Louis A. Trevisan, MD

Editor’s note: This article summarizes the 

American Psychiatric Association Annual Meeting

 Course 0209, “Updates in Geriatric Psychiatry,” which took place on Saturday, May 16, at the Sheraton Centre Toronto Hotel, 2nd Floor, Dominion Ballroom North, from 8 AM to 12 PM. Dr Trevisan, Associate Clinical Professor in the Department of Psychiatry at the Yale School of Medicine and the Acting Chief of Psychiatry at VA Connecticut Healthcare System, was one of the presenters.

[[{"type":"media","view_mode":"media_crop","fid":"23910","attributes":{"alt":"depression in the elderly","class":"media-image media-image-right","id":"media_crop_4416801470268","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3120","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Louis A. Trevisan, MD","typeof":"foaf:Image"}}]]In the elderly, mood disorders often accompany substance use disorders and anxiety disorders. Moreover, they portend dementing illness and other medical problems of the elderly. It is estimated that the prevalence of major depression is 1% to 3% in the elderly population; it is higher (6% to 14.4%), however, in long-term–care facilities.

 Some of the biological factors that contribute to risk of late-life depression include female sex, vascular changes, and comorbid medical illness. Significant psychosocial factors include disability and functional decline as well as loss of a spouse or other loved one.

Screening, recognition, and treatment of mood disorders in late life significantly decrease morbidity associated with many problems encountered by the elderly. The elderly completed 18% of all suicides in 2000, while individuals 65 years or older made up 13% of the population.

Many older adults experience loneliness, profound psychosocial changes, loss of a spouse, and stresses associated with chronic medical problems, as well as the surreptitious, harmful, and often hazardous use of alcohol and prescription opioid medications. Prescription pain medications and sedative anxiolytics are regularly started by primary care physicians or general psychiatrists who treat patients with chronic pain and anxiety. These medications are often ineffective in the long run and become extremely difficult to terminate. They may, in fact, contribute to the depressive symptoms experienced by so many of the elderly.

Mood disorders in the elderly (eg, major depression) respond to several different approaches, such as antidepressants, psychotherapy, and ECT. Traditional antidepressant augmentation strategies as well as specialized evidence-based and supportive psychotherapy are widely used in late-life depression, and ECT has been found to be safe and effective in late-life treatment-resistant depression.

Treatment of late-life depression is important in terms of reducing caregiver burden. The elderly population is growing as is medical burden. We are keeping people alive longer and they often become sicker and more vulnerable to loneliness, substance misuse, and despair. Treatment of depression in later life offers remarkable opportunities to effect real change in people’s lives. Treating depression and substance abuse in the elderly has the promise of not only helping the individual but also reducing the burden on caregivers.

Our ability to screen for substance use and psychiatric problems in the elderly has improved, but many problems still go undetected and undertreated. We are experiencing a rapid increase in the number of older adults with psychiatric problems and substance misuse that need informed/expert treatment. Currently, there are fewer than 1900 board-certified geriatric psychiatrists in the US.

Given our current educational models, it will be impossible to train adequate numbers of geriatric psychiatrists to meet the growing needs for clinical services for older adults with psychiatric illness. Because of the shortage of geriatric psychiatrists, general adult psychiatrists, primary care clinicians, advance practice nurses, and physician assistants will be expected to ease the burden and care for many of our older adults with psychiatric substance use problems.

The theme of depression in late life transcends all of the talks that were offered in course 0209 at APA 2015. The course on geriatric mood, anxiety, psychosis, and substance use disorders provided valuable updates on the epidemiology, signs, symptoms, assessment, and evidence-based treatment of these growing concerns. It is imperative that if we are to address the needs of the elderly, more general psychiatrists, primary care physicians, and advanced practice nurses have to learn to recognize and treat the problem as well as know when to refer to the geriatric or addiction psychiatrist for specialized treatment.

This article was originally posted on May 8, 2015 and has since been updated.


Updates in Geriatric Psychiatry at the APA Meeting is designed for the general psychiatrist, advanced practice nurse, or primary care physician. Four Faculty contributors from Yale University Department of Psychiatry and the University of Connecticut, Department of Psychiatry, are presenting this 

The Topics covered will include Geriatric Depression, Anxiety, Psychosis in Late Life, and Substance Abuse in Late Life. These topics will be covered by Kristina Zydanis, MD, of the University of Connecticut School of Medicine; Kirsten Wilkins, MD; Ilse Weichers, MD, MHS; and Louis Trevisan, MD, MEd, of Yale University School of Medicine.

Course Director Rajesh Tampi, MD, of Case Western Reserve and Yale University Schools of Medicine, is an award-winning educator and leader in the field of geriatric psychiatry. The educational objectives of this course include helping the generalist understand the epidemiology, assessment, and treatment of mood disorders, anxiety disorders, depression, psychotic disorders, and substance use disorders in older adults.

