Saturday, September 28, 2013

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)

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


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
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

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
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

Pharmacological treatment of Insomnia
-trazadone best evidence
-gabapentin equivocal
  • benzo and z drugs

if concurrent disorder treat with SSRI
higher risk of suicide in elderly

No comments: