Alcohol Abuse and Dependence

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Alcohol Abuse and Dependence

Post by Dr Sarhan on Sun Jan 06, 2008 12:26 pm

The use of alcohol to such an extent that it causes physical or psychosocial harm. Physiologic dependence implies tolerance (ie, increasing amounts are needed to get the same effect) and withdrawal symptoms when consumption ceases.
Between 2 and 10% of the community-dwelling elderly meet the criteria for alcohol abuse or dependence. In addition, drinking behavior that falls short of a formal diagnosis of alcoholism causes considerable morbidity and mortality among the elderly.

Epidemiology

About 50% of persons >= 65 years report using alcohol at least occasionally; however, persons > 75 are less likely than younger adults to drink alcohol or to be alcoholic.
There is considerable geographic variation in alcohol consumption among the elderly. For example, in east Boston, 70% of elderly persons surveyed reported drinking alcohol within 1 year; 8.4% reported consuming two or more drinks per day. In contrast, in rural Iowa, only 46% reported drinking alcohol within 1 year; 5.4% reported consuming two or more drinks per day.
The prevalence of alcoholism is higher among elderly persons in health care settings than among the general elderly population: 4 to 10% among patients seen by primary care physicians (an additional 10 to 15% of these patients drink heavily but are not considered alcoholics), 14% among emergency department patients, 10 to 21% among hospital inpatients, and 3 to 49% among nursing home residents. The rate of alcohol-related hospitalizations among the elderly is high; it is slightly higher than that for myocardial infarction.
Populations with a large proportion of chronically ill or disabled persons usually have lower rates of alcohol consumption, although these populations include some persons whose illness or disability has been caused by heavy alcohol consumption. Social interaction may also affect alcohol use; retirement community residents with more active social lives are more likely to drink heavily than those who socialize less.
In up to one third of elderly alcoholics in treatment programs, problem drinking is of relatively recent onset. These late-onset alcoholics often have more intact social resources than their long-term counterparts and may have started drinking because of age-related losses and stresses.
The prevalence of heavy drinking and alcoholism declines after age 65 for several reasons:


  • The current elderly population has lower lifelong drinking habits than its predecessors.
  • The female-to-male population ratio increases with age, and women are less likely to consume alcohol.
  • Declining health or functional impairments, which accompany aging, often lead to a decrease in alcohol intake.
  • Alcohol-related illnesses and injuries prevent many alcoholics from surviving to old age.

Physiology

Elderly persons develop higher blood alcohol levels per amount consumed because of age-related changes that alter the absorption and distribution of alcohol, the most important of which are increased body fat and decreased lean body mass and total body water. There may be an age-related decrease in the activity of gastric alcohol dehydrogenase. It is unclear whether this age-related decrease occurs in women, but women have a lower level of gastric alcohol dehydrogenase activity than men.
Most alcohol is metabolized in the liver by alcohol dehydrogenase. The liver's ability to metabolize alcohol declines with age, but this change is not clinically important. Although renal function usually declines with age as well, < 5% of ethanol is excreted renally. Susceptibility to psychomotor effects of alcohol may increase with age.

Pathophysiology

Although light to moderate drinking is associated with better health (especially less cardiovascular disease), consuming more than two drinks per day increases the risk of adverse effects, including hypertension, cancer (particularly of the head, neck, and esophagus), and cirrhosis. For the elderly, who have higher blood alcohol levels per amount consumed, the National Institute on Alcohol Abuse and Alcoholism recommends a limit of one drink per day. Alcoholism is commonly accompanied by nutritional deficiencies, particularly deficiencies of thiamine, folate, pyridoxine, niacin, and vitamin A. Thiamine deficiency can lead to Wernicke's encephalopathy and Korsakoff's syndrome. Other deficiencies, such as hypomagnesemia, hypocalcemia, and hypokalemia, may be important in acute intoxication or withdrawal.
Elderly persons who drink heavily are particularly susceptible to declines in cognitive and physical functioning, although the amount of alcohol required to produce such declines is unknown. The pattern of alcohol use is also important in determining the risk of illness or injury; for example, the number of drinks consumed per occasion is an important risk factor for death from injury, whereas the frequency of such drinking occasions is not.
Many drugs used commonly by the elderly interact adversely with alcohol. Cimetidine, ranitidine, and nizatidine inhibit gastric alcohol dehydrogenase, thereby increasing blood alcohol levels by 30 to 40%. The increased alcohol levels may cause somnolence, imbalance, and delirium. Alcohol taken with drugs that suppress central nervous system function (eg, benzodiazepines) may impair balance and predispose to falls, cause somnolence, and slow reaction time, which may contribute to automobile accidents. Nonsteroidal anti-inflammatory drugs, when taken with alcohol, prolong bleeding time and increase gastric inflammation. Determining correct warfarin dosing can be difficult when a patient is drinking variable amounts of alcohol because of varying rates of metabolism in the liver. Acetaminophen combined with alcohol may lead to liver failure; because the amount required to cause harm is highly individual, people who take acetaminophen daily are advised to abstain from alcohol use.

