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.
Dr Karim Dar
St Bernards Hospital, London
Often early onset
Usually Progressive, Sometimes Fatal
Relapsing & Remitting
50 to 70%
40 to 60%
30 to 50%
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
Addiction Treatment Does Work
Percent of Patients Who Relapse
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
CMAJ Mar 20, 2001; 164(6)
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
Falls, bruises, burns
New problems in decision making
Unusual response to medicationsSigns & Symptoms
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
or getting over effects
given up or reduced
- 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with their patients
- 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)
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?
≥2 YES = positive
sensitivity = 63%, specificity = 82%
BUT, ↓ sensitivity with ↑ age
With cut-off of 1 = positive,
sensitivity = 86%, specificity 78% in elderly
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?
Increased Serum EtOH for a
Absolute quantities of alcohol and / or drugs consumed / ingested may be relatively small and still bring on major complications.
Medical Consequences on a Senior
Lower extremities: - Balance
others’ deficits persist or improve slowly, after years of sobriety
≥1 of: aphasia
disturbance in executive
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
→ difficulty with complex reasoning, planning, abstract reasoning, judgement, attention & memory
ARD poorer performance on:
initial letter fluency
fine motor control
free recall but recognition memory OK
(J. Geriatr. Psychiatry & Neurology 2000:13:141)
confrontation naming (BNT)
Some of the concerns and fears elderly report when thinking about treatment:
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.
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
medical aspects of substance abuse;
mental health issues;
growing older with dignity, etc.
The Substance Use Behavior Chain
Immediate/ Short Term
Conseq. + or -
Situations/ + Feelings + Cues + Urges
1st drink or
Use of drug
Long Term Consequences
Home/alone + bored and depressed + beer in refrigerator + “A drink will help me forget my troubles.”
First sip of beer
Continue drinking, anger her children, and impair health
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.
- social network
- proximity to and relation with family
- real physical and mental limitations
"…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."