ALCOHOL IN THE ELDERLY Dr. Sheryl Spithoff &

Dr. Suzanne Turner

Addition Medicine Fellows

Contact: Suzanne.Turner@camh.ca

¡ Mental health and addiction dx: § Account 4.7% of all SJHC ED visits § 766 patients / 16,000 § 35% of these patients were addiction-related

¡ This estimate does not capture other substance-related diagnoses (i.e. non-mental health) § Falls § Failure to cope § Liver failure § GI bleed

BURDEN OF ILLNESS

The Mental Health and Addictions Emergency Department Flow Mapping Project*

¡ US Screening Study (Onen 2005) § 5.3% of elderly ER patients had current alcohol

disorder

¡ Assuming case identification rates of 20% (standard), then about 300 elderly substance users in one year at SJHC Emergency Room

BURDEN OF ILLNESS

¡ Monitoring of Health Effects ¡ Withdrawal Management ¡ Medications for craving ¡ Relapse prevention ¡ Connecting to other services

¡ And most importantly: § Treatment works § Without treatment the risks to the elderly are

significant

WHAT THE ADDICTION MD CAN OFFER?

¡ Elderly can have more prolonged withdrawal and higher risk of delirium

¡ Higher risks in withdrawal of: §  cognitive impairment (including delirium) § daytime sleepiness § weakness § high blood pressure

¡ Some elderly may not be suitable for outpatient w/d because following would have to be true: § Adequate social support § No significant withdrawal symptoms § No comorbid illness § No complicated withdrawal (no seizures, no delirium)

HARMS (1): WITHDRAWAL

¡ Low to moderate alcohol use may protect against vascular dementia (Ganguli, 2005) § No heavy drinkers in this study

¡ Heavy alcohol use increases risk of all types of dementia (Thomas, 2001) § Alcoholics perform worse than controls on cognitive

testing, but better than Alzheimer’s (Liappas, 2007)

¡ Alcohol-induced cognitive impairment remains stable and may improve with abstinence § Further research in this area is needed (Oslin, 2003)

HARMS (2): DEMENTIA

¡ A high proportion of elderly depressed patients have an alcohol use disorder § 30% in one study

¡ A high proportion of elderly alcoholics have concurrent depression (Blixen 1997, Blow 2000)

¡ Alcohol use is a major risk factor for suicide in the elderly

HARMS (3): DEPRESSION

HARMS (4): LIVER DISEASE

Alcoholic Liver Disease

Fatty Liver First and most common phase of liver disease Usually no symptoms REVERSIBLE WITH ABSTINENCE

Alcoholic Hepatitis Usually no symptoms but CAN be VERY severe Repeated and prolonged episodes can lead to cirrhosis

Cirrhosis CAN BE SERIOUS AND EVEN FATAL

¡  Over 10-20 years, 10–20% risk of cirrhosis with: §  3 drinks/day (men), 2 drinks/day (women)

¡  In early stages, if stop drinking they can do well as the cirrhosis stabilizes and can be symptom-free

¡ Most effective treatment is abstinence because cirrhosis often not reversible

¡  If severe cirrhosis can get on transplant list §  Need six months to two years of abstinence + treatment program to

be eligible

HARMS (5): CIRRHOSIS

¡  Encephalopathy §  Coma, confusion or altered level of consciousness §  The confusion can lead to high risk of accidents and death

¡  Ascites §  Fluid building up in the belly § Makes it difficult to breath, walk and higher risk of infection (as the

fluid is a good breeding ground for bacteria) §  Infection puts patient at ++ high risk of death

¡  Varices §  Enlarged blood vessels in the liver and spleen can cause extensive

and life-threatening bleeding

HARMS (5): CIRRHOSIS

¡ There are few addiction programs specifically designed for older adults (Schulz 2003)

¡ Elderly have difficulty accessing existing programs: § long waiting lists, complex admission procedures, and

multiple appointments ¡ Most programs are based on group therapy

§ can be intimidating for older patients ¡ MDs can help navigate the system and make sure

patients get in-hospital treatment, appropriate medical treatment and ongoing monitoring

