This chapter is divided into three main sections, focussing respectively on alcohol use disorders (AUDs), medication use disorders (MUDs), and use of illegal substances and nicotine, in older people. In each section we focus in detail on definitions and diagnosis, epidemiology, aetiology, clinical features, investigations, screening, management, and prognosis. More is known about AUDs in older people, hence this section is the longest, but MUDs in older people is also a significant problem and abuse of illegal drugs may become increasingly important in future years.
Alcohol use disorders (AUDs) in older people
Introduction
The ageing of populations worldwide means that the already significant problem of alcohol use disorders (AUDs) in older people is likely to become even more important in future years. However, AUDs in older people are neglected and underdiagnosed, for the reasons outlined in Table 8.5.2.1, and unless these factors are tackled proactively there exists a real danger of AUDs in older people becoming a silent epidemic, with negative impacts on all aspects of health and well-being(1) (see Table 8.5.2.2).
Definitions and diagnosis
AUD is a general and broad term, used to include a wide range of alcohol-related problems, as outlined in Table 8.5.2.3. Alcohol status may also change throughout life, with one-third of older people with AUDs developing such problems for the first time in later life (late-onset AUDs). A more severe course of AUD, higher levels of antisocial personality and stronger family histories of AUDs are seen in those with early-onset AUDs.
Because of the effects of physical and cognitive ageing, pharmacokinetic changes, the increased prevalence of comorbid illness, and interactions with prescribed medication, older people are likely to encounter AUDs at levels of intake lower than the general population. Therefore, the recommended levels of intake for the general population (i.e. up to 21 and 14 units per week for men and women, respectively(2)) may be inappropriately high for older people. However, apart from the NIAAA recommendations of no more than one drink per day for older people,(3) there is a lack of guidance on safe levels of alcohol intake, and the pursuit of obvious and ‘down and out’ drinkers may lead to a significant amount of more subtle and clinically ‘silent’ AUDs being missed.
Furthermore, the diagnostic criteria used by ICD-10 and DSM-IV used to describe harmful use and alcohol dependence syndrome may not be applicable to older people, as evidence of diagnostic criteria such as craving, compulsion, tolerance, and withdrawal features may be less clear-cut and masked by other medical conditions, and older people may be less likely to encounter the financial, occupational, family and legal consequences of AUDs (see also Table 8.5.2.1 and section on screening).
Table 8.5.2.1 Reasons for the neglect and underdiagnosis of AUDs in older people
Patient factors
Older people may be less likely to volunteer information on alcohol intake/AUDs
Recall of alcohol intake may be inaccurate due to cognitive impairment
Features of AUDs may be atypical or masked (e.g. presenting as falls, confusion)
Pharmacokinetic changes, comorbid illness, and drug-interactions mean alcohol-related problems may arise even at relatively low levels of intake
Health service factors
Health care professionals less likely to ask older people about alcohol intake and AUDs
Health care professionals less likely to refer older people for treatment, even when AUD detected
Inappropriate screening and diagnostic tools used
Therapeutic pessimism in treating older people
Inappropriately high levels for ‘recommended’ or ‘healthy’ levels of intake
Family and societal factors
Family members may be less likely to perceive AUD as a problem in older relatives
Ageist attitudes lead to risk of AUDs in older people being perceived as ‘understandable’
AUDs in older people less ‘noisy’, with less impact on absenteeism, antisocial behaviour, crime
Epidemiology
The prevalence of AUDs in older people varies depending on the screening and diagnostic criteria used, clinical and socio-demographic characteristics (men having levels 4-6 times higher than women) and the level of severity of AUD being defined. In community-based studies, for example, 2-4 per cent of older people have been estimated to have alcohol misuse or dependence,(4) with higher rates of 16 per cent (men) and 2 per cent (women) when looser criteria such as excessive alcohol consumption are used.(5) Clinical populations of older people have higher levels of AUDs, with emergency department, nursing home and psychiatric inpatients being described as having levels of 14, 18, and 23 per cent, respectively.(6,7,8)
The true prevalence of AUDs in older people is often underestimated, for the reasons outlined in Table 8.5.2.1. It is likely, however, that the actual levels of alcohol consumption and AUDs do decline with age.(9,10) This decline may be due to factors such as premature death of those with AUDs, reduced physiological reserve and comorbid medical illness leading to reduced alcohol intake, age-cohort effects and age-related changes in social networks, occupational, and financial status.
Aetiology, risk factors, and associations
These factors can be broadly described as being biological/medical, social, and psychological in nature. Genetic factors are likely to be important in relation to both early-onset(11) and late-onset AUDs.(12) The genetic risk for AUDs may also overlap with risk for other mental disorders such as antisocial personality disorder, other drug use problems, anxiety disorders, and mood disorders.(13) AUDs may have a cause and effect relationship with medical illness.
Important social aetiological factors are likely to include male gender, bereavement, age-cohort effects, culture and ethnicity, religion, and marital status (higher levels of AUDs in divorced and single). Some social factors, such as marital problems, may have a two-way relationship with AUDs.
Table 8.5.2.2 Physical, neuropsychiatric, and socio-demographic aspects of AUDs in older people
Macrocytosis (acute effect of alcohol intake and due to vitamin B12 and folate deficiency in chronic AUD)
Anaemia (due to gastrointestinal problems)
Musculoskeletal
Falls and fractures
Reduced bone density
Myopathy
Metabolic
Hypoglycaemia
Hyperuricaemia
Elevated lipids
Diabetes more difficult to control
2. Neuropsychiatric factors
Cognitive impairment and dementia
Frontal lobe impairment
Wernicke-Korsakoff syndrome
Cerebellar cortical degeneration
Central pontine myelinosis
Marchiafava-Bignami disease
Depression
Psychosis
Intoxication
Withdrawal syndrome (may be more difficult to treat in older people)
Suicide
3. Socio-demographic
Male gender
Divorced, widowed, and single status
Social isolation
Upper and lower ends of socio-economic spectrum
4. Other
Alcohol-drug interactions
Aspiration pneumonia
Road traffic and other accidents
Relevant personality factors include the stronger association between antisocial personality, hyperactivity, and impulsivity in ‘early-onset’ compared to late-onset AUDs, who may have higher levels of ‘neuroticism’ and depression.(14)
AUDs in older people, as in all populations, may also have a two-way relationship with psychiatric disorders such as depression and anxiety disorders. For example, an older person may begin drinking in an effort to self-medicate depressive symptoms, or they may become depressed because of their drinking.(15)
Binge drinking (i.e. episodic bouts of excessive alcohol intake)
Problem drinkers/harmful use/abuse
Alcohol dependence syndrome
‘Early-onset’ versus ‘late-onset’
Clinical features and comorbidity
AUDs in older people are linked to significant morbidity and mortality, affecting practically all aspects of physical, neuropsychiatric and social health and well-being,(1,16) as summarized in Table 8.5.2.2.
Pharmacokinetic changes (reduced physiological reserve, reduced metabolic efficiency, and increased volume of distribution due to a higher fat to lean muscle ratio, leading in turn to relatively higher blood alcohol concentrations in older people) along with the general effects of physical and cognitive ageing, increasing frailty, reduced functional ability, and higher levels of concomitant prescription drug use means that alcohol is relatively more toxic to older people than younger people. Furthermore, as outlined earlier, such toxic effects may be subtle and may be missed or mistaken for other conditions.
AUDs in older people are associated with a wide range of mental disorders, such as depression, psychosis, withdrawal syndromes, cognitive impairment, and dementia(17) (see Table 8.5.2.2) and are also associated with an increased risk of suicide.(18) The relationship between alcohol use and brain damage and dementia is complex,(19) in that AUDs may increase the risk for different types of dementia(20) and there also exist diagnostic entities known as ‘amnesic syndrome associated with alcohol use’ (ICD-10) or ‘alcohol-induced persisting dementia’ (DSM-IV). In contrast, light to moderate alcohol use may protect against dementia.(21)
(a) Clinical assessment
The assessment of AUDs in older people begins with a thorough clinical interview and history of alcohol use (quantity and frequency of drinking, beverage type, drinking context), mental state examination, physical examination and collateral history if available, and with the patient’s consent. If indicated by the initial history, additional questions should be asked about features of alcohol dependence syndrome, as they relate to the patient’s physical and psychosocial health. Questions should be framed in a sensitive and non-judgemental way, as patients may disengage and be lost to treatment and follow-up if they feel threatened by the assessment procedure.
(b) Further investigations in AUDs
Following a detailed history and examination, other investigations may be indicated and should be directed by the patient’s clinical status. These may include: blood tests to check the following: urea and electrolytes; full blood count; liver function tests; vitamin B12 and folate levels; neuroimaging (CT or MRI brain); gastrointestinal investigations such as ultrasound, CT, or MRI examinations of the abdomen, upper gastrointestinal endoscopy, and liver biopsy; basic cardiovascular investigations such as electrocardiogram and other more detailed investigations if indicated, e.g. echocardiogram and 24 h blood pressure monitoring.
(c) Screening for AUDs in older people
Screening programmes should aim to detect both clear-cut and subtle cases of AUDs in older people. It must be remembered that screening tests are not diagnostic in themselves, but positive results should lead on to further investigations. Screening methods may be based on self-report alcohol screening instruments such as the CAGE,(22) the AUDIT,(23) and biophysical measures such as blood tests checking mean corpuscular volume and liver function tests.
A systematic review of self-report alcohol screening instruments in older people(24) revealed that the CAGE was the most widely studied, but that sensitivity and specificity varied depending on the clinical characteristics of the population in question. However, the CAGE is the most well recognized alcohol screening instrument and is quickly and easily administered, so the authors would recommend use of at least this instrument, along with further investigations and assessment scales if problems are detected.
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