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Sleep complaints by older adults constitute a very common situation faced by health care providers. However, not all professionals respond to the complaint the same way. Some will briefly assess the complaint and resort rather quickly to medication while others will assess the complaint carefully in order to exclude the diagnosis of primary insomnia and prescribe alternative interventions to improve sleep. When medicine is prescribed, the type of compound often selected is benzodiazepine. However, benzodiazepine carries a significant risk of adverse reaction, including drug dependency, both of which are clinical problems that should not be underrated, especially when treating a subjective complaint and not a specific diagnosis.
Key words: insomnia, benzodiazepine, dependency, addiction, older adults.
Smoking is the leading cause of preventable death worldwide. Though older adults are the segment of the population least likely to smoke, they incur significant morbidity and mortality from tobacco use and can benefit from quitting. Older smokers have beliefs regarding smoking and motivating factors for cessation that differ from younger adults. Clinicians should understand these unique factors and can then use strategies to assist the older adult in smoking cessation.
Key words: smoking cessation, tobacco, epidemiology, older adults, prevention.
Most practitioners assume that the use of illegal or “street” drugs is confined to the young. However, a recent phenomenon has been the use of such drugs by individuals above the age of 50. Social trends play a part: many older addicts began using in the 1960s. Others share the use of illegal drugs with other family members as a mode of family recreation. The latter trend is probably more common in inner cities where drugs are more easily obtained. Older men are twice as likely to use illegal drugs as are older women, though the latter outnumber the former demographically. Many illegal drugs, especially cocaine, methamphetamines, and even marijuana have cardiovascular effects that are especially dangerous when they occur in older individuals who may already have underlying cardiovascular disease. Practitioners must be vigilant about querying patients about their use of illegal drugs, no matter what their age, and especially if cardiovascular illness is involved.
Key words: older adults, illegal drugs, cardiovascular disease, cocaine, methamphetamines.
The number of older adults who drink to excess is not known, partly because primary health practitioners seldom screen for this problem. The signs of alcohol abuse are vague prior to late-stage liver failure and many of them are attributed to normal aging. Two types of alcohol dependence are commonly seen in older adults: type I is a late-onset alcohol dependence in which depression, chronic illness, or life changes such as retirement precipitate drinking, while type II is mainly genetic and reflects lifelong drinking that has not been previously identified by health professionals. Pharmacologic agents such as naltrexone and acamprosate have been shown in a number of clinical trials to be useful in care. A great many others are still in testing phases. Nonpharmacologic management is also effective, especially when teamed with drug therapy. Some of these are cognitive behavioural therapy, motivational enhancement therapy, and counselling that the primary care physician can do in the office, also known as the brief intervention approach. There is much that can be done if alcohol dependence is recognized.
Key words: alcohol, aging, older adults, dependence, liver disease.
The day before writing this editorial, we assessed an older woman in memory clinic whose function seemed well preserved despite her complaints of memory impairment. Her history revealed that she has been smoking large amounts of marijuana for over 40 years. We will not know until prolonged follow-up whether she will decide to stop her marijuana use, and whether this will have any impact on her cognitive function (which was impaired on formal testing). At least she gave up cigarettes 10 years ago!
This assessment made me wonder whether I have missed similar cases in the past by not asking the right questions, and whether others also make the same mistakes I have committed. It seems to me that we do this because we think older adults are “different” from us and do not have the same desires that younger people have. Now that I am getting much older, I realize that we remain human even as we age. It is clear from the medical literature that older people also abuse various substances, particularly alcohol and tobacco. In fact, the cohort of older smokers is often very severely addicted because they have been smoking for so long. After reading this issue, I hope to correct my oversights in the future.
Although there are more teetotalers among older adults than younger adults, the percentage of problem drinkers is probably not substantially different. With comorbidity, particularly cognitive or psychiatric, even a relatively modest intake of alcohol can be quite dangerous. This topic is reviewed in the article “Unhealthy Alcohol Intake among Older Adults” by Dr. Ann Schmidt Luggen. This article is also the subject for our CME program with this issue.
As the cohort that started smoking in earlier eras ages, all clinicians will see many older smokers. The first barrier that health care professionals face is the nihilistic belief that the damage is done and there is no point in stopping smoking now. Using the example of a single health problem, acute coronary syndromes, there is persuasive evidence that smoking cessation, even for those in their 80s, is beneficial in preventing future events. The special article published several years ago in the American Journal of Medicine by David Alter and David Naylor (now president of University of Toronto), makes the point that most effective interventions in cardiac diseases are even more useful in older patients who have higher event rates. How we help our patients is addressed in the article “Smoking Cessation in Older Adults: A Review” by Dr. Victoria Walker and Dr. Heather Whitson. Stopping (or preventing) smoking is possibly the most effective health intervention that modern health care has to offer.
Sleeping pill abuse has been a major problem with the current cohort of older adults, possibly because benzodiazepines were considered to be very safe when first introduced. Dr. Phillipe Voyer and Dr. Michel Préville have written the article “Insomnia and Benzodiazepine Dependency among Older Adults” that addresses this difficult problem. Our last theme article, “Older Adults and Illegal Drugs” by Dr. Katherine Schlaerth, addresses the type of problem I discussed at the beginning. While there is some hope that the next cohort of older adults will contain fewer cigarette smokers, the opposite is likely true for the number who use illegal drugs.
We also have our usual collection of articles on important geriatric topics. The article “Chronic Primary Insomnia among Older Individuals” by Dr. Børge Sivertsen ties in with our theme article on benzodiazepines. The changing landscape in the “Diagnosis and Current Management of Abdominal Aortic Aneurysm” is discussed by Dr. Oren Steinmetz and Dr. Peter Midgely. Dr. Kerstin Steiber Roger discusses the common and often perplexing problem of “End-of-Life Care and Dementia.” Dr. Michael Starr and Dr. Elizabeth Hazel have contributed the article “Giant Cell Arteritis: An Update on Diagnosis and Management.” On my last rotation as an attending physician on general medicine, I cared for an older man with HIV infection. With current HIV management, survival to old age is not uncommon. Susan Eldred, RN and Wendy A. Gifford, RN, discuss this phenomenon in their article “HIV and the Older Adult: Challenges in Prevention and Treatment.”Our caregiving article this month is on “Support for Caregivers of Older Adults with Chronic Conditions: A Canadian Perspective” by Dr. Lili Liu, Ms. Alison Barnfather and Dr. Miriam Stewart.
Enjoy this issue,
Barry Goldlist
