Okay. Well, welcome, everyone. We'll go ahead and get started. My name is Art Woloszek, and I'll be one of our three presenters today for talking about substance use in older adults. We really, really, really appreciate your all being here and your interest in this topic. This is a bit of an underexplored area, but quite burgeoning given our aging populations and given the higher prevalence of substance use disorders among older adults. So we will cover that. First off, let me just tell you a little bit about my co-presenters and me. So to my left is Dr. Susan Lehman. She is the Patricia B. and William T. Bright Professor in Mental Wellness and the Clinical Director of the Division of Geriatric Psychiatry and Neuropsychiatry at the Johns Hopkins University School of Medicine. She's Professor of Psychiatry and Behavioral Sciences and the Geriatric Psychiatry Fellowship Director at Johns Hopkins University School of Medicine. She's been an outstanding colleague to work with over the years in a variety of presentations and writing together, including a book that will be talking about substance use in older adults. She's also past president of ADEMSEP, the organization involved in medical student education in the U.S. Our co-presenter, who we're certain will be arriving any moment now, is Dr. Sandy Swantek. She is the Section Chief of Geriatric Psychiatry at Rush University in Chicago. She is the current president of the American Association for Geriatric Psychiatry, also a co-author of one of the chapters in our book, Substance Use in Older Adults. She is also about to be elevated as a Distinguished Fellow of the American Psychiatric Association, so she'll be departing a little bit early to make sure that she has time for that. We're going to change the sequence of our presentation a little bit, so if you have the slides online, we're going to be flipping Dr. Swantek's and Dr. Lehman's presentation. Dr. Swantek will go second and Dr. Lehman will go third. We do not have any relevant financial relationships to disclose. So let me just give you a little bit of an overview. This is an ambitious agenda, we recognize. We're going to be presenting for about 70 minutes, and then we'll have 20 minutes left over for your questions. And because it's only 70 minutes to cover the entire topic of older adults and substance use, this is going to be a survey. It's an overview of these areas. We're going to provide some general information around these topics that you see here. And for more detailed information, we're happy to answer questions, and we're also happy to direct you to our book just published in the last couple of weeks, Substance Use in Older Adults, which is available in the bookstore upstairs. If you do buy it and you have feedback for us, we would be delighted to hear it. So let us know what we got right and not right in the book. But hopefully, we really wrote the book as a resource for clinicians. You are seeing patients, you're seeing older adults with substance use issues. How do you practically manage those folks? So that's what the book is about. And today, what we'll do is we'll present a bit of an overview in that topic. So I'm going to start with my section. I'm going to do kind of a more introductory part of the presentation. So what I'm going to cover is an overview of substance use disorders in older adults. So just a bit of explanation. So SUD, short for substance use disorder, so you're going to see that referred to throughout. There is other terminology. There's substance-related and addictive disorders, SRADs. That's kind of the broader term. That also includes things like internet addiction, for example, and gambling. We've chosen for the book and for this presentation to stay focused on traditional substance use disorders, alcohol, nicotine, cannabis, opioids, and so on. So we're going to use the term SUD or S-U-D-S. I'm going to also talk some about screening and assessment and then just some general principles around treatment of substance use disorders in older adults. And then Drs. Swantek and Lehman will go into greater detail about specific substance use disorders. I should say, in terms of the literature, I mean, just as we were, you know, researching the book and putting it together, there isn't a ton of research on substance use disorders in older adults. So there's some, but often we're extrapolating. So we're extrapolating information from younger adults, applying maybe just some good geropsych common sense around how we might translate that information into the geriatric population. But there is a shortage of high-quality research, which is, you know, it's interesting given what I'm going to show you right now, which are our demographics. The slide on the left is sort of very obvious and really well known. We have an aging population. And this isn't just in the United States, but really throughout the world, we're seeing dramatically aging populations. So in the U.S., you see some of the specific numbers here. So in 2020, there were nearly 57 million people in the U.S., 65 and up. And that's going to go up dramatically. And that's going up dramatically because we have a baby boom generation that started being born in 1946, started turning 65 in 2011, started turning 85 in 2031. So we're seeing the effects of that now with a rapidly aging population. And then you layer that on top of what's going on in terms of substance use. So on the right, I actually just spent 20 minutes double-checking these numbers because they're sort of so astonishing. They come from the same data set. It's the NSDUH, or the National Survey on Drug Use and Health. So just going from 2018 to 2021, one-year prevalence, last-year prevalence of substance use disorders in the millions among people who are 65 and up in the U.S. went up from 1 million to 4.3 million. And as best as I can tell, it's not a methodology issue. They weren't asking different questions. It's prevalence in the last year of any substance use disorder, including alcohol and illicit drugs. And that number has gone up dramatically just in the course of several years. And so some of that is because of the impact of the picture on the left. There are more older adults. Some of it, though, also is that, you know, it's interesting. When the chapters were coming back for the book, a lot of the authors were citing literature about baby boomers and having a different perspective on drug and alcohol use. I'm like, come on. I don't believe that. That's just stereotyping about a generation. But in fact, there is a fair amount of literature to support that in the United States, in general, many baby boomers have generally much more permissive attitudes with respect to alcohol and cannabis use and other substances. And that doesn't necessarily directly translate into substance use disorders, but that may be a factor in terms of seeing greater problematic use. And we're going to talk about that as well. So you can have a substance use disorder, which of course, you know, is a problem because you have a functional impairment as a result of it, or you can have at-risk use of substances like alcohol and cannabis and so on. So we'll talk a little bit about those distinctions. And this is just the substance use disorder population, not the at-risk. There are going to be some challenges in the diagnosis and treatment of substance use disorders in older adults. So again, this is a very quick survey. There's a lot of numbers behind these things, but just to go into, give you a little bit of detail about it. So older adults are at increased risk of the effects of substance use. So that makes sense. So older adults have smaller brains in general than younger adults. So they have fewer GABA receptors, for example. And so alcohol, which acts on GABA receptors, is going to have a greater effect because there are more easily saturate those receptors. Older adults are more likely to have medical comorbidities. And of course, alcohol and other substances exacerbate all those medical comorbidities. Substances are another drug in the world of drug-drug interaction. So we think about this a lot, caring for older adults, trying to avoid polypharmacy. And someone who is drinking alcohol, using cannabis, smoking, etc., it's another substance in that soup in the person's body that is potentially resulting in drug-drug or drug-substance interactions. And then a huge issue in our population, of course, is cognitive impairment and trying to avoid cognitive impairment. You know, if you ask older adult patients, you know, what are they worried about, one of the big things on that list is developing Alzheimer's or dementia and losing their independence as a result. And so often in terms of motivational interviewing strategies, this is a take that I'll have. It's like, well, you know, what are values that are important to you, and if one of those values is maintaining your independence as long as possible and preserving your cognition as long as possible, then cutting back on alcohol, cannabis, excessive use of opiates and benzos and so on could be supportive of your goal. Substance use disorders are often unrecognized or ignored in older adults, and in a couple of slides I'll show you some more information about that. Most substance use disorder treatments do not offer programs specifically for older adults. So ironically, older adults tend to do quite well in substance use disorder programs. Like even if you look at, like, 