Who First Introduced the Chelsea Family to Recovery From Alcoholism?
Alcoholism in the Elderly
Am Fam Physician. 2000 Mar 15;61(half-dozen):1710-1716.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Commodity Sections
- Abstruse
- Definitions of Alcohol-Related Bug
- Epidemiology
- Pharmacology of Alcohol and Aging
- Adverse Furnishings of Excessive Alcohol Use
- Identification of Alcohol Problems in Older Adults
- Clinical Management
- Treatment Options
- References
Alcohol abuse and alcoholism are common but underrecognized problems amidst older adults. One third of older alcoholic persons develop a trouble with booze in later life, while the other two thirds abound older with the medical and psychosocial sequelae of early-onset alcoholism. The mutual definitions of booze corruption and dependence may not apply as readily to older persons who accept retired or take few social contacts. Screening instruments tin can be used by family physicians to identify older patients who take problems related to alcohol. The effects of alcohol may be increased in elderly patients because of pharmacologic changes associated with aging. Interactions betwixt alcohol and drugs, prescription and over-the-counter, may also be more than serious in elderly persons. Physiologic changes related to aging can alter the presentation of medical complications of alcoholism. Management of alcohol withdrawal in elderly persons should be closely supervised by a health intendance professional. Alcohol treatment programs with an elder-specific focus may improve outcomes in some patients.
When caring for older patients who have bug related to booze use, family unit physicians often encounter interrelated medical, behavioral, social and environmental factors. In such cases, physicians must maintain a high alphabetize of suspicion and a non-judgmental mental attitude, and should be able to recognize patient defenses and finer support the patient's family members. A flexible arroyo allows physicians to individualize handling for avant-garde historic period, physical and cognitive harm, express financial resources and varying patient preferences.
Primal shifts in the delivery of wellness care are changing the patterns of treatment for alcohol abuse.ane Patients with mild problem drinking who do not meet the criteria for alcohol abuse or dependence may benefit from brief, targeted counseling past their family physician.2 Some older alcoholic patients may refuse referral to treatment programs because of perceived negative stigma. Family physicians must manage medical complications, coordinate alcohol-related treatment and address the consequences of alcoholism for family members and the community.
Definitions of Alcohol-Related Bug
- Abstract
- Definitions of Alcohol-Related Problems
- Epidemiology
- Pharmacology of Booze and Aging
- Adverse Effects of Excessive Alcohol Utilize
- Identification of Alcohol Problems in Older Adults
- Clinical Direction
- Handling Options
- References
Criteria from the Diagnostic and Statistical Transmission of Mental Disorders, 4th ed. (DSM-Iv) for alcohol abuse and dependence are listed in Table i.three These criteria may exist more difficult to apply to older persons, especially those who are retired or isolated from frequent social interaction.4,v The International Classification of Diseases-ten of the World Health Organization has added an additional category, "hazardous drinking," to describe an private's pattern of booze utilize that may result in negative consequences, although he or she does non meet criteria for booze dependence or abuse.6
TABLE i
Criteria for Substance Abuse and Dependence
| Substance abuse | ||
| A. A maladaptive pattern of use leading to clinically significant impairment or distress, with one or more of the following symptoms within a 12-month period: | ||
| 1. Recurrent substance utilise resulting in a failure to fulfill major role obligations at work, school or dwelling house (e.g., repeated absences or poor work performance related to substance use; substance-related absences or expulsions from school; neglect of children or household). | ||
| 2. Recurrent utilise in situations in which it is physically hazardous (east.g., driving an automobile or operating a machine when impaired past substance use). | ||
| 3. Recurrent legal bug related to substance employ (e.g., arrests for substance-related disorderly bear). | ||
| iv. Continued utilize despite persistent or recurrent social or interpersonal issues acquired or exacerbated past the effects of the substance (e.g., arguments with spouse most consequences of intoxication; physical fights). | ||
| B. The symptoms have never met the criteria for substance dependence for this class of substance. | ||
| Substance dependence | ||
| A maladaptive blueprint of substance apply, leading to clinically pregnant damage or distress, as manifested past three or more of the following, occurring at whatsoever time in the aforementioned 12-month period: | ||
