Psychoeducation about the risks of combining alcohol with medications and excessive alcohol use is important. A number of clinical trials have shown that approximately 10% to 30% of problem drinkers have been able to reduce their drinking after brief 1- to 3-session interventions.13
The need for detoxification and the potential for serious withdrawal symptoms should be carefully evaluated. Regardless of the treatment modality chosen, psychotherapy and other interventions need to be tailored for each patient. Groups of patients of similar ages are ideal because they increase patient comfort and adherence.
Psychotherapy is often recommended on either an outpatient or inpatient basis, depending on the severity of the problem. Recommendations for specific therapeutic modalities are extrapolated from studies on younger populations because of the lack of such research on older adults. Motivational interviewing has been validated as an effective method to ascertain an individual's willingness to change and to enhance motivation for change.14 Cognitive-behavioral therapy is also widely used in the treatment of substance abuse.13 In addition, initial studies of brief therapeutic interventions have shown promise in older adults.15
The opiate antagonist naltrexone reduces cravings for alcohol and is intended to be prescribed as adjunctive treatment to psychosocial support to reduce the risk of alcohol relapse. A dosage of 50 mg/d was found to be safe in a 12-week, randomized, placebo-controlled trial in 44 older veterans with alcohol dependence. However, there were no differences in the number of patients who experienced relapse or who remained abstinent in the naltrexone and placebo groups.16
Generally, disulfiram should not be prescribed for the elderly because of the increased risk of delirium and other serious adverse effects.17 Acamprosate is thought to exert its therapeutic effect by modulating the excitatory glutamate amino acid system in the brain. It may be safer and more effective for patients with liver dysfunction; however, it should be used cautiously in elderly patients with impaired renal function. A meta-analysis of studies of acamprosate in younger adults showed a 13% improvement in 12-month continuous abstinence rates.18
Finally, there are no known pharmacokinetic studies of buprenorphine/naloxone in older adults with opioid dependence. Sublingual buprenorphine/naloxone must be administered with caution in the elderly because of the increased risk of respiratory suppression and sedation. Lower dosages in the elderly are recommended.
Participation in Alcoholic Anonymous meetings is an important part of treatment. Meetings that have an age-matched cohort provide mutual support, allow for peer bonding, and foster the establishment of peer sobriety networks.
As we are faced with a growing population of older adults, a better understanding of the issues that they confront is crucial. Studies are needed to identify the best ways to integrate screening into general medical settings as well as to understand the neurobiology of substance use disorders in the older adult with medical and cognitive comorbidities and to determine which specific treatment interventions are safe and effective.
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