12-step programs, the response rates for older adults in 12-step programs is quite robust, especially if the programs are kind of more specifically tailored to older adults as opposed to mixed-age populations. But as it stands, it's only about a quarter of substance use disorder programs in the United States offer programming specifically for older adults. And then the number I'm about to give you is kind of staggering. So most older adults with SUDs do not receive treatment. So in a study looking at Medicare populations, so virtually everyone in the United States who's 65 and up has Medicare, of those folks who had diagnosed substance use disorders, only 11% received any treatment whatsoever. So that is sort of a horrifying statistic, but also means that we have a tremendous opportunity to address substance use in the other 89% of older adults. Here, you know, none of this should come as a great shock, but substances have a variety of negative medical effects in older adults. A lot of this is true in younger adults as well, but amplified in older adults. So for alcohol, things like stroke, intracranial bleed, of course, cognitive impairment and dementia. It's an interesting, complicated story and sort of potentially a talk in and of itself, kind of the relationship between longitudinal alcohol use and development of cognitive impairment. But in general, the effect is not good. There's a negative association. And certainly once someone has cognitive impairment, then alcohol is likely to only accelerate that process. Tobacco, you're, of course, very well aware of all the risks. These are all higher in older adults. And cannabis. So we'll hear later about cannabis, but cannabis use has increased dramatically among older adults. The cannabis of today is very different from the cannabis of the late 1960s and early 1970s when our older adults may have had their previous round of using cannabis. And older adults are much more susceptible to the negative effects of cannabis as well, including, we have very little literature on this, but I suspect older adults will be especially hit hard by cannabis hyperemesis syndrome. So a syndrome that results from excess cannabis use. And, you know, if you're in your 70s or 80s, the last thing you want to be doing is vomiting all the time in terms of volume status and electrolytes and health and so on. Here a little bit more on the barriers. This is maybe a little more about some of the psychological factors as well as systems level factors. So at the patient level, actually one of the easier things to address would be lack of knowledge. So, you know, cannabis has been legalized for medical use in most states and for recreational use in many states. So that would seem like, well, that's giving a stamp of approval. It's okay to use these substances. That's of course not in fact true for older adults where likely the risks are going to greatly outweigh the benefits. So that may be a psychoeducational opportunity for us around the risks of cannabis use. There may be lack of awareness of the extent of use. So in other words, someone in their 40s and 50s drank three to four drinks a day, which maybe wasn't a problem then, but now they're in their 70s or 80s and that's a significant problem. And there are a number of defense mechanisms. I won't go into great detail here, but you probably heard all these in taking care of folks with substance use disorders like minimizing, I only take one extra oxycodone per week or rationalizing, I only drink because my wife died or threatening, just try and stop me from going to happy hour and so on. So people have a number of defense mechanisms that may interfere with our ability to address their substance use disorders. Families, families are sometimes worried, but sometimes they're not. Sometimes they're enabling like, well, dad's had a hard life. He's 80. If he wants to drink, he can drink. That could be a reasonable attitude unless the drinking is resulting in cognitive issues, falls risk, threats to safety, et cetera. We own part of this problem as well. We have to make sure that we're screening older adults for substance use disorders and then addressing those appropriately. And older adults with substance use issues also face ageism. So sort of another layer of significant problems on top of the stigma associated with substance use disorders. So I just said that we have a responsibility with respect to screening. So I thought I would just go over that a little bit. So the U.S. Preventative Services Task Force recommends screening for unhealthy alcohol use in primary care settings in adults 18 and up with brief behavioral counseling to reduce unhealthy alcohol use. We'll go into a little more detail on that later. And then also screening about unhealthy drug use in adults 18 years or older when services for accurate diagnosis, effective treatment, and appropriate care can be offered. So according to the USPSTF, unhealthy alcohol use is defined as a spectrum from risky drinking on up to alcohol use disorder. And then unhealthy drug use is use of substances that are illegally obtained or nonmedical use of prescription psychoactive medications. So I would argue in a psychiatric setting, all older adults should be assessed for tobacco use, unhealthy alcohol use, and drug use. And that's built into my psychiatric diagnostic interview of any new patient that I'm meeting. There are a variety of tools that are available. Many of these are validated in older adults, like the ASIST, the CAGE-AD. So it's the CAGE modified to, instead of saying drinking, saying drinking or drug use. So the four classic CAGE questions of cutting down and guilt about use and I'm blanking. The eye opener. And what's A? Annoyed. Thank you. Thank you. Thank you all. A very interactive process here. So the CAGE-AD, the audit. So the audit is my personal favorite for alcohol use. So those are the three consumption questions. The Audit C are the three consumption questions of the Alcohol Use Disorders Inventory Test. So that's built into my initial assessment. And then there are others like the MASS-G and the SMASS-G. There is the NIDA quick screen, which is pretty cool and handy. It's online. Patients can do it themselves. It's not validated in older adults. So a little caution about the use of that. So in terms of addressing barriers, so again, you know, being open and frank about asking about tobacco, alcohol and other drug use in older adults and explaining why. Why this might be an important issue to address and specifically because older adults may be more susceptible to the effects of these substances. And if they have use disorders, we have effective treatments to address those things. Of course, we want to do these things in a private and secure location. There might be some modifications we may need to do. So many older adults experience hearing impairment. And so I just bought, for the first time in 20 years in psychiatric practice, a pocket talker. It's been fantastic. So just have that available. So if someone didn't bring their hearing aids or they have undiagnosed or unaddressed hearing impairment, just getting that pocket talker on has made a world of difference in terms of making sure people can hear me in my interviews. Being open, honest, empathic, nonjudgmental, segwaying and signposting. So I'll often do this as, well, we've talked a lot about your depression and anxiety. Let me ask you about something else that might be affecting your mood. I first want to ask you some questions about alcohol use and then go into that. So a little bit of segwaying may make that a less kind of painful experience for the patient or more likely for them to open up about that. Focusing on goals. So this is huge. A lot of what we do in geriatric psychiatry anyway is what does the person want to accomplish? What's important to them in terms of maintaining independence, maintaining their cognition, not falling, being able to spend time with their family, being able to do their hobbies and crafts and volunteering and so on. So and again, this is kind of classic motivational interviewing kinds of things, using those as helping people move ahead from pre-contemplation to contemplation to action with respect to their substance use. Okay. I do want to say a little bit about language. So I've certainly been guilty of this, of sort of using language that could potentially be stigmatizing and kind of in two different domains, one around age and one around substance use. So in general, we recommend not using terms like the aged, elders, the elderly, senior citizens, seniors, and instead saying older adults, older people, older patients, older individuals. I did a find and replace through the entire book to make sure that we were using those terms. And then certainly on the substance use side, so addict, not good, alcoholic, user, we really try to avoid using those. We use person first language. So a person with an alcohol or with alcohol use disorder as opposed to an alcoholic. And that's to recognize that the illness does not define the person, they're a human being who have a condition that then is treatable. The word habit, it's recommended to use substance use disorder or drug addiction instead. Clean or dirty has some connotation. So instead being very specific, positive or negative, toxicology screen. And then I have used the term clean and sober a lot and I've really tried to move away from that to, again, more technical