Alcohol Misuse in Late Life: Treatment Issues

Presenters at this symposium, held at the American Association for Geriatric Psychiatry’s 2003 Annual Meeting, compared the broad array of treatment choices for late-life addiction and described the effects of alcohol consumption on late-life chronic disorders.

Models of Care for At-Risk Drinking in Older Primary Care Patients

Frederick C. Blow, PhD, of the University of Michigan and the Veterans Affairs Medical Center, both in Ann Arbor, described the use of brief motivational interventions in older individuals who exhibited alcohol dependence or at-risk drinking and reviewed functional and symptomatic outcomes of two models of care in such individuals.

Brief Motivational Interventions for Substance Abuse Disorders
Brief interventions are focused, time-limited sessions that target a specific behavior, such as alcohol misuse. The goals of these interventions are not to replace prevention efforts or formal specialized treatments, but rather to reduce alcohol consumption and potentially facilitate treatment initiation. This is important in older individuals, who are particularly sensitive to the stigma of alcohol misuse and who generally prefer motivational enhancement rather than specialty care programs.

Two major trials conducted at the University of Wisconsin and at the University of Michigan have found that approximately 38% of older individuals with drinking problems reduced their alcohol consumption to below recommended limits or stopped drinking as a result of one 20-minute advice session. Furthermore, talking to older individuals about their drinking behavior appeared to reduce alcohol-related visits to the emergency department over a 12-month period, and thereby might help to reduce healthcare utilization.

The PRISMe Study
The PRISMe Study, a large randomized treatment trial, examined the effects of specialty care programs and brief motivational interventions on late-life alcohol use, including both at-risk drinking and alcohol dependence. Primary care patients were systematically screened to identify elderly individuals with at-risk drinking, depression, or anxiety. Enrolled subjects subsequently were randomized to one of two treatment arms: an existing behavioral health specialty care system (referral arm) or a collaborative care program (collaborative arm) that used brief motivational interventions
integrated within primary care.

Methods Used in PRISMe Study
The short Michigan Alcoholism Screening Test, geriatric version (MAS-G) was used to assess the average quantity and frequency of alcohol consumption. Enrolled subjects comprised men who drank > 14 standard drinks/week, women who had > 12 standard drinks/ week, and binge drinkers (> 4 standard drinks on a given day).

The referral arm of the study included direct referral to predominantly geriatric psychiatry programs. The collaborative care arm included three workbook-driven brief interventions (mean time 20–22 minutes) during the first 3 months, with enhancements (transportation, reduced costs to patients) to motivate the individuals to reduce or stop drinking.

Results of PRISMe Study
Of the older individuals who screened positive for alcohol misuse (> 1 standard drink/day), Caucasians comprised the highest proportion among ethnic groups, and men outnumbered women 4 to 1. This ratio between men and women was lower among African Americans. More young-old (aged 65–74 years) subjects were heavy drinkers than were old-old (> 75 years) individuals. Of the at-risk drinkers, most were Caucasian men aged 65–74 years, and many were veterans. Moreover, 25% of at-risk individuals reported a history of heavy drinking and 14% had history of binge drinking.
Not surprisingly, most of these older adults believed they did not drink too much, with < 50% recognizing that they needed to reduce their drinking. Dr. Blow underscored the need to educate older individuals on the negative health consequences of even small increases in alcohol consumption.

The PRISMe findings indicate that screening for alcohol misuse in older primary care patients can identify hard-to-find individuals with drinking problems. Moreover, at-risk drinkers were 2.5 times more likely to attend integrated care than referral care programs. “Older adults are very reluctant to go to specialty care for their drinking problems,” explained Dr. Blow, and this has implications for the design of treatment approaches.

Treatment of Alcohol Dependence in Specialized Addiction Settings

Valerie J. Slaymaker, PhD, Director of the Butler Center for Research at Hazelden, Center City, Minnesota, described a study comparing middle-aged subjects (50–64 years) and older adults (> 65 years) in terms of treatment of alcohol dependence, mental health, and medical functioning. Also examined were gender differences, treatment completion rates, and outcomes at 1 month after discharge.

The Hazelden Model of Treatment
The study involved a retrospective analysis of individuals aged > 50 years who were admitted to centers providing specialized inpatient rehabilitation treatments, especially for the elderly. Treatment was based on the Hazelden model of care, which incorporates the Twelve-Step philosophy of Alcoholics Anonymous (AA). Treatment was provided by an interdisciplinary team of licensed professionals, including counselors, psychiatrists, and wellness specialists. The Substance Abuse Inventory assessed substance use variables, and the SF-12 was used to measure mental health and medical functioning.

