Instructor: Independent Study
Developed by: Tisha D. Anyanike, MD (2007)
Revised by: Sharee A. Wiggins, NP, Post-MS(N), BC-GNP, BC-ANP (2009; 2007)
Edited by: Mary McDonald, MD
Specific Learning Objectives
A. Introduction
Before reviewing the learning objectives and content, please take the Pre-Test.
Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.
B. Knowledge - students should be able to describe:
C. Skills - students should be able to demonstrate specific skills (case based):
D. Attitude
Students should be able to address alcohol or drug problems with older adults and their families without prejudice or stereotype.
E. Readings
Required Reading
American Geriatric Society. Position paper: Alcohol use disorders in older adults. Annals of Long-Term Care 2006; 14(1):23-26. Available online: http://www.annalsoflongtermcare.com/article/5143
Recommended Reading
Culberson, J. W. (2006). Alcohol use in the elderly: Beyond the CAGE. Part I of 2: Prevalence and patterns of problem drinking. Geriatrics, 61(10).
Culberson, J. W. (2006). Alcohol use in the elderly: Beyond the CAGE. Part 2 of 2: Screening instruments and treatment strategies. Geriatrics, 61(11).
Holbert, K. R., and Tueth, M. J. (2004). Alcohol abuse and dependence: A clinical update on alcoholism in the older population. Geriatrics, 59(9).
Moore, A. A., Seeman, T., Morgenstern, H., Beck, J. C., & Reuben, D. B. (2002). Are there differences between older persons who screen positive on the CAGE questionnaire and the Short Michigan Alcoholism Screening Test – Geriatric version. JAGS,50(5); 858-862.
Rigler, S. K. Alcoholism in the Elderly. American Family Physician 2000; 61:1710-6. Available online: http://www.aafp.org/afp/20000315/1710.html
Roberts, A., Marshall, E. J., & Macdonald, A. J. D. Which screening test for alcohol consumption is best associated with “at risk” drinking in older primary care attenders? PrimaryCare Mental Health 2005; 3(2); 131-138.
U.S. Preventive Services Task Force (USPSTF). Recommendation Statement: Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. 2004, April. Available online at: http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm
G. Cases
According to the American Geriatrics Society (AGS) 2003 Clinical Guidelines for Alcohol Use Disorders in Older Adults, roughly 50% of persons over age 65 drink alcohol. Alcohol use may be potentially risky behavior in up to 15% of older adults. Abuse or dependence is present in 2-4% with a preference for males in this age group by about five to one in comparison to women. The prevalence rate is generally lower than that found in younger adults. This may be due, in part, to the fact that older patients may be less likely to report a history of excessive alcohol use and healthcare workers may have a lower index of suspicion in older patients leading to under diagnosis and under detection. There are many obstacles to diagnosis and treatment including denial, uncertainty, pessimism, and elder discrimination.
There are a number of risk factors that may contribute to the development of alcoholism or dependence in the older adult. Emotional and social problems such as bereavement, losses, recent retirement, boredom and social isolation are common risk factors. Untreated or poorly managed persistent pain, sensory impairments, disability, depression/anxiety, insomnia and cognitive impairment are important medical risk factors which may increase the chances of developing problematic alcohol use. A past personal or family history of alcohol abuse is a risk factor in all age groups. Studies have also shown that there is a high occurrence of concurrent diagnosis of alcoholism and mental illness.
The older adult has been found to have an increased sensitivity to the effects of alcohol, especially in the central nervous system. They also have higher blood alcohol levels per amount consumed, due to decreased gastric alcohol dehydrogenase and lower volume of distribution. Alcohol use seems to have a negative impact on the older patient’s ability to handle physiologic stress increasing their vulnerability to falls, delirium, gastrointestinal disease, bleeding, and susceptibility to infection.
