© Geriatric Times. All rights reserved.
Alcohol and Drug Dependence in Older Adults
by Arline Kaplan
| Geriatric Times |
 |
September/October 2000 |
|
Vol. I |
|
Issue 3 |
A 78-year-old retired professor who became severely confused following elective
surgery; a 75-year-old woman who complained to her doctor about weight problems
and mood swings and suggested that amphetamines had helped her before; and a
retired pilot who fell down some stairs and broke his hip-all of these patients
suffer from alcohol and/or other drug dependence, according to treatment expert
Marc Schuckit, M.D., professor of psychiatry at the University of California,
San Diego.
Health care professionals frequently miss diagnosing alcohol and drug
dependence in older populations, although the prevalence of substance use
disorders is 2% to 3% among older women and perhaps 10% among older men,
Schuckit told attendees at the recent U.S. Geriatric & Long-Term Care
Congress in Las Vegas.
Schuckit, director of the Alcohol and Drug Treatment Program and the Alcohol
Research Center at the San Diego VA Medical Center, said that in medical
settings, the prevalence is much higher.
"Among the people who come into the emergency room who are aged 65 and
older, the rate of alcohol dependence pushes 15%. And among the acute
psychiatric admissions involving older patients, it is probably at least 20%,"
Shuckit said. "So if you are in a geriatric clinic someplace…it is
likely that a substantial proportion of the older people coming to see you are
alcohol- or drug-dependent…If you don't have a high index of suspicion,
you are going to miss them."
The clinical course of alcohol dependence in older patients is fairly
predictable, according to Schuckit. About 40% develop alcohol dependence after
the age of 45 to 50, and 60% are people who have misused alcohol for many years
but have been lucky enough to live that long. The late-onset alcoholics
generally have fewer health problems, more social supports, fewer prior
treatments and an overall better prognosis than the early-onset alcoholics
(Rigler, 2000).
The odds ratio of early death among older alcoholics is increased between
fourfold and sixfold compared to the general population, said Schuckit.
Alcoholics also have elevated risks for hip fracture, ulcer disease,
difficult-to-treat diabetes, liver problems, infections and other disorders.
Even compared to younger alcoholics, older alcohol-dependent individuals are
more likely to demonstrate psychiatric/neurological problems, including
cognitive deficits.
The cognitive changes associated with heavy intake of alcohol include
decreased frontal and cerebellar volume, increased brain ventricular size, and
a possible increased rate of dementia progression, as well as a possible
process of increased brain aging, he explained. Alcohol, other brain
depressants and stimulants also are associated with increased risk of
depressive episodes.
When working with depressed older adults, clinicians should ask themselves
whether any sleep impairment, decreased appetite, moodiness, sadness and
cognitive impairment they see could be related to the patient's use of alcohol
or other brain depressants or the use of stimulants, Schuckit said.
Causal Factors
While there is substantial literature about potential causes of alcohol and
drug dependence in older adults, Schuckit said he is "not very impressed with
an ability to draw solid conclusions."
Retirement may be one contributing factor.
"I have known a fair number of alcohol-dependent women who seem to be able
to keep their drinking in check until the kids grew up and left the house, or
until they retired from their careers," he said. Similarly, he has treated many
men who kept their drinking within limits during their military careers, but
became dependent on alcohol after retirement.
Increased exposure to poorly regulated prescription medications among older
adults might also increase the risk for depressant, opioid and stimulant drug
dependence, Schuckit said. Physicians may be prescribing higher doses than they
should without adequate monitoring. Twenty-seven percent of all antianxiety
prescriptions and 38% of hypnotic prescriptions in 1991 were written for older
adults, according to a national report (Center for Substance Abuse Treatment,
1998).
Also complicating the picture are age-associated changes in physiological
functioning, which can increase the effect of a few drinks. These changes
include decreases in percentage of body water, slower oxidation of alcohol and
some medications, and increasing brain sensitivity to depressant drugs, along
with a greater number of medical problems. The use of alcohol, stimulants or
opioids can magnify those problems and interfere with the effects of prescribed
drugs.
Treatment Considerations
Schuckit divided drugs of abuse into categories based upon their most
prominent effects at usual doses (Schuckit, 2000).
Depressants include alcohol, benzodiazepines, barbiturates and
barbiturate-like drugs, and the newer sleep medications, such as zolpidem
(Ambien) and zaleplon (Sonata). These drugs dampen neuronal activity, Schuckit
said, but aren't very good at pain killing.
"All of these drugs cause an intoxication similar to alcohol, all of these
medications cause a physical dependence similar to alcohol and all of these
drugs have a withdrawal syndrome that looks very much like alcohol," he
said.
Opiates include almost all prescription pain pills, except for a few
anti-inflammatories, as well as heroin, codeine and methadone (Dolophine).
"These drugs kill pain prominently. At the same time, they decrease the
digestive tract activity…and have some anti-cough or decreased ciliary
action in the respiratory tract," Schuckit said. "The withdrawal from all those
opioids looks very similar. Darvon [propoxyphene] withdrawal is almost
identical to heroin withdrawal."
Stimulants make up the third class of drugs most relevant to older
individuals, Schuckit said. That class includes amphetamines, cocaine, and
prescription and over-the-counter weight-reducing drugs.
"You are most likely to be seeing people who are taking borrowed
amphetamines or over-the-counter weight-reducing pills…or someone for
whom [a physician] prescribed a stimulant…for depression," he said,
adding that the use of stimulants for depression is not well supported in the
medical literature.
Moving to specifics, Schuckit noted that depressants, stimulants and opioids
are the only three classes of drugs with any clinically relevant withdrawal
syndrome.
Acute withdrawal is treated in any age range by first doing a physical
examination.
"Why? Because if you have a physical disorder, for example diabetes or an
infection, and you go into withdrawal, your withdrawal will be much worse than
if you go into [it] healthy," Schuckit said.
The next thing the clinician considers regarding alcohol, stimulant or
opioid withdrawal is to provide general education about withdrawal symptoms and
offer verbal and cognitive support. For example, saying, "You are going to feel
a lot better in a few days; I will help you," can help reduce a patient's
anxiety.
In alcohol-dependent patients, the withdrawal symptoms appear within four to
eight hours after they stop drinking. The withdrawal syndrome in older or
younger people will peak in intensity on day 2. To help with the symptoms,
Schuckit usually recommends long-acting benzodiazepines such as diazepam
(Valium). Some older people who have some persistent cognitive problems might
be best approached with short-acting benzodiazepines such as lorazepam (Ativan)
and oxazepam (Serax). Expect a marked diminution of the withdrawal syndrome by
day 5, he said, but also be aware of protracted minor withdrawal.
"Older people or younger people…at day 5 are having less autonomic
dysfunction, they are having less sleep problems, they are having less
moodiness, less tremor, but they still have all of those. And they will have
those problems at decreasing levels for the next three to six months," he
said.
He warned that older people often respond to withdrawal by getting confused,
and he suggested hospitalization. "Be very careful to not misdiagnose a
dementing process here," he said.
With opioid withdrawal, Schuckit said no one has convulsions or delirium, so
one can usually approach the syndrome with cognitive/behavioral measures alone.
As to medications, Schuckit explained that in most states, it is illegal to use
opioids to treat withdrawal symptoms. Therefore, for flu-like withdrawal
symptoms, he uses low doses of clonidine (Catapres); for diarrhea, he uses
loperamide (Imodium), an opioid not absorbed by the body; and for gut pain, he
uses the anti-inflammatory naproxen (Naprosyn).
For stimulant withdrawal, Schuckit said there are no medications appropriate
for any age range. These patients "are going to eat too much, sleep too much
and be depressed for three to five days, and there is no medication that's
going to help," he said. "Do a good physical exam and basically try to help
through psychological support."
Schuckit said that during rehabilitation, health care professionals need to
help patients achieve a high motivation for compliance for whatever they need
to do: changing their diet, increasing their exercise, changing the ways they
do things, and staying away from alcohol and drugs.
"If you visit alcohol and drug treatment programs aimed at older people,
that's what they do, but they do it with more groups that focus on issues of
loneliness, issues of loss, issues of how to relate to your children and issues
of how to deal with your medical problems," he said.
Considering medications to be used in rehabilitation, Schuckit said there
are currently no medications that have worked better than placebo for stimulant
dependence, and there are no medications that have been proven to be
cost-effective in the rehabilitation of alcohol dependence.
"ReVia (naltrexone) adds about 10% to 15% to the outcome…and it's
moderately expensive. There's a new drug coming from Europe called Campral
(acamprosate) that helps maybe 15% to 20%," he said.
For opioid dependence, two drugs are potentially useful-methadone and
naltrexone-but he knows of no data on the use of those drugs in older
populations.
Despite the limitations, health care professionals treating older adults
dependent on alcohol or other drugs can be somewhat optimistic about their
patients' futures, Schuckit said. Patients who are aged 65 or 70 and dependent
on alcohol or other drugs can markedly improve their level of functioning, or
become absolutely sober and clean.
References
Center for Substance Abuse Treatment (1998), Substance abuse among older
adults. Treatment Improvement Protocol (TIP) Series 26. Rockville, Md.:
Substance Abuse and Mental Health Services Administration, DHHS Publication No.
(SMA) 98-3179. Available at: text.nlm.nih.gov. Accessed July 16.
Rigler SK (2000), Alcoholism in the elderly. Am Fam Physician
61(6):1710-1716.
Schuckit MA (2000), Drug and Alcohol Abuse: A Clinical Guide to Diagnosis
and Treatment, 5th ed. New York: Kluwer Academic Press.
Schuckit, MA (1999), New findings in the genetics of alcoholism. JAMA
281(20):1875-1876.