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Alcohol problems in the elderly. Dr Karim Dar Consultant Psychiatrist St Bernards Hospital, London. Outline. Introduction-beliefs about addictions and its treatment Epidemiology Risk factors & signs/symptoms Diagnostic issues Screening Medical and psychiatric comorbidity Treatments.

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alcohol problems in the elderly

Alcohol problems in the elderly

Dr Karim Dar

Consultant Psychiatrist

St Bernards Hospital, London

outline
Outline
  • Introduction-beliefs about addictions and its treatment
  • Epidemiology
  • Risk factors & signs/symptoms
  • Diagnostic issues
  • Screening
  • Medical and psychiatric comorbidity
  • Treatments
what are the beliefs about addiction
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
what are the facts about addiction
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…
addiction is a health problem
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
addiction is treatable
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
addiction is a chronic disease

Addiction is a Chronic Disease

Often early onset

Usually Progressive, Sometimes Fatal

Chronic Course:

Relapsing & Remitting

slide9

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.

what s happening in the brain
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
brain
Brain

CMAJ Mar 20, 2001; 164(6)

what s happening in the brain13
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
sensible drinking
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)
slide22

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

prevalence geriatric alcohol problems
Prevalence Geriatric Alcohol Problems
  • A & E Departments….. 14%
  • Medical inpatients……. 6-11%
  • Psychiatric inpatients… 20%
  • Nursing home patients.. Up to 49%
early v late onset alcoholism
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).
risk factors26
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).
risk factors cont
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
signs symptoms
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
symptom identification
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
problems with definitions
Problems with Definitions
  • Substance Misuse
  • At-risk or Hazardous Use
  • Problem Use
  • Substance Abuse
  • Substance Dependence
diagnostic criteria for substance dependence in older adults
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

dsm iv dependence criteria
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

practitioner barriers to identification
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)

individual barriers to identification
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)

goals and rationale for screening
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
screening39
SCREENING
  • Several brief, practical screening tools for alcoholism exist:

CAGE

MAST-G

AUDIT

screening40
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?

screening41
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

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

screening44
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
physiologic changes with age
Physiologic Changes with Age

Decreased Lean

Body Mass

Decreased Total

Body Water

Decreased gastric

EtOH Dehydrogenase

Increased Serum EtOH for a

given dose

decreased tolerance in geriatric patients diagnostic adaptation and sensitivity to mature adult
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.
slide47

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

medical consequences
Medical consequences
  • Osteoporosis
    • conflicting results, may be related to socioeconomic status - role of nutrition
    • likely plays a role
medical consequences49
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
psychiatric comorbidity
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
dementia risk alcohol use
Dementia risk & alcohol use
  • There is an inverse U shaped relationship between alcohol consumption and dementia risk
  • 2 yr follow-up study of 2632 participants found that excessive drinking had a 45% increased risk of dementia (Deng et al 2006).
  • Chronic alcoholism is associated with deficits in executive functioning and visuo-spatial ability ( Crews et al 2005)
  • Abstinence results in improvement within months in men but after years in women (Dom et al 2005)
alcohol related dementia
Alcohol-related dementia
  • Victor : ARD is chronic form of cognitive problems after acute Korsakoff stage
  • With abstinence there is recovery from some deficits, usually in a few weeks after cessation

others’ deficits persist or improve slowly, after years of sobriety

dsmiv a lcohol induced persisting dementia
DSMIV alcohol-induced persisting dementia
  • A: multiple cognitive deficits manifested by both:

memory impairment

≥1 of: aphasia

apraxia

agnosia

disturbance in executive

functioning

dsmiv alcohol induced persisting dementia
DSMIV alcohol-induced persisting dementia
  • B: these deficits each cause significant impairment in social or occupational functioning & represent a significant decline
  • C: deficits don’t occur exclusively during the course of delirium & persist beyond the usual duration of substance intoxication or withdrawal
dsmiv alcohol induced persisting dementia55
DSMIV alcohol-induced persisting dementia
  • Evidence from the Hx, P/E or lab findings that the deficits are etiologically related to the persisting effects of substance use
  • In 1998, Oslin et al. proposed clinical criteria for alcohol-related dementia
alcohol related dementia56
Alcohol related dementia
  • Why controversial??
  • Lack of consistent neuropathological findings in dementia associated with alcohol
  • Sulcal widening & ventricular enlargement commonly found in patients with heavy alcohol use but noted with & without cognitive impairment & can reverse with abstinence
alcohol related dementia57
Alcohol related dementia
  • ↑evidence of overlap between WK syndrome & ARD

