Learning Objectives
By the end of this section, you will be able to:
- Discuss risks, screening, and stigma related to alcohol use in older adults
- Outline the clinical management of an older adult with alcohol use problems
- Summarize aftercare for older adults in alcohol use recovery
Older adults are likely to be living with chronic health problems, using prescription and nonprescription medications and remedies. In addition, older adults generally have a lower physical tolerance for alcohol. These factors put older adults at risk for falls, accidents, injuries, drug interactions, and medical complications (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). While many sources caution “limited” alcohol consumption for older adults, a safe intake level may be difficult to determine.
Alcohol Use in Older Adults
The Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) reports that alcohol is the most used and misused substance among older adults, and more than 10 percent engage in binge drinking. Friends and family may overlook an older adult’s alcohol use, and alcohol consumption may be socially accepted (National Institute on Aging, 2022). Tolerance for alcohol and the cumulative effects of drinking change over the lifespan, however (National Institute on Aging, 2022).
Effects and Risks for Older Adults in Relation to Alcohol Abuse
As stated, there are effects of using alcohol that are unique to older adults. As people age, the body has a lower tolerance for alcohol, leading to a faster feeling of the effects of alcohol. This can create higher risks that the older adult can fall, have a car accident, or become injured.
Alcohol consumption can also worsen many health conditions. With diabetes, the liver stops releasing glucose while processing alcohol, which can drop blood glucose quickly. This causes hypoglycemia and, with the effects of the alcohol, it is easy to miss the symptoms of hypoglycemia. Severe hypoglycemia can lead to seizures, coma, and death. With hypertension, drinking too much alcohol can increase blood pressure and, with regular overuse of alcohol, can lead to uncontrolled hypertension and the associated risks. Chronic heavy alcohol use increases the risk for osteoporosis by decreasing bone density and weakening bones. Alcohol worsens memory issues and, in some cases, with long-term use, can cause dementia. Given that alcohol is a depressant, it will naturally contribute to mood disorders. All of this is on top of the long-term effects that chronic use of alcohol has on people of all ages, such as liver problems.
Mixing alcohol and prescriptions and even over-the-counter medications can be very dangerous. Some frequently used drugs that can cause serious alcohol interactions include, but are not limited to the following (National Institute on Alcohol Abuse and Alcoholism, 2019):
- nonsteroidal anti-inflammatory drugs (NSAIDs), which can increase risk of strokes, ulcers, and stomach bleeding
- blood-thinning medications, which can cause bleeding from minor injury, stomach or GI bleeding, and bruising
- sleep medications, which can cause impaired breathing, drowsiness, lack of motor control, and falls
- acetaminophen (Tylenol; also can be an ingredient in over-the-counter products and some prescription medications) combined with alcohol is one of the most common causes of major liver damage
- over-the-counter antihistamines, which may cause increased sleepiness and falls
- herbal treatments may have effects with alcohol, such as drowsiness, blood pressure changes, or liver damage
Screening for Older Adults Who Abuse Alcohol
All older persons should be screened for alcohol, tobacco, prescription drug, and illicit drug use at least once a year, according to the consensus panel’s recommendations from the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020). It is important to start with a complete history of substance use. Screening can result in better health and earlier treatment. There are a variety of screening tools available, but one, the Short Michigan Alcoholism Screening Test–Geriatric Version (SMAST-G), is specific to older adults.
Link to Learning
This presentation describes substance use disorder and addictions among older adults in health centers. The adapted SMAST-G is shown as well as how to generally screen older adults and provide brief interventions.
Stigma and Ageism
In the United States, older adults abusing alcohol is underestimated, underreported, misdiagnosed, and untreated. Many factors contribute to this, such as mistaking symptoms for other issues, a lack of education, denial, ageism, myths, stigma, and scant study and data. Stigma is a negative view that society holds on a specific group of people or on a behavior that a group exhibits. Discrimination of older adults due to stereotypes that are negative and inaccurate is considered ageism.
In the case of alcohol use disorder (AUD), older adults face ageism and stigma from all levels of society, including health-care professionals. Glazier and Ko (2023) write that nurses and medical providers may interact with older adults differently than with younger clients, listen less, and attribute sensory impairments to cognitive decline. Providers may order less diagnostic testing and may minimize some complaints as due to older age. According to Glazier and Ko (2023), geriatricians may be more effective as primary care providers for older adults.
Clinical Management for Alcohol Abuse in Older Adults
The treatment of AUD in older adults should be very closely monitored by a medical provider. It has been found that brief interventions for alcohol misuse can help with AUD and risk reduction. Brief interventions can be the starting point for many before moving into more intensive treatment. The focus is on helping the client to abstain or reduce their alcohol intake to decrease their health-related risks. Brief intervention starts with screening and a discussion of their alcohol use and determination of heavy use versus AUD. If AUD is determined, assess readiness to change and discuss reduction of intake and/or referral to treatment. If a client needs detoxification, the decision should be made of outpatient versus inpatient. Given medical comorbidities, outpatient detoxification is not common.
