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Diagnosing And Treating Alcohol Abuse In Older Adults

This information on alcohol abuse is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only.  Recommendations depend on the needs of individual patients and the resources available.

Prevelance
Risk Factors and Symptoms
Diagnosis
Management

Prevelance

  • The prevalence of heavy drinking (12 to 21 drinks per week) in older adults is estimated at 3 to 9 percent (Liberto et al., 1992).
  • One-month prevalence estimates of alcohol abuse and dependence in this group are much lower; they range from 0.9 percent (Regier et al, 1988) to 2.2 percent (Bailey et al., 1965).
  • Alcohol abuse and dependence are approximately four times more common among men than among women (1.2 percent vs. 0.3 percent) aged 65 and older (Grant et al., 1994). Although lifetime prevalence rates for alcoholism are higher for white men and women between ages 18 and 29, African American men and women have higher rates among those 65 years and older. The lifetime prevalence rates for alcoholism among Hispanic men were between those of whites and African Americans. Hispanic females had a much lower rate than those for whites and African Americans (Helzer et al., 1991).
  • The rate of alcohol dependence among older adults (aged 65 and older) who come to the emergency room is almost 15% (Kaplan, 2000).
  • The rate of alcohol dependence among older adults (aged 65 and older) who come to the emergency room is almost 15% (Kaplan, 2000).

Bailey, M. B., Haberman, P. W., & Alksne, H. (1965). The epidemiology of alcoholism in an urban residential area. Quarterly Journal of Studies on Alcohol, 26, 19 40.

Grant, B. F., Harford, T. C., Dawson, D. A., Chou, P. S., & Pickering, R. P. (1994). Prevalence of DSM-IV alcohol abuse and dependence: United States, 1992. Alcohol Health and Research World, 18, 243.

Helzer, J. E., Burnam, A., & McEvoy, L. T. (1991). Alcohol abuse and dependence. In L. N. Robins & D. A. Regier (Eds.), Psychiatric disorders in America: The Epidemiologic Catchment Area Study (pp. 81 115). New York: Free Press.

Kaplan, Arline. (2000) Alcohol and Drug Dependence in Older Adults. Geriatric Times. 1,3.

Liberto, J. G., Oslin, D. W., &smp; Ruskin, P. E. (1992). Alcoholism in older persons: A review of the literature. Hospital and Community Psychiatry, 43, 975 984.

Regier, D. A., Boyd, J. H., Burke, J. D. Jr, Rae, D. S., Myers, J. K., Kramer, M., Robins, L. N., George, L. K., Karno, M., & Locke, B. Z. (1988). One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Archives of General Psychiatry, 45, 977 986.

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Risk Factors and Symptoms

Risk factors for developing an alcohol abuse problem

  • Having a mental health disorder; half of all individuals with severe mental health problems are also substance abusers
  • Having an alcoholic parent

Alcohol abuse can contribute to:

  • Physical health problems:
    • Chronic obstructive pulmonary disease
    • Cirrhosis of the liver
    • Hypertension and heart disease
    • Neuropathy
    • Peptic ulcer disease
    • Sleep disorders
    • Cancer
    • Premature death
  • Mental health problems:
    • Anxiety
    • Dementia
    • Depression
    • Suicide
  • Social problems such as:
    • Family problems
    • Financial difficulties
    • Homelessness
    • Violence and victimization

Symptoms of alcohol abuse

  • Increased consumption and frequency of consumption of alcohol
  • Increased tolerance to the effects of alcohol
  • Confusion, disorientation, blurred vision
  • Gastrointestinal problems (nausea, vomiting)
  • Insomnia, unusual drowsiness
  • Lack of physical coordination
  • Malnutrition
  • Slurred speech
  • Urinary problems (incontinence, retention)
  • Withdrawal symptoms (e.g., nausea, headache, anxiety, depression, sleeplessness) when one drinks less than usual

Other potential causes of symptoms

  • Another physical health problem
  • Abuse of sedative-hypnotic drugs such as benzodiazepines (e.g., clonazepam)