Chronic health conditions may be aggravated by chronic alcohol consumption. The AGS Clinical Guideline reports that 30% of older adults who use alcohol may trigger or worsen chronic conditions. Potential conditions affected by alcohol use include: cirrhosis, gastrointestinal bleeding, ulcers, gastro esophageal reflux, gout, hypertension, dysrhythmias, alcohol cardiomyopathy, diabetes, osteoporosis, malnutrition, gait disorders, peripheral neuropathy, loss of libido, dehydration, hypothermia, aspiration pneumonia, late-onset seizure disorder, depression, anxiety, and other psychiatric conditions. Older adults who experience unrelieved pain, sleep disturbance, anxiety and depression may use alcohol to self-medicate these conditions. The amount of alcohol required over time to induce or aggravate these many chronic conditions is not clear, and there is likely individual intrinsic variability as well. Nevertheless, a very careful medical and social history that considers an alcohol link should be undertaken.
Additionally, medication-alcohol interactions or alcohol use with other substances (legal and illegal) can result in adverse outcomes. There are a number of medications -- which cover almost every class -- that may interact adversely with alcohol (see Table 1). Some clinical clues that may raise the index of suspicion for alcohol problems include: a) new or worsened memory, b) depression and/or anxiety, c) neglected hygiene or appearance, d) poor appetite, and e) sleep disruption. It is, therefore, imperative that a careful social history be taken at least yearly to screen for alcohol use and abuse.
Table 1 - Medications that may interact adversely with alcohol
Medication
Effect
Benzodiazepines, opioids, barbiturates, antihistamines (including non-sedating), TCAs
Synergistic sedating effects, increase sedation, impaired psychomotor function; altered pharmacodynamics
Warfarin episodic alcohol: increased activity
chronic alcohol use: reduced activityAcetaminophen, INH, phenylbutazone
increase hepatotoxicity
Metronidazole, sulfas, long-acting oral hypoglycemics
nausea/vomiting
H2 blockers
raise alcohol levels; decreased gastric alcohol dehydrogenase activity
ASA, NSAIDs
damage to gastric mucosa; increased GI bleed risk
NTG, hydralazine
hypotension
Sulfonamides, tolbutamide may cause disulfiram type reaction Acetaminophen, INH, Phenylbutazone alcohol may increase hepatotoxicity potential of these medications Antihypertensives, antidiabetic agents, drugs for ulcers, gout, heart failure
alcohol exacerbates the underlying disease
According to the U.S. Preventive Services Task Force (USPSTF) and the World Health Organization (WHO), alcohol misuse is the language used to denote any of these patterns of risk: hazardous, harmful, and alcohol dependence.
Potential barriers to identifying problematic alcohol use in older adults include:
- alcohol ageism by professionals
- denial on the part of medical professionals, family and friends
- comorbidities that complicate the presentation
- older adults may feel shame and be reluctant to talk about the problem
- fewer work and social responsibilities of typical older adults may hide impairments that would otherwise surface
- ageism pessimism in the older patient about alcohol treatment and recovery
There are also pattern difference in late-onset drinkers vs early onset problem drinking (Culberson 2006 reference). Up to 30% of older alcoholics do not develop problem drinking until late life. Late onset patterns occur after age 55. In contrast with earlier life onset, these older drinkers tend to be more women than men, typically of a higher socioeconomic status, have less prevalent family history of alcoholism, fewer or less serious legal and social consequences, more reversible cognitive loss. However, the treatment relapse rates are similar for both early onset and let-life problem drinkers.
The American Medical Association Guidelines for screening the older adult for alcohol abuse/dependence recommends that all patients 65 years or older be screened annually. It is suggested that this be accomplished with a simple question: “How often do you have a drink containing alcohol?” If the patient reports having a drink containing alcohol then further questioning should occur, including, “How many days per week? On a typical day how many drinks? How often do you have three or more drinks on one occasion?”
Once screening is completed, the older adult should be categorized as low risk or at risk. A patient is considered low risk if during screening they indicated that they have no more than one drink per day and a maximum of two drinks on one occasion; CAGE (see below) score of zero; no dysfunction related to drinking; and no medications that interact with alcohol or conditions that may be triggered or worsened by alcohol.
One Drink Equivalents:
- 12 ounces of beer
- 5 ounce glass of wine
- Mixed drink containing 1.5 ounce of liquor/distilled spirits
Note: 1 drink = 14 grams (0.6 ounces) of alcohol.