1. At autopsy, patients noted to have WK lesions but clinical hx of global cognitive impairment

2. PET scan study showed no difference in brain metabolism of patients with alcohol- induced dementia & those with WK syndrome

alcohol related dementia58
Alcohol related dementia
  • Memory, visuospatial function, tasks requiring speed & frontal lobe function often abnormal in cognitively impaired alcoholics

→ difficulty with complex reasoning, planning, abstract reasoning, judgement, attention & memory

alcohol related dementia59
Alcohol-related dementia
  • Language & verbal skills spared, anomia less likely
  • Saxton et al looked at ARD & AD neuropsych profiles

ARD poorer performance on:

initial letter fluency

fine motor control

free recall but recognition memory OK

(J. Geriatr. Psychiatry & Neurology 2000:13:141)

alcohol related dementia60
Alcohol related dementia
  • Probable AD did more poorly on:

confrontation naming (BNT)

recognition memory

animal fluency

orientation

  • No difference in global function between AD & ARD based on MMSE scores
  • BUT, small sample size
slide62

Some of the concerns and fears elderly report when thinking about treatment:

          • Treatment takes too long
          • It’s embarrassing to tell people
          • Treatment is just for kids
          • Treatment is just for “hard core addicts”
          • Treatment is too expensive
          • Being away from home
slide63

Some of the concerns and fears elderly report regarding

  • “12-Step” and “self-help” meeting attendance:
  • - Being uncomfortable going out at night
  • - Type of language used by some people at meetings (e.g. swearing, slang)
  • - Appearance or location of the place where the meeting is held (e.g. having to walk through a crowd of people smoking outside the entrance to the meeting room; up / down stairs; loud sounds; hearing problems)
  • - Not comfortable or used to talking about themselves
  • - Some of the issues discussed at meetings
  • (abuse, same-sex relationships, violence, etc.)
  • - Afraid they might see or be seen by someone they know
historical considerations notes
Historical Considerations: Notes

Some older adults remember stories about AA, which was founded in 1935, as a place needed only by “low bottom drunks.”

Some have a personal history of trying to get sober before and failing, despite their own best efforts and perhaps lots of help from others. Relapse is not clearly understood and needs to be.

Not too long ago (before the 1960’s) many alcoholics were treated in psychiatric wards as a result of their presentation and behavior when drinking. Many older adults associate substance abuse treatment with this type of approach: being “locked up” or labeled “crazy”.

Still strong stigma in the current generation of older adults about having a substance abuse problem: still viewed as a moral issue rather than a diagnosable medical condition.

sensitivity to the senior s reality
Sensitivityto the Senior ’s Reality
  • Most seniors have strong social supports.
  • Often resilient; they have coping skills to build upon.
  • Living longer, continuing to develop intellectually, emotionally and spiritually.
  • Improved health status and access to health care.
  • Informed consumers.
  • Users of many “social” and community services
treatment recommendations
Treatment Recommendations

1. Age-specific, group treatment - supportive, not confrontive

2. Attend to negative emotions: depression, loneliness, overcoming losses

3. Teach skills to rebuild social support network

  • Employ staff experienced in working with elders
  • Link with aging, medical, and institutional settings
  • Slower pace & age-appropriate content
  • Create a “culture of respect” for older clients
  • Broad, holistic approach to treatment recognizing age-specific psychological, social & health aspects
  • Adapt treatment to address gender issues
helping older adults make the first step to treatment
Helping Older Adults Make the First Step to Treatment
  • The health care system is a ripe gateway to treatment.
  • Family concern is a motivating factor
  • If a health care professional informs an older person of the potential loss of independence, functioning and quality of life, motivation to change grows.
brief intervention
Brief Intervention
  • From 1 to 5 brief sessions targeting a specific health behavior
  • Used in those with harmful use
  • Offers advice, education, motivation enhancement approaches, feedback, contracting eg drink diaries
  • Goals:
    • Reduce alcohol or substance use
    • Motivate individual to change behavior
    • Facilitate treatment entry
brief intervention projects
Brief Intervention Projects
  • Project GOAL (Guiding Older Adult Lifestyles)(Fleming et al., 1999; University of Wisconsin)
    • Brief physician advice for 156 adult at-risk drinkers
    • Reduced consumption (35%-40%) at 12 months
  • Health Profile Project Univ. of Michigan (Blow and Barry)
    • In home, motivational enhancement session reduced at-risk drinking at 12 months (n=454)
  • Staying Healthy Project American Society on Aging (California - Cullinane et al.)
    • More than 4300 people screened
    • About 6% drinking more than recommended
    • Almost 40% reduction of alcohol use
withdrawal in the elderly
Withdrawal in the Elderly
  • Onset of withdrawal delayed (days)
  • May be prolonged
  • Often presents with confusion
  • Hallucinations (visual/tactile) may persist for months
withdrawal
Withdrawal
  • Anxiety
  • Agitation
  • Tremors
  • Autonomic hyperactivity
  • Seizures
  • Nausea & vomiting
  • Hallucinations-visual,tactile,auditory
  • Insomnia
i alcohol detoxification concerns in geriatric patients
I. Alcohol Detoxification Concerns in Geriatric Patients
  • Severe withdrawal and comorbid medical illness and limited support means that usually managed as inpatients
  • Outpatient with family support in few cases
  • Awareness of altered pharmacokinetics and drug interactions essential
  • Avoid Disulfiram in the elderly
  • Acamprosate much safer option
ii alcohol detoxification concerns in geriatric patients
II. Alcohol Detoxification Concerns in Geriatric Patients
  • Confusion (rather than tremor) early withdrawal sign
  • Duration of withdrawal/hallucinosis increased
  • Rule out DTs in confused elderly
  • Replace electrolytes and nutrients
  • Short acting benzodiazepines (Oxazepam)
  • Parenteral thiamine unless contraindicated should be given
treatment suggestions
Treatment SUGGESTIONS..
  • Groups:
    • Grief group
    • Leisure skills group
    • Life transition group
    • Reminiscent therapy group
    • Educational groups:

