James W. Campbell MD, MS
ESSENTIALS OF DIAGNOSIS
Studies from the Center for Medicare and Medicaid report that smoking is the single most preventable cause of illness. Over 10% of the population 65 years and older are smokers; specifically, 12.9% of persons aged 65-74 smoke and 6.1% of persons older than 75 smoke. Smokers older than 65 are identified as the most likely to benefit from smoking cessation.
Tobacco abuse reduction is one of the most well-developed areas of prevention. Strategies include public education, office interventions, formal cessation programs, and pharmacological assistance. In 2002, Medicare began a limited program to address smoking cessation specifically in the older population, but no large-scale prevention programs target seniors.
Smoking is debated in terms of its effect on cognition. Recent studies have not shown a relationship between smoking and measures of general cognitive ability, executive function, and memory when corrected for age, education, and other health conditions. These studies need to be examined closely; when one controls for other tobacco-use related health conditions (ie, cerebrovascular accidents, coronary artery disease, and hypertension), the mechanisms by which tobacco places a person at greater risk of cognitive decline may be eliminated and create a false protective effect. An association with osteoporosis is found for smokers and former smokers with chronic obstructive pulmonary disease independent of their use of corticosteroids.
The pharmacological options in smoking cessation are well substantiated. Nicotine substitution by patch improves success rates in smoking cessation. Adjunctive pharmacotherapy is also beneficial. The use of bupropion assists with smoking cessation. Smoking cessation highlights another important aspect of behavior change; despite common assumptions to the contrary, repeated attempts to quit improve success. This suggests the value of educating those who have quit and relapsed that their chance for success in the future is significant. Each attempt to quit provides the quitter with a new set of skills and knowledge. Interest in quitting appears to be rising among older persons. Medicare Stop Smoking Programs funded by Medicare are underway in Alabama, Missouri, Ohio, Oklahoma, Nebraska, and Wyoming.
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Alcoholism is the third most common psychiatric disorder among older persons. Up to 16% of men and 8% of women have alcohol use disorders. Alcohol use significant enough to impair health is present in up to 20% of patients hospitalized on medical-surgical units. Too often the diagnosis is missed as a result of not screening. Simple screening tools with good sensitivity are available, and excellent tools for diagnostic confirmation with high specificity are validated in older populations. Treatment for substance abuse disorders through brief intervention and more classical treatments have been found to be effective in older patients.
Alcoholism, alcohol dependence, and alcohol addiction are used synonymously in this chapter. Many classify alcoholism as chronic or late onset depending on the presentation of first symptoms before or after age 65. Although of interest, these 2 groups do not perform significantly differently in treatment. Alcoholism can be considered to be active or in remission, and activities such as relapse prevention groups act as mechanisms to prolong a remission.
Although alcoholism is at its core a heritable disease, much of the inherent medical risk in the elderly patient's consumption of various substances lies in the altered pharmacokinetics present in older individuals (see Chapter 41: Principles of Drug Therapy). All ingested agents have a decrease in volume of distribution. The volume of distribution of water-soluble agents is particularly altered as the body fat-body water ratio changes with age. Alcohol, a classic water-soluble drug, produces a much higher blood alcohol concentration in an older person than in a younger person of the same weight. Genetic predisposition to alcoholism is estimated to account for 40-60% of alcoholism cases.
Alcohol abuse prevention is predominantly aimed at younger persons. However, there are significant programs now specifically designed to address alcoholism prevention in elders. In Virginia, a statewide program to detect and prevent geriatric alcoholism has included a 7-year follow-up; this follow-up documented the program's ability to enhance detection and increase assistance to identified persons with alcoholism risks.