language, more specific language, accurate language on in remission or recovery, abstinent from drugs, not drinking or taking drugs. So on the assessment side, so I apologize, there's a lot of words there, but basically in our psychiatric interviews, we should absolutely be asking about substance use, asking about activities of daily living. We need that for a variety of reasons, including making diagnoses, asking about pain. So pain and substance use disorders are often quite comorbid with each other. And then risk of falling, for example, something like the timed up and go test. So that's a huge motivator for folks. Folks do not want to fall down because they recognize that a bad fall and a fracture can have a significant impact on their life and substances can increase the risk of that. I won't go into detail here, but I've listed on the right some laboratory evaluation. And at the end of the day, we really we need to use the DSM and come up with accurate psychiatric diagnoses. This is a figure from a wonderful article. So if you don't buy the book, that's okay, I won't hold it against you. But you should read Susan Lehman and Michael Fingerhood's New England Journal of Medicine article from 2018, which is a beautiful overview of substance use disorders in older adults. So it's a terrific resource. So this is a slide that or a table from Dr. Lehman and Dr. Fingerhood's article about if you look at the DSM criteria for substance use disorder, how might those be modified in older adults? I'm going to talk quickly about kind of treatment in general for older adults. So it really begins with psychoeducation. And I've been impressed by how that alone can be a significant factor. People often don't recognize the negative effects of alcohol, cannabis, other substances. And so just that step can be a huge step towards folks moving their substance use disorder into remission. We use motivational interviewing techniques just like we would with younger adults. A lot of older adults with substance use disorders have trauma histories. And so applying the principles of trauma-informed care can be helpful as well. If folks don't meet criteria for a use disorder, then one thing we can do is monitor for the development of substance use disorders. And then when people do have diagnoses of substance use disorders, we have a variety of evidence-based interventions, psychosocial interventions, quit lines, pharmacotherapy. We'll talk a little bit about that later, and 12-step programs, and then formalized SUD programs. A little bit on SBIRT. So there is a modification of SBIRT for older adults called BRITE. SBIRT is Screening, Brief Intervention, Referral to Treatment. So that's been the SAMHSA model for substance use treatment, especially for alcohol, but also applied to other substance use disorders for 20 plus years. So the idea is you screen, you do brief behavioral interventions in the office, and then if people need a higher level of care, then refer for treatment. And BRITE was an adaptation of that in Florida for older adults and found really nice outcomes, as you can see in the right, a marked reduction in past 30-day use of alcohol and illegal drugs with that model. So some evidence base to approach that adaptation of SBIRT for older adults. This you'll be familiar with from any sort of addictions background. This is not any different in older adults using motivational interviewing. I still remember from residency, someone teaching me oars, you sort of oar your way, row your way into a conversation with open-ended questions, affirmations, reflective listening, and summarization. And hopefully you're helping people move from pre-contemplation to contemplation, to preparation, to action, and then maintenance of their sobriety. This too is borrowed from Dr. Lehman and Dr. Fingerhood. So this is an adaptation of SBIRT basically for older adults. So this is the FRAMES approach for motivational counseling. Feedback is provided from screening assessments. So we did a screening tool. We did the Audit C. Here was your score. Here's what the score tells me, et cetera. So giving people information about that. Responsibility for change comes from the patient, so empowering them. Advice for making a change comes from a clinician so that we can be in a position to recommend treatments. A menu of options is given. Empathy characterizes the clinician's approach. And self-efficacy will enable the patient to pursue ongoing follow-up. So in terms of specific syndromes that may arise in older adults, so again, we've got intoxication syndromes, withdrawal syndromes, I won't go into detail here, but the bottom line is these can be worse in older adults. And they can present with things like delirium. So part of the differential diagnosis for a delirium workup will include is a person intoxicated or withdrawing from substances. So kind of keep that in mind in your assessment of mental status changes. In terms of specific treatments, we'll hear more about this later. We can talk about this more later. But there are, of course, FDA approved and evidence based approaches. Less data on these in older adults, but would certainly be reasonable things to use in older adults. Alcohol use disorder, naltrexone, acamprosate, probably not disulfiram. I'm personally not a fan of that. But I mean, some folks would argue for that. I'd be worried about someone having a disulfiram reaction who's an older adult who, say, has cardiac disease. That may not go so well for them. For tobacco use disorder, I have many discussions with my patients about nicotine replacement and or varenicline and or bupropion, all evidence based treatments. And then the gold standard for older adults with opioid use disorder, buprenorphine and naltrexone with a smaller database for methadone. I think in the interest of time, I'm actually just going to skip ahead to Dr. Swantek. Welcome, Dr. Swantek. Yes. And I've introduced you and accoladed you and so on. So I'm going to hand things over to talk specifically about tobacco use disorder, alcohol use disorder, and health care disparities. All right. And you may be able to see me. And I wore my tall shoes. It happens. Well, thank you for inviting me to be here. It's a pleasure to be here. It's interesting. After all the years that I've done this work, it's only been in the last couple of years that I've been seeing, and I work in a university outpatient clinic specifically for geriatric patients, and it's only been in the last few years that I've seen more and more older adults with substance misuse problems. And I'm confident that this represents the wave moving on into the later years of the post-World War II generation, which grew up trying all sorts of interesting things and has liberally, not all, but many have made liberal use of substances. And so, of course, in their own denial of their aging experience, continue using. And that presents opportunities for us. Well, that was interesting. Let me make sure I know what I'm doing here. Enter or click? Maybe click there. Get that going. There we go. So we'll start out with tobacco. The prevalence of tobacco smoking in community older adults is about 12%. And despite recognition of tobacco use as a risk factor for increased morbidity and mortality, and despite public health initiatives that truly did result in declines in tobacco use, the number of tobacco using older adults is still going to double by 2050, which is not more people smoking, but the result of the surge in the numbers of older adults and the relaxed attitudes. So this prevalence varies with geographic, sociodemographic, gender, racial, and ethnic differences. Patterns of use, most consume cigarettes. Approximately 1% consume electronic cigarettes. Tobacco misuse depends on a complex interaction of variables. Socioeconomic status, there's an increased probability of tobacco use among divorced, black people, those who have less education regardless of their cultural or ethnic background. Higher BMI and homelessness. Cultural characteristics, acculturation, stress. The community capacity to launch control initiatives all play a role in who's smoking and who's not. This is a quick reminder of the diagnostic criteria for tobacco misuse. I'm not going to read this slide. It is a problematic pattern of tobacco use leading to clinically significant impairment as manifested by at least two symptoms, including persistent desire and craving during a 12-month period and involves tolerance and withdrawal symptoms. Dependence can occur within two weeks of first use and is characterized by tolerance, cravings, sense of the need to use it, and withdrawal when they don't get it. There are cravings, depressed mood, potential for irritability, frustration, anger, anxiety, difficulty concentrating, and restlessness. Late life use most often represents a disorder formed in youth when tobacco was considered cool or glamorous or a sign of maturity. Some of us remember those days. Or it's the result of receiving cigarettes in rations packets. Those cigarettes were in the rations until 1975. So those people, many of them obviously are still alive. This habit is deeply ingrained. And it's associated with pleasurable activities, meals, coffee, alcohol, before going to the bathroom, happiness, stress, after sex. The consequences of this are poor physical function, higher morbidity, mortality, and health care costs. Smoking in late life is associated with increasing social isolation because lots of people have stopped smoking. And you don't have that many people to hang around with and smoke. It's also associated with loneliness. And that, in part, is due to the natural attrition of the social circle as a person's friends and family begin to die or move to other communities. Older adult smokers experiencing higher levels of psychological distress and health problems may be more motivated to quit smoking than those with fewer problems. And this creates a target for cessation protocols. Additional motivation to quit includes cessation's impact on modifiable risk factors, such as morbidity and mortality. Keep hearing me say that. Heart disease, fall risk, lung disease, cancer, or dementia. And it's important to remember that smokers don't realize how obnoxious a habit it is. If you've ever lived with a smoker, and I happened to grow up in a household with two parents who were chain smokers for decades, and even as I developed bronchial problems and asthma, there was no, they just didn't have the ability to appreciate the distress that this habit was causing. Because, one, they were addicted. Two, they didn't have a lot of other pleasurable activities in their lives. It was an economically distressed household at times. And this was their thing and part of their identity. And to give that up was terribly difficult. And they made attempts in their, I think their 60s, 50s and 60s, started to attempt to stop smoking. And made multiple attempts to stop before they finally did. And that's the typical pattern. Seven years out, I was astonished when they said to me, boy, we didn't know how bad that stuff stunk. And when they redid their house, they realized that all that smoking created more work and cost more money to clean. Because the walls, the wallpaper, the carpeting was infused with the oils from their tobacco use. They were years after their last cigarette before they were able to appreciate the distress their habit caused for their family. Participants in the 30-year-long Framington Heart Study were more likely to quit if their spouse, sibling, a friend, or a co-worker were stopping themselves or had stopped. And it's important to think about and remember what abstinence from any harmful substance begins with, which is you think about it, pre-contemplation. Then there's contemplation or preparation to abstain. Initiation, an attempt at abstinence, usually a failure or relapse, one, two, three, or four. And then multiple re-attempts. And then finally, lasting abstinence. So how do we assist our patients in this process? We start at every patient interaction. When I think about that, I think about a patient I've been treating for 28 years, had multiple problems with alcohol and other things before she came into my practice. And her only remaining habit is cigarettes. And she's now in her mid-70s. And I have learned that every time I bring up tobacco, every time her PCP brings up tobacco, she gets pissed, really pissed, and yells. And I'm used to her yelling and reminding her that it's not that I'm trying to be abusive. It's not that I'm trying to take anything away from her. I'm trying to help her have a healthier life, to live a little longer, to live a little more pleasurably. But in spite of the fact that she now has mild emphysema, she continues to refuse. And this is one person that I doubt I'll ever convince to stop smoking. But it's still worth a try. When we're meeting new people for the first time, screening tools become a useful tool to assess how much they're smoking, how long have they been addicted, what is the smoking associated with that reinforces the habit. The tools are useful and, at times, can identify an intervention or a way to approach abstinence that will be useful and potentially successful. Screening is straightforward. In the past 12 months, how often have you used any tobacco products? And any response other than never is positive. Your work is cut out. Do you smoke? OK. Here's one of our goals. Encouraging cessation using the five R's can be useful. Relevance. We ask the person to think about why quitting would be personally relevant. You're on a tight budget. You don't have much money. Costs are going up. Cigarettes cost a fortune, which in itself actually results in some people tapering themselves because they just can't afford it. But for those who manage to pull together the dollars to buy that pack, we can focus on the economic impact. What else might you be doing? Might you be able to afford to go to a movie? Might you be able to afford that streaming service that you would like if you weren't smoking? So relevance. And I'm not even talking about health notice because it's often irrelevant to the person who's socially isolated and using cigarettes to soothe themselves. We talk about the risks. We ask the patient to identify potential negative consequences of tobacco smoke or of tobacco use. And sometimes that is useful, and sometimes it doesn't work at all. In fact, it gets the patient annoyed or, for my one patient, pissed. We ask them to identify the roadblocks, asking them to say, what's the barrier? What gets in the way of you not lighting up first? What could get in the way of you lighting up? Or what stops you from stopping? And then repetition. The motivational intervention in the best practice would be to repeat that intervention every time the patient comes in and interacts with us. And sometimes, after years, the patient will stop smoking. But when we have the older adult with tobacco use in our office, they've been using for years. They've got lots of reasons to continue. And it will take a long time to convince them, unless there's some acute event like lung cancer. Smoking in late life, as I mentioned earlier today, when we offer medication plus counseling, we have an increased rate of success in helping the patient quit. One or the other is not as successful. It has to be a two-point treatment. And then, of course, successful adherence with medication requires regular contact and ongoing support. The FDA approved eight smoking cessation treatments. There are nicotine patches, gum, and lozenges that are over-the-counter, no prescription needed. There's nicotine nasal spray and nicotine inhaler, bupropion, and Varenkline, I said? Varenikline, Chantix. Chantix, yeah. I have forever pronounced that drug name incorrectly. As of April 2023, the nicotine oral spray is not available in the United States, which seems like that would be useful. But it is available in Canada, Australia, and elsewhere. Careful use of pharmacotherapy is advised for those with medical contraindications, of course, or those who smoke less than 10 cigarettes daily. They may actually not need some of those pharmacologic interventions. And with any of the pharmacologic interventions, as we would say in the rest of geriatric psychiatry pharmacotherapy, you start low, you go slow, and you titrate to effectiveness or intolerable side effects. The key is don't stop too soon. So on to alcohol. Data released by the CDC this past February showed that the annual number of alcohol-related deaths from 2020 through 2021 exceeded 178,000 deaths. And that's more than the deaths from all drug overdoses combined. Now, alcohol, cigarettes, it's in the environment. It's all around us. It's relatively acceptable. And yet, it causes incredible morbidity and mortality. And we don't address it as seriously as we need to. I'm hearing my phone ring in my ear if I look a bit distracted. Who knows? An analysis by the National Institute on Alcohol Abuse and Alcoholism shows people over 65 have accounted for 38% of that 178,000 people. Between 1999 and 2020, the percent, it was a 237% increase in alcohol-related deaths among adults age 55-plus. And it was higher than for any age group, except for 25- to 34-year-olds. In March 2024, the New York Times published an article reporting that in an aging population, there's a foreshadowing of a continuing surge even if older adults' drinking behavior does not change. And again, I can see in my own practice, I'm seeing more and more people coming in with alcohol misuse. So I think it's always a good idea to take a moment to remind ourselves what the standard drink is. Recognizing that alcohol is a toxin, and with a nod to our British colleagues, who are far stricter in their advice than we are, we suggest that for older adults without chronic medical conditions, there should be no more than two drinks per day or seven drinks per week for an older adult with, and for the older adult with chronic medical conditions. And for an older adult with chronic medical problems, really abstinence from alcohol is the goal. It is the gold standard. When I'm attempting to convince somebody to stop drinking, and one of my most powerful arguments is to start with a discussion of alcohol as a toxin. How little you drink, it's affecting the brain. Now, when people come to see me, because I also do a lot of dementia work, they're often afraid that they may also have dementia. And I find that tying the idea of alcohol with increased risk for dementia is a really powerful argument. It may not result in total cessation, but it does promote a decrease in use. So I encourage them to think of it as their treat per week. If you're going to drink, pick one day a week and that's your drink day and you have one and then we go over what that one looks like. Because of industry advertising and the like, there are older adults out there who are drinking, you know, their wine glass, have you bought wine glasses lately? You can get a glass that will fit half a bottle of wine. I ask them, how big are the glasses? Always ask, how big is the glass? You know, we thought it was funny in medical school when our instructors told us that, but it's true. Oh, I only have one glass, doc. Yeah, how big's the glass? Oh, it's a tumbler. But I don't fill it to the top. It's just a tumbler. So beer, 12 ounces, about 5% of alcohol. Malt liquor or flavored malt beverages such as hard seltzer, 8 to 10 ounces would be standard. That's about 7%. Alcohol, table wine, a standard drink is 5 ounces. It's not really that much. It's a sip and that's about 12% alcohol. Fortified wine, 3 to 4 ounces, 17% alcohol. Cordials, liquors, aperitifs, 2 to 3 ounces. This stuff's potent. 