Clinical Focus
Primary Psychiatry. 2005;12(1):32-40
Alcohol Use Disorders in the Elderly
Stephen Ross, MD
Focus Points
• Alcohol continues to be the most commonly abused substance in the
elderly, despite the fact that the prevalence of alcohol use disorders
(AUDs) declines with age.
• The elderly undergo physiological changes that increase their sensitivity
to alcohol and thus increase the deleterious effects of alcohol upon them.
This is true even in individuals who drink minimal amounts of alcohol
but experience adverse events when, for instance, alcohol use is combined
with certain medications.
• Psychosocial factors associated with aging, such as the loss of a spouse or
social networks, loneliness, isolation, and depression, contribute significantly as etiologic factors in the development of AUDs in the elderly.
• Since the vast majority of elderly individuals have regular contact with
physicians, there are ample opportunities to screen for AUDs. However,
many patients are not adequately screened due either to lack of training
on the part of physicians or bias that such disorders are not worth treating in this population.
• Treatment is effective across the spectrum of AUDs in the elderly.
Treatment philosophies should focus on communicating with these
patients in an empathic, respectful manner, with an emphasis on simple
and clear communications that take into account cognitive changes associated with aging, both normal and abnormal.
Abstract
Despite a growing body of literature indicating an increase in alcohol use disorders (AUDs) among the elderly, this group of patients has historically been ignored.
The elderly are a vulnerable group who suffer a disproportionate amount of physical
and psychosocial distress. Any alcohol use in this population, but especially excessive
use, poses unique problems biologically, psychologically, and socially. This article
will summarize the classification, prevalence, assessment, and treatment of AUDs in
the elderly, with an emphasis on the special needs and unique aspects of engaging
and treating this patient population.
Introduction
Alcohol use disorders (AUDs) encompass a spectrum of problems related to
alcohol use, ranging from mild misuse,
to abuse and dependence. Alcohol use
in the United States is most prevalent
in individuals 18–45 years of age and
declines with age.1 This decline in
overall use does not mean that the
problem becomes negligible. Among
individuals ≥55 years of age, alcohol is the most commonly abused
substance in patients admitted to
publicly funded substance abuse
treatment programs.2
AUDs are far more prevalent than any
other addictive disorder in elderly individuals, including the abuse of prescription drugs such as benzodiazepines.3,4
With adults ≥65 years of age becoming the fastest growing segment of the
population in the US, treatment for their
health-related issues, including problems
related to AUDs, poses a great challenge
both from financial and public health
perspectives. However, despite the growing number of individuals ≥65 years of
age suffering from AUDs, these disorders
remain under diagnosed and under treated leading some to call these disorders
part of an “invisible epidemic.”5
Aging induces physiological changes
that make the elderly more susceptible to
the deleterious effects of alcohol.6 Given
these changes, the National Institute on
Alcohol Abuse and Alcoholism (NIAAA)
have made the following recommendations in terms of age-appropriate drinking levels in individuals ≥65 years of
age: No more than one drink/day (with
one drink defined as 12 ounces of beer
at 5% alcohol, or five ounces of wine at
12% alcohol or a 1.5 ounce shot of hard
liquor at 40% alcohol), a maximum of two
drinks on any occasion, and even lower
limits for women.7 These limitations highlight how any alcohol use in the elderly
can potentially be problematic, even if it
does not cause an abuse or dependence
syndrome as defined by the Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV).8 One could
define alcohol misuse in the elderly as
any alcohol use, not necessarily heavy use
or meeting criteria for alcohol abuse or
dependence, that leads to either subjective distress, discrete adverse events, or
functional decline. Together, the spectrum
of AUDs in the elderly exacerbate their
already heightened risk for injury, disease,
and social/financial deterioration.9
Stephen Ross, MD, is clinical assistant professor of psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, at the New York
University School of Medicine in New York City.
Disclosure: The author does not have an affiliation with or financial interest in any commercial organization that might pose a conflict of interest.
Please direct all correspondence to: Stephen Ross, MD, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of
Medicine, 104 E. 40th Street, Suite 802, New York, NY 10016; Tel: 212-681-9790; E-mail: [email protected].
32
Primary Psychiatry © MBL Communications, January 2005
Alcohol Use Disorders in the Elderly
The first section of this article discusses the classification, prevalence,
and risk factors associated with AUDs
in the elderly. The second describes
how to do a comprehensive evaluation, including medical, psychiatric,
and psychosocial assessments. The last
section discusses comprehensive treatment and what factors are associated
with positive treatment outcomes.
Classification/Prevalence
Alcohol Misuse Disorders:
Potentially Risky, Risky, and Problem
Drinkers
Precise rates of AUDs in the elderly
vary because studies sample different
patient populations, such as the elderly
living in nursing homes or independently. Moreover, the exact definition
of alcohol misuse, and diagnostic criteria used, has varied from study to
study. Some experts on AUDs in the
elderly employ the model of “risky”
and “problem” alcohol use instead of
the DSM-IV model of alcohol abuse
and dependence, allowing for greater
specificity and flexibility in describing
the phenomenology of the spectrum
of alcohol use in this population.10 A
focus of some studies has been on risky
drinking, defined as heavy drinking
that does not result in progressive functional decline but can lead to discrete
negative consequences. Another focus
has been on problem drinking, defined
as heavy drinking which does result
in functional decline and which may
or may not reflect DSM-IV criteria for
either alcohol abuse or dependence.