The most widely used screening tool is the simple four-item CAGE questionnaire. Once it is known that the patient does drink alcohol, the following four questions are asked:
“Have you ever felt you should Cut down on your drinking?”
“Have people Annoyed you by criticizing your drinking?”
“Have you ever felt Guilty about your drinking?”
“Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?”A positive response to any of these questions indicates a potential problem with alcohol use and warrants further investigation. Two affirmative responses signal probable alcoholism, and an affirmative response to all four is pathognomonic for alcoholism. The CAGE has been criticized for failure to detect hazardous drinking (having negative outcomes of alcohol use).
This is a 10 item questionnaire specifically for use in older adults. A score of 2 or more “yes” responses suggests a problem with alcohol. The tool may be viewed online at: http://pathwayscourses.samhsa.gov/aaac/pdfs_aaac/mast-g.pdf
A study by Moore, Seeman, et al., published in JAGS, 2002 concluded that < 50% persons age 55 and older who had a positive screen on either the CAGE tool or the SMAST-G tool, screened positive on both tools. The authors speculated that the tools were possibly capturing different characteristics of unsafe drinking in this age group.
This tool was not designed to specifically screen for “at risk” drinking among older persons. However, a 2005 British study published by Roberts et al. found that the tool did perform well in older adult primary care patients (N = 500) using different cut-off scores for men and women. According to the USPSTF, it is the most widely studied alcohol screening tool for detection alcohol problems in primary care. “It is sensitive for detecting alcohol misuse and abuse, or dependence and can be used alone or embedded in broader health risk lifestyle assessments.” The tool can be viewed online at: http://www.ccbh.com/pdfs/providers/wbh/articles/current/AlcoholAbuseAuditCScreening.pdf
The Diagnostic and Statistical Manual IV (DSM-IV), gives specific guidelines for diagnosis of alcohol abuse and alcohol dependence (see table 3). It is important that these two diagnoses be recognized as separate, but intervention recommendations are generally the same. The CAGE questionnaire, DSM IV, and other screening tools may not be as applicable to older patients because of their differing life and health characteristics. They are less likely to encounter the social, legal, and occupational consequences of alcohol abuse. There are no set limits of alcohol intake based on age though the NIAAA (National Institute on Alcohol Abuse and Alcoholism) recommends no more than one drink per day. These tools also do not take into account lifetime alcohol consumption which may be an important factor in older patients.
Table 3 -- Alcohol Abuse vs. Alcohol Dependence by DSM-IV
Alcohol Abuse - Met >1 of the following criteria and does not meet criteria for dependence:
Alcohol Dependence - >3 of the following criteria met:
Recurrent drinking resulting in failure to fulfill major obligations at work/home
Tolerance
Recurrent drinking in situations that may be hazardous
Withdrawal
Recurrent alcohol related legal problems
Drinking in larger amounts or for longer period of time than intended
Continued drinking despite persistent or recurrent social problems related to alcohol
Persistent desire to drink or unsuccessful effort to control
A lot of time spent in efforts to obtain or use alcohol or recover from effects
Important social, occupational, or recreational activities given up due to drinking
All older adults who drink should be counseled about safe drinking, while intervention should occur in those who are in the at risk category or meet criteria for alcohol abuse or dependence. Those who are at risk should have intervention which includes counseling, involvement of family members or caregivers, and treatment options. In the office, a brief intervention may include feedback about the patient’s responses to screening questions, review of types of drinkers and where the patients drinking fits into population norms, reasons for drinking, consequences of heavy drinking, reasons to cut down or quit, sensible drinking limits and ways to cut down or quit, and coping mechanisms. The practitioner should consider a drinking agreement or contract with the patient to assist in treatment and also should summarize the discussion.
The older adult is more sensitive to the effects of many medications and therefore detoxification should occur in the hospital setting. Withdrawal may be manifested by increased tremor, insomnia, nausea/vomiting, hallucinations, anxiety, or psychomotor agitation. Reduced doses of benzodiazepines and the use of shorter acting benzodiazepines are recommended in acute withdrawal. Benzodiazepines may need to be scheduled or administered with symptoms on a case by case basis. Detoxification may take longer in older adults and cognitive impairment due to alcohol may persist for several months. All patients should also receive vitamin supplementation, including thiamine, as most patients with alcoholism also have nutritional deficiencies due to poor diet and may also have impaired physiologic efficiency in the use of nutrients.
Pharmacotherapy (e.g. disulfiram or naltrexone) in general is not very useful in the treatment of alcoholism in older adults due to side effects and limited studies in the elderly.
Treatment of alcohol abuse or dependence should be age specific, supportive, and non-confrontational. The focus of treatment should be coping with depression, loneliness, and loss, as well as building a social support network. The role of family or other support cannot be emphasized enough. They may be helpful in assisting the patient in seeking care, providing accurate history, providing support during detoxification or other treatment, assisting in coordination of home services, and assisting in making decisions. Treatment in older adults should be done by experienced staff with an interest in working with this age group and links to community and case management services should be made available.
XV. Resources for additional help
Alcoholism in the Elderly: Case 1
65 year-old male…
You are seeing a 65 y/o retired WM in your office for evaluation of recent falls. He lives alone and has been to the ED twice for this problem and all workups were negative. His past medical history is significant for hypertension, diabetes, and GERD. He takes a daily baby aspirin, metformin, norvasc, and ranitidine. On further questioning, you find out that his wife died 6 months ago after a long illness. The patient admits that he has lost weight and has not had much of an appetite. His blood sugars have also been running higher even though he states that he takes his medications as prescribed. You do a CAGE screen and find out that he has been having 3 beers after dinner almost daily over the last 2 months as well as an occasional beer in the morning to help him “get started.” He knows he probably shouldn't be drinking, but has been having difficulty cutting back.
Questions:
- What are the patient’s risk factors for alcohol abuse?
- What is his CAGE score?
- What are your other concerns?
- How would you proceed?
- What other screen might you consider using and why?
You discuss with the patient your concern that he may be developing a problem with drinking and do a brief intervention to counsel him on the consequences of his drinking. He agrees to cut back to 1 drink a day and also agrees with your plan to treat him for depression. You make an appointment to see him back in clinic in 1 week to follow up and ask him to bring someone he trust with him. On follow-up, the patient is accompanied by his daughter and reports that he has been successful in limiting his alcohol to one drink or less per day. His daughter has agreed to help her father get to the local senior citizens center to participate in the weekly chess games (his favorite game), congregate noon meal, and twice weekly exercise classes. Two months later you see the patient again and he reports that he feels much better and is enjoying life. He only has a drink on special occasions and feels his depression has resolved. He thanks you profusely for helping him.
Alcoholism in the Elderly: Case 2
78 year-old female…
You receive a call from the Emergency Department that your patient, Mrs. R, was brought in by ambulance confused and combative. She is a married 78 year-old female who has been your patient for about 3 years. When you go to the hospital to see her, you find her husband and daughter in the waiting room. They tell you that Mrs. R had been fine up until today when they noticed that she was acting “strange.” She seemed agitated with everyone and even had some hallucinations. When her daughter mentioned taking her to the doctor to be looked at she became very upset. Her husband also noticed that she seemed “shaky” today. You go to see her and notice that she is much calmer than you expected after a dose of ativan. All of her testing has been basically negative except for mild anemia. The Emergency Department physician reports that the patient’s husband said his wife had stopped having her evening glass of Vodka about 3 days ago, which she had been doing for about 30 years, after she read an article in a magazine on alcohol abuse. The Emergency Department physician asks you what you want to do next?
Questions:
- What should be your next step in Mrs. R’s treatment?
- What would you do to help avoid further symptoms?
- What advice would you tell her family and what advice would you give to them when they ask how they can help Mrs. R?
You decide to admit Mrs. R for alcohol withdrawal. After discussion with her and her family they agree that she should undergo detoxification and treatment. You decide to continue her on a fixed schedule of ativan to control her symptoms of withdrawal and also start her on a multivitamin with thiamine replacement. You recommend an outpatient treatment program and advise her family that they will be an important part of her treatment success through encouragement and support. Mrs. R. is discharged home five days later to her daughter’s home. The hospital social worker arranges for outpatient treatment and provides her number if they need assistance. The patient will follow up with you in the office three days after discharge.
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The University of Kansas Medical Center