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ALCOHOLISM IN THE ELDERLY
Victory Springs Senior Health Associates

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Ursula McClymont, M.D.

Alcoholism is defined as “a primary chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations.  The disease is often progressive and fatal.  It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.” 

Alcoholism is often an unrecognized problem in the elderly.  The failure to diagnose alcoholism in this patient population is multifactorial.  Physicians have a lower index of suspicion with elderly alcoholic patients than they do with younger patients; patients and family members are more likely to hide the problem; many of the symptoms of alcoholism may be attributed to “old age.” 

Identifying problems with alcohol is important because of the multiple medical consequences in the elderly.  Studies have shown that 3-9% of people over age 65 are heavy  (>2 drinks/day) alcohol users.   Twenty to fifty percent of hospitalized older patients are heavy alcohol users.  Twenty percent of older psychiatric inpatients are heavy users of alcohol.  Approximately 10-50% of patients in emergency departments with alcohol related medical problems are older than 60.  Elderly men are five times more likely to be alcoholics than are elderly women.  Morbidity and mortality are increased in the elderly alcoholic.

There are two groups of elderly alcoholics: (1) early onset, and (2) late onset.  Early onset alcoholics account for approximately 70% of elderly alcoholics.   These patients have problems most of their lives.  Family history of alcoholism is more common in early onset than in late onset.  Late onset alcoholics account for approximately 30% of elderly alcoholics.  The onset is usually after age 50 and is usually triggered by a major life stressor (i.e., death of a spouse, retirement).

There are age-related changes that increase the likelihood of adverse reaction with alcohol consumption, even if consumption pattern remains unchanged.  As one ages the body’s fat content increases and lean body mass decreases.  This causes a decrease in total body water.  Alcohol is only distributed in body water; therefore, each drink causes higher blood alcohol levels as it has a smaller area in which to be distributed.  The enzyme Alcohol Dehydrogenase (ADH) is the enzyme responsible for metabolizing alcohol.  The enzyme does this in the stomach and liver.  As one ages, there is a decrease in gastric ADH.  Because of this, the amount of alcohol broken down in the stomach is decreased.  More alcohol is delivered to the liver for metabolism.  The liver is unable to rapidly metabolize the extra alcohol and blood levels of alcohol increase.

 

Common consequences of alcohol use and abuse include cirrhosis and other liver disease, falls and fracture, dementia, delirium, malnutrition, poor compliance with medications, cardiaomyopathy and anemia.  Alcohol is toxic to almost every organ system:    

Withdrawal from intoxication may be confused for other medical conditions in the elderly.  The severity of withdrawal symptoms may be increased by comorbid conditions, polypharmacy and decreased physiological reserve.  Common symptoms of withdrawal include hand tremors, difficulty sleeping, nausea or vomiting, irritability, anxiety, transient hallucinations, confusion and seizures.  The standard treatment for withdrawal symptoms is benzodiazepines.  Abstinence is the only definitive cure.  The best place for treatment of alcoholism is an addiction program; however, some patients may be effectively treated in the primary care physician’s office.  A good support system increases the likelihood of  successful treatment.

 

Because of the high prevalence of alcoholism in hospital inpatient and psychiatric populations, all hospitalized patients must be asked about their pattern of using alcohol.  Family members who suspect a patient is having problems with alcohol should mention their concerns to the patient’s physician.  Two sensitive questionnaires for diagnosing alcoholism are CAGE items and The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G).  Any positive response on CAGE or 5 or more  “yes” responses on MAST-G are indicative of problems with alcohol.

On the CAGE test the patient is asked if he/she ever feels the need to Cut-down on the amount of alcohol consumed, gets Annoyed when others criticize their use of alcohol, feels Guilty about drinking habits or needs an Eye-opener in the mornings.  The MAST-G has 24 yes/no questions:

  1.  After drinking have you ever noticed an increase in your heart rate or beating in your chest?

  2.   When talking with others, do you ever underestimate how much you actually drink?

  3.   Does alcohol make you sleepy so that you often fall asleep in your chair?

  4.   After a few drinks, have you sometimes not eaten or been able to skip a meal, because you didn’t feel hungry?

  5.   Does having a few drinks help decrease your shakiness or tremors?

  6.  Does alcohol sometimes make it hard for you to remember parts of the day or night?

  7.   Do you have rules for yourself that you won’t drink before a certain time of day?

  8. Have you lost interest in hobbies or activities you used to enjoy?

  9.  When you wake up in the morning, do you ever have trouble remembering part of the night before?

  10.   Does having a drink help you sleep?

  11.   Do you hide your alcohol bottles from family members?

  12.  After a social gathering, have you ever felt embarrassed because you drank too much?

  13.   Have you ever been concerned that drinking might be harmful to your health?

  14.  Do you like to end an evening with a nightcap?

  15. Did you find your drinking increased after someone close to you died?

  16. In general, would you prefer to have a few drinks at home rather than go out to social events?

  17.   Are you drinking more now than in the past?

  18. Do you usually take a drink to relax or calm your nerves?

  19.  Do you drink to take your mind off your problems?

  20. Have you ever increased your drinking after experiencing a loss in your life?

  21. Do you sometimes drive when you have had too much to drink?

  22.  Has a doctor or nurse ever said they were worried or concerned about your drinking?

  23.  Have you ever made rules to manage your drinking?

  24.    When you feel lonely does having a drink help?

 

Alcoholism is a significant health problem in the elderly population.  More than 2.5 million people are affected.  The elderly alcoholic is more likely to present with health related complaints than with criminal or antisocial behavior problems.  The elderly

alcoholic rarely identifies the problem and is less likely to accurately report the true quantity of alcohol consumed.


The Michigan Alcoholism Screening Test-Geriatric Version can be found in “Alcoholism in the Elderly: Diagnosis, Treatment, Prevention, Guidelines for Primary Care Physicians.”  The Guidelines, endorsed by the American Society of Addiction Medicine, are available from the American Medical Association’s department of geriatric health.  © The Regents of the University of Michigan, 1991.