Upon completing the course, attendees will have a better understanding of the neurobiology and treatment of these prominent issues in the aging population. Additional emphasis will be placed on the screening and formal assessment of these disorders in late life. The course will discuss 4 major psychiatric disorders in late life: mood disorders, anxiety disorders, psychotic disorders, and substance use disorders. The course intends to be a one-stop shop for those who hope to receive the most up-to-date information on these psychiatric disorders in late life. Of particular interest is the lecture by Dr Zydanys on depression and mood disorders in the elderly.

Dr Trevisan is Associate Clinical Professor in the department of psychiatry at the Yale School of Medicine in New Haven, Conn. He is the Acting Chief of Psychiatry at VA Connecticut Healthcare System. He is certified in addiction and geriatric psychiatry and teaches in both the addiction and geriatric psychiatry fellowships at Yale University.

 Hybels CF, Blazer DG, Hays JC. Demography and epidemiology of psychiatric disorders in late life. In: Blazer DG, Steffens DC, eds. 

The American Psychiatric Publishing Textbook of Geriatric Psychiatry

. 4th ed. Washington, DC: American Psychiatric Publishing; 2009:19-44.

 Attupurath R, Menon RC, Nair SV, et al. Late-life depression. 

Articles

Many older adults experience loneliness, profound psychosocial changes, and loss. Screening, recognition, and treatment of mood disorders in late life significantly decrease morbidity associated with many problems encountered by the elderly.

Update on Geriatric Depression and Anxiety

Is your older patient using or abusing drugs or alcohol? In this video, Louis A. Trevisan, MD, helps to answer frequently asked questions about substance abuse in older adults:

How can general psychiatrists provide effective intervention when a substance abuse (SA) problem is identified?

What are the clues that suggest that an older person may be having a substance abuse problem?

Is there an efficient and effective means of screening older adults who may be at risk for SA-or who may already be abusing alcohol or another agent?

When is a comprehensive examination for substance abuse warranted?

How can the general psychiatrist realistically provide effective intervention when a substance abuse problem is identified?

Dr Trevisan is Associate Clinical Professor in the Department of Psychiatry at the Yale School of Medicine in New Haven, Connecticut. He is the Acting Chief of Psychiatry at VA Connecticut Healthcare System. He is certified in addiction and geriatric psychiatry and teaches in both the addiction and geriatric psychiatry fellowships at Yale University.

Is your older patient using or abusing drugs or alcohol? This video reviews how general psychiatrists can provide effective intervention when a substance abuse problem is identified.

Substance Abuse by “Mature” Adults

We are pleased to present this Q&A with Dr Louis Trevisan, who is part of a comprehensive review course titled “Addictions and Their Treatment” at this year’s 

Psychiatric Times (PT): What topic did you select for the AAAP meeting and why?

I chose to lecture about elderly substance abuse and women and substance abuse because both groups are large and underserved in addictions. These two groups are part of our AAAP review course for the Addiction Boards, and I have been doing a form of this lecture for about five years now. I think that these two special populations are very important because they are usually unrecognized, underserved, and in general overlooked by the general psychiatrist, as well as the average addiction psychiatrist and geriatric psychiatrist.

Information about special populations can also be used by general practitioners/internists, advanced practice nurse practitioners, and allied health practitioners. If I can help spread the word that there is a problem in general with treating these patients and help practitioners recognize, assess and treat or appropriately refer these patients to a qualified clinician, then I have succeeded to a degree.

PT: What aspects of addiction do you plan to cover?

 I will cover the epidemiology, recognition, assessment, and treatment of substance  use disorder in the elderly and in women. I will talk about these populations in general terms and in specific terms with emphasis on tobacco, marijuana misuse, alcohol use disorders, and prescribed medication misuse, as well as other illicit drugs.

Prescribed medication misuse is a huge problem in this country, and women and the elderly are not exempt. It is therefore essential that psychiatrists conduct proper screening for use and misuse of alcohol and prescribed opioid and sedative medications. Screening will be covered, as well as a discussion on instruments and techniques that clinicians can use to screen and assess the need for treatment. Methods to engage the elderly and women in appropriate treatments will be discussed. Evidence-based pharmacological treatments and evidence-based therapies as well as 12-step programs are efficacious in these two special populations. Additionally, this is a theme that will pervade the entire course.

PT: Some who consider themselves “medication management only” psychiatrists may wonder how addiction psychiatry is relevant to them. Can you tell us about that?

 I think that most “medication management” psychiatrists would agree that when you are prescribing medications, it is very important to know if someone is using or misusing medications or illicit drugs, alcohol or tobacco, or has a significant history of abusing prescribed medications, alcohol, tobacco, or illicit drugs. I think the day psychiatrists take a narrow view of their patients has long departed.

Many people out there are being prescribed all types of medications. We are a pill-oriented society and it is never more evident than in the growing cohort of older Americans in “baby boomer generation.” They have been exposed to more medications, alcohol, marijuana, and other illicit drugs than any previous cohort.

We are seeing baby boomer aged patients in increasingly greater numbers. They have pain problems, they are aging, and additionally they are driven to extend their productive life span and are living longer than any other generation to date. They continue to be exposed to opioid medications for chronic pain, as controversial as this is. So it is of the utmost importance that all physicians and allied health professionals learn about substance abuse, its prevalence, how to screen for it and at least how to refer to an appropriate clinician for further assessment and treatment.

