Relapse Prevention and Maintaining Abstinence in Older Adults with
Alcohol Use Disorders
Christopher Barrick, Ph.D. and Gerard J. Connors, Ph.D.
Research
Institute on Addictions
University at Buffalo, The State University of
New York
Abstracted from Drugs & Aging, 19, 583-594, 2003.
In this review of the literature, researchers considered
common assumptions about older adults and alcohol use. They found that
alcohol abuse by
seniors may be underestimated, although treatments appear equally effective
across
age groups.
Findings
- Alcohol abuse by older adults is under-diagnosed
for several possible reasons. The effects of alcohol use among older
adults tend
to be less clearly
visible
than among other age groups. Older adults are less likely to seek
treatment. There may be a lack of previous alcohol abuse by the patient,
since approximately
one-third of older adults with alcohol use problems first develop
their drinking problem after the age of 60.
- Under-diagnosis of problem
drinking in older adults is unfortunate because the risks associated
with alcohol abuse and relapse for the elderly
are significant. These risks include anxiety, interpersonal conflict, depression,
loneliness,
loss and/or social isolation.
- Treatments such as cognitive-behavioral
therapy, group and family therapies, and self-help groups are effective
and offer much-needed social
support. Medications such as naltrexone and acamprosate also work well and
their adverse effects for most are benign.
Alcohol Use Disorders Among Older Adults
- Definitions. Alcohol abuse is defined as continued drinking despite adverse life
effects. With alcohol dependence, a person not only experiences significant
life effects but also cognitive, behavioral, and physical
symptoms. Alcohol dependence symptoms include craving or a compulsion
to drink; the inability
to limit one’s drinking; withdrawal symptoms like
nausea, shaking, anxiety; and the need for increasing
amounts of
alcohol in order to feel
its effects.
- Prevalence. Recent work suggests that the prevalence
rates of drinking among older adults have been underestimated. Forty-nine
percent
of individuals aged 60 years or older in the U.S. consume alcohol and heavy
drinking occurs
in 1.5% of this age group. There have been reports suggesting
an
increase in the proportion of older adult problem drinkers when people
first enter
their retirement years as well as when they are faced
with separation or divorce.
- Onset. Older problem drinkers aged 60 years or
greater are divided into early- and late-onset categories. Late-onset
drinkers
are
usually defined as older
adults whose problems with alcohol begin in their 60s
or following retirement. This group comprises up to one-third of older adult
alcohol
abusers
and
appears more frequently in females than males. Late-onset alcohol
abuse is often associated with difficulties in coping with a broad array
of age-related changes and stressors, and has a better prognosis following
treatment,
relative
to earlier-onset drinking problems.
- Clinicians should
gather a drinking history and screen for misuse. Retirement and the
stressors of aging should be monitored and addressed.
Relapse
- A return to drinking after a period of abstinence
may occur. There are several age-specific issues relevant to relapse
in the elderly.
They include depression,
loneliness, loss, and broader social isolation. In
addition, cognitive impairments typically associated with aging,
whether resulting
from dementia,
depression,
stroke or other conditions, need to be assessed for
their impact on understanding relapse.
- Patients should be educated
about relapse. Counselors and patients should collaborate in identifying
high-risk situations for
relapse and then work together on identifying means of coping with these situations
without drinking.
High-risk situations for older adults more often
involve personal
issues rather than indirect social pressure.
Maintaining Abstinence
Longer periods of abstinence are associated with strategies
such as recalling the benefits of sobriety as well as
the difficulties of drinking-related
problems, avoiding risky people and places, and attending
self-help meetings
like AA. Other concepts that might be helpful with
older adults include a supportive, non-confrontational approach;
developing skills to cope with negative emotions; re-building a support
network; and offering appropriate medical and social linkages.
Overview
of Treatment Approaches and Self-help Groups
- Cognitive-behavioral treatment (CBT), which
focuses on coping with high-risk situations and enhancing coping
skills, has
proven
to help prevent relapse. CBT is suited to helping older adults with stressful
events
such as
loss
of family and friends, retirement, and physical
decline.
- Group and family therapies help counteract loneliness
and offer peer support. Older adults report preferring senior-focused
groups.
- Organizations such as AA, Rational Recovery,
and Self-Management And Recovery Training (SMART), have seen increasing
numbers
of older members and senior-focused
groups. These groups appear to be very important
to relapse prevention.
Pharmacological Adjuncts
- Deterrent medications alter the body’s response to alcohol,
making ingestion of even small amounts of alcohol unpleasant.
Disulfiram is the most widely used medication. When consumed
prior to
ingesting
alcohol,
drinkers experience adverse physical reactions
including nausea, vomiting, and facial
flushing