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.