Stephen Ross, MD, is clinical assistant professor of psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, at the New York University School of Medicine in New York City.
Disclosure: The author does not have an affiliation with or financial interest in any commercial organization that might pose a conflict of interest.
Please direct all correspondence to: Stephen Ross, MD, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine, 104 E. 40th Street, Suite 802, New York, NY 10016; Tel: 212-681-9790; E-mail: email@example.com.
• Alcohol continues to be the most commonly abused substance in the elderly, despite the fact that the prevalence of alcohol use disorders (AUDs) declines with age.
• The elderly undergo physiological changes that increase their sensitivity to alcohol and thus increase the deleterious effects of alcohol upon them. This is true even in individuals who drink minimal amounts of alcohol but experience adverse events when, for instance, alcohol use is combined with certain medications.
• Psychosocial factors associated with aging, such as the loss of a spouse or social networks, loneliness, isolation, and depression, contribute significantly as etiologic factors in the development of AUDs in the elderly.
• Since the vast majority of elderly individuals have regular contact with physicians, there are ample opportunities to screen for AUDs. However, many patients are not adequately screened due either to lack of training on the part of physicians or bias that such disorders are not worth treating in this population.
• Treatment is effective across the spectrum of AUDs in the elderly. Treatment philosophies should focus on communicating with these patients in an empathic, respectful manner, with an emphasis on simple and clear communications that take into account cognitive changes associated with aging, both normal and abnormal.
Despite a growing body of literature indicating an increase in alcohol use disorders (AUDs) among the elderly, this group of patients has historically been ignored.
The elderly are a vulnerable group who suffer a disproportionate amount of physical and psychosocial distress. Any alcohol use in this population, but especially excessive use, poses unique problems biologically, psychologically, and socially. This article will summarize the classification, prevalence, assessment, and treatment of AUDs in the elderly, with an emphasis on the special needs and unique aspects of engaging and treating this patient population.
Alcohol use disorders (AUDs) encompass a spectrum of problems related to alcohol use, ranging from mild misuse, to abuse and dependence. Alcohol use in the United States is most prevalent in individuals 18–45 years of age and declines with age.1 This decline in overall use does not mean that the problem becomes negligible. Among individuals ≥55 years of age, alcohol is the most commonly abused substance in patients admitted to publicly funded substance abuse treatment programs.2
AUDs are far more prevalent than any other addictive disorder in elderly individuals, including the abuse of prescription drugs such as benzodiazepines.3,4 With adults ≥65 years of age becoming the fastest growing segment of the population in the US, treatment for their health-related issues, including problems related to AUDs, poses a great challenge both from financial and public health perspectives. However, despite the growing number of individuals ≥65 years of age suffering from AUDs, these disorders remain under diagnosed and under treated leading some to call these disorders part of an “invisible epidemic.”5
Aging induces physiological changes that make the elderly more susceptible to the deleterious effects of alcohol.6 Given these changes, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have made the following recommendations in terms of age-appropriate drinking levels in individuals ≥65 years of age: No more than one drink/day (with one drink defined as 12 ounces of beer at 5% alcohol, or five ounces of wine at 12% alcohol or a 1.5 ounce shot of hard liquor at 40% alcohol), a maximum of two drinks on any occasion, and even lower limits for women.7 These limitations highlight how any alcohol use in the elderly can potentially be problematic, even if it does not cause an abuse or dependence syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).8 One could define alcohol misuse in the elderly as any alcohol use, not necessarily heavy use or meeting criteria for alcohol abuse or dependence, that leads to either subjective distress, discrete adverse events, or functional decline. Together, the spectrum of AUDs in the elderly exacerbate their already heightened risk for injury, disease, and social/financial deterioration.9
The first section of this article discusses the classification, prevalence, and risk factors associated with AUDs in the elderly. The second describes how to do a comprehensive evaluation, including medical, psychiatric, and psychosocial assessments. The last section discusses comprehensive treatment and what factors are associated with positive treatment outcomes.
Alcohol Misuse Disorders:
Potentially Risky, Risky, and Problem Drinkers
Precise rates of AUDs in the elderly vary because studies sample different patient populations, such as the elderly living in nursing homes or independently. Moreover, the exact definition of alcohol misuse, and diagnostic criteria used, has varied from study to study. Some experts on AUDs in the elderly employ the model of “risky” and “problem” alcohol use instead of the DSM-IV model of alcohol abuse and dependence, allowing for greater specificity and flexibility in describing the phenomenology of the spectrum of alcohol use in this population.10 A focus of some studies has been on risky drinking, defined as heavy drinking that does not result in progressive functional decline but can lead to discrete negative consequences. Another focus has been on problem drinking, defined as heavy drinking which does result in functional decline and which may or may not reflect DSM-IV criteria for either alcohol abuse or dependence. As defined above, however, alcohol misuse in the elderly population can encompass any alcohol use, including non-heavy drinking, that may lead to discrete negative consequences but not necessarily to progressive functional decline. For the purposes of this article, this is defined as “potentially risky” drinking. Examples in individuals ≥65 years of age commonly occur when any alcohol use is combined with certain medical conditions (ie, Alzheimer’s dementia, diabetes, hypertension,) or with certain medications, both prescription (ie, benzodiazepines,) or over-the-counter (ie, non steroidal anti-inflammatory drugs), leading to adverse events (ie, falls, gastrointestinal bleeding, hypoglycemia). It is difficult to know the true prevalence of potentially risky drinking in the elderly since little research has been devoted to this subgroup of individuals with AUDs. In contrast, more research has been devoted to risky and problem elderly drinkers. However, given the lack of uniform criteria, community prevalence rates of risky drinking reported in the elderly range from 3% to 25%, and the rates for problem drinking vary from 2.2% to 9.6% depending on the sample and measures used.11 The large differences in these studies underscore the difficulty in precisely identifying and describing the scope of these disorders.
Alcohol Abuse and Dependence
In contrast to risky or problem drinking, the community prevalence rates for alcohol dependence are significantly lower, with household surveys revealing only approximately 2% to 3% of elderly men and <1% of elderly women suffering from this disorder.12
Classification of Problem Drinking in the Elderly
One group of elderly patients with problem drinking patterns has been classified as the early-onset group. These patients have longstanding alcohol problems that usually begin in their 20s or 30s. This subgroup comprises approximately two thirds of older patients with problem drinking.13 Early-onset drinkers tend to continue maladaptive drinking patterns as they age. Psychiatric comorbidity tends to be the norm in this group, with major affective disorders and thought disorders being the most common. Moreover, this group tends to have severe medical complications secondary to chronic heavy alcohol use.14-16
A second subgroup, late-onset drinkers, comprise approximately one third of elderly problem drinkers. They tend to be physically and psychologically healthier than early problem onset drinkers. Moreover, they tend to have less alcoholism among family members, are of a higher socioeconomic status, have less psychopathology, and less alcohol-related chronic illness. Significantly, their drinking problems tend to begin in response to a recent loss, such as the death of a spouse.17
Despite their differences, these groups are similar in that they can both benefit from treatment. Even though late-onset problem drinkers have a more favorable psychological and physical profile and tend to resolve their drinking problems more often without formal treatment, there is little evidence to suggest that they are more responsive to alcohol treatment than patients who are early-onset drinkers.18
Risk Factors for AUDs
The elderly experience physiological and biological changes that increase their sensitivity to alcohol and decrease their tolerance for alcohol (Table 1). As a result of aging, there is a decrease in lean body mass, with a concomitant increase in body fat and a decrease in total body water. Since alcohol is water soluble, the concentration of ingested alcohol will be greater in an older person. The elderly also have lowered levels of alcohol dehydrogenase in the gastric mucosa, leading to a delay in metabolizing alcohol, with serum levels remaining elevated for longer periods of time. Given these physiologic changes, smaller amounts of alcohol intake in the
elderly, relative to a younger cohort of individuals, produce greater intoxication and toxicity.6
Older women drink less often and are less likely to drink heavily compared to older men.19 However, women are more likely than men to start drinking heavily later in life.20 Older men are at much higher risk of developing alcohol-related problems compared to older women.21,22
Having a family history of AUDs or genetic predisposition is a well-known risk factor for development of AUDs throughout one’s lifespan.23
Previous History of an AUD
There is also a strong correlation between having a history of an AUD and the recurrence of the problem later in life, often in response to a major loss, with relapse possible even after many years of abstinence.17
Psychiatric comorbidity is another well-known risk factor in elderly patients who develop AUDs. Approximately 25% of elderly patients with AUDs have comorbid major depression. There is evidence that comorbid mood disorders, especially major depression, either precipitate or maintain AUDs in late-onset problem drinkers, particularly women.24,14 Other disorders that are common in this population are cognitive spectrum disorders and anxiety spectrum disorders, both of which co-occur in 10% to15% of elderly individuals with AUDs.12
Chronic medical illness predisposes the elderly to AUDs as well. Elderly patients who develop late-onset problem drinking, or who relapse after having early problem drinking, often do so to medicate uncomfortable physical states brought on by the myriad of medical problems that commonly affect the elderly. In particular, chronic pain syndromes and insomnia are linked to the initiation and/or maintenance of AUDs in the elderly.5
Social factors also play an important role in the initiation of AUDs in the elderly. For many, the aging process is a difficult experience filled will loss, physical and psychological deterioration, shame, and humiliation. Many become isolated and lonely, cut off from their normal support network of family and friends. Other significant losses include the loss of one’s occupation/income, loss of mobility, and loss of independence in general. Alcohol, for certain individuals, can become a means to cope with stressful events, albeit one that can cause further problems. In one prospective study comparing late-onset problem drinkers with non-problem stable drinkers, the problem drinkers were more likely to have a history of responding to stressors and negative affective states with increased alcohol use.25 Moreover, AUDs are most prevalent in elderly patients who have been divorced or separated and in men who have been widowed.5 In fact, the highest rate of completed suicide in all groups is in elderly caucasian men who drink heavily and suffer from depression in the context of the death of a spouse.26 Finally, it is important to assess for spouses of family members who are actively misusing alcohol or other substances, as this too increases the risk of developing or maintaining an AUD.12
Given that approximately 87% of elderly patients regularly see a physician, the primary care setting remains the best place to screen for such AUDs.5 Other potential sources of screening include friends, family members, home health aids, meal delivery personnel, and staff members at senior citizen centers, social clubs, health fairs, and nursing homes. However, since only approximately 5% of individuals ≥65 years of age live in nursing homes, trained staff in this setting is only one limited way to screen for AUDs in these patients.