As defined above, however, alcohol
misuse in the elderly population can
encompass any alcohol use, including non-heavy drinking, that may lead
to discrete negative consequences but
not necessarily to progressive functional decline. For the purposes of this
article, this is defined as “potentially
risky” drinking. Examples in individuals ≥65 years of age commonly occur
when any alcohol use is combined
with certain medical conditions (ie,
Alzheimer’s dementia, diabetes, hypertension,) or with certain medications,
both prescription (ie, benzodiazepines,)
or over-the-counter (ie, non steroidal
anti-inflammatory drugs), leading to
adverse events (ie, falls, gastrointestinal
bleeding, hypoglycemia). It is difficult
to know the true prevalence of potentially risky drinking in the elderly since
little research has been devoted to this
subgroup of individuals with AUDs. In
contrast, more research has been devoted to risky and problem elderly drinkers. However, given the lack of uniform
criteria, community prevalence rates of
risky drinking reported in the elderly
range from 3% to 25%, and the rates
for problem drinking vary from 2.2%
to 9.6% depending on the sample and
measures used.11 The large differences
in these studies underscore the difficulty in precisely identifying and describing the scope of these disorders.
Alcohol Abuse and Dependence
In contrast to risky or problem drinking, the community prevalence rates
for alcohol dependence are significantly lower, with household surveys
revealing only approximately 2% to
3% of elderly men and <1% of elderly
women suffering from this disorder.12
Classification of Problem
Drinking in the Elderly
One group of elderly patients with
problem drinking patterns has been
classified as the early-onset group.
These patients have longstanding alcohol problems that usually begin in
their 20s or 30s. This subgroup comprises approximately two thirds of
older patients with problem drinking.13
Early-onset drinkers tend to continue
maladaptive drinking patterns as they
age. Psychiatric comorbidity tends
to be the norm in this group, with
major affective disorders and thought
disorders being the most common.
Moreover, this group tends to have
severe medical complications secondary to chronic heavy alcohol use.14-16
A second subgroup, late-onset drinkers, comprise approximately one third
of elderly problem drinkers. They tend
to be physically and psychologically
healthier than early problem onset
drinkers. Moreover, they tend to have
less alcoholism among family members, are of a higher socioeconomic
status, have less psychopathology, and
less alcohol-related chronic illness.
Significantly, their drinking problems
tend to begin in response to a recent
loss, such as the death of a spouse.17
Despite their differences, these groups
are similar in that they can both benefit
from treatment. Even though late-onset
problem drinkers have a more favorable psychological and physical pro-
file and tend to resolve their drinking
problems more often without formal
treatment, there is little evidence to
suggest that they are more responsive
to alcohol treatment than patients who
are early-onset drinkers.18
Risk Factors for AUDs
Physiological Factors
The elderly experience physiological
and biological changes that increase
their sensitivity to alcohol and decrease
their tolerance for alcohol (Table 1). As a
result of aging, there is a decrease in lean
body mass, with a concomitant increase
in body fat and a decrease in total body
water. Since alcohol is water soluble, the
concentration of ingested alcohol will be
greater in an older person. The elderly
also have lowered levels of alcohol dehydrogenase in the gastric mucosa, leading to a delay in metabolizing alcohol,
with serum levels remaining elevated
for longer periods of time. Given these
physiologic changes, smaller amounts of
alcohol intake in the elderly, relative to a
younger cohort of individuals, produce
greater intoxication and toxicity.6
Gender
Older women drink less often and
are less likely to drink heavily compared to older men.19 However, women
Table 1
Risk Factors for AUDs
Physiological
• Decreased total body water and
decreased levels of gastric alcohol
dehydrogenase
Gender
• Older men at higher risk
Family History of AUDs
Prior History of an AUD
Psychiatric Comorbidity
• Major Depression, anxiety/cognitive
spectrum disorders
Chronic Medical Illness
• Especially causing chronic pain and
insomnia
Social Factors
• Loss of spouse/income/mobility/independence, substance-abusing family members, poor support network
Medications that can adversely interact with alcohol (See Table 3)
AUDs=alcohol use disorders.