| 1. Tolerance, as defined past either of the following: | ||
| A need for markedly increased amounts of the substance to achieve intoxication or desired effect. | ||
| Markedly macerated effect with continued use of the same corporeality of the substance. | ||
| 2. Withdrawal, equally manifested past either of the following: | ||
| Characteristic withdrawal syndrome from the substance. | ||
| The same (or closely related) substance is taken to salve or avert withdrawal symptoms. | ||
| iii. The substance is often taken in larger amounts or over a longer menstruum of time than was intended. | ||
| four. There is a persistent desire or unsuccessful efforts to cutting down or command substance employ. | ||
| v. A bully deal of time is spent in activities necessary to obtain the substance (e.thousand., visiting multiple doctors or driving long distances), use the substance (e.one thousand., chain smoking), or recover from its effects. | ||
| 6. Important social, occupational or recreational activities are given up or reduced because of substance utilise. | ||
| 7. The substance utilise is continued despite knowledge of having a persistent or recurrent concrete or psychologic problem probable to accept been acquired or exacerbated by the substance (due east.g., current cocaine use despite recognition of cocaine-induced depression, or connected drinking despite recognition that an ulcer was made worse by booze consumption). | ||
| Specify if: with physiologic dependence: evidence of tolerance or withdrawal (i.e., detail i or 2 is present); without physiologic dependence: no evidence of tolerance or withdrawal (i.e., neither detail one nor 2 is present). | ||
The equivalent of 0.v oz of booze is considered one drink: approximately 1.5 oz of distilled spirits, 12 oz of beer or 5 oz of vino. For men and women 65 years of age or older, the National Institute on Alcohol Abuse considers one beverage per mean solar day to be the maximum corporeality for "moderate" booze utilise.6
Epidemiology
- Abstract
- Definitions of Alcohol-Related Problems
- Epidemiology
- Pharmacology of Alcohol and Aging
- Adverse Furnishings of Excessive Alcohol Use
- Identification of Alcohol Issues in Older Adults
- Clinical Management
- Handling Options
- References
In the future, every bit the older population grows, increasing numbers of older alcoholics will crave health intendance.7 Although alcohol problems are often underreported, alcohol utilise remains common amid older persons. In a study of community-dwelling persons 60 to 94 years of age, 62 pct of the subjects were plant to drink alcohol, and heavy drinking was reported in 13 percent of men and 2 percentage of women.viii Overall, virtually 6 pct of older adults are considered heavy users of booze. In this study, heavy drinking is defined as having more two drinks per twenty-four hours.8
Alcoholic patients frequently require wellness intendance in many different settings, with the highest rates of care seen in emergency, infirmary, psychiatric institution and nursing facility settings.9 In a study of 1989 Medicare hospital claims information, researchers constitute that 1.one pct of all hospitalizations amidst beneficiaries were for booze-related diagnoses, and a college pct of admissions cited booze use equally an underlying or associated factor.10
However, overall consumption of alcohol in the population appears to refuse with advancing historic period.4 Researchers question whether this finding represents a truthful decrease in consumption as individuals age, or if information technology reflects differences in alcohol utilise between current cohorts of older persons when cross-sectionally compared with younger cohorts.iv Nearly longitudinal data suggest little change in booze consumption equally people age. If change occurs, booze employ typically decreases.4 Reasons for a decrease in or spontaneous cessation of alcohol apply amongst older persons include increased physiologic effects per drink, medical issues that limit accessibility or desirability of alcohol, financial strain and a trend toward fewer social events that emphasize booze consumption.11
About two thirds of elderly alcoholic patients started drinking at a young age.7 Some attrition from booze-related death occurs, but many persons with early-onset alcoholism survive to develop booze-related illnesses compounded by changes associated with aging. Persons with early-onset alcoholism have a higher prevalence of antisocial beliefs and family history of alcoholism. Reject in socioeconomic status and family estrangement are frequently seen in this group.12 Late-onset drinking accounts for the remaining one third of elderly persons who abuse booze, among whom a higher level of teaching and income is found.vii Stressful life events, such as bereavement or retirement, may trigger late-onset drinking in some, but not all, persons.13 Retirement does non predict substantial changes in booze apply for most persons.14