Symptoms and Signs

Some important symptoms of alcoholism may manifest atypically in the elderly, making the diagnosis challenging. Elderly drinkers are less likely to consume extremely large quantities, because fewer drinks are needed to raise their blood alcohol levels. In addition, loss of control of drinking may be more subtle.
Social decline may present differently in the elderly. Because elderly persons are less likely to be working or driving, they are less likely to be recognized as alcoholics by employers or the police. Social decline may therefore manifest as poor self-care, malnutrition, failure to thrive, or withdrawal from activities.
Alcoholic elderly persons may present with such medical complications as hypertension or diabetes that is difficult to control, frequent gastrointestinal disturbances, peripheral neuropathy, or unexplained seizures, or with problems related to dose adjustment of drugs such as warfarin and phenytoin. Alcohol-related trauma, however, is less common among elderly alcoholics than among younger alcoholics. Alcoholism or heavy drinking may cause or exacerbate age-related disorders (ie, geriatric syndromes).
Withdrawal symptoms are similar in elderly and younger patients but are often mistaken for other medical conditions in the elderly. Early symptoms of withdrawal, such as tremulousness, tachycardia, and tachypnea, as well as later symptoms, such as delirium, seizures, and hallucinations, are sometimes attributed to other causes.
Laboratory findings: There is no specific laboratory test for alcoholism. Elevated g-glutamyltransferase, which indicates induction of liver enzymes, and elevated mean corpuscular volume may suggest alcoholism, although these levels are also commonly elevated in the nonalcoholic elderly. A blood alcohol level > 100 mg/dL (> 21.7 mmol/L) without signs of intoxication is a good indication of tolerance to alcohol and usually signifies alcoholism.
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Re: Alcohol Abuse and Dependence

Post by Dr Sarhan on Sun Jan 06, 2008 12:27 pm

Screening and Diagnosis

One of the most useful screening instruments is the CAGE questionnaire, which asks the following:


  • Have you ever felt you should cut down on your drinking?
  • Does criticism of your drinking annoy you?
  • Have you ever felt guilty about drinking?
  • Have you ever had an "eye opener" (a drink first thing in the morning) to steady your nerves or to get rid of a hangover?
Two or more affirmative answers to these questions indicate a probable diagnosis of alcoholism. However, many persons who are not dependent on alcohol drink heavily enough to cause medical complications; these heavy drinkers are unlikely to be detected by the CAGE questions. Therefore, questions regarding the quantity and frequency of alcohol use should be asked in addition to the CAGE questions.
The National Institute on Alcohol Abuse and Alcoholism recommends asking the following three questions:


  • On average, how many days per week do you drink alcohol?
  • On a typical day when you drink, how many drinks do you have?
  • What is the maximum number of drinks you had on any given occasion in the past month?
Questions that specify the type of alcoholic beverage sometimes improve reporting. Also, patients may define "a drink" in various ways, so specifying the quantity of alcohol meant may be necessary. Men who consume more than two drinks per day, women who consume more than one drink per day, and anyone who consumes more than four drinks per occasion are at risk of adverse consequences.
Further questioning should focus on symptoms of alcoholism and on alcohol-related issues (eg, loss of control of drinking, tolerance to alcohol, history of withdrawal symptoms, previous treatment for alcoholism) as well as on adverse effects of drinking (eg, family disturbances, citations for driving while intoxicated, alcohol-related illness or injury). Often, a trusting relationship with the physician must be developed slowly before patients will openly discuss alcohol misuse.
The patient is usually the most reliable source of a drinking history. However, cognitive impairment (common among elderly alcoholics) and denial can impede this process. In such cases, family members, close friends, or caregivers can provide the pertinent history. Information from others can also be very helpful when an alcoholic denies problem drinking, although family members sometimes help the alcoholic avoid detection.