Ross S. Primary Psychiatry. Vol 12, No 1. 2005
Primary Psychiatry © MBL Communications, January 2005
33
S. Ross
are more likely than men to start drinking heavily later in life.20 Older men
are at much higher risk of developing
alcohol-related problems compared to
older women.21,22
Family History
Having a family history of AUDs or
genetic predisposition is a well-known
risk factor for development of AUDs
throughout one’s lifespan.23
Previous History of an AUD
There is also a strong correlation
between having a history of an AUD
and the recurrence of the problem
later in life, often in response to a
major loss, with relapse possible even
after many years of abstinence.17
Psychiatric Comorbidity
Psychiatric comorbidity is another
well-known risk factor in elderly patients
who develop AUDs. Approximately 25%
of elderly patients with AUDs have
comorbid major depression. There
is evidence that comorbid mood disorders, especially major depression,
either precipitate or maintain AUDs
in late-onset problem drinkers, particularly women.24,14 Other disorders
that are common in this population
are cognitive spectrum disorders and
anxiety spectrum disorders, both of
which co-occur in 10% to15% of elderly
individuals with AUDs.12
Medical Illness
Chronic medical illness predisposes
the elderly to AUDs as well. Elderly
patients who develop late-onset problem drinking, or who relapse after having early problem drinking, often do
so to medicate uncomfortable physical
states brought on by the myriad of medical problems that commonly affect the
elderly. In particular, chronic pain syndromes and insomnia are linked to the
initiation and/or maintenance of AUDs
in the elderly.5
Social Factors
Social factors also play an important
role in the initiation of AUDs in the
elderly. For many, the aging process is a
difficult experience filled will loss, physical and psychological deterioration,
shame, and humiliation. Many become
isolated and lonely, cut off from their
normal support network of family and
friends. Other significant losses include
34
the loss of one’s occupation/income,
loss of mobility, and loss of independence in general. Alcohol, for certain
individuals, can become a means to
cope with stressful events, albeit one
that can cause further problems. In one
prospective study comparing late-onset
problem drinkers with non-problem
stable drinkers, the problem drinkers
were more likely to have a history of
responding to stressors and negative
affective states with increased alcohol
use.25 Moreover, AUDs are most prevalent in elderly patients who have been
divorced or separated and in men who
have been widowed.5 In fact, the highest
rate of completed suicide in all groups
is in elderly caucasian men who drink
heavily and suffer from depression in
the context of the death of a spouse.26
Finally, it is important to assess for
spouses of family members who are
actively misusing alcohol or other substances, as this too increases the risk of
developing or maintaining an AUD.12
Comprehensive Evaluation
Screening
Given that approximately 87% of
elderly patients regularly see a physician, the primary care setting remains
the best place to screen for such AUDs.5
Other potential sources of screening
include friends, family members, home
health aids, meal delivery personnel, and
staff members at senior citizen centers,
social clubs, health fairs, and nursing
homes. However, since only approximately 5% of individuals ≥65 years of
age live in nursing homes, trained staff
in this setting is only one limited way to
screen for AUDs in these patients.
Despite the regular contact with primary care physicians, only a minority
of elderly patients will directly seek help
from their doctors for their alcoholrelated problems.27 This may be due in
part to intense shame and fear of being
judged. Compounding this lack of selfreferral, it is unlikely that physicians
will identify an AUD despite frequent
contact with these patients. This may
be due partly to inadequate training.
Another partial cause could be physician bias, where physicians erroneously
or prejudicially assume that AUDs in
this population are not worth identifying because they cannot be treated successfully, or that it is not worth devoting time and energy to patients who
are toward the end of their life span.5
Primary Psychiatry © MBL Communications, January 2005
In addition, AUDs in the elderly tend
to present with symptoms mimicking
those of other common illnesses in this
population, such as major depression,
dementia, and hypertension.
Experts who work with elderly
patients with AUDs have noted that
since these individuals are often acutely sensitive to the stigma of having an
AUD, it is important to ask screening
questions in an empathic, nonjudgmental manner. The use of stigmatizing words such as alcoholic should be
avoided. Getting collateral information
from family members, friends, and
other healthcare providers is essential,
given that the history from the patient
may be limited by such factors as
shame, denial, or memory impairment
due to either primary cognitive disorders or alcohol misuse.
Screening Methods and Instruments
Quantity/Frequency: Potentially
Risky and Risky Drinking
Initially, the evaluating clinician
should ask about quantity, frequency,
and patterns of alcohol use. Doing so is
important in order to identify any alcohol use that may be part of potentially
risky drinking. This approach is also
best at identifying risky drinkers who
are misusing alcohol. These patients
tend to display less denial and minimization regarding the amount of alcohol they use and any alcohol-related
problems, compared to patients who
have a greater severity of adverse consequences such as those with alcohol
dependence.28 Specifically, clinicians
in either a primary care or psychiatric setting can ask how many days a
week the individual drinks alcohol,
the number of drinks consumed in a
typical day, and the maximum number
of drinks consumed on any given occasion in the previous month (Table 2).
Problem Drinkers and Alcohol Abuse
or Dependence Syndromes
If the goal is to identify problem drinkers or those with alcohol abuse or dependence, after this initial screen, the use of
formal, standardized screening measures
is more appropriate.29 Three screening
instruments commonly used in this population are the CAGE questionnaire,30
the Michigan Alcoholism Screening TestGeriatric Version (MAST-G; Table 3),31 and
the Alcohol Use Disorders Identification
Test (AUDIT).32 The CAGE questions
are as follows: Have you ever felt you
Alcohol Use Disorders in the Elderly
ought to Cut down on your drinking?