Patients with late-onset alcoholism generally take greater resources and family support, are more likely to consummate treatment and accept somewhat better outcomes than patients with early-onset alcoholism.12,15 A longitudinal study of prognosis for older alcoholics found an overall 21 percent stable remission of late-life drinking at iv years, with late-onset alcoholics almost twice as likely every bit early-onset alcoholics to accept stable remission from handling.xv
Pharmacology of Alcohol and Aging
- Abstruse
- Definitions of Alcohol-Related Problems
- Epidemiology
- Pharmacology of Alcohol and Aging
- Agin Effects of Excessive Alcohol Utilise
- Identification of Alcohol Problems in Older Adults
- Clinical Direction
- Treatment Options
- References
Effects of alcohol at the cellular and organ levels are altered past changes in physiology related to aging. Absorption of alcohol from the gastrointestinal tract is equally rapid among all age groups.ix Notwithstanding, the loss of lean body mass related to aging may reduce the volume of booze distribution, resulting in an increased peak ethanol concentration with whatever given dose of alcohol.9,sixteen
Interactions that occur with alcohol, medication and the physical changes related to aging are important.ix Alcohol interacts with numerous commonly prescribed drugs.7 Drug assimilation is affected by delayed gastric emptying and increased small bowel transit time related to alcohol use. Heavy drinkers who are malnourished may have hypoalbuminemia and altered protein bounden. Blood flow through the liver and metabolic capacity decrease with crumbling. Acutely, alcohol impairs liver office, only chronic alcohol consumption may cause liver enzyme induction and enhanced drug metabolism. Fluctuating drug clearance may occur, particularly in patients who rampage beverage. For drugs with narrow therapeutic indexes, such as warfarin (Coumadin) or anticonvulsants, unpredictable clearance can have particularly chancy consequences. Alcohol can adversely affect adherence to treatment, and medication regimens may be entirely abandoned during drinking binges. Concomitant abuse of or dependence on other drugs, such as benzodiazepines, occurs in most 15 per centum of older alcoholic patients.17
Adverse Effects of Excessive Alcohol Employ
- Abstract
- Definitions of Alcohol-Related Issues
- Epidemiology
- Pharmacology of Alcohol and Aging
- Adverse Furnishings of Excessive Alcohol Use
- Identification of Booze Issues in Older Adults
- Clinical Management
- Treatment Options
- References
Booze has adverse effects on all organ systems.sixteen Physiologic reserve against stressors is weakened in older persons who drink excessively. Older persons are particularly vulnerable to falls and conditions such as delirium.
Older adults are predisposed to falls when reserve in postural support mechanisms is lost. Alcohol impairs balance and judgment, and the diuretic consequence of alcohol may cause orthostasis. Some chronic alcoholics develop myopathy, and forcefulness is often impaired. A decrease in sensory input and human foot drop can occur with peripheral neuropathy, which along with cerebellar damage causes the classically described wide-based ataxic gait. Osteoporosis, combined with the detrimental effects of alcohol on gait and balance, results in college age-adjusted rates of hip fracture amidst older alcoholic patients.vii
Several different syndromes that involve impairment of encephalon function can occur in alcoholic patients. Such syndromes are oftentimes superimposed on other diseases that cause cognitive impairment in older adults. Delirium, or acute confusional country, may occur during withdrawal from alcohol. Wernicke's encephalopathy describes an acute state of confusion, clutter and abnormal eye movements that are related to thiamine deficiency. Korsakoff 's syndrome refers to an isolated memory deficit, which oft manifests in confabulation. Global cognitive damage is more common, constituting an booze-related dementia that may be accompanied past profound cerebral atrophy. Such patients may improve equally superimposed delirium clears with abstinence, just remainder deficits in memory and judgment commonly remain.16
Gastrointestinal disease and bleeding are common reasons for emergency department visits by older alcoholics.18 Elevated liver enzymes are found in xviii percentage of older alcoholics,19 and may indicate alcoholic hepatitis, fatty liver or cirrhosis. One half of elderly patients with cirrhosis die inside one twelvemonth of diagnosis.16
Moderate drinking may exacerbate hypertension, and heavy drinking increases the risk of stroke. "Holiday centre syndrome" refers to an episode of dysrhythmia later on an alcohol rampage. Although alcoholic cardiomyopathy can occur with chronic, heavy alcohol use, more than cardiac deaths among older adults are caused by ischemic heart disease than by alcohol-related heart illness.
