Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5538_Библиотеки_им_академика_М_И_Перельмана
.pdf
166 Substance Use in Older Adults
the past year, yet <1 in 10 adult smokers succeeds (U.S. Department of
Health and Human Services 2020). Smokers can and do quit smoking.
Since 2002, former smokers have outnumbered smokers (U.S. Department of Health and Human Services 2020). Older adult smokers with
higher levels of psychological distress and health problems may be
more motivated to quit smoking than those with fewer problems
(Sachs-Ericsson et al. 2009).
The first step in smoking cessation is identifying the older adults
who smoke. All patient interactions offer opportunities for tobacco use
screening, particularly when the interaction includes identifying a new
chronic illness. Older adults newly diagnosed with a stroke, cancer,
lung disease, heart disease, or diabetes mellitus may be 3.2 times more
likely to make a smoking cessation attempt than without such a diagnosis (Choi and DiNitto 2015). These interactions come at a time when the
olde
r adult is more susceptible to smoking cessation advice, resulting in
better smoking cessation outcomes (Quiñones et al. 2017).
Tobacco use screening and cessation advice are frequently implemented with patients already diagnosed with chronic illnesses or smoking-
lated cancer and less frequently recommended in patients without
re
chronic illness, resulting in missed opportunities (Jamal et al. 2012). These
opportunities represent a significant portion of health care interactions
with older adults (Choi and DiNitto 2015). Although 85% of older adult
current smokers diagnosed with smoking-related cancer recalled a health
care provider advising them to quit within the past year, the number is far
lower for older adults without chronic illness (51%) (Bailey et al. 2018).
Adults were more likely to receive smoking cessation advice if they reported two or more office visits in the past year (Huang et al. 2018; U.S.
Public Health Service 2000). Every clinical encounter should include a discussion on smoking cessation and its importance for health.
Tobacco use screening may be affected by patient gender, age, race,
and ethnicity (Cokkinides et al. 2008). Black and Hispanic smokers were
less likely than white smokers to be asked about tobacco use, to be advised to quit smoking, or to receive tobacco cessation interventions
when making a quit attempt (Cokkinides et al. 2008). English- or Spanish-speaking Hispanic patients report tobacco use screening less frequently and fewer smoking cessation medication prescriptions than
non-Hispanic white patients (Bailey et al. 2018). Without support or encouragement, researchers found that African American smokers are
less likely to quit tha
Regular screening for tobacco use is recommended at all clinical interactions (U.S. Public Health Service 2000). Tobacco screening tools are
often nonspecific to older adults and rely on social cues more com-
n white smokers (Kulak et al. 2016).
Tobacco Use Among Older Adults 167
Table 6–1. Screening and brief assessment of tobacco use
Screening:
“In the past 12 months, how often have you used any tobacco products?”
For any answer other than “never,” perform the Brief Assessment.
Brief Assessment: (score 1 for each “yes”)
“In the past 3 months, did you smoke a cigarette containing tobacco or use
any other nicotine delivery pr
tobacco)?”
“In the past 3 months, did you usually smoke more than 10 cigarettes or
vape, use an e-cigar
“In the past 3 months, did you usually smoke/use an e-cigarette, vape, or
chew to
Note. The TAPS tool includes the questions listed above regarding tobacco use. A score
of 2 or more on the Brief Assessment has sensitivity of 74% and specificity of 89% for
tobacco use disorder.
Source. McNeely et al. 2016.
bacco within 30 minutes after waking?”
ette, or chew tobacco more than 10 times each day?”
oduct (e.g., e-cigarette, vaping, or chewing
monly observed in younger populations. A brief screening tool may
still provide a good starting point from which clinicians can begin discussing the importance of smoking cessation (Han and Moore 2018).
The Tobacco, Alcohol,
Prescription Medication, and Other Substance
Use (TAPS) tool has been validated in primary care, although not specifically with older adults (Table 6–1) (McNeely et al. 2016; also available online for patients and clinicians: https://nida.nih.gov/taps2/).