Have people Annoyed you by criticizing
your drinking? Have you ever felt bad or
Guilty about your drinking? Have you
ever had a drink first thing in the morning (Eye opener) to steady your nerves or
get rid of a hangover? The CAGE is commonly used in primary care settings and
is highly sensitive and specific in identifying alcohol-related problems, especially
related to more severe AUDs. Two or
more positive responses are considered
indicative of probable alcohol abuse or
dependence, and even one affirmative
response should be followed up.33 This
is especially true of elderly individuals
given their increased sensitivity to the
adverse effects of alcohol. The MAST-G
was specifically designed for the elderly
patient and is both highly sensitive and
specific in detecting AUDs in this population across a variety of screening settings.34,35 The AUDIT was developed by
the World Health Organization to identify individuals whose alcohol use has
become harmful or hazardous to their
health. It can be used in multiple settings,
including primary care and psychiatric
clinics. It is a 10 item screening questionnaire that can identify risky or problem
drinkers, or those with alcohol abuse or
dependence. The length of the AUDIT
may limit its use as compared to the
CAGE, but its first three items have been
helpful in identifying risky drinkers.36
Evaluation of Motivational Stages of
Change
It is vital to assess how motivated any
patient with an AUD is for a change in
drinking behavior, even patients on the
lowest end of the severity spectrum, who
drink minimally, but suffer adverse consequences. The transtheoretical model
of change, as developed by Prochaska
and DiClemente,37 describes the following stages of change: Precontemplation,
Contemplation, Preparation, Action and
Maintenance. Precontemplation is the
stage marked by denial, where an individual is not considering any need to change
their drinking behavior. Contemplation
is characterized by ambivalence, where
one is increasingly aware of the negative consequences of alcohol use. In the
Preparation stage, the individual believes
that change is needed but has not made
any attempts yet. In Action, initial and
persistent attempts at change occur.
Finally, Maintenance involves the retention of the changes made.
Table 2
Screening for AUDs in the Elderly in the Primary Care Setting
When?
• Initial evaluations, annual visits, routine visits, follow-up visits
• Before prescribing a medication that could adversely interact with any alcohol
use or in patients already taking such medications
Who?
Every patient, especially those with risk factors (See Table 1) and particularly those with:
• Health problems that could be adversely affected by any alcohol use
• Functional impairment: Impaired ADLs/IADLS and/or social/family/legal problems
• Medical problems suggestive of heavy alcohol use (ie, new onset or poorly
controlled HTN, gastrointestinal problems, recurrent accidents/injuries/falls)
• Physical examination findings suggestive of heavy alcohol use (ie, physical stigmata
of alcoholic cirrhosis)
• Laboratory findings suggestive of heavy alcohol use (ie, elevated MCH, GGT)
• Mental status exam abnormalities, especially dysphoric or anxious affect, or
cognitive deficits
Initial screening (quantity/frequency): Potentially Risky and Risky Drinkers
• Amount per day, number of days per week, maximum number of drinks per
occasion over the past month
• If patient admits to using alcohol in the initial screening questions, administer the:
CAGE, MAST-G, or AUDIT to assess for more severe AUDs (problem drinking, alcohol abuse, or alcohol dependence)
For all patients found to have any AUD, assess for their motivational stage
AUDs=alcohol use disorders; ADLs=activities of daily living; IADLs=instrumental activities of daily living;
HTN=hypertension; MCH=mean corpuscular hemoglobin; GGT=γ-glutamyltransferase; MAST-G=Michigan
Alcoholism Screening Test-GeriatricVersion; AUDIT=Alcohol Use Disorders Identification Test.
Ross S. Primary Psychiatry. Vol 12, No 1. 2005
Functional Evaluation
In addition to screening for the presence of an AUD in an elderly patient,
it is important to evaluate the level of
functional impairment caused by the use
of alcohol. The elderly tend to have functional problems that are different from
their younger counterparts. For example,
instead of poor work performance as a
result of alcohol misuse, their inability to
shop for themselves may be more pertinent. In general, functional health assessment refers to an individual’s capacity to perform activities of daily living
(ADLs), which include walking, dressing,
bathing, and feeding oneself, and instrumental activities of daily living (IADLs),
which include higher cognitive functions
such as managing finances, shopping,
meal preparation, and medication compliance. Alcohol use in the elderly can
compromise both ADLs and IADLs. In
Table 3
Short Michigan Alcoholism Screening
Test-Geriatric Version (SMAST-G)
In the past year:
1. When talking with others, do you
underestimate how much you
actually drink?
2. After a few drinks, have you sometimes not eaten or have been able
to skip a meal because you did not
feel hungry?
3. Does having a few drinks help
decrease your shakiness or tremors?
4. Does alcohol sometimes make it
hard for you to remember parts of
the day or night?
5. Do you usually take a drink to relax
or calm your nerves?
6. Do you drink to take your mind off
your problems?
7. Have you ever increased your drinking
after experiencing a loss in your life?
8. Has a doctor or nurse ever said they
were worried or concerned about
your drinking?
9. Have you ever made rules to manage
your drinking?
10. When you feel lonely, does having
a drink help?
Three or more positive responses is
indicative of a recent or current alcohol
use problem.
Reprinted from: Blow FC. Michigan Alcoholism
Screening Test—Geriatric Version (MAST-G). Ann
Arbor, Michigan; University of Michigan Alcohol
Research Center: 1991.
Ross S. Primary Psychiatry. Vol 12, No 1. 2005
Primary Psychiatry © MBL Communications, January 2005
35
S. Ross
one study, alcohol use was more strongly
associated with functional impairment
than age, smoking, use of anxiolytics, or
a history of stroke.38
ture of these two agents, especially in
older women, often results in negative
outcomes, including falls, accidents, and
cognitive decline.40 (Table 4)
to frank dementia. Any alcohol can
exacerbate cognitive impairments in
the elderly, ranging from mild memory
impairment to dementias.
