Principles and Practice of Geriatric Psychiatry

Mohammed T. Abou-Saleh, Cornelius L. E. Katona, Anand Kumar, Mohammed T. Abou-Saleh, Cornelius L. E. Katona, Anand Kumar

• Publisher: Wiley
• Year: 2011
• ISBN:
  9781119956662
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

The renowned Principles and Practice of Geriatric Psychiatry, now in its third edition, addresses the social and biological concepts of geriatric mental health from an international perspective. Featuring contributions by distinguished authors from around the world, the book offers a distinctive angle on issues in this continually developing discipline.

Principles and Practice of Geriatric Psychiatry provides a comprehensive review of:

• geriatric psychiatry spanning both psychiatric and non-psychiatric disorders
• scientific advances in service development
• specific clinical dilemmas

New chapters on:

• genetics of aging
• somatoform disorders
• epidemiology of substance abuse
• somatoform disorders
• care of the dying patient

Continuing the practice of earlier editions, the major sections of the book address aging, diagnosis and assessment and clinical conditions, incorporating an engaging discussion on substance abuse and schizophrenic disorders. Shorter sections include the presentation of mental illness in elderly people from different cultures—one of the most popular sections in previous editions. Learning and behavioural studies, as well as models of geriatric psychiatry practice, are covered extensively. This book provides a detailed overview of the entire range of mental illness in old age, presented within an accessible format.

Principles and Practice of Geriatric Psychiatry is an essential read for psychiatrists, geriatricians, neurologists and psychologists. It is of particular use for instructors of general psychiatry programs and their residents.

Part I

Mental and Behavioural Disorders Due to Psychoactive Substances

106

Alcohol Abuse and Treatment in the Elderly

Helen H. Kyomen¹ and Benjamin Liptzin²

¹McLean Hospital, Belmont, MA and Harvard Medical School, Boston, MA, USA

²Department of Psychiatry, Baystate Medical Center, Springfield, MA and Tufts University School of Medicine, Boston, MA, USA

INTRODUCTION

Alcohol abuse in the elderly involves the persistent and intended use of ethyl alcohol despite problems caused by its use^1,2. It is often overlooked, as elderly with alcohol abuse may present with non-specific concerns such as confusion, mood lability, depression, anxiety, unusual behaviour, self-neglect, falls, injuries, diarrhoea, malnutrition, myopathy, incontinence, hypothermia^3–5 and motor vehicle accidents⁶. However, as these conditions are evaluated, signs of the characteristic addictive use of ethyl alcohol may be uncovered with: (i) tolerance; (ii) withdrawal symptoms; (iii) loss of control of use; (iv) social decline; and (v) mental and physical decline². Late-life alcoholism is a substantial problem. In a recent population representative study which included 4236 non-institutionalized elderly, at-risk alcohol use was described by 13% of men and 8% of women, and binge drinking was reported by over 14% of men and 3% of women⁷. In another recent study of 24 863 elderly primary clinic patients, 21.5% were moderate drinkers, 4.1% were at-risk drinkers and 4.5% were heavy or binge drinkers⁸.

EFFECTS OF ALCOHOL IN THE ELDERLY

Older people are at greater risk and more vulnerable to the toxic effects of alcohol for two main reasons:

1. The elderly have a decreased volume of distribution due to decreased muscle mass, a greater proportion of fat and a smaller water compartment. These all result in a higher blood alcohol level than in a younger adult for the same amount of alcohol consumed^9,10. In a younger person, larger amounts of alcohol consumption may be necessary before detrimental effects from alcohol abuse become grossly evident. A susceptible elderly person may reach this threshold for hazardous use of alcohol after drinking relatively less.

2. The general decrease in the capacity to withstand stress and maintain homeostasis as well as a higher risk for medical illness and disability in elderly people may hinder adaptation to the noxious effects of alcohol and magnify the consequences of alcohol abuse in the elderly¹¹.

The interaction of these two main factors places the elderly alcohol-using person at greater risk for multiple impairments resulting from the use of alcohol.

There are many possible detrimental effects from alcohol abuse in the elderly. Among them are the following:

1. Driving ability can be adversely affected with the consumption of minimal amounts of alcohol. In some elderly, relatively small amounts of alcohol can exacerbate or lead to confusion, visuospatial impairment, problem-solving deficits, motor impairment¹² and motor vehicle accidents⁶.