BARRIERS TO TREATMENT

AT-RISK DRINKING VS ADDICTION

¡ Men: § No more than 15 drinks per week § No more than 3 drinks per sitting

¡ Women § No more than 10 drinks per week § No more than 2 drinks per sitting

¡ Special Occasions: § Men: no more than 4 drinks § Women: no more than 3 drinks

LOW RISK DRINKING GUIDELINES

¡ AT-RISK DRINKERS § Drink above the low-risk drinking guidelines § Able to drink moderately § Few social consequences § Do not go through withdrawal § Often respond to physician advice and reduction

¡ ALCOHOLICS § Withdrawal symptoms § Continue to drink despite harms § Neglect of responsibilities § Generally require abstinence and intensive treatment

AT-RISK DRINKERS VS ALCOHOLICS

At-risk Drinker Alcohol Addiction

Withdrawal Symptoms No Often

Amount Consumed More than 14/week 40-60/week or more

Drinking Pattern Variable, depends on situation

Tends to drink set amount

Social Consequences Nil or mild Often severe

Physical Consequences Nil or mild Often severe

Social Stability Usually Often not

Neglect of major responsibilities

No Yes

AT-RISK DRINKERS VS ALCOHOLICS

¡ Older, at-risk drinkers that received advice from their primary care doctors about reducing consumption showed significant REDUCTION in: § 7-day alcohol use (Fleming, 1999) § episodes of binge drinking §  frequency of excessive drinking (> 21 drinks/week)

¡ This difference was followed over time § Differences still present after 12 months

¡ BOTTOM LINE: THESE PATIENTS LISTEN TO THEIR DOCTOR

AT-RISK DRINKERS: MD ADVICE

¡ Consumption limits for older adults should be lower (Chermack, 1996)

¡ Recommend no more than 1 drink per day

¡ Avoiding heavy drinking (consuming five or more drinks in 24h) § could further reduce the risk of alcohol-related symptoms for

older adults

LOW-RISK GUIDELINES FOR THE ELDERLY

¡  Review low-risk drinking guidelines ¡  Link drinking to individual patient situation

§  Fatty liver, alcoholic hepatitis, falls, etc

¡  Emphasize that mood, sleep, energy level will improve with reduced drinking §  Screen and treat depression

¡  Ask patient to commit to a drinking goal: §  Reduced drinking or abstinence §  If unwilling to commit, continue to ask about drinking at every

office visit

¡ Monitor blood work at baseline and follow-up ¡  Have regular follow-up with alcohol at the top of the agenda

MANAGEMENT OF AT-RISK DRINKING

¡ Sip drinks, don't gulp

¡ Avoid drinking on an empty stomach.

¡ Dilute drinks with mixer.

¡ Alternate alcoholic with non-alcoholic drinks

¡ Put a 20-minute "time-out" between the decision to drink and taking the drink

HARM-REDUCTION STRATEGIES

PSYCHOTHERAPY & ELDERLY

¡ Cognitive behavioural treatment associated with sustained abstinence in age-matched group (Schonfeld, 2000)

¡ 16 weekly group sessions using cognitive-behavioral (CB) and self-management approaches.

¡ Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use,

PSYCHOTHERAPY: ELDERLY

¡ Modules to teach coping skills for coping with §  social pressure, §  being at home and alone, §  feelings of depression and loneliness, §  anxiety and tension, §  anger and frustration, §  cues for substance use, §  urges (self-statements), §  and slips or relapses.

¡  At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters.

¡  The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.

PSYCHOTHERAPY: ELDERLY

¡ Following have evidence to be effective in elderly populations: § cognitive-behavioural therapy, § group and family therapies § self-help groups

¡ In fact, group and family therapies and self-help groups may be of particular benefit to older adults because of the emphasis on social support.

PSYCHOTHERAPY: ELDERLY POPJLATIONS

DRUG THERAPY & ELDERLY

¡ Alcohol treatment for older adults is at least as effective as for younger patients (Barrick 2002, Lemke 2002, 2003.)

¡ Medicinal adjuncts are also equally effective in the elderly

¡ Need strict compliance and careful monitoring of adverse effects are especially important in patients who take multiple medications.

¡ Because of their benign adverse effect profiles, naltrexone and acamprosate are particularly good pharmacological agents for relapse prevention in older adults.

MANAGEMENT OF ALC DEP

Special Application Covered (but off-label) Not covered

Revia (Naltrexone)* Campral (Acamprosate)

Baclofen** Topamax (Topirimate)**

Antabuse (Disulfiram)*** Zofran (Ondansetron)

PHARMACOTHERAPY: ODB COVERAGE

* Must be tried first unless a contraindication to Revia and then an application for Campral can be initiated

** Lower dose suggested in elderly – may not be effective for alcohol ***Causes patients to be physically ill – could precipitate severe medical emergencies in the elderly and generally avoided in this population

¡ Well tolerated ¡ Safe: No major liver side effects ¡ No differences between placebo (sugar pill)

and Revia § in the number of subjects remaining abstinent § The number of subjects who relapsed

¡ But if the patient “sampled” alcohol § Only half as likely to relapse!

REVIA (NALTREXONE): PREVENTS RELAPSE

¡ Elderly patients are more likely to take naltrexone regularly § Compliance was much better (Oslin, 2002)

¡ Higher retention to naltrexone ¡ Less likely to relapse than younger patients taking

naltrexone ¡ More attendance at therapy sessions than younger

patients taking naltrexone ¡ Older adults appear to respond well to a medically-

oriented program that is supportive and individualized

REVIA (NALTREXONE): COMPLIANCE

¡ Treat alcohol and mood disorders at the same time

¡ Consider a trial of antidepressant medication if: § Symptoms persist after four weeks of abstinence § Patient unable to sustain abstinence for several weeks § Primary mood disorder: depression precedes drinking; strong

family history § Severe depression (suicidal ideation, hospital admissions)

¡ Long-term benzodiazepine use in heavy drinkers creates risk of accidents, overdose and misuse

ALCOHOL DEPENDENCE: MOOD

¡ Treatment of comorbid depression and substance use: § Effective in general adult populations (Nunes 2004) § Leads to marked reductions in psychiatric hospital days

(Granholm 2003, Kominski 2001)

¡ Anti-depressants and counselling leads to: § Decreased drinking (Oslin, 2005) § Improved mood

¡ Alcohol use is a major risk factor for suicide § Access to alcohol treatment is a protective factor for

suicide in the elderly (She, 2006)

DEPRESSION: TREATMENT WORKS

¡ The elderly are at high risk of life-threatening conditions associated with their drinking

¡ Elderly patients listen to advice from their doctors about safe drinking limits

¡ Psychotherapy (particularly family and age-matched group thearpy) is effective in the elderly

¡ Drug therapy such as naltrexone works well in helping patienst to reduce drinking and prevent relapse

SUMMARY: TREATMENT

PHYSICAL DEPENDENCE

¡ Many patients with an alcohol addiction have a physical dependence on alcohol

¡  PHYSICAL DEPENDENCE INCLUDES:

¡  Tolerance- increased amounts to have same effect

¡ Withdrawal- syndrome with typically opposite effects to the substance

PHYSICAL DEPENDENCE

¡ WHAT’S HAPPENING IN THE BRAIN?

¡  Alcohol is complex but one main action- causes sedation

¡  Alcohol increases inhibitory activity, decreases excitatory activity

¡  Brain adapts and up-regulates in the face of chronic alcohol use

¡  If alcohol is removed- brain goes into overdrive

¡ Mild symptoms: §  tremor, § anxiety, §  Irritability

¡ Settles after a few day

¡ No medical treatment needed

¡ Severe symptoms: ¡  anxiety ¡  Nausea & vomiting, ¡  headache, ¡  sensory disturbances, ¡  rapid heart-rate, ¡  hypertension, ¡  tremor, ¡  sweats, ¡  agitation

¡ Starts 6 to 12 hours (up to several days)

¡ peak at day 3-5 ¡  resolve by day 7-10 ¡ Needs medical

treatment

ALCOHOL WITHDRAWAL

SEVERE WITHDRAWAL: DELIRIUM TREMENS

¡ Severe withdrawal can progress to delirium tremens ¡  5% cases ¡ onset 2-4 days after last drink

¡ delirium= hallucinations, agitation, disorientation and confusion

¡ autonomic overdrive= tremor, fast heart-rate, high blood pressure, fever, and sweating

¡ medical emergency with risk of death of 5%

SEVERE WITHDRAWAL: SEIZURES

¡ Seizures § Usually 12-72 hours after last drink § Can be single or multiple

¡ Need to see a doctor for Investigation if: §  first withdrawal seizure > age 40, §  focal features, § Prolonged – a seizure lasted more than 30 seconds §  recurrent >2 § abnormal neuro exam (i.e. they look like they’ve had a stroke –

drooping of the face, not able to move an arm or leg, etc) § outside typical time frame (if > 7 days)

ALCOHOL WITHDRAWAL: SUMMARY

¡ Alcohol withdrawal is a serious medical illness

¡ An MD or (RN-EC) should assess any patient with: § symptoms of withdrawal § at risk of withdrawal (ie history of heavy drinking in

patient admitted to hospital)

¡ Assess withdrawal symptoms, provide management plan and treatment

ALCOHOL WITHDRAL: PLANNED WITHDRAWAL

¡  An MD (or RN-EC) should assess all patients with alcohol addiction who are planning to stop drinking

¡  to determine risk of more significant withdrawal and provide a medical management plan (if indicated) §  THERE ARE SOME PATIENTS THAT SHOULD NOT PLAN TO STOP

DRINKING WITHOUT MEDICATION OR OUTSIDE A HOSPITAL SETTING

¡  develop a long-term addiction treatment plan

ALCOHOL WITHDRAWAL: ONLY ONE COMPONENT OF TREATMENT

¡  “Detox” is one small step in recovery process ¡  Important because it allows patient to engage in a more

meaningful way in treatment

¡  Rarely is successful insolation

¡ Must be integrated into ongoing treatment and the MD (RN-EC can help to put the other pieces of an ongoing treatment plan into place)

PLANNED WITHDRAWAL: RISK ASSESSMENT

¡ Low risk § unlikely to need medical management for

withdrawal

¡ Higher risk group § need close observation and medical management

¡ Two options for the higher risk groups: § outpatient withdrawal § inpatient withdrawal

ALCOHOL WITHDRAWAL: LOW RISK

¡ Low risk group:

¡ no significant withdrawal in past, no seizures, arrhythmias

¡ no “relief” drinking ¡ drinking <40 drinks per week ¡ no significant concurrent illness

PLANNED WITHDRAWAL: LOW RISK

¡  Caveat- Withdrawal course not always predictable- genetic factors seem to play a large role

¡ Warn patient of risks of alcohol withdrawal and to seek treatment if needed

¡  If any concerns have patient should be assessed next day and be monitored by reliable partner/ friend

ALCOHOL WITHDRAWAL: ELDERLY

¡ Elderly can be a low risk group but NEED closer follow-up

¡ Evidence is unclear if severe withdrawal is more common in elderly but course of withdrawal appears to be more complicated

¡ Medical problems/illnesses (co-morbidities), multiple medications that may affect course of withdrawal

ALCOHOL WITHDRAWAL: ELDERLY

¡ Some smaller older studies found increased severity of withdrawal in older age groups (Brower 1994; Liskow 1989)

¡ Criticized for comparing to very young adults <30 yo (very low risk severe withdrawal) and small sample sizes

WITHDRAWAL- ELDERLY

¡ Newer, larger studies §  (Kraemer 1997, Wetterling 2000, Wojnar 2001)

¡ Found no increase in severity scores or doses of benzodiazepines for elderly

¡ Did find longer stays and increase risk delirium* §  (Kraemer 1997, Wojnar 2001) §  * not statistically significant Wojnar 2001

PLANNED WITHDRAWAL: HIGHER RISK

¡ Patients who don’t fall into low risk group need medical management

¡ Either inpatient detox or outpatient day detox

¡ Treated with sedative medications

¡ Benzodiazepines (valium, ativan) have best evidence

WITHDRAWAL TREATMENT: BENZOS

¡ Benzodiazepines (Ativan, valium)

¡ Act at inhibitory neurotransmitter receptors (GABA receptors)

¡ these are the transmitters that go into “overdrive” when the patient stops drinking

¡ Treat symptoms and stop progression from mild to more severe withdrawal

WITHDRAWAL TREATMENT: BENZOS

§ Benzodiazepines are often dosed symptom-based with standardized protocol- CIWA (Clinical Institute Withdrawal Assessment)

§ Need MD (RN-EC) support because Elderly need more close observation

§ Need specialized medications (not “standard” protocol

§ Elderly- use short-acting benzodiazepine like lorazepam §  lower risk of sedation, confusion, respiratory depression

WITHDRAWAL TREATMENT: OUTPATIENT

¡ Many younger patients can be managed with planned outpatient withdrawal

¡  Treated with benzodiazepine protocol in MDs office in day, once withdrawal symptoms settle they are discharge home or to non-medical detox

¡  Phone or in person follow-up next day ¡  Safe, cost effective

OUTPATIENT WITHDRAWAL

¡ Criteria for outpatient management §  Initial CIWA score between 8-15

§ No hx seizures, dysrhythmias or severe withdrawal in past

§ No serious medical or psychiatric illness § Stable home situation, partner/ friend to monitor § No polysubstance use § Can come in for daily visits (or phone follow-up) § Not pregnant

OUTPATIENT WITHDRAWAL: ELDERLY

¡ Outpatient management of withdrawal in elderly

¡ Age over 60 is “relative contraindication” in some sources

¡ Typically use lorazepam protocol § since short-acting benzodiazepine symptoms may

reoccur- need close f/u

INPATIENT WITHDRAWAL

¡ Two options for inpatient withdrawal

¡ Non-urgent: CAMH- medical detox- patients or physician can refer

¡ Urgent: refer to ER § either end up admitted under medicine or § treated in ER and discharged home (or to non-

medical detox)

ALCOHOL WITHDRAWAL: TREATMENT OPTIONS

¡ Other drugs used for withdrawal

§ Anti-seizure medications and baclofen look promising for mild withdrawal, unclear for more severe withdrawal

§ Anti-psychotics- generally avoid unless underlying psychosis- (many prolong QT, some lower seizure threshold)

SUBACUTE WITHDRAWAL

¡ Acute alcohol withdrawal usually resolves in 7 days, often less.

¡ However subacute symptoms can last for months. § anxiety, agitation, irritability, poor sleep §  (also consider underlying mood disorder)

¡ Gabapentin- reduced risk of relapse in first 6 weeks when combined with naltrexone (Anton 2011)

SUBACUTE WITHDRAWAL

¡ Many studies have shown that poor sleep is associated with higher risk of relapse

¡  Review- Treatment for sleep disturbances in alcohol recovery (Arnedt 2007)

¡  Non pharmacological - Cognitive behavioural therapy has best evidence,* other options- sleep hygiene education, sleep restriction, stimulus control

¡  *Four la rge meta -ana lyses showed CBT to be equal o r super io r in improv ing s leep compared to medicat ions - s tud ies in non -a lcoho l dependent pat ients (Arnedt 2007)

SUBACUTE WITHDRAWAL

¡ Pharmacological treatment of insomnia in alcohol recovery: a systematic review. (Kolla 2011) § Trazodone best evidence, but one study found

increase in return to drinking § Gabapentin equivocal; topiramate and

carbamazepine showed subjective benefit § Acamprosate showed some improvement in small

study § Some evidence for benzodiazepines, quetiapine

however these drugs are usually viewed as second line because of risks and/or side effects

WITHDRAWAL: SUMMARY

¡  Alcohol withdrawal can be a serious life-threatening il lness

¡  Elderly - more complicated withdrawal and seem to be at increased risk delerium

¡  All patients with an alcohol addiction should be assessed by MD or RN(EC) prior to stopping drinking

¡  Over age 60- relative contraindication to outpatient management of withdrawal

¡  Detox is only one step in treating an addiction- a chronic il lness

¡  Needs to be integrated into an ongoing treatment plan with medical care, counseling, therapy, group programs