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The worldwide population of those aged 65 years and older has increased rapidly in the last century. It is estimated that by 2030, the number of adults aged 65 and older in the United States will be approximately 70 million, representing roughly 20% of the population.1 Elderly persons are prescribed the highest proportion of drugs and use medications, both prescription and over-the-counter, in much higher amounts than younger adults.2 Some estimates project that by 2040, the elderly will consume 40% of all prescriptions.3 With the aging of the baby boomer generation, there is also an anticipated increase in substance abuse among the elderly, which is due to this population group using these substances more than previous generations.1,4-6 It has been estimated that the number of individuals requiring some form of substance abuse treatment in the United States will be 4.4 million in 2020, compared to 1.7 million in 2000-2001.7
Managing Multiple Health Conditions
The increase in prescription medication use among seniors, including polypharmacy, ie, the use of multiple medications to deal with multiple disease states,8 also contributes to abuse. Medications prescribed for anxiety, insomnia, and chronic pain tend to be rife within this population,9,10 and it is not uncommon for patients in this age range to be concomitantly prescribed a gamut of medications to manage multiple health conditions such as hypertension or diabetes.11 It has been estimated that approximately 2.7 million people over age 50 will use prescription medications non-medically by 2020 and that psychoactive medications with the potential for abuse are already in use by about 1 in 4 of the elderly.9 The abuse of both prescription and illicit drugs in this population is important as it can lead to other cognitive and physical impairments, putting these individuals at greater risks for events such as traffic accidents, falls, and suicide.
The National Survey on Drug Use and Health demonstrated that from 2006 to 2008 an estimated 4.7% of adults aged 50 or older used illicit drugs in the past year.12 Beyond the perspective of general health, drug abuse also has an impact on patients in the dental office, particularly with regard to consideration of drug interactions, consent, and negative effects on oral health.13
A variety of factors can prompt the elderly to abuse substances. These factors differ from those that lead teenagers and young adults to abuse substances. The younger population group abuses substances primarily to experience euphoria and garner peer acceptability, while among seniors factors associated with drug abuse include social isolation, previous or current history of substance use or mental illness, and exposure to potentially addictive medication.9 Being female is also a factor linked to substance abuse among the elderly. Women as a group tend to be prescribed more psychoactive medications and for longer durations compared to men, with the prescription and usage of such medications frequently corresponding to recent divorces or the loss of a spouse, and for coping with anxiety and depression.9 Social isolation relates to living alone or with a non-significant other (eg, in a group home) and is a common phenomenon in the elderly population, particularly with changing social structures in Western society.
The prevalence of comorbid substance abuse and mental illness is well established: individuals with substance abuse disorders have high rates of mental illness with a direct association between the magnitude of comorbidity and severity of substance use disorders.14 Finally, potentially addictive medications include any medications that have psychoactive properties or in which tolerance may develop. Given these factors and the associated health changes with aging, it is unsurprising that drug abuse is a real occurrence among elderly patients. Common drugs of abuse among the elderly include alcohol, central nervous system (CNS) depressants, opioids, and illicit drugs. These are discussed in the following section.
Common Drugs of Abuse and their Effects
A CNS depressant, alcohol exerts its effects through its interactions with receptors for acetylcholine, serotonin, gamma-aminobutyric acid (GABA), and N-methyl-D-aspartate (NMDA) glutamate receptors, and by altering neuronal membranes, ion channels, enzymes, and receptors. Generally, alcohol is widely available. Even routine consumption of alcohol in the elderly is worth noting given its potential for interactions with other medications that an elderly patient may be using. Such an interaction could result in, for example, gastric bleeding or increased sedation. Additionally, alcohol's decreased volume of distribution in this population results in increased effects.15 Indeed, it has been reported in the literature that as much as 75% of individuals over age 65 use a medication that can interact with alcohol, and 19% of individuals taking one of those medications concomitantly use alcohol.16
Examples of medications that can interact with alcohol include nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, benzodiazepines, barbiturates, and opioids. Table 1 summarises the interaction of alcohol with drugs that are commonly prescribed in dentistry.17-19
The effects of alcohol are well known, and moderate use is capable of causing feelings of euphoria and decreased stress or tension. The extent of alcoholism and abuse of alcohol among the elderly population is difficult to estimate due to a lack of sensitive and specific tools that have been validated in this age category.20 One estimate from a 2001-2002 study reported a prevalence of alcohol abuse in those aged 45 to 64 years as 3.54% of the overall population and for those over 65 as 1.21% of the overall population.21 Critically, alcohol abuse tends to be more prevalent among men: in those same age categories of the male population, 5.5% and 2.36%, respectively, were found to abuse alcohol.21 Among men, it has been reported that major motivators behind alcohol abuse include being divorced, widowed, or separated, thereby making this population particularly at risk for alcohol abuse.22 The chronic use of alcohol alone can result in a variety of pathologies, including liver cirrhosis23 and cognitive impairment,24 as well as the development of alcohol dependence.
Central Nervous System (CNS) Depressants
Benzodiazepines are by far the most commonly prescribed sedative or hypnotic agents in the elderly and are often prescribed on a chronic basis.25,26 The classic example of a benzodiazepine is diazepam. Pharmacologically, benzodiazepines exert their effect by enhancing GABA's effects, resulting in depression of the CNS. Tolerance to benzodiazepines develop over time and results in the need for increased dosages to maintain the drug's therapeutic effect and the emergence of drug dependency, which is well reported in the literature.27,28 Benzodiazepines have been associated with a host of issues in the elderly patient, most critically being implicated in elderly suicides. One study reported benzodiazepines as being the sole agent associated with drug poisoning suicides in 72% of cases, with the terminal cause of death most commonly being drowning in the patient's bathtub.29
Benzodiazepine usage has been directly linked to falls,30,31 hip fractures,32 and even car accidents,33 due to its effects on the patient's cognitive function and coordination. Studies have directly implicated long-term benzodiazepine usage with cognitive decline.34
Related to the benzodiazepines, another class of CNS depressants commonly abused are barbiturates. Barbiturates, such as pentobarbital, exert their mechanism of action by interacting with the GABA receptor and enhance the effects of GABA, resulting in CNS depression. Much like benzodiazepines, barbiturates have been demonstrated to result in increased occurrences of falls and fractures in the elderly population35and are associated with suicides and deaths.36 Compared to the benzodiazepines, barbiturates have a much lower therapeutic window and are associated with more complications and adverse effects, resulting in a decreased prevalence in prescription of this class of drug.
Opioids are commonly prescribed analgesics in the elderly. Capable of providing both analgesia and euphoria, these drugs exert their mechanism of action through interactions with opioid receptors. Classic examples of opioids include fentanyl, hydromorphone, meperidine, morphine, oxycodone, and codeine. The elderly are often prescribed opioids due to the existence of chronic or persistent pain conditions, typically brought about through falls, surgery, or conditions such as cancers.37
Of all the analgesics in use today, opioids have received the most scrutiny by healthcare professionals and the general public. While highly potent and efficacious, concerns have arisen over their adverse effects as well as potential for abuse, addiction, and death.38 Such concerns may not be entirely unfounded with studies demonstrating a rapid increase in frequency of opioid prescription compared to historical data.39 The abuse of opioids and opioid dependency is often related to debilitating pain and/or psychiatric conditions, with one study reporting that 75% of opioid-dependent patients had these conditions.40
Much like with the aforementioned benzodiazepines, the abuse of opioids has been shown to be related to falls, with side effects of prolonged administration including sedation, dizziness, nausea and vomiting, constipation, and respiratory depression. When opioids are used concurrently with benzodiazepines and other CNS depressants like alcohol, the risk of sedation and falls increases due to their potential for additive effects.
Geriatric individuals may also abuse illicit drugs, such as cocaine and cannabis. Cocaine is a stimulant and exerts its effects centrally by preventing the re-uptake of dopamine, facilitating feelings of euphoria. The abuse of cocaine as a drug by elderly and older individuals has been on the rise, with admissions to substance abuse facilities increasing since 1998.41 Among adults reported to be dependent on or abusing illicit drugs, cocaine is one of the most common, second only to marijuana.7 Cocaine is more commonly abused by males and "younger" elderly, and it has been estimated that in urban centers cocaine use in the elderly may be as high as one in 50.42
The effects of cocaine use are well documented and can result in a variety of complications of nearly every organ system. Critically, cocaine use is well known to be related to cerebral infarctions or myocardial infarctions, both of which are already more common in the elderly compared to the general population.43,44
Cannabis can act as both a stimulant and depressant and exerts its mechanism of action through cannabinoid receptors. Highly lipid soluble, cannabis accumulates within fatty tissues and has a tissue elimination half-life of approximately 1 week, with complete elimination taking up to 1 month.45 It is, therefore, unsurprising that in elderly patients, who have relatively higher levels of adipose tissue compared to younger individuals, cannabis can quickly accumulate and result in toxicity.
As previously mentioned, cannabis is the most common drug of abuse among the elderly, with approximately two in five individuals who abuse drugs using cannabis.7 Among individuals who use cannabis, the risk of developing depression is higher than the non-using population46; this is an important consideration considering that the elderly already are at higher risk of developing depression. Other health effects of chronic use of cannabis include a general "slowing down" of ability to react and process information and reduction in physical coordination and performance, resulting in increased propensities for accidents and falls.47,48
Implications for Dental Practice
Given the wide-reaching effects of drug abuse and the aging of the dental-going population,1 prudent clinicians should be aware of the medications and substances being used by their patients. A thorough medical history and social history should be taken to ascertain the use of any substances, including alcohol or other drugs. Questions with respect to how much, how often, and for what purpose must be asked and considered.
With respect to patient characteristics, the patient who abuses drugs tends to have decreased self-image, lack of motivation, and depression, which impacts adversely on their oral hygiene and ability to maintain appointments with healthcare providers.49 Abusers of drugs such as benzodiazepines and opioids may exhibit significant xerostomia, which in the elderly population compounds on both aging-related decreased salivary flow and medication-related xerostomia, resulting in increased caries rates and increased periodontal disease rates. The location of caries in drug abusers also differs, presenting as cervical or smooth surface caries.50 Aside from caries, the dentition may also present with hypersensitivity51 and traumatic injuries.52 In the soft tissue, oral lesions may be more frequently noted in drug abusers; however, whether this is directly due to drug abuse or the concomitant use of tobacco is uncertain.52
As described previously, the clinician must consider the potential for drug interactions, particularly with respect to the prescription and use of any sedative medications or analgesics, with possible outcomes including the death of the patient. Typically used sedative agents in dentistry include benzodiazepines and nitrous oxide. Where either a medical history or the history of drug usage is unclear, sedation should not be administered. Both of these agents may result in interactions with other sedatives that the patient may have taken, and, thus, a deeper level of sedation than intended may occur.
Local anesthetics used in dentistry are relatively innocuous when administered by the prudent clinician who follows typical protocols (eg, not exceeding maximum dosages or ensuring negative aspiration).53 More important to consider is the epinephrine amount being administered in the local anesthetic as a vasoconstrictor, particularly given the potential for comorbid cardiac conditions attributed to the elderly, as well as the potential for triggering of cardiac dysrhythmias in patients who abuse cocaine.53
The clinician must also recognize that the management of pain of a dental nature in elderly patients may require a holistic approach and dealing with the sources of pain, rather than a purely pharmacological approach. Finally, it is important to recognize when patients may be attempting to acquire prescription medications by "doctor shopping" and to utilize best judgment when making decisions as to when and/or how much to prescribe of any controlled substance with the potential for addiction. Table 2 summarizes the dental management of the elderly patient abusing drugs.
The elderly represent a large and continuously growing population group with multiple medical conditions and myriad medications. The abuse of drugs, both legal and illegal, is an absolutely real occurrence among elderly patients that has implications on their overall and oral health. Dentists must be careful to recognize patients who potentially may be abusing drugs and review their own protocols with respect to prescription of agents such as opioids or CNS depressants. Dental practitioners should ensure that the safety of their patients remains at the forefront of their concern and be prepared to work with other healthcare professionals to assist this population.
About the Authors
Kester F. Ng, BHSc, DDS
Private Practice, Huntsville, Ontario, Canada
Aviv Ouanounou, BSc, MSc, DDS
Assistant Professor, Department of Clinical Sciences,Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Private Practice, Toronto, Ontario, Canada
Queries to the author regarding this course may be submitted to firstname.lastname@example.org.
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