Diagnosis and treatment of alcohol dependence in older alcoholics

Background

Alcohol abuse and dependence are major problems afflicting older adults. Even though the concept of alcohol or drug abuse as a distinct phenomenon in older adults was introduced in 1964 [6], many researchers believed it was a rare occurrence not meriting special attention. It was believed that these older alcoholic patients either died early or recovered spontaneously, often without treatment [7], [8], [9]. Alcohol dependence was believed to evolve rarely in later life. As recently as 1987, the

Prevalence of alcohol dependence and abuse among older alcoholic patients

Estimates of prevalence rates among older alcoholic patients vary from 3%–25% depending on the population sampled [1], [9]. SAMHSA data [16] from a 2000 National Household Survey on Drug Abuse (NHSDA), however, suggests that 38% of older adults used alcohol in the past month, with 9% reporting binge use (five or more drinks on the same occasion for at least 1 day in the past 30 days), and 2% reporting heavy alcohol use (five or more drinks on the same occasion for 5 or more days in the past 30

Effects of alcohol in older alcoholic patients

As patients with alcohol dependence age, there are age-related changes that can potentiate the negative effects of alcohol. Lean body mass and total body water decrease, whereas total body fat content increases. As a consequence, the body's total volume of distribution decreases, leading to increased blood alcohol levels even when no change occurs in the rate or amount of alcohol consumption [31], [32]. Older alcoholic patients have decreased gastric concentrations of alcohol dehydrogenase, an

Binge drinking

Binge drinking involves large amounts of alcohol consumed over short periods of time. The definition of binge drinking may vary from four, five, six, or more drinks per drinking occasion. For older alcoholic patients, the amount of alcohol consumed as part of a binge is probably lower. This type of drinking pattern is common and may be difficult to identify. Various excuses are used to start drinking binges. Because no pervasive use of alcohol is obvious, family and friends may fail to see the

Diagnosis of alcohol-related problems in older alcoholic patients

Although more than 80% of older alcoholic patients see physicians regularly, almost half of the patients most in need of treatment for alcoholism do not seek this treatment. Physicians who see these patients often miss alcohol dependence or other related problems, even with frequent contacts [59], [60]. To minimize this oversight, several screening tools have been recommended for use in older alcoholic patients to identify their alcohol dependence and related problems [61]. The CAGE

Treatment of alcohol dependence in older alcoholic patients

Recent reports suggest that hospitalization rates for alcohol-related problems approach those for cardiac problems [65]. There are also reports that older alcoholic patients with alcohol-related problems are more likely to visit the emergency department rather than their primary care physician [21]. This suggests that older alcoholic patients may consume excessive health resources and that the effective treatment of these disorders could minimize this consumption.

Most recommendations for the

Inpatient versus residential treatment

Treatment recommendations can be based on the American Society of Addiction Medicine (ASAM) guidelines, which outline specific criteria used in deciding the level of care needed. Although these criteria were developed for younger adults and have not been validated in older alcoholic patients, they provide some guidance. The ASAM criteria suggest that the presence of withdrawal risks, medical risks, or psychiatric risks warrants inpatient treatment. If there is high relapse potential, lack of

Collateral medical and psychiatric treatment

Older alcoholic patients often struggle with comorbid psychiatric conditions, such as depression and anxiety disorders [72], [73]. If these disorders are treated adequately, the rate of relapse for alcoholism can be decreased significantly. Several studies have shown that concomitant psychiatric treatment can positively influence treatment for alcohol dependence [74]. These studies looked at the general adult population, however, and not older alcoholic patients.

Ongoing alcohol use can

Individual and group therapy

Little is known about the effects of psychotherapy in decreasing relapse rates among older adults. Extrapolating from the general population, individual and group psychotherapy increases the chances of maintaining sobriety and decreases relapse potential. Williams et al showed that attendance at outpatient counseling sessions helped prevent relapse [83]. Yalom et al reported that interactional therapy in alcohol-dependent patients resulted in reduced relapse rates and reduced alcohol

Self-help group meetings (Alcoholics Anonymous)

Several studies have reported on the potential of self-help groups in maintaining sobriety in younger adults. In one study, Alcoholics Anonymous (AA) attendance after discharge from in-patient treatment was associated with longer sobriety or decreased drinking up to 8 years after completing treatment [91]. Pisani et al reported that attendance at AA meetings over an 18-month period helped to maintain sobriety in chronic alcoholic patients [71]. Chappel suggested that self-help groups like AA

Summary

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like