Alcohol%20problems%20in%20the%20elderly

1
Alcohol problems in the elderly

• Dr Karim Dar
• Consultant Psychiatrist
• St Bernards Hospital, London

2
Outline

• Introduction-beliefs about addictions and its
  treatment
• Epidemiology
• Risk factors signs/symptoms
• Diagnostic issues
• Screening
• Medical and psychiatric comorbidity
• Treatments

3
What are the beliefs about addiction?

• the treatment isnt effective
• the prognosis is hopeless
• reoccurrences of active disease are evidence of
  treatment failure
• patients are non-compliant with treatment

4
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

5
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

6
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

7
Addiction is a Chronic Disease

• Often early onset
• Usually Progressive, Sometimes Fatal
• Chronic Course
• Relapsing Remitting

8
(No Transcript)
9
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.
10
Whats 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 -gt
  limbic and cortical areas
• Dopaminergic projection most implicated in reward

11
Brain
12
Its a brain disease.
13
Whats 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

14
Neurons
15
(No Transcript)
16
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 gt65
• Older people are one of the least well informed
  when asked about alcohol units (Lader Meltzer
  2001)

17
(No Transcript)
18
At Risk Drinking Britain
19
Proportion Drinking more than daily guidelines on
one day in previous week (ONS, 2002)
20
Men Drinking above sensible levels (ONS, 2002)
21
Women drinking above sensible levels (ONS, 2002)
22
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
23
Prevalence Geriatric Alcohol Problems

• A E Departments.. 14
• Medical inpatients. 6-11
• Psychiatric inpatients 20
• Nursing home patients.. Up to 49

24
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).

25
Risk Factors
26
Risk Factors

• Alcohol use disorders may arise in elderly people
  in the context of bereavement, changing role, or
  illness (OConnell, 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).

27
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

28
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

29
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
  Alzheimers disease or other dementias

30
Diagnosis Issues
31
Problems with Definitions

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

32
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

33
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

34
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
35
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)

36
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)

37
Screening
38
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

39
SCREENING

• Several brief, practical screening tools for
  alcoholism exist
• CAGE
• MAST-G
• AUDIT

40
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?

41
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

42
MAST-G

• 24 items (has shorter version)
• 5 yes responses indicative of alcohol problem
• High sensitivity specificity in a wide range of
  settings

43
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?

44
SCREENING

• BUT, MAST-G CAGE dont 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

45
Physiologic Changes with Age
Decreased Lean Body Mass
Decreased Total Body Water
Decreased gastric EtOH Dehydrogenase
Increased Serum EtOH for a given dose
46
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.

47
Consider alcohol and drug use and the Medical
Consequences on a Senior

• Central Nervous
• - Neuropathy
• DTs
• W-K syndrome
• Sleep Patterns
• Prescriptions and OTCs
• - Interactions
• - Negation
• Heart
• -Atrial fibrillation
• -CHD
• Digestion
• Ca nasopharynx oesophagus
• Blood pressure
• -Stroke

Organ function Liver -cirrhosis -cancer Orthope
dics - Falls - Twists - Breaks Continence
Pain Lower extremities - Balance - Pain -
Mobility
48
Medical consequences

• Osteoporosis
• conflicting results, may be related to
  socioeconomic status - role of nutrition
• likely plays a role

49
Medical consequences

• Trauma
• falls risk increases with level of alcohol intake
• significant with gt1000 gm/month
• Alcohol one of the three main reasons for falls
  in the elderly
• Cause significant morbidity and mortality

50
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 gt65 are 16x more likely to die of suicide
  ( Grabbe et al 1997).
• Poorer response to treatment

51
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)

52
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

53
DSMIV alcohol-induced persisting dementia

• A multiple cognitive deficits manifested by
  both
• memory impairment
• 1 of aphasia
• apraxia
• agnosia
• disturbance in executive
• functioning

54
DSMIV alcohol-induced persisting dementia

• B these deficits each cause significant
  impairment in social or occupational functioning
  represent a significant decline
• C deficits dont occur exclusively during the
  course of delirium persist beyond the usual
  duration of substance intoxication or withdrawal

55
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

56
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

57
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

58
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

59
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 200013141)

60
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

61

• TREATMENT

62

• Some of the concerns and fears elderly report
  when thinking about treatment
• Treatment takes too long
• Its embarrassing to tell people
• Treatment is just for kids
• Treatment is just for hard core addicts
• Treatment is too expensive
• Being away from home

63

• 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

64
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 1960s) 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.

65
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

66
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

67
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.

68
Brief Interventions
69
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

70
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 (n454)
• 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

71
Withdrawal in the Elderly

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

72
Withdrawal

• Anxiety
• Agitation
• Tremors
• Autonomic hyperactivity
• Seizures
• Nausea vomiting
• Hallucinations-visual,tactile,auditory
• Insomnia

73
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

74
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

75
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.

76
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

77
A Three Stage CBT Approach

1. Behavior analysis begin with a substance use
   profile to identify each clients antecedents and
   consequences for substance use. Create an
   individualized substance use behavior chain.
2. Teach clients 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.

78
A-B-C Approach to Treatment The Substance Use
Behavior Chain
Behavior
Consequences
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
79
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.

80
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
  clients individual needs.
• Have a strong sober support system (e.g. 12 step
  meetings, church, family, close friends).

81
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
82
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

83
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

84
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