Management of Alcohol Use Disorders in Older Adults: What Doctors Need to Know

Screening and Identification

Alcohol Consumption History

• Ask all elderly patients at baseline, annual physical
• Elicit a specific weekly consumption
• Convert patient’s response into standard drinks: 12 oz. of beer, 5 oz. of wine, or 1.5 oz. of spirits.
• Ask about patients’ maximum consumption on one day in the past one to three months
• Physical examination and screen for infections and any concurrent medical disorders ( eg anemia, UTI, chest )

Screening questionnaires

Short Michigan Alcoholism Screening Questionnaire (Geriatric Version)

CAGE

• Have you ever felt you ought to CUT DOWN on your drinking?
• Have people ANNOYED you by criticizing your drinking?
• Have you felt bad or GUILTY about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE OPENER)?

*Screen is positive if 2 “yes” out of 4 (men), 1 “yes” for women.
*CAGE is retrospective – may indicate a past problem not current

Laboratory measures

Diagnosis

Most heavy drinkers are ‘at-risk drinkers’ or ‘problem drinkers’. They drink above the low-risk guidelines, but are often able to drink moderately, have not suffered serious social consequences of drinking, and do not go through withdrawal. They often respond to brief physician advice and reduced drinking strategies.

Alcohol-dependent patients often have withdrawal symptoms, rarely drink moderately, continue to drink despite knowledge of social or physical harm, and spend a great deal of time drinking, neglecting other responsibilities. They generally require abstinence and more intensive treatment.

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Management of Older Adults with alcohol issues

Approach to office management

• See the patient frequently, with alcohol at the top of the agenda
• Always ask about alcohol and express concern about ongoing drinking
• When feasible, ask a spouse, relative of friend to attend the visits
• Routinely offer pharmacotherapy (see below)

Management of At Risk Drinking

• Review low-risk drinking guidelines
• Link alcohol to patient’s own health condition if possible
• Emphasize that mood, sleep, energy level will improve with reduced drinking. Ask patient to commit to a drinking goal: reduced drinking or abstinence
• If unwilling to commit, continue to ask about drinking at every office visit
• If reduced drinking goal chosen: Have patient specify when, where and how much they intend to drink. Give tips on avoiding intoxication (see below). Ask patient to keep a daily record of drinks consumed
• Monitor GGT and MCV at baseline and follow-up
• Identify triggers to drinking (e.g., emotions, social events), develop plan to deal with triggers
• Have regular follow up
• Consider referral to alcohol treatment program if problem persists

Factors contributing to alcohol use in the elderly

• Grief due to loss of spouse, adult children moving away etc.
• Boredom due to retirement and loss of roles
• Chronic pain
• Depression
• Insomnia
• Loneliness and isolation: Difficult to leave house to attend treatment or participate in non-drinking activities
• Shame, especially among women, which may make them reluctant to disclose their drinking and seek help

Strategies to Avoid Intoxication (Harm Reduction Approach)

• Drink no more than one standard drink per hour, and no more than two drinks per day
• Sip drinks, don’t gulp
• Avoid drinking on an empty stomach.
• Dilute drinks with mixer
• Alternate alcoholic with non-alcoholic drinks
• Put a 20-minute “time-out” between the decision to drink and taking the drink
• Avoid people and places associated with heavy drinking

Falls due to intoxication

• If cognitive or visual impairment or ataxia, recommend abstinence. If drinking have a sober person present
• For other patients, advise no more than one drink per hour (see strategies to avoid intoxication)
• Don’t drink within one hour of bedtime
• Ask for assistance if need to walk while intoxicated
• Taper off benzodiazepines

Failure to thrive

• Due to combination of depression, cognitive impairment, chronic intoxication and withdrawal, poor nutrition etc.
• Often requires hospital admission and discharge to supportive environment or long term care home

Management of Alcohol Dependence

• Explain health effects of alcohol, linking them to patient’s condition; reversible with abstinence
• Explain that within days and weeks of abstinence, most patients have improved sleep, mood, energy level
• Explain that alcohol dependence is a chronic illness: it can happen t ‘good’ people; effective treatments are available; prognosis is good with treatment
• Ask whether patient is willing to commit to a drinking goal (abstinence or reduced drinking)
• If the patient is not ready to commit, ask about drinking & readiness to change at each visit
• If ready to commit, negotiate a drinking goal in writing + daily log: Abstinence more likely to be successful. If reduced drinking goal chosen, encourage a time-limited trial
• Consider planned detoxification if at risk for withdrawal (6+ drinks/day, morning or afternoon tremor/anxiety)
• Treat concurrent conditions e.g. anxiety, depression, hypertension, liver diseas
• Encourage patient to keep away from people & places associated with drinking: Spend time with family, friends. Go for walk daily as health permits. Regular wake and sleep hours. Regular activities outside the house as feasible
• Review options for formal treatment – residential, day or outpatient
• Arrange follow-up; routinely monitor drinking through self-report, GGT, MCV
• Encourage access to local addiction services through: the Connex DART database or through a local directory. Consider home alcohol treatment services if available
• AA provides group support, practical advice, helps to overcome loneliness and boredom. Or senior specific counseling program. Alanon for families or caregivers
• Acknowledge successes, even if partial or temporary
• If relapse, encourage patient to contact you & reconnect with local addiction services including seniors program and or AA & aftercare

Management of common alcohol-related depression, anxiety, insomnia, mood and anxiety disorders

• May be primary or alcohol-induced.
• Alcohol-induced disorders tend to resolve within weeks of abstinence/reduced drinking, whereas primary disorders remain the same or improve only marginally.

Management

• Always ask about mood in patients with alcohol problems, and ask about alcohol use in patients with mood or anxiety problems.
• Treat alcohol and mood disorders concurrently.
• Consider a trial of antidepressant medication if: Symptoms persist after four weeks of abstinence - Patient unable to sustain abstinence for several weeks - Primary mood disorder: depression precedes drinking; strong family history - Severe depression (suicidal ideation, hospital admissions)
• Long-term benzodiazepine use in heavy drinkers creates risk of accidents, overdose and misuse.

Insomnia, non-restorative sleep

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Other alcohol-related medical problems

Hypertension

• Consumption of 3+ drinks/day can cause or exacerbate hypertension
• Patients with alcohol-induced HTN tend to be refractory to antihypertensive medication
• HTN resolves within weeks of abstinence/reduced drinking

Neurological conditions

• Alcohol-induced dementia, cerebellar ataxia, peripheral neuropathy, parkinsonism
• Conditions often improve with abstinence, over weeks/months.

Dilated cardiomyopathy

• Presents with heart failure and arrhythmias
• Excellent prognosis; sometimes completely resolves within months of abstinence
• GI Bleed (gastritis, esophagitis, Mallory-Weiss tear, esophageal varices)

DELIRIUM DURING WITHDRAWAL

• Heightened sense of anxiety, tremulousness, visual, auditory hallucinations and other perceptual disturbance, fluctuating level of consciousness.

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Treatment with Medications

Medications for at-risk drinking and alcohol dependence

• Anti-alcohol medications should be routinely offered to alcohol-dependent patients. They reduce alcohol use, have a good safety profile, and help retain patients in psychosocial treatment.
• Disulfiram, naltrexone, acamprosate: Level I evidence of effectiveness
• Topiramate, gabapentin, (baclofen): Level II evidence, not officially indicated for alcohol dependence. Therefore Level I medications should be tried first. Document the clinical rationale for use of topiramate, baclofen. Secondly obtain coverage for naltrexone acamprosate (Section 8). Baclofen can cause or worsen depression
• Disulfiram causes a toxic reaction if patients drink. It is most effective when dispensed by a person who observes the patient taking the medication. Naltrexone reduces the reinforcing effects of alcohol, and alcohol cravings. Acamprosate may work by reducing cravings and subacute withdrawal symptoms such as insomnia and anxiety. The choice of medication is based on individual considerations (side effects, cost etc.).
• Titrate dose until cravings are mild and patient is abstinent, or troublesome side effects emerge
• Duration of treatment: Three to six months or longer. Discontinue when patient is abstinent for at least several months and remains confident that he or she no longer needs the medication to prevent relapse. Discontinue when patient remains confident that he or she no longer needs it to prevent relapse. Restart medication should the patient relapse.
• For patients on Ontario Drug Benefits, the physician must apply for an Individual Clinical Review to obtain coverage for naltrexone and acamprosate. Disulfiram is available as a compounded medication. The patient can ask his/her pharmacy to arrange for compounding.

Prescribing benzodiazepines and opioids

• Risk of overdose and accidents greatly increased when combining benzodiazepines or opioids with alcohol
• Both medications should be routinely tapered in to the lowest effective dose in the elderly

KEY FACTS

Low-risk for the elderly (65 or older)

No more than:

• For men, no more than 1 – 2 standard drinks per day, with no more than 7 per week in total
• For women, no more than 1 standard drink per day with no more than 5 per week in total;

Non-drinking days are recommended every week.

Depending upon health, frailty, and medication use some adults should transition to these lower levels before age 65. As general health declines, and frailty increases, alcohol should be further reduced to 1 drink or less per day, on fewer occasions, with consideration given to drinking no alcohol.

Standard drink = 12-ounce (341ml) bottle of regular (5%) beer, five ounces (142 ml) of (12%) table wine or 1.5 ounces (43 ml) of 80-proof liquor.

Ask about size and alcohol content of beverage

Avoid alcohol or drink only under supervision if:

• Frail elderly
• At risk for falls (ataxia, cognitive or visual impairment)
• On sedating medications (e.g. benzodiazepines, opioids)
• Medical illnesses made worse by alcohol, e.g. gastritis or ulcer, pancreatitis, liver disease
• Mood disorder

Note: Light drinking in the elderly associated with delayed cognitive decline and reduced risk of heart disease and type II diabetes. However, heavy drinking is more hazardous in the elderly than in younger adults, because they have higher alcohol levels per drink, lower tolerance to the intoxicating effects of alcohol, and are at greater risk for falls and other harms.

Prepared by: The EENet Community of Interest for Specialized Geriatric Addictions, supported by Geriatric Mental Health, Addictions, and Behavioural Issues Community of Practice, The brainxchange (formerly the Seniors Health Knowledge Network (SHKN) & Alzheimer’s Knowledge Network (AKE))

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