Alcoholism in elders is often missed. Many of the classical clues are mistakenly attributed to age-related changes or diseases common in old age (Table 39-1). Many of the consequences that drive a younger person into treatment job loss, divorce, or legal pressuresare less likely to occur in older persons. One of the best clinical clues is the use of other substances, particularly nicotine. Seventy percent of alcoholics smoke > 20 cigarettes/day compared with 10% of the general population. Alcohol abuse should be investigated in patients with anxiety and mood disorders. Even such common conditions as hip fractures should trigger screening for alcoholism because research has shown a 2.6-times increased risk of hip fracture over 5 years in patients with a history of admission for alcohol-related disorders. Physical stigmata of alcoholism do occur but are a late
finding in alcoholism, and screening is best aimed at an earlier stage of the disease.
Table 39-1. Clinical clues to the diagnosis of alcoholism misattributed to diseases common in old age.
Confusion, dizziness, drowsiness, and dryness of mouth are among the common side effects of alcohol use.
Many attempts have been made to find a useful screening laboratory test for detecting early alcoholism. To date, no test with reasonable sensitivity and specificity exists. Elevations in MCV and γ-glutamyltransferase are reasonably sensitive but nonspecific. Alterations in AST and ALT most often represent advanced disease.
Carbohydrate-deficient transferrin (currently available at specialized centers) is a possibly useful test to measure intake over time. However, the test shows more promise as a monitor of treatment than as a tool for screening patients for alcoholism.
Currently, no imaging studies are useful in the detection of early-stage disease.
Standardized questionnaires are the current gold standard for diagnosis. The Geriatric version of the Michigan Alcoholism Screening Test is still one of the best tools available (Figure 39-1). The short version is a brief test with a sensitivity of 52% and a specificity of 96%. The AUDIT tool also has very high specificity. The CAGE assessment has been well studied and exhibits excellent sensitivity. This tool is composed of 4 simple questions based on the CAGE mnemonic:
The CAGE is 91% sensitive and 48% specific.
Interview technique is important because the order of questions has been shown to affect the screening tools. The CAGE becomes less sensitive if preceded by questions on quantity and frequency. The CAGE, well delivered, can enable the diagnosis of alcoholism even in a patient with significant denial. The patient may offer as evidence of control the ability to cut down on drinking. The simple fact that the patient is working to limit intake helps make the diagnosis of alcoholism. Another more recently developed tool, the Alcohol-Related Problems Survey (short version), also has a sensitivity of 92% and a specificity of 51%.
There are a large number of prolonged standardized diagnostic tools (eg, the Substance Abuse Disorders Diagnostic Schedule). These tools are valuable in research settings and are used as entry points to intensive treatment but are not appropriate for primary care settings. The most important goal in primary care is to perform some form of screen on all persons.
It is noteworthy that older women are often omitted from clinical studies even though 12% of older women regularly drink in excess and older women have a swifter progression to alcohol-related illnesses. Older women represent the most underscreened and underdiagnosed population. Older women who are moderate to heavy drinkers have been found to have many misconceptions about alcohol and drug use. They are also less likely to be assessed for nonprescribed drug use despite the fact that OTC drug use is higher in women than in men.
Alcoholism is in the differential diagnosis, either as a cause or exacerbating factor, in almost all geriatric syndromes. Likewise, alcohol abuse, heavy alcohol use, or alcoholism can be a direct etiological factor or a clear cause of worsening of many of the diseases prevalent in old age. One important consideration is the differentiation of aging from substance use abuse disorders. Table 39-2 lists some examples of presentations often incorrectly attributed to aging that may actually be symptomatic of pathological alcohol use.
As many as 10% of demented individuals suffer from an alcohol-induced dementia. This dementia often goes unrecognized despite being one of the most responsive to treatment. Differentiating alcohol-induced dementia from Alzheimer's disease or multi-infarct dementia is critical since alcohol-induced dementia improved dramatically with sobriety. Alcohol abuse often coexists with depression, dysthymia, or anxiety. An estimated 10-15% of depressed persons use alcohol to self-medicate. Alcohol has been associated with an increased risk of falls, osteoporosis, and fractures.
