ALCOHOL IN THE ELDERLY Dr. Sheryl Spithoff & Dr. Suzanne Turner Addition Medicine Fellows Contact: Suzanne.Turner@camh.ca
BURDEN OF ILLNESS Mental health and addiction dx: Account 4.7% of all SJHC ED visits 766 patients / 16,000 35% of these patients were addiction-related This estimate does not capture other substance-related diagnoses (i.e. non-mental health) Falls Failure to cope Liver failure GI bleed The Mental Health and Addictions Emergency Department Flow Mapping Project*
BURDEN OF ILLNESS US Screening Study (Onen 2005) 5.3% of elderly ER patients had current alcohol disorder Assuming case identification rates of 20% (standard), then about 300 elderly substance users in one year at SJHC Emergency Room
WHAT THE ADDICTION MD CAN OFFER? Monitoring of Health Effects Withdrawal Management Medications for craving Relapse prevention Connecting to other services And most importantly: Treatment works Without treatment the risks to the elderly are significant
HARMS (1): WITHDRAWAL Elderly can have more prolonged withdrawal and higher risk of delirium Higher risks in withdrawal of: cognitive impairment (including delirium) daytime sleepiness weakness high blood pressure Some elderly may not be suitable for outpatient w/d because following would have to be true: Adequate social support No significant withdrawal symptoms No comorbid illness No complicated withdrawal (no seizures, no delirium)
HARMS (2): DEMENTIA Low to moderate alcohol use may protect against vascular dementia (Ganguli, 2005) No heavy drinkers in this study Heavy alcohol use increases risk of all types of dementia (Thomas, 2001) Alcoholics perform worse than controls on cognitive testing, but better than Alzheimer s (Liappas, 2007) Alcohol-induced cognitive impairment remains stable and may improve with abstinence Further research in this area is needed (Oslin, 2003)
HARMS (3): DEPRESSION A high proportion of elderly depressed patients have an alcohol use disorder 30% in one study A high proportion of elderly alcoholics have concurrent depression (Blixen 1997, Blow 2000) Alcohol use is a major risk factor for suicide in the elderly
HARMS (4): LIVER DISEASE Alcoholic Liver Disease Fatty Liver First and most common phase of liver disease Usually no symptoms REVERSIBLE WITH ABSTINENCE Alcoholic Hepatitis Usually no symptoms but CAN be VERY severe Repeated and prolonged episodes can lead to cirrhosis Cirrhosis CAN BE SERIOUS AND EVEN FATAL
HARMS (5): CIRRHOSIS Over 10-20 years, 10 20% risk of cirrhosis with: 3 drinks/day (men), 2 drinks/day (women) In early stages, if stop drinking they can do well as the cirrhosis stabilizes and can be symptom-free Most effective treatment is abstinence because cirrhosis often not reversible If severe cirrhosis can get on transplant list Need six months to two years of abstinence + treatment program to be eligible
HARMS (5): CIRRHOSIS Encephalopathy Coma, confusion or altered level of consciousness The confusion can lead to high risk of accidents and death Ascites Fluid building up in the belly Makes it difficult to breath, walk and higher risk of infection (as the fluid is a good breeding ground for bacteria) Infection puts patient at ++ high risk of death Varices Enlarged blood vessels in the liver and spleen can cause extensive and life-threatening bleeding
BARRIERS TO TREATMENT There are few addiction programs specifically designed for older adults (Schulz 2003) Elderly have difficulty accessing existing programs: long waiting lists, complex admission procedures, and multiple appointments Most programs are based on group therapy can be intimidating for older patients MDs can help navigate the system and make sure patients get in-hospital treatment, appropriate medical treatment and ongoing monitoring
AT-RISK DRINKING VS ADDICTION
LOW RISK DRINKING GUIDELINES Men: No more than 15 drinks per week No more than 3 drinks per sitting Women No more than 10 drinks per week No more than 2 drinks per sitting Special Occasions: Men: no more than 4 drinks Women: no more than 3 drinks
AT-RISK DRINKERS VS ALCOHOLICS AT-RISK DRINKERS Drink above the low-risk drinking guidelines Able to drink moderately Few social consequences Do not go through withdrawal Often respond to physician advice and reduction ALCOHOLICS Withdrawal symptoms Continue to drink despite harms Neglect of responsibilities Generally require abstinence and intensive treatment