Despite the regular contact with primary care physicians, only a minority of elderly patients will directly seek help from their doctors for their alcohol-related problems.27 This may be due in part to intense shame and fear of being judged. Compounding this lack of self-referral, it is unlikely that physicians will identify an AUD despite frequent contact with these patients. This may be due partly to inadequate training. Another partial cause could be physician bias, where physicians erroneously or prejudicially assume that AUDs in this population are not worth identifying because they cannot be treated successfully, or that it is not worth devoting time and energy to patients who are toward the end of their life span.5 In addition, AUDs in the elderly tend to present with symptoms mimicking those of other common illnesses in this population, such as major depression, dementia, and hypertension.
Experts who work with elderly patients with AUDs have noted that since these individuals are often acutely sensitive to the stigma of having an AUD, it is important to ask screening questions in an empathic, nonjudgmental manner. The use of stigmatizing words such as alcoholic should be avoided. Getting collateral information from family members, friends, and other healthcare providers is essential, given that the history from the patient may be limited by such factors as shame, denial, or memory impairment due to either primary cognitive disorders or alcohol misuse.
Screening Methods and Instruments
Quantity/Frequency: Potentially Risky and Risky Drinking
Initially, the evaluating clinician should ask about quantity, frequency, and patterns of alcohol use. Doing so is important in order to identify any alcohol use that may be part of potentially risky drinking. This approach is also best at identifying risky drinkers who are misusing alcohol. These patients tend to display less denial and minimization regarding the amount of alcohol they use and any alcohol-related problems, compared to patients who have a greater severity of adverse consequences such as those with alcohol dependence.28 Specifically, clinicians in either a primary care or psychiatric setting can ask how many days a week the individual drinks alcohol, the number of drinks consumed in a typical day, and the maximum number of drinks consumed on any given occasion in the previous month (Table 2).
Problem Drinkers and Alcohol Abuse or Dependence Syndromes
If the goal is to identify problem drinkers or those with alcohol abuse or dependence, after this initial screen, the use of formal, standardized screening measures is more appropriate.29 Three screening instruments commonly used in this population are the CAGE questionnaire,30 the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G; Table 3),31 and the Alcohol Use Disorders Identification Test (AUDIT).32 The CAGE questions are as follows: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover? The CAGE is commonly used in primary care settings and is highly sensitive and specific in identifying alcohol-related problems, especially related to more severe AUDs. Two or more positive responses are considered indicative of probable alcohol abuse or dependence, and even one affirmative response should be followed up.33 This is especially true of elderly individuals given their increased sensitivity to the adverse effects of alcohol. The MAST-G was specifically designed for the elderly patient and is both highly sensitive and specific in detecting AUDs in this population across a variety of screening settings.34,35 The AUDIT was developed by the World Health
Organization to identify individuals whose alcohol use has become harmful or hazardous to their health. It can be used in multiple settings, including primary care and psychiatric clinics. It is a 10 item screening questionnaire that can identify risky or problem drinkers, or those with alcohol abuse or dependence. The length of the AUDIT may limit its use as compared to the CAGE, but its first three items have been helpful in identifying risky drinkers.36
Evaluation of Motivational Stages of Change
It is vital to assess how motivated any patient with an AUD is for a change in drinking behavior, even patients on the lowest end of the severity spectrum, who drink minimally, but suffer adverse consequences. The transtheoretical model of change, as developed by Prochaska and DiClemente,37 describes the following stages of change: Precontemplation, Contemplation, Preparation, Action and Maintenance. Precontemplation is the stage marked by denial, where an individual is not considering any need to change their drinking behavior. Contemplation is characterized by ambivalence, where one is increasingly aware of the negative consequences of alcohol use. In the Preparation stage, the individual believes that change is needed but has not made any attempts yet. In Action, initial and persistent attempts at change occur. Finally, Maintenance involves the retention of the changes made.
