe reactions as hip fractures from falls, withdrawal seizures or delirium, and worsened depression leading to suicide attempts (American Psychiatric Association, 1994). However, all undesirable reactions may be more serious in frail older adults and in those with multiple chronic diseases and cannot be ignored (Lapane et al., 1995; Solomon et al., 1993).

Anxiolytics

Figure 3-3 summarizes information about some of the anxiolytics most frequently prescribed for acute or chronic anxiety in older adults. The figure depicts the generic and most usual brand name for these medications as well as the elimination half-life or duration of action in the body. Note that Figures 3-3 and 3-4 both contain the names of benzodiazepines_their designations as anxiolytics or sedative/hypnotics are based on properties that drive marketing decisions. Some physicians may choose, for example, to use lorazepam as either an anxiolytic or sedative depending on the circumstances.

Figure 3-3: Commonly Prescribed Anxiolytics.

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Figure 3-3: Commonly Prescribed Anxiolytics.

Figure 3-4: Commonly Prescribed Sedative/Hypnotics.

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Figure 3-4: Commonly Prescribed Sedative/Hypnotics.

An estimated 95 percent of benzodiazepine prescriptions for older adults in this country are ordered for anxiety and insomnia, with only 5 percent used as adjuncts for general anesthesia, as muscle relaxants, or as anticonvulsants (Ray et al., 1993). Numerous studies, including the 1990 American Psychiatric Association Task Force report, have concluded that the vast majority of use of these agents is appropriate, with only occasional overprescribing by physicians for some patient subgroups or misuse by patients (Salzman, 1990, 1993b; Winger, 1993; Woods and Winger, 1995). Even among the small group of respondents to household surveys who have acknowledged taking benzodiazepines that were not prescribed for them (less than 6 percent), the vast majority borrowed pills from significant others and used them for symptom relief, not recreational purposes. Moreover, worldwide experience with the short-term use of benzodiazepines to relieve acute anxiety, situational stress, and transient insomnia indicates that these medications are unusually safe and efficacious, with very little liability for dose increases, prolonged use, or addictive dependence (Salzman, 1993b).

Although most people use benzodiazepines for short periods of time without developing problems, others take them past the point where they are effective and thus are at risk for adverse effects including tolerance and abuse. By 1990, as many as a fourth of anxiolytic users had taken these medications for a year or more (Winger, 1993). Several studies in the United States and Britain confirm that long-term users (for a year or more) of benzodiazepines are likely to be older than age 45 and female with substantial psychological stress, dysphoric or depressive symptoms, and multiple chronic physical illnesses or somatic problems (Salzman, 1993b; Winger, 1993). Benzodiazepine use for longer than 4 months is of particular concern among older adults. The physiological aging process decreases the body's ability to absorb and metabolize drugs, allowing the drug to accumulate more rapidly than in younger people and increase the likelihood of toxicity and adverse effects. Benzodiazepines have variable rates of absorption, with metabolism occurring primarily in the liver. Because the longer acting benzodiazepines have active metabolites, some of which have very long half-lives - up to 200 hours in the case of flurazepam - the duration of action is often longer than expected. They are also more likely to produce residual sedation and other adverse effects such as decreased attention, memory, cognitive function, and motor coordination and increased injurious falls or motor vehicle crashes (Weiss, 1994; Solomon et al., 1993; Fouts and Rachow, 1994; Ray et al., 1993; Winger, 1993). By contrast, some shorter acting benzodiazepines are not as likely to produce toxic or dependence-inducing effects with chronic dosing. One reason is that these drugs have no active metabolites. Furthermore, because the oxidative pathway is often impaired in older adults and in those with liver disease, it is best to choose drugs that are not metabolized by this pathway. Such drugs include oxazepam (Serax) and lorazepam. Because of these unpleasant and potentially hazardous side effects of many benzodiazepines, the Panel recommends caution in selecting the most appropriate benzodiazepine for elderly patients.

Unfortunately, both long- and short-acting benzodiazepines tend to result in physiological dependence, even when these medications are taken at therapeutic doses and for as short a period as 2 months (Woods and Winger, 1995). Many of the most unpleasant withdrawal effects can be alleviated by gradually tapering the dose rather than stopping it abruptly. Even if the dose is tapered, however, withdrawal symptoms are experienced by 40 to 80 percent of people who discontinue benzodiazepines after 4 to 6 months of regular use (Miller et al., 1985; Speirs et al., 1986). Such symptoms as anxiety, agitation, lethargy, nausea, loss of appetite, insomnia, dizziness, tremor, poor coordination, difficulty concentrating, depersonalization, or confusion may occur after stopping either long or short half-life benzodiazepines. Symptoms usually peak toward the end of the tapered discontinuation and disappear altogether within 3 to 5 weeks (Winger, 1993; Rickels and Schweizer, 1993). In a few psychiatric patients, the withdrawal syndrome has been known to persist for several months (Solomon et al., 1993).

The rebound effects experienced in withdrawal usually mimic the original symptoms for which the benzodiazepine was prescribed (e.g., anxiety, insomnia, panic). Those effects occur in as many as one-third to one half of patients after even 1 or 2 months of benzodiazepine therapy, may be more intense than before treatment began, and are frequently misperceived by frightened patients as a return of the initial problem (Rickels and Schweizer, 1993; Salzman, 1993b). Rebound effects, however, are sudden and transient, whereas a relapse entails a gradual but persistent return of the original symptoms that may continue unabated unless treated again with benzodiazepines or other appropriate medications (Rickels and Schweizer, 1993).

Unfortunately, misperceived rebound effects may lead some patients to self-medicate by supplementing doses during withdrawal unless the tapering is sufficiently gradual to ameliorate symptoms and the patient is counseled that these rebound effects are transient and to be expected (Rickels and Schweizer, 1993). Unlike withdrawing from alcohol, however, the difficulty in abstaining during the acute phase of benzodiazepine withdrawal is not followed by any further craving once the patient is drug-free (Winger, 1993). It appears that most patients withdrawn from benzodiazepines can maintain abstinence.

The question of whether the benefits outweigh the disadvantages of chronic benzodiazepine therapy is far from settled. Followup studies have found that more than half of patients (50 to 66 percent) treated with benzodiazepine anxiolytics or hypnotics experience a relapse of the original symptoms within a year of discontinuing benzodiazepine use (Atkinson et al., 1992). Half of these patients resume use of benzodiazepines. Longer followup studies indicate that a majority eventually resume use, whether intermittently or chronically (Finlayson, 1984). The reasons for discontinuation have to be examined in an individually calculated risk-benefit model by weighing the linkage between untreated anxiety or insomnia and alcoholism, depression, and suicide (Woods and Winger, 1995). Many researchers, moreover, argue that anxiety is undermedicated with benzodiazepines and that as many as 60 percent of patients who have legitimate medical or psychological reasons for high levels of stress and anxiety do not seek or obtain relief for these conditions (Salzman, 1993a).

Salzman (1993b) makes a compelling case that chronic benzodiazepine use may be appropriate for patients he characterizes as older (but not necessarily elderly), with a number of chronic illnesses and compromised physical and/or psychosocial functioning. This group includes patients who are often in pain, dysphoric, or depressed as well as anxious, suffering from insomnia, or willing to visit their physicians. Chronic users of this type may experience side effects from benzodiazepines or incur mild interactions with other drugs they are taking, but they are not purposefully abusing psychoactive drugs or mixing them with alcohol. Benzodiazepine prescriptions seem to be clearly indicated for patients with overwhelming stress or anxiety that compromises functioning for short periods of time and for chronically medically ill, usually older, patients (Salzman, 1993b).

One new drug, the serotonin agonist buspirone, is a promising alternative to benzodiazepines for the treatment of chronic anxiety with associated depressive symptoms. It apparently produces minimal sedative effects and little or no impairment of cognitive or psychomotor functioning, is not synergistic with most other psychoactive drugs or alcohol, and has little observed potential for causing tolerance or dependence, withdrawal, or overdose. Buspirone does not have the muscle relaxant or anticonvulsant properties of benzodiazepines. However, it does have some side effects at higher doses, and it is not immediately or invariably effective in ameliorating anxiety. The efficacy of buspirone for older patients is still being examined; it may precipitate some manic effects. Also, dosages should be reduced for those with decreased renal or hepatic functioning (Winger, 1993; Weiss, 1994; Ray et al., 1993; Bezchlibnyk-Butler and Jeffries, 1995).

Sedative/Hypnotics

Sleep disturbances are a common complaint among older adults, occurring in approximately half of Americans over age 65 who live at home and in two-thirds of those in long-term care facilities. Complaints about insomnia, which increase with advancing age, occur in conjunction with a variety of psychiatric, medical, or pharmacological problems as well as the changing circadian rhythms that accompany the aging process (National Institutes of Health, 1990; Fouts and Rachow, 1994; Mullan et al., 1994).

As previously noted, benzodiazepines have replaced older and more toxic hypnotics (e.g., secobarbital, ethchlorvynol, glutethimide), which have a high addiction liability and difficult-to-treat overdose potential and which also tend to accumulate in older adults with chronic dosing as their capabilities for drug absorption and elimination diminish (Solomon et al., 1993; Bezchlibnyk-Butler and Jeffries, 1995). Nearly two out of five prescriptions for benzodiazepines (38 percent) in 1991 were written for older patients (National Institutes of Health, 1990; Fouts and Rachow, 1994). As with anxiolytics, the shorter acting hypnotic benzodiazepines are generally favored over longer acting ones that tend to accumulate in older adults and produce undesirable effects in the central nervous system. Today, the most commonly prescribed hypnotic benzodiazepines are oxazepam, temazepam, triazolam, and lorazepam (Fouts and Rachow, 1994).

Unfortunately, hypnotic benzodiazepines, like the anxiolytics, also tend to be prescribed for longer than needed for efficacy, a situation that leads to the well-known drawbacks of withdrawal and rebound insomnia (Fouts and Rachow, 1994). In 1990, for example, 23 percent of adults who used benzodiazepine hypnotics (mostly the short-acting triazolam) had used them nightly for at least 4 months (Woods and Winger, 1995).

Figure 3-4 displays information about some sedative/hypnotics frequently prescribed for insomnia, listing the generic name, the common trade name, and the elimination half-life or expected duration of action in the body. The commonly prescribed oxazepam and lorazepam are listed with the benzodiazepine anxiolytics.

Although aging changes sleep architecture, decreasing the amount of time spent in the deeper levels of sleep (stages three and four) and increasing the number and duration of awakenings during the night, these new sleep patterns do not appear to bother most medically healthy older adults who recognize and accept that their sleep will not be as sound or as regular as when they were younger (National Institutes of Health, 1990; Mullan et al., 1994). Rather, insomnia complaints among older adults are usually associated with a secondary medical or psychiatric disorder, psychosocial changes and stressors, or the use of medications that interfere with sleep (National Institutes of Health, 1990; Mullan et al., 1994).

aRefer to product information insert for each drug as to its suitability for use in older adults.

Among the drugs causing poor sleep patterns are the antidepressant monoamine oxidase (MAO) inhibitors and SSRIs; anti-Parkinson medications; appetite suppressors; the beta-blocker for hypertension, propranolol (Inderal); and alcohol. Sleep apnea, in particular, may be aggravated by the use of a benzodiazepine (Culebras, 1992). Insomnia has also been related to depression and anxiety, Alzheimer's disease, Parkinson's disease, cardiovascular disease, arthritis, pain, urinary problems, prostate disease, pulmonary disease, hyperthyroidism, and endocrinopathies. Sleep disruption as well as anxiety commonly accompany other psychosocial adjustments such as retirement, bereavement, dislocation, or traumatic situations (National Institutes of Health, 1990; Mullan et al., 1994). Sleep complaints are also associated with female gender, living alone or in a nursing facility, activity limitations, and sleep habits such as excessive daytime napping (Mullan et al., 1994).

With respect to treatment of insomnia, a 1990 National Institutes of Health consensus development conference statement pertaining to sleep disorders of older adults specifically cautioned against relying on hypnotic benzodiazepines as the mainstay for managing insomnia (National Institutes of Health, 1990). Although these medications can be useful for short-term amelioration of temporary sleep problems, no studies demonstrate their long-term effectiveness beyond 30 continuous nights, and tolerance and dependence develop rapidly (Mullan et al., 1994; National Institutes of Health, 1990; Salzman, 1993b). In fact, symptomatic treatment of insomnia with medications should be limited to 7 to 10 days with frequent monitoring and reevaluation if the prescribed drug will be used for more than 2 to 3 weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30-day supply of hypnotics should be prescribed. Given the changes associated with drug metabolism among older patients, all hypnotic medications should be used with caution, especially those with long half-lives (National Institutes of Health, 1990; Fouts and Rachow, 1994; Mullan et al., 1994). As with the anxiolytic benzodiazepines, withdrawal effects signifying physiological dependence are common concomitants of precipitous medication discontinuation, especially of the short-acting compounds. The REM sleep rebound effects from abruptly stopping a chronically administered benzodiazepine hypnotic can last 1 to 3 weeks or longer (Mullan et al., 1994; Fouts and Rachow, 1994).

Furthermore, sedative/hypnotics, as well as benzodiazepines, used for sleep induction may cause confusion and equilibrium problems in older users who get up frequently during the night (e.g., to go to the bathroom). When treating older adults, situations likely to increase the incidence of falls with subsequent injury should be avoided at all costs. In addition, drugs taken at night for sleep induction will be potentiated by any alcohol the individual has used during the evening.