The 5 A’s is a screening and brief intervention tool developed for tobacco use in primary care and useful for the assessment of older adults. See
Table 6–2 for the components of the 5 A’s. Brief advice to quit can increase
quitting by 1%–3%, making it more effective than sel
f-help (Stead et al.
2013). Although an intervention such as the 5 A’s takes less than 10 minutes, in actual practice, it is often shortened or skipped altogether (Stead et
al. 2013). In a briefer, 5-minute version, called “2 A’s and an R,” the physician asks, advises, and refers the patient for tobacco use disorder treatment,
typically a telephone counse
ling service (Schroeder and Morris 2010).
Studies show high rates of physicians asking about tobacco (>80%) but
much lower rates of all other interventions (<25%) (Tong et al. 2010). There
is evidence that tobacco screening occurs at reduced rates among racial and
ethnic minority groups and the uninsured (Jamal et al. 2012).
Three-fourths (75%) of older smokers report behavioral health conditions, including depression and anxiety (Strong et al. 2017). Tobacco
use is also associated with increase
d risk of suicide (Han et al. 2017).
Mental health screening must accompany tobacco use screening. The
168 Substance Use in Older Adults
Table 6–2. The 5 A’s
Ask about tobacco use Identify and document tobacco use status
(e.g., with TAPS; see Table 6–1).
Advise to quit Urge every older adult who uses tobacco to
quit:
“It is important that you qu
and I can help you.”
“A
s your doctor, I need you to know that
quitting smoking is the m
you can do to protect your health now and in
the future.”
Assess willingness to quit “Are you willing to give quitting a try?”
Assist in quit attempt For older adults willing to quit, help them with
the quit plan (e.g., setting a quit date). Use
evidence-based psychosocial and pharmacological interventions, as described in the
main text.
older adults not willing to quit, use moti-
For
vational interviewing strategies to explore
readines
tion to quit (see Table 6–3).
Arrange follow-up Schedule in-person, video, or telephone fol-
low-up within first week of quit date.
Note. The 2 A’s and an R intervention combines the “ask” and “advise” steps above
with “referring” the patient to resources such as a tobacco quitline.
Source. Schroeder and Morris 2010; adapted from Fiore et al. 2008.
s for change and enhance motiva-
it smoking now,
ost important thing
U.S. Preventive Services Task Force recommends annual lung cancer
screening using low-dose computed tomography for smokers ages 55–
80 (Krist et al. 2020).
We recommend that initial psychiatric assessments of older adults include screening for use of all substances, including nicotine. For the older
adult smoker
, pursue a gentle exploration of the rationale for continued
smoking, the patient’s understanding of the risks of continued smoking,
and identification of the patient’s experienced benefits of smoking. Armed
with this information, educate the patient on the benefits of tobacco cessation and offer support in the process, including pharmacologic intervention to assist the patient in cessation. If the patient is not ready to quit,
encourage them to consider cessation and assure them that you are ready
to help them when they are ready. It is important to regularly revisit tobacco cessation with these patients. Repeated discussions are associated
with increased successful smoking cessation, particularly after adverse
Tobacco Use Among Older Adults 169
events such as a hospitalization or new diagnosis of a chronic disease
(Doolan and Froelicher 2008; Keenan 2009; Westmaas et al. 2015).
For the patient ready to quit, provide resources and, if they choose,
pharmacologic sup
port, which we discuss next.
MANAGEMENT
Quitting smoking is beneficial at any age (Gellert et al. 2012). Nicotine
addiction is a chronic, relapsing condition, and successful cessation may
require repeated intervention and multiple attempts to quit (Fiore et al.
2008). Effective tobacco dependence treatments are available; every patient using tobacco should be offered at least one of these treatments
re et al. 2008). Tobacco dependence treatments are cost-effective rel-
(Fio
ative to other medical and disease prevention interventions (Fiore et al.