Patients who corruption alcohol are immunosuppressed and, thus, are at increased risk of infection and poor outcomes. Aspiration pneumonia occurs with vomiting and a decreased level of consciousness during intoxication. Many older adults were exposed to tuberculosis during babyhood, and physicians should remain vigilant for reactivated affliction in older alcoholic patients. The possibility of concomitant human immunodeficiency virus infection should not be overlooked in older patients with atypical infections, particularly those who have a history of polysubstance corruption.
Nutritional deficiencies, especially of folate and thiamine, occur when food intake is reduced because calories are derived from booze, or when access to nutritious nutrient is limited. Macrocytosis should prompt a search for vitamin deficiencies of B12 and folate, but it tin be acquired from a direct alcohol effect without a state of nutritional deficiency.
Cancers of the head, neck and esophagus are associated with chronic alcohol abuse, and the adventure is compounded by concomitant smoking. Liver cancers occur at increased rates among patients with cirrhosis.
Alcoholic patients experience disturbed sleep, with insomnia, restlessness and suppression of rapid-eye-movement sleep. Concomitant psychiatric illness, including depression, is common amidst older adults who abuse alcohol. For alcoholic patients, psychiatric consultation facilitates identification and integrated treatment of any comorbid psychiatric status.
Identification of Alcohol Problems in Older Adults
- Abstract
- Definitions of Alcohol-Related Problems
- Epidemiology
- Pharmacology of Alcohol and Aging
- Adverse Effects of Excessive Alcohol Use
- Identification of Alcohol Bug in Older Adults
- Clinical Management
- Treatment Options
- References
A full general approach to the clinical management of older alcoholics, beginning with identification of the problem, is outlined in Table two. Alcohol abuse and dependence are under-recognized among older adults.20 The stereotypical concept of a "down and out" alcoholic hinders recognition of alcohol issues among older adults, particularly among older women.5 Various constellations of findings should heighten suspicion of an alcohol problem (Tabular array iii). Physicians should keep in heed that geriatric patients with alcohol corruption or dependence may nowadays with new or increasing cognitive decline or self-intendance deficits.
Tabular array 2
Treatment Steps for Alcoholism in Older Patients
| Place patients requiring further evaluation. | ||
| Office screening protocol | ||
| Loftier index of suspicion when suggestive constellations of findings | ||
| Information well-nigh booze use and sequela | ||
| Pattern and amount | ||
| Social, family unit, legal, medical sequelae | ||
| Prior personal history | ||
| Family unit history | ||
| Determine patient readiness to discuss handling. | ||
| Appraise patients requiring detoxification. | ||
| Decision of run a risk for complicated withdrawal | ||
| History of astringent withdrawal symptoms, seizures or delirium tremens | ||
| Unstable concomitant medical conditions | ||
| Impairment of cognition and cocky-care | ||
| Extent of family unit back up | ||
| Availability of a prompt way to obtain higher level of intendance if outpatient detoxification is initiated | ||
| Plan for postdetoxification handling in coordination with other professionals. | ||
| Determination of resources and limitations | ||
| Patient preferences | ||
| Eligibility for treatment programs | ||
| Insurance coverage | ||
| Availability of community back up groups | ||
| Transportation | ||
| Family involvement | ||
| Considerations for frail elders | ||
| Comprehensive geriatric assessment | ||
| Customs-agency referrals equally appropriate | ||
| Nursing facility placement in certain situations | ||
Table iii
Findings That Suggest Trouble Drinking in Older Adults
| Cognitive reject or self-care deficits |
| Nonadherence with medical appointments and handling |
| Unstable or poorly controlled hypertension |
| Recurrent accidents, injuries or falls |
| Frequent visits to the emergency department |
| Gastrointestinal issues |
| Unexpected delirium during hospitalization |
| Estrangement from family |
| Constellation of laboratory findings such as elevated hateful corpuscular volume on CBC, γ-glutamyl transpeptidase |
Several brief, practical screening tools for alcoholism are available. The CAGE questionnaire, shown in Tabular array 4, and the Michigan Alcoholism Screening Exam (MAST) are widely used.20 However, these instruments practise not distinguish contempo from remote drinking behavior, and amidst patients sixty years of age and older, the Cage screen is insensitive with usual scoring for detecting binge drinking.21 Therefore, supplemental information nigh the current quantity, frequency and pattern of alcohol use should be obtained.
