Alcohol use disorder in seniors

Alcohol use disorder in seniors

Contributed by: Mat Rose MD - View bio 

Case

Mrs. Smith, 81 years old and living independently in an apartment, is in to see you for follow-up of a broken wrist, for which she was seen in ER two weeks ago. She’s accompanied by her daughter, Rose, who’s an occupational therapist. She’s in a cast, and has a recent-looking bruise on her right temple area. She appears otherwise okay.

Mrs. Smith recounts that she had “just tripped when I turned too quickly to get to the phone--I still have a normal phone, you know.” You ask if the bruise was related, and she replies that that was from banging her head on an open cupboard door the other day. Rose pipes up to add that her mom seems to be having more accidents lately. Mrs. Smith makes a sour face and says, “I’m just fine, you worry too much.”

You review the ER report: she was brought in by her neighbour who had come over for their habitual mid-morning coffee date and found Mrs. Smith in distress. ER doctor noted “strong perfume smell, alcohol?” The patient denies.

You ask Rose to step out of the room, and with tactful but direct questioning, Mrs. Smith reveals that she was drinking and yes, she starts drinking every morning because she feels so ill otherwise. She emphasizes the fact that she “never pours more than 1oz at a time.” She buys a 750mL (“26-ouncer”) of vodka every two days.

Issue

Alcohol use disorders (AUD) occur at all ages, and consequences of unhealthy drinking are often what lead to encounters with the health care system. Risk of health issues related to alcohol use increases with age.^1,2

Background

It is estimated that over 60% of North Americans over the age of 65 drink alcohol, and up to 22% at levels consistent with AUD. Besides musculoskeletal injuries, alcohol in the aging population is associated with increased all-cause mortality: stroke; fatal aortic aneurysm; heart failure; gastritis and ulcers; diabetes; hypertension; alcoholic liver disease; and infections. And it likely contributes significantly to cognitive decline and dementia, as well as many types of cancer. Rates of alcohol use screening and treatment recommendations in ERs and primary care are neither consistent nor high.^3,4,5 

Evidence

Assessment

When screening for AUD, use a validated questionnaire: the CAGE questionnaire is well-known, but the AUDIT-C and TWEAK are also recommended. The SMAST-G is specifically for the older population.^6,7 At least ask about “any alcohol use at all” and quantify daily or weekly intake.

Refer to the Canadian Guidelines on Alcohol Use Disorder Among Older Adults - 2019 for specific recommendations regarding lower-risk drinking, screening, assessment, interventions including counseling and medications, and referral to treatment.⁸

It is fundamental to treatment planning that those providing treatment of an AUD understand their patients regarding acceptance of the diagnosis and willingness to change. In the face of denial of a problem, the clinician can always cite the negative health effects of alcohol and caution their patients to “avoid excess alcohol use, and feel free to discuss options if they feel the situation is perhaps more than they can manage on their own”.⁹

Treatment

Initial considerations²

• Polypharmacy: the elderly are often on multiple medications, increasing the risk of drug interactions and adverse effects, which can be magnified in the presence of alcohol use. Conversely, alcohol use may interfere with regular use of prescribed medications, either due to an assumption that medications shouldn’t be taken when drinking or from forgetfulness due to intoxication or after-effects.
• Metabolism: age-related changes in liver and kidney function affect the metabolism and clearance of medications, necessitating dosage adjustments. Alcohol use can have a direct effect on this as well.
• Comorbidities: other health conditions independent of or related to alcohol use, such as liver disease, cardiovascular disease and cognitive impairments can complicate AUD management.

Medications

There are effective medications for the treatment of AUD, but results are always better when combined with psychotherapy, whether peer-support groups or individual counseling such as cognitive behavioral therapy (CBT).¹⁰ The elderly are more susceptible to adverse effects and care is needed in determining which medication may be the most appropriate.^11,12 Examples include:

• Disulfiram - very problematic in the elderly and rarely used now in any age group.
• Acamprosate - safe in liver disease, caution when renal impairment is present.
• Naltrexone - can cause hepatoxicity, so monitoring of liver function is required: it will block the effect of opioid analgesics. 

There are numerous other medications used off-label, such as gabapentin, topiramate, ondansetron and varenicline, which show promise, but are best employed by practitioners familiar with the pharmacological treatment of AUD.

Counseling and Psychosocial Support

It is important to recognize that AUD is usually associated with significant social and psychological issues, either as a cause or a consequence, or eventually both. Supports including family and friends need to be engaged in a constructive manner, and they often need education about addiction and how best to assist in making positive changes.¹⁰ 

Peer support groups (AA, SMART) are as effective for the elderly as for any age group. 

Bottom Line

1. Regular screening for alcohol use is recommended in the elderly.^7,13
2. Opportunistic screening--for example, in this case of an injury--is nearly essential.^3,4
3. Establish consensus with your patient--not just their family--that there is a problem and that changes need to be made. Barring interest in change, institute harm reduction measures and revisit the issue frequently.¹³
4. Concerning alcohol use in the elderly (or anyone) can be a reason to notify authorities and withdraw driving privileges.
5. For severe AUD, referral to an addiction medicine specialist and/or a specialized geriatric program may be necessary. Hospitalization may be required for detoxification and stabilizing of particularly frail and/or medically complicated.¹³
6. In the presence of alcohol use, controlled or not, a thorough medication review is required to identify problems arising from interactions with alcohol or from compliance.

Recommendations and treatment plan

Mrs. Smith reluctantly admits that her alcohol use is “getting out of hand,” but she insists she can stop drinking on her own. Despite her recent physical injuries, she is very healthy and taking only hydrochlorothiazide for mild hypertension. She denies ever having had withdrawal symptoms from alcohol, although it has been many years since she’s gone more than 24 hours without alcohol. She refuses to consider a medically-supervised detoxification facility and will “just stop.” She agrees to try naltrexone when you point out “why refuse something that may help you succeed in this attempt? At worst you’ll have some side effects and we’ll just stop it.” She takes it without side effects.

Over the next two weeks, your medical office assistant who knows Mrs. Smith very well joins forces with Mrs. Smith’s daughter and they call or drop by every day. Mrs. Smith is feeling quite “dragged out” but insists she has been without alcohol and is managing fine. Her friend in her apartment building convinces her to try SMART Recovery, as it “worked absolute wonders” for her son. He takes Mrs. Smith to her first meeting.

References

1. O'Connell H, Chin AV, Cunningham C, Lawlor B. Alcohol use disorders in elderly people--redefining an age old problem in old age. BMJ. 2003 Sep 20;327(7416):664-7
2. National Institute of Alcohol Abuse and Alcoholism (n.d.) Alcohol's Effects on Health - Research-based information on drinking and its impact - Older Adults. Accessed 29 Feb 2024. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/older-adults
3. Keming Yuan MS et al. Emergency Department Visits for Alcohol-Associated Falls Among Older Adults in the United States, 2011 to 2020. Ann Emerg Med 2023;82(6):666-677.
4. Myran DT et al. Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study. CMAJ Jul 2019;191(29) E804-E810.
5. Uong S, Tomedi LE, Gloppen KM, Stahre M, Hindman P, Goodson VN, Crandall C, Sklar D, Brewer RD. Screening for Excessive Alcohol Consumption in Emergency Departments: A Nationwide Assessment of Emergency Department Physicians. J Public Health Manag Pract. 2022 Jan-Feb 01;28(1):E162-E169.
6. Naegle MA. Screening for alcohol use and misuse in older adults: using the Short Michigan Alcoholism Screening Test--Geriatric Version. Am J Nurs. 2008 Nov;108(11):50-8. https://www.ndbh.com/Docs/PCP/Michigan Alcoholism Test (SMAST-G).pdf
7. Chatterton B, Agnoli A, Schwarz EB, Fenton JJ. Alcohol Screening During US Primary Care Visits, 2014-2016. J Gen Intern Med. 2022 Nov;37(15):3848-3852. 
8. Canadian Coalition for Seniors’ Mental Health 2019. Canadian Guidelines on Alcohol Use Disorder Among Older Adults 2019. Accessed 29 February 2024. https://ccsmh.ca/wp-content/uploads/2019/12/Final_Alcohol_Use_DisorderV6.pdf
9. Public Health Agency of Canada - Canadian Coalition Seniors Mental Health. Alcohol & Aging - Rethink How You Drink (2023) . Accessed 29 Feb 2024. https://ccsmh.ca/wp-content/uploads/2023/11/WEB-CCSMH-Alcohol-Use-Brochure-Eng.pdf
10. van Amsterdam J, Blanken P, Spijkerman R, van den Brink W, Hendriks V. The Added Value of Pharmacotherapy to Cognitive Behavior Therapy And Vice Versa in the Treatment of Alcohol Use Disorders: A Systematic Review. Alcohol 2022;57(6):768-775. 
11. McPheeters M, O’Connor EA, Riley S, et al. Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis. JAMA. 2023;330(17):1653–1665. 
12. Castrén S, Mäkelä N, Alho H. Selecting an appropriate alcohol pharmacotherapy: review of recent findings. Curr Opin Psychiatry. 2019 Jul;32(4):266-274
13. Spithoff S, Kahan M. Primary care management of alcohol use disorder and at-risk drinking. Can Fam Phys, Jun 2015, 61 (6) 515-521.