Demographics and Use Variables
Most of the individuals in the middle-aged and older adult groups were Caucasian with some form of college education. These subjects are important to study, because they tend to exhibit more at-risk drinking, stated Dr. Slaymaker.

No differences were noted between the two groups in gender distribution, the number of days of alcohol use in the 90 days before admission, or in the number of days of heavy drinking. They also were similar in the number of previous inpatient treatments for substance abuse. The middle-aged individuals were more likely to have a drug dependency problem (P < 0.01) and were more likely to have attended outpatient treatments for drug dependency (P < 0.001).

Psychiatric and Medical Functioning
The middle-aged and older groups did not differ in terms of suicide attempts, depression, or anxiety at admission. However, the middle-aged group was more likely (P < 0.01) to have concerns regarding mental and emotional health, although similar numbers in both groups were taking psychotropic medications. The older adults had poorer medical functioning (P < 0.001), but both groups had similar incidences of chronic illness. Significantly (P < 0.01) more of the middle-aged individuals were smokers.

Outcomes at 1 Month and Gender Comparisons
One-month outcomes for abstinence were ~ 85% in both groups, after adjustment for SF-12 scores, psychotropic medication use, and prior outpatient treatment for substance abuse (Figure 1). Although middle-aged and older adults were equally likely to be attending AA meetings, the middle-aged individuals were more likely to have obtained an AA sponsor at 1 month (P < 0.05), be undergoing psychotherapy (P < 0.05), and be taking psychotropic medications
(P < 0.01). More (P < 0.01) middle-aged individuals stated that their quality of life had improved at 1 month.

In the older group, no gender differences were noted in number of days of (heavy) alcohol use, but women were more likely (P < 0.05) to use benzodiazepines, have attended outpatient mental health therapy (P < 0.01), and have attempted suicide (P < 0.05). The only gender difference in outcomes was a higher rate of smoking among women (P < 0.01).

Prospective Study of One-Year Outcomes
A second prospective study was conducted by Hazelden to examine 1-year outcomes among older adults. Adults
(N = 67) entering the older adult unit at Hazelden’s Florida facility completed the Addiction Severity Index (ASI) at baseline and again at 6 and 12 months after discharge. Continuous abstinence was maintained by 71% of patients at the 6-month follow-up evaluation and by 60% of patients at the 12-month evaluation. Improvements were noted in alcohol, drug, family/social, quality of life, and psychiatric ASI scores, and most of the participants attended AA meetings.

Conclusions from Hazelden and Other Studies
Older adults respond as well as middle-aged individuals to alcohol treatment, and might have better long-term outcomes. Although older adults are not as engaged in mental health therapy, they do attend AA meetings, maintain abstinence, and exhibit significant improvements in their quality of life and social functioning for up to 12 months.

The Treatment of Coexisting Alcohol Dependence and Other Behavioral Problems in Older Populations

David W. Oslin, MD, of the Section of Geriatric Psychiatry at the Center for Studies on Addiction, University of Pennsylvania in Philadelphia, and the Philadelphia Veterans Affairs Medical Center, described the effects of alcohol consumption on the treatment of late-life depression and dementia and discussed treatment strategies for these comorbid conditions.

Coexisting Alcohol Dependence and Depression: Implications for Treatment
The coexistence of alcohol dependence and depression, which involves factors such as social support and genetics (Figure 1), can severely impair functioning in older individuals (Blow, et al. Hospital Community Psychiatr. 1992;43:990). Moreover, the prevalence of major depression among alcohol-dependent subjects increases with age (Blow, et al, 1992).

Treatment of this comorbidity generally is sequenced: the alcohol dependence is treated first and depression is treated only after abstinence is achieved. However, Dr. Oslin believes that distinguishing between substance-induced and primary depression is often not possible; therefore, treatment strategies should focus simultaneously on both problems.

Concurrent Treatment of Depression and Alcohol Dependence
Oslin et al. have studied such a concurrent approach in individuals aged > 55 years with depressive syndrome and coexisting alcohol dependence (Oslin. Unpublished data, 2003). The subjects participated in 10 weekly sessions of individual psychosocial supportive therapy that focused on both alcohol misuse and depression. All of the subjects received sertraline 100 mg and subsequently were randomly assigned to receive either naltrexone 50 mg or placebo. Naltrexone is not an abstinence-supporting drug, but prevents relapsing or return to heavy drinking in some people. Outcomes were recorded at 3 months.

Effects of Alcohol Consumption on Depression
As expected for older adults, > 80% of the participants completed the study. Approximately 50% had no relapses of heavy drinking, and depression remitted in approximately 50% of the subjects. However, no differences in effects were noted between placebo and naltrexone in terms of overall improvement. Thus, “just preventing relapses is not enough to treat comorbid depression,” Dr. Oslin stated. He believes an abstinence-supporting drug would be more appropriate than naltrexone.

