Alcohol Use Disorders in the Elderly

Alcohol Use Disorders in the Elderly

Sept. 28, 2013

Sheryl Spithoff MD CCFP

University of Toronto

Suzanne D. Turner MBS, MD CCFP

Univeristy of Toronto

This lecture was given at the Canadian Society of Addiction Medicine, Vancouver ,2013

These are my rough notes which hopefully give a gist of the breath and depth of information. This was an excellent presentation by two very fine clinicians with obvious experience and caring.  

Past Year Alcohol Use by age

CAMH Monitor 2011

discernible increse in past year alcoyol use age 65 and older

-58.8% in 1997 to 71.8% in 2011

High % of daily drinking are in greater than 65 yo age range

M greater than Women

Burden of Illness

Blow, 2012, Mann 2013

By 2030 , older adults will represent greater than 19% of total US pop.  

Low Risk Drinking Guidlines - no more than 15 / week, no more than 3 drinks/siting

Percentage exceeding LRDG (low risk drinking guidelines)

Significant

Consumption limit for older adults should be lower

-Older men -recommend no mor than 1 drink per day Chermack 19956

For women this should be the amount

Max 2 drink  Blow 1998

American Geriatrics Society define high risk drinking as 

greater than 3 drinks on a single sitting

Barrier to treatment

-fewer addiction programs for older adults 

elderly have difficulty accessing existing program- long wait lists, complex adminission procedures, multip appointments

-most have group therapies and group therapies are commonly intimidating for older pop

Brief Intervention

Chermack 1996, Blow 1998

Review low risk drinking guide lines

Link drinking to individual patient situation

Emphacize that mood, sleep, energy level will improve with reduced drinking

Ask patient to committ to drinking goad - write a prescription

Older at risk drinkers showed significant reduction in 

-7 day alcohol use

-episodes of binge drinking

-frequency of excessive drinking (greater than 21 drinks/wek

The reduction was followed over time with differences present at 12 months

Cognitive Behaviour Therapy

-sustained abstinence with age matched group

16 weekly group sessions using CBT

at 6 months those who completed program had higher rates of abstinence

CBT worked well with older veterans with medical and psychaitric and addiction problems

DRUG THERAPY

alcohol treatment is as effective as with younger adults

pharmacotherapy is equally effective

Need strict compliance and monitoring of adverse effects

Naltrexone (Revia) 

-well tolerated in older adult population

Safe

No difference between placebo and revia

Elderly more likely to be complianc

higher retention rates

less likely to relapse

more attendance at therapy than younger

older adults respond well to medical treatment 

Psychotherapy and Naltrexone work well in elderly

ACUTE ALCOHOL WITHDRAWAL

mild - irritable, tremor, anxiety - resolve in a few days

moderate- anxiety, headache, N&V , sensory disturbance, tachycardia, HTN, tremor, sweater,s usually start 6-12 hours after and clear us 7-10 days

5 % of patient severe problems

Seizures usually 12 to 22 hours

More severe in older age groups, benzodiazpeine requirements greaters - in older studies

New studies no greater severity and no more benzo needed but comorbity and longer stays

Planned Withdrawal

-Do risk assessemnt

Divide

Low risk - no adminssion

High risk - close observation and medical management

Both groups need ongoing treatment plan

PLanned withdrawal, low risk

• no ‘relief drinking’
• no history of seizures or arrythmias
• drinking less than 40 per week in younger or 20 per week for elderly

Planned Withdrawal, Higher Risk

• need medcial management
• Benzodiazepines have best evidence for acohol withdrawal

Cochrane Review - benzodiazepen - librium recommendations

But for elderly - Pepper et al 1996 - select short acting benzodiazepine in elderly - ie ativan, lorazepam

Outpatient withdrawal

Blondell 2005 - criteria

Initial CIWA between 8 and 15

 no history of seizures or arrythmians

Age over 60 ‘relative contraindication’

• increase risk of confusion/delirium

Outpatient management

-carefully select if over 60

-must meet low risk criteria

Evans 1996

At 3 months, 2/4 abstinent

improvement in MMSE

Inpatient withdrawal

supportive treatment, fluids, electrolytes, 

be careful co morbidity

more frequent review

start 1-2 mg

beware of arrythmia and sedation

anti psychotic s - generally avoid

-prolong qt - almost all first and second generation

if used doe ekg to check qTC

Some lower seizure threshold-

Subacute Withdrawal

-may last for months

agitation, irritability, poor sleep, anxiety

Gabapentin has been used

Insomnia a risk for relapse

-cbt best evidence

-sleep hygeine education

No studies for CBT ofr insomnia in elderly 

reduce time spend in bed when not sleeping

leave bed if difficult sleeping

establish and maintain regularity

avoid daytime naps

etc

Pharmacological treatment of Insomnia

-trazadone best evidence

-gabapentin equivocal

• benzo and z drugs

q&a

if concurrent disorder treat with SSRI

higher risk of suicide in elderly