In addition to screening for the presence of an AUD in an elderly patient, it is important to evaluate the level of functional impairment caused by the use of alcohol. The elderly tend to have functional problems that are different from their younger counterparts. For example, instead of poor work performance as a result of alcohol misuse, their inability to shop for themselves may be more pertinent. In general, functional health assessment refers to an individual’s capacity to perform activities of daily living (ADLs), which include walking, dressing, bathing, and feeding oneself, and instrumental activities of daily living (IADLs), which include higher cognitive functions such as managing finances, shopping, meal preparation, and medication compliance. Alcohol use in the elderly can compromise both ADLs and IADLs. In one study, alcohol use was more strongly associated with functional impairment than age, smoking, use of anxiolytics, or a history of stroke.38
Physical Examination/Laboratory Measures
A thorough physical examination along with laboratory analysis should be performed on all elderly patients suspected of having an AUD. On physical exam, findings such as hypertension, the stigmata of alcoholic cirrhosis, and ataxia due to cerebellar damage are suggestive of an AUD, especially the more severe types. Several laboratory findings are suggestive of an AUD. In one study looking at patients ≥65 years of age, the most common abnormal laboratory values were increased mean corpuscular hemoglobin (MCH; 71%), increased aspartate aminotransferase (AST; 56%), increased γ-glutamyltransferase (GGT; 55%), and increased mean corpuscular volume (MCV; 44%). Other notable blood value increases were uric acid at 21% and triglycerides at 16%.39
Medical Review of Systems
A complete medical review of systems is essential as many medical problems in the elderly can either be caused or worsened by alcohol misuse, prompting one to search for alcohol as a potential etiologic source. A list of common problems, although by no means exhaustive, includes cardiac problems (hypertension, arrhythmias, and cardiomyopathy); liver damage (including fatty liver, alcoholic hepatitis, and cirrhosis); gastrointestinal problems (such as gastritis, esophagitis, esophageal varices, and hemorrhage); immune system impairment; malnutrition; and endocrinological problems including decreased bone density.
Alcohol has drug-drug interactions with a variety of medications. It is important to know of the potential adverse interactions between alcohol and common medications used by elderly patients which can occur even in patients who drink minimally (ie, potentially risky drinking). Of particular concern in the elderly is the use of alcohol with benzodiazepines, especially those with longer half-lives (ie, diazepam, clonazepam) used to medicate such common problems in the elderly, such as insomnia and anxiety. The mixture of these two agents, especially in older women, often results in negative outcomes, including falls, accidents, and cognitive decline.40 (Table 4)
Psychiatric and Neurological Evaluation
A thorough psychiatric evaluation is warranted in all elderly patients presenting with an AUD. As mentioned previously, major depression is the most common comorbid disorder in elderly patients with AUDs, followed by anxiety and cognitive spectrum disorders. Depressive or anxiety symptoms can either be caused or exacerbated by alcohol. Taking a careful history helps to determine whether the depressive or anxiety symptoms pre or postdate the drinking problem. If it is definitely determined that the depressive or anxious symptoms were solely due to alcohol use and quickly remit with abstinence, then psychotropic intervention is not warranted. However, often it is difficult to determine which condition came first, and ultimately treatment is indicated if symptoms cause significant impairment and/or if they persist.
A complete psychiatric evaluation should include a review of concomitant substance misuse in addition to alcohol. Other than alcohol, the most commonly misused substances by the elderly are nicotine and psychoactive prescription medications (ie, benzodiazepines).41 The abuse of illicit drugs in the elderly, such as marijuana, cocaine, or heroin, is a rare phenomenon except in those who abused them previously.4,21
A thorough evaluation should assess for sleep problems. The following sleep changes that normally occur with age and lead to insomnia are worsened by the use of alcohol: increased episodes of rapid eye movement (REM) sleep, decreased REM length, decreased stage III and IV sleep, and increased awakenings.42 Disruptions in sleep can exacerbate other psychiatric conditions in the elderly, especially mood disorders.
A full neurological work-up is warranted, as patients with a history of heavy alcohol use can display a spectrum of cognitive impairment from subtle deficits in memory, visual-spatial skills, abstraction, and problem solving, to alcohol amnestic disorders (ie, Wernicke-Korsakoff’s syndrome), to frank dementia. Any alcohol can exacerbate cognitive impairments in the elderly, ranging from mild memory impairment to dementias.
A complete social evaluation is vital given that social risk factors play a role in the initiation and maintenance of AUDs in the elderly. It is important to evaluate the patient’s social network and identify which members are supportive of treatment and which are potentially hazardous to the patient. Harmful network members include active substance abusers, those who “enable” the patient’s alcohol misuse, and those who abuse the patient physically, sexually, or emotionally. Since abuse in the elderly is not infrequent given their vulnerabilities, this is a vital area to be discussed with patients. In addition, the evaluation should make sure the patient has adequate housing and access to food. Mobility, adequate transportation, and access to medical care must also be assessed and considered.
Several experts who work with elderly patients with AUDs believe it is important to understand the specific ways to engage them.5 It is imperative to be empathic, respectful, and straightforward, with attention given to simple and clear communications geared toward the elderly patient’s slower informational processing abilities. Confrontational approaches, common in substance abuse treatment, are rarely helpful. Instead, “gentle persuasion” is a more effective approach. It is also important to keep in mind what motivates elderly patients, and what are the germane, age-appropriate issues they care about. Examples include financial stability, independent functioning, access to medical care, physical well-being, pain management, and social interaction.
This awareness allows for greater empathic attunement with the patient and a stronger therapeutic alliance. Another way of increasing engagement with the patient is to involve a broad social network in the patient’s treatment plan, including family members, friends, visiting nurses, social workers, primary care physicians, or religious members (Table 5).
