ALCOHOL IN THE ELDERLY

(1)

ALCOHOL IN THE ELDERLY

Dr. Sheryl Spithoff & Dr. Suzanne Turner

Addition Medicine Fellows

(2)

¡

Mental health and addiction dx:

§

Account 4.7% of all SJHC ED visits

§

766 patients / 16,000

§

35% of these patients were addiction-related

¡

This estimate does not capture other

substance-related diagnoses (i.e. non-mental

health)

§

Falls

§

Failure to cope

§

Liver failure

§

GI bleed

BURDEN OF ILLNESS

(3)

¡

US Screening Study (Onen 2005)

§ 

5.3% of elderly ER patients had current alcohol

disorder

¡

Assuming case identification rates of 20%

(standard), then about

300 elderly substance

users in one year at SJHC Emergency Room

(4)

¡

Monitoring of Health Effects

¡

Withdrawal Management

¡

Medications for craving

¡

Relapse prevention

¡

Connecting to other services

¡

And most importantly:

§

Treatment works

§

Without treatment the risks to the elderly are

significant

(5)

¡ 

Elderly can have more prolonged withdrawal and higher

risk of delirium

¡ 

Higher risks in withdrawal of:

§ cognitive impairment (including delirium)

§ daytime sleepiness

§ weakness

§ high blood pressure

¡ 

Some elderly may not be suitable for outpatient w/d

because following would have to be true:

§ Adequate social support

§ No significant withdrawal symptoms

§ No comorbid illness

§ No complicated withdrawal (no seizures, no delirium)

(6)

¡

Low to moderate alcohol use may protect

against vascular dementia (Ganguli, 2005)

§

No heavy drinkers in this study

¡

Heavy alcohol use increases risk of all types of

dementia (Thomas, 2001)

§

Alcoholics perform worse than controls on cognitive

testing, but better than Alzheimer’s (Liappas, 2007)

¡

Alcohol-induced cognitive impairment remains

stable and may improve with abstinence

§

Further research in this area is needed (Oslin, 2003)

HARMS (2): DEMENTIA

(7)

¡

A high proportion of elderly depressed

patients have an alcohol use disorder

§ 

30% in one study

¡

A high proportion of elderly alcoholics have

concurrent depression (Blixen 1997, Blow

2000)

¡

Alcohol use is a major risk factor for suicide in

the elderly

(8)

HARMS (4): LIVER DISEASE

Alcoholic Liver Disease

Fatty Liver First and most common phase of liver disease Usually no symptoms

REVERSIBLE WITH ABSTINENCE

Alcoholic Hepatitis Usually no symptoms but CAN be VERY severe Repeated and prolonged episodes can lead to cirrhosis

(9)

¡  Over 10-20 years, 10–20% risk of cirrhosis with: § 3 drinks/day (men), 2 drinks/day (women)

¡  In early stages, if stop drinking they can do well as the

cirrhosis stabilizes and can be symptom-free

¡  Most effective treatment is abstinence because cirrhosis often

not reversible

¡  If severe cirrhosis can get on transplant list

§ Need six months to two years of abstinence + treatment program to be eligible

(10)

¡  Encephalopathy

§ Coma, confusion or altered level of consciousness

§ The confusion can lead to high risk of accidents and death

¡  Ascites

§ Fluid building up in the belly

§ Makes it difficult to breath, walk and higher risk of infection (as the fluid is a good breeding ground for bacteria)

§ Infection puts patient at ++ high risk of death

¡  Varices

§ Enlarged blood vessels in the liver and spleen can cause extensive and life-threatening bleeding

(11)

¡

There are few addiction programs specifically

designed for older adults (Schulz 2003)

¡

Elderly have difficulty accessing existing

programs:

§

long waiting lists, complex admission procedures, and

multiple appointments

¡

Most programs are based on group therapy

§

can be intimidating for older patients

¡

MDs can help navigate the system and make sure

patients get in-hospital treatment, appropriate

medical treatment and ongoing monitoring

(12)