24% alcohol. I recall a song, a folk singer, have some Madeira, Madeira, all about his attempts to get a young woman drunk. It's funny, but it's not. Brandy or cognac, 1.5 ounces, 40% alcohol. And then the distilled spirits, the gin, the rum, the vodka, whiskey. A standard drink is about 1.5 ounces and that's 40% alcohol. So these things, these things are strong. Diagnosing alcohol use disorder using DSM criteria is challenging since for the older adult population because we don't have occupational impairment to assess. It's not relevant when people are retired. However, we can assess for a cognitive impairment, sleep disturbance, depression, or other such problems in older adults. The assessment of alcohol misuse is suspected when we see macrocytosis on the complete blood count with an elevated AST to ALT ratio of greater than 2 to 1. Elevated GGT, CDT, or ETG are highly specific in identifying recent alcohol use. Now remember, if that patient is macrocytotic, your first goal is to rule out a serum B12 deficiency because, of course, as people age, they don't absorb B12 as well as they did in their younger years. And you can have macrocytosis and may suspect alcohol, but until you've ruled out B12 deficiency, you can't address that. Most alcohol screening instruments are not really specific to older adults. Instruments like the CAGE are popular. They're easier to use. They'll give you a clue. Unlike the CAGE, the audit C focuses on questions related to consumption itself and that's a good screener for at-risk drinking and alcohol use in older adults. And at-risk drinking refers to drinking that increases the chance that an older adult is going to develop problems related to alcohol use. The SHORT, the MAS, the SHORT Michigan Alcohol Screening Tool is a tool that is specific for the geriatric population and may give you the best information. But honestly, just talking about it. My approach is when I'm meeting someone for the first time or if I'm re-screening, when was your last drink? That's like the recency of the alcohol use is more often than not your greatest clue to what's really going on. There will be folks whose eyes will widen and they'll pause and they'll look at their partner and say, I don't know. And I'm thinking, okay, this is not a problem, but I still have to wait till they tell me it's been two years, ten years, you know, somebody's graduation or something like that. The person who says last week, well, you're gonna want to want to tease that out a little further. But that really gives you the best information for how much time you're going to spend on that in your evaluation. When we're talking about age sensitive treatment, we want to be supportive. We want to be non-confrontational. Remember, where they come from, what they're drinking, the amount they're drinking is probably considered normal. We have people who have grown up in social settings, cultural settings, where a lot of alcohol is just part of the way they do things. Thinking about a lady that came into my office about ten months ago and she came for bereavement. Her spouse had died and the family thought she was grieving excessively. And as I interviewed her, I realized that one of the things that could potentially be contributing to the problem was that she was drinking every night. She was lonely. She was alone. And at family gatherings, holiday gatherings, the family wanting to show their love again, a culture that alcohol use is a sign of affection, sort of like a brisket in some families. It's a little glass of whiskey or a little glass of wine. And when you have your grandchildren bringing you your third glass of wine at the holiday dinner, well you're not going to say no to your grandson, are you? So we actually did an intervention where first we educated the patient and got her to understand that if she wanted to continue living independently, if she wanted to do her best to avoid dementia, we needed to get rid of the majority, if not all, of the alcohol. But that wasn't good enough. We had to talk to the family and help them understand that while this is a thing you do, this is not a thing you do for granny because she just can't drink like that anymore. It's not good for her health. You don't want to hurt granny, do you? And we were able to get to most of the children and the grandchildren and with that combined intervention for those who still offered her alcohol, she felt she had the strength, the social strength, to say no, bring me a soda or a pop, whatever you call it, in your part of the country. Things that I use to convince the patient that it's time to get rid of the alcohol is to start with saying, you know as you get older, you don't metabolize that alcohol as well as you used to and it can worsen your heart disease, liver, renal disease. There's an increased risk of cancer, fall risk, sleep disruption. In fact, it may completely obliterate sleep the night of a drink. And of course, there are all of the interactions with prescription medications. Treatment works. Lack of Medicare-mandated treatment parity interferes. Detoxification of alcohol withdrawal syndrome follows the severity of the withdrawal itself. Mild, severe. Severe meaning looks a bit like DT. Transient visual, tactile, or auditory hallucinations, illusions, grand mal seizure. Obviously, you're going to hospitalize those people. But a milder withdrawal syndrome, a lot of times, if you need to watch these patients carefully, but they can get through that at home. Confusion, however, can be a predominant symptom of alcohol withdrawal and it may not be accompanied by the autonomic hyperactivity that we see in younger people. And so, it's important to recognize that the patient who's confused and actively imbibing or has recently stopped imbibing may themselves be going into a withdrawal that requires your hospitalizing them. Supplementation may be needed. Thiamine before glucose to prevent Wernicke's encephalopathy. Electrolyte correction along with benzos used on a fixed taper or symptom-triggered protocol. Lorazepam or oxazepam, as you likely know, are most commonly used in these situations because they bypass oxidative metabolism in the liver. One of the things that I consistently do with my patients who are still drinking and not real excited about cutting back or even cutting back is to make sure that they're regularly taking B12. Get them on B12 automatically and some thiamine. Long-term pharmacologic treatment for alcohol use disorder has not really been studied thoroughly in older adults and this should be an imperative. There are three medications approved for alcohol use disorder. Naltrexone, acamprosate and disulfiram. Two additional medications with off-label use for alcohol use disorder are gabapentin and topiramine. I join Dr. Walachek in shuddering to think of putting an older adult on disulfiram. The thought of it scares me. Non-pharmacologic management, you know, we start with motivational interviewing. The elderly study showed that patients with mood disorders drank more at baseline. They also cut down their consumption of alcohol when motivational interviewing and CBT, cognitive behavioral therapy, were implemented. Motivational interviewing addresses the ambivalence among patients about entering treatment and it evaluates the perception of behavior change and encourages them to formulate reasons and plans to change dysfunctional behavior. It also gives you a target to focus on with them. Multiple studies have demonstrated the effectiveness of CBT therapy. I've got two, what, one minute, zero minutes? Okay. Health disparities are differences in any health-related factor, disease burden, diagnosis, response to treatment, quality of life, health behaviors, access to care and oh so much more, among all population groups. Health behaviors are just one small part of the picture. While we currently have the beginnings of understanding, we still need to learn much more in the years ahead. Disparities vary. Disparities by race or ethnicity vary with age. Disparities in treatment access. Can the patient use telehealth? Do they have computer access, internet access? Can they turn a computer on? If they have a cell phone that's smart, do they have the smarts to be able to use it for treatment? Age-friendly design. You got to think about the eyes. Our eyes don't see quite so well as we get older and if we're trying to read that tiny little screen, it hurts and oftentimes it's impossible because cool designers like to use gray faded out print and they can't read it. I can't read it anymore. I empathize. There are socioeconomic variables and barriers obviously and insurance barriers. There