Withdrawal from Alcohol for Older Adults
Alcohol withdrawal is characterized by two or more of the following symptoms:
- autonomic hyperactivity
- increased tremor
- sleeplessness
- nausea or vomiting
- transitory visual, tactile, or auditory hallucinations or illusions
- psychomotor agitation
- anxiety
- grand mal seizures
Although only around 5 percent of drinkers experience delirium or seizures during withdrawal, older adults with co-occurring medical issues and limited physiologic reserve require monitoring while undergoing detoxification. In a study of alcohol withdrawal among hospitalized clients, the older clients had a higher risk of delirium, falls, and reliance on others to perform everyday tasks (Joshi et al., 2021). Older adults may experience protracted confusion, which could lengthen their hospital stay and increase their chance of being sent to an extended care facility after discharge. Hospitalization is frequently advised for older clients with AUD undergoing detox for close monitoring.
Hospital or Home Care for Older Adults with Alcohol Abuse Issues
As in the preceding discussion, the decision to treat the older adult in inpatient treatment or with outpatient treatment is complex. Given the risks of outpatient detoxification, inpatient care may be more advantageous for this age group. The risks of withdrawal are high, and the medications used to manage the withdrawal have their own risks when used in older adults. Figure 24.4 shows the treatment algorithm for alcohol use in older adults.
Pharmacology
The cornerstone of pharmacologic therapy of alcohol withdrawal is the use of benzodiazepines; these can be given either regularly or as symptoms arise. Currently, there are no specific guidelines for managing withdrawal with benzodiazepines in older adults. When considering risk versus benefit, the benefit of using benzodiazepines may outweigh the risks. The risks of withdrawal with seizures and death are greater than the risks of acute delirium due to the use of benzodiazepines. Acute delirium is a common withdrawal symptom even without the use of benzodiazepines. Supplementing with thiamine and other vitamins, addressing electrolyte imbalances, and receiving general supportive care are all examples of concurrent treatment during detoxification. There are several medications available for treatment of AUD; some are used clinically but are not approved by the FDA for that use.
- Acamprosate (approved by the FDA) is used for maintenance of abstinence from alcohol in those who have completed detoxification and are currently abstinent. It promotes balance of neurotransmitters and should not be used in those with reduced kidney function.
- Disulfiram causes an unpleasant reaction when alcohol is consumed and is appropriate for highly motivated clients who have completed detoxification. This drug should not be taken within twelve hours of alcohol consumption in any form (mouthwash, cough syrups), and should not be used by individuals with heart disease or cardiovascular disease, risk of liver toxicity, or those with high levels of impulsivity or suicide risk.
- Naltrexone reduces alcohol cravings and can reduce the number of drinks that a daily drinker consumes. It should not be used in those with liver dysfunction.
- Gabapentin is not FDA approved for AUD, but it may still be helpful, used off-label, for mild withdrawal. As an anticonvulsant, gabapentin reduces central nervous system excitation. It should not be used in those with kidney disease, and it increases risk of falls.
- Topiramate is not approved for AUD, but it may be helpful in reducing cravings. Extended release should not be used in those with recent alcohol use. There is also a risk of weight loss and short-term cognitive impairment, so it should not be a first-line choice in older adults.
Aftercare for Older Adults in Recovery
After initiating treatment, it is important to implement continual follow-up to monitor clients during acute and chronic recovery and to prevent relapse. Provide continuous education through all levels of treatment and recovery by providing training on how to manage stress, triggers, and cravings. Education and skills training should focus on three foundational skills: coping skills, social skills, and communication skills.
An advocate and support system can make the difference between success and failure. Older adults encounter a lot of loss, so grief is frequent and can lead to relapse. Moreover, the physical, social, and health changes that come with aging can be stressful, so those without a strong support system or with poor coping mechanisms will always be at high risk for relapse.
Twelve-Step Program for Older Adults
Twelve-step programs can be very beneficial for older adults. These programs address both loneliness and addiction. One of the tenets of twelve-step programs is being of service and accepting help. This is vital to older adults who may not have a social network or support system. The program connects people in order to support each other and therefore provides socialization that can help prevent relapse. The segregation between young and old that is seen in the general community is not present in twelve-step groups. Older adults receive respect and younger members value their life experience (Gibson, 2021). Older adults are encouraged to share how they managed life’s challenges and how they persevered to make it through. The groups foster acceptance.
Family Support, Referrals for Older Adults with Alcohol Abuse Issues
Family support for older adults with AUD can help both the family and the client. Families who participate in therapy with their loved one benefit as much as the person with AUD. There are also mutual help groups like Al-Anon that provide support for children, spouses, and other family members of people with alcohol addiction. Family members must be careful to avoid a situation of codependency where they are potentiating the problem by enabling the addicted person to continue their self-destructive behavior. Support groups can be very helpful in pointing out these behaviors and helping the enabler to alter their behaviors. A primary care provider can refer older adults with AUD or clients can self-refer. Nurses can provide support by advocacy and education. An individual’s health insurance company is a good place to start to find out what the benefit coverage is as well as if there are local in-network treatment options. There are also multiple online resources for finding and accessing treatment:
- Substance Abuse and Mental Health Services Administration: Find Help
- National Institute on Alcohol Abuse and Alcoholism (NIAAA): Alcohol Treatment Navigator
- Medicare Rights Medicare Interactive: Treatment for Alcoholism and Substance Use Disorder
- Center for Medicare Advocacy: Medicare Coverage of Mental Health and Substance Abuse Services
- Alcoholics Anonymous: A.A. for the Older Alcoholic—Never Too Late
- Al-Anon Family Groups: Who Are Al-Alanon Members?