2008). Medica
and tobacco use cessation counseling sessions in 12 months (Medicare.gov 2022). Three types of counseling are effective: practical counseling, social support as part of treatment, and social support arranged
outside treatment (Fiore et
lationship between the intensity of tobacco dependence counseling and
its ef
fectiveness. A multimodal approach is most effective for successful
smoking cessation and sustained tobacco use abstinence in adults older
than 50. Combination therapy—most frequently, psychotherapy plus
nicotine replacement—is more effective than pharmacological or behavioral interventions alone (Chen and Wu 2015).
Older adults attempting to quit, and those who succeed, most often
use counseling with or without FDA-approved cessation medication.
Older adults are more likely to use nicotine replacement therapy than
other medications (Henley et al. 2019).
The American Society of Addiction Medicine (ASAM) developed an
gorithm for matching services, interventions, and treatment settings
al
to the problems, strengths, skills, and resources of each person with a
substance use disorder (Mee-Lee and Shulman 2020). An outpatient
treatment program run by addiction treatment professionals may be appropriate for stable and cooperative patients. These programs are typically 1–2 hours weekly and include group and individual counseling
and outpatient programs (Williams et al. 2016). A more intensive intervention involves smoking cessation counseling performed with a
knowledgeable health car
tual session for an average of 15 hours (Mottillo et al. 2009). Cessation
success correlates
re Part B (Medical Insurance) covers up to eight smoking
al. 2008). There is a strong dose-response re-
e professional in a group, individual, or vir-
with the number of completed counseling sessions.
170 Substance Use in Older Adults
Some with tobacco use disorder will meet criteria for a higher level
of care, but there are almost no intensive outpatient, residential, or inpatient programs in the United States (Williams et al. 2016). The Mayo
Clin
ic offers an intensive 5-day residential program providing pharmacotherapy and intensive counseling (insurance may not cover this program). Participants receive a detailed treatment and relapse prevention
and telephone follow-ups after discharge. Participants had higher
plan
6-month smoking abstinence rates compared with a similar cohort receiving only outpatient treatment (Hays et al. 2011). Hospitalized patients with tobacco use disorder benefit from intensive counseling that
begins during the hospitalization and continues with suppor
tacts for ≥ 1 month after discharge (Rigotti et al. 2012).
tive con-
Psychoeducation of Patients and Families
The Adult Use of Tobacco Survey (Orleans et al. 1994) revealed that half
of older smokers believe that smoking is not as much of a health risk as
being 20 pounds overweight. Older smokers underestimate the harms of
smoking and the benefits of quitting (Orleans et al. 1994). More than half
of tobacco users wrongly believe they can significantly decrease their
health risks if they cut their smoking in half (Vickerman et al. 2021).
Tobacco cessation discussions must address the reasons older adults
smoke, including smoking as s
control. Discuss cessation with the older adult during every encounter.
Brief intervention counseling discussions are more effective than simply
advising a patient to quit (Andrews et al. 2004). The 5 R’s (Table 6–3)
guide clinicians in tobacco cessation discussions and include engaging the
patient in conversations th
patient and others, the relevance of tobacco use to the patient’s current
health concerns, the risks of continuing tobacco use, and the roadblocks
interfering with cessation as well as the rewards or benefits of stopping tobacco use. This motivational intervention should be repeated at every encounter (Agency for Healthcare Research and Quality 2012).
ocialization, stress management, or weight
at examine the risk of tobacco exposure to the
Psychotherapeutic and Psychosocial
Interventions
Giving up a long-established habit can challenge a person’s ability to
manage stress, especially without a social support system. The older
adult’s self-concept significantly impacts the course of their tobacco
use. A strong identity as a smoker predicts lower rates of quit attempts
and higher rates of smoking relapse (Falomir-Pichastor et al. 2020).
