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)

Inpatient/Outpatient Detoxification Treatment

One of the first issues to consider for an older patient with a substance dependence diagnosis is whether detoxification is necessary. If so, the clinician must decide whether to hospitalize the patient or manage the case on an outpatient basis.

No studies or reports specifically assess the potential risks or benefits of outpatient detoxification among older adults. However, detoxification is generally seen as medically riskier for an older person. Until more research is available, best clinical judgment must guide such decisions. For more information on detoxification, see TIP 19, Detoxification From Alcohol and Other Drugs.

When deciding whether to hospitalize an older patient for withdrawal from prescription drugs, it is important to consider medical safety and potential access to the abused drugs. Factors indicating the need for inpatient detoxification include:

• A high potential for developing dangerous abstinence symptoms such as a seizure or delirium. This can happen if the dosage of alcohol or drug has been particularly high or prolonged and has been discontinued abruptly. It also can happen in patients who have experienced these serious symptoms at any time.
• Suicidal ideation or threats.
• The presence of other major psychopathology.
• Unstable or uncontrolled comorbid medical conditions requiring 24-hour care or parenterally administered medications (e.g., kidney disease, diabetes).
• Mixed addictions (e.g., alcohol, sedative-hypnotic drugs).
• A lack of social support at home or living alone with continued access to the abused substances.
• A failure to respond to outpatient treatment.

Older patients detoxifying from psychoactive prescription drugs on an inpatient basis should not be stabilized on high doses of benzodiazepines or barbiturates with a long or intermediate half-life. These drugs can accumulate and result in toxicity and cognitive impairment after hospital discharge. This impairment can interfere with functional capabilities and hamper participation in continuing treatment.

The choice of drug and drug schedule should also be guided by the length of the hospitalization. If a long-acting drug such as clonazepam (Klonopin) or an intermediate-acting one such as chlordiazepoxide (Librium) is used to detoxify an older patient, the hospitalization will likely be extended. An additional risk is that the patient will exhibit no signs of the abstinence syndrome until days or even weeks after leaving the hospital.

In general, the initial dose of a drug for suppression and management of withdrawal symptoms should be one-third to one-half the usual adult dose. This dose should be sustained for 24 to 48 hours to observe reactions. Then it should gradually be tapered with close attention to clinical responses.¹

The clinician overseeing detoxification from alcohol or prescription drugs must decide on the level of care necessary to maintain abstinence. Patients with high relapse or withdrawal potential and patients with severe medical or psychiatric comorbidity will require hospitalization. Regular monitoring of the patient’s vital signs and objective symptoms of withdrawal also is needed.

Short-acting benzodiazepines (e.g., oxazepam [Serax], lorazepam [Ativan]) are customarily used as detoxification agents because alcohol-addicted patients are cross-tolerant to these substances. The use of oxazepam or lorazepam is warranted in patients with severe liver disease. Metabolism of these benzodiazepines does not depend on hydroxylation by the liver. Thus, they do not accumulate in the liver and cause adverse effects.²

The benzodiazepine dosage is decreased daily over the course of the detoxification process. Medications should be used more cautiously than with younger patients. These include clonidine (Catapres) and methadone for opiate withdrawal and phenobarbitol for barbiturate withdrawal.

In general, older patients require lower doses of many medications. The principle of starting at a lower dose and titrating at a slower rate should be followed for detoxification. In addition to treating acute withdrawal symptoms, clinicians need to ensure that alcoholic patients take supplemental doses of thiamin, folate, and multivitamins. Such supplements counteract the vitamin depletion often associated with excessive alcohol use.

References

1. Finlayson, R.E. Misuse of prescription drugs. International Journal of the Addictions 1995, 30(13-14): 1871-1901.
2. Brower, K.J.; Mudd, S.; Blow, F.C.; Young, J.P.; and Hill, E.M. Severity and treatment of alcohol withdrawal in elderly versus younger patients. Alcoholism: Clinical and Experimental Research 1994, 18(1):196-201.

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