© Geriatric Times. All rights reserved.
Alcoholism and At-Risk Drinking in the Older Population
by Rebecca N. Zisserson and David W. Oslin, M.D.
Geriatric Times September/October 2003 Vol. IV Issue 5
Alcohol dependence is one of the leading causes of disability worldwide. It is associated with increased morbidity and mortality from disease-specific disorders, and it increases the risks for such diseases as hypertension or trauma related to falls or motor vehicle accidents. Alcohol misuse, however, is often not appreciated as relevant to the care of older adults (Murray and Lopez, 1996). The public health impact of alcohol dependence, as well as other substance use disorders, will likely increase with the growing number of older adults.
The current population cohort of 30- to 50-year-olds represents a group who were raised during the 1950s and 1960s and, as such, participated in the increased use of and addiction to heroin, cocaine, tobacco and alcohol. Both a history of substance dependence and current usage will likely have physical and mental health consequences for this cohort as it ages. Although research in late-life addictions has developed slowly, recent research has underscored the prevalence and disability related to substance abuse in late life, as well as the efficacy of both psychotherapeutic and pharmacological treatments for late-life alcoholism. Moreover, there is emerging evidence that reduction in alcohol use among older adults with alcohol dependence can lead to improvement in health-related quality of life.
Defining Problem Drinking
Older adults pose special concerns for the development of alcohol consumption guidelines. Compared with younger people, older adults have an increased sensitivity to alcohol as well as medications. Any alcohol use can be problematic for patients who use specific over-the-counter or prescription medications (especially psychoactive medications such as benzodiazepines, barbiturates and antidepressants) (Fraser, 1997; Onder et al., 2002). Because of these issues, alcohol use recommendations for older adults are generally lower than those set for adults under age 65: no more than one standard drink/day or seven standard drinks/week, and no more than two standard drinks on any drinking day (Blow, 1998; National Institute on Alcohol Abuse and Alcoholism, 1995).
Drinking guidelines highlight an important distinction between problem drinking or at-risk drinking and alcohol dependence. Alcohol dependence refers to a medical disorder characterized by loss of control, preoccupation with alcohol, continued alcohol use despite adverse consequences, and physiological symptoms such as tolerance and withdrawal. Older adults engaging in problem or at-risk use are drinking at a level that either has resulted in, or substantially increases the likelihood of, adverse medical, psychological or social consequences. Individuals engaging in problem or at-risk drinking often do not meet criteria for alcohol dependence.
Because some of the classic symptoms of dependence such as employment problems or legal problems are not present, individuals and practitioners may underestimate the risks of this level of consumption. At-risk or problem drinking has been demonstrated to lead to injuries from falls, depression, memory problems, liver disease, cardiovascular disease, cognitive changes and sleep problems (Gambert and Katsoyannis, 1995; Kivela et al., 1989; Liberto et al., 1992). Thus, at-risk drinking represents an appropriate target for interventions.
In addition to these categories of problematic drinking behavior, individuals may also consume alcohol at levels of low risk or be considered abstainers. Abstinence refers to drinking no alcohol in the previous year. While the majority of older adults are abstainers (60% to 70%), it is important to ascertain why alcohol is not used. Some individuals are abstinent because of a previous history of alcohol problems and may require preventive monitoring to determine if any new stresses could exacerbate an old pattern. In addition, a previous history of at-risk drinking or alcohol dependence may increase the risks for developing other mental health problems in late life, such as depressive disorders or cognitive problems (Saunders et al., 1991).
Low-risk or moderate alcohol use falls within the recommended guidelines for consumption and is not associated with problems. Older adults in this category drink within recommended drinking guidelines, are able to employ reasonable limits on alcohol consumption, and do not drink when driving a motor vehicle or when using contraindicated medications.
Epidemiology
The most recent studies that have examined the epidemiology of substance use disorders among the elderly have focused on specialty care settings, such as primary care physician practices, nursing homes or hospitals. The prevalence of at-risk problem drinking among older adults has been estimated as 1% to 15% (Adams et al., 1996). Despite the common occurrence of alcohol problems, most elderly patients have not been recognized as problem drinkers by health care personnel. Moreover, few elderly patients with alcohol problems seek help in specialized addiction treatment settings. Given the high utilization of general medical services by the elderly, physicians and other health care professionals can be crucial in identifying those in need of treatment and providing appropriate interventions based upon clinical need.
Screening and Diagnosis
Because of the increased risk of alcohol misuse in patients with other mental health problems, particularly depression, it is important to screen for alcohol abuse and dependence in mental health care settings (Kessler et al., 1996). To be able to practice prevention and early intervention with older adults, clinicians need to screen for alcohol use (frequency and quantity), drinking consequences and alcohol/medication interaction problems. Although it is not helpful to engage in debates with patients over exact amounts consumed, quantifying consumption in terms of standard alcohol drinks is important in improving assessment outcomes.
