CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Special Issues Related to Heavy Drinking

Heavy drinking among older adults is less common than at-risk or moderate drinking. However, it may be overrepresented in certain populations, such as addiction centers. Among older adults, heavy drinking is defined as more than 28 drinks per week or 3 or more days of binge drinking per week. The prevalence of heavy drinking is estimated to be 1 to 3 percent of the population, with higher prevalence rates in clinical settings.

Diagnosis and Intervention

Although heavy drinking is defined by the quantity and frequency of drinking, persons who drink in this range are likely to also meet diagnostic criteria for alcohol dependence. Despite the low prevalence, heavy drinking is associated with greater morbidity and mortality. It may require a greater intensity of intervention to successfully reduce a patient’s consumption.

Because brief interventions do not require physician involvement, it is important to consider the resources and limitations of the setting in which the intervention takes place. In a setting such as an addiction clinic where there will be a higher prevalence of heavy drinkers, the clinic will need additional resources. For example, a physician may need to augment the brief intervention for the problems associated with heavy drinking.

In a primary care setting, the intervention may be provided by a nurse or other nonphysician member of the team. In such cases, the primary care physician may need guidance in managing the patient. This includes reminders about which laboratory studies to order or how to manage withdrawal. In settings that do not have physician involvement, heavy drinkers may have to be referred to another setting.

Medical Issues

Heavy drinking and alcohol dependence can lead to a wide variety of physical health problems, including liver disease, alcohol-related dementia, and cardiomyopathy. Heavy drinking and alcohol dependence can also exacerbate a number of physical health disorders such as cerebrovascular accidents (strokes), chronic obstructive lung disease, hypertension, and diabetes.

Because of the relationships between heavy drinking and health disorders, it is particularly important among older heavy drinkers that a thorough physical examination takes place. The exam should focus on the organ systems most likely to suffer alcohol-related damage.

In general, the physical examination for a patient who is a heavy drinker would include a focused neurologic exam and a cognitive assessment. The clinician should look for evidence of peripheral neuropathy and cranial nerve dysfunction. The clinician should also focus the examination on the liver, spleen, and cardiovascular system; evidence of trauma that may have occurred from falls; and other related issues.

In addition to blood pressure (for signs of hypertension) and weight (to check for malnutrition), the following laboratory studies are recommended during an initial examination or annual followup examination:

• Complete blood count. Macrocytic anemia is often associated with heavy drinking.
• Liver studies (aspartate aminotransferase serum [AST], alanine aminotransferase [ALT], gamma glutamyltransferase [GGT]). Elevations in any of these numbers may indicate liver fibrosis or early liver failure. In patients who have abnormal elevations of these figures, especially GGT, the lab value can be used to track progress in treatment. See Frequency of Laboratory Abnormalities in Older and Younger Alcoholic Inpatients.
• Albumin. Low albumin levels are a sign of malnutrition and can be a sign of severe alcoholism.

Because persons who are heavy drinkers are more likely to also have poor nutritional habits, it is common to recommend that these patients take multivitamins. Thiamin deficiency is a particular concern for heavy drinkers because this deficiency can lead to the neurologic disorder known as Wernicke-Korsakoff syndrome. This syndrome has the principal features of dementia and psychotic symptoms.

It is recommended that heavy drinkers be started on thiamin supplementation to address any deficiencies. The recommended dose is 100 mg per day and should be continued for 3 months after the person has reduced or eliminated his or her drinking. Vitamins and thiamin can be recommended for longer periods when patients continue to drink or when there is evidence of malnutrition or cognitive impairment.

Heavier drinking increases the likelihood that a person will need medical detoxification. This is especially true when the treatment goal calls for dramatically reducing or eliminating consumption. All patients who are heavy drinkers should be evaluated for their potential to experience withdrawal symptoms. See Alcohol Withdrawal. Treatments for heavy drinking include inpatient detoxification and rehabilitation, self-help groups, and pharmacotherapy. (See Formal Treatment.)

More information is available in Alcohol Problems in Older Adults: Prevention and Management, by Kristen Lawton Barry, David W. Oslin, and Frederic C. Blow, recently published by Springer Publishing Company.