PT: Why should adult psychiatrists be informed about special populations in addiction psychiatry?

 We go through profound biological and psychosocial changes as we age, and we often experience many life-altering changes, including: retirement, loss of a spouse, and the development of perhaps chronic medical problems. Women are unique and have special needs in many health-related aspects, not to mention specifically in terms of substance use and abuse. In the cases of the elderly and women, the guidelines for the consumption of alcohol changes as we age.

The National Institute on Alcohol Abuse and Alcoholism 

 that after the age of 65, moderate use of alcohol is characterized by one drink per day or no more than 7 drinks per week for both men and women.1 Consuming more alcohol than this may be termed “hazardous consumption.” This is a decrease for men, but not for women.

Many men do not adapt to this and with retirement continue or increase their drinking. Women seem to be more susceptible to the use of alcohol, as they do not metabolize alcohol in the same way that men do. Their volume of distribution is smaller, and therefore, they have more of an alcohol effect for a smaller amount consumed.

Women appear to have decreased oxygenation of ethanol (decrease ADH activity) in their gastric lining, therefore allowing a greater amount of alcohol to reach the blood prior to a first pass effect of the liver. Consequently, women seem to be much more susceptible to the ravages of prolonged alcohol use or misuse and their course can “telescope.”

Our country is fast becoming and has really always been a melting pot of different ethnic groups, some of whom have acculturated easily and others who are more marginalized and underserved. Ethnic groups with different unique cultural overlays have different biological interactions with as well as personal and group approaches to substance use and abuse. For example, Native Americans, Asian Americans, African Americans, and Hispanic Americans do not seek treatment or respond to treatment in the same way as Caucasian Americans.

These are just a few of the issues that are relevant to adult general psychiatrists as well as primary care clinicians. Another group that is important is LGBT. These issues are also discussed in “Addictions and Their Treatment” by a psychiatrist who is expert in this topic, Petros Levounis, MD.

In summary, obtaining a history that is informed by age, gender, sexual orientation, and cultural/ethnic history and attempting to understand the patient within the context of their special population will be critical to screening for drug-related problems and developing a successful, tailored alcohol or drug referral strategy and treatment plan.

Offsay J. Treatment of alcohol-related problems in the elderly. 

Oslin DW. Treatment of late-life depression complicated by alcohol dependence. Am. 

Liberto JG, Oslin DW. Early versus late onset of alcoholism in the elderly. 

O’Connell H, Chin AV, Hamilton F, et al. A systematic review of the utility of self-report alcohol screening instruments in the elderly. 

Walitzer KS1, Dearing RL. Gender differences in alcohol and substance use relapse. 

1. Sobell LC, Sobell MB. Alcohol Consumption Measures. National Institute on Alcohol Abuse and Alcoholism. August 2004. 

http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/measures.htm

Medication misuse and alcohol abuse are a huge problem in the US, and women and the elderly are not exempt. In this Q&A, an expert touches on the epidemiology, recognition, assessment, and treatment of substance use disorder in these two populations. 

Special Populations in Addiction Psychiatry: The Elderly and Women

The National Institute on Alcohol Abuse and Alcoholism estimates that approximately 18 million people in the US suffer from alcohol use disorders, and 52% of the population report current use of alcohol: 35% of the general population do not drink at all; 37% drink at low-risk levels; and 28% drink at heavy or at-risk (hazardous) levels. Heavy drinking affects an estimated 23% of individuals aged 12 and older, according to the Substance Abuse and Mental Health Services Administration.

A significant number of people who use alcohol will transition to alcohol misuse, heavy drinking, hazardous (at-risk) drinking, and alcohol dependence. Alcohol use disorders may last most of a person’s lifetime and are considered chronic. However, National Epidemiological Survey on Alcohol and Related Conditions data reveal that more than 70% of persons who meet criteria for alcohol dependence have a single episode that lasts on average 3 to 4 years. Many people who seek formal treatment go on to remain alcohol-free, and many apparently recover without formal treatment. Nevertheless, in some people the course is chronic and relapsing, with multiple treatment episodes and a consequent steady decline in health.

Historically and to some extent currently, the conventional wisdom concerning treatment is to strive for complete abstinence. Traditional treatments have heralded this approach. The alcohol-misusing patient is detoxified, abstains from drinking, gets into treatment, and seeks the support of family and primary care provider. If he or she “falls off the wagon,” the only recourse is to call the sponsor or family member [[{"type":"media","view_mode":"media_crop","fid":"25031","attributes":{"alt":"Alcohol use disorders","class":"media-image media-image-right","id":"media_crop_5190572251225","media_crop_h":"322","media_crop_image_style":"-1","media_crop_instance":"2229","media_crop_rotate":"0","media_crop_scale_h":"344","media_crop_scale_w":"200","media_crop_w":"187","media_crop_x":"69","media_crop_y":"21","style":"width: 159px; height: 274px; margin: 0px; float: right;","title":" ","typeof":"foaf:Image"}}]]and get back into treatment. This approach does not always work-many persons fail to make the proper adjustments, or just cannot stay “sober,” or abstinent. There are periods of uncontrollable drinking and destruction interspersed with periods of shaky abstinence.

The realization that treatment does not have to be an all or nothing proposition is now in the forefront of modern medical treatment. Behavioral and psychopharmacological treatments emerged in the past 5 to 10 years. Psychotherapies such as motivational techniques, cognitive-behavioral therapies, relapse prevention, 12-step facilitation, and novel computerized techniques now augment and advance the treatment of alcohol use disorder. In addition, several medications seem to be effective, including naltrexone (oral and injectable), disulfiram, acamprosate, and the anticonvulsant topiramate.

The 3 excellent Special Reports in this issue by Ismene L. Petrakis, MD; Kathleen M. Carroll, MD; and Henry R. Kranzler, MD, and Leah R. Zindel, RPh, MALS, review advancements in the treatment of alcohol use disorders. Dr Petrakis, explores the co-occurrence of alcohol use disorders and psychiatric comorbidity and reviews the available medications. Dr Carroll examines the current direction of computer-based therapies to augment the treatment of alcohol used disorders. Finally, Dr Kranzler and Ms Zindel review Dr Kranzler’s research with topiramate and provide an introduction into the nascent field of personalized medicine for alcohol use disorders.

Dr Trevisan is Associate Clinical Professor in the department of psychiatry at Yale University School of Medicine, New Haven, Conn, and Acting Chief of the Mental Health Service Line at VA Connecticut Healthcare System, West Haven, Conn. He reports no conflicts of interest concerning the subject matter of this Special Report. 

An overview of special coverage on advances in the treatment of alcohol use disorders. 

Brave New Directions in Alcohol Use Disorders: An Overview

Elderly alcohol misuse is well documented and the rising numbers of elderly indicate that substance abuse and its treatment in this population is now a pressing public health concern. The number of persons aged 60 years and over has exceeded

, the majority living in developed countries.

 Addiction specialists and organizations for the elderly anticipate a large number of baby boomers will need help with fighting alcohol misuse.

 has different attitudes toward treatment than the generation that came before them.

 This age group is rapidly moving into the treatment realm of the practicing general, geriatric, and addiction psychiatrist.

 As a cohort it is hypothesized that this group will have a more lenient attitude and greater need for treatment for alcohol than previous generations.

[[{"type":"media","view_mode":"media_crop","fid":"23890","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_167439479585","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1996","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":" ","typeof":"foaf:Image"}}]]Epidemiology


Current community samples of alcohol use disorders (AUDs) from the National Epidemiological Survey of Alcohol and Related Conditions indicate that of those aged 65 and older, 2.36% of men and 0.38% of women met criteria for alcohol abuse.

AUDs represent a continuum of problematic alcohol use. The terms heavy use, hazardous use, and harmful use have been defined to capture use of alcohol in amounts that are harmful to physical health but that do not necessarily meet DSM-5 criteria for Alcohol Use Disorder. These terms are defined according to number of drinks consumed. Measures that are based on quantity or frequency of alcohol consumption may more accurately describe the extent of problematic alcohol use in the elderly. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for adults aged 65 and older defines 7 drinks in one week as moderate drinking. These guidelines are the same for men and women.

Several quantity- and frequency-based surveys of alcohol use have been conducted in the last decade. Each of these surveys sampled older adults in the community. Using pooled data, the 

 describes the drinking patterns of those aged 60 or older. Of those who reported drinking during the year before the survey, 50% of men and 39% of the women were almost daily drinkers; 5.9% of all men and 0.9% of all women aged over 60 reported binge drinking once a month or more.

 In treatment settings such as doctors’ offices and emergency departments, substance abuse diagnosis is perhaps 10-fold more frequent than in the community setting.


Often clinicians and family members are hesitant to ask if the older adult is having problems with alcohol. Traditionally accepted ways of detecting problems with substances (eg, time lost from work, legal problems, or decreased participation in important social activities) are not helpful in older adults because they generally have fewer activities and obligations.

 Older adults are likely to experience more problems with relatively small amounts of alcohol used because of increased sensitivity, slower metabolism, and a smaller volume of distribution.

 Cognitive impairment may interfere with the ability of the older adult to self-monitor intake or understand feedback from healthcare providers. A more complete assessment may be needed to detect and treat alcohol misuse problems in the elderly.

Types of alcohol problems in older adults


Two groups of older individuals meeting AUD criteria are hypothesized-those diagnosed with AUD before age 60 and those who developed problems after age 60.8. Patients with an earlier onset AUD appear to have a more severe course of illness. This group makes up about two-thirds of the alcohol misusing drinkers in the elderly. They are predominantly male, have more alcohol-related medical problems and psychiatric comorbidities

 They tend to be less well-adjusted and have more antisocial traits.

Patients with later-onset AUD usually have a milder clinical picture with fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include more women, and are likely to begin their alcohol use after a stressful event, such as retirement, loss of a spouse, job, or home. Other risk factors for development of later life AUD include a personal and family history of alcohol abuse or dependence, chronic pain, predisposition to affective or anxiety disorders, and decreased alcohol metabolism.

Alcohol misuse in older adults is often underdiagnosed in medical practice. The US Preventive Services Task Force recommends routine alcohol screening be performed; however, there is insufficient screening for excessive alcohol consumption in the elderly. Only 13% of primary care physicians use a formal screening tool for alcohol problems.

 have been developed for assessment of substance abuse. The CAGE questionnaire is the most widely studied alcohol-screening instrument, which was initially validated in young and middle-aged people.

 In the elderly, a score of 1 or more on this simple yes/no questionnaire consisting of 4 items is considered the cut-off for probable AUD. The test can be quickly applied and assesses lifetime prevalence of alcohol problems.

 The CAGE questionnaire provides higher specificity for the most severe cases, but it is of less value for the broader spectrum of alcohol misuse or hazardous use.

A shorter version of the Alcohol Use Disorders Identification Test (AUDIT)-the AUDIT-5-is often used with older adults.

 It was developed to identify people with hazardous levels of drinking.

The Michigan Alcohol Screening Test-Geriatric Version ( MAST-G) and its shorter version (SMAST-G) are self-administered check lists. They were designed to identify a population that drinks less.

 These screening devices may include a larger proportion of women.

The SMAST-G may identify a larger number of older persons with AUDs than does CAGE.

 Fewer than half of people who screen positive on either CAGE or SMAST-G screened positive on both measures. A screening strategy that uses both measures may identify more AUDs in older adults with various demographic characteristics.

In the office, in addition to using screening tests, clinicians should also monitor patients for excessive daytime sleeping, declines in personal grooming and hygiene, and withdrawal from family, friends, and normal social activities.


Aging interferes with the body’s ability to adapt to the presence of alcohol.12 The medical evaluation of older adults who may be drinking alcohol excessively requires attention to the unique physiological features of the elderly and their increased susceptibility to alcohol. The elderly have a greater sensitivity to alcohol and a more limited cognitive reserve. Also, an age-related decrease in the volume of distribution results in 20% higher blood alcohol concentration per volume.

 The NIAAA considers 1 drink daily to be the maximum amount for moderate alcohol use in men and women older than 65.

Nearly every organ in the body can be adversely affected by hazardous alcohol intake. The primary medical consequences of alcohol misuse in the elderly include: (1) mental status changes, (2) risk of falls, and (3) medication interactions.

Cognitive dysfunction can be caused by a number of organic and external conditions, including medications. Alcohol causes cognitive impairment in a dose-related fashion in the acute setting. Chronic alcohol consumption has been shown to cause persistent cognitive deficits with associated cortical atrophy and ventricular dilatation on brain scan. Consequently it is important to recognize the underlying incidence of diminished mental function in the elderly that ranges from mild cognitive impairment to dementia. The strongest risk factor for dementia is older age. The acute and chronic effects of alcohol are additive to any underlying cognitive infirmity in the geriatric patient.

Falls occur in approximately 30% of community-living adults who are older than 65 years of age.

 The elderly are at risk for falls because of impaired balance, poor judgment, arthritis, myopathy, neuropathy, CNS atrophy, cerebellar degeneration, and hypotension. In addition, a history of problem drinking is associated significantly with greater risk of falls.

The geriatric population consumes a disproportionate percentage of pharmaceuticals. A survey in 2002 showed that 94% of women aged 65 years or older took at least 1 medication; 57% took 5 or more; and 12% took 10 or more medications. Men aged 65 years or older also reported high rates of medication use.

 Confusion may be an early sign of an adverse effect. Alcohol use can directly or indirectly affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity.

High mean corpuscular volume (MCV) and elevated gamma-glutamyl transpeptidase (GGT) are commonly used as simple biological screening instruments for alcohol misuse. However, these tests alone were found to be poor screening instruments for older adults with AUDs and should be used in conjunction with CAGE, AUDIT-5, or SMAST-G.

• The prevalence of elderly substance abuse has been well documented and the rising numbers of older baby boomers indicate that alcohol misuse, its diagnosis, and treatment will shortly be one of the most pressing public health concerns in the developed world
• There is a need to develop more time-efficient and valid screening instruments to aid in identifying older adults who are at risk for AUD
• Improved overall medical understanding of the common problems associated with aging will help clinicians discern patients with alcohol misuse in this vulnerable population.
• Laboratory testing (GGT) and (MCV) may be helpful in addition to CAGE, SMAST-G, and AUDIT-5.


I would like to thank Jonathan Neal, BS for his technical assistance in preparing the manuscript for publication.

This article was originally posted online on 4/10/2014.

Dr Trevisan is Associate Clinical Professor in the Department of Psychiatry at the Yale School of Medicine in New Haven, Connecticut. He is the Acting Chief of Psychiatry at VA Connecticut Healthcare System. He is certified in addiction and geriatric psychiatry and teaches in both the addiction and geriatric psychiatry fellowships at Yale University. He reports no conflicts of interest concerning the subject matter of this article.

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Alcohol misuse in older adults is often underdiagnosed in medical practice. This age group is rapidly moving into the treatment realm of the practicing general, geriatric, and addiction psychiatrist.

