Treatment of Alcohol-Related Problems in the Elderly

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Treatment of Alcohol-Related
Problems in the Elderly Julian Offsay, MD R E V I E W Dr. Offsay is Clinical Assistant Professor
of Psychiatry at the University of Con-
necticut Health Center, Farmington,
and staff psychiatrist at the Institute of
Living, Hartford, CT. A lthough figures vary from one study to another, available evi-
dence indicates that alcoholism in the elderly is underdiag-
nosed and undertreated. 1 Community studies generally have shown that about 2-3 percent of men over the age of 65 years meet criteria for alcoholism, with the incidence in women being perhaps
one-third of that. 2,3 When the focus is shifted to the medical office or the inpatient setting, the figures may increase tenfold, and are usually even
higher for elderly persons seen in the emergency room. 4 Furthermore, there is a general consensus that with the aging of the baby boom gen-
eration, these figures will increase significantly. Among older drinkers there appears to be two different groups in terms of age of onset of alcoholic drinking (Table I). 5 Early-onset alco- holics tend to comply with the common stereotype of the chronic alco-
holic. They typically begin as teenagers or in their early twenties, and
often impair their health, vocational life and personal relationships
severely as they progress from youth through middle age. Many do not
reach old age for obvious reasons. Later-onset alcoholics are mainly
people who drank moderately, or even rarely, but then either increased Alcoholism in the elderly is under-
diagnosed and undertreated. As im-
portant as the situation is presently, it
will become more imperative with the
aging of the baby boom generation.
Greater clinician awareness of the
problem will, hopefully, improve our
ability to identify and help these pa-
tients. This can be done in general
medical settings, using efficient
screening tools and brief questioning.
People identified as having a drinking
problem can often be helped by brief,
cost-effective counseling sessions. The
provider need not be a mental health
professional. More severe problems
will require specialist intervention.
Medications are available for detoxifi-
cation and for relapse prevention. At-
tention also must be paid to medical
and psychiatric comorbidities. Older
adults will differ in terms of what
their optimal treatment setting may
be. Some will do best in a program for
seniors, and others may benefit from
a mixed-age setting. An optimistic,
supportive approach, devoid of ageist
pessimism, can yield positive results.
( Annals of Long-Term Care: Clinical Care and Aging 2007;15[7]:39-44) Table I: Characteristics of Early-Onset vs Later-Onset Alcoholics Early-Onset Alcoholics Later-Onset Alcoholics Genetics Gender Education Income Health Precipitants high genetic load lesser load lower level much higher in men better educated relatively more women more affluent generally thought to be more endogenous more illness lower thought to be related to later-life stresses and changes healthier 39 Annals of Long-Term Care / Volume 15 , Number 7 / July 2007 altc0707SAOffsayReview.qxd 6/29/07 9:53 AM Page 39 40 Annals of Long-Term Care / Volume 15 , Number 7 / July 2007 ALCOHOLISM dependence diagnosis requires widespread impairment,
with the addiction essentially taking over ones life.
Actual tolerance and physical dependence are usually
present to some degree, but are not required to make
the diagnosis. In order to accurately identify alcoholic problems in patients, clinicians must be actively searching for them
and asking the right questions. Literature has consis-
tently documented our failure to make the diagnosis
and, perhaps of even greater concern, the lack of appro-
priate treatment even when the diagnosis is made. 1 Elderly patients may present differently from younger
patients, who often come to attention through work-
related or legal problems. Signs that might be sugges-
tive in the older patient include impaired cognition;
sleep disturbance; decline in personal hygiene; frequent
falls and bruising; gastrointestinal problems, including
bleeding; gait disturbance; increased anxiety; and auto
accidents (Table II). An assessment tool may be useful and can be part of a routine office visit. The CAGE assessment 7 is a brief questionnaire that is easy to use but is not very sensi-
tive. Two tools that have proven useful in the elderly are
the Michigan Alcoholism Screening Test-Geriatric Ver-
sion (MAST-G) 8 and the Alcohol Use Disorders Iden- tification Test (AUDIT) 9 (Table III). Having established the diagnosis, the next step is to enlist the patient in treatment. As is common knowl-
edge, this may be a challenge. A frank discussion with
the patient will help reveal the degree of denial or resis-
tance. The author has found that older patients are their intake in association with the changes brought
about by the aging process, or ran into problems
because they could no longer handle the amount of
alcohol they consumed earlier in life. Among the
physiologic changes that account for reduced toler-
ance in the elderly are a decrease in lean tissue and
water, with a relative increase in fatty tissue. Accord-
ingly, a given amount of alcohol is distributed in a
smaller volume, and blood levels are higher. Also,
older people have less alcohol dehydrogenase in their
stomachs, so, again, a drink raises blood levels more
than it did at a younger age. Furthermore, the elderly
brain is far more sensitive to alcohol. EVALUATING A PATIENT WITH AN
ALCOHOL PROBLEM In order to assess the severity of a given patients alco-
hol problem, we inquire about the quantity and pat-
tern of drinking. A standard drink contains between
1/2 and 3/4 ounce of pure alcohol. This is approxi-
mately the amount in a shot of 80-proof liquor, a 12-
ounce glass of beer, or a 5-ounce glass of wine. The cur-
rent recommendation, from the National Institute on
Alcohol Abuse and Alcoholism, is that persons over age
65 limit their consumption to one standard drink per
day, and to no more than two on any occasion. Women
are more vulnerable to alcohols deleterious effects
and are generally advised to drink less. (Guideline is
available in Treatment Improvement Protocol # 26,
available from the Substance Abuse and Mental
Health Services Administration [SAMHSA]. 6 The reader is advised to visit the SAMHSA site on the Inter-
net [http://samhsa.gov], as it is a source of valuable
information and publications.) The terms at risk and problem drinking have been found useful in terms of evaluating severity. At risk is
drinking that has not yet led to identifiable conse-
quences, but which is likely to do so in the future.
