Ephedrine Abuse in a Patient with Dementia

Introduction

Alcohol and drug dependence are two of the leading causes of disability in the world.¹ However, the full extent of substance abuse in older patients is unknown.² Despite the common occurrence and disability associated with substance use in older adults, these problems often go undiagnosed in this population.³ There is a myth fueled by age-related bias that substance use disorders occur in young and middle-aged adults but not in the elderly.⁴ As the number of older adults increases, the scope of mental health problems—including substance abuse—will increase.⁵ As elderly persons with substance abuse age and develop dementia, clinicians will be confronted with treating patients with these problems. We present a case of substance abuse in a person with dementia and discuss diagnosis and treatment in the older population.

The Case

Mrs. R, a 78-year-old widowed female living at home with a full-time, 24-hour-a-day home health aide, presented for an evaluation at a geriatric psychiatry office. She had become increasingly more forgetful over the past two years and had been diagnosed with dementia of the Alzheimer’s type. For the past six months she was noted to appear more anxious by her family. She was sleeping erratically, was restless, and exhibited increasing psychomotor activity. She had a labile mood and would cry on and off for no reason. She was agitated at times and tried to strike her family members on one occasion. She exhibited some referential beliefs, as well as paranoid delusions regarding the home health aide stealing from her. She had no prior psychiatric history. She had a medical history significant for hypertension, which had worsened recently and required the addition of ramipril to her standing atenolol.

Both Mrs. R and her family denied any history of substance use or alcohol use in recent history, but did report that the patient was always concerned with her weight and had a remote history of using diet pills up to 20 years earlier; they denied recent use. She was seen by her private medical doctor two months earlier for the above symptoms and had a negative medical work-up. She was started on sertaline 50 mg daily six weeks earlier and quetiapine 25 mg at bedtime about two weeks earlier for her worsening symptoms. Her Mini-Mental State Examination score was 20/30 with poor short-term memory and recall.

Mrs. R presented with her son and her home health aide for the evaluation. The aide stated that during the past six months the patient would ask her to take her to a local health food store where she would buy “vitamins”; the family was not aware of this taking place. The family went to the patient’s home to examine the pills and found them to contain ephedrine. Mrs. R stated that she was taking them for weight loss. The family was instructed to remove the pills from her possession.

For the next few weeks Mrs. R’s symptoms were unchanged, with some worsening paranoia requiring an increase in her quetiapine dose. Her home health aide then found additional pills in her purse. The family thoroughly searched the house and found several stashes of well-hidden ephedrine pills that were then removed. The aide was instructed not to take the patient to any pharmacies or health food stores, and all medications were closely monitored, supervised, and administered by her family. Within one month, the patient improved greatly, was sleeping well, was no longer anxious, and had no psychotic symptoms. Her quetiapine was tapered off and discontinued with no recurrence of psychotic symptoms after one year.

Discussion

A particular problem for older adults is the misuse of prescription and over-the-counter medications that include sedatives, hypnotics, narcotic and non-narcotic analgesics, diet aids, and decongestants. A common problem is the inappropriate overuse of medications with limited documentation of effectiveness and the use of multiple medications. Older adults may share medications, use higher doses for longer periods than prescribed, and can eventually develop tolerance and dependence problems.¹ The two major classes of prescription drugs subject to abuse by older patients are the benzodiazepine sedative-hypnotics and the opioid analgesics; central nervous system (CNS) stimulants and non-benzodiazepine sedative-hypnotics are also a problem (Table I).⁶ Such misuse of prescription and non-prescription medications is associated with increased morbidity and mortality, including falls and fractures.⁷ Clinical and functional problems include sedation, confusion, and cognitive problems.⁸

Prevalence and Epidemiology of Substance Abuse
The estimated 1-year prevalence rates for alcohol abuse and dependence is 2.75% for older males and 0.51% for older women.⁹ Mental health settings have higher rates than those seen in the community, with one study showing a rate of 8.6%.¹⁰ Less is known in the literature about the epidemiology of substance use disorders other than alcoholism in the elderly. The Epidemiologic Catchment Area Study found the lifetime prevalence of drug abuse and dependence to be 0.12% for older men and 0.06% for older women. The lifetime history of illicit drug use was 2.88% for older men and 0.66% for older women. There were no active cases reported in either gender.¹¹ Anecdotally, older heroin users are usually life-long addicts who have survived.² In one study, one-third of all older patients (> 65 yr) developed dependence to prescription drugs after age 60 and required inpatient treatment for their dependence.¹²

A review of the charts of 90 older patients (> 65 yr) admitted to a psychiatric hospital using strict diagnostic criteria found that 21% of the patients were chemically dependent. Of those, half were not recognized by their physicians as dependent patients.¹³ Older adults tend to abuse nicotine, alcohol, and prescription drugs rather then illegal drugs such as marijuana, heroin, or cocaine.¹² Risk factors associated with drug abuse in older adults include female sex, social isolation, history of substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential¹⁴ (Table II).

Substance Use in Dementia
There are significant data in the literature on alcohol-induced dementia. However, our literature search revealed almost no data or research on substance use disorders in elderly patients with dementia. One study in Denmark compared risk factors for hospitalization in individuals diagnosed with dementia alone versus individuals with dementia and comorbid bipolar disorder. Patients with dementia had a 3% risk of alcohol abuse and a 1% risk of other substance use disorder (n = 37,304) versus a 15% risk of alcohol abuse and a 10% risk of other substance use disorder in patients with dementia and comorbid bipolar disorder (n=1011).¹⁵

Screening and Diagnostic Tools

To our knowledge, there are no known screening instruments for drug misuse or abuse in older patients found in the literature. Even the DSM-IV criteria for substance abuse and dependence may not apply to older patients because they may not work or drive, and therefore have no obvious evidence of social or interpersonal problems due to substance abuse.¹² Clinicians are known to routinely miss symptoms of substance abuse in older patients or to misdiagnose them. In one study, only 1% of primary care physicians correctly diagnosed a substance abuse problem when presented patient scenarios. The rest misdiagnosed them with depression, anxiety, or other medical issues¹⁶ (Table III).

A careful assessment of patients who receive or request any psychoactive drug is appropriate, including a screening for substance use and a yearly reassessment of patients to evaluate for side effects or inappropriate use. In addition, a thorough evaluation including a toxicology screen is needed for any older patient who presents with new or unexplained confusion, delirium, falls, insomnia, incontinence, self-neglect, depression, housing problems, or social isolation.⁴ Further research on developing specific and appropriate screening tools for substance use disorders in older patients is needed.

Treatment and Prevention
There are also limited data and research about the prevention and treatment of substance use disorders in older patients. In practice, any elderly patient using a psychoactive drug should be a candidate for a trial of stopping the medication.⁴ The rationale for the trial of being off the medication, as well as the risk of withdrawal symptoms, should be made clear to the patient and caregivers (if appropriate). The patient's consent should be obtained. Alternative management for control of symptoms should be discussed with the patient. Studies have shown that older adults treated for substance use disorders have a good prognosis and treatment outcomes equivalent to or better than younger adults.¹⁷ Treatments can include counseling, family interventions, motivational counseling, as well as specialized treatment such as inpatient/outpatient detoxification, inpatient/outpatient rehabilitation, and maintenance treatment with psychotherapy, self-help groups, or 12-step groups¹⁸ (Table IV).

In patients with dementia, the above interventions may be ineffective due to cognitive deficits. As such, caregivers and family members need to be contacted to coordinate care. They may be unaware of the patient abuse of psychoactive drugs and may need to restrict access or even remove the drugs from the patient’s environment.

Conclusion

Substance use disorders are often misdiagnosed in older persons. The data show that with proper assessment and diagnosis, older individuals do respond to treatment. Very little is known or published regarding older patients with dementia and substance use. The case presented above of an elderly female patient who was abusing over-the-counter stimulants (“diet pills”) highlights the problem of a patient with a remote history of using substances who starts using them again as she becomes cognitively impaired, and “forgets” that she is no longer taking them. With proper assessment and questioning, and using family and environmental interventions, the patient was weaned off the stimulants and had great improvement in her levels of anxiety and agitation. Unfortunately, more research is needed into screening, assessing, and treating substance use disorders in older patients in general, and in patients with dementia specifically.