Alcohol problems in the elderly Dr Karim Dar Consultant Psychiatrist St Bernards Hospital, London.
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Transcript of Alcohol problems in the elderly Dr Karim Dar Consultant Psychiatrist St Bernards Hospital, London.
Alcohol problems in the elderly
Dr Karim Dar
Consultant Psychiatrist
St Bernards Hospital, London
Outline 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
What are the facts about addiction?
it occurs secondary to biological vulnerability
it is a disease of the brain, manifested in aberrant behavior
it is a chronic disease, in which relapse and remission recur episodically…
Addiction is a Health Problem Not just a social problem Not just a criminal justice problem Not just a moral problem Not a personal weakness Not ‘willful misconduct’ ADDICTION IS NOT A DESIRED
STATE
Addiction is Treatable But not via detox alone But not via acute interventions alone But not via treating psychiatric co-
morbidities alone
Compliance = for other chronic illnesses Outcomes = for other chronic illnesses
Addiction is a Chronic Disease
Often early onset
Usually Progressive, Sometimes Fatal
Chronic Course:
Relapsing & Remitting
Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses
Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses
00
1010
2020
3030
4040
5050
6060
7070
8080
9090
100100
Drug Dependence
Drug Dependence
Type I DiabetesType I
DiabetesHypertensionHypertension AsthmaAsthma
40 t
o 60
%40
to
60%
30 t
o 50
%30
to
50%
50 t
o 70
%50
to
70%
50 t
o 70
%50
to
70%
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
Per
cen
t of
Pat
ien
ts W
ho
Rel
apse
Per
cen
t of
Pat
ien
ts W
ho
Rel
apse Addiction Treatment Does WorkAddiction Treatment Does Work
What’s happening in the brain?
Modulation of “reward system” Medial forebrain bundle connects ventral
tegmental area to nucleus accumbens Also pathways that project from VTA and
NAcc -> limbic and cortical areas Dopaminergic projection most implicated in
reward
CMAJ Mar 20, 2001; 164(6)
Brain
“It’s a brain disease….”
What’s happening in the brain? Drugs of abuse act
directly by influencing action of dopamine indirectly by affecting modulating pathways
such as GABA, opioid, serotoninergic, acetylcholine and noradrenergic
CMAJ Mar 20, 2001; 164(6)
Neurons
Sensible drinking In the USA NIAA recommends that people
older than 65 consume no more than 1 standard drink per day ( NIAAA 2003)
In the UK no recommendation for those >65 Older people are one of the least well
informed when asked about alcohol units (Lader & Meltzer 2001)
At Risk Drinking : Britain
0%
5%
10%
15%
20%
25%
30%
1992
MenDrinking>21 unitsper weekWomenDrinking>14 unitsper week
Proportion Drinking more than daily guidelines on one day in previous week (ONS, 2002)
05
101520253035404550
16-24
25-44
45-64
>65
MenWomen
Men Drinking above ‘sensible’ levels (ONS, 2002)
0%5%
10%15%20%25%30%35%40%45%50%
16-24
>16 >65
>4 units>8 units
Women drinking above ‘sensible’ levels (ONS, 2002)
0%
5%
10%
15%
20%
25%
30%
35%
40%
16-24
>16 >65
>3 units>6 units
15.9
56.8
37.8
12.8
7.8
58.3
30.3
7.64.9
53.0
21.1
5.31.0
37.5
9.4
2.30
10
20
30
40
50
60
70
Any IllicitDrug Use
Any AlcoholUse
"Binge"Alcohol use
HeavyAlcohol Use
18 to 25
26 to 34
35 to 54
55 or Older
Percentage of Adults Aged 18 or Older Reporting Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000. (source NHSDA, 2001)
Per
cen
t R
epo
rtin
g U
se i
n P
ast
Mo
nth
12% of 55+ age group are either binge or heavy alcohol users
Prevalence Geriatric Alcohol Problems
A & E Departments….. 14%
Medical inpatients……. 6-11%
Psychiatric inpatients… 20%
Nursing home patients.. Up to 49%
Early v. Late Onset AlcoholismEarly onset: Describes those who have a lifelong pattern of drinking, have probably
been alcoholic all their life, and are now elderly. More likely to have chronic alcohol-related medical problems such as
cirrhosis, organic brain syndrome, and co-morbid psychiatric disorders. Late onset: Describes those who have become alcoholic in their drinking pattern for
the first time late in life. Often triggered by a stressful life event. Generally represented by milder cases with fewer accompanying
medical problems. More amenable to treatment, more likely to have spontaneous
recovery, but also more likely to be overlooked by health care professionals (Liberto & Oslin, 1995).