Medical Evaluation
Physical Examination/Laboratory
Measures
A thorough physical examination
along with laboratory analysis should
be performed on all elderly patients suspected of having an AUD. On physical
exam, findings such as hypertension,
the stigmata of alcoholic cirrhosis, and
ataxia due to cerebellar damage are
suggestive of an AUD, especially the
more severe types. Several laboratory
findings are suggestive of an AUD. In
one study looking at patients ≥65 years
of age, the most common abnormal
laboratory values were increased mean
corpuscular hemoglobin (MCH; 71%),
increased aspartate aminotransferase
(AST; 56%), increased γ-glutamyltransferase (GGT; 55%), and increased mean
corpuscular volume (MCV; 44%). Other
notable blood value increases were uric
acid at 21% and triglycerides at 16%.39
Medical Review of Systems
A complete medical review of systems
is essential as many medical problems
in the elderly can either be caused or
worsened by alcohol misuse, prompting one to search for alcohol as a
potential etiologic source. A list of common problems, although by no means
exhaustive, includes cardiac problems
(hypertension, arrhythmias, and cardiomyopathy); liver damage (including fatty liver, alcoholic hepatitis, and
cirrhosis); gastrointestinal problems
(such as gastritis, esophagitis, esophageal varices, and hemorrhage); immune
system impairment; malnutrition; and
endocrinological problems including
decreased bone density.
Alcohol-Medication Interactions
Alcohol has drug-drug interactions with a variety of medications.
It is important to know of the potential adverse interactions between alcohol and common medications used by
elderly patients which can occur even
in patients who drink minimally (ie,
potentially risky drinking). Of particular concern in the elderly is the use of
alcohol with benzodiazepines, especially
those with longer half-lives (ie, diazepam, clonazepam) used to medicate
such common problems in the elderly,
such as insomnia and anxiety. The mix-
Psychiatric and Neurological
Evaluation
A thorough psychiatric evaluation is
warranted in all elderly patients presenting with an AUD. As mentioned
previously, major depression is the
most common comorbid disorder in
elderly patients with AUDs, followed
by anxiety and cognitive spectrum
disorders. Depressive or anxiety symptoms can either be caused or exacerbated by alcohol. Taking a careful
history helps to determine whether
the depressive or anxiety symptoms
pre or postdate the drinking problem.
If it is definitely determined that the
depressive or anxious symptoms were
solely due to alcohol use and quickly
remit with abstinence, then psychotropic intervention is not warranted.
However, often it is difficult to determine which condition came first, and
ultimately treatment is indicated if
symptoms cause significant impairment and/or if they persist.
A complete psychiatric evaluation
should include a review of concomitant
substance misuse in addition to alcohol.
Other than alcohol, the most commonly
misused substances by the elderly are
nicotine and psychoactive prescription
medications (ie, benzodiazepines).41 The
abuse of illicit drugs in the elderly, such
as marijuana, cocaine, or heroin, is a
rare phenomenon except in those who
abused them previously.4,21
A thorough evaluation should
assess for sleep problems. The following sleep changes that normally
occur with age and lead to insomnia
are worsened by the use of alcohol: increased episodes of rapid eye
movement (REM) sleep, decreased
REM length, decreased stage III and
IV sleep, and increased awakenings.42
Disruptions in sleep can exacerbate
other psychiatric conditions in the
elderly, especially mood disorders.
A full neurological work-up is warranted, as patients with a history of
heavy alcohol use can display a spectrum of cognitive impairment from
subtle deficits in memory, visual-spatial skills, abstraction, and problem
solving, to alcohol amnestic disorders
(ie, Wernicke-Korsakoff’s syndrome),
Social Evaluation
A complete social evaluation is vital
given that social risk factors play a role
in the initiation and maintenance of
AUDs in the elderly. It is important to
evaluate the patient’s social network and
identify which members are supportive
of treatment and which are potentially hazardous to the patient. Harmful
network members include active substance abusers, those who “enable” the
patient’s alcohol misuse, and those who
abuse the patient physically, sexually, or
emotionally. Since abuse in the elderly
is not infrequent given their vulnerabilities, this is a vital area to be discussed
with patients. In addition, the evaluation should make sure the patient has
adequate housing and access to food.
Mobility, adequate transportation, and
access to medical care must also be
assessed and considered.
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Primary Psychiatry © MBL Communications, January 2005
Table 4
Common Alcohol–Medication Adverse
Interactions
• Alcohol—benzodizepines: falls, injuries, accidents, cognitive deficits
ranging from amnesia to dementia
• Alcohol—medications that inhibit
acetaldehyde dehydrogenase causing the alcohol-disulfiram reaction
Examples: metronidazole, sulfonylureas (especially chlorpropamide),
isoniazid
• Alcohol—medications that cause gastrointestinal problems such as gastritis
and hemorrhage
Examples: non steroidal anti-inflammatory drugs, aspirin
• Alcohol—medications for diabetes
mellitus causing prolonged hypoglycemia due to inhibition of hepatic
gluconeogenesis
Examples: sulfonylureas and insulin
• Alcohol—coumadin: increases the
risk of bleeding by altering coumadin’s anti-coagulation efficacy
• Alcohol—cimetidine:
cimetidine
inhibits gastric alcohol dehydrogenase, already lowered in the elderly,
leading to more rapid rises in blood
alcohol levels causing greater intoxication and toxicity.