Treatment

Counseling: Even brief counseling by the primary care physician can greatly reduce alcohol consumption. Educational materials to assist with brief intervention are available from the National Institute on Alcohol Abuse and Alcoholism. Essential elements of counseling include informing the patient of the adverse effects of drinking and setting limits on drinking. For persons with severe abuse or dependence, abstinence should be the goal, and formal treatment is often necessary.
Many heavy drinkers do not realize that their drinking is excessive and that it is endangering their health. They are often helped by seeing test results that confirm the adverse consequences of their drinking (eg, elevated liver function test results). Keeping a diary of alcohol consumption is also helpful for many patients. Strategies for coping with the desire to drink should be discussed. If coexisting medical and psychosocial problems may be contributing to the perceived need for alcohol, more effective coping strategies should be suggested or referrals for more lengthy counseling made. For example, chronic pain may lead to increased alcohol use, and effective pain management may lower alcohol intake.
Structured programs: Programs designed specifically for the elderly are rare. Such programs are adapted to medical, cognitive, and psychiatric disorders as well as to social issues common in the elderly (eg, coping with retirement). However, elderly patients in mixed-age programs appear to have the same rate of success as their younger counterparts. About 50% remain abstinent 1 year after treatment. After completing a structured treatment program or in lieu of it, many elderly alcoholics are greatly helped by Alcoholics Anonymous and other nonprofessional treatment programs.
Alcoholics with dementia rarely can maintain abstinence unless their access to alcohol is restricted. Because cognitive impairment may lessen only after several months, a long-term alcohol-free residential program is recommended. However, such programs are uncommon, and nursing home placement is often the only alternative.
Pharmacotherapy: Because alcohol withdrawal predisposes the elderly to medical complications (eg, delirium) and because the elderly may take longer to recover than younger patients, hospitalization during this period is recommended. Short-acting benzodiazepines (eg, lorazepam, oxazepam) are the safest and most effective drugs for ameliorating symptoms of alcohol withdrawal, including minor withdrawal symptoms, such as tremulousness and tachycardia. If seizures, delirium, or other serious withdrawal complications occur or if there is a history of these symptoms during previous alcohol withdrawal, scheduled doses of a benzodiazepine, followed by dosage tapering, are indicated. For all patients experiencing alcohol withdrawal, thiamine 100 mg IM daily for 3 days, then 100 mg po daily, should be administered prophylactically to prevent Wernicke's encephalopathy. A thorough medical evaluation is essential, because nutritional deficiencies, fluid and electrolyte imbalances, and concurrent medical disorders are very common.
Antipsychotic drugs lessen delirium but may increase the risk of seizures during withdrawal. Although magnesium deficiency may contribute to hypertension or seizures during withdrawal, studies do not support the routine use of magnesium sulfate in treating withdrawal symptoms.
Naltrexone, an opiate antagonist, decreases the craving for alcohol. It can reduce relapse rates by 50% when combined with psychosocial intervention. The usual dose of 50 mg/day is well tolerated by most elderly patients. The most common adverse effects are nausea (occurring in 10 to 15% of patients) and headache (occurring in 7%). Disulfiram, which produces unpleasant effects when alcohol is consumed concurrently, is less effective than naltrexone and may cause hypotension in elderly patients, especially in patients with underlying heart disease. Acamprosate, an anticraving drug used in Europe, appears promising and will probably soon be available in the USA.
Palliation: If the patient cannot stop drinking, disease management includes lengthening the periods of abstinence, maximizing function, and minimizing suffering. Continued counseling about the benefits of decreasing alcohol intake, although perhaps not immediately effective, often has long-term benefit. When combined with nursing assessment and care coordination as well as attention to social problems addressed by a social worker, such treatment may lower mortality rates from alcoholism and improve quality of life.

Nursing Issues

The fields of substance abuse and geriatrics both have recognized the benefits of a team approach to care. Nurses are indispensable in every phase of detection and management of substance abuse and dependence among the elderly. Because nurses often spend more time with patients than do physicians, they have a greater opportunity to identify problems with alcohol and other drugs. Home care nurses can observe patients in their homes, where signs of substance abuse may be more evident than in formal medical settings. In geriatric medical settings, nurses often do extensive assessment of physical and cognitive functioning, during which sequelae of substance abuse, such as gait problems or cognitive impairment, may be detected. The same questions recommended for screening are also useful in the realm of nursing, although more subtle clues to substance abuse, such as poor self-care or loss of interest in other activities, may also be valuable. Educating patients and families about adverse effects of the substance use and benefits of cessation as well as offering support through the intervention process is essential.
Nurses are often involved in initiating treatment as well as in the treatment process itself and in aftercare. It is difficult for people to acknowledge their addiction and enter treatment, and emotional support during this phase can make or break the success of treatment. Nurses may be the first to notice signs of withdrawal and work with physicians to manage it. They are often involved in counseling during the active treatment phase. Nurse-managed aftercare programs have been shown to decrease the risk of relapse after active treatment.

Patient and Caregiver Issues

Family members and caregivers as well as patients are often unaware of the adverse effects of heavy drinking. In addition, loved ones may not wish to interfere with drinking if it seems to please the elderly person. Teaching family members and caregivers about the harmful effects of drinking (eg, dementia, incontinence, depression, gait disturbances) and the benefits of abstinence can be helpful. Possible interactions between alcohol and prescription drugs should be discussed.

End-of-Life Issues

Alcoholism can be a terminal disease, in which case physicians, nurses, and social workers can help with concerns about dying, getting affairs in order, and making decisions about medical interventions under various circumstances.
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