Alcohol Misuse or Abuse

Drug Rehabilitation

Drinking, per se, is not physically or medically harmful, even among older adults. In fact, light to moderate alcohol consumption (eg, an average of one drink per day) among healthy older adults can have health benefits, especially with regard to heart health and longevity. Alcohol in moderate amounts may also promote relaxation and reduce social anxiety. However, alcohol abuse is associated with numerous negative health effects, especially among older adults. Alcohol abuse can cause serious illness, worsen other medical conditions, interfere with needed medications, and greatly decrease overall quality of life.

The terms "light," "moderate," and "heavy" drinking can mean different things to different people. In medical terms, one drink per day is defined as one 12-oz beer, one 4-oz glass of wine, or one 1-oz shot of liquor. A bottle of wine or a six-pack of beer should not be considered as "one" drink.

A good definition of "low to moderate" drinking for older adults is "drinking that falls within the recommended guidelines for consumption and is not associated with problems." Older adults in this category drink an amount that falls within recommended guidelines and are able to set reasonable limits on their alcohol consumption. For example, they do not drink when driving a motor vehicle or boat, or when taking certain medications.

A good definition of "problem drinking," or the level of drinking that begins to be linked with mental health or physical problems, is more than one drink each day for older women, or more than two drinks each day for older men. However, drinking that causes problems is problem drinking, regardless of the amount.

Causes Many older adults with alcohol problems are simply continuing a pattern of behavior or addiction that began earlier in life. Often, they have a family history of alcoholism, are not well-adjusted socially, and may have had previous legal problems related to alcohol. Alcohol abuse that begins in later life is often due to the stresses and losses associated with aging. People in this category often point to life events as the cause for their drinking. However, early retirement, premature health problems, and other life stresses can also be caused by alcohol abuse, rather than be the cause of it. 

Many older adults with alcohol problems are simply continuing a pattern of behavior or addiction that began earlier in life. Often, they have a family history of alcoholism, are not well-adjusted socially, and may have had previous legal problems related to alcohol. Alcohol abuse that begins in later life is often due to the stresses and losses associated with aging. People in this category often point to life events as the cause for their drinking. However, early retirement, premature health problems, and other life stresses can also be caused by alcohol abuse, rather than be the cause of it.

Problems associated with alcohol abuse The most common medical problems associated with long-term alcohol abuse or dependence include the following:

• liver disease (eg, cirrhosis)
• chronic obstructive lung disease
• peptic ulcer
• psoriasis
• falls
• malnutrition
• mental impairment

Smoking makes matters worse and increases the risk of lung diseases, especially cancer. Alcohol abuse can also interfere with treatment for other problems. For example, even moderate alcohol use complicates the treatment of depression. 

 

Alcohol can affect every part of the nervous system, either directly or indirectly (eg, by using up nutrients such as B vitamins). Long-term alcohol dependence can cause significant problems with the nervous system, including confusion, clumsiness, muscle problems, coma, and deterioration of the brain and spinal cord. Some experts estimate that 5-10% of dementia is caused by alcohol abuse.

Some people who abuse alcohol have additional psychiatric problems. In fact, older adults with alcohol abuse or dependence are nearly three times more likely to have another mental disorder. Alcoholism has been linked to mood disorders, suicide, dementia, anxiety disorders, and sleep disturbances. Alcohol is sometimes used by older people for self-medication, to ease the emotional pain of psychiatric or physical illness. People with alcohol abuse and dependence also tend to smoke, which further compromises their health.

Sleep problems can be a sign of alcohol misuse or abuse. Alcohol may help someone fall asleep, but it actually decreases the amount of restful sleep throughout the night. This in turn increases anxiety and irritability. People who abuse alcohol are also lighter sleepers who wake up early in the morning, which can result in feeling tired and sluggish during the day. People with insomnia should never use alcohol as a way to fall asleep.

Another major problem associated with alcohol misuse in older adults is the danger of interactions between alcohol and other drugs, including over-the-counter medications. Of the 100 most frequently prescribed drugs, over half interact with alcohol. Alcohol slows the metabolism of some medications, resulting in the drug having stronger effects on the body. However, alcohol can weaken the effects of other drugs, including blood thinners, drugs used for seizure disorders, and some of the oral medications used to treat diabetes. Alcohol also increases the effects of sedatives, which can decrease alertness and the ability to move around. Frequent use of alcohol also increases the likelihood of bleeding in the intestines among people taking arthritis medication or aspirin.

Withdrawal Withdrawal symptoms can occur when alcoholics stop drinking and include the following:

• shakiness
• agitation
• sweating
• hallucinations
• seizures

The amount of time from the last drink to when typical symptoms of alcohol withdrawal begin is usually 24-36 hours. Approximately 5% of older alcoholic adults experience severe withdrawal problems called delirium tremens (the DTs). This serious form of alcohol withdrawal is a medical emergency. Older people have a high risk of death from withdrawal, and complete withdrawal from alcohol may take a long time. 

 

Identifying alcohol abuse Alcoholism often goes undiscovered in older adults. Other medical problems, psychosocial problems, and effects of medication may make the signs of alcoholism difficult to recognize. In addition, symptoms such as confusion, falls, and physical problems may be incorrectly thought of as simply due to aging. Some older people may have confusion or severe hearing loss, making it difficult to question them about their alcohol use. The stigma associated with having an alcohol problem, especially among older adults, may prevent some health professionals from even asking if such a problem exists. 

Healthcare providers use several screening questionnaires to identify people at risk of alcohol abuse. Four key questions can provide a quick way to gauge alcohol abuse:

• "Have you ever felt you should slow down on your drinking?"
• "Have you ever felt annoyed by criticism about your drinking?"
• "Have you ever felt guilty or bad about drinking?"
• "Have you ever felt the need for an "eye-opener" in the morning to steady your nerves?"

A "yes" answer to any two of these questions indicates that a problem is likely. A "yes" answer to even one question indicates a possible problem that should be further evaluated. 

 

Your healthcare provider will likely ask about past alcohol use, to find out if you stopped drinking or cut down because of previous problems. People with a history of alcohol problems may need to be monitored in case new stresses cause them to "fall off the wagon." A history of at-risk drinking or alcohol dependence also increases the risk of developing other mental health problems in later life, such as depression or confusion.

Treatment Prevention is clearly is the most effective treatment of alcohol abuse. Often, all that is needed to stop a problem before it starts is for healthcare providers or family members to show personal concern and to provide support, advice, and education on the effects of alcohol. In some cases, healthcare providers may ask people to keep a diary of their drinking patterns to help them recognize a potential problem. 

People with long-standing alcohol problems usually need more forceful treatment. Fortunately, research has shown that older alcoholics do not have to hit "rock-bottom" before accepting treatment.

When an alcohol problem is identified, people important in the affected person's life need to seek instruction from experienced counselors to learn how to correctly motivate the person to begin treatment. Counseling can offer ways to deal with the negative behaviors of an alcoholic person, as well as ways to reduce or stop personal behaviors that might actually be encouraging alcohol intake or making it possible. Sometimes well-intended family members do not realize that their own behavior allows (or even ensures) that the person's addiction to alcohol continues. Confrontation the problem drinker as a group-an intervention-is one way to get the problem into the open and, if all goes well, to begin treatment. However, it is important to learn how to handle this situation in a supportive way, rather than being antagonistic.

Many options are available to treat problem drinkers, including the following:

• psychotherapy
• education
• inpatient or outpatient management
• specialized drugs

The treatment plan should be modified to fit to the needs of the individual. For example, a chronic alcoholic and an at-risk social drinker would not be treated the same way. The at-risk drinker may need only to learn that others are concerned and to receive some advice and education in order to cut down. Older adults usually accept this type of approach, which can lead to substantially less use of alcohol among those at-risk for problems. In addition, trying to force the at-risk social drinker to accept a more rigorous program, such as Alcoholics Anonymous ("AA") or inpatient rehabilitation, may do more harm than good. 

 

Medical support Medical support usually begins with a thorough history, physical, and laboratory examination. This should include determining the potential for sudden withdrawal, which can be life threatening in older adults. People who are severely dependent on alcohol, who have a high potential for problems in withdrawal, or who have other medical or psychiatric problems may need to be hospitalized before an outpatient treatment and management program can begin. The person is initially weaned off alcohol under medical supervision while hospitalized-a process called detoxification. 

People with a long history of alcohol use should take multivitamins daily. Healthcare providers may also prescribe additional B vitamins, because levels often become dangerously low in alcoholism. People with very poor nutrition, mental difficulties, or nervous system problems may need to have their vitamin B12 level checked. Vitamin K supplements may be needed for people with bleeding problems.

Many people report symptoms of depression when they are not drinking. These symptoms usually get better after 3-4 weeks of a treatment program. Antidepressant medications are sometimes useful and are given after about 4 weeks of abstinence.

Treatment of withdrawal Alcohol withdrawal is a serious medical emergency that should be undertaken only under the supervision of a physician. Treatment with medications to help with withdrawal symptoms is often needed during detoxification or initial rehabilitation. For example, people with severe agitation, hallucinations, or paranoia may need antipsychotic drugs. Older adults should be monitored continually for signs and symptoms of alcohol withdrawal throughout detoxification, especially as medication dosages are adjusted. 

Rehabilitation The outlook for recovery from alcoholism in older adults is generally good. Older people recovering from alcoholism are more likely than younger people to stay in treatment and remain sober. Regardless of age, all alcoholics should be considered to be always "in recovery," because there is no known cure that can allow problem drinkers to "start over" in social drinking without having a problem potentially develop again. 

Rehabilitation programs for alcohol (and other drug dependence) use many strategies. Individual therapy can help a person overcome denial that he or she has an alcohol problem and can work on underlying problems, such as grief or difficulty in adjusting to retirement. Group therapy provides education on alcoholism, additional assistance in overcoming denial, and can help people develop other ways of coping. Groups also provide emotional support and can give a person a sense of belonging and renewed self-respect.

Medication can also help during rehabilitation. For example, people with underlying psychiatric problems may benefit from drug treatment for depression or anxiety. In addition, a drug called naltrexone can help people who have stopped drinking avoid a relapse. In younger alcoholics, a drug called disulfram is used sometimes. If someone drinks alcohol while taking disulfram, they will get sick to the stomach. Disulfram is not typically used in older adults because of possible side effects involving the heart.

Joining AA helps many older adults. AA is a worldwide group of recovering alcoholics who assist others in their recovery. About a third of the people in AA are 50 and older. Each step of AA's 12-step program is important for successful treatment.

Family members or others who may have unknowingly allowed or encouraged the older person's alcohol abuse should also become involved in the treatment process. Involvement in groups like Al-Anon (a companion group to Alcoholics Anonymous) can help these family members and friends recognize and change their own harmful patterns of behavior. Al-Anon also offers relief and support to family members or caregivers who have been stressed, mistreated, or even victimized by an alcoholic. Other community and volunteer resources, such as senior citizens groups, visiting nurses, church groups, halfway houses, etc, are also available. Some retirement communities have developed their own support groups for people with alcohol problems.