Elderly Alcohol Use Disorders: Epidemiology, Screening, and Assessment Issues

Addiction specialists and organizations for the elderly anticipate a tidal wave of baby boomers who will need help fighting addictions, often for different substances and with different attitudes toward treatment than the generation that came before them.

 The leading edge of the baby boom generation is rapidly moving into the treatment realm of geriatric psychiatry.

 As a cohort, baby boomers experimented more with alcohol and illicit drugs than did previous generations. It is therefore hypothesized that this group will have more lenient attitudes about alcohol and illicit drug use than previous generations.

When one pairs open attitudes about alcohol and illicit drug use with older adults’ exposure to and misuse of prescribed medications, elderly substance abuse presents a challenging and widespread public health problem.

 In this review, I will discuss the epidemiology, assessment, medical implications, and treatment of substance abuse in older adults.

The most current community samples of alcohol use disorders come from the National Epidemiologic Survey on Alcohol and Related Conditions, in which rates for past alcohol abuse and dependence were presented by age and sex categories. Among those 65 years and older, 2.36% of men and 0.38% of women met criteria for alcohol abuse. Averaging the sexes, 1.21% of the population 65 years or older met criteria for alcohol abuse; rates for alcohol dependence were lower-0.39% in men and 0.13% in women.

It can be argued that alcohol use disorders represent one end of a continuum of problematic alcohol use. The terms “hazardous use” and “harmful use” have been used to
define consumption of alcohol in amounts that are harmful or potentially harmful to physical health but that do not necessarily meet DSM-IV criteria for abuse or dependence. These terms are defined according to number of drinks consumed. Measures that are based on quantity and/or frequency of alcohol consumption may more accurately describe the extent of problematic alcohol use in the elderly.

Several quantity- and frequency-based surveys of alcohol use have been conducted in the past decade. Each of these surveys attempted to sample the civilian elderly in the community, although survey methods differed from one study to another. Using pooled data from 1997 through 2001, the National Health Interview Survey describes the drinking patterns of those 60 years or older.

 Of those who reported drinking alcohol during the year before the survey, half of the men and 39% of the women were almost daily drinkers; 5.9% of all men aged over 60 years and 0.9% of all women aged over 60 years reported binge drinking once a month or more.

In treatment settings such as doctors’ offices and emergency departments, substance abuse diagnosis is perhaps 10-fold more frequent than in the community setting.

 Although data are scarce on illegal drug use or prescription medication misuse among the elderly, evidence suggests that misuse and abuse of prescription drugs by older adults is a growing problem.

demonstrated that up to 11% of older women misuse prescription drugs and that nonmedical use of drugs among adults older than 50 years will increase to 2.7 million by the year 2020.

There is growing evidence that female sex is a major risk factor for problems associated with prescription drug abuse.

 Older women are more likely than men to consume benzodiazepines. This may be associated with recent divorce or widowhood, lower educational level, lower income, poorer health status, depression, and/or anxiety.

It is difficult to assess substance abuse in the elderly. Often clinicians and family members are hesitant to ask whether the older adult is having problems with substance use or misuse of prescription medications. Traditionally accepted ways of detecting problems with substances (eg, time lost from work, legal problems, or decreased participation in important social activities) are not helpful in older adults because they generally have fewer activities and obligations.

 Older adults are likely to experience more problems with relatively small amounts of substances because of increased sensitivity, slower metabolism, and a smaller volume of distribution.

 Cognitive impairment may interfere with the ability of the older adult to self-monitor intake or interpret feedback from health care providers. A more complete assessment to detect and treat substance abuse problems may be needed for older patients.

There are 2 groups of older alcohol-dependent patients-those who became dependent before and those who became dependent after age 60 years.

 There is also a group of older adults who do not meet criteria for dependence but are at risk for drinking problems. Other terms used in the elderly include “problem drinking” and “hazardous drinking.” These terms have recently been described in the literature. Findings from these studies suggest that a preventive model may be superior to a disease model in identifying older adults at risk for a drinking problem.

Patients with early-onset alcohol-dependence appear to have a more severe course of illness. They make up about two-thirds of the dependent drinkers in the elderly, are predominantly male, and have more alcohol-related medical problems and psychiatric comorbidities.

 They tend to be less well-adjusted and have more antisocial traits, and they may need more treatment based on traditional medical disease models.

Patients with later-onset alcohol-dependence tend to have a milder clinical picture and fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include more women, and are likely to begin their alcohol use after a stressful event, such as loss of a spouse, job, or home. Other risk factors for the development of later-life alcohol dependence include a personal and family history of alcohol abuse or dependence, chronic pain, predisposition to affective or anxiety disorders, and decreased alcohol
metabolism.

Hazardous or at-risk use of alcohol is that which exceeds the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. For adults 65 years and older, hazardous use is 3 or more drinks at one sitting or more than 7 drinks a week. These guidelines are the same for men and women. With the new NIAAA guidelines for alcohol consumption in the elderly, hazardous use of alcohol is a problem that likely needs more attention using a preventive model in the primary care setting.