Risk Factors
Risk Factors 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.) 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
Anxiety Blackouts, dizziness Depression Disorientation Mood swings Falls, bruises, burns Family problems Financial problems Headaches Incontinence
Increased tolerance Legal difficulties Memory loss New problems in
decision making Poor hygiene Seizures, idiopathic Sleep problems Social isolation Unusual response to
medications
Symptom Identification Applying quantity and frequency levels appropriate
for younger adults to elders may cause failure to identify substance use problems
Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed to aging
Sleep problems associated with chronic conditions, particularly cardiovascular disease and pain
Falls attributed to poor lower body strength, poor balance, or vision limitations
Anxiety attributed to psychosocial concerns Confusion/memory problems associated with Alzheimer’s
disease or other dementias
Diagnosis Issues
Problems with Definitions
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 abuseDSM-IV criteria for substance abuse
and dependence may not be and dependence may not be
adequate to diagnose older adults adequate to diagnose older adults
with substance use problemswith 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
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 assumptionsFailure to recognize symptomsLack of knowledge about screeningPhysician discomfort with substance
abuse topic- 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with their patients
(CASA, 2000)
Individual Barriers to IdentificationAttempts at self-diagnosis Description of symptoms attributed to
aging process or diseaseMany do not self-refer or seek treatment
- Although most older adults (87 percent) see physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek services for substance abuse
(Raschko, 1990)
Screening
Goals and rationale for screening Identify at risk, problem and dependent
drinkers Determine need for further assessment
and treatment Incidence high enough to justify
screening Effective treatments exist Treatments available are cost effective
SCREENING Several brief, practical screening tools
for alcoholism exist:
CAGE
MAST-G
AUDIT
SCREENING CAGE questionnaire:
Ever felt you should CUT DOWN?
Have people ANNOYED you by criticizing your drinking?
Ever felt GUILTY about your drinking?
Ever felt like EYE OPENER?
SCREENING CAGE
≥2 YES = positive
sensitivity = 63%, specificity = 82%
BUT, ↓ sensitivity with ↑ age
With cut-off of 1 = positive,
sensitivity = 86%, specificity 78% in elderly
MAST-G 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
concerned about your drinking? 9. Have you ever made rules to manage your drinking?10. When you feel lonely, does having a drink help?
SCREENING 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 TotalBody Water
Decreased gastricEtOH Dehydrogenase
Increased Serum EtOH for agiven dose
Decreased Tolerance in Geriatric Patients...
Diagnostic “adaptation” and sensitivity to mature adult
Slowed metabolic breakdown and elimination.
pace / duration of detox, withdrawal, stabilization.
Blood levels persist longer.
“CNS”: Age-associated central nervous system sensitivity.
Absolute quantities of alcohol and / or drugs consumed / ingested may be relatively small and still bring on major complications.
Organ function
Liver:-cirrhosis-cancer
Orthopedics: - Falls- Twists- Breaks
Continence
Pain
Lower extremities: - Balance- Pain- Mobility
Central Nervous:- Neuropathy-DTs-W-K syndrome
Sleep Patterns
Prescriptions and OTC’s: - Interactions - “Negation”
Heart-Atrial fibrillation-CHDDigestionCa nasopharynx & oesophagus
Blood pressure-StrokeNutrition:- Appetite
Consider alcohol and drug use and the Medical Consequences on a Senior
Medical consequences
Osteoporosis conflicting results,
may be related to socioeconomic status - role of nutrition
likely plays a role
Medical consequences Trauma
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 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 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 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 A: multiple cognitive deficits manifested by
both:
memory impairment
≥1 of: aphasia
apraxia
agnosia
disturbance in executive
functioning
DSMIV alcohol-induced persisting dementia 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 Evidence from the Hx, P/E or lab
findings that the deficits are etiologically related to the persisting effects of substance use
In 1998, Oslin et al. proposed clinical criteria for alcohol-related dementia
Alcohol related dementia Why controversial?? Lack of consistent neuropathological findings
in dementia associated with alcohol Sulcal widening & ventricular enlargement
commonly found in patients with heavy alcohol use but noted with & without cognitive impairment & can reverse with abstinence
Alcohol related dementia ↑evidence of overlap between WK syndrome
& ARD
1. At autopsy, patients noted to have WK lesions but clinical hx of global cognitive impairment
2. PET scan study showed no difference in brain metabolism of patients with alcohol- induced dementia & those with WK syndrome
Alcohol related dementia Memory, visuospatial function, tasks
requiring speed & frontal lobe function often abnormal in cognitively impaired alcoholics
→ difficulty with complex reasoning, planning, abstract reasoning, judgement, attention & memory
Alcohol-related dementia Language & verbal skills spared, anomia less likely Saxton et al looked at ARD & AD neuropsych profiles
ARD poorer performance on:initial letter fluencyfine motor controlfree recall but recognition memory OK
(J. Geriatr. Psychiatry & Neurology 2000:13:141)
Alcohol related dementia Probable AD did more poorly on:
confrontation naming (BNT)
recognition memory
animal fluency
orientation No difference in global function between AD
& ARD based on MMSE scores BUT, small sample size
• 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
Most seniors have strong social supports.
Often resilient; they have coping skills to build upon.
Living longer, continuing to develop intellectually,
emotionally and spiritually.
Improved health status and access to health care.
Informed consumers.
Users of many “social” and community services
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 network4. Employ staff experienced in working with elders5. Link with aging, medical, and institutional settings6. Slower pace & age-appropriate content7. Create a “culture of respect” for older clients8. Broad, holistic approach to treatment recognizing
age-specific psychological, social & health aspects9. Adapt treatment to address gender issues
Helping Older Adults Make the First Step to Treatment
The health care system is a ripe gateway to treatment.
Family concern is a motivating factor
If a health care professional informs an older person of the potential loss of independence, functioning and quality of life, motivation to change grows.
Brief Interventions
Brief Intervention From 1 to 5 brief sessions targeting a
specific health behavior Used in those with harmful use Offers advice, education, motivation
enhancement approaches, feedback, contracting eg drink diaries
Goals: Reduce alcohol or substance use Motivate individual to change behavior Facilitate treatment entry
Brief Intervention Projects Project GOAL (Guiding Older Adult Lifestyles)
(Fleming et al., 1999; University of Wisconsin)
Brief physician advice for 156 adult at-risk drinkers
Reduced consumption (35%-40%) at 12 months
• Health Profile Project Univ. of Michigan (Blow and Barry)
In home, motivational enhancement session reduced at-risk drinking at 12 months (n=454)
Staying Healthy Project American Society on Aging (California - Cullinane et al.)
More than 4300 people screened
About 6% drinking more than recommended
Almost 40% reduction of alcohol use
Withdrawal in the Elderly Onset of withdrawal delayed (days) May be prolonged Often presents with confusion Hallucinations (visual/tactile) may persist for
months
Withdrawal
Anxiety Agitation Tremors Autonomic hyperactivity Seizures Nausea & vomiting Hallucinations-
visual,tactile,auditory Insomnia
I. Alcohol Detoxification Concerns in Geriatric Patients
Severe withdrawal and comorbid medical illness and limited support means that usually managed as inpatients
Outpatient with family support in few cases Awareness of altered pharmacokinetics and
drug interactions essential Avoid Disulfiram in the elderly Acamprosate much safer option
II. Alcohol Detoxification Concerns in Geriatric Patients
Confusion (rather than tremor) early withdrawal sign
Duration of withdrawal/hallucinosis increased Rule out DTs in confused elderly Replace electrolytes and nutrients Short acting benzodiazepines (Oxazepam) Parenteral thiamine unless contraindicated
should be given
Treatment SUGGESTIONS.. Groups:
Grief group Leisure skills group Life transition group Reminiscent therapy group Educational groups:
medical aspects of substance abuse;
mental health issues;
bereavement;
growing older with dignity, etc.
Risk Factors For Relapse Loneliness, boredom Chronic pain Unresolved grief Sleep disturbances Untreated mental health issues – e.g. depression, anxiety Lack of support for recovery Chronic medical problems Prolonged stress Difficulty in managing daily affairs – e.g. finances, chores Unsuitable living environment Lack of understanding about relapse or lack of a relapse
prevention plan
A Three Stage CBT Approach
1. 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.”
2. 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.
3. Teach specific skills to address these high risk situations to prevent relapse.
“A-B-C” Approach to Treatment:The Substance Use Behavior Chain
Behavior
Antecedents
Long Term Consequences
(always negative)
Situations/ + Feelings + Cues + Urges Thoughts
Consequences
First sip of beer
Feel happierHome/alone + bored and depressed + beer in refrigerator + “A drink will help me forget my troubles.”
1st drink orUse of drug
Immediate/ Short Term
Conseq. + or -
Continue drinking, anger her children, and impair health
Relapse Prevention Strategies For Older Adults (1 of 2)
Help clients develop meaningful leisure, social or vocational activities.
Work with client and their physician on pain control strategies (ideally, non chemical ones).
Address grief issues throughout treatment and refer for additional supportive services when needed.
Teach clients good sleep habits (e.g. forego a daytime nap) and non chemical ways to cope with sleep disturbances.
Be sure that mental health issues are being addressed and treated.
Relapse Prevention Strategies For Older Adults (2 of 2)
Be sure client is keeping medical appointments, taking medications as prescribed and communicating changes in health status to physician.
Teach stress management skills throughout treatment.
Develop a relapse prevention plan tailored to the 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 relapseis 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 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 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