Instead of relying on drugs as a first line of approach, treatment should initially be directed toward any underlying disorder (e.g., depression, alcoholism, panic states, anxiety) (Mullan et al., 1994). Having the patient keep a sleep diary may be useful for obtaining a more objective clarification of sleep patterns because insomnia is notoriously subjective. Also, the importance of good sleep hygiene cannot be underestimated (Mullan et al., 1994; National Institutes of Health, 1990; Fouts and Rachow, 1994). Patients may need to be educated about regularizing bedtime, restricting daytime naps, using the bedroom only for sleep and sexual activity, avoiding alcohol and caffeine, reducing evening fluid intake and heavy meals, taking some medications in the morning, limiting exercise immediately before retiring, and substituting behavioral relaxation techniques (National Institutes of Health, 1990; Fouts and Rachow, 1994).

Withdrawal from sedative/hypnotic medications (as well as anxiolytics) should be carefully monitored. Withdrawal is characterized by increased pulse rate, hand tremor, insomnia, nausea or vomiting, and anxiety. A grand mal seizure may occur in as many as 20 to 30 percent of dependent persons if withdrawal symptoms are untreated. Hallucinations similar to those associated with alcoholic delirium tremens (DTs) may also be present.

Several precautions about particular drugs should be noted. Specifically, triazolam rapidly achieved notoriety and was banned in the United Kingdom and other European countries after its 1979 introduction with accompanying reports of bizarre, idiosyncratic panic and delusional reactions as well as adverse side effects of confusion, agitation, and anxiety (Woods and Winger, 1995; Winger, 1993). More serious side effects are still more consistently and more frequently reported with triazolam than with temazepam, a similar short-acting hypnotic benzodiazepine (Woods and Winger, 1995). It appears that older patients are more likely than younger ones to experience increased sedation and psychomotor impairment with this medication and to report an increased incidence of adverse behavioral reactions if the dose is greater than 0.125 mg (Fouts and Rachow, 1994).

Another recently introduced but popular hypnotic, zolpidem (Ambien), does not have the anxiolytic, muscle relaxant, or anticonvulsant properties of benzodiazepines. It has been touted as a safer sleep medication because it does not disrupt physiological sleep patterns at low doses and appears to have relatively mild, dose-related adverse effects. However, zolpidem is much more costly than the benzodiazepines, an important consideration for low-income older patients. Also, lower doses (beginning at 5 mg) must be used in older patients to avoid hazardous confusion and falls (Winger, 1993; Fouts and Rachow, 1994; Ray et al., 1993; Bezchlibnyk-Butler and Jeffries, 1995). Because of its recent introduction, there is limited information available on the possible undesirable effects of zolpidem for the older patient.

Several antihistamines, usually used for relief of allergies and available as over-the-counter medications, are also taken as sleeping aids because of their sedating properties (e.g., Benadryl). Antihistamines are also combined with over-the-counter analgesics and marketed as nighttime pain medications (e.g., Tylenol PM). However, older adults appear to be more susceptible to adverse anticholinergic effects from these substances 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 develops within days or weeks, these antihistamines have questionable efficacy and are not recommended for older adults who are living alone (Ray et al., 1993; Fouts and Rachow, 1994; National Institutes of Health, 1990; Bezchlibnyk-Butler and Jeffries, 1995).

Opiate/Opioid Analgesics

An estimated 2 to 3 percent of noninstitutionalized older adults receive prescriptions for opioid analgesics (Ray et al., 1993). Opioids are undeniably effective for management of severe pain such as that occurring after surgery and serious trauma and periodically in some medical illnesses (e.g., gout, inflammatory bowel disease). This acute pain is usually short-lived and resolves within days to weeks at most. Opioid analgesics are also used to treat cancer-related pain, which is experienced by nearly all patients with advanced disease and by one-third-to-one-half of patients in earlier stages. The use of opioid medications for these purposes is widely acceptable in medical practice (Portenoy, 1993).

In addition to the rapid development of tolerance and physiological dependence, other problems are associated with opioid prescriptions for older patients. Opioid dose requirements decrease with age: The onset of action is slowed by the decreased rate of gastrointestinal absorption of orally ingested narcotics, and the duration of action is longer because of older patients' decreased metabolism and liver functioning. Older adults also have more adverse side effects because of changes in receptor sensitivity with age. The less potent opioids, codeine and propoxyphene (Darvon), cause sedation and mild, dose-related impairment of psychomotor performance, whereas the more potent opioids, oxycodone (Percodan) and intramuscular meperidine (Demerol), induce substantial impairment of vision, attention, and motor coordination. No apparent relation between age and sedation is observed in patients treated with morphine and pentazocine (Talwin) (Solomon et al., 1993; Ray et al., 1993).

