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November/December 2017
Addictions and Neurocognitive Disorders: What Counsel Can Primary Care Providers Offer? Addictive behaviors in older adults with neurocognitive disorders require specialized interventions as well as education for family members and caregivers. Addictions affect people of all ages, genders, ethnicities, and religious groups. Sometimes older individuals develop addictions early in life that then continue into old age. Many are acquired after retiring or experiencing a significant loss, such as the death of a loved one. However, those that occur after a neurocognitive disorder are the focus of this article. Many therapies available to noncognitively impaired older individuals will simply not work due to the neurocognitive disorder regardless of when the addiction developed. Most available treatments require cognitive ability with an adequate memory. Irrespective of the origin of the neurocognitive issue, older individuals will have memory/cognitive issues that will affect treatment. Consider the following cases in which the specific information has been modified to protect confidentially. In case 1, a 79-year-old with a PhD who was a full professor at a major university developed a frontotemporal neurocognitive disorder and drank alcohol (sometimes excessively) his entire adult life into postretirement and after the development of the neurocognitive disorder. He had fallen a few times, and his memory was poor to the point that he could not remember the quantity of alcohol he had consumed on any given day. In case 2, a male diagnosed with a frontotemporal dementia (neurocognitive disorder) spent $4 million on lottery tickets before his family realized what was happening. In case 3, a female in her late 70s with a poor memory who had been diagnosed with mild to moderate Alzheimer's disease exhibited a shopping addiction where she purchased multiple items from the internet and local stores using credit cards, and then never opened the packages arriving at her home. In case 4, a wealthy individual recently diagnosed with Alzheimer's disease was taking Ambien 10 mg, Ativan, Tylenol PM (Benadryl) every night and repeated Ativan at some time during the night in order to sleep. When he was advised that he was abusing medications and harming his memory, and under his primary care physician's supervision should reduce and eliminate many of these medications, he terminated the conversation and the relationship. In case 5, a 70-year-old regularly visited a local casino to play the slot machines. When his concerned wife asked their son to find him and request that he return home, the son observed his father with a masked face sitting at the machine mechanically hitting the buttons, unconcerned with the outcome of the game and unaware of his son's efforts to take him home. His diagnosis was Parkinson's disease. Further discussion of these cases will appear later in the article. Categorizing Disorders In an attempt to work with patients with neurocognitive disorders, we must be aware that addictions can include substance abuse. According to the Substance Abuse and Mental Health Services Administration, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer uses the terms substance abuse and substance dependence; rather, it refers to substance use disorders, which are defined as mild, moderate, or severe, to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual. Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. Substances include alcohol, tobacco, caffeine, cannabis, stimulants, hallucinogens, over-the-counter medications, and opioids, which many older people with and without neurocognitive disorders take for pain. Primary care physicians would be wise to remember that many baby boomers have previous substance abuse issues, and all should be assessed for prior addictions. Providers also need to recognize process addictions, addictions of behavior such as shopping, gambling, internet (baby boomers), sex, and food/beverage consumption. In individuals with neurocognitive disorders possessing a process or a substance addiction, it will be potentially harmful to them, undermine the provider's treatment, and cause families a significant amount of concern and distress. Appropriate Interventions Providers should evaluate an individual's medications. Medications such as serotonin (for mood regulation), norepinephrine (for mediating arousal), and dopamine (for reward regulation) may all be factors in impulsivity, mood disorders, and impaired control, leading to gambling behavior or other compulsive addictions. Recently, according to a Medscape article, "Pathological lmpulsivity: Is a Drug the Reason?" by Douglas S. Paauw, MD, published online in March 2017, Abilify has been identified as producing side effects that include eating disorders as well as sex and gambling proclivities. Providers need to assess for any head trauma or stroke that could lead to disinhibition in patients who may have reduced impulse control. Individuals with bipolar disorder, some personality disorders, and schizophrenia have higher rates of gambling addictions. Providers should consider a "brown bag" medication review to identify and evaluate patients' medications, including prescription drugs from all prescribers, over-the-counter, supplemental, and topical medications, as well as when medications are taken. The elderly often consider medications safe and harmless and do not appreciate that they can lead to overuse/abuse. Once the assessment by all professionals including the primary care physician, geriatric care managers, social workers, geriatric nurses, possibly pharmacists, and family members is complete, the next issue is treatment. This can be tricky because an individual's loss of cognitive abilities due to a neurocognitive disorder can rule out several therapies that might be utilized by a therapist working with a cognitively intact individual. Treatments such as cognitive behavioral therapy, Alcoholics Anonymous, Narcotics Anonymous, reminiscing therapy, and counseling may be options depending on the degree of cognitive impairment. What can a primary care provider do to improve the situation? Start with a complete