Ross S. Primary Psychiatry. Vol 12, No 1. 2005
Alcohol Use Disorders in the Elderly
Treatment
Engagement
Several experts who work with
elderly patients with AUDs believe it is
important to understand the specific
ways to engage them.5 It is imperative to be empathic, respectful, and
straightforward, with attention given
to simple and clear communications
geared toward the elderly patient’s
slower informational processing abilities. Confrontational approaches, common in substance abuse treatment,
are rarely helpful. Instead, “gentle persuasion” is a more effective approach.
It is also important to keep in mind
what motivates elderly patients, and
what are the germane, age-appropriate issues they care about. Examples
include financial stability, independent functioning, access to medical care, physical well-being, pain
management, and social interaction.
This awareness allows for greater
empathic attunement with the patient
and a stronger therapeutic alliance.
Another way of increasing engagement
with the patient is to involve a broad
social network in the patient’s treatment plan, including family members,
friends, visiting nurses, social workers,
primary care physicians, or religious
members (Table 5).
General Goals of Treatment
The first goal of treatment is to
promote a change in drinking behavior either via use reduction or abstinence, depending on the severity of
the AUD and the motivational stage of
the patient. Use reduction falls under
the general category of “harm reduction,” which aims to diminish the
harm caused by alcohol use. Examples
range from getting potentially risky
drinkers with dementia who refuse
total abstinence to drink even less than
the age-appropriate drinking levels in
individuals ≥65 years of age, or getting patients with alcohol dependence,
also refusing abstinence, to agree not
to use alcohol in the most potentially
hazardous situations, such as drinking and driving. For those patients
who are able to achieve abstinence,
relapse-prevention techniques become
vital to maintain sobriety. Second, it is
important to treat comorbid medical,
psychiatric, or neurologic conditions
that may either be exacerbated by
or contribute to the development of
AUDs. The next goal is to address psychological factors that promote AUDs
in the elderly, such as issues of loss,
loneliness, or problems with relationships. Finally, it is vital to address
social factors that promulgate AUDs,
Table 5
Treatment Planning
Engagement/Treatment philosophy
• Avoid confrontational approaches if possible. Use “gentle persuasion”
• Communicate with empathy in a straightforward, simple manner
• Pay attention to what is important to patients and what motivates them
• Involve family members or other social support individuals whenever possible
Treatment
• Matched to severity of AUD
• Brief interventions for “potentially risky” and “risky” drinkers in primary care setting as well as serial follow-up assessments of alcohol-related problems
• More formal treatment in specialized programs for “problem” drinkers or those
with alcohol abuse or dependence
• Assess for the need for outpatient or inpatient detoxification
• Tailored to motivational stage of the patient: abstinence-oriented treatment versus
harm reduction. Motivational interviewing used to increase motivation for change
• Importance of treating comorbid conditions: medical or psychiatric
• Psychosocial modalities: motivational interviewing, supportive psychotherapy,
relapse prevention and other cognitive-behavioral interventions, family/marital
therapy, group therapy including AA, and community outreach services
• Pharmacologic interventions for alcohol dependence: naltrexone, acamprosate,
and possibly ondansetron/mirtazapine and/or anti-convulsants (ie, topiramate).
• Avoid the use of disulfiram in the elderly
AUD=alcohol use disorder; AA=Alcoholics Anonymous.
Ross S. Primary Psychiatry. Vol 12, No 1. 2005
for example, the lack of a support network and inadequate access to food,
shelter, or medical care.
Treatment Settings
Potentially Risky and Risky Drinking
There are a range of therapeutic settings used to treat elderly patients with
AUDs varying in types of treatment and
level of intensity of treatment services.
The least intensive approaches occur in
primary medical or psychiatric outpatient settings that are not designed to
provide specialized alcohol treatment
services. Such approaches tend to be
helpful for patients with less severe
forms of AUDs. Brief interventions for
potentially risky or risky drinkers are
commonly used in these settings. This
treatment modality is supportive, time
limited, and requires minimal training
to administer. In addition to trained
physicians, home health aides, case
managers, social workers, nurses, and
physicians’ assistants can use this type
of intervention. Examples of brief interventions include psychoeducation about
the risks of any alcohol use combined
with certain medications or excessive
alcohol use, direct feedback on adverse
behavior when drinking, and expression
of empathy. Other examples include
relating reasons for cutting down or
quitting, emphasis on the patient’s ability to change their behavior, and advice
to effectuate a change in drinking behavior by several methods such as setting
goals, contracting, and behavior-modification planning. A number of clinical
trials have shown that approximately
10% to 30% of problem drinkers have
been able to reduce their alcohol intake
in brief interventions lasting from one to
three sessions.43,44
Follow-up is also vital in these
patients, especially those who remain
in the pre contemplative or contemplative stages of change. Given that so
many patients regularly follow-up with
their primary care physicians, these
doctors need to continue to ask about
alcohol use during every visit, continue
to assess for adverse events, and continue to encourage and advise patients
on changing their drinking behavior.