Alcohol abuse and alcohol dependence in older adults are often underdetected in medical practice. Despite the US Preventive Services Task Force recommendation for routine alcohol screening, there is insufficient screening for excessive alcohol consumption in the elderly. Only 13% of primary care physicians use a formal screening tool for alcohol problems.

Several questionnaires have been developed for assessment of substance abuse. The CAGE questionnaire is the most widely studied alcohol-screening instrument that was initially validated in young and middle-aged persons.

 A score of 2 or more on this simple yes/no questionnaire of 4 items is considered the cutoff for probable alcoholism. The test can be quickly administered and assesses lifetime prevalence of alcohol problems. However, past versus current problems are not differentiated.

The AUDIT (Alcohol Use Disorders Identification Test) is a 10-item self-report screening instrument that specifically identifies current use disorders. It was developed to identify people with hazardous levels of drinking. A shorter version of the test, the AUDIT-5, is often used with older adults.

The MAST-G (Michigan Alcohol Screening Test–Geriatric Version) is a 24-item self-report screening tool with elderly-specific questions. The MAST-G and its shorter version (SMAST-G) were designed to identify a population that drinks less than heavy drinkers or those with alcohol dependence.

 A larger proportion of women may have been screened with these instruments.

 The MAST-G does not distinguish recent from past drinking, and the length of the test may prevent its routine use.

When CAGE and SMAST-G were compared in one study, people who screened positive on SMAST-G alone were older than those who screened positive on CAGE alone or those who screened positive on both CAGE and SMAST-G. This may indicate that SMAST-G identifies a larger number of older persons with alcohol use disorders than does CAGE.

 The same study showed that fewer than half of persons who screened positive on either CAGE or SMAST-G screened positive on both measures. This finding suggests that a screening strategy that uses both measures may identify more alcohol use disorders in older adults with various demographic characteristics.

The Alcohol-Related Problems Survey (ARPS) is an 18-item self-administered screening measure that focuses on the relationship between alcohol use and medical problems, medication use, and functional status. The results classify patients as nonhazardous, hazardous, or harmful drinkers. There is also a short version-shARPS.

 This screening instrument showed very good sensitivity but only moderate specificity in a population of internal medicine clinical patients. The time taken to administer the test may be a limitation.

High mean corpuscular volume is commonly used as a simple screening instrument for alcohol misuse. However, this test was found to be a poor screening instrument for older adults with alcohol use disorders.

There are few, if any, validated screening instruments for detecting problems related to prescription medication abuse. Blow

 recommends screening elderly patients who may be abusing prescription medication by collecting a detailed history and looking for signs of prescription misuse (eg, excessive worry about whether the medication is working, attachment to a particular psychoactive medication, or excessive anxiety about the supply and timing of medications). In addition, clinicians need to monitor patients for excessive daytime sleeping; declines in personal grooming and hygiene; and withdrawal from family, friends, and normal social activities.

Factors associated with prescription medication misuse and drug abuse in the elderly include female sex, social isolation, history of substance use or mental health disorder, medical exposure to prescription drugs with abuse potential, poor health status, and polypharmacy. Other general indicators of prescription medication misuse may include loss of motivation, memory problems, family or marital discord, new difficulties with activities of daily living, drug-seeking behavior, and doctor shopping.

The medical evaluation of older adults who may be drinking alcohol excessively requires attention to the unique physiological features of the elderly and their increased susceptibility to alcohol. The NIAAA considers 1 drink daily to be the maximum amount for moderate alcohol use in men and women older than 65 years.

 An age-related decrease in the volume of distribution results in 20% higher blood alcohol concentration per volume.

 Evidence from clinical and preclinical studies indicates that aging interferes with the body’s ability to adapt to the presence of alcohol.

There is a U- or J-shaped curve association between alcohol consumption and all-cause mortality.

 Nearly every organ can be adversely affected by hazardous alcohol intake. As we consider the medical consequences of alcohol in the elderly, 3 areas deserve particular attention: mental status, risk of falls, and medication interactions.

Cognitive dysfunction can be caused by a number of organic and external conditions, including medications. Alcohol causes cognitive impairment in a dose-related fashion in the acute setting. Chronic alcohol consumption has been shown to cause persistent cognitive deficits with associated cortical atrophy and ventricular dilatation on brain scan. Consequently, it is important to recognize the underlying incidence of diminished mental function in the elderly, which ranges from mild cognitive impairment to dementia.

Dementia is prevalent and is characterized by a decline in cognition that affects memory and by at least 1 of the following cognitive disturbances: agnosia, aphasia, apraxia, or disturbance in executive functioning. The strongest risk factor for dementia is older age. The 1% prevalence of dementia among individuals aged 60 to 69 years doubles every 5 years to about 39% in those aged 90 to 95 years.

 The acute and chronic effects of alcohol are additive to any underlying cognitive infirmity in the geriatric patient.

Falls occur in approximately 30% of community-living adults who are older than 65 years and who are at increased risk of serious injury, functional decline, and increased health care use; this rate increases to 50% for those 80 years and older.