Tobacco Use Among Older Adults 171
Table 6–3. The 5 R’s, for when patients are not yet ready to quit using
tobacco
Relevance: Encourage the patient to consider why quitting would be person-
ally relevant.
Risks: Ask the patient to identify potential negative consequences of tobacco
use.
Rewards:
Roadblocks: Ask the patient to identify barriers or impediments to quitting.
Repetition: The motivational intervention should be repeated every time an
unmotivated
have failed in previous quit attempts should be told that most people make
repeated quit attempts before they are successful.
Source. Agency for Healthcare Research and Quality 2012.
Ask the patient to identify potential benefits of stopping tobacco use.
patient has an interaction with a clinician. Tobacco users who
Greater tobacco dependence severity predicts a lower likelihood of
adopting a self-concept as an ex-smoker (Falomir-Pichastor et al. 2020).
Successful tobacco abstinence requires coping skills that help prevent relapse and manage stress, negative moods, and cravings. Coping
skills may include exercise, yoga, deep breathing, mindfulness, and
other personally meaningful activities (Andrews et al. 2004). Those reporting greater distress tolerance are more likely to quit successfully
(Schlam et al. 2020).
Personal stress management often requires adequate social support.
Smokers (relative
to nonsmokers) more often report feelings of loneliness, social isolation, and depression and are less likely to engage in
community and social activities with fami
ly or friends (Choi and DiNitto 2015; Philip et al. 2022). Older adult smokers are more likely to be
divorced and live alone than nonsmokers (Choi and DiNitto 2015). Living with a spouse or partner can provide social support that positively
influences t
obacco cessation (Honda 2005).
Although any behavioral intervention is beneficial, some evidence
suggests
that face-to-face support is more effective than phone support
alone in adults older than 50 (Chen and Wu 2015). Other psychosocial
interventions, including individually tailored self-help materials and
direct advice from a physician or nurse, provide moderate benefits in
increasing smoking cessation rates (Siu and U.S. Preventive Services
Task Force 2015). Self-help is the most frequently used but least effective
method of quitting (Centers for Disease Control and Prevention 2011).
Internet-based and electronic aids and interventions are associated
wit
h a higher likelihood of tobacco use cessation (Chen et al. 2012). In-
terventions may include interactive and noninteractive internet forums,
172 Substance Use in Older Adults
web-based smoking cessation programs, and internet-based counseling
or peer coaching through email and mobile telephone text messages
(Chen et al. 2012). As increasing numbers of older adults have gained
internet access and computer proficiency, internet-based cessation programs provide increased access to smoking cessation interventions.
Pharmacotherapy
Adding medications to counseling increases successful quitting compared with either counseling or medication alone (Williams et al. 2016).
macotherapy with or without behavioral counseling interventions
Phar
helps adults achieve smoking cessation (Krist et al. 2020). Despite consistent evidence demonstrating the efficacy of nicotine replacement
therapy, medications, or e-cigarettes, adult tobacco users remain confused about the relative risks of smoking, vaping, and the use of quit
medications (Vickerman et al. 2021). Drivers of continued abstinence include pharmacotherapy adherence, second-week abstinence, female
gender, and e
cessful adherence with medication requires regular contact and ongoing support (Brown and Bussell 2011).
The FDA has approved eight smoking cessation treatments (see Table
6–4). Nicotine patches, gum, and lozenges are available without a prescription (Stead et al. 2013). Nicotine nasal spray, nicotine inhaler, bupropion
, and varenicline require a prescription. As of January 2024, the
nicotine oral spray is not available in the United States, although it is available in Canada, Australia, and elsewhere. All eight FDA-approved treatments effectively manage tobacco withdrawal symptoms and are strongly
sociated with abstinence from tobacco (Fiore et al. 2008; Hartmann-
as
Boyce et al. 2018; Nides et al. 2020). The use of these treatments for up to
6 months is generally safe and well tolerated (Fiore et al. 2008).
Careful use of pharmacotherapy is advised for those with medical
contraindications or who smoke <
For older adults, physicians prescribe pharmacotherapy with the same
consideration used for any psychotropic: start low, go slow, and titrate
to effectiveness or intolerable side effects.
arlier experiences with abstinence (Hays et al. 2010). Suc-
10 cigarettes daily (Fiore et al. 2008).
Nicotine Replacement Therapy
All forms of nicotine replacement therapy (NRT) are more effective in
promoting abstinence than controls (placebo or no treatment) (Hartmann-Boyce et al. 2018). It is always safer to use NRT than tobacco
products. NRT is the most studied pharmacological treatment in older
adults, who may in fact have a higher response rate than younger adults
(Cawkwell et al. 2015).
Tobacco Use Among Older Adults 173
Table 6–4. Pharmacotherapy for smoking cessation
Drug class Medications Notes
Over-the-counter
NRT
Prescription NRT
Others Varenicline Most effective treatment; even more
Over-the-counter and prescription status refers to the United States, as of January 2024.
NRT=nicotine replacement therapy; SR=sustained release; XL=extended release.
Nicotine patch,
nicotine gum,
nicotine lozenge
Nicotine nasal
spray,
nicotine
oral spray,
nicotine inhaler
Bupropion Twice-daily SR version is FDA
People with heavier use of tobacco
or sever
may benefit from higher doses or
combination of NRT.
Note risk of skin irritation with
patch formulation in older
Start before quit date.
effect
combination with NRT.
Dosing is 0.5 mg qd for 3 days, then
0.5 mg bid for 3 days, then 1 mg
bid for 11 weeks.
Start 1 week before quit date.
approv
but once-daily XL version is likely
equivalent and may promote
adherence.
Dosing of SR version is 150 mg qd
for 3–7 days, then 150 mg bid.
Dosing of XL version is 150 mg qd
for 3–7 days, then 300 mg qd.
Contraindicated in people with
seiz
e withdrawal symptoms
adults.
ive when taken in
ed for smoking cessation,
ure disorders.
NRT is well tolerated; side effects of note include skin irritation from
patches (which could be of particular concern to older adults, who may
have thinner and more friable skin) and irritation to the inside of the
mouth from gum and tablets (Hartmann-Boyce et al. 2018). Chest pain
and palpitations are more common with NRT than controls, but overall
uncommon (2.5% vs. 1.4%) (Hartmann-Boyce et al. 2018).
Starting nicotine replacement before a person’s quit day is more effective than starting on the quit day itself. There is no distinct advantage
of one form of nicotine re
placement, although women may find inhalers more effective than men (Narayanan et al. 2009). All forms of replacement therapy—gum, lozenge, inhaler, or patch—offer similar quit
rates, but there may be some advantages for higher doses of gum or
patch (Lindson et al. 2019). The efficacy of 4 mg nicotine gum may be
174 Substance Use in Older Adults
greater than that of 2 mg. Similarly, nicotine patches with higher doses
of 21 or 25 mg are more effective in promoting tobacco use cessation
than lower doses; however, even higher doses of 42 or 45 mg may not
bring additional benefits (Lindson et al. 2019). High doses of NRT or
NRT combinations may be especially helpful for those with high levels
of tobacco use or history of severe withdrawal (Fiore et al. 2008).
Bupropion and Other Antidepressants
Bupropion for tobacco cessation has not been specifically studied in older
adults, but there is strong evidence demonstrating its evidence in adults in
general (Howes et al. 2020; Patnode et al. 2021). Bupropion is likely as effective as NRT, although the combination does not appear to be more effective than either one alone (Howes et al. 2020). The efficacy of bupropion
for tobacco cessation is not associat
bid psychiatric condition (Howes et al. 2020). Bupropion is well tolerated,
with insomnia being a common neuropsychiatric side effect, experienced
by 12% of people in one study (Anthenelli et al. 2016). It would seem that
bupropion would be an especially good choice for older adults with depression and tobacco use disorder, since bupropion could address both.
The sustained-release (SR) twice-daily formulation is FDA approved for tobacco cessation, typically starting at 150 mg once daily and
increasing
is likely bioequivalent and perhaps easier to adhere to, given its oncedaily dosing (Williams et al. 2021). Note that it is a strong cytochrome
P450 2D6 inhibitor, resulting in possible drug–drug interactions (Williams et al. 2021). Its use is contraindicated in people with a history of
se
izure disorders and bulimia nervosa (Williams et al. 2021).
There is some evidence supporting the use of nortriptyline as a second-line tobacco cessation treatment (Fiore et al. 2008; Howes et al.
2020). Nortriptyline is not approved by the FDA for tobacco cessation
and should be used with caution in older adults. There is no evidence
supporting the use of any other antidepressant for tobacco cessation
(Patnode et al. 2021).
to 150 mg twice daily. The extended-release (XL) formulation
ed with whether a person has a comor-
Varenicline
Varenicline is a partial agonist at nicotinic acetylcholine receptors in the
ventral tegmental area (Williams et al. 2021). In addition to preventing
nicotine withdrawal, varenicline diminishes the reward experienced
from tobacco use (Williams et al. 2021). Varenicline is more effective
than either NRT or bupropion for tobacco cessation, especially in
Tobacco Use Among Older Adults 175
women (Anthenelli et al. 2016; Patnode et al. 2021; Williams et al. 2021).
Varenicline in combination with NRT is more effective than varenicline
alone (Koegelenberg et al. 2014). While the efficacy of varenicline in
older adults has not been studied, it has been found to be safe and well
tolerated in older adults (Cawkwell et al. 2015). Previously, there had
been concern about depression and suicidal ideation with varenicline,
but the FDA removed the black box warning in 2016, citing evidence
that the risk was lower than previously suspected and acknowledging
that the benefits of quitting smoking outweigh those risks (U.S. Food
and Drug Administration 2016).
Varenicline is dosed at 0.5 mg once daily for 3 days, then 0.5 mg
twice dail
taken with meals to reduce the common side effect of nausea (Williams
et al. 2021). Ideally, it would be started 1 week before the planned quit
date.
y for 3 days, then 1 mg twice daily for 11 weeks. It should be
Electronic Cigarettes
E-cigarettes used alone or in combination with traditional cigarettes may
have less potential to produce dependence than traditional cigarettes and
thus are a potential aid in tobacco cessation (Shiffman and Sembower
2020). In conjunction with psychotherapy, e-cigarettes may help achieve
higher tobacco abstinence rates than counseling alone, although the benefit
may not be sustained over time (Eisenberg et al. 2020). However, the overall evidence supporting the use of e-cigarettes for smoking cessation is
mixed (P
role of e-cigarettes in tobacco cessation (Thomas et al. 2021).
atnode et al. 2021). More research is necessary to determine the
Recommendations Regarding Pharmacotherapy
Medications should be offered to all older adult smokers (except where
contraindicated; for example, smokeless tobacco users, light smokers,
or those with medical contraindications) (Fiore et al. 2008). Treatment
planning begins with an open dialogue exploring the risks and benefits
of the available treatments and the importance of treatment adherence
(Fiore et al. 2008). The patient who exercises autonomy in choosing their
treatment may be more likely to adhere to treatment and communicate
with the clinician if treatment is unsuccessful. Other factors influencing
treatment selection include insurance coverage, out-of-pocket costs,
likelihood of adherence, incidence of dental or skin conditions when
considering gum or the patch, and prior successful treatment with a
specific medication (Fiore et al. 2008). Clinicians should schedule regular follow-ups to monitor adherence, tolerability, and effectiveness.
Соседние файлы в папке Библиотека им академика М.И. Перельмана