There is continued great debate regarding the beneficial effects of low-dose drinking. In younger persons, this may well represent a chance to influence cardiovascular risk factors. However, no clear evidence exists of benefits from drinking for elders. On the contrary, many diseases and medications used by the elderly have contraindications to alcohol use.
Figure 39-1. Geriatric version of the Michigan Alcoholism Screening Test. Courtesy F. Blow. Used with permission.
An organized approach to screening, diagnosis, and treatment of substance abuse in elders is summarized in Figure 39-2. The treatment of all substance abuse disorders is based on the model of Alcoholics Anonymous (AA) and similar 12-step programs. Brief counseling in a primary care setting is often effective to initiate recovery. Family involvement is key to success in the treatment of substance abuse. Paradoxically, a patient coerced into treatment has nearly as good a chance of long-term success as a patient who initially self-referred. The standard prescription includes discontinuation of all substance use, attendance at 90 meetings in the first 90 days, and regular involvement in the program and meetings.
AA is the most readily available program, and its tenets can be adapted for any substance. Although formal research on the principles of AA is by definition difficult, studies have shown that patient attendance at 90 meetings in the first 90 days to be the most powerful predictor
of long-term sobriety. AA is geriatric friendly, and 33% of all calls to AA are from persons older than 55. A nonjudgmental approach without “labeling” appears to be more effective in older persons, who are still strongly averse to accepting the label “alcoholic.” A less threatening approach such as “you may be drinking more than is healthy” or “your drinking appears to be having a negative impact on your life” gives better results. Presenting treatment in the framework of hope is a far more successful strategy for behavior change than fear.
Table 39-2. Clinical clues to the diagnosis of alcoholism misattributed to normal aging.
Detoxification needs to be closely medically monitored because the older person is more susceptible to medical complications. Aversive drugs such as disulfiram are of limited utility in older persons because a disulfiram reaction may have major medical consequences. Newer
drugs such as naltrexone, although well grounded in appropriate physiology, are substantially limited by cost.
Figure 39-2. Organized approach to screening, diagnosis, and treatment of substance abuse in elders.
Pharmacological adjuncts to treatment still require a solid primary treatment program.
Problem drinking can be successfully treated by brief intervention by primary care physicians. This technique is time and cost efficient with surprisingly good results. Simple physician education of patients regarding risks and benefits of continued use combined with 1 follow-up resulted in a significant success rate on the order of 10-15%. Although this rate is low in absolute terms, it is high compared with the success of treatment of other chronic diseases in 2 visits. At the end of intensive treatment, older patients showed significant change in most areas targeted for treatment; motivation, cognition, and interpersonal support improved more than expected. Older alcoholics in general have a better prognosis than younger alcoholics, which may be because the older cohort is more likely to have monosubstance abuse.
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The rates of use of nonprescribed illicit drugs are thought to be low among the elderly, although rigorous studies are not currently available. The national comorbidity study suggests that illicit drug use declines with age. Screening based on consequences and treatment based on brief intervention and 12-step programs are effective for all substance abuse disorders.
Elders tend to use nonprescribed over-the-counter (OTC) drugs frequently. However, only 11% of physicians routinely ask about OTC use during primary care encounters.
Interactions among alcohol, illicit drugs, and prescription and over-the-counter medications are potentially serious problems in the elderly. Two thirds of older people use OTC and two thirds of OTC use is analgesics; arthritis pain accounts for ~75% of analgesic use. These analgesics include aspirin, nonsteroidal anti-inflammatory drugs, and acetaminophen products. Acetaminophen specifically interacts with alcohol and can form a dangerous drug-drug interaction. Acetaminophen is found in many OTC and prescription combination agents and, therefore, can easily be ingested in toxic doses. Older patients are also taking significant amounts of prescription drugs. These prescribed drugs can interact with the OTC agents. Special caution must be exercised because many drugs are now available both OTC and by prescription. This creates the potential for error as a patient may be getting excessive doses of a class of drugs by combining OTC drugs with prescribed medications.
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