are disparities in the completion of treatment programs. Suntay found that black older adults were 37% less likely to complete a substance use treatment program compared to whites, while Hispanic older adults were 26% more likely to complete a substance use treatment than whites. Why? What are we doing wrong? What are we not identifying? Because there's some variables there we need to address to improve those numbers. In addition to health care, clinicians have to acknowledge the cultural barriers, understand the cultural barriers if we're going to get anywhere in treating these various populations. Older adults face unique barriers to treatment like social isolation, limited mobility, financial issues, transportation issues, as well as shame. One study found that lack of readiness and cost-limited insurance were the most frequently mentioned treatment barriers among older adults. And this is an issue also for tobacco. There are patients that want inpatient treatment for their tobacco use disorder. It's not available. It just isn't done, or if it is done, it's massively expensive and out-of-pocket. Thank you for your attention and I'll hand it over to Dr. Lehman. All right, well thank you all for hanging in here. We said this was going to be kind of a brief survey. It's going to touch a lot of things. In the remaining time, I have a bit of an ambitious agenda, so I'm going to breeze through a little more quickly because I want to be sure really to get to all of the topics here with you. I'm really glad that Dr. Swantek took the time she did to talk about alcohol because that is the most misused substance in older people, far and away of all of the other ones that I'm going to talk to you today. But the second one that's most used is cannabis, and it's really important that I can have a little bit of time to talk about that one, and that'll be third. So let me go a little bit quickly and talk about opioid use disorders with you, and it may surprise you to hear that the lifetime prevalence of heroin use and heroin use disorder has increased in older people. We think about this in young people all the time, but are older patients really? And yet we are seeing it. We are really seeing it. And so in fact, it's two very interesting things about this to tell you. First of all, the number of older adults who are entering inpatient treatment for the very first time tripled in the 10 years between 2007 and 2017, which is very interesting. And also a late-onset heroin use has been increasing. What is this phenomenon? And this is a very interesting graph that I think that I want to talk to you about that just came out in 2021. And what you will see here, I don't know if I have a pointer, but you can see two lines going up, right? The light gray, the dark gray. So dark gray is what's called typical onset of heroin use disorder, but the light gray is late onset. What is that condition? So typical onset is before the age of 30, probably what we've been taught in medical school, what we think about the patients we took care of out in our training. These individuals, by and large, started using heroin before the age of 30, and they have persisted. They've continued to take it. It's become a chronic condition for them. They are more likely to be individuals who are receiving medication treatment, and that's good. But this other condition has been identified late onset. It may surprise you. The definition of late onset here is not after the age of 60, but after the age of 30. But these individuals are a little bit different. They started later. Why? Many started off with prescription opioids for a pain problem, and it was acute pain, and that got followed by illicit opioid use. And I can see how this has happened, because I'm going to relate to you a patient of mine, and you may be seeing this as well in many of your patients who get prescribed opioid medications for a pain disorder. And physicians now don't want to prescribe it long-term, but after a period of time, the patient still hasn't gotten off of the opioid, and then the physician quickly wants to cut it off. I saw this happen with a patient of mine, and she panicked, and she had to find something, because otherwise she would have gone into acute withdrawal. Luckily for her, and I'm saying luckily, because I really felt she probably needed to go inpatient to get off of the opioid medication, her primary care doctor took over. But in many cases, people are turning to other things such as heroin. These individuals late onset, more likely to use heroin every day, less likely to inject heroin. So what we are seeing also is rates of opioid use disorder have been increasing dramatically among older adults, even among older adults over the age of 65. And here is the one of the biggest worries, because there has been a marked increase in opioid overdose fatalities since 1999. Look at that line. It's only gone up. The slope of the line is frightening. This is older people over the age of 55. In this same paper, I wanted to tease it out. Who are these people who are experiencing opioid overdoses? And I'm going to show you the next slide, because it's really dramatic. Since 2013, before 2013, the highest rates before 2013 were seen among Hispanic or Latino men or non-Hispanic black men, non-Hispanic American and Indians, and Alaska Native men and women. However, since 2013, the greatest increases in opioid overdoses have been among non-Hispanic black men. And look at this, which is here, this one. Look at this slide here, which is, look at that blue line. This is the same data, but the reason it looks different is because the y-axis now had to change in order to show this massive spike. And so we need to be very concerned about opioid use disorder. And remember that 30% of those who have used heroin continue into older age. As Dr. Walasek said, we need to have universal screening for all substances. The increase in heroin use suggests the need for increased teaching on training, not only to identify it and treat it, and to consider buprenorphine, which often is not considered. Ages to sometimes can get in the way here. We might often think that older adults who have lifelong substance use burnout, they don't burn out with age any more than older patients with bipolar disorder. That's a condition that doesn't necessarily burn, definitely doesn't burn out with age. But also to consider that older adults can develop new onset substance use problems. But we often think, well, older people lack the capacity to change, and as you've heard from Dr. Walasek, absolutely not. Motivational interviewing techniques, which we use for younger people, can be highly effective. So overall, I think when we're thinking about opioid use, we do need to think about addressing chronic pain, because that often is the driver for opioid medication misuse, which potentially could also lead to heroin use. And just to remind you that opioid use disorder, there are, for those who have significant disorder, there are approved treatments, methadone, buprenorphine, and naltrexone. And of those, buprenorphine is tolerated the best in older people. So now I'm going to talk about prescription medication misuse. And what does that mean? So this is defined as the intentional or unintentional use of a prescribed prescription medication that doesn't conform to the directions. It's a patient got the prescription, but they didn't use it the way the doctor prescribed it. It can involve taking more of a medicine that's prescribed or using it for a different purpose. Early in my career as a psychiatrist, I remember I had an older woman with a bad depression, and she was given oxycodone by her 80 year old husband for her depression. He gave it to her. He had been given it for some pain condition, and he said, well maybe this will help you get better because your medicine from your psychiatrist isn't helping enough. That's an example of substance misuse, and it can be different family members also giving a medication to an individual. I also want to talk to you about what we are doing and what our colleagues are doing in medicine, which so often older patients are being co-prescribed benzodiazepines and opioid medications together. And in fact, the findings are showing that co-prescribing of benzodiazepines and opioids together has been rapidly increasing. And you can see this in this graph, where the one on the far right there shows the two together, the rates keep going up year after year. Why is that a worry? Why do we care about both types of medication being prescribed in the older adult? The reason, obviously, is we worry because the two together have potential for harm, falls leading to hip fractures, traffic accidents, as well as intoxication syndromes. And there's one more, which is that co-prescription of opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. And if you look here on this graph, on the bar graph, this shows you those individuals who are the one on the far left is no misuse of these medications, and then opioid misuse only, benzodiazepine misuse only, and association with suicidal thoughts. The one on the right, look how dramatic that is. That's the two of them prescribed together. So prescription opioid and benzodiazepine misuse associated with suicidal ideation, we spoke about that in the last slide. And I think what this means to us is that particularly when we know that we have a patient who comes to us, and perhaps we are prescribing