physical, neurocognitive, and psychiatric assessment. Based on the results, treat what can be treated with nonpharmacological and pharmacological treatments. If pain causes an individual to utilize opiates, try nonpharmacological approaches such as transcutaneous electrical nerve stimulation, meditation, and NSAIDs. If there is depression or anxiety, a primary care provider can treat with appropriate medications. However, if a patient is in the very early stages of a neurocognitive disorder, perhaps cholinesterase inhibitors would be appropriate. If the cognitive disorder responds, it may prove beneficial. Providers should also review all medications to ascertain whether a medication is the root of the addictive behavior. In consultation with the family, a physician or other geriatric care professional may call for an environmental intervention. If a patient is receiving advertisements or other materials from concerns such as casinos or stores that could elicit the addictive behavior, eliminate the trigger by preventing the communications from reaching the individual, thereby eradicating the trigger and changing the behavior. Consult with a recreational therapist or an activity therapist to provide meaningful activities for a patient to replace previous behaviors associated with the addictive activities. Therapeutic activity can be based on interests and pursuits from an individual's past that are not affected by the neurocognitive disorder such as religious endeavors, sorting items, art, music, swimming, riding a bike (not alone), and spending time with grandchildren or pets. A day care program could provide a nonaddictive environment for patients while providing opportunities to socialize and engage in other activities. Harm reduction, a model developed by the Dutch, focuses on minimizing the risks and consequences of drugs or alcohol and encourages individuals to switch from liquor to wine or beer and to reduce the amount consumed. If gambling is the issue, limit the time spent and dollars available. When shopping is the concern, provide transportation and/or limit to once per week as opposed to daily, and regulate the time spent at the shopping site. Attempt to control internet usage. The goal is to place the computer in a public area of the home where variables such as behavior, usage, time limits, and site subscription can be monitored. Mix caffeinated coffee with noncaffeinated coffee or switch to completely noncaffeinated. Provide smokers with nicotine gum or smokeless cigarettes and limit where and when to smoke as well as the number of cigarettes. Look for ways to reduce the impact of the addictive behavior. Bear in mind that some individuals with and without a neurocognitive disorder will never completely stop an addictive behavior. Educate the caregivers and providers, who need to be cognizant of the types of addiction, interventions, and how to appropriately participate in the treatment plan. Case Analysis Case 2: In the case of the male diagnosed with a frontotemporal dementia who spent $4 million on lottery tickets before his family realized what was happening, removing his ability to purchase tickets and placement in a personal care facility for patients with neurocognitive disorders resolved the problem. In the facility he was able to engage in appropriate activities. Unfortunately, the family lacked specific knowledge of frontotemporal neurocognitive disorders and had difficulty with issues related to his inhibitions and impulsiveness. Case 3: In the case of the woman in her late 70s who had been diagnosed with mild to moderate Alzheimer's disease and exhibited a shopping addiction in which she used credit cards to purchase numerous items via the internet and local stores and then failed to open the delivered packages, following diagnosis of Alzheimer's disease, she was permitted to shop for short periods of time with restrictions (accompanied by a caregiver). Credit cards were slowly withdrawn so as not to produce a catastrophic reaction. As the disease progressed, specialized care placement became necessary, and the situation was resolved. Case 4: In the case of the wealthy individual recently diagnosed with Alzheimer's disease who was taking multiple medications to go to sleep and remain asleep, the patient terminated the relationship with his provider. In the absence of a primary care provider to present solutions, no intervention was offered, and the patient lacked any form of insight into his abuse of prescription and over-the-counter medications. Case 5: In the case of the 70-year-old who regularly played the slot machines at the local casino and whose concerned wife and son sought to prevent his addictive behaviors, his Parkinson's disease diagnosis added clarity to his situation and care. Once his physician reevaluated and adjusted his medications for Parkinson's disease, the problem ceased. He had had no prior history of a gambling addiction. Families and caregivers are desperate for help in managing the addictions outlined above, and many other families and caregivers fail to recognize the situations as addictions, which results in frustration and anger. Primary care physicians as well as other geriatrics professionals can help. It requires a thorough assessment, one or more appropriate interventions until success is achieved, and education for all involved. Neurocognitive disorders coupled with addiction, while difficult to treat, are not unresolvable or hopeless. — James Siberski, MS, CMC, is an assistant professor of gerontology and the director of the geriatric care management graduate certificate program at Misericordia University in Dallas, Pennsylvania. He is also an adjunct faculty member at University of Scranton. — Carol Siberski, MS, CRmT, C-GCM, is a geriatric care manager in private practice and participates in research in geriatrics and intellectual disabilities in Pennsylvania.
IMPULSE CONTROL DISORDERS RELATED TO PARKINSON'S DISEASE Key Facts • Family should be engaged in the treatment. • Address ICD during every office visit. Clinical Best Practices • Ask patient regularly about development of ICDs. • Refer to psychiatry if changes in medication do not work. — SOURCE: NATIONAL PARKINSON FOUNDATION (PARKINSON'S TOOLKIT) |
