Psychiatric Emergencies in the Elderly

Alcohol abuse/dependence

Estimates of the prevalence of alcohol(Drug information on alcohol)ism among the elderly vary because studies define use differently (self-reports vs strict diagnostic criteria) and have targeted different populations (community vs medical settings). Approximately 2% to 4% of community-dwelling elders, 14% of emergency department (ED) older patients, 18% medical inpatients, and more than 20% of psychiatrically hospitalized elderly patients meet criteria for alcohol abuse or dependence.⁴² Problem drinking affects the elderly population differently than the younger patients in that it is more likely to complicate the course of comorbid medical conditions, can adversely influence effects of commonly prescribed medications, and can exacerbate cognitive problems, which lead to markedly increased morbidity and mortality.^43,44

Age-related physiological changes make elderly patients more vulnerable to the intoxicating effects of alcohol. The volume of distribution for alcohol diminishes as the total body water decreases, leading to higher peak concentration for a given amount of alcohol. Also, decreased activity of alcohol dehydrogenase in the stomach increases the intoxicating effects of alcohol.⁴⁵ Alcoholism develops in about two-thirds of elderly alcoholics before age 40; early-onset alcoholism tends to have more pervasive psychiatric and medical comorbidities and a higher incidence of familiar patterns of use. One-third of elderly alcoholics began the problematic drinking pattern later in life, typically in response to stressful life events (eg, retirement, functional decline, or death of a spouse).

Alcohol abuse and dependence are frequently underrecognized and undertreated. The reasons that the diagnosis is missed appear to be multifactorial. First, applying DSM-IV-TR criteria for substance abuse and dependence may be difficult in this population (Table 8). Second, patients, families, and providers may assume that older adults’ quality of life will remain poor even if they are successfully treated for their substance abuse.⁴⁶ Third, many older drinkers attribute their alcohol problems to a breakdown in moral values that causes a sense of shame and stigma and ultimately prevents them from seeking help. Furthermore, difficulty applying criteria to a variety of nonspecific symptoms (falls, sleep problems, confusion, irritability), stereotyping (physicians are less likely to detect alcohol problem in women, the educated, and those of higher socioeconomic status), and abbreviated office/ED visits may further impede the clinician’s ability to detect alcohol-related problems in the elderly.^47-49

Routine screening is recommended in all older patients, particularly those undergoing major life transitions or presenting with nonspecific physical symptoms. Several brief, practical, and well-validated screening tools for alcoholism are available. The AUDIT-C (Alcohol Use Disorders Identification Test) questionnaire and the MAST-G (Michigan Alcoholism Screening Test–Geriatric Version) are commonly used tools that can facilitate detection.⁵⁰

The first step in treating substance-abusing elderly patients is to determine the risk of withdrawal syndrome. The presence of comorbid medical problems, limited reserve, susceptibility to kindling, and vulnerability to adverse effects of the medications used to treat withdrawal may significantly increase the risk of complicated withdrawal syndrome in this population.⁵¹ A history of complicated detoxifications, seizures or delirium tremens, or unstable medical comorbidities warrant inpatient detoxification.⁵² Following completion of medical detoxification, elderly patients should be referred to residential, day treatment, or outpatient programs where psychological interventions such as psychoeducation, counseling, and motivational interviewing can be provided.

The use of medications to promote abstinence has not been studied extensively in elderly persons. Naltrexone(Drug information on naltrexone) showed some efficacy (prevention of relapse) in patients aged 50 to 74 years.⁴² Project TREAT (Trial for Early Alcohol Treatment) and Project GOAL (Guiding Older Adults Lifestyles) investigated the impact of brief physician advice with at-risk, nondependent drinkers and demonstrated a positive effect on drinking patterns.⁵³