The prescribing of opioid analgesics for chronic nonmalignant pain (not associated with cancer) is a controversial issue. Although long-term treatment of chronic pain with opiates or opioids has not traditionally been accepted by either patients or physicians, a growing body of evidence suggests that prolonged opioid therapy may be both effective and feasible. Convincing and persuasive testimony has also been given by a number of clinicians and medical associations regarding the successful management of lengthy opioid treatment in patients with chronic nonmalignant pain (Portenoy, 1993).

These advocates note that both acute and chronic pain in the United States is more usually under- than overmedicated for a variety of patient- and provider-related reasons, not the least of which is fear of addiction. In addition, patients may believe that stoicism is virtuous, that pain is an inevitable and intractable part of the illness or disease, or that prescribed medications are too costly, too complex to manage, or likely to have numerous and undesirable side effects. Clinicians also may underprescribe because of fear of sanctions (Portenoy, 1993).

The disagreements among clinicians regarding management of long-term opioid therapy reflect different perspectives regarding the dangers and persistence of psychological dependence following physical addiction and the potential for psychosocial disintegration into an addictive, drug-abusing lifestyle. Many researchers point out that clinical populations can be successfully withdrawn from opiates and opioids without dire consequences. One study, for example, found that only 4 of nearly 12,000 patients who were prescribed morphine for self-administration became addicted (Chapman and Hill, 1989). Other practitioners argue that patients' quality of life improves (e.g., less medical care utilization) if they are kept on opioids and manage pain without addiction (Finlayson et al., 1986a, 1986b). Also, opioid analgesics are usually contraindicated if the patient has a history of alcoholism or another substance abuse or dependence disorder.

Opioid withdrawal is accompanied by restlessness, dysphoric mood, nausea or vomiting, muscle aches, tearing and yawning, diarrhea, fever, and insomnia. Although opioid withdrawal is uncomfortable, it is not life-threatening or particularly dangerous compared with untreated withdrawal from benzodiazepines.

Figure 3-5 displays information about some of the more commonly prescribed opiate/opioid analgesics, listing the generic and brand names with comments about indications and effects.

Figure 3-5: Commonly Prescribed Opiate/Opioid Analgesics.

Table

Figure 3-5: Commonly Prescribed Opiate/Opioid Analgesics.

Interactions With Other Drugs and With Alcohol

Drug-drug and drug-alcohol interactions are of increased importance in older adults for several reasons. Because older adults take more prescription and over-the-counter drugs than younger adults and many continue to drink, the potential for interactions is enhanced. An interaction is likely to be more problematic in an older adult because of slowed metabolic and clearance mechanisms, resulting in a delay in the resolution of the unfavorable reaction. The aging body is also more susceptible to adverse interactions. The presence of chronic diseases tends to increase the number of medications used by older adults. Thus the risk for drug interactions is increased in those for whom an adverse reaction would be most dangerous. Further research is needed on specific drug-drug interactions and on drug-alcohol combinations that can be deadly, such as alcohol and diazepam.

Source: Korrapati and Vestal, 1995.

Any use of drugs and alcohol carries risk, abuse of these substances raises the risk, and multiple drug abuse (polypharmacy) further increases the risk. A recent study documented the many possible unfavorable reactions between prescription drugs and alcohol (Korrapati and Vestal, 1995) (see Figure 3-6). For example, chronic alcoholics who use even therapeutic doses of acetaminophen may experience severe hepatoxicity. Alcohol can increase lithium toxicity and enhance central nervous system depression in persons taking tricyclic antidepressants. High doses of benzodiazepines used in conjunction with alcohol or barbiturates can be lethal (American Psychiatric Association, 1994).

Drug-drug interactions can be extremely dangerous and dramatic - the combination of meperidine with an MAO inhibitor can cause marked blood pressure fluctuations, excitability, rigidity, hyperreflexia, hyperthermia, coma, and even death. More often, however, such interactions produce subtle or mild quantitative effects. A change in sleep, appetite, or an increase in anxiety may be the only sign and could lead a clinician to increase the dose of a medication that is already contributing to the adverse reaction. To use psychoactive prescription and over-the-counter drugs wisely, both physicians and consumers need to understand how the aging process influences responses to medication and to recognize how vulnerable older adults are both to their misuse and abuse.

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