Signs of alcohol abuse

  • Health, relationship, legal, or work problems because of drinking
    • Eviction from place of residence
    • Neglect of grooming and hygiene
    • Withdrawal from friends, family, and neighbors
  • Unusual behavior because of drinking
    • Calling restaurants in advance to determine whether they serve alcohol
    • Considering the amount of alcohol that will be available at social events; drinking before parties; asking to mix one s own drinks at social gatherings; guarding alcoholic beverages
    • Sleeping during the daytime
    • Discontinuing usual activities
    • Hiding empty containers for alcohol in the garbage or elsewhere
  • Unsafe behavior because of drinking
    • Evidence of  unexplained injuries such as bruises, burns, or fractured bones
    • Minor car accidents

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Diagnosis

The Diagnostic and Statistical Manual (DSM IV) defines an alcohol use disorder as one s recurrent consumption of alcohol even after one has experienced work, legal, relationship, or physical problems because of drinking:

Alcohol Abuse


A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12--month period:

  1. recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance re-lated to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use)
  3. recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct)
  4. continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication, physical fights). The symptoms have never met the criteria for Substance Dependence for this class of substance.

Alcohol Dependence

A maladaptive pattern of alcohol use, leading to clinically significant impair-ment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. tolerance, as defined by either of the following:
    1. a need for markedly increased amounts of alcohol to achieve in-toxication or desired effect
    2. markedly diminished effect with continued use of the same amount of alcohol
  2. withdrawal, as manifested by either of the following:
    1. the characteristic withdrawal syndrome for alcohol
    2. the same (or a closely related) substance is taken to relieve or avoid with-drawal symptoms
  3. alcohol is often taken in larger amounts or over a longer period than was intended
  4. a persistent desire or unsuccessful efforts to cut down or control alcohol use
  5. a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
  6. important social, occupational, or recreational activities are given up or re-duced because of alcohol use
  7. alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.

Diagnostic Instruments

  • Screening tools for identifying alcohol abuse in older adults include:
    • A clinical interview with open-ended questions
    • A drinking history
    • A self-administered screening test that can be distributed during a talk about alcohol and older adults. This form of self-scored test can also be distributed in senior centers and senior housing facilities.
  • Assessment tools for the diagnosis of alcoholism include:
  • More Specialized Assessments
    Depending on initial assessment, some patients may require further evaluation for:
    • Medical problems
    • Psychological issues
    • Other substance abuse

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Management

Management of alcoholism may include drug therapy, psychotherapy, or both.

Medication

Several types of drug therapies are effective in managing alcoholism. When choosing a medication, consider the patient s age, coexisting medical and psychiatric illnesses, response to medications, and possible drug interactions.

  • Drugs used to control alcohol abuse include:
    • Naltrexone (Revia) may reduce one’s craving for alcohol. This drug is prescribed for patients who are still drinking alcohol.
    • Disulfiram (Antabuse) causes a severe physical reaction in people who continue to drink alcohol. This severe reaction helps to prevent relapse, especially in binge drinkers.
    • Acamprosate may help individuals who are dependent on alcohol to drink less and in some cases to stop drinking altogether.
    • Serotonergic agents are being investigated for their potential use in substance abuse.
    • Lithium is sometimes given to individuals with both alcoholism and depression.

Psychotherapy

Psychosocial interventions for alcoholism include motivational intervention; cognitive behavioral therapy (CBT); group therapy (such as marital and family therapy); and psychodynamic psychotherapy to address coexisting disorders or stressors. Support, reassurance, and education are important elements of each of these interventions. Other factors to keep in mind when choosing a particular intervention are:

  • Older adults may be motivated to stop drinking because of concerns about their health and their desire to remain independent and financially secure.
  • The most successful interventions include the patient in decision-making, and these interventions are respectful of the individual s ethnic and cultural beliefs and experiences.
  • With the patient’s permission, the inclusion of family members and other health care providers in the treatment process can also be very helpful.
  • Both the experience of alcoholism and the stage of addiction may differ among individuals, and one individual may need different types of treatment throughout the course of his or her chronic problem with alcohol.