Table 4.
Muzzle Questionnaire*
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Clinical Direction
- Abstract
- Definitions of Alcohol-Related Issues
- Epidemiology
- Pharmacology of Booze and Aging
- Agin Effects of Excessive Alcohol Apply
- Identification of Alcohol Problems in Older Adults
- Clinical Management
- Treatment Options
- References
Alcohol withdrawal is manifested by two or more of the following symptoms: autonomic hyperactivity; increased tremor; indisposition; nausea or vomiting; transient visual, tactile or auditory hallucinations or illusions; psychomotor agitation; anxiety; or grand mal seizures.iii Although merely almost v percent of alcoholics develop delirium or seizures during withdrawal,three older persons with comorbid medical conditions and decreased physiologic reserve should be closely supervised while undergoing detoxification.vii In a study of alcohol withdrawal in hospitalized patients, the older patients had an increased chance of delirium, falls and dependency in daily activities.22 Older adults may have prolonged confusion, resulting in a longer hospital stay and a higher take a chance for belch to an extended care setting.22 For detoxification of older alcoholic patients, hospitalization generally is recommended.7 Thus, outpatient detoxification should exist considered only for medically stable persons with a skillful social support system, who tin reliably report escalating symptoms and who could be rapidly transferred to an increased level of intendance, if needed.
Benzodiazepines are the mainstay of pharmacologic management of booze withdrawal; they can exist administered on a stock-still schedule or every bit symptoms occur. Unfortunately, data are defective nigh optimal practices specific to geriatric patients. A recent review of the literature on pharmacologic treatment of alcohol withdrawal did non observe evidence to make elder-specific changes to the treatment recommendations.23 All the same, some experts recommend shorter-interim benzodiazepines for elderly patients; longer-acting benzodiazepines can cause prolonged and excessive sedation because of pharmacologic changes related to crumbling.24 Concomitant treatment during detoxification includes thiamine and other vitamin supplementation, correction of electrolyte disturbances and general supportive care. Judicious doses of neuroleptic medication may be required if hallucinations occur.
Treatment Options
- Abstract
- Definitions of Alcohol-Related Issues
- Epidemiology
- Pharmacology of Alcohol and Crumbling
- Agin Furnishings of Excessive Alcohol Utilize
- Identification of Alcohol Problems in Older Adults
- Clinical Management
- Treatment Options
- References
Following detoxification, older patients can receive farther treatment from inpatient programs, day handling, outpatient therapy or community-based groups. Completion rates appear to be modestly better for elder-specific booze treatment programs compared with mixed-age programs.25,26 Historic period-specific 12-step programs accept been evaluated, but data on outcomes are limited.25 Disulfiram (Antabuse) is not recommended for use in older patients because of the increased risk of serious adverse furnishings.vii,24,25 Naltrexone (Trexan) is an opiate antagonist that reduces cravings, only its role in the treatment of older alcoholics has not been established.
Delays from the time of diagnosis or detoxification to enrollment in a treatment program should be avoided.7 Substance abuse teams can facilitate this goal. Patients vary in capability of and motivation for treatment, burden of comorbid affliction, extent of family support, insurance coverage and eligibility, and admission to transportation. Family physicians should assess the resources and limitations of their patients, coordinate care with interdisciplinary squad members and recommend treatment options. Family unit members have an important role in the treatment of elderly alcoholics (Table 5) and should take access to support and education almost alcoholism. Physically or cognitively fragile elderly patients may benefit from comprehensive geriatric assessment and referral to appropriate community agencies for domicile care, nutritional programs, transportation and other services. Nursing dwelling placement may be the most appropriate treatment selection for some refractory, long-term alcoholics with dementia.
TABLE v
Role of Family Members
| Seek medical attending for pass up in patient's cognition or self-care. |
| Corroborate data on recent and lifetime drinking problems. |
| Participate if confrontation is needed. |
| Provide support during detoxification and chronic treatment. |
| Help in coordination with customs services at habitation. |
| Make decisions for older alcoholics with impaired cognition who are unable to procedure information, weigh consequences or communicate decisions. |
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REFERENCES
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16. Smith JW. Medical manifestations of alcoholism in the elderly. Int J Aficionado. 1995;30:1749–98.
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