the benzodiazepine for anxiety or as an adjunct for depression, they're probably getting the opioid medication from their internist, be thinking about the risk for suicidal thoughts, and be sure to have a low threshold to be screening for them. Long-term benzodiazepine prescription actually is really common among older patients. And a lot of it is being done by our colleagues in primary care. It might surprise you to see this graph, which is showing that even among, it's in the column on the right, 65 to 80, long-acting benzodiazepines prescribed by years are the most common in older patients, and especially common in older women. So why are older patients getting prescribed benzodiazepines for long periods of time, and why are doctors continuing them? Well, I think we have to consider what might be the reasons that patients cannot prescribe these medications in the first place. And they're prescribed more often by our colleagues in medicine than by us, but we do it too. Anxiety, of course, anxiety disorders, and depression with anxiety, and sleeplessness are the big reasons why. What we often see, though, is that they can be continued for years without a good indication that the need has continued. And years could be 20 years on a benzodiazepine. Some of you, I'm seeing some heads nodding. You've seen this in your practice. Sometimes they're prescribed for symptoms without looking at what's the reason why. We know, as psychiatrists, if we see a patient who isn't sleeping, we start to think, well, what's the differential diagnosis? Why might they not be sleeping? We could think of a lot of different reasons. We might not reflexively just automatically prescribe a benzodiazepine, but sometimes that happens. So I've given talks, actually, to my colleagues in medicine who are beginning to realize that they are very worried about long-term benzodiazepine prescriptions in their older patients and want to know about safely deprescribing. Deprescribing has become a very important concern, particularly in medicine. And that's a good thing in many ways. How can we safely get older patients off of medication, particularly what might be doing harm that they might not need anymore? Whenever I give talks, though, to non-psychiatric audiences of other physicians, I always stress that not only do you want to have an approach that provides for safe tapering of the medicine, but you need to address why was it started to begin with. We know, as psychiatrists, that often anxiety might be the most prominent symptom of a depressive disorder. But benzodiazepines alone are not going to treat depression. So we need to think about, is there depression there that we need to be treating? We need to think about, if the person isn't sleeping, why are they not sleeping at night? Do they have a disruption of circadian rhythms? Are they ingesting too much caffeine? Is there something else going on that they're taking that's keeping them up at night that needs to be addressed? Very important to establish mutual goals. Will the patient establish a taper schedule with them? That will be safe. Write it down, what you're going to do day by day, week by week. Review it, and have flexibility if a patient's having trouble. So the bottom line here is that many older adults are on long-term benzodiazepines. They can be successfully tapered if done collaboratively with taper schedules, but also with a goal to address the initial concerns that were there that got them for which the benzodiazepine was initially started, and make sure that they don't reemerge and we take care of them. So I do want to talk to you here before we have to end at the end of the day about cannabis use. Because as I told you, this is now the second most misused substance and used substance among older patients. I can't tell you as a geriatric psychiatrist how much I am seeing this in my practice. And you may be seeing this too. Patients are coming to me, and they're asking questions about this. So the trend in the prevalence of pasture cannabis use has been increasing dramatically. And I'm going to go back to what you heard at the very beginning from Dr. Walasek. The reason why really has to do that the baby boomer generation, again, the generation of those adults who were born between 1946 and 1964, at every decade of their life, at every age, they have had higher rates of substance use compared to the generation before at a comparable age. And many of them used cannabis in their youth and have continued through middle age and through now older age as well. So we are seeing pasture cannabis use that is increasing and increasing use across all different categories, among women, among white, non-white, those with college education, those with more limited education. Interestingly, we're seeing increased use, particularly high, among those individuals also getting mental health treatment. Those are our patients. And also those who also were reported pasture alcohol use. That might put them now even at double risk. So perhaps you can see here, and I'm sorry I don't have a pointer, that lifetime use in 2019, lifetime use in 2020, look how it keeps going up for the ages 60 to 64, and 65 and older, and also past month also keep going up in older adults. What we're also seeing is that with an increase in use, a concomitant decrease in perceived risk in using cannabis. This is a fascinating study. What did these people do in the study? Well, they asked them, and the question was, how much do people risk harming themselves physically and in other ways when they smoke cannabis once or twice a week? They did not distinguish between medical use or recreational use. And what they found was that people could say no risk, slight risk, moderate risk, great risk. But the perceived risk decreased dramatically over these four years periods of time. And there you go. So part of the reason why people are using it is they perceive the risk is not so great anymore, and the risk is highly associated, even more so in those states where marijuana has been legalized for medical use or for recreational use. So why do older adults turn to cannabis products? Why might they be using them? Well, I think, again, we have to acknowledge that some of the symptoms for which cannabis is reported to be useful have been for conditions that maybe this patient wasn't helped by standard pharmacotherapies, like chronic pain, like sleep disorders. It's often said, well, this would be really good for that. And whereas our standard therapies sometimes fall short. As a plant product, people tend to say, well, if it's a plant, if it's natural, it has to be safer than taking prescription medications. A couple of years ago, I gave a talk to my nurses on our geriatric psychiatry inpatient unit, talking about trends in substance use. And the nurses gave me feedback. They said, you know, they talked about their parents, not the patients on the floor. I wanted them to understand our patients. But my young nurses said, I'm concerned about my mother. She has depression. She doesn't want to take antidepressant medication. She thinks it's dangerous. She'd rather use cannabis. A number of them felt like using, their parents felt using cannabis was safer than using standard psychotropic medication. So it's really interesting. And then there's this widespread belief that because it has been illegal and it hasn't been studied, it probably has unexplored tremendous potential. That's a general belief out in the public. Now, I'm not going to address for you, does cannabis have a beneficial therapeutic effect for chronic pain or other kinds of neurologic conditions? I'm not going to talk about that. But I do want to, you should know that a really, really excellent review paper came out in 2019 in The Lancet, which is a very respected journal. And they looked at all of the randomized controlled studies and observational studies where cannabis was used for conditions we care about, depression, anxiety, ADHD, Tourette syndrome, PTSD, and psychosis. And the conclusion was they found little evidence for the effectiveness of pharmaceutical CBD or medicinal cannabis for the treatment of any of these mental disorders. This is good evidence. And I want you to know that what's out there in the literature is anecdotes. Anecdotes are not the same as scientific evidence. There is some literature that for patients who use cannabis and also have depression, it makes it harder to recover from a depressive episode. What do we know about pharmacokinetics and pharmacodynamics in older adults? Well, there are very few studies have been done. One of my patients is an 83-year-old man who I was treating for depression. And he was partially better but not fully well. And he said, well, Dr. Lehman, I'm going to go to the cannabis dispensary and see if they can help me. And I cautioned him about it and I said, you know, it's not been well studied, it's not been studied. You are 83 years old, you have all of these medical problems, you are on 10 to 12 other prescription medications for all these other medical conditions. He said, well, I'll ask about it. So he did. He went to the cannabis dispensary and asked and said, well, look, I'm on all of these other medicines. Is it okay for me to use cannabis? And the person, oh, sure. Oh, sure. And I said, well, that should have been a reason to run away because there have been no studies about that. There are no studies of whether this is safe or what the interactions are with all of the things that you are taking. We do know that THC, you know, which is the highly potent psychoactive element, and cannabidiol are highly lipophilic, high volumes of distribution. But we really lack any pharmacodynamic data on interactions with any other prescription medications. And remember, although it's out there as medicinal cannabis, only three products are approved by the FTA for any kind of treatment. And these are, none of them are for psychiatric conditions. One is to treat severe epilepsy. The other is to treat severe anorexia and weight loss in patients with AIDS. And the other for refractory nausea and vomiting due to chemotherapy. There are harms of cannabis in older adults. This is a fantastic paper. I really recommend it to you. And Dr. Walasek, I think, touched upon the same table. He independently was drawn to it, as I was showing you that there are psychomotor impairments, cognitive impairments, cardiovascular impairments, and even mental health impairments. This is specifically for older adults using cannabis. So why are people drawn to them? One of my favorite articles that I'm going to recommend to you came out in 2020 in The Atlantic. It's not a medical journal, as you know. It's a commentary. But the title of this essay, which is very, I think it should interest all of us as psychiatrists, America Loves Its Unregulated Wellness Chemicals. And it tried to explore, psychologically, why is there such an appeal for medication that's in a completely unregulated industry? It has no oversight in any way. And here are two quotes from the article. Cannabinoids are a salesman's dream. When little is known, virtually anything can be passed off as possible. Isn't that insightful? And Americans aren't waiting for more formal answers on what cannabinoids can do for them. Now is the ideal time to market novel, inexpensive, widely available substances outside their traditional health care industry. So the rates of cannabis use are rising among older adults. And yes, they can have harms. I saw a patient who came to me because of dementia. And she had early to moderate Alzheimer's disease. Her husband was asking her and giving her cannabis to help with her anxiety. It only made her cognitive impairment worse and made her more confused. It was not good for her. Older adults are more vulnerable to the cognitive, psychiatric, and cardiovascular effects of cannabis compared to younger adults. Cannabis hyperemesis syndrome, which Dr. Walasek mentioned to you, includes recurrent episodes of nausea, vomiting, which might be particularly concerning for older adults. And it's important, though, as for cannabis, as for opioids, as for alcohol, all of those to maintain a nonjudgmental approach in being able to explore and discuss these and help guide our patients. We want all of our patients to live lives of the best and highest level of well-being. So thank you very much. I'm sorry that we've covered so much with you here that we only have about four minutes left for discussion. But thank you for sticking with us. What questions do you folks have? Hi, thank you very much for this wonderful talk and at least late hours you have to stay here too. So I'm a geriatric psychiatrist and I agree with you. I've been from New York, I've been seeing increasing number of people with substance abuse. Even though we have separate clinic for that, we have to refer them out, so it's kind of for them even worse because they have to see me as a psychiatrist and then go to a separate location for their therapy. So I think that's not a good model, but I have a specific question. I have patients who have dementia, like one specifically a male from Brazil who retired has mild to moderate dementia and so not that demented so he couldn't go out and go to the liquor store so he's he managed still to because the family couldn't control him it gets very irritable if family tried to control him so he whenever he get a chance and some money he would just get the liquors. I'm thinking about he's already an antidepressant so that doesn't seem to work and for this kind of irritability he's not stopping drinking. I'm thinking about naltrexone, but more valproate acid. I just don't know what's the best choice. He's like in his mid-70s. So if I'll just restate if it's okay and tell me if I'm getting this wrong. So one was an observation that the way we do substance use disorder treatment may not work very well the way it's sort of split between if you have severe enough illness you go to a substance use disorder clinic less so that be psychiatric clinic. I completely agree it's a huge frustration of mine. We you know our system like many other systems are segregated in that fashion and of course there's federal regulation or around that and so on but it's extraordinarily frustrating. It sounds like the second question was what would we recommend in terms of treatment of at risk at least at risk alcohol use in an older adult with dementia who is still able to sneak out of the home has enough wherewithal to sneak out of the home and drink alcohol or buy alcohol rather than drink it. Is that was that your question? He goes to buy at the gas station. Gas station. His guy and the family had talked to the sellers but they wouldn't because they want to make money. So he goes to his local. He drinks daily still. Okay. Well I had a similar situation as well and actually we had a patient and every time she drank she developed alcoholic hallucinosis and paranoia and she would get so frightened by her hallucinations she would end up being hospitalized. We'd get her better. She'd go home and then it would happen again because she would bully her husband to go to the corner liquor store and get her liquor and he couldn't take it anymore and would go. This is really really tough because you can't do it alone without working with the family. Maybe they maybe they need to take away his ability to use money or anytime that it comes they need to they need to take the alcohol and get it out of the house. You have to be able to have a good relationship with the family and get them on board. They don't always agree with you. I think taking a medication in somebody who you know I can see why you'd want to do naltrexone to try to lower his desire for it but who's going to remember to give it to him and he's not going to remember to take it. You know so it's really because I think it's really dealing with the behavior and perhaps perhaps what we need to be think about and I think you know Dr. Wallacek and Dr. Swantek were saying this sometimes in this area we're thinking of harm reduction. The ideal would be total abstinence of course but sometimes we're really thinking what can we do to reduce the harms. It is real harm to him. I had a patient who was a lawyer and he with bipolar disorder but also a drinking problem and he and he became sober and and was in remission and recovery for many years and he gave talks to the American Bar Association as an exemplar of somebody who would overcome his problem and then he started drinking again and then he started drinking with his son and they went out drinking together and my patient fell, hit his head, had a subdural hematoma and it becomes a beginning of constant of cognitive impairment. So the I think we have to make the case and perhaps to the families that this is not benign. There are real risks. Good luck. I'm sorry I don't think there's an easy answer for you. You don't have experience like maybe like other mood stabilizers because just so he's less irritable. As a family actually tried to control him it just they couldn't. So the family has HRA on board but unfortunately it just okay. Thank you. So we'll take one more question. I just have a quick question about the cognitive impairments in older people using cannabis. I have a patient who used to smoke, treating from depression, but he used to smoke when he was young, like in his 20s or something. Went many years without smoking. State that he lived in became legal. So he started smoking, and he says that he is able to learn better. He said he started taking piano lessons. This guy's like 75 years old, and he says that he's learning piano. He's doing a lot better. And I'm just wondering, I know with psilocybin, they say that it increases dendritic branching and increases BDNF. I'm wondering about, do you know anything about cannabis? Yeah, there's no evidence of that. I mean, it could be, you know, remember feelings aren't facts. So just because he feels that way doesn't necessarily mean it's cause and effect. I would absolutely support the piano lessons, though. That actually, I was talking to Dr. Wallace because it's another interest of mine, that actually has, there is some studies to show that does have benefit on cognition. Learning an instrument at any age, it's even better if you started when you were young and then even went back to it later. But the piano will benefit his thinking. Maybe that's what's going on. Exactly. And people have actually seen benefits in even just in 8 to 10 week studies. So I would encourage him to keep practicing. Well, thank you all very much. Appreciate you hanging in there, Class 515. Thank you.

substance use disorders

older adults

aging population

alcohol

cannabis

baby boomer generation

polypharmacy

cognitive impairment

motivational interviewing

prescription medications

benzodiazepines

opioids

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