AT-RISK DRINKERS VS ALCOHOLICS At-risk Drinker Alcohol Addiction Withdrawal Symptoms No Often Amount Consumed More than 14/week 40-60/week or more Drinking Pattern Variable, depends on situation Tends to drink set amount Social Consequences Nil or mild Often severe Physical Consequences Nil or mild Often severe Social Stability Usually Often not Neglect of major responsibilities No Yes
AT-RISK DRINKERS: MD ADVICE Older, at-risk drinkers that received advice from their primary care doctors about reducing consumption showed significant REDUCTION in: 7-day alcohol use (Fleming, 1999) episodes of binge drinking frequency of excessive drinking (> 21 drinks/week) This difference was followed over time Differences still present after 12 months BOTTOM LINE: THESE PATIENTS LISTEN TO THEIR DOCTOR
LOW-RISK GUIDELINES FOR THE ELDERLY Consumption limits for older adults should be lower (Chermack, 1996) Recommend no more than 1 drink per day Avoiding heavy drinking (consuming five or more drinks in 24h) could further reduce the risk of alcohol-related symptoms for older adults
MANAGEMENT OF AT-RISK DRINKING Review low-risk drinking guidelines Link drinking to individual patient situation Fatty liver, alcoholic hepatitis, falls, etc Emphasize that mood, sleep, energy level will improve with reduced drinking Screen and treat depression Ask patient to commit to a drinking goal: Reduced drinking or abstinence If unwilling to commit, continue to ask about drinking at every office visit Monitor blood work at baseline and follow-up Have regular follow-up with alcohol at the top of the agenda
HARM-REDUCTION STRATEGIES Sip drinks, don't gulp Avoid drinking on an empty stomach. Dilute drinks with mixer. Alternate alcoholic with non-alcoholic drinks Put a 20-minute "time-out" between the decision to drink and taking the drink
PSYCHOTHERAPY & ELDERLY
PSYCHOTHERAPY: ELDERLY Cognitive behavioural treatment associated with sustained abstinence in age-matched group (Schonfeld, 2000) 16 weekly group sessions using cognitivebehavioral (CB) and self-management approaches. Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use,
PSYCHOTHERAPY: ELDERLY Modules to teach coping skills for coping with social pressure, being at home and alone, feelings of depression and loneliness, anxiety and tension, anger and frustration, cues for substance use, urges (self-statements), and slips or relapses. At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters. The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.
PSYCHOTHERAPY: ELDERLY POPJLATIONS Following have evidence to be effective in elderly populations: cognitive-behavioural therapy, group and family therapies self-help groups In fact, group and family therapies and selfhelp groups may be of particular benefit to older adults because of the emphasis on social support.
DRUG THERAPY & ELDERLY
MANAGEMENT OF ALC DEP Alcohol treatment for older adults is at least as effective as for younger patients (Barrick 2002, Lemke 2002, 2003.) Medicinal adjuncts are also equally effective in the elderly Need strict compliance and careful monitoring of adverse effects are especially important in patients who take multiple medications. Because of their benign adverse effect profiles, naltrexone and acamprosate are particularly good pharmacological agents for relapse prevention in older adults.
PHARMACOTHERAPY: ODB COVERAGE Special Application Covered (but off-label) Not covered Revia (Naltrexone)* Baclofen** Antabuse (Disulfiram)*** Campral (Acamprosate) Topamax (Topirimate)** Zofran (Ondansetron) * Must be tried first unless a contraindication to Revia and then an application for Campral can be initiated ** Lower dose suggested in elderly may not be effective for alcohol ***Causes patients to be physically ill could precipitate severe medical emergencies in the elderly and generally avoided in this population
REVIA (NALTREXONE): PREVENTS RELAPSE Well tolerated Safe: No major liver side effects No differences between placebo (sugar pill) and Revia in the number of subjects remaining abstinent The number of subjects who relapsed But if the patient sampled alcohol Only half as likely to relapse!