General Goals of Treatment
The first goal of treatment is to promote a change in drinking behavior either via use reduction or abstinence, depending on the severity of the AUD and the motivational stage of the patient. Use reduction falls under the general category of “harm reduction,” which aims to diminish the harm caused by alcohol use. Examples range from getting potentially risky drinkers with dementia who refuse total abstinence to drink even less than the age-appropriate drinking levels in individuals ≥65 years of age, or getting patients with alcohol dependence, also refusing abstinence, to agree not to use alcohol in the most potentially hazardous situations, such as drinking and driving. For those patients who are able to achieve abstinence, relapse-prevention techniques become vital to maintain sobriety. Second, it is important to treat comorbid medical, psychiatric, or neurologic conditions that may either be exacerbated by or contribute to the development of AUDs. The next goal is to address psychological factors that promote AUDs in the elderly, such as issues of loss, loneliness, or problems with relationships. Finally, it is vital to address social factors that promulgate AUDs, for example, the lack of a support network and inadequate access to food, shelter, or medical care.
Potentially Risky and Risky Drinking
There are a range of therapeutic settings used to treat elderly patients with AUDs varying in types of treatment and level of intensity of treatment services. The least intensive approaches occur in primary medical or psychiatric outpatient settings that are not designed to provide specialized alcohol treatment services. Such approaches tend to be helpful for patients with less severe forms of AUDs. Brief interventions for potentially risky or risky drinkers are commonly used in these settings. This treatment modality is supportive, time limited, and requires minimal training to administer. In addition to trained physicians, home health aides, case managers, social workers, nurses, and physicians’ assistants can use this type of intervention. Examples of brief interventions include psychoeducation about the risks of any alcohol use combined with certain medications or excessive alcohol use, direct feedback on adverse behavior when drinking, and expression of empathy. Other examples include relating reasons for cutting down or quitting, emphasis on the patient’s ability to change their behavior, and advice to effectuate a change in drinking behavior by several methods such as setting goals, contracting, and behavior-modification planning. A number of clinical trials have shown that approximately 10% to 30% of problem drinkers have been able to reduce their alcohol intake in brief interventions lasting from one to three sessions.43,44
Follow-up is also vital in these patients, especially those who remain in the pre contemplative or contemplative stages of change. Given that so many patients regularly follow-up with their primary care physicians, these doctors need to continue to ask about alcohol use during every visit, continue to assess for adverse events, and continue to encourage and advise patients on changing their drinking behavior.
Problem Drinkers and Alcohol Abuse or Dependence Syndromes
Elderly patients with more moderate-to-severe AUDs should be treated by specialized addiction providers (ie, psychiatrists, psychologists, nurse practitioners, or social workers) in either a private practice setting or a formal specialized alcohol treatment program. Treatment intensity in this setting ranges from treatment once a week in an outpatient program, to encounters several times a week in intensive outpatient programs, to daily contact in day programs. Treatment can include pharmacotherapeutic interventions such as outpatient detoxification, medications that reduce cravings (i.e. naltrexone), and psychosocial interventions such as individual, group, and family therapy.
Inpatient programs are reserved for the most extreme cases. They include inpatient detoxification programs, inpatient rehabilitation programs, inpatient dual diagnosis units, and long-term residential programs. Inpatient detoxification programs are suitable for elderly patients who are at high risk for severe withdrawal symptoms or who have failed all outpatient modalities. Following detoxification, these patients are often transferred to inpatient rehabilitation programs, or alternatively, some programs provide both services in the same setting. Patients with severe medical problems are often admitted to acute inpatient medical settings. Patients with severe comorbid psychiatric problems often need admission to an inpatient dual diagnosis unit, usually for behavior that poses a danger to themselves or others. Long-term residential programs or nursing homes are needed for patients with, for example, comorbid chronic, severe, persistent mental illness, and/or chronic, severe medical illnesses, or patients with severe, non-remitting drinking behavior along with comorbid dementia.
Irrespective of treatment setting, programs that treat elderly patients with AUDs should possess several unique components and be guided by certain fundamental treatment principles.24,45 Supportive, non confrontational approaches are preferable, with the goal of enhancing the patient’s self-esteem. The establishment, or re-establishment, of a patient’s support network is important to make the patient feel more connected to others and to promote use reduction or abstinence. The pace of the treatment must be adjusted to reflect cognitive changes associated with aging, or to account for either primary cognitive disorders or ones secondary to alcohol use. Furthermore, the intensity and frequency of contact in any particular treatment setting should be individualized to match the patient’s needs and motivational stage, and to reflect the severity of their AUD and other co-morbid conditions. There should be a focus, especially in relapse prevention, on dealing with depression, physical pain, loneliness, and loss, as these are potential alcohol-use triggers in this patient population. It is crucial in any setting to have staff members who have training and interest in working with this patient population. Finally, any treatment setting or program has to have direct access or the referral capacity for consultation services, including medical, psychiatric, and case management services.
Treatment planning needs to be comprehensive and include a wide range of clinical interventions ranging from psychosocial to psychopharmacologic modalities (Table 5).