Problem drinking pertains to a pattern that has led to
one or more adverse consequences. The labels of alco-
hol abuse and dependence define conditions of greater
magnitude. Abuse generally involves major conse-
quences in at least one area of functioning, while a Table II: Signs Suggestive of an Alcohol Problem Impaired cognition Sleep disturbance Poor personal hygiene Frequent falls or bruising Gastrointestinal complaints and/or bleeding Gait disturbance Physical jitteriness or increased anxiety Auto accidents altc0707SAOffsayReview.qxd 6/29/07 9:53 AM Page 40 ALCOHOLISM generally responsive to family concerns. If a patient is
seriously resistant, a family meeting, or even a formal
intervention can be very effective. An intervention is a
facilitator-guided process meant to confront patient
denial. It is advised that clinicians receive appropriate training prior to leading an intervention on their own.
Typically, there is an initial planning meeting with the
concerned family or friends. The ground rules are
laid out. These include the use of I statements, to
focus on how the alcoholic behavior affects the speak-
er. There are no accusations or recriminations. Anyone
unable to comply is eliminated. With elderly persons,
it is recommended that only a few people attend, and
that no very young people (eg, grandchildren) attend 10 (Table IV). The type of drinking determines the next steps. In the case of at-risk or problem drinking, the patient does not
require detoxification or inpatient treatment. If he is will-
ing to engage, then his degree of denial and readiness for
change are assessed. He may benefit from brief alcohol
counseling (BAC) (Table V). In some cases, a great deal
can be accomplished with just a few brief encounters.
The professional need not be a mental health specialist. Primary care physicians, advanced practice regis- tered nurses, and others involved in general medical
practice can learn to become effective in this area. The
general elements involve educating the patient about
his/her pattern of drinking as it compares to the norm, Table III: Screening Instruments for Alcoholism The CAGE questionnaire is named for the acronym formed by a key word in each of four questions: 1. Have you ever thought you should Cut down on your drinking?
2. Have people Annoyed you by asking about your drinking?
3. Ever felt Guilty about your drinking?
4. Ever need a morning drink to steady your nerves (Eye opener)? The limitation with the CAGE is that many problem drinkers will not score the 2 affirmative responses required
to be considered clinically significant. The Alcohol Use Disorders Identification Test (AUDIT) A 10-question scale with a possible maximum score of 40. A score above 8 is considered clinically significant. Typical questions include: How often do you have a drink containing alcohol? and Have you or someone else been injured as a result of your drinking? The Michigan Alcoholism Screening TestGeriatric Version (MAST-G) A 24-question YES/NO test, with 5 or more YES responses being significant. Typical questions include: When talking with others, do you ever underestimate how much you actually drink? and Does having a drink help you sleep? Each of the last two tests are considered to be more sensitive than is the CAGE. The MAST-G is available in a
short version that is also considered to be valid and reliable. Table IV: Alcohol Intervention Meet beforehand in order to assess how each
person sees the situation. Explain that the focus is on how the patients
drinking affects the speaker. There are to be no accusations and no rancor. If someone is too angry to participate properly,
do not include them. With elderly patients, it is recommended that
the number of family or friends be limited to
two or three, to avoid a confusing or over-
whelming experience for the patient. Also, to preserve the older persons dignity, try
to avoid including much younger people, such
as grandchildren. 41 Annals of Long-Term Care / Volume 15 , Number 7 / July 2007 altc0707SAOffsayReview.qxd 6/29/07 9:53 AM Page 41 ALCOHOLISM the relation of his/her drinking to symptoms and ill-
nesses, and ways to enhance motivation and monitor
change. Just a few conversations can bring about posi-
tive change. 11,12 Some patients, however, may benefit from sessions with an experienced substance abuse pro-
fessional, possibly utilizing a technique such as Millers
motivational enhancement therapy. 13 For those who meet criteria for alcohol abuse or dependence, more robust intervention is required. The
severity of the withdrawal process is difficult to predict,
due to personal variability and lack of accuracy of
patient histories. An objective tool such as the Clinical
Institute Withdrawal Assessment (CIWA) 14 should be used. It monitors intensity of withdrawal symptoms
and can be used with an inpatient or outpatient. The decision to initiate detoxification as an outpa- tient versus as an inpatient is an important and com-
plex one. Some patients can be safely and effectively
withdrawn in the outpatient setting. In order to assess
the appropriateness of outpatient detoxification, a
number of factors need to be taken into account. First,
do we have access to a reliable history? This is relevant
both in terms of accurate information about the cur-
rent drinking pattern and in terms of prior experience
with detoxification efforts. Also, it is imperative that a
responsible caregiver be actively involved. The time course of alcohol withdrawal is such that those who are likely to develop problems will show
signs of autonomic hyperactivity within 8 to 16 hours
after the last drink. The CIWA scale can then be used
to assess the degree of withdrawal symptomatology. A
moderate score would be between 8 and 15. In that
range, one might choose to treat with an appropriate
short-acting benzodiazepine and follow the patient
closely, communicating with the patient and caregiver
daily over the 5-7-day withdrawal period. There are many patients for whom the inpatient set- ting would be more appropriate. As in all areas of clin-
ical practice, ones professional judgment inevitably
plays a role. If the patients CIWA score is over 15, that
could presage major problems. Also, a history of with-
drawal delirium or seizures would call for hospital-
based detoxification. Further, hospitalization is indicat-
ed for patients who are suicidal, who have complex medical and/or psychiatric comorbidities, or who lack
adequate supports in the community. Additional bene-
fits of hospitalization are lack of access to alcohol, break
from the usual environment (which could be part of
the problem), opportunity to obtain diagnostic and
treatment services efficiently, and the opportunity to
mobilize family and friends, which often occurs when
someone is hospitalized. MEDICATIONS Medication can play a variety of roles in treatment.
Medications may be divided into those used for detox-
ification, those used to prevent relapse, and those used
to treat psychiatric comorbidities. The standard drugs
for withdrawal remain the benzodiazepines. The par-
ticular drugs recommended are those that are metabo-
lized by conjugation alone, a process relatively undi-
minished in the elderly. Oxazepam and lorazepam are
both widely used. The CIWA scale can be used every 4
hours to assess patient status, with a dose of medication
being given for any score above 6 or 7. Anticonvulsants
such as divalproex and carbamazepine have long been
known to ameliorate withdrawal symptoms and are
still being actively studied in this regard. It is not
known whether they offer any specific benefit over ben-
zodiazepines in the geriatric population. Table V: Brief Alcohol Counseling Can be performed by a variety of trained professionals. Share the results of the screening with the patient. Educate the patients about geriatric alcohol consumption guidelines. Explain the link between patients drinking and
any symptoms or conditions. Request that the patient begin a drinking diary. Educate about Alcoholics Anonymous (AA), and
encourage attendance. If patient is willing to try AA, advise that he/she
find a sponsor. Arrange a follow-up meeting to evaluate progress. 42 Annals of Long-Term Care / Volume 15 , Number 7 / July 2007 altc0707SAOffsayReview.qxd 6/29/07 9:53 AM Page 42 ALCOHOLISM Drugs currently available for relapse prevention include disulfiram, naltrexone, and acamprosate (Table
VI). Disulfiram, which blocks the action of aldehyde
dehydrogenase, causes the accumulation of acetalde-
hyde when combined with alcohol. This reaction can
lead to serious and extremely unpleasant consequences.
It is potentially dangerous in the elderly, and should
never be given to a patient with cognitive impairment.
The effect can last as long as 2 weeks after the last dose.
Interestingly, studies usually fail to show efficacy, which
is thought to be due to noncompliance. Naltrexone is
an opiate antagonist that was approved for treatment of
alcoholism in 1995. Apparently, both the pleasure
derived from drinking and the craving to drink are
related to the endogenous endorphin system. Two landmark studies, both published in the Archives of General Psychiatry in 1992, demonstrated the safety
and efficacy of naltrexone in reducing craving and
relapse in a general adult population. 15,16 Oslin and col- leagues 17 studied a group of veterans between ages 50 and 70 years and also found evidence of safety and efficacy.
In addition, Oslin et al 18 compared older adults (mean age, 62.6 yr) with younger adults (mean age, 41.7 yr) in
terms of compliance with, and efficacy of, treatment
with naltrexone and supportive psychosocial therapy.
They found that the older adults did better in terms of
treatment adherence and reduced relapse rates. 18 A recent development has been the Food and Drug Administration (FDA) approval of monthly injections of long-acting naltrexone for the treatment of alco-
holism. Initial studies are favorable in terms of efficacy
and tolerability. 19 There have not yet been any studies in the elderly. There were concerns about increases of
hepatic enzymes in some early studies of naltrexone, but
the doses used were significantly higher (eg, 300 mg
daily) than the presently recommended 50 mg per day.
A guideline for prescribing either naltrexone or disulfi-
ram, which also can raise hepatic enzymes, has been to
avoid prescribing if hepatic enzymes are doubled, and to
stop the medication if they go up to threefold. Acamprosate was approved by the FDA largely on the basis of data from European studies. Its purported
mechanism of action involves stabilization of the cere-
bral glutamate system. It would, thereby, presumably
reduce some of the cerebral dysfunction thought to
underlie the protracted abstinence syndrome present in
those who have drunk heavily over long periods of time.
It is a drug with a relatively benign side-effect profile and
would appear to be safe in the elderly, although no spe-
cific studies have been done in older adults. In a recent
large multicenter study, acamprosate was significantly
less effective than naltrexone on all measures. 20 Among the most important comorbid conditions are clinical depression, anxiety disorders, and dementia.
As a large percentage of alcoholics experience depres-
sion at the outset of treatment, and then recover in just
a few weeks or less, it is recommended to avoid pre-
scribing antidepressant medications during the first Table VI: Medications for Relapse Prevention Disulfiram Naltrexone Acamprosate NO NO NO YES Probably YES YES YES NO Studied in Elderly? Safe in Elderly? Evidence-Based Efficacy? Potentially Hepatotoxic Mechanism NO YES YES Inhibits acetaldehyde, dehy- drogenase; causes dangerous cardiovascular reactions Blocks opiate receptors; decreases the pleasure of drinking Decreases the activity of the glutamate system, therefore, correcting the presumed hyperactivity of the postacute withdrawal brain 43 Annals of Long-Term Care / Volume 15 , Number 7 / July 2007 altc0707SAOffsayReview.qxd 6/29/07 9:53 AM Page 43 ALCOHOLISM week or two. Antidepressants appear to be helpful in
reducing alcohol intake in patients with true clinical
depression. However, they do not seem to show the
same effect in persons without depression. In fact, there
are a small number of studies that have shown
increased drinking in a subset of alcoholics treated with
selective serotonin reuptake inhibitors (SSRIs). 21,22 For anxiety disorders, the challenge has always been to find a medication that will not, itself, be abused.
First choice is generally an SSRI or selective serotonin
norepinephrine reuptake inhibitor (SSNRI). Of
course, benzodiazepine use in this population is doubly
fraught with potential dangers. In addition to the usual
geriatric concerns about impaired cognition, coordina-
tion, and alertness, we have the danger of addiction and
of dangerous combination with alcohol. Although it
has never been popular among clinicians, buspirone is
a drug that is safe in this population. Older patients
may have dementia symptoms for a combination of
reasons. However, primary alcohol appears to be as a
causative factor; a trial of a medication for Alzheimers
disease may be worth considering. FOLLOW-UP SUPPORT In terms of follow-up and relapse prevention, there is evi-
dence that older people may do better in programs with
patients of similar age. 23 For example, a patient might do better in a general geriatric day treatment program than
in a mixed-age alcoholism program. If available, a geri-
atric day program could be supplemented with atten-
dance at general adult relapse prevention groups. (Such
programming is available where the author works, at the
Institute of Living in Hartford, CT.) Of course, the geriatric population is enormously varied in terms of level of health and vigor. It is certain-
ly true that many older patients would do better and feel
more comfortable in a mixed-age setting. Patients
should be referred to Alcoholics Anonymous (AA). It
should be noted that about one-third of AA attendees
are over age 50. This is a setting that is quite supportive
and that emphasizes that it is never too late. It is rec-
ommended that the patient acquire a sponsor, and that
contacts be made with others for support, and for help with transportation, if that is a problem. And, finally,
supportive psychotherapy may be helpful to many
patients. The author has had a long career in geriatric
psychiatry, and has found that what some older patients
may lack in flexibility, they more than make up for in
sincerity and a true investment in the relationship.
Older alcoholics may be carrying an enormous burden
of guilt and remorse that may respond every bit as well
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