Screening can be done as part of routine mental and physical health care and should be updated annually, before the older adult begins taking any new medications, or in response to problems that may be alcohol- or medication-related. In addition to questions about quantity and frequency, standard assessments such as Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G), the CAGE and the Alcohol Use Disorders Identification Test (AUDIT) are often used with older adults. Clinicians can follow up the brief assessment questions about consumption and consequences with a few more in-depth questions about consequences, health risks and social/family issues. To assess dependence, questions should be asked about alcohol-related problems, a history of failed attempts to stop or to cut back, or withdrawal symptoms such as tremors. Clinicians should refer any patient thought to be dependent for a diagnostic evaluation and possible specialized alcohol treatment with an emphasis on treatment targeted to older adults.
Treatment
Relatively little formal research has been conducted on the comparative efficacy of various approaches to addiction treatment in older adults. However, research suggests that older adults who do engage in treatment can have substantially better outcomes and are more likely to complete treatment, compared to younger adults (Oslin et al., 2002). Thus, in contrast to popular beliefs, older adults are quite amenable to treatment. Furthermore, results from adherence studies have shown that age-specific programming improved treatment completion and resulted in higher rates of attendance at group meetings compared to mixed-age treatment (Kofoed et al., 1987).
A practical and cost-effective initial approach to at-risk and problem drinking is low-intensity or brief interventions (Barry, 1999). Brief intervention strategies have ranged from relatively unstructured counseling and feedback to more formal structured therapy and have relied heavily on concepts and techniques from the behavioral self-control training literature. In a randomized clinical trial, Fleming et al. (1999) showed that older adults can be engaged in brief intervention protocols, the protocols are acceptable in this population, and there is a substantial reduction in drinking among the at-risk drinkers receiving the interventions compared to a control group. Geriatric mental health care providers should be familiar with delivering brief intervention therapy, both as a primary treatment tool and as a way to motivate patients for more formal addiction treatment.
Pharmacological treatments have not traditionally played a major role in the long-term treatment of older alcohol-dependent adults. Until recently, disulfiram (Antabuse) was the only medication approved for the treatment of alcoholism, but was seldom used in older patients because of concerns about adverse effects. In 1995, the opioid antagonist naltrexone (ReVia) was approved by the U.S. Food and Drug Administration for the treatment of alcoholism, and this medication was found to be safe and effective in preventing relapse and reducing the craving for alcohol for the treatment of middle-aged patients with alcohol dependence (O'Malley et al., 1992; Volpicelli et al., 1992).
Our group has extended this line of research by studying a group of older veterans ages 50 to 70. The results were similar to other clinical trials, with half as many naltrexone-treated subjects relapsing to significant drinking compared to those treated with placebo (Oslin et al., 1997). Although this study did not include many elderly subjects, it does raise the hope that opioid antagonists may have clinical efficacy among older alcoholics.
Recently, acamprosate (Campral) has been studied as a promising agent in the treatment of alcoholism (Sass et al., 1996). Although the exact action of acamprosate is still unknown, it is thought to reduce glutamate response, but not as a typical N-methyl-D-aspartate (NMDA) blocker (Pelc et al., 1997). Although the existing clinical evidence favoring acamprosate is impressive, there have been no studies indicating the efficacy of acamprosate among elderly patients. (The FDA has not yet approved acamprosate for use in the United States--Ed.)
Comorbidity
A few studies indicate that dual diagnosis with alcoholism is important among the elderly. In a sample of community-dwelling elderly, almost half of the 4.5% of individuals with a history of alcohol abuse had a comorbid diagnosis of depression or dysthymia (Blazer et al., 1987). Alcoholics who suffer from depression have been shown to have a more complicated clinical course of illness with an increased risk of suicide and more social dysfunction than alcoholics who are not depressed (Cook et al., 1991).
The relationship between alcohol use and dementing illnesses such as Alzheimer's disease is complex. While alcohol-related dementia may be difficult to differentiate from Alzheimer's disease, there is a consensus that alcohol contributes significantly to the acquired cognitive deficits of late life. For example, Finlayson et al. (1988) found 25% of elderly patients presenting for alcohol treatment had organic brain syndrome associated with alcoholism. As might be expected, patients with alcohol-related dementia who become abstinent do not show a progression in cognitive impairment compared to those with Alzheimer's disease (Oslin and Cary, 2003).
Summary
Over the last several years, there has been a growing awareness that addictive disorders among the elderly are a common public health problem. Epidemiological studies suggest that alcoholism is present in up to 4% of the elderly, and there is at least one report suggesting that the prevalence of alcoholism among older adults is on the rise (Liberto and Oslin, 1995; Osterling and Berglund, 1994). Moreover, problem or hazardous drinking is estimated to be even more common among the elderly than alcoholism (Barry et al., 1998; Liberto and Oslin, 1995). Yet there continues to be a gap in the number of older adults who are referred for treatment or those who receive treatment for addictive disorders.
Although there are many reasons for patients not to be engaged in treatment, recommending effective treatment is partially based upon its availability. Toward this end, there needs to be better dissemination of information regarding efficacious treatments currently available for alcoholism and other addictive disorders as well as continued development of more effective treatments for older adults.
Ms. Zisserson completed her undergraduate training at the University of Pennsylvania and is currently completing a National Institute of Mental Health-sponsored summer internship program in the Section of Geriatric Psychiatry at the University of Pennsylvania.
Dr. Oslin is assistant professor of psychiatry at the University of Pennsylvania Medical Center and the Philadelphia Veterans Affairs Medical Center.
References
Adams WL, Barry KL, Fleming MF (1996), Screening for problem drinking in older primary care patients. JAMA 276(24):1964-1967.
Barry KL (1999), Brief interventions and brief therapies for substance abuse. Treatment Improvement Protocol (TIP) Series No. 34. Available at: ncadi.samhsa.gov/govpubs/BKD341/. Accessed Aug. 21, 2003.
Barry KL, Blow FC, Walton MA et al. (1998), Elder-specific brief alcohol intervention: 3-month outcomes. Alcohol Clin Exp Res 22:30A.
Blazer D, Hughes DC, George LK (1987), The epidemiology of depression in an elderly community population. Gerontologist 27(3):281-287.
Blow FC, ed. (1998), Substance abuse among older Americans. Treatment Improvement Protocol (TIP) Series No. 26. Available at: ncadi.samhsa.gov/govpubs/BKD250/. Accessed Aug. 21, 2003.
Cook BL, Winokur G, Garvey MJ, Beach V (1991), Depression and previous alcoholism in the elderly. Br J Psychiatry 158:72-75.
Finlayson RE, Hurt RD, Davis LJ Jr, Morse RM (1988), Alcoholism in elderly persons: a study of the psychiatric and psychosocial features of 216 inpatients. Mayo Clin Proc 63(8):761-768.
Fleming MF, Manwell LB, Barry KL et al. (1999), Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract 48(5):378-384.
Fraser AG (1997), Pharmacokinetic interactions between alcohol and other drugs. Clin Pharmacokinet 33(2):79-90.
Gambert SR, Katsoyannis KK (1995), Alcohol-related medical disorders of older heavy drinkers. In: Alcohol and Aging, Beresford T, Gomberg E., eds. New York: Oxford University Press, pp70-81.
Kessler RC, Nelson CB, McGonagle KA et al. (1996), Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br J Psychiatry Suppl 30:17-30 [see comment].
Kivela SL, Nissinen A, Ketola A et al. (1989), Alcohol consumption and mortality in aging or aged Finnish men. [Published erratum J Clin Epidemiol 42(7):701.] J Clin Epidemiol 42(1):61-68.
Kofoed LL, Tolson RL, Atkinson R et al. (1987), Treatment compliance of older alcoholics: an elder-specific approach is superior to "mainstreaming." Journal of Studies on Alcohol 48(1):47-51.
Liberto JG, Oslin DW (1995), Early versus late onset of alcoholism in the elderly. Int J Addict 30(13-14):1799-1818.
Liberto JG, Oslin DW, Ruskin PE (1992), Alcoholism in older persons: a review of the literature. Hosp Community Psychiatry 43(10):975-984.
Murray CJL, Lopez AD, eds. (1996), The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, Mass.: Harvard University Press.
National Institute on Alcohol Abuse and Alcoholism (1995), Diagnostic criteria for alcohol abuse. Alcohol Alert 30(PH 359):1-6.
O'Malley SS, Jaffe AJ, Chang G et al. (1992), Naltrexone and coping skills therapy for alcohol dependence: a controlled study. Arch Gen Psychiatry 49(11):881-887.
Onder G, Pedone C, Landi F et al. (2002), Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc 50(12):1962-1968.
Oslin DW, Cary MS (2003), Alcohol-related dementia: validation of diagnostic criteria. Am J Geriatr Psychiatry 11(4):441-447.
Oslin D, Liberto JG, O'Brien J et al. (1997), Naltrexone as an adjunctive treatment for older patients with alcohol dependence. Am J Geriatr Psychiatry 5(4):324-332.
Oslin DW, Pettinati HM, Volpicelli JR (2002), Alcoholism treatment adherence: older age predicts better adherence and drinking outcomes. Am J Geriatr Psychiatry 10(6):740-747.
Osterling A, Berglund M (1994), Elderly first time admitted alcoholics: a descriptive study on gender differences in a clinical population. Alcohol Clin Exp Res 18(6):1317-1321.
Pelc I, Verbanck P, Le Bon O et al. (1997), Efficacy and safety of acamprosate in the treatment of detoxified alcohol-dependent patients. A 90-day placebo-controlled dose-finding study. Br J Psychiatry 171:73-77.
Sass H, Soyka M, Mann K, Zieglgansberger W (1996), Relapse prevention by acamprosate. Results from a placebo controlled study in alcohol dependence. [Published erratum Arch Gen Psychiatry 53(12):1097.] Arch Gen Psychiatry 53(8):673-680.
Saunders PA, Copeland JR, Dewey ME et al. (1991), Heavy drinking as a risk factor for depression and dementia in elderly men. Findings from the Liverpool longitudinal community study. Br J Psychiatry 159:213-216.
Volpicelli JR, Alterman AI, Hayashida M, O'Brien CP (1992), Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry 49(11):876-880 [see comment].