The study results demonstrated the robust negative effect of alcohol consumption on depression response in older subjects: even one episode of heavy drinking (4–5 drinks in one day) was associated with significantly lower rates of remission of depression (P = 0.001) and of completion of the trial (P = 0.02). Only 38% of subjects were well at study end (i.e., no depression and no alcohol misuse), while 30% remained depressed and relapsed, despite weekly psychotherapy, antidepressant medication, and possibly naltrexone treatment. The remaining subjects were either only depressed (16%) or only relapsed (16%). Thus, treatment of alcoholism is necessary but is not always sufficient to achieve remission of depression. “Many options are available and should be used for the treatment of alcoholism and depression,” recommended Dr. Oslin.

Role of Abstinence in Treatment of Coexisting Alcohol Dependence and Depression
In another trial involving light (0–1 drink/week), moderate (2–6 drinks/ week), and heavy (> 7 drinks/week) older drinkers receiving inpatient treatment for major depression, enforced abstinence resulted in substantial improvement in mental health among the moderate drinkers (Oslin, et al. Am J Geriatr Psychiatr. 2000;8(3):215). This effect was even more pronounced among the heavy drinkers. Moreover, nearly all of the patients remained abstinent after their hospitalization. These findings indicate that abstinence should be encouraged even among light and moderate drinkers, suggested Dr. Oslin. Similarly, abstinence among patients with alcohol-related dementia also has been associated with stabilization of their cognitive and functional impairment (P = 0.006) (Oslin, et al. Am J Geriatr Psychiatr. 2003; in press). However, while abstinence is often desired, it is not the only goal of treatment. Dr. Oslin urged healthcare providers to treat both coexisting conditions simultaneously with a multimodal approach.

The Need for Treatment Access: Policy Implications for Treating Late-Life Addictions

Among older adults with alcohol problems, several factors affect access to treatment, stated Brenda M. Booth, PhD, of the University of Arkansas for Medical Sciences in Little Rock. These factors include affordability (cost of health insurance), accessibility (travel time), availability of other services, and acceptability by the patient that treatment is necessary (overcoming stigma of alcohol misuse). In addition, the services provided should accommodate the needs of specific patients (e.g., women in veterans affairs centers or dually diagnosed patients).

Factors Affecting Treatment Entry Among Older Adults
Dr. Booth noted that factors such as alcohol dependence, psychiatric comorbidity, and male gender have been shown to be accurate predictors of treatment entry. In addition, transportation can influence access to treatment, because older individuals may not be able to drive themselves to outpatient programs. Moreover, few specialty programs designed for older adults are available, and many older individuals do not recognize or accept that they may have an alcohol problem. This denial reduces their motivation to enter treatment, Dr. Booth explained.

The situation is further compounded by the community and personal stigma surrounding alcohol misuse among older persons. Often neither older patients nor their healthcare providers will want to discuss substance abuse issues. Thus, older adults are not aware of or are reluctant to take part in intervention programs. Dr. Booth believes that family support in such situations can help to encourage treatment entry. Dr. Booth went on to describe a community study in which at-risk older adults were able to achieve safe drinking levels after receiving brief interventions (interviews).

The Rural Alcohol Study
In a community sample of rural and urban subjects, at-risk drinking was defined according to DSM-IV criteria at a screening interview. Subsequently, four 6-monthly interviews were conducted. Individuals who sought treatment for alcohol misuse were not included in the analysis.

Among older subjects, the rates of at-risk drinking declined over the period of the four interviews. In addition, older adults were able to achieve safe drinking levels over this period. Thus, older age was associated with lower levels of DSM-IV alcohol diagnosis over time. However, Dr. Booth cautioned, this study included few older adults, and some at-risk drinkers reduced their alcohol consumption without intervention. The latter finding raises the possibility that the study itself might have served as an intervention in some cases.

Noting that predictors of continuous levels of problematic drinking included comorbid psychiatric disorders, illegal drug use, and social consequences of drinking, Dr. Booth speculated that these factors could serve as triggers for more immediate intervention—for example, at an elder community center.

Reaching At-Risk Drinkers in the Population
The current infrastructure for treating older adults with alcohol problems is inadequate, Dr. Booth believes. To increase treatment access for older patients, an array of programs should be available at locations with large geriatric populations, such as primary care offices, retirement homes, and community centers. Brief or potentially extended interventions and educational programs, which may be conducted at such facilities, can help to reduce the stigma and misinformation surrounding alcohol consumption among older adults, Dr. Booth concluded.