Alcohol Use Disorders in Older Adults

AGS CLINICAL PRACTICE GUIDELINES SCREENING RECOMMENDATION

All patients 65 or older should be asked about their use of alcohol at least annually to identify possible alcohol use disorders.

RATIONALE

About half of the population aged > 65 drinks alcohol; up to 15% may be experiencing health risks from either the amount of alcohol they consume alone or the combination of alcohol use with medications and chronic diseases; 2-4% may have abuse or dependence (“alcoholism”).

Age-Related Physiological Changes that Affect Risks Associated with Alcohol
Older adults have higher blood alcohol levels per amount consumed than do younger adults, due to decreased gastric alcohol dehydrogenase and lower volume of distribution.

Aging may increase sensitivity to alcohol, particularly in the central nervous system.

Medications that May Interact Adversely with Alcohol
90% of older adults use medications, and as many as 100% may interact adversely with alcohol. Alcohol combined with:

• H2 blockers, aspirin may raise alcohol levels.
• benzodiazepines, tricyclic antidepressants, narcotics, barbiturates, antihistamines may increase sedation and impair psychomotor function.
• aspirin, NSAIDs may increase bleeding time and cause gastric inflammation and bleeding.
• metronidazole, sulfonamides, longer-acting oral hypoglycemics (tolbutamide, chlorpropamide) may cause disulfiram-like response, with nausea/vomiting.
• reserpine, aldomet, nitroglycerine, hydralazine may produce hypotension.
• acetaminophen, isoniazid, phenylbutazone may increase hepatotoxicity.
• antihypertensives, antidiabetic drugs, drugs for ulcers, gout, and heart failure may exacerbate the underlying disease.
• benzodiazepines, narcotics, barbiturates, warfarin, propranolol, isoniazid, and tolbutamide may alter drug metabolism.

Chronic Conditions that May Be Triggered or Worsened by Alcohol Use
30% of older adults who drink alcohol may trigger or worsen chronic conditions including:

• Cirrhosis and other liver conditions, gastrointestinal bleeding, ulcers or gastroesophageal reflux disease
• Gout, hypertension or diabetes
• Insomnia, gait disorders
• Depression, anxiety or other mental conditions

SPECIAL ATTENTION TO THE PATIENT WHO USES MORE THAN ONE SUBSTANCE

Be aware of use of other potentially addictive substances in addition to alcohol (prescription drugs like sedatives or narcotic analgesics, illicit drugs, nicotine); they may interact/reinforce each other. Added expertise with diagnosis and management, and inpatient treatment may be needed.

CLINICAL CLUES

• Memory loss, cognitive impairment
• Depression, anxiety
• Neglect of hygiene, appearance
• Poor appetite, nutritional deficits
• Sleep disruption
• Hypertension refractory to therapy
• Blood sugar control problems
• Seizures refractory to therapy
• Impaired balance and gait, falls
• Recurrent gastritis and esophagitis
• Difficulty managing warfarin dosing

RISK FACTORS

• Emotional and social problems - Bereavement, losses (spouse, friends, family, function), retirement, social isolation, boredom
• Medical problems - Pain, vision and hearing loss, disability, insom- nia, cognitive impairment, depression or anxiety
• History - Past personal or family history of an alcohol use disorder

WHAT TO ASK FIRST

“How often do you have a drink containing alcohol, including any beer, wine, or liquor/spirits?”

FOLLOW UP WITH THOSE WHO HAVE HAD ANY ALCOHOL IN THE LAST YEAR, BY ASKING:

• “On average, how many days per week do you drink alcohol?”
• “On a typical day when you drink, how many drinks do you have?” (1 drink = 12 ounces of beer [can or bottle], 4-6 ounces of wine [medium wine glass], 1.5 ounces of liquor/spirits [one shot glass], or 4 ounces of sherry, liqueur, or aperitif)
• “How often do you have 3 or more drinks on one occasion?”

THEN, ASK THE CAGE QUESTIONS

• Have you ever felt that you should CUT down on your drinking?
• Have people ever ANNOYED you by criticizing your drinking?
• Have you ever felt GUILTY about your drinking?
• Have you ever had a drink (EYE OPENER) first thing in the morning to steady your nerves or get rid of a hangover? (A score of > 0 indicates possible alcohol use disorder)

LAB TESTING

Inadequate sensitivity/specificity for screening

Several may be useful adjuncts for corroboration:

Elevated gamma-glutamyl transpepticlase (GGT), mean corpuscular volume (MCV), carbohydrate-deficient transferrin (CDT) for suspicion of heavy drinking; blood alcohol level > 100 mg/dl without intoxication may suggest tolerance

CLASSIFYING YOUR FINDINGS

Low-Risk Drinking
• No more than 1 drink per day and a maximum of 2 drinks on any drinking occasion (National Institute on Alcohol Abuse and Alcoholism recommendations)
• 0 CAGE score
• No evidence of dysfunction related to drinking (physical, psychological, or social)
• Not using medications that interact adversely with alcohol or have conditions that alcohol may trigger or worsen

At-Risk Drinking
• On average, > 1 drink per day, or > 7 drinks per week, or > 3 drinks on heavier drinking occasions
• Or any drinking and > 0 on the CAGE • Evidence of drinking-related dysfunction
• Using alcohol and medications in combinations that might interact adversely
• Using alcohol and having conditions that may be triggered or worsened by alcohol

Alcohol Abuse or Dependence (DSM-IV) (Difficulties with these criteria among older adults are noted below in italics)
Abuse: > 1 of the following criteria met, and has never met criteria for dependence
• Recurrent drinking resulting in the failure to fulfill major obligations at work or in the home (less applicable to older adults who may have fewer obligations)
• Recurrent drinking in situations where it is physically hazardous
• Recurrent alcohol-related legal problems (older adults uncommonly have these problems)
• Continued drinking despite persistent or recurrent social problems caused or worsened by alcohol (older adults may not realize these problems are related to drinking)

Dependence: > 3 of the following criteria met
• Tolerance, or requiring more alcohol to get “high” (older adults may have problems with even low intake due to increased sensitivity to alcohol and higher blood alcohol levels)
• Withdrawal, or drinking to relieve/prevent withdrawal (older adults who develop dependence may not develop physiological dependence)
• Drinking in larger amounts, or for a longer period of time than intended (older adults may have increased cognitive problems as a result of alcohol use and may not be able to monitor intake)
• Persistent desire to drink, or unsuccessful efforts to cut down or control drinking
• A lot of time spent in activities necessary to obtain or use alcohol or recover from effects
• Important occupational, social, or recreational activities given up or reduced due to drinking (older adults may have fewer activities, making detection of problems more difficult)
• Drinking continues despite knowledge of persistent/recurrent physical or psychological problems likely to be caused/worsened by alcohol (older adults may not know or understand that problems are related to use, even after medical advice)

INTERVENTIONS

Recommendation
Counsel all non-abstainers about safe drinking, intervene if at risk drinking or abuse/dependence. Be alert for dual diagnoses (i.e., drinking/depression); involve family/caregivers whenever possible, but watch for enabling behavior.

Low-Risk Drinkers
Prevent future drinking problems by periodically asking about alcohol use.

At-Risk Drinking
In a supportive and non-confrontational manner, state your medical concern and describe the impact that alcohol is having on the older adult’s health or functioning.

Spell out how reducing or stopping alcohol use will improve the person’s health and functioning. Assess the patient’s understanding of the benefit.

Give specific advice on safe amounts/frequency of drinking (on average, < 1 drink per day, < 7 drinks per week, < 3 drinks on heavier drinking occasions). Counsel against concurrent drinking and use of drugs that interact with alcohol.

Counsel regarding amounts of alcohol that may trigger or cause conditions.

Recommend no alcohol if planning activities impaired by alcohol (driving, operating machinery, caregiving for others); give reminder that it takes about 1 hour for the body to metabolize 1 drink.

Point out to patient their specific potential for alcohol-medication/alcohol-disease interactions, as incentive for following advice on controlling their drinking.

Present options for addressing the problem and include family members if needed. Consider formal prescription or contract with patient, specifying plan to adhere to your advice or conduct a brief intervention.

Brief Intervention with Older Adults
• Personalized feedback about patient’s responses to screening questions about alcohol use
• Review types of drinkers in the United States and where the patient’s drinking patterns fit into the population norms for his or her age group
• Reasons for drinking
• Consequences of heavier drinking including physical, psychological, social and functional
• Reasons to cut down or quit drinking (e.g., maintaining independence, physical health, mental capacity)
• Sensible drinking limits and strategies for cutting down or quitting (e.g., developing social opportunities that do not involve alcohol, volunteer activities, hobbies)
• Drinking agreement in the form of a prescription
• Ideas on coping with risky situations
• Summarize discussion

Abuse/Dependence
In a supportive and non-confrontational manner, state your medical concern and describe the impact that alcohol is having on the older adult’s health or functioning. Spell out how reducing or stopping alcohol use will improve the person’s health and functioning. Assess motivation to change and present options for addressing the problem and include family members if needed.

National hotline to assist in locating treatment providers: 1-800-662-HELP (4357) https://findtreatment.samhsa.gov

Features of preferred treatment options for abuse/dependence among older adults
• Age-specific, supportive, and non-confrontational group treatment that aims to build or rebuild the client’s self-esteem
• A focus on coping with depression, loneliness, and loss
• A focus on rebuilding the person’s social support network
• An appropriate pace and content of treatment
• Staff members who are interested and experienced in working with older adults
• Linkages with medical services, community-based services and case management

Psychosocial Treatment Options
Self-help groups (i.e., Alcoholics Anonymous) Professional (i.e., psychodynamic, cognitive-behavioral, motivational counseling, social support, family therapy, age-specific inpatient/outpatient). These may be delivered to individuals or groups or a combination.

Pharmacotherapy Overview
• Disulfiram - Modest to low efficacy in clinical trials, limited role in older adults due to cardiac effects.
• Psychoactive adjuncts - clinical trials of anxiolytics and antidepressants have shown modest benefit if patients have concurrent anxiety and/or depression and almost no studies have included elderly patients.
• Naltrexone - opioid antagonist; clinical trials (only 1 in older adults) showed it to be a relatively effective adjunct to psychosocial therapy, reducing likelihood of return to clinically significant drinking and relapse.
• Future agents (in clinical trials, U.S.A. or Europe) - nalmefene: like naltrexone, an opioid antagonist, but possibly greater potency and less toxicity; and acamprosate: a derivative of a GABA analogue.

FOLLOW-UP

Family/peer support critical for long-term success Review need for maintenance counseling, for both successfully abstinent, and also refractory patients.

Last updated November 2003

Updated by Alison A. Moore, MD, MPH, David Geffen School of Medicine at UCLA, and the American Geriatrics Society Clinical Practice Committee, and using materials from Substance Abuse Among Older Adults, Treatment Improvement Protocol Series 26, DHHS Publication No. (SMA) 98-3179, Substance Abuse and Mental Health Services Administration.