Problem Drinkers and Alcohol Abuse
or Dependence Syndromes
Elderly patients with more moderate-to-severe AUDs should be treated
by specialized addiction providers
(ie, psychiatrists, psychologists, nurse
Primary Psychiatry © MBL Communications, January 2005
37
S. Ross
practitioners, or social workers) in
either a private practice setting or a
formal specialized alcohol treatment
program. Treatment intensity in this
setting ranges from treatment once
a week in an outpatient program, to
encounters several times a week in
intensive outpatient programs, to daily
contact in day programs. Treatment
can include pharmacotherapeutic
interventions such as outpatient detoxification, medications that reduce
cravings (i.e. naltrexone), and psychosocial interventions such as individual,
group, and family therapy.
Inpatient programs are reserved for
the most extreme cases. They include
inpatient detoxification programs, inpatient rehabilitation programs, inpatient
dual diagnosis units, and long-term
residential programs. Inpatient detoxification programs are suitable for elderly patients who are at high risk for
severe withdrawal symptoms or who
have failed all outpatient modalities.
Following detoxification, these patients
are often transferred to inpatient rehabilitation programs, or alternatively, some
programs provide both services in the
same setting. Patients with severe medical problems are often admitted to acute
inpatient medical settings. Patients with
severe comorbid psychiatric problems
often need admission to an inpatient dual
diagnosis unit, usually for behavior that
poses a danger to themselves or others.
Long-term residential programs or nursing homes are needed for patients with,
for example, comorbid chronic, severe,
persistent mental illness, and/or chronic,
severe medical illnesses, or patients with
severe, non-remitting drinking behavior
along with comorbid dementia.
Treatment Philosophy
Irrespective of treatment setting, programs that treat elderly patients with
AUDs should possess several unique
components and be guided by certain
fundamental treatment principles.24,45
Supportive,
non
confrontational
approaches are preferable, with the goal
of enhancing the patient’s self-esteem.
The establishment, or re-establishment,
of a patient’s support network is important to make the patient feel more connected to others and to promote use
reduction or abstinence. The pace of the
treatment must be adjusted to reflect
cognitive changes associated with aging,
or to account for either primary cognitive disorders or ones secondary to alco38
hol use. Furthermore, the intensity and
frequency of contact in any particular
treatment setting should be individualized to match the patient’s needs and
motivational stage, and to reflect the
severity of their AUD and other co-morbid conditions. There should be a focus,
especially in relapse prevention, on
dealing with depression, physical pain,
loneliness, and loss, as these are potential alcohol-use triggers in this patient
population. It is crucial in any setting to
have staff members who have training
and interest in working with this patient
population. Finally, any treatment setting or program has to have direct access
or the referral capacity for consultation
services, including medical, psychiatric,
and case management services.
Treatment Modalities
Treatment planning needs to be comprehensive and include a wide range
of clinical interventions ranging from
psychosocial to psychopharmacologic
modalities (Table 5).
Psychosocial Modalities
For all elderly patients with AUDs
who display prominent denial or ambivalence about the need for a change in
their drinking habits, including those
with potentially risky or risky drinking, motivational interviewing (MI) is
a useful technique.46 MI is a non confrontational, client-centered treatment
that is well-suited for elderly patients in
the precontemplative or contemplative
stages of change with the goal of moving the patient along the motivational continuum. Aspects of MI include
expression of empathy, working with
ambivalence, assessing a patient’s readiness for change, assessing strengths
and barriers to change, eliciting motivational responses, and placing the
responsibility of change directly with
the patient. MI has many aspects in
common with brief interventions used
in potentially risky and risky drinkers
as described above. However, unlike MI,
brief interventions give direct advice to
change behavior and provide a menu of
options to effectuate change.
Supportive psychotherapy can also
be effective with elderly patients
across the spectrum of AUDs. The
focus is for the therapist to improve
the patient’s adaptive functioning by
being open, directive, and empathic.
A particular focus is to listen for
themes of loss, grief, and sadness.
Primary Psychiatry © MBL Communications, January 2005
Relapse prevention, another psychotherapeutic modality, can be particularly
useful especially for patients with more
moderate to severe AUDs who are struggling to remain abstinent. Relapse prevention is a type of cognitive-behavioral
therapy (CBT) based on social learning
theory, with the premise that abstinent
patients experience internal and external cues that initiate craving that leads
to lapses (ie, slips) or relapses.47 This
therapy strives to help the patient identify triggers, cope with cravings, and
manage high-risk situations.
Complementing individual psychotherapy, group psychotherapy is a
commonly used treatment modality
across all age groups and has been
described by some as “the treatment
of choice for chemical dependency.”48
Having an aged-matched cohort of
peers provides mutual support, allows
for peer bonding, and fosters the establishment of peer sobriety networks.
Alcoholics Anonymous (AA) is a good
example of this for patients with alcohol dependence, especially when meetings include mostly elderly patients.
Moreover, psychoeducational and
CBT-oriented groups such as relapse
prevention groups are also commonly
used in most specialized addiction
treatment settings.
Whenever possible, family therapy
should be made available. Involving
family members is useful as a way to
strengthen the patient’s support network
and as a means to promote abstinence.
For patients who are married, marital
therapy may be indicated as well.
Community outreach services are particularly important for this patient population. Many are widowed, divorced, or
single and live alone with little outside
contact. As such, they benefit tremendously from services including assertive case
management; home health aides; meal
delivery programs; and transportation
to and from appointments, AA meetings,
or social clubs.
Psychopharmacologic Modalities
It is important to treat psychiatric
comorbidity, including major depression, anxiety spectrum disorders,
bipolar disorders, and psychotic spectrum disorders, across the spectrum of
AUDs in the elderly. Untreated, these
comorbid conditions can worsen the
course and severity of the patient’s
AUD, even those on the less severe side
of the spectrum.
Alcohol Use Disorders in the Elderly
Psychopharmacologic Treatment
for Elderly Patients with Alcohol
Dependence
There are medications targeted to
reduce alcohol use or promote abstinence in patients with alcohol dependence. Disulfiram is an acetaldehyde
dehydrogenase inhibitor that causes
an aversive reaction when taken with
alcohol. Use of this agent is limited in the elderly due to their higher
risk for adverse cardiovascular events
caused by acetaldehyde toxicity and
disulfiram induced hepatic toxicity.
Naltrexone is a long-acting opiate
antagonist that appears safe and effective in the elderly. It has been reported
to decrease craving, increase the time
to first drink, and increase the time
to heavy drinking once patients with
alcohol dependence have their first
drink.49 Side effects are usually mild,
and include nausea, headaches, anxiety, and in rare cases, liver damage.
Acamprosate, which is thought to act
as a glutaminergic-system stabilizer,
has shown promise as an anti-craving
agent in patients with alcohol dependence. Used in Europe since 1989,
it has just been approved for use in
the US and will be available in early
2005. Patients treated with acamprosate exhibited a significantly greater
rate of treatment completion, time
to first drink, abstinence rate, and/
or cumulative abstinence duration
compared to placebo.50 Ondansetron
which is a 5-HT3 receptor antagonist
has been shown to decrease alcohol
use in early-onset alcohol-dependent
patients.51 This has suggested the possible utility of mirtazapine, which has
5-HT3 receptor antagonism as well,
in patients with alcohol dependence,
especially with comorbid depressive or anxiety spectrum disorders.
Finally, anticonvulsants have been
studied for use in alcohol dependence
as anti-craving agents. A recent randomized, placebo-controlled study
with oral topiramate for the treatment of alcohol dependence found
that, compared to placebo, patients
treated with topiramate reported
fewer drinks per day, fewer heavy
drinking days, more total time abstinent, and less craving for alcohol.52
However, topiramate should be used
with caution in the elderly given that
cognitive impairment is a known side
effect of the medication.53
Treatment Outcome
Despite bias that prevents recognition of AUDs in elderly patients or
deems such patients as untreatable,
research shows that treatment does
work in this population. As described
above, brief interventions can be effective for patients with potentially risky
or risky drinking. In general, treatment outcomes are as good or better for older patients compared to
younger ones.54 As a group, the elderly
are more likely to be compliant and
remain in longer-term outpatient programs.55 Other factors that increase
positive treatment outcomes in the
elderly include coercion (ie, courtmandated treatment), spousal involvement in treatment, and being treated
in an age-matched setting.12
Conclusion
Presently, AUDs in the elderly are
poorly recognized and insufficiently
treated. AUDs range from potentially
risky patients who do not drink regularly
or heavily to those with alcohol dependence. Issues of loss and loneliness,
increased medical illness, and increased
biological sensitivity to the deleterious
effects of alcohol, leave the elderly at
unique risk for AUDs. Any individual
≥65 years of age who drinks any amount
of alcohol can be at risk for developing adverse events given the increased
biological sensitivity to alcohol and the
potential for adverse interactions with
common medical illnesses and medications used in this population.
Screening instruments for patients
with moderate to severe AUDs, such
as the CAGE and MAST-G, are simple
to perform and have a relatively high
degree of sensitivity and specificity. A
careful psychiatric and medical workup is essential in the diagnosis and subsequent treatment of alcohol-related
problems in this population.
Once the severity of the AUD has
been determined, appropriate treatment and referral is necessary. For less
severe alcohol misuse, brief interventions may be sufficient in the primary
care setting. However, as the severity of
the problem increases, specialized treatment settings ranging from outpatient
to inpatient become necessary. Across
treatment settings, one should be mindful of the unique problems that the
elderly face. Empathic, non confrontational, and slower types of interactions
are more effective. Treatment should be
broad and comprehensive by addressing the biological, psychological, and
social factors that contribute to AUDs in
this population. Treatment may encompass brief, time-limited interventions,
as well as individual, group (especially
AA meetings and relapse prevention),
family, and couples therapies. These
should be accompanied by psychiatric
and medical oversight, if needed. A special emphasis on building or re-building a supportive, abstinent social network, especially for those with alcohol
dependence, is important. Given the
issues of loss and family disintegration
in these patients, providing community
outreach services is important as well.
Treatment works best when done in
an age-matched milieu, where staff are
specifically trained and dedicated to
working with the elderly. PP
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