In 2011, there were more than 750,000 drug related emergency room (ER) visits by adults 65 years or older – that’s over 2,000 ER visits a day – according to data from DAWN (Drug Abuse Warning Network). While most of these visits involved adverse reactions to legally prescribed medications or accidental ingestion of drugs, more than 105,000 of the drug-related ER visits involved using alcohol with medications or other substances, nonmedical use of medications, or illicit drug use. The raw data reveal that older adults need emergent care at alarming rates because of medications they are prescribed.
The truth is that most physicians either don’t understand or aren’t well trained on the dangers of drug interactions among older adults, especially when multiple mood-altering agents are involved. The stage is set for potentially deadly consequences when healthcare professionals treat a patient’s symptoms rather than probing for the root cause. Side effects and complications from the original medication may then result in additional prescriptions to counter these side effects and complications.
For example, if someone is prescribed opioids or benzodiazepines, they become more easily fatigued. They experience a form of inter-dose withdrawal, where they don’t feel well and lack energy. A physician might then prescribe a stimulant to improve the fatigue. After a while, this becomes a deadly cocktail of medications.
Drug interactions are far too common
Adverse interactions between multiple medications are a major problem in older patients. It’s unhealthy to combine medicines this way and doesn’t treat the patient’s underlying health issues. Older people tend to have a large number of comorbid medical conditions -- such as heart disease or lung disease -- and mixing these medications could affect patients from a cardiovascular standpoint. For example, stimulant use in setting of low energy from opioid use may place the older patient at risk for a cardiovascular event.
Other interactions can result from non-addictive medications as well. Beta blockers are a great medicine for patients with heart disease, but they tend to make people drowsy, especially as people age. Combine a beta blocker with a prescription for opioids or benzodiazepines, suddenly the person is so sleepy he/she is at risk for a fall. Falls are extremely dangerous among the elderly because a broken bone can be a death sentence.
Drug misuse and addiction among older adults are bigger problems than most people realize.
Approximately half of the older patients we see at Caron have some form of inappropriately prescribed medications. An elderly woman came to us recently with an opioid problem which began as a legitimate prescription of opioids to treat her chronic pain. This eventually led to her buying illicit opioids. She also suffered from anxiety, for which she was prescribed gabapentin. That made her dangerously lethargic.
The gabapentin, in this situation, was simply a Band-Aid, one medication on top of many others prescribed over the years. Opioids can be a source anxiety when people develop a tolerance and experience withdrawal symptoms in between doses of the opioid. This was likely the case for this patient. Her treatment at Caron weaned her off opioids, managed her chronic pain with alternative approaches and simplified her medications, eliminating those that weren’t helpful but potentially harmful.
Older people die of overdoses, too
Recently, an elderly man suffered a fatal overdose caused by medications prescribed by a doctor. His family members then became alarmed that his wife may also be taking too many medications and at risk for an overdose, so they brought her to Caron for evaluation and treatment.
Though drug overdoses among older adults don’t make as many headlines, the CDC reports that adults 55 and older saw the second highest jump in overdose deaths in 2017. Overdoses can be potentially fatal for anyone. However, older adults are especially susceptible. Lower dosages can cause problems. The patient also has fewer physiological reserves than a younger person because as people age, their bodies also become more sensitive to the effects of a drug. For example, a dose of a medication or drug that had been easily tolerated for years can suddenly become a problem.
Warning signs of a problem
If you’re the loved one of an older adult, there are things you should watch for if you suspect a problem:
- Sudden changes in behavior
- Changes in daily routine
- Disrupted sleep
- Changes in self-care and personal hygiene
- Changes in social activities
- Forgetting more
- Falling asleep during normal activities
- Increased anxiety
- Mood swings including angry outbursts
- Aberrant behaviors
For example, maybe they no longer seem to care about how they look, or maybe they have poor hygiene. In some cases, they may be isolating and not going out with friends a couple times a week like they always did. Perhaps they can’t remember the phone call from last night. These could be red flags that something more significant is going on.
Many of these issues are also normal symptoms of getting older, which is why this is sometimes so hard to catch. The key is to look for a sudden shift in behavior, but it is often hard for caretakers to tell there is a problem. Typically, the family wonders if there is something going on, but they don’t act until something more severe happens, such as fall, and the person ends up in an emergency room.
I encourage people to act on their concerns because earlier invention can be lifesaving. Equally important is to hold a doctor accountable who shrugs off an issue as simply a sign of getting older.
Identification of the problem is the biggest challenge and it’s important not to minimize the seriousness of the behaviors. If a person is diagnosed with a substance use disorder, it should be followed-up by referral to the appropriate level of treatment. Once in treatment, address the issues at hand and get the problem under control. Then, after treatment, obtain a referral for aftercare and on-going management.
Much like alcohol rehab for older adults, treatment and on-going management must address underlying issues that led to the addiction in the first place, whether that is chronic pain, insomnia or other co-occurring physical or mental health issues. It is important to explore non-addictive medications and modalities. Physicians are trained to respond to such problems by prescribing medications. However, research as well as our experience in treating these issues, shows that alternative approaches to managing chronic pain are far more effective long-term. People are often skeptical at first to alternative approaches. At Caron, for example, we find that education by their treating physician empowers them to embrace this approach and commit to giving it a try. They’re more functional and their quality of life improves.
I can’t emphasize enough that there is hope and it’s never too late for treatment. No one is ever too old to be healthy and have a purposeful life.
By Caron Medical Staff
By Carol Waldman