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CONSIDER: SUBSTANCE ABUSE

Definition Acute Intoxication: Functional impairment, behavioral and mental status changes that occur according to specific drug. Intoxication may be manifested in psychomotor agitation or retardation, confusion, diaphoresis (stimulants), slurred speech, unsteady gait, impaired memory, or sleepiness (depressants, sedatives, anxiolytics). Intoxication also occurs as a result of drug interaction where drug effects are strengthened by another drug, medication or food supplement (herbs). It can occur as a result of drug misuse, naïve medication choices by the prescriber or self-medication by the patient.1

Assessment/Screening Tools

Quantity-Frequency Index: Types of drugs, Frequency of use: Function of Substance used, Amount of drug used. (See Table of Potential Causes below).

Assessment Screening Questions

  • Review older adult's baseline mental status and compare with observations.
  • Perform a Mini Mental Status Exam.
  • Conduct a modified physical assessment: observe gait, balance, eye contact, color, vital signs, and psychomotor behavior.
  • Obtain collateral history from family, significant others, neighbors.
  • Ask direct questions about all medications, herbal products/food supplements/alcohol and/or other drug used that day.
  • Assess for alcohol on breath.

Engage the older adult: It is essential that the nurse 1) state the purpose of questions about substances used and link them to health and safety, 2) be empathic and non-judgmental, 3) ask questions when the older adult is alcohol and drug free, 4) inquire re: older adult's understanding of the questions

Atypical Presentation:

  • Signs of acute intoxication in elders are not dissimilar to those of confusion and memory loss associated with delirium, depression and Alzheimer's disease. (See delirium, dementia topics). A key element of the assessment is timing and identification of onset of behavioral changes.
  • Older adults may have substance use and dependence problems even though the signs and symptoms do not parallel those listed in the DSM-IV TR.2
  • Consultation with family, health care providers, care providers in constant contact with the older adult is essential. It is very important, that the etiology of the behavior be identified as early as possible.

Most Likely Causes of Acute Intoxication in Older Adults: Assessment and Interventions

Potential Underlying Cause of Acute Intoxication Physical Findings Nursing Actions
Substance Abuse: a maladaptive pattern of substance use evidenced in recurrent and significant adverse consequences related to the repeated use of substances. Repeated findings of intoxication on observation over a period of 12 months. Assess for neuro-psychiatric conditions using the Mental Status exam, Geriatric Depression Scale or Hamilton Anxiety Scale.
Obtain sleep history, which may indicate use of drugs in combination or excessive alcohol consumption as disrupters of sleep. (see Sleep Topic).
Assess intake of all drugs("Brown Bag" strategy),including alcohol,OTC, prescription and nicotine.
If positive for alcohol use by BAL (Blood Alcohol Level),AOB (Alcohol on breath) or self-report, assess for last time of use and amount used.
Educate and assess motivation using FRAMES model - Feedback, Responsibility, Advice, Menu, Empathy, Self-Efficacy (See Table: Assessment and Interventions in Want to Know More section)
Communicate findings to principal care providers.
Document of observations, interventions.
Counsel patient to reduce drug use (Harm Reduction) and engage in relationship healing/ building, community or intellectually rewarding activities, spiritual growth to increase non-drinking rewards.
Interaction of multiple drugs Findings of gait disturbance, confusion, memory loss following the intake of alcohol and anxiolytics, sedatives, herbal medications and/or analgesics. Use Quantity/Frequency Index (Q/F Index) to review all medications, illicit alcohol and tobacco and over-the -counter drugs ingested in the last 24 hours (See Want to Know More section).
Provide psychoeducation to older adult and caregivers: Review all medications, time of self-administration, dosage and side effects. Teach about interaction of medications with alcohol, marijuana, anxiolytics and sedatives: i.e. consumption of one or two glasses of wine on occasion prohibits taking an hypnotic. Similarly, smoking marijuana should not be combined with anxiolytics, alcohol, the herb Kava or sedatives.
Refer to community based Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups and encourage meeting attendance. Educate family and older adult on drug dependent behavior.
Communicate with all providers regarding observed patterns.
Document of observations, interventions.
Substance Dependance Observed pattern of self-administration of a drug that is maladaptive and results in development of tolerance, withdrawal and compulsive drug taking behavior.2 Dependence is both physiologic (with tolerancea and withdrawalb) and psychologic. Give Feedback to the older adult about the observation of patterns of excessive use of a substance.
Advise the older adult about potential mental and physical health outcomes of dependence on alcohol or other drugs.
Assess the older adult's readiness to change behavior.
Consult with primary care providers and addictions specialist regarding appropriate Referrals.
Educate patient and family regarding health problems, proposed plans and expected outcomes.
Substance Misuse Reported pattern of using drugs for reasons other than for which they are prescribed, i.e. using anxiolytics on a daily basis versus as needed or using prescription or illicit drugs in combination with alcohol. Give Feedback to the older adult on behavioral changes observed, if any.
Review reasons for Misuse: consider naïve use, intentional, efforts to address pain, anxiety, etc. Educate older adult and family on health consequences of drug misuse.
Communicate with principal care providers regarding findings.
Monitor changes in drug/alcohol use at each visit.
Definitions
a. Tolerance: 1) a need for markedly increased amounts of a substance to achieve intoxication or the desired effects or 2) markedly diminished effects with the continued use of the same amount of a substance.
b. Withdrawal: 1) a characteristic group of signs and symptoms which has its onset following the sudden cessation of consumption of a drug (including alcohol and nicotine) that induces physiologic dependence.

( Modified from American Psychiatric Association, 2000)


References
1. Inaba, D.S. & Cohen, W.E. (1997). Uppers, downers, all arounders. 4th ed. Ashland, Oregon: CN Publications.

2. American Psychiatric Association. (2000). Diagnostic and statistical manual of Mental Disorders-IV-TR. 4th ed. Washington, D.C.: American Psychiatric Association.


Last updated - Novemeber 2005