Transcript Alcohol problems in the elderly

Alcohol problems in the
elderly
Dr Karim Dar
Consultant Psychiatrist
St Bernards Hospital, London
Outline
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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
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What are the facts about
addiction?
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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
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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
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But not via detox alone
But not via acute interventions alone
But not via treating psychiatric comorbidities 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
100
Addiction Treatment Does Work
90
80
40
30
20
50 to 70%
50
30 to 50%
60
50 to 70%
70
40 to 60%
Percent of Patients Who Relapse
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
10
0
Drug
Type I Hypertension Asthma
Dependence Diabetes
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
What’s happening in the
brain?
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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
Brain
CMAJ Mar 20, 2001; 164(6)
“It’s a brain disease….”
What’s happening in the
brain?
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Drugs of abuse act
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directly by influencing action of dopamine
indirectly by affecting modulating pathways
such as GABA, opioid, serotoninergic,
acetylcholine and noradrenergic
Neurons
CMAJ Mar 20, 2001;
164(6)
Sensible drinking
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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
30%
25%
Men
Drinking
>21 units
per week
Women
Drinking
>14 units
per week
20%
15%
10%
5%
0%
1992
Proportion Drinking more than daily
guidelines on one day in previous week
(ONS, 2002)
50
45
40
35
30
25
20
15
10
5
0
Men
Women
16- 25- 45- >65
24 44 64
Men Drinking above
‘sensible’ levels (ONS, 2002)
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
>4 units
>8 units
1624
>16
>65
Women drinking above
‘sensible’ levels (ONS, 2002)
40%
35%
30%
25%
20%
15%
>3 units
>6 units
10%
5%
0%
1624
>16
>65
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
56.8
58.3
53.0
60
18 to 25
26 to 34
35 to 54
55 or Olde r
30.3
40
7.6
5.3
2.3
12.8
9.4
7.8
4.9
1.0
10
21.1
30
20
37.8
37.5
50
15.9
Percent Reporting Use in Past Month
70
0
Any Illicit
Drug Use
Any Alcohol
Use
"Binge"
Alcohol use
Heavy
Alcohol Use
Prevalence
Geriatric Alcohol Problems
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A & E Departments…..
14%
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Medical inpatients…….
6-11%
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Psychiatric inpatients…
20%
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Nursing home patients..
Up to 49%
Early v. Late Onset Alcoholism
Early onset:
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Describes those who have a lifelong pattern of drinking, have probably
been alcoholic all their life, and are now elderly.
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More likely to have chronic alcohol-related medical problems such as
cirrhosis, organic brain syndrome, and co-morbid psychiatric disorders.
Late onset:
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Describes those who have become alcoholic in their drinking pattern for
the first time late in life.
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Often triggered by a stressful life event.
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Generally represented by milder cases with fewer accompanying
medical problems.
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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
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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.)
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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
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Anxiety
Blackouts, dizziness
Depression
Disorientation
Mood swings
Falls, bruises, burns
Family problems
Financial problems
Headaches
Incontinence
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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
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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
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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
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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 abuse
and dependence may not be
adequate to diagnose older adults
with 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
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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 assumptions
 Failure to recognize symptoms
 Lack of knowledge about screening
 Physician discomfort with substance
abuse topic
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- 46.6% of primary care physicians found it
difficult to discuss prescription drug abuse
with their patients
(CASA,
2000)
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
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- 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
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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
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Several brief, practical screening tools
for alcoholism exist:
CAGE
MAST-G
AUDIT
SCREENING
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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
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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
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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
SCREENING
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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 Total
Body Water
Decreased gastric
EtOH Dehydrogenase
Increased Serum EtOH for a
given dose
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.
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Slowed metabolic breakdown and
elimination.
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pace / duration of detox, withdrawal, stabilization.
Blood levels persist longer.
“CNS”: Age-associated central nervous system
sensitivity.
Consider alcohol and drug use and the
Medical Consequences on a Senior
Organ function
Liver:
-cirrhosis
-cancer
Central Nervous:
- Neuropathy
-DTs
-W-K syndrome
Sleep Patterns
Orthopedics:
- Falls
- Twists
- Breaks
Prescriptions and
OTC’s:
- Interactions
- “Negation”
Continence
Heart
-Atrial fibrillation
-CHD
Digestion
Ca nasopharynx &
oesophagus
Pain
Lower extremities:
- Balance
- Pain
- Mobility
Blood pressure
-Stroke
Nutrition:
- Appetite
Medical consequences
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Osteoporosis
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conflicting results,
may be related to
socioeconomic
status - role of
nutrition
likely plays a role
Medical consequences
Trauma
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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
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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
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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
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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
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A: multiple cognitive deficits manifested by
both:
memory impairment
≥1 of:
aphasia
apraxia
agnosia
disturbance in executive
functioning
DSMIV alcohol-induced
persisting dementia
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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
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Evidence from the Hx, P/E or lab
findings that the deficits are etiologically
related to the persisting effects of
substance use
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In 1998, Oslin et al. proposed clinical
criteria for alcohol-related dementia
Alcohol related dementia
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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
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↑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
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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
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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 2000:13:141)
Alcohol related dementia
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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
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Most seniors have strong social supports.
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Often resilient; they have coping skills to build upon.
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Living longer, continuing to develop intellectually,
emotionally and spiritually.
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Improved health status and access to health care.
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Informed consumers.
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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 network
4. Employ staff experienced in working with elders
5. Link with aging, medical, and institutional settings
6. Slower pace & age-appropriate content
7. Create a “culture of respect” for older clients
8. Broad, holistic approach to treatment recognizing
age-specific psychological, social & health aspects
9. Adapt treatment to address gender issues
Helping Older Adults Make the
First Step to Treatment
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The health care system is a ripe gateway to
treatment.
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Family concern is a motivating factor
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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
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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
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Project GOAL (Guiding Older Adult Lifestyles)
(Fleming et al., 1999; University of Wisconsin)
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Brief physician advice for 156 adult at-risk drinkers
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Reduced consumption (35%-40%) at 12 months
Health Profile Project Univ. of Michigan (Blow and Barry)
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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.)
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More than 4300 people screened
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About 6% drinking more than recommended
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Almost 40% reduction of alcohol use
Withdrawal in the Elderly
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Onset of withdrawal delayed (days)
May be prolonged
Often presents with confusion
Hallucinations (visual/tactile) may persist for
months
Withdrawal
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Anxiety
Agitation
Tremors
Autonomic hyperactivity
Seizures
Nausea & vomiting
Hallucinationsvisual,tactile,auditory
Insomnia
I. Alcohol Detoxification Concerns in
Geriatric Patients
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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
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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..
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Groups:
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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
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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.
2.
3.
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.”
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.
Teach specific skills to address these high
risk situations to prevent relapse.
“A-B-C” Approach to Treatment:
The Substance Use Behavior Chain
Antecedents
Situations/ + Feelings + Cues + Urges
Thoughts

Behavior
1st drink or

Use of drug

Consequences

Immediate/
Short Term
Conseq. + or Long Term
Consequences
(always negative)
Home/alone + bored and depressed +
beer in refrigerator + “A drink will help
me forget my troubles.”
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First sip
of beer
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Feel happier
Continue drinking,
anger her children,
and impair health
Relapse Prevention Strategies
For Older Adults (1 of 2)
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Help clients develop meaningful leisure, social or vocational activities.
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Work with client and their physician on pain control strategies (ideally, non
chemical ones).
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Address grief issues throughout treatment and refer for additional supportive
services when needed.
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Teach clients good sleep habits (e.g. forego a daytime nap) and non chemical
ways to cope with sleep disturbances.
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Be sure that mental health issues are being addressed and treated.
Relapse Prevention Strategies
For Older Adults (2 of 2)
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Be sure client is keeping medical appointments, taking
medications as prescribed and communicating changes in health
status to physician.
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Teach stress management skills throughout treatment.
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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 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
Research Questions
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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
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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