2. Cognitive impairments suggesting dementia may be caused by alcohol abuse. Though some cognitive impairment can result from even social drinking, chronic consumption of higher doses of alcohol has been shown to cause marked cognitive deficits with associated cortical atrophy and ventricular dilatation on brain scan¹².

3. Elderly alcoholics have a higher prevalence of alcohol-related medical conditions than the elderly population at large. Such conditions include alcoholic liver disease, alcoholic cardiomyopathy, hypertension, chronic obstructive pulmonary disease, neurological diseases (including cognitive disorders and peripheral neuropathy), malnutrition, osteopenia, psoriasis, peptic ulcer disease and various cancers^3,12,13.

4. Alcohol use can adversely affect the elimination of some drugs and add to the toxicity of others. This places an elderly person with medical illness or disability who is taking prescription medication at great risk for having subtherapeutic or adverse effects from the medication^14,15. The magnitude of this problem is evident when one considers that the elderly are the largest per capita prescription drug users¹⁶ and the most at risk for medication associated adverse events¹⁷.

5. The depressant effects of alcohol on the central nervous system may mimic or contribute to depression in the elderly. Some elderly with depressed mood may resort to drinking in order to ‘self-medicate’ themselves. This may alleviate the depressive symptoms initially, but later lead to an increase in depression, anxiety, sleep disturbances and impotence^18,19.

6. Alcohol can contribute to malnutrition in the elderly. Malnutrition can result from the interaction of the following factors^20,21:

(a) Food intake can be hindered if the elderly alcoholic develops depressed mood, becomes apathetic and experiences loss of appetite. If the elderly alcoholic’s impaired ambulation or driving results in a reduced capacity to obtain food, or if limited financial resources are used to purchase alcohol instead of food, dietary intake may be restricted further.

(b) The effect of alcohol on the gastrointestinal tract is to produce malabsorption of fats, fat-soluble vitamins, calcium, magnesium, iron and zinc. The active transport of B vitamins is also impaired.

(c) Alcohol can contribute to increased losses of magnesium, phosphate, potassium and zinc through the urine. If vomiting and diarrhoea occur, there may be increased loss of sodium, potassium and chloride.

(d) Alcohol use increases the requirements for folate and pyridoxine.

7. Alcohol use contributes to accidents and injuries that may lead to fractures or subdural hematomas^3,6,22 .

8. Heavy use of alcohol is associated with greater mortality^23–25.

9. Alcoholism can disrupt the elderly alcoholic’s family structure and cohesiveness, and may even lead to family violence. This can result in dysfunctional family relationships, with consequent increased difficulty in treatment of the alcohol-related problems.

Despite the many unfavourable effects of alcohol abuse in the elderly, researchers have also reported positive aspects of alcohol use. Light to moderate alcohol consumption has been associated with decreased mortality risk^24,25, reduced risk of substantial functional health decline²⁶, better cognitive health and well-being^27,28, improved bone mineral density²⁹ and, in elderly coronary patients, elevated high-density lipoprotein cholesterol³⁰.

CHARACTERISTICS OF ELDERLY ALCOHOL ABUSERS

Elderly alcohol abusers differ from younger alcohol abusers in a number of ways. Alcohol abuse in the elderly is often associated with clusters of stressors such as job retirement, widowhood, the deaths of close friends and relatives, medical illness and disability in oneself and one’s peers, and perceived loss of meaningful roles or functions. Some authors consider late-onset alcoholism to be associated with tension reduction, where alcohol is used to regulate stress. However, the extent to which alcohol abuse in the elderly is precipitated by stress is unclear. Some researchers have found little or unexpected change in alcohol consumption or drinking behaviour due to life stressors^31,32.

The time of onset of alcohol abuse may also significantly differentiate the younger alcoholic from the older one^10,33,34. The early-onset alcoholics have a greater amount of psychopathology and family history of alcoholism than the late-onset alcoholics. The early-onset alcoholics are characterized by being male relatives of alcoholic men with histories of violence with and without alcohol, legal problems due to alcohol use and illegal substance abuse. The late-onset alcoholics are characterized by having isolated alcohol-induced problems with health, marital relationships, or self-care, and much reduced histories of arrests, violence or other substance abuse. Many elderly with alcohol problems fall into the late-onset alcoholic group. These findings suggest that the aetiology and predisposition of a person to an alcohol use disorder may differ by onset age. If this is so, the treatments and interventions for an alcohol use disorder may also differ with age of onset and need to be individualized accordingly. Individual feelings towards alcohol use are affected by exposure to cultural and historical attitudes³⁵. For example, the experience of the American elderly alcoholic may differ from that of younger alcoholics in that the elderly alcoholic and his peers may have been exposed to the turmoil of the Prohibition era³⁶. The moral issues highlighted in this historical period may influence the willingness that some elderly may have in recognizing and accepting a diagnosis of and treatment for alcoholism. In some retirement communities, evening cocktails are a part of the social routine, leading some individuals to increase their prior alcohol consumption.

THE RECOGNITION OF ALCOHOL ABUSE IN THE ELDERLY

Alcohol abuse in the elderly often comes to the attention of health professionals through presentation with a non-specific medical or psychiatric symptom, such as self-neglect, falls, confusion, emotional lability, depression, unusual behaviour, injuries, diarrhoea, malnutrition, myopathy, incontinence or hypothermia. In cases where alcohol abuse is suspected, alcohol dependence must be considered. Alcohol dependence is suggested when there is: (i) tolerance; (ii) withdrawal symptoms; (iii) loss of control of use; (iv) social decline; and (v) mental and physical decline^2,37.

Tolerance to alcohol may be assessed by establishing a reliable history of the patient’s drinking pattern. Corroboration from family members and others close to the patient may be crucial. Tolerance is suggested if the patient exhibits a quantity and frequency of drinking which is increased over his baseline pattern of drinking. A patient with tolerance to alcohol will require a greater quantity of alcohol to achieve the same amount of inebriation that a lower quantity had been able to achieve previously. Tolerance is strongly suggested if there has been at least a 50% increase in the amount of alcohol required to attain a given effect^2,37.

Withdrawal symptoms occur when a patient who is physically dependent on alcohol experiences a rapid decrease in blood alcohol concentration. In an older person, the onset of withdrawal may be delayed by days after drinking cessation, and the duration of withdrawal may be prolonged^37,38. Symptoms of the alcohol withdrawal syndrome stem from autonomic hyperactivity and include tachycardia with a pulse of greater than 110 beats per minute, tachypnea, hypertension, low-grade fever, sweating, nausea, vomiting, hand tremors and increased anxiety. In some cases, the patient may develop seizures or delirium tremens with confusion, agitation and visual or tactile hallucinations. An elderly patient undergoing withdrawal may experience one or all of these symptoms^37,38.

Loss of control means that the patient is no longer able to consistently choose the amount of alcohol consumed in a given situation³⁷. The patient may also experience blackouts, and behave and feel in unpredictable ways.

Social decline in the elderly alcoholic is assessed from a baseline of age-appropriate behaviours^2,37,38. Many elderly people no longer hold a steady job, do not drive or hold a driver’s license, and have lost many of their close friends and associates with whom they used to socialize. Thus, it may not be as appropriate to assess for social decline by investigating these areas of the elderly patient’s life as it would be in a younger patient. However, it is relevant and revealing to ask elderly people if they are in contact with their children or grandchildren, and to what extent. It is also useful to find out whether the patient’s relatives express any concern about the patient’s alcohol use. Investigating the patient’s functioning with respect to hobbies or other enjoyed activities can also be useful.

Physical, psychological and laboratory findings may also uncover problems with alcohol use^37–39. Addictive alcohol use can lead to malnutrition, gastrointestinal upset and bleeding, delirium, falls, depression, hypertension and neglect of self. Recurrent diseases of the stomach, pancreas or liver may also be caused by excessive alcohol abuse. These medical conditions often bring the elderly alcoholic to clinical attention. Laboratory results of macrocytosis, elevated mean corpuscular volume and increased liver enzyme levels, especially gamma glutamyl transpeptidase, may correlate with alcohol abuse in the elderly. Carbohydrate-deficient transferrin is approved by the Food and Drug Administration (FDA) as a clinical diagnostic test for identifying heavy alcohol use³⁹. Blood alcohol levels, and urine or breath tests for alcohol, may be used to confirm alcohol intoxication.

Assessment of tolerance, withdrawal, loss of control, social decline and mental and physical decline are useful clinical parameters to recognize and diagnose alcohol addiction. Several screening instruments have been devised to help clinicians recognize alcoholism. These scales typically assess the quantity and frequency of drinking, social and legal problems resulting from alcohol abuse, health problems related to excessive alcohol use, symptoms of addictive drinking and/or self-recognition of alcohol-related problems^40,41. Three screening instruments that are commonly used with the elderly are the CAGE screen⁴², the Short Michigan Alcoholism Screening Test-Geriatric Version (S-MAST-G)⁴³ and the Alcohol Use Disorders Identification Test (AUDIT)⁴⁴.

The CAGE screen is the most widely used. ‘CAGE’ is a mnemonic for the questions: Have you ever felt a need to Cut down on drinking? Have you ever felt Annoyed by others enquiring about your drinking? Have you ever felt Guilty about drinking? Do you ever use alcohol for an Eye-opener? If two or more of these questions are answered positively, a need for more extensive evaluation for alcohol abuse is indicated. The validity of the CAGE screen for alcoholism in the elderly has been examined empirically⁴².

A more detailed screen is the 10-item S-MAST-G⁴³ or the original 24-item MAST-G⁴⁵. The S-MAST-G was developed for screening older adults in various settings and has excellent psychometric characteristics. Scores of ≥2 on the S-MAST-G or of ≥5 on the MAST-G are indicative of possible problems with alcohol.

The AUDIT⁴⁴ emphasizes the identification of harmful drinking and need for current treatment. It was validated in a sample of non-elderly adults and is composed of two parts: a 10-item AUDIT Core Questionnaire and an 8-item AUDIT Clinical Procedure. The AUDIT Core Questionnaire includes specific questions about the quantity and frequency of drinking and can be incorporated into a general interview or medical history. In the original study sample, all alcoholics scored ≥9 on the AUDIT Core Questionnaire. The AUDIT Clinical Procedure complements the AUDIT Core Questionnaire and includes questions about clinical signs associated with harmful drinking, such as fractures, tremors and hepatic abnormalities. The AUDIT Clinical Procedure may be especially helpful in evaluating patients who underestimate their alcohol-related problems. A short version of the AUDIT, the AUDIT-C⁴⁶, is a 3-item screen composed of the alcohol consumption questions of the AUDIT. The AUDIT-C has been reported to be a valid primary care screen for heavy drinking and/or current alcohol abuse/dependence. Various versions of the AUDIT have been used widely, but for older adults, the overall accuracy is low and multiple screening methods are recommended^47,48.

THE TREATMENT OF ALCOHOL ABUSE IN THE ELDERLY

In acutely intoxicated patients, a thorough evaluation for and treatment of other co-existing medical or psychiatric problems must be initiated at the same time as the patient is being detoxified. Providing adequate nutrition and hydration is especially important in the elderly alcoholic due to increased nutritional problems and impaired thirst mechanisms in the elderly. Benzodiazepines are generally avoided in most elderly due to their potential for causing delirium. However, if significant withdrawal symptoms occur, benzodiazepines should be administered according to assessments of alcohol withdrawal severity^38,49. Withdrawal severity may be evaluated using the revised Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar)⁵⁰ and taking sequential vital sign measurements. Elderly patients may experience a delayed onset of and more severe withdrawal from alcohol and require higher doses of benzodiazepines than younger patients³⁸. In general, detoxi...

Table of contents

• Cover
• Title
• Copyright
• Contributors
• Preface
• Preface to Second Edition
• Preface to First Edition
• PART A: HISTORICAL BACKGROUND
• PART B NORMAL AND ABNORMAL AGEING
• PART C: DIAGNOSIS AND ASSESSMENT
• PART D: DEGENERATIVE AND RELATED DISORDERS
• PART E: AFFECTIVE DISORDERS
• PART F: SCHIZOPHRENIC DISORDERS AND MOOD-INCONGRUENT PARANOID STATES
• PART G: NEUROSES (ANXIETY DISORDERS)
• PART H: PERSONALITY DISORDERS
• PART I: MENTAL AND BEHAVIOURAL DISORDERS DUE TO PSYCHOACTIVE SUBSTANCES 663
• PART J: LEARNING AND BEHAVIOURAL STUDIES 687
• PART K: CULTURAL DIFFERENCES, SERVICE PROVISION AND TRAINING IN OLD AGE PSYCHIATRY 711
• Subject Index