AT-RISK DRINKING VS

ADDICTION

(13)

¡

Men:

§ No more than 15 drinks per week

§ No more than 3 drinks per sitting

¡

Women

§ No more than 10 drinks per week

§ No more than 2 drinks per sitting

¡

Special Occasions:

§ Men: no more than 4 drinks

§ Women: no more than 3 drinks

(14)

¡

AT-RISK DRINKERS

§ Drink above the low-risk drinking guidelines

§ Able to drink moderately

§ Few social consequences

§ Do not go through withdrawal

§ Often respond to physician advice and reduction

¡

ALCOHOLICS

§ Withdrawal symptoms

§ Continue to drink despite harms

§ Neglect of responsibilities

§ Generally require abstinence and intensive treatment

(15)

At-risk Drinker Alcohol Addiction

Withdrawal Symptoms No Often

Amount Consumed More than 14/week 40-60/week or more Drinking Pattern Variable, depends on

situation Tends to drink set amount Social Consequences Nil or mild Often severe

Physical Consequences Nil or mild Often severe Social Stability Usually Often not Neglect of major

responsibilities No Yes

(16)

¡

Older, at-risk drinkers that received advice from their

primary care doctors about reducing consumption

showed significant REDUCTION in:

§ 7-day alcohol use (Fleming, 1999)

§ episodes of binge drinking

§ frequency of excessive drinking (> 21 drinks/week)

¡

This difference was followed over time

§ Differences still present after 12 months

¡ 

BOTTOM LINE: THESE PATIENTS LISTEN TO THEIR DOCTOR

(17)

¡

Consumption limits for older adults should be lower

(Chermack, 1996)

¡

Recommend no more than 1 drink per day

¡

Avoiding heavy drinking (consuming five or more

drinks in 24h)

§ could further reduce the risk of alcohol-related symptoms for

older adults

(18)

¡  Review low-risk drinking guidelines

¡  Link drinking to individual patient situation

§ Fatty liver, alcoholic hepatitis, falls, etc

¡  Emphasize that mood, sleep, energy level will improve with

reduced drinking

§ Screen and treat depression

¡  Ask patient to commit to a drinking goal:

§ Reduced drinking or abstinence

§ If unwilling to commit, continue to ask about drinking at every

office visit

¡  Monitor blood work at baseline and follow-up

¡  Have regular follow-up with alcohol at the top of the agenda

(19)

¡

Sip drinks, don't gulp

¡

Avoid drinking on an empty stomach.

¡

Dilute drinks with mixer.

¡

Alternate alcoholic with non-alcoholic drinks

¡

Put a 20-minute "time-out" between the decision

to drink and taking the drink

(20)

PSYCHOTHERAPY &

ELDERLY

(21)

¡

Cognitive behavioural treatment associated

with sustained abstinence in age-matched

group (Schonfeld, 2000)

¡

16 weekly group sessions using

cognitive-behavioral (CB) and self-management

approaches.

¡

Group sessions begin with analysis of

substance use behavior to determine high-risk

situations for

alcohol or drug use,

(22)

¡  Modules to teach coping skills for coping with

§ social pressure,

§ being at home and alone,

§  feelings of depression and loneliness,

§ anxiety and tension,

§ anger and frustration,

§ cues for substance use,

§ urges (self-statements),

§ and slips or relapses.

¡  At 6-month follow-up, program completers demonstrated

much higher rates of abstinence compared to noncompleters.

¡  The results suggest that CB approaches work well with older

veterans with significant medical, social, and drug use problems.

(23)

¡

Following have evidence to be effective in

elderly populations:

§

cognitive-behavioural therapy,

§

group and family therapies

§

self-help groups

¡

In fact, group and family therapies and

self-help groups may be of particular benefit to

older adults because of the emphasis on

social support.

(24)

DRUG THERAPY &

ELDERLY

(25)

¡ 

Alcohol treatment for older adults is at least as effective

as for younger patients (Barrick 2002, Lemke 2002,

2003.)

¡ 

Medicinal adjuncts are also equally effective in the

elderly

¡ 

Need strict compliance and careful monitoring of adverse

effects are especially important in patients who take

multiple medications.

¡ 

Because of their benign adverse effect profiles,

naltrexone and acamprosate are particularly good

pharmacological agents for relapse prevention in older

adults.

(26)

Special Application Covered (but off-label) Not covered Revia (Naltrexone)* Campral (Acamprosate) Baclofen** Topamax (Topirimate)** Antabuse (Disulfiram)*** Zofran (Ondansetron)

PHARMACOTHERAPY: ODB COVERAGE

* Must be tried first unless a contraindication to Revia and then an application for Campral can be initiated

** Lower dose suggested in elderly – may not be effective for alcohol ***Causes patients to be physically ill – could precipitate severe

medical emergencies in the elderly and generally avoided in this population

(27)

¡

Well tolerated

¡

Safe: No major liver side effects

¡

No differences between placebo (sugar pill)

and Revia

§

in the number of subjects remaining abstinent

§

The number of subjects who relapsed

¡

But if the patient “sampled” alcohol

§

Only half as likely to relapse!

(28)

¡

Elderly patients are more likely to take naltrexone

regularly

§ Compliance was much better (Oslin, 2002)

¡

Higher retention to naltrexone

¡

Less likely to relapse than younger patients taking

naltrexone

¡

More attendance at therapy sessions than younger

patients taking naltrexone

¡

Older adults appear to respond well to a

medically-oriented program that is supportive and

individualized

(29)

¡

Treat alcohol and mood disorders at the same time

¡

Consider a trial of antidepressant medication if:

§ Symptoms persist after four weeks of abstinence

§ Patient unable to sustain abstinence for several weeks

§ Primary mood disorder: depression precedes drinking; strong

family history

§ Severe depression (suicidal ideation, hospital admissions)

¡

Long-term benzodiazepine use in heavy drinkers

creates risk of accidents, overdose and misuse

(30)

¡

Treatment of comorbid depression and substance

use:

§

Effective in general adult populations (Nunes 2004)

§

Leads to marked reductions in psychiatric hospital days

(Granholm 2003, Kominski 2001)

¡

Anti-depressants and counselling leads to:

§

Decreased drinking (Oslin, 2005)

§

Improved mood

¡

Alcohol use is a major risk factor for suicide

§

Access to alcohol treatment is a protective factor for

suicide in the elderly (She, 2006)

(31)

¡

The elderly are at high risk of life-threatening

conditions associated with their drinking

¡

Elderly patients listen to advice from their doctors

about safe drinking limits

¡

Psychotherapy (particularly family and age-matched

group thearpy) is effective in the elderly

¡

Drug therapy such as naltrexone works well in

helping patienst to reduce drinking and prevent

relapse

(32)

PHYSICAL DEPENDENCE

¡  Many patients with an alcohol addiction have a physical

dependence on alcohol

¡  PHYSICAL DEPENDENCE INCLUDES:

¡  Tolerance- increased amounts to have same effect

¡  Withdrawal- syndrome with typically opposite effects to the

(33)

PHYSICAL DEPENDENCE

¡  WHAT’S HAPPENING IN THE BRAIN?

¡  Alcohol is complex but one main action- causes sedation

¡  Alcohol increases inhibitory activity, decreases excitatory

activity

¡  Brain adapts and up-regulates in the face of chronic

alcohol use

(34)

¡ 

Mild symptoms:

§ tremor,

§ anxiety,

§ Irritability

¡ 

Settles after a few day

¡ 

No medical treatment

needed

¡ 

Severe symptoms:

¡  anxiety

¡  Nausea & vomiting,

¡  headache, ¡  sensory disturbances, ¡  rapid heart-rate, ¡  hypertension, ¡  tremor, ¡  sweats, ¡  agitation

¡ 

Starts 6 to 12 hours

(up to several days)

¡ 

peak at day 3-5

¡ 

resolve by day 7-10

¡ 

Needs medical

treatment

(35)

SEVERE WITHDRAWAL:

DELIRIUM TREMENS

¡

Severe withdrawal can progress to delirium tremens

¡

5% cases

¡

onset 2-4 days after last drink

¡

delirium= hallucinations, agitation, disorientation

and confusion

¡

autonomic overdrive= tremor, fast heart-rate, high

blood pressure, fever, and sweating

(36)

SEVERE WITHDRAWAL: SEIZURES

¡

Seizures

§ Usually 12-72 hours after last drink

§ Can be single or multiple

¡

Need to see a doctor for Investigation if:

§ first withdrawal seizure > age 40,

§ focal features,

§ Prolonged – a seizure lasted more than 30 seconds

§ recurrent >2

§ abnormal neuro exam (i.e. they look like they’ve had a stroke –

drooping of the face, not able to move an arm or leg, etc)

(37)

ALCOHOL WITHDRAWAL: SUMMARY

¡

Alcohol withdrawal is a serious medical illness

¡

An MD or (RN-EC) should assess any patient

with:

§

symptoms of withdrawal

§

at risk of withdrawal (ie history of heavy drinking in

patient admitted to hospital)

¡

Assess withdrawal symptoms, provide

(38)

ALCOHOL WITHDRAL:

PLANNED WITHDRAWAL

¡  An MD (or RN-EC) should assess all patients with alcohol

addiction who are planning to stop drinking

¡  to determine risk of more significant withdrawal and

provide a medical management plan (if indicated)

§  THERE ARE SOME PATIENTS THAT SHOULD NOT PLAN TO STOP

DRINKING WITHOUT MEDICATION OR OUTSIDE A HOSPITAL SETTING

(39)

ALCOHOL WITHDRAWAL:

ONLY ONE COMPONENT OF TREATMENT

¡  “Detox” is one small step in recovery process

¡  Important because it allows patient to engage in a more

meaningful way in treatment

¡  Rarely is successful insolation

¡  Must be integrated into ongoing treatment and the MD

(RN-EC can help to put the other pieces of an ongoing treatment plan into place)

(40)

PLANNED WITHDRAWAL:

RISK ASSESSMENT

¡

Low risk

§

unlikely to need medical management for

withdrawal

¡

Higher risk group

§

need close observation and medical management

¡

Two options for the higher risk groups:

§

outpatient withdrawal

(41)

ALCOHOL WITHDRAWAL: LOW RISK

¡

Low risk group:

¡

no significant withdrawal in past, no seizures,

arrhythmias

¡

no

“

relief

”

drinking

¡

drinking <40 drinks per week

(42)

PLANNED WITHDRAWAL: LOW RISK

¡  Caveat- Withdrawal course not always predictable- genetic

factors seem to play a large role

¡  Warn patient of risks of alcohol withdrawal and to seek

treatment if needed

¡  If any concerns have patient should be assessed next day and

(43)

ALCOHOL WITHDRAWAL: ELDERLY

¡

Elderly can be a low risk group but NEED closer

follow-up

¡

Evidence is unclear if severe withdrawal is more

common in elderly but

course of withdrawal

appears to be more complicated

¡

Medical problems/illnesses (co-morbidities),

multiple medications that may affect course of

withdrawal

(44)

ALCOHOL WITHDRAWAL: ELDERLY

¡

Some smaller older studies found increased severity

of withdrawal in older age groups (Brower 1994;

Liskow 1989)

¡

Criticized for comparing to very young adults <30 yo

(very low risk severe withdrawal) and small sample

sizes

(45)

WITHDRAWAL- ELDERLY

¡

Newer, larger studies

§ (Kraemer 1997, Wetterling 2000, Wojnar 2001)

