Treatment of Alcohol-Related Problems in the Elderly
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Julian Offsay, MD
Although figures vary from one study to another, available evidence indicates that alcoholism in the elderly is underdiagnosed and undertreated.1 Community studies generally have shown that about 2-3 percent of men over the age of 65 years meet criteria for alcoholism, with the incidence in women being perhaps one-third of that.2,3 When the focus is shifted to the medical office or the inpatient setting, the figures may increase tenfold, and are usually even higher for elderly persons seen in the emergency room.4 Furthermore, there is a general consensus that with the aging of the “baby boom” generation, these figures will increase significantly.
Among older drinkers there appears to be two different groups in terms of age of onset of alcoholic drinking (Table I).5 “Early-onset” alcoholics tend to comply with the common stereotype of the chronic alcoholic. They typically begin as teenagers or in their early twenties, and often impair their health, vocational life and personal relationships severely as they progress from youth through middle age. Many do not reach old age for obvious reasons. “Later-onset” alcoholics are mainly people who drank moderately, or even rarely, but then either increased their intake in association with the changes brought about by the aging process, or ran into problems because they could no longer handle the amount of alcohol they consumed earlier in life. Among the physiologic changes that account for reduced tolerance in the elderly are a decrease in lean tissue and water, with a relative increase in fatty tissue. Accordingly, a given amount of alcohol is distributed in a smaller volume, and blood levels are higher. Also, older people have less alcohol dehydrogenase in their stomachs, so, again, a drink raises blood levels more than it did at a younger age. Furthermore, the elderly brain is far more sensitive to alcohol.
Evaluating a Patient with an Alcohol Problem
In order to assess the severity of a given patient’s alcohol problem, we inquire about the quantity and pattern of drinking. A “standard drink” contains between ½ and ¾ ounce of pure alcohol. This is approximately the amount in a shot of 80-proof liquor, a 12-ounce glass of beer, or a 5-ounce glass of wine. The current recommendation, from the National Institute on Alcohol Abuse and Alcoholism, is that persons over age 65 limit their consumption to one standard drink per day, and to no more than two on any occasion. Women are more vulnerable to alcohol’s deleterious effects and are generally advised to drink less. (Guideline is available in Treatment Improvement Protocol # 26, available from the Substance Abuse and Mental Health Services Administration [SAMHSA].6 The reader is advised to visit the SAMHSA site on the Internet [http://samhsa.gov], as it is a source of valuable information and publications).
The terms at risk and problem drinking have been found useful in terms of evaluating severity. At risk is drinking that has not yet led to identifiable consequences, but which is likely to do so in the future. Problem drinking pertains to a pattern that has led to one or more adverse consequences. The labels of alcohol abuse and dependence define conditions of greater magnitude. Abuse generally involves major consequences in at least one area of functioning, while a dependence diagnosis requires widespread impairment, with the addiction essentially taking over one’s life. Actual tolerance and physical dependence are usually present to some degree, but are not required to make the diagnosis.
In order to accurately identify alcoholic problems in patients, clinicians must be actively searching for them and asking the right questions.
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