For all elderly patients with AUDs who display prominent denial or ambivalence about the need for a change in their drinking habits, including those with potentially risky or risky drinking, motivational interviewing (MI) is a useful technique.46 MI is a non confrontational, client-centered treatment that is well-suited for elderly patients in the precontemplative or contemplative stages of change with the goal of moving the patient along the motivational continuum. Aspects of MI include expression of empathy, working with ambivalence, assessing a patient’s readiness for change, assessing strengths and barriers to change, eliciting motivational responses, and placing the responsibility of change directly with the patient. MI has many aspects in common with brief interventions used in potentially risky and risky drinkers as described above. However, unlike MI, brief interventions give direct advice to change behavior and provide a menu of options to effectuate change.
Supportive psychotherapy can also be effective with elderly patients across the spectrum of AUDs. The focus is for the therapist to improve the patient’s adaptive functioning by being open, directive, and empathic. A particular focus is to listen for themes of loss, grief, and sadness.
Relapse prevention, another psychotherapeutic modality, can be particularly useful especially for patients with more moderate to severe AUDs who are struggling to remain abstinent. Relapse prevention is a type of cognitive-behavioral therapy (CBT) based on social learning theory, with the premise that abstinent patients experience internal and external cues that initiate craving that leads to lapses (ie, slips) or relapses.47 This therapy strives to help the patient identify triggers, cope with cravings, and manage high-risk situations.
Complementing individual psychotherapy, group psychotherapy is a commonly used treatment modality across all age groups and has been described by some as “the treatment of choice for chemical dependency.”48 Having an aged-matched cohort of peers provides mutual support, allows for peer bonding, and fosters the establishment of peer sobriety networks. Alcoholics Anonymous (AA) is a good example of this for patients with alcohol dependence, especially when meetings include mostly elderly patients. Moreover, psychoeducational and CBT-oriented groups such as relapse prevention groups are also commonly used in most specialized addiction treatment settings.
Whenever possible, family therapy should be made available. Involving family members is useful as a way to strengthen the patient’s support network and as a means to promote abstinence. For patients who are married, marital therapy may be indicated as well.
Community outreach services are particularly important for this patient population. Many are widowed, divorced, or single and live alone with little outside contact. As such, they benefit tremendously from services including assertive case management; home health aides; meal delivery programs; and transportation to and from appointments, AA meetings, or social clubs.
It is important to treat psychiatric comorbidity, including major depression, anxiety spectrum disorders, bipolar disorders, and psychotic spectrum disorders, across the spectrum of AUDs in the elderly. Untreated, these comorbid conditions can worsen the course and severity of the patient’s AUD, even those on the less severe side of the spectrum.
Psychopharmacologic Treatment for Elderly Patients with Alcohol Dependence
There are medications targeted to reduce alcohol use or promote abstinence in patients with alcohol dependence. Disulfiram is an acetaldehyde dehydrogenase inhibitor that causes an aversive reaction when taken with alcohol. Use of this agent is limited in the elderly due to their higher risk for adverse cardiovascular events caused by acetaldehyde toxicity and disulfiram induced hepatic toxicity. Naltrexone is a long-acting opiate antagonist that appears safe and effective in the elderly. It has been reported to decrease craving, increase the time to first drink, and increase the time to heavy drinking once patients with alcohol dependence have their first drink.49 Side effects are usually mild, and include nausea, headaches, anxiety, and in rare cases, liver damage. Acamprosate, which is thought to act as a glutaminergic-system stabilizer, has shown promise as an anti-craving agent in patients with alcohol dependence. Used in Europe since 1989, it has just been approved for use in the US and will be available in early 2005. Patients treated with acamprosate exhibited a significantly greater rate of treatment completion, time to first drink, abstinence rate, and/or cumulative abstinence duration compared to placebo.50 Ondansetron which is a 5-HT3 receptor antagonist has been shown to decrease alcohol use in early-onset alcohol-dependent patients.51 This has suggested the possible utility of mirtazapine, which has 5-HT3 receptor antagonism as well, in patients with alcohol dependence, especially with comorbid depressive or anxiety spectrum disorders. Finally, anticonvulsants have been studied for use in alcohol dependence as anti-craving agents. A recent randomized, placebo-controlled study with oral topiramate for the treatment of alcohol dependence found that, compared to placebo, patients treated with topiramate reported fewer drinks per day, fewer heavy drinking days, more total time abstinent, and less craving for alcohol.52 However, topiramate should be used with caution in the elderly given that cognitive impairment is a known side effect of the medication.53
Despite bias that prevents recognition of AUDs in elderly patients or deems such patients as untreatable, research shows that treatment does work in this population. As described above, brief interventions can be effective for patients with potentially risky or risky drinking. In general, treatment outcomes are as good or better for older patients compared to younger ones.54 As a group, the elderly are more likely to be compliant and remain in longer-term outpatient programs.55 Other factors that increase positive treatment outcomes in the elderly include coercion (ie, court-mandated treatment), spousal involvement in treatment, and being treated in an age-matched setting.12
Presently, AUDs in the elderly are poorly recognized and insufficiently treated. AUDs range from potentially risky patients who do not drink regularly or heavily to those with alcohol dependence. Issues of loss and loneliness, increased medical illness, and increased biological sensitivity to the deleterious effects of alcohol, leave the elderly at unique risk for AUDs. Any individual ≥65 years of age who drinks any amount of alcohol can be at risk for developing adverse events given the increased biological sensitivity to alcohol and the potential for adverse interactions with common medical illnesses and medications used in this population.
Screening instruments for patients with moderate to severe AUDs, such as the CAGE and MAST-G, are simple to perform and have a relatively high degree of sensitivity and specificity. A careful psychiatric and medical work-up is essential in the diagnosis and subsequent treatment of alcohol-related problems in this population.
Once the severity of the AUD has been determined, appropriate treatment and referral is necessary. For less severe alcohol misuse, brief interventions may be sufficient in the primary care setting. However, as the severity of the problem increases, specialized treatment settings ranging from outpatient to inpatient become necessary. Across treatment settings, one should be mindful of the unique problems that the elderly face. Empathic, non confrontational, and slower types of interactions are more effective. Treatment should be broad and comprehensive by addressing the biological, psychological, and social factors that contribute to AUDs in this population. Treatment may encompass brief, time-limited interventions, as well as individual, group (especially AA meetings and relapse prevention), family, and couples therapies. These should be accompanied by psychiatric and medical oversight, if needed. A special emphasis on building or re-building a supportive, abstinent social network, especially for those with alcohol dependence, is important. Given the issues of loss and family disintegration in these patients, providing community outreach services is important as well. Treatment works best when done in an age-matched milieu, where staff are specifically trained and dedicated to working with the elderly. PP
1. Helzer JE, Burnam A, McEvoy LT. Alcohol abuse and dependence. In: Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, NY: The Free Press/MacMillan, Inc.; 1991:81-115.
2. Substance Abuse and Mental Health Services Administration. The NHSDA Report: Alcohol Use. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2001.
3. Holroyd S, Duryee JJ. Substance use disorders in a geriatric psychiatry outpatient clinic: Prevalence and epidemiologic characteristics. J Nerv Ment Dis. 1997;185(10):627-632.
4. Jinks MJ, Raschko RR. A profile of alcohol and prescription drug abuse in a high-risk community-based elderly population. DICP. 1990;24(10):971-975.
5. Blow FC. Special Issues in treatment: older adults. In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, eds. Principles of Addiction Medicine. 3rd ed. Chevy Chase, MD. American Society of Addiction Medicine, Inc.;2003: 581-607.
6. Smith JW. Medical manifestations of alcoholism in the elderly. Int J Addict. 1995;30(13-14):1749-1798.
7. National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Physicians’ Guide to Helping Patients with Alcohol Problems. Rockville, MD: NIAAA, National Institutes of Health; 1995.
8. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
9. Tarter RE. Cognition, aging, and alcohol. In: Beresford TP, Gomberg E, eds. Alcohol and Aging. New York, NY: Oxford University Press; 1995:82-97.
10. Blow FC. Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series No. 26. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment; 1998.
11. Liberto JG, Oslin DW, Ruskin PE. Alcoholism in older persons: A review of the literature. Hosp Community Psychiatry. 1992;43(10):975-984.
12. Atkinson R. Alcoholism and the elderly. In: Johnson BA, Ruiz P, Galanter M, eds. Handbook of Clinical Alcoholism Treatment. Baltimore, MD: Lippincott Williams & Wilkins; 2003:259-272.
13. Alcoholism in the elderly. Council on Scientific Affairs, American Medical Association. JAMA. 1996;275:797-801.
14. Schonfeld L, Dupree LW. Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol. 1991;52:587-592.
15. Atkinson RM. Substance use and abuse in late life. In: RM Atkinson, ed. Alcohol and Drug Abuse in Old Age. Washington, DC: American Psychiatric Press; 1984:1-21.
16. Atkinson RM, Turner JA, Kofoed LL, et al. Early versus late onset alcoholism in older persons: Preliminary findings. Alcohol Clin Exp Res. 1985;9:513-515.
17. Atkinson RM, Ganzini L. Substance abuse. In: Coffey CE, Cummings JL, eds. Textbook of Geriatric Neuropsychiatry. Washington, DC: American Psychiatric Press; 1994:297-321.
18. Atkinson RM. Late onset problem drinking in older adults. Int J Geriatr Psychiatry. 1994;9:321-326.
19. Gomberg ESL. Older women and alcohol use and abuse. In: Galanter M, ed. Recent Developments in Alcoholism: Volume 12. Alcoholism and Women. New York, NY: Plenum Press; 1995:61-79.
20. Menninger J. Assessment and treatment of alcoholism and substance related disorders in the elderly. Bull Menninger Clin. 2002;66(2):166-183.
21. Myers JK, Weissman MM, Tischler GL et al. Six-month prevalence of psychiatric disorders in three communities: 1980-1982. Arch Gen Psychiatry. 1984;41:959.
22. Atkinson RM. Aging and alcohol use disorders: diagnostic issues in the elderly. Int Psychogeriat. 1990;2:55-72.
23. Heller DA, McLearn GE. Alcohol, aging, and genetics. In: Beresford TP, Gomberg E, eds. Alcohol and Aging. New York, NY: Oxford University Press; 1995:99-114.
24. Dupree LW, Broskowski H, Schonfeld L. The Gerontology Alcohol Project: A behavioral treatment program for elderly alcohol abusers. Gerontologist. 1984;24:510-516.
25. Schutte KK, Brennan PL, Moos RH. Predicting the development of late-life late-onset drinking problems: a 7-year prospective study. Alcohol Clin Exp Res. 1998;22(6):1349-1358.
26. Roy A. Suicide. In: Kaplan HI, Sadock BJ, eds. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1998:867-872.
27. Dehart SS, Hoffmann HG. Screening and diagnosis of “alcohol abuse and dependence” in older adults. Int J Addict. 1995;30:1717-1747.
28. Williams GD, Aitken SS, Malin H. Reliability of self-reported alcohol consumption in a general population survey. J Stud Alcohol. 1985;46(3):223-227.
29. Conigliaro J. Principles of screening and early intervention: In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, eds. Principles of Addiction Medicine., 3rd ed. Chevy Chase, MD. American Society of Addiction Medicine, Inc.; 2003:325-336.
30. Ewing JA. The CAGE questionnaire. JAMA. 1984;252:1907.
31. Blow FC, Brower KJ, Schulenberg JE, et al. The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcohol Clin Exp Res. 1992;16:372.
32. Babor TF, de la Fuente JR, Saunders J et al. AUDIT—The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva, Switzerland: World Health Organization; 1992
33. Girela E, Villanueva E, Hernandez-Cueto C, et al. Comparison of the CAGE questionnaire versus some biochemical markers in the diagnosis of alcoholism. Alcohol Alcohol. 1994;29:337-343.
34. Morton JL, Jones TV, Manganaro MA. Performance of alcoholism screening questionnaires in elderly veterans. Am J Med. 1996;101(2):153-159.
35. Joseph CL, Ganzini L, Atkinson RM. Screening for alcohol use disorders in the nursing home. J Am Geriatr Soc. 1995;43(4):368-373.
36. Gordon, AJ, Maisto SA, McNeil M, et al. Three questions can detect hazardous drinkers. J Fam Pract. 2001;4:313-320.
37. Prochaska JO, DiClemente CC, Norcross JC. In: search of how people change: applications to the addictive behaviors. Am Psychol. 1992;47:1102-1114.
38. Ensrud KE, Nevitt MC, Yunis C, et al. Correlates of impaired function in older women. J Am Geriatr Soc. 1994;42:481-489.
39. Hurt RD, Finlayson RE, Morse RM, Davis LJ. Alcoholism in elderly persons: medical aspects and prognosis of 216 inpatients. Mayo Clin Proc. 1988;63:753-760.
40. Roy W, Griffin M. Prescribed medications and the risk of falling. Topics in Geriatric Rehabilitation. 1990;5(20):12-20.
41. Goldberg RJ, Burchfiel CM, Reed DM, et al. A prospective study of the health effects of alcohol consumption in middle-aged and elderly men: The Honolulu Heart Program. Circulation. 1994;89:651-659.
42. Haponick EF. Sleep disturbances of older person: Physicians’ attitudes. Sleep. 1992;15(2):168-72.
43. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Int Med. 1997;12(5):274-283.
44. Fleming MJ, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039-1345.
45. Schonfeld L, Dupree LE. Treatment approaches for older problem drinkers. Int J Addict. 1995;30(13&14):1819-1842.
46. Miller W, Rollnick SS. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: The Guilford Press; 1991.
47. Marlatt GA, Gordon JR, eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, NY: The Guilford Press; 1985.
48. Matano RA, Yalom ID. Approaches to chemical dependency: chemical dependency and interactive group therapy-a synthesis. Int J Group Psychother. 1991;41:269-293.
49. Krystal JH, Cramer JA, Krol WF, Kirk GF, Rosenheck RA. Naltrexone in the treatment of alcohol dependence. N Engl J Med. 2001;345(24):1734-1739.
50. Mason BJ. Treatment of alcohol-dependent outpatients with acamprosate: a clinical review. J Clin Psychiatry. 2001;62(suppl 20):42-48.
51. Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: A randomized controlled trial. JAMA. 2000;284:963-971.
52. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomized controlled trial. Lancet. 2003;17;361(9370):1677-1685
53. Meador KJ, Loring DW, Hulihan JF, et al. Differential cognitive and behavioral effects of topiramate and valproate. Neurology. 2003;13;60(9):1483-1488.
54. Atkinson RM. Treatment programs for aging alcoholics. In: Beresford T, Gomberg E, eds. Alcohol and Aging. New York, NY: Oxford University Press; 1995, 186-210.
55. Oslin D, Liberto JG, O’Brien J, et al. Naltrexone as an adjunctive treatment for older patients with alcohol dependence. Am J Geriat Psychiatry. 1997;5:324-332.