¡

Found no increase in severity scores or doses of

benzodiazepines for elderly

¡

Did find longer stays and increase risk delirium*

§ (Kraemer 1997, Wojnar 2001)

(46)

PLANNED WITHDRAWAL: HIGHER RISK

¡

Patients who don

’

t fall into low risk group need

medical management

¡

Either inpatient detox or outpatient day detox

¡

Treated with sedative medications

¡

Benzodiazepines (valium, ativan) have best

(47)

WITHDRAWAL TREATMENT: BENZOS

¡

Benzodiazepines (Ativan, valium)

¡

Act at inhibitory neurotransmitter receptors (GABA

receptors)

¡

these are the transmitters that go into “overdrive”

when the patient stops drinking

¡

Treat symptoms and stop progression from mild to

(48)

WITHDRAWAL TREATMENT: BENZOS

§ Benzodiazepines are often dosed symptom-based with

standardized protocol- CIWA (Clinical Institute Withdrawal Assessment)

§ Need MD (RN-EC) support because Elderly need more close

observation

§ Need specialized medications (not “standard” protocol

§ Elderly- use short-acting benzodiazepine like lorazepam

(49)

WITHDRAWAL TREATMENT: OUTPATIENT

¡  Many younger patients can be managed with planned

outpatient withdrawal

¡  Treated with benzodiazepine protocol in MDs office in day,

once withdrawal symptoms settle they are discharge home or to non-medical detox

¡  Phone or in person follow-up next day

(50)

OUTPATIENT WITHDRAWAL

¡

Criteria for outpatient management

§ Initial CIWA score between 8-15

§

No hx seizures, dysrhythmias or severe withdrawal in

past

§

No serious medical or psychiatric illness

§

Stable home situation, partner/ friend to monitor

§

No polysubstance use

§

Can come in for daily visits (or phone follow-up)

(51)

OUTPATIENT WITHDRAWAL: ELDERLY

¡

Outpatient management of withdrawal in

elderly

¡

Age over 60 is

“

relative contraindication

”

in

some sources

¡

Typically use lorazepam protocol

§

since short-acting benzodiazepine symptoms may

(52)

INPATIENT WITHDRAWAL

¡

Two options for inpatient withdrawal

¡

Non-urgent: CAMH- medical detox- patients

or physician can refer

¡

Urgent: refer to ER

§

either end up admitted under medicine or

§

treated in ER and discharged home (or to

(53)

ALCOHOL WITHDRAWAL:

TREATMENT OPTIONS

¡

Other drugs used for withdrawal

§

Anti-seizure medications and baclofen look

promising for mild withdrawal, unclear for more

severe withdrawal

§

Anti-psychotics- generally avoid unless underlying

psychosis- (many prolong QT, some lower seizure

threshold)

(54)

SUBACUTE WITHDRAWAL

¡

Acute alcohol withdrawal usually resolves in 7

days, often less.

¡

However subacute symptoms can last for months.

§ anxiety, agitation, irritability, poor sleep

§ (also consider underlying mood disorder)

¡

Gabapentin- reduced risk of relapse in first 6

weeks when combined with naltrexone (Anton

2011)

(55)

SUBACUTE WITHDRAWAL

¡  Many studies have shown that poor sleep is associated with

higher risk of relapse

¡  Review- Treatment for sleep disturbances in alcohol

recovery (Arnedt 2007)

¡  Non pharmacological - Cognitive behavioural therapy has

best evidence,* other options- sleep hygiene education, sleep restriction, stimulus control

¡  * Fo u r l a r g e m et a - a n a l y s e s s h owe d C B T to b e e q u a l o r s u p e r i o r i n i m p rov i n g s l e e p c o m p a r e d to m e d i c a t i o n s - s t u d i e s i n n o n - a l c o h o l d e p e n d e n t p a t i e n t s (A r n e d t 2 0 07 )