 The elderly are more at risk for falls because of impaired balance, judgment, arthritis, myopathy, neuropathy, CNS atrophy, cerebellar degeneration, and hypotension. Also, because of osteopenia and osteoporosis, falls are more likely to lead to fractures. Inability to get up after a fall adds to mortality and morbidity. A history of problem drinking is associated significantly with greater risk of falls.

The geriatric population consumes a disproportionate percentage of medication. A survey in 2002 showed that 94% of women 65 years or older took at least 1 medication, 57% took 5 or more, and 12% took 10 or more medications; men 65 years or older also reported high rates of medication use.

 Geriatric patients are subject to increased risk of medication-related misadventures: if all the medications are taken, the risk of adverse effects and drug-drug interactions is increased; if the medications are not taken, a disease state can worsen and may prompt a clinician to add or change medications inappropriately. Adverse effects (including those of over-the-counter medications) rank fifth among the greatest and most preventable health threats to older adults.

Confusion may be an early sign of an adverse effect. Alcohol use can directly or indirectly affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity. Thus, older adults who drink and who have medical illness or disability and who are taking a medication are at great risk for adverse effects.

Age-specific treatment approachesresult in better adherence and fewer relapses.

 Treatment guidelines from the Substance Abuse and Mental Health Services Administration indicate that treatment should include age-appropriate group therapy, address loss early in treatment, and teach skills to rebuild social support networks. It is recommended that staff be experienced in working with the elderly and use a slower pace and age-appropriate content. A culture of respect with an atmosphere of support and change rather than confrontation should be created within the therapeutic setting.

 assessed participants in the older alcoholics rehabilitation program of the US Department of Veterans Affairs who were randomly assigned to reminiscence therapy versus traditional care programs. They found that developing patient self-esteem and peer relationships was superior to confrontational approaches typical of traditional care programs. Several studies have evaluated elder-specific Brief Alcohol Intervention (BAI) projects. The Table provides some characteristics of BAI. The Guiding Older Adult Lifestyles project that used brief physician advice for 156 at-risk drinkers was shown to reduce alcohol consumption by 34% at 12-month follow-up.

Results of the Health Profile Project demonstrated that a motivational enhancement session reduced at-risk drinking at 12 months (N = 454).

 The Staying Healthy Project undertaken by the American Society on Aging noted that about 6% of the older adults sampled were drinking more than recommended and that a brief intervention resulted in about 40% reduced consumption of alcohol.

 The Gerontology Alcohol Project targeted adults with late-life onset alcohol abuse. Using day treatment and a group format (cognitive-behavioral therapy), 75% of the participants maintained drinking goals and no one returned to steady drinking.

The Computerized Alcohol-Related Problems Survey demonstrated that a brief intervention that provided feedback and psychoeducation to at-risk drinkers was effective in primary care settings.

 The Primary Care Research in Substance Abuse and Mental Health (PRISM) trial randomized 414 older at-risk alcohol users to integrated primary care intervention or to referral to a specialist provider, such as a substance abuse clinic. The trial showed that alcohol users who received the integrated intervention were twice as likely to remain in treatment.

Three medications have been approved for treatment of alcohol problems; however, there are few pharmacological treatment studies of alcohol dependence in older adults and no known studies of other drugs of abuse. Disulfiram, which blocks the action of acetaldehyde dehydrogenase, causes a buildup of acetaldehyde in the body. If alcohol is ingested, the reaction is too dangerous for older persons. Hypotension and cardiac adverse effects are the main problems. Naltrexone is a Î³ opioid antagonist that has been shown to help prevent relapse in older adults who drank alcohol excessively.

Acamprosate is a glutamatergic medication that received FDA approval for the treatment of alcohol dependence in abstinent drinkers. There have been no studies using this medication to treat older adults who are alcohol-dependent. The drug is metabolized renally and thus kidney function should be monitored in patients taking this medication. Topiramate, an anticonvulsant medication that potentiates g-aminobutyric acid has shown recent success in treating initiation of abstinence (the period of treatment directly following acute detoxification from alcohol when patients may be most vulnerable to relapse).

However, because it may cause cognitive impairment, it is an unlikely treatment for the elderly.

The 2 agents used to treat opioid dependence are methadone and buprenorphine/naloxone. Although these harm-reduction pharmacological treatments are widely used for opioid addicts, there are no studies of these medications in the elderly population.

The well-documented prevalence of elderly substance abuse and the aging of the baby boom generation indicate that substance abuse and its treatment in the elderly will shortly be one of the most pressing public health concerns. Consequently, there is a need to develop more time-efficient and valid screening instruments to help identify older adults who are at risk.

Clinical trials of medications to treat substance abuse in the elderly are lacking, and more needs to be learned about how our current medication armamentarium can be used in this aging population. Treatment trials with cholinesterase inhibitors and memantine may offer more information about the interplay of cognitive impairment and at-risk alcohol use in the elderly. Treatment trials of opiate substitution therapy are needed as well.

The leading edge of the baby boom generation is rapidly moving into the treatment realm of geriatric psychiatry. As a cohort, baby boomers experimented more with alcohol and illicit drugs than did previous generations.