medical aspects of substance abuse;

mental health issues;

bereavement;

growing older with dignity, etc.

risk factors for relapse
Risk Factors For Relapse
  • Loneliness, boredom
  • Chronic pain
  • Unresolved grief
  • Sleep disturbances
  • Untreated mental health issues – e.g. depression, anxiety
  • Lack of support for recovery
  • Chronic medical problems
  • Prolonged stress
  • Difficulty in managing daily affairs – e.g. finances, chores
  • Unsuitable living environment
  • Lack of understanding about relapse or lack of a relapse prevention plan
a three stage cbt approach
A Three Stage CBT Approach
  • Behavior analysis – begin with a substance use profile to identify each client’s antecedents and consequences for substance use. Create an individualized “substance use behavior chain.”
  • Teach client’s how to identify the components of that chain so that he or she can understand the high risk situations for alcohol or drug use.
  • Teach specific skills to address these high risk situations to prevent relapse.
slide78

“A-B-C” Approach to Treatment:

The Substance Use Behavior Chain

Consequences

Behavior

Antecedents

Immediate/ Short Term

Conseq. + or -

Situations/ + Feelings + Cues + Urges

Thoughts

1st drink or

Use of drug

Long Term Consequences

(always negative)

Home/alone + bored and depressed + beer in refrigerator + “A drink will help me forget my troubles.”

First sip of beer

Feel happier

Continue drinking, anger her children, and impair health

relapse prevention strategies for older adults 1 of 2
Relapse Prevention Strategies For Older Adults (1 of 2)
  • Help clients develop meaningful leisure, social or vocational activities.
  • Work with client and their physician on pain control strategies (ideally, non chemical ones).
  • Address grief issues throughout treatment and refer for additional supportive services when needed.
  • Teach clients good sleep habits (e.g. forego a daytime nap) and non chemical ways to cope with sleep disturbances.
  • Be sure that mental health issues are being addressed and treated.
relapse prevention strategies for older adults 2 of 2
Relapse Prevention Strategies For Older Adults (2 of 2)
  • Be sure client is keeping medical appointments, taking medications as prescribed and communicating changes in health status to physician.
  • Teach stress management skills throughout treatment.
  • Develop a relapse prevention plan tailored to the client’s individual needs.
  • Have a strong sober support system (e.g. 12 step meetings, church, family, close friends).
slide81

Continuing Rehabilitation

and

Recovery In The Community

1. Elderly require multiple linkages to community services, agencies, and resources as well as healthcare providers.

2. No single treatment program can provide necessary range of continued service in community

3. When community-based services are not well-managed or not provided for an extended period of time, the rate of relapse

is very high.

4. Effective case management Implementation of discharge plans.

5. Consider:

- social network

- proximity to and relation with family

- real physical and mental limitations

research questions
Research Questions
  • Clinical needs of older adults in treatment
  • Gender differences
  • Diverse populations
  • Factors associated with treatment success
  • Efficacy and safety of pharmacotherapy
  • Longer term outcomes
conclusions
Conclusions
  • These are a common but under recognised problem
  • Increased awareness among health care professionals needed
  • Elderly benefit from treatment
  • Good liaison between services essential
  • Policy makers need to highlight this need in NSFs
plato has the last word
Plato has the last word

"…I may be forgiven for saying, as a physician, that drinking deep is a bad practice, which I never follow, if I can help, and certainly do not recommend to another, least of all to any one who still feels the effects of yesterday's carouse."

Plato's Symposium