From the American Association of Geriatric PsychiatryQuick Interventions Can Prevent Drug Interactions
NEW ORLEANS—Primary care physicians will benefit from a greater awareness of the age-specific disease characteristics and treatment needs of elderly patients with alcohol problems, specialists advised during a session on alcohol and the elderly at the American Association of Geriatric Psychiatry annual meeting.
“Although the statistics for the prevalence of late-life alcoholism are not overwhelming, they are large enough to be important. Studies show we are not doing a good job in helping these people,” said Julian Offsay, MD, of the Institute of Living, Hartford, Conn.
Dr Offsay said that most elderly patients with alcohol problems are missed, and when they are identified, only half are treated. “Sometimes, we only diagnose the problem when an elderly person is hospitalized and goes into DTs [delirium tremens].”
Yet simple measures can help many patients. “Shockingly brief interventions can make a significant difference in at-risk and problem drinkers,” he observed.
(J Aging Health.
The Primary Care Research in Substance Abuse and Mental Health in the Elderly 2004; 16:3-27) study of 23,828 elderly persons defined “at-risk drinking” as:
• >14 drinks/week for men
• >12 drinks/week for women.
By this definition, 6% of the elderly are at risk, according to Colleen J. Northcott, MD, PhD, of the University of British Columbia, Vancouver, Canada.
“Physiologic factors can make a modest amount of alcohol a problem in the elderly,” Dr Northcott emphasized. Fasting blood alcohol levels are at least 20% higher in 60-year-old than in 30-year-old men. This translates into age-related declines in lean body mass and total body water, slower metabolism via alcohol dehydrogenase, decreased hepatic clearance, and greater central nervous system sensitivity.
Comorbid conditions and many types of medications can interact adversely with alcohol, particularly the types of medications often used by older patients:
• Acute alcohol use increases the effects of anticoagulants, hypoglycemics, and phenytoin, and causes disulfiram-like reactions with hypoglycemic agents such as sulfonylurea antibiotics (beta-lactams)
• Chronic use increases hepatic microsomal metabolism, which decreases the effects of anticoagulants, hypoglycemics, and phenytoin
• Because alcohol affects cytochrome P3A4 substrates, excessive consumption can potentiate the effects of antidepressants, antipsychotics, sedatives, and calcium channel blockers—agents that are used by many older patients
• Histamine2-blockers can increase alcohol absorption
• Cognition and organ function can be affected by cold and allergy remedies, anticholinergic antihistamines, sympathomimetics (eg, pseudoephedrine), caffeinated drugs, and nonsteroidal antiinflammatory drugs.
Look for Clues
In the elderly, the presentation of alcohol abuse tends to be biomedical rather than social and behavioral. Some 90% of abusers have major health problems.
Look for certain characteristics that are more frequently associated with alcohol problems in older adults. These would include:
• Men who are single and living alone
• Persons with a history of past abuse
• Smokers or patients with chronic obstructive pulmonary disease
• Persons with signs of self-neglect
• Those with a pattern of injury.
Other medical clues are:
• Recent loss
• Chronic pain
• Suspicious laboratory findings
• Alcohol-specific disorders, such as cirrhosis
• Depressed or anxious mood
• Impaired cognition
• Worsening of other health conditions
• Suicidal ideation.
David W. Oslin, MD, of the University of Pennsylvania and VA Medical Center, Philadelphia, said that the best treatments are individualized. At-risk patients may respond to brief interventions by the primary care physician, but the alcohol-dependent person usually requires specialty care.
Brief interventions are good for targeting specific health behaviors—such as light drinking that interferes with concurrent medications—and for nondependent heavy drinkers. Counseling is limited to about 5 to 20 minutes of nonpejorative discussions for up to 5 sessions. The goal is to reduce, not completely cease, drinking.
A more assertive approach is needed for those who abuse or depend on alcohol. This may include a full intervention (with the family) and will usually involve a professional specializing in alcohol abuse.
Age-Based Relapse Prevention
For relapse prevention, adaptive treatments that are age-appropriate may engage patients over longer periods of time. Geriatric day programs are often preferable to drug and alcohol centers that cater to young people, the presenters agreed.
Cognitive behavioral therapy with therapists who understand geriatric issues, 12-step programs, and motivational interviewing (nonjudgmental counseling sessions encouraging introspection and insight by the patient) can be effective.
For maintenance, consider naltrexone (ReVia), which blocks opiate receptors, thereby reducing alcohol-induced euphoria. Dr Oslin notes he often prescribes naltrexone for abstinence maintenance, adding that his experience has shown the drug is safe in reduced doses. “I used to be afraid of hepatic toxicity with naltrexone, but this was with 300 mg/day. I have since found it is effective and safe at 50 mg/day.”
Speakers noted that selective serotonin reuptake inhibitors (SSRIs) facilitate abstinence only in patients who are depressed and that they do not affect consumption of alcohol. Anecdotally, some patients have reported drinking more while taking SSRIs, possibly because the drug quells the feelings of guilt that serve to control their drinking.
All the experts urged physicians not to ignore these patients. “If treatment is age-appropriate, close to 75% of older adults will respond,” Dr Oslin said.
FOR PHYSICIANS • Updated Beers List: Drugs to Avoid in Older Adults
• Only 50% of elderly patients who are identified with alcohol problems are receiving treatment.
• Because of physiologic changes with aging, even a small amount of alcohol can be a problem.
• Alcohol interacts with many medications older patients take regularly. Chronic diseases and depression can trigger drinking.