REVIA (NALTREXONE): COMPLIANCE Elderly patients are more likely to take naltrexone regularly Compliance was much better (Oslin, 2002) Higher retention to naltrexone Less likely to relapse than younger patients taking naltrexone More attendance at therapy sessions than younger patients taking naltrexone Older adults appear to respond well to a medicallyoriented program that is supportive and individualized
ALCOHOL DEPENDENCE: MOOD Treat alcohol and mood disorders at the same time Consider a trial of antidepressant medication if: Symptoms persist after four weeks of abstinence Patient unable to sustain abstinence for several weeks Primary mood disorder: depression precedes drinking; strong family history Severe depression (suicidal ideation, hospital admissions) Long-term benzodiazepine use in heavy drinkers creates risk of accidents, overdose and misuse
DEPRESSION: TREATMENT WORKS Treatment of comorbid depression and substance use: Effective in general adult populations (Nunes 2004) Leads to marked reductions in psychiatric hospital days (Granholm 2003, Kominski 2001) Anti-depressants and counselling leads to: Decreased drinking (Oslin, 2005) Improved mood Alcohol use is a major risk factor for suicide Access to alcohol treatment is a protective factor for suicide in the elderly (She, 2006)
SUMMARY: TREATMENT The elderly are at high risk of life-threatening conditions associated with their drinking Elderly patients listen to advice from their doctors about safe drinking limits Psychotherapy (particularly family and age-matched group thearpy) is effective in the elderly Drug therapy such as naltrexone works well in helping patienst to reduce drinking and prevent relapse
PHYSICAL DEPENDENCE Many patients with an alcohol addiction have a physical dependence on alcohol PHYSICAL DEPENDENCE INCLUDES: Tolerance- increased amounts to have same effect Withdrawal- syndrome with typically opposite effects to the substance
PHYSICAL DEPENDENCE WHAT S HAPPENING IN THE BRAIN? Alcohol is complex but one main action- causes sedation Alcohol increases inhibitory activity, decreases excitatory activity Brain adapts and up-regulates in the face of chronic alcohol use If alcohol is removed- brain goes into overdrive
ALCOHOL WITHDRAWAL Mild symptoms: tremor, anxiety, Irritability Settles after a few day No medical treatment needed Severe symptoms: anxiety Nausea & vomiting, headache, sensory disturbances, rapid heart-rate, hypertension, tremor, sweats, agitation Starts 6 to 12 hours (up to several days) peak at day 3-5 resolve by day 7-10 Needs medical treatment
SEVERE WITHDRAWAL: DELIRIUM TREMENS Severe withdrawal can progress to delirium tremens 5% cases onset 2-4 days after last drink delirium= hallucinations, agitation, disorientation and confusion autonomic overdrive= tremor, fast heart-rate, high blood pressure, fever, and sweating medical emergency with risk of death of 5%
SEVERE WITHDRAWAL: SEIZURES Seizures Usually 12-72 hours after last drink Can be single or multiple Need to see a doctor for Investigation if: first withdrawal seizure > age 40, focal features, Prolonged a seizure lasted more than 30 seconds recurrent >2 abnormal neuro exam (i.e. they look like they ve had a stroke drooping of the face, not able to move an arm or leg, etc) outside typical time frame (if > 7 days)
ALCOHOL WITHDRAWAL: SUMMARY Alcohol withdrawal is a serious medical illness An MD or (RN-EC) should assess any patient with: symptoms of withdrawal at risk of withdrawal (ie history of heavy drinking in patient admitted to hospital) Assess withdrawal symptoms, provide management plan and treatment
ALCOHOL WITHDRAL: PLANNED WITHDRAWAL An MD (or RN-EC) should assess all patients with alcohol addiction who are planning to stop drinking to determine risk of more significant withdrawal and provide a medical management plan (if indicated) THERE ARE SOME PATIENTS THAT SHOULD NOT PLAN TO STOP DRINKING WITHOUT MEDICATION OR OUTSIDE A HOSPITAL SETTING develop a long-term addiction treatment plan
ALCOHOL WITHDRAWAL: ONLY ONE COMPONENT OF TREATMENT Detox is one small step in recovery process Important because it allows patient to engage in a more meaningful way in treatment Rarely is successful insolation Must be integrated into ongoing treatment and the MD (RN- EC can help to put the other pieces of an ongoing treatment plan into place)
PLANNED WITHDRAWAL: RISK ASSESSMENT Low risk unlikely to need medical management for withdrawal Higher risk group need close observation and medical management Two options for the higher risk groups: outpatient withdrawal inpatient withdrawal
ALCOHOL WITHDRAWAL: LOW RISK Low risk group: no significant withdrawal in past, no seizures, arrhythmias no relief drinking drinking <40 drinks per week no significant concurrent illness
PLANNED WITHDRAWAL: LOW RISK Caveat- Withdrawal course not always predictable- genetic factors seem to play a large role Warn patient of risks of alcohol withdrawal and to seek treatment if needed If any concerns have patient should be assessed next day and be monitored by reliable partner/ friend