Motivational Intervention

Patients may move through motivational intervention, a four-stage treatment plan, at different rates:

  1. Engagement: The clinician creates a relationship of trust with the individual and engages him or her in the treatment process.
  2. Persuasion: The clinician motivates the individual to consider the role of alcohol in his or her life and to participate in his or her own recovery process.
  3. Active treatment: The clinician teaches the individual the skills necessary to manage alcoholism. These skills may include avoiding alcohol and learning to socialize without it and managing stress and other feelings without alcohol.
  4. Prevention of relapse: After the individual has maintained a stable remission for six months or more, the clinician teaches him or her the skills necessary to maintain recovery. These skills may include:
    • Participating in self-help groups
    • Developing social skills (e.g., listening, expressing feelings)
    • Identifying new activities to replace alcohol abuse
    • Exploring new work opportunities

Cognitive behavioral therapy (CBT) can last up to several months. CBT treatments may include:

  • Finding ways to reduce negative thinking
  • Learning relaxation skills to ease anxiety in social situations
  • Improving interpersonal skills (such as conversation and assertiveness)

Assertive community treatment (ACT) connects older adults who struggle with alcoholism with helpful services and treatment programs. These efforts also encourage patients to comply with treatment.

Group therapy may include:

  • Social skills training (teaching the person to avoid social situations that might encourage alcohol abuse)
  • Education groups
  • Persuasion and active treatment groups: Persuasion groups are for individuals who are just beginning treatment for their alcohol problem. In these supportive, long-term groups, participants share with each other the role of substance use in their lives. Many members of these groups go on to seek treatment for substance abuse. Active treatment groups are for individuals who have decided to address their alcohol abuse. Participants learn to recognize triggers of their substance problem and share coping skills with each other.
  • Single and multiple family interventions and therapy
  • Medication support groups
  • Consumer-run self-help groups (e.g., 12-step programs such as Alcoholics Anonymous and other programs such as Rational Recovery, Dual Recovery Anonymous, and Double Trouble)

Psychodynamic psychotherapy to address coexisting disorders or stressors. This form of therapy is often used in addition to CBT and/or medications.

Combined pharmacotherapy and psychotherapy

Because of the broad range of symptoms among older adults who experience alcoholism, it is not possible to make a general recommendation regarding the efficacy of medication, psychotherapy, or a combination of the two types of therapy.

Suggested Guidelines for Treatment

The clinician should be aware of the wide variety of other medical and psychiatric conditions that may complicate alcohol abuse and its treatment.

The decision to use one treatment method over another may depend in part on:

  • Other medical or psychiatric illnesses that the patient may have
  • His or her history of substance use

Care for suicidal patients

Refer patients who present safety risks to themselves or others to a hospital emergency department or urgent psychiatric evaluation.

Initial Intervention

The clinician or team of caregivers helps the patient to begin working through the stages of motivational intervention. Additional assistance such as pharmacological treatment and family education and residential services may be required.

Detoxification

Individuals who stop drinking alcohol may experience mild symptoms (anxiety, insomnia) to severe symptoms (seizures, delirium tremens) of alcohol withdrawal. Medical monitoring, whether in the hospital or in an outpatient facility, is especially important for those who experience a severe case of withdrawal. Medications can be used to prevent or address these symptoms.

Active Treatment

During this phase of treament, the individual, with the support of the integrated treatment team and perhaps group therapy, works toward controlling his or her alcohol abuse problem. The patient and his or her clinician establish goals (such as overcoming the craving to drink) and find ways to meet them (e.g., by learning to use distraction when cravings arise).

The patient may not notice the effects of either pharmacotherapy or psychotherapy for several weeks after treatment begins.

  • Lack of a response to medication or repeated relapses may be due to:
    • Non-compliance
    • Inadequate dosing
    • Inadequate duration of therapy
    • The need for psychotherapy
  • Look for improvement in the patient’s:
    • Relationships
    • Ability to live independently
    • Ability to maintain a job or work toward educational goals

Assess the individual regularly until he or she attains stable remission of his or her alcohol abuse disorder. Patients who relapse may require further pharmacotherapy or psychotherapy.

Relapse Prevention

Once the individual has abstained from substance abuse for six months or more, he or she works toward preventing a relapse. Those who have maintained remission for a year or more and have finished acute treatment are considered to be in recovery.

Adapted from: