Alcohol problems in the elderly

1. Alcohol problems in the elderly Dr Karim Dar Consultant Psychiatrist St Bernards Hospital, London

2. Outline • Introduction-beliefs about addictions and its treatment • Epidemiology • Risk factors & signs/symptoms • Diagnostic issues • Screening • Medical and psychiatric comorbidity • Treatments

3. What are the beliefs about addiction? • the treatment isn’t effective • the prognosis is hopeless • reoccurrences of active disease are evidence of treatment failure • patients are non-compliant with treatment

4. What are the facts about addiction? • it occurs secondary to biological vulnerability • it is a disease of the brain, manifested in aberrant behavior • it is a chronic disease, in which relapse and remission recur episodically…

5. Addiction is a Health Problem • Not just a social problem • Not just a criminal justice problem • Not just a moral problem • Not a personal weakness • Not ‘willful misconduct’ • ADDICTION IS NOT A DESIRED STATE

6. Addiction is Treatable • But not via detox alone • But not via acute interventions alone • But not via treating psychiatric co-morbidities alone • Compliance = for other chronic illnesses • Outcomes = for other chronic illnesses

7. Addiction is a Chronic Disease Often early onset Usually Progressive, Sometimes Fatal Chronic Course: Relapsing & Remitting

9. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Addiction Treatment Does Work 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

10. What’s happening in the brain? • Modulation of “reward system” • Medial forebrain bundle connects ventral tegmental area to nucleus accumbens • Also pathways that project from VTA and NAcc -> limbic and cortical areas • Dopaminergic projection most implicated in reward

11. Brain CMAJ Mar 20, 2001; 164(6)

12. “It’s a brain disease….”

13. What’s happening in the brain? • Drugs of abuse act • directly by influencing action of dopamine • indirectly by affecting modulating pathways such as GABA, opioid, serotoninergic, acetylcholine and noradrenergic

14. Neurons

16. Sensible drinking • In the USA NIAA recommends that people older than 65 consume no more than 1 standard drink per day ( NIAAA 2003) • In the UK no recommendation for those >65 • Older people are one of the least well informed when asked about alcohol units (Lader & Meltzer 2001)

18. At Risk Drinking : Britain

19. Proportion Drinking more than daily guidelines on one day in previous week (ONS, 2002)

20. Men Drinking above ‘sensible’ levels (ONS, 2002)

21. Women drinking above ‘sensible’ levels (ONS, 2002)

22. Percentage of Adults Aged 18 or Older Reporting Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000. (source NHSDA, 2001) 12% of 55+ age group are either binge or heavy alcohol users Percent Reporting Use in Past Month

23. Prevalence Geriatric Alcohol Problems • A & E Departments….. 14% • Medical inpatients……. 6-11% • Psychiatric inpatients… 20% • Nursing home patients.. Up to 49%

24. Early v. Late Onset Alcoholism Early onset: • Describes those who have a lifelong pattern of drinking, have probably been alcoholic all their life, and are now elderly. • More likely to have chronic alcohol-related medical problems such as cirrhosis, organic brain syndrome, and co-morbid psychiatric disorders. Late onset: • Describes those who have become alcoholic in their drinking pattern for the first time late in life. • Often triggered by a stressful life event. • Generally represented by milder cases with fewer accompanying medical problems. • More amenable to treatment, more likely to have spontaneous recovery, but also more likely to be overlooked by health care professionals (Liberto & Oslin, 1995).

25. Risk Factors

26. Risk Factors • Alcohol use disorders may arise in elderly people in the context of bereavement, changing role, or illness (O’Connell, Chin, Cunningham, & Lawlor, 2003) • Alcohol may be used to relieve the boredom or depression stemming from unfulfilled expectations. • Losses such as a decline in economic status, the death of a spouse or close friends, and deterioration of health with worsening medical problems, are all risk factors for drinking in the elderly; alcohol may be used to reduce psychological, emotional,or physical stress (Menninger, 2002).