ALCOHOL WITHDRAWAL: ELDERLY Elderly can be a low risk group but NEED closer follow-up Evidence is unclear if severe withdrawal is more common in elderly but course of withdrawal appears to be more complicated Medical problems/illnesses (co-morbidities), multiple medications that may affect course of withdrawal
ALCOHOL WITHDRAWAL: ELDERLY Some smaller older studies found increased severity of withdrawal in older age groups (Brower 1994; Liskow 1989) Criticized for comparing to very young adults <30 yo (very low risk severe withdrawal) and small sample sizes
WITHDRAWAL- ELDERLY Newer, larger studies (Kraemer 1997, Wetterling 2000, Wojnar 2001) Found no increase in severity scores or doses of benzodiazepines for elderly Did find longer stays and increase risk delirium* (Kraemer 1997, Wojnar 2001) * not statistically significant Wojnar 2001
PLANNED WITHDRAWAL: HIGHER RISK Patients who don t fall into low risk group need medical management Either inpatient detox or outpatient day detox Treated with sedative medications Benzodiazepines (valium, ativan) have best evidence
WITHDRAWAL TREATMENT: BENZOS Benzodiazepines (Ativan, valium) Act at inhibitory neurotransmitter receptors (GABA receptors) these are the transmitters that go into overdrive when the patient stops drinking Treat symptoms and stop progression from mild to more severe withdrawal
WITHDRAWAL TREATMENT: BENZOS Benzodiazepines are often dosed symptom-based with standardized protocol- CIWA (Clinical Institute Withdrawal Assessment) Need MD (RN-EC) support because Elderly need more close observation Need specialized medications (not standard protocol Elderly- use short-acting benzodiazepine like lorazepam lower risk of sedation, confusion, respiratory depression
WITHDRAWAL TREATMENT: OUTPATIENT Many younger patients can be managed with planned outpatient withdrawal Treated with benzodiazepine protocol in MDs office in day, once withdrawal symptoms settle they are discharge home or to non-medical detox Phone or in person follow-up next day Safe, cost effective
OUTPATIENT WITHDRAWAL Criteria for outpatient management Initial CIWA score between 8-15 No hx seizures, dysrhythmias or severe withdrawal in past No serious medical or psychiatric illness Stable home situation, partner/ friend to monitor No polysubstance use Can come in for daily visits (or phone follow-up) Not pregnant
OUTPATIENT WITHDRAWAL: ELDERLY Outpatient management of withdrawal in elderly Age over 60 is relative contraindication in some sources Typically use lorazepam protocol since short-acting benzodiazepine symptoms may reoccur- need close f/u
INPATIENT WITHDRAWAL Two options for inpatient withdrawal Non-urgent: CAMH- medical detox- patients or physician can refer Urgent: refer to ER either end up admitted under medicine or treated in ER and discharged home (or to nonmedical detox)
ALCOHOL WITHDRAWAL: TREATMENT OPTIONS Other drugs used for withdrawal Anti-seizure medications and baclofen look promising for mild withdrawal, unclear for more severe withdrawal Anti-psychotics- generally avoid unless underlying psychosis- (many prolong QT, some lower seizure threshold)
SUBACUTE WITHDRAWAL Acute alcohol withdrawal usually resolves in 7 days, often less. However subacute symptoms can last for months. anxiety, agitation, irritability, poor sleep (also consider underlying mood disorder) Gabapentin- reduced risk of relapse in first 6 weeks when combined with naltrexone (Anton 2011)
SUBACUTE WITHDRAWAL Many studies have shown that poor sleep is associated with higher risk of relapse Review- Treatment for sleep disturbances in alcohol recovery (Arnedt 2007) Non pharmacological - Cognitive behavioural therapy has best evidence,* other options- sleep hygiene education, sleep restriction, stimulus control *Four large meta-analyses showed CBT to be equal or superior in improving sleep compared to medications- studies in non-alcohol dependent patients (Arnedt 2007)
SUBACUTE WITHDRAWAL Pharmacological treatment of insomnia in alcohol recovery: a systematic review. (Kolla 2011) Trazodone best evidence, but one study found increase in return to drinking Gabapentin equivocal; topiramate and carbamazepine showed subjective benefit Acamprosate showed some improvement in small study Some evidence for benzodiazepines, quetiapine however these drugs are usually viewed as second line because of risks and/or side effects
WITHDRAWAL: SUMMARY Alcohol withdrawal can be a serious life-threatening illness Elderly- more complicated withdrawal and seem to be at increased risk delerium All patients with an alcohol addiction should be assessed by MD or RN(EC) prior to stopping drinking Over age 60- relative contraindication to outpatient management of withdrawal Detox is only one step in treating an addiction- a chronic illness Needs to be integrated into an ongoing treatment plan with medical care, counseling, therapy, group programs