Alcoholism

James W. Campbell, Barbara Resnick and Gregg A. Warshaw

Prevalence and impact

The diagnosis of alcoholism is often missed in older patients. Many of the classic clues are mistaken for age-related changes or diseases. The psychosocial factors that are often pivotal in moving younger alcoholics into treatment (spouse, job, and legal pressures such as being charged with driving while intoxicated) are less likely to occur in older adults. Age-associated pharmacokinetic changes make the quantity of ethanol used a less reliable indicator of problems, falsely reassuring the health care professional. Moreover, diagnosis, prognosis, and treatment are complicated by comorbid conditions commonly found in older adults. Clinicians must be alert to the significance of features such as falling, incontinence, poor social support, cognitive decline, depression, noncompliance, and others.

Alcoholism is difficult to diagnose, and yet can be successfully treated in older adults. Treatment modalities may be different than those used with younger individuals.

CASE 1 James Beem (Part 1)

James Beem is a 79-year-old seat-belted driver involved in a car crash. He has suffered a femur fracture, unilateral rib fractures, and a laceration of the left arm. He has been stabilized in the trauma bay and is currently in the surgical intensive care unit for monitoring. You have been asked to consult on hospital day 2 regarding his mental status (Mini-Mental State Exam [MMSE] 17/30) and hypertension (blood pressure 202/106 mmHg, pulse 96). He has a past history of hypertension, glaucoma, cataracts, and hyperlipidemia.

1. Which of the many completed laboratory investigations do you seek first?

2. A family member is waiting to see you. What questions will you ask first?

Definition

Alcohol dependency is a medical syndrome. This is most important. It determines the types of treatment and professional responsibility for care. Early in the twentieth century, alcoholism was defined in moralistic terms: treatment involved condemnation and punishment, and was in the scope of the religious and criminal justice systems. Although Benjamin Rush launched a health education campaign that warned the public about the hazards of alcoholic beverages in the early nineteenth century, it was not until the rise of Alcoholics Anonymous (AA) in the 1930s and the recognition of AA in 1956 by the American Medical Association that alcohol dependency became clearly categorized as a disease.¹ Alcoholism was thus moved from the legal system and placed in the purview of public health. The medical community then developed diagnostic criteria and prevalence and natural history data, and screening and treatment modalities were defined.

In 1975 the World Health Organization defined the drinking behaviors characteristic of alcohol-dependence syndrome: drink-seeking behaviors, increased tolerance of alcohol, repeated withdrawal symptoms, repeated relief or avoidance of withdrawal symptoms by further drinking, subjective awareness of a compulsion to drink, and reinstatement of the syndrome after abstinence.² In this chapter the terms alcoholism, alcohol dependence, and alcohol addiction are used synonymously. These terms imply development of tolerance, withdrawal reactions, loss of control of alcohol use, and psychosocial decline.³

A practical classification scheme for elderly alcoholics identifies four patterns: (1) chronic, (2) intermittent, (3) late onset, and (4) reactive.⁴ Reactive alcoholism, implying impaired use after psychosocial stressors, has not been a clinically useful term. Many individuals categorized as “reactive” alcoholics, with further investigation, are found to have a prior significant history of alcohol use. Although some studies simply distinguished late from early onset in terms of the four-part classification, chronic and intermittent alcoholism are almost always early onset, and reactive may be either late or early onset because the drinking is in response to a biopsychosocial stress. Two thirds of older alcoholics fall in the chronic or intermittent class, and one third are true late onset.⁵

Current (past month) use of alcohol is defined as at least one drink in the past 30 days. Binge use is five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days. Recent studies have emphasized the negative effects of binge use.⁶ Heavy use of alcohol refers to five or more drinks on the same occasion on each of 5 or more days in the past 30 days.⁷

Only one third of elderly alcoholics can truly be categorized as “late onset.”

Prevalence

Of the elderly, 5% to 10% are heavy alcohol users. It is estimated that there are a half million elderly alcoholics in the United States.⁵ Alcoholism is the third most prevalent psychiatric disorder among elderly men (15%), surpassed only by dementia and anxiety disorders.⁸ Elderly alcoholics often present to the health care system through associated diagnoses.⁹ Older persons hospitalized for general medical and surgical procedures and institutionalized elderly demonstrate a prevalence of approximately 18% of alcohol abuse.³ One third of older alcoholics are estimated to have begun their alcohol abuse after age 65.⁵ The binge drinking rate for older adults is still substantial despite being lower than it was in 2009, when it was 9.8%.⁷ Being female, older, college educated, and African American were associated with a lower risk of being a heavy or binge drinker. Conversely, having depression, being a current smoker, and having an alcoholic parent were associated with increased risk of being a heavy or binge drinker.¹⁰ Retirement is not consistently a contributor to heavy or binge drinking behavior.¹¹

The older alcoholic is likely to drink only five to six times per week and only four to five drinks per occasion,¹² yet ethanol has greater pharmacologic impact as we age. Ethanol absorption does not change with increasing age. However, at an unchanged rate of ethanol intake, peak blood concentration is on average higher in the elderly. This is a result of the smaller volume of distribution. Ethanol is distributed in body water, which is decreased in elderly persons.⁴

The rate of illicit drug use continues to be quite low (1%) among older adults, and decreases with increasing age.⁷ The alcohol-dependent elderly patient is unlikely to be cross-addicted to other illicit drugs; however, the possibility of misuse of prescription medications must be considered. Misuse of prescription medications is estimated to occur in more than 10% of elders.

Table 34-1 summarizes the factors contributing to the low reported rates of alcoholism and to the increased impact of drinking in old age. Many of these factors arise from society’s unwillingness to label older persons as alcoholics because of the continued stigma. The mistaken thought that older alcoholics are untreatable is prevalent and therapeutic nihilism reduces detection. In addition, health care providers do not frequently consider alcohol as a possible comorbid condition in patients presenting to the clinic or acute care setting with a clinical problem (e.g., uncontrolled hypertension, increased confusion, nausea).

TABLE 34-1

Factors Affecting Reported Rate and Impact of Alcoholism

Age-Related Factors	Other Factors Causing Low Reported Rates	Other Factors Increasing Impact
Increased biologic sensitivity (lower body water ratio, less efficient liver)	Institutionalized people excluded from community surveys	Institutionalized people not being diagnosed or treated
Underdiagnosis by health care providers	Less overall driving, so less driving while intoxicated	Coexisting conditions limit sensory input while driving
Cohort values and underreporting	Cognitive impairment	Increased concomitant disease
Less socialization and less awareness by peers of drinking behaviors	Spontaneous remission	Increased prescription and nonprescription drug use
Less job or legal pressure to initiate treatment	Selective survival
Family unwillingness to report	Ill health Financial constraints