27. Risk Factors (cont.) • Male • Socially isolated • Single • Separated or Divorced • Substance abuse earlier in life • Co-morbid psychiatric disorders (especially mood disorders) • Family history of alcoholism • Concomitant substance abuse of nicotine and psychoactive prescription medicines

28. Anxiety Blackouts, dizziness Depression Disorientation Mood swings Falls, bruises, burns Family problems Financial problems Headaches Incontinence Increased tolerance Legal difficulties Memory loss New problems in decision making Poor hygiene Seizures, idiopathic Sleep problems Social isolation Unusual response to medications Signs & Symptoms

29. Symptom Identification • Applying quantity and frequency levels appropriate for younger adults to elders may cause failure to identify substance use problems • Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed to aging • Sleep problems associated with chronic conditions, particularly cardiovascular disease and pain • Falls attributed to poor lower body strength, poor balance, or vision limitations • Anxiety attributed to psychosocial concerns • Confusion/memory problems associated with Alzheimer’s disease or other dementias

30. Diagnosis Issues

31. Problems with Definitions • Substance Misuse • At-risk or Hazardous Use • Problem Use • Substance Abuse • Substance Dependence

32. Diagnostic Criteria for Substance Dependence in Older Adults The Treatment Improvement Protocol (TIP #26) Consensus Panel determined: DSM-IV criteria for substance abuse and dependence may not be adequate to diagnose older adults with substance use problems

33. DSM-IV Dependence Criteria • Tolerance • Withdrawal • Use in larger amounts or for longer than intended • Desire to cut down or control use • Great deal of time spent in obtaining substance or getting over effects • Social, occupational, or recreation activities given up or reduced • Use despite knowledge of physical or psychological problem

34. Applying DSM-IV Criteria to Older Adults

35. Practitioner Barriers to Identification • Ageist assumptions • Failure to recognize symptoms • Lack of knowledge about screening • Physician discomfort with substance abuse topic - 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with their patients (CASA, 2000)

36. Individual Barriers to Identification • Attempts at self-diagnosis • Description of symptoms attributed to aging process or disease • Many do not self-refer or seek treatment - Although most older adults (87 percent) see physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek services for substance abuse (Raschko, 1990)

37. Screening

38. Goals and rationale for screening • Identify at risk, problem and dependent drinkers • Determine need for further assessment and treatment • Incidence high enough to justify screening • Effective treatments exist • Treatments available are cost effective

39. SCREENING • Several brief, practical screening tools for alcoholism exist: CAGE MAST-G AUDIT

40. SCREENING • CAGE questionnaire: Ever felt you should CUT DOWN? Have people ANNOYED you by criticizing your drinking? Ever felt GUILTY about your drinking? Ever felt like EYE OPENER?

41. SCREENING • CAGE ≥2 YES = positive sensitivity = 63%, specificity = 82% BUT, ↓ sensitivity with ↑ age With cut-off of 1 = positive, sensitivity = 86%, specificity 78% in elderly

42. MAST-G • 24 items (has shorter version) • ≥5 yes responses indicative of alcohol problem • High sensitivity & specificity in a wide range of settings

43. S-MAST-G 1. When talking with others, do you ever underestimate how much you actually drink? 2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't 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?

44. SCREENING • BUT, MAST-G & CAGE don’t distinguish recent from remote drinking • CAGE insensitive re binge drinkers and women • information on behavioural & health effects more useful than frequency & level of alcohol consumption • AUDIT focuses on consumption

45. Physiologic Changes with Age Decreased Lean Body Mass Decreased Total Body Water Decreased gastric EtOH Dehydrogenase Increased Serum EtOH for a given dose

46. Decreased Tolerance in Geriatric Patients...Diagnostic “adaptation” and sensitivity to mature adult Absolute quantities of alcohol and / or drugs consumed / ingested may be relatively small and still bring on major complications. • Slowed metabolic breakdown and elimination. • pace / duration of detox, withdrawal, stabilization. • Blood levels persist longer. • “CNS”: Age-associated central nervous system sensitivity.

47. Consider alcohol and drug use and the Medical Consequences on a Senior • Central Nervous: • - Neuropathy • DTs • W-K syndrome • Sleep Patterns • Prescriptions and OTC’s: • - Interactions • - “Negation” • Heart • -Atrial fibrillation • -CHD • Digestion • Ca nasopharynx & oesophagus • Blood pressure • -Stroke • Nutrition: • - Appetite Organ function Liver: -cirrhosis -cancer Orthopedics: - Falls - Twists - Breaks Continence Pain Lower extremities: - Balance - Pain - Mobility

48. Medical consequences • Osteoporosis • conflicting results, may be related to socioeconomic status - role of nutrition • likely plays a role

49. Medical consequences Trauma • falls risk increases with level of alcohol intake • significant with >1000 gm/month • Alcohol one of the three main reasons for falls in the elderly • Cause significant morbidity and mortality

50. Psychiatric Comorbidity • 13% with a lifetime diagnosis of depression also met criteria for lifetime alcohol abuse (Grant et al 1995) • Elderly with alcohol dependence 3x more likely to have depression than those without (Grant et al 1995) • People >65 are 16x more likely to die of suicide ( Grabbe et al 1997). • Poorer response to treatment