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

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?

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 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 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

Often early onset

Usually Progressive, Sometimes Fatal

Chronic Course:

Relapsing & Remitting

Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses

Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

Drug Dependence

Drug Dependence

Type I DiabetesType I

DiabetesHypertensionHypertension AsthmaAsthma

40 t

o 60

%40

to

60%

30 t

o 50

%30

to

50%

50 t

o 70

%50

to

70%

50 t

o 70

%50

to

70%

Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse Addiction Treatment Does WorkAddiction Treatment Does Work

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

CMAJ Mar 20, 2001; 164(6)

Brain

“It’s a brain disease….”

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

CMAJ Mar 20, 2001; 164(6)

Neurons

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)

At Risk Drinking : Britain

0%

5%

10%

15%

20%

25%

30%

1992

MenDrinking>21 unitsper weekWomenDrinking>14 unitsper week

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

05

101520253035404550

16-24

25-44

45-64

>65

MenWomen

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

0%5%

10%15%20%25%30%35%40%45%50%

16-24

>16 >65

>4 units>8 units

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

0%

5%

10%

15%

20%

25%

30%

35%

40%

16-24

>16 >65

>3 units>6 units

15.9

56.8

37.8

12.8

7.8

58.3

30.3

7.64.9

53.0

21.1

5.31.0

37.5

9.4

2.30

10

20

30

40

50

60

70

Any IllicitDrug Use

Any AlcoholUse

"Binge"Alcohol use

HeavyAlcohol Use

18 to 25

26 to 34

35 to 54

55 or Older

Percentage of Adults Aged 18 or Older Reporting Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000. (source NHSDA, 2001)

Per

cen

t R

epo

rtin

g U

se i

n P

ast

Mo

nth

12% of 55+ age group are either binge or heavy alcohol users

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 AlcoholismEarly 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 Factors

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.) 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

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

Diagnosis Issues

Problems with Definitions

Substance Misuse At-risk or Hazardous Use Problem Use Substance Abuse Substance Dependence

Diagnostic Criteria for Substance Dependence in Older Adults

The Treatment Improvement Protocol

(TIP #26) Consensus Panel determined:

DSM-IV criteria for substance abuseDSM-IV criteria for substance abuse

and dependence may not be and dependence may not be

adequate to diagnose older adults adequate to diagnose older adults

with substance use problemswith substance use problems

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

Applying DSM-IV Criteria to Older Adults

Tolerance Even low intake may cause problems due to body changes

Withdrawal May not develop physiological dependence

Use in larger amounts or for longer than intended

Cognitive impairment interferes with self-monitoring

Desire to cut down or control use Same across life span

Time in obtaining substance or getting over effects

Negative effects with relatively low use

Activities given up or reduced May have fewer activities

Use despite knowledge of problems May not know problems are related to use

Practitioner Barriers to Identification

Ageist assumptionsFailure to recognize symptomsLack of knowledge about screeningPhysician 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 IdentificationAttempts at self-diagnosis Description of symptoms attributed to

aging process or diseaseMany 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)

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

SCREENING Several brief, practical screening tools

for alcoholism exist:

CAGE

MAST-G

AUDIT

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?

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 24 items (has shorter version)

≥5 yes responses indicative of alcohol problem

High sensitivity & specificity in a wide range of settings

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?

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

Decreased Lean Body Mass

Decreased TotalBody Water

Decreased gastricEtOH Dehydrogenase

Increased Serum EtOH for agiven dose

Decreased Tolerance in Geriatric Patients...

Diagnostic “adaptation” and sensitivity to mature adult

Slowed metabolic breakdown and elimination.

pace / duration of detox, withdrawal, stabilization.

Blood levels persist longer.

“CNS”: Age-associated central nervous system sensitivity.

Absolute quantities of alcohol and / or drugs consumed / ingested may be relatively small and still bring on major complications.

Organ function

Liver:-cirrhosis-cancer

Orthopedics: - Falls- Twists- Breaks

Continence

Pain

Lower extremities: - Balance- Pain- Mobility

Central Nervous:- Neuropathy-DTs-W-K syndrome

Sleep Patterns

Prescriptions and OTC’s: - Interactions - “Negation”

Heart-Atrial fibrillation-CHDDigestionCa nasopharynx & oesophagus

Blood pressure-StrokeNutrition:- Appetite

Consider alcohol and drug use and the Medical Consequences on a Senior

Medical consequences

Osteoporosis conflicting results,

may be related to socioeconomic status - role of nutrition

likely plays a role

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 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 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 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 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 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 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 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 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 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 dementia Language & verbal skills spared, anomia less likely Saxton et al looked at ARD & AD neuropsych profiles

ARD poorer performance on:initial letter fluencyfine motor controlfree recall but recognition memory OK

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

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

• TREATMENT

• 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

• 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

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

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

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

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

3. Teach skills to rebuild social support network4. Employ staff experienced in working with elders5. Link with aging, medical, and institutional settings6. Slower pace & age-appropriate content7. Create a “culture of respect” for older clients8. Broad, holistic approach to treatment recognizing

age-specific psychological, social & health aspects9. Adapt treatment to address gender issues

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 Interventions

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 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 Onset of withdrawal delayed (days) May be prolonged Often presents with confusion Hallucinations (visual/tactile) may persist for

months

Withdrawal

Anxiety Agitation Tremors Autonomic hyperactivity Seizures Nausea & vomiting Hallucinations-

visual,tactile,auditory Insomnia

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

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.. 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 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

1. 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.”

2. 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.

3. Teach specific skills to address these high risk situations to prevent relapse.

“A-B-C” Approach to Treatment:The Substance Use Behavior Chain

Behavior

Antecedents

Long Term Consequences

(always negative)

Situations/ + Feelings + Cues + Urges Thoughts

Consequences

First sip of beer

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

1st drink orUse of drug

Immediate/ Short Term

Conseq. + or -

Continue drinking, anger her children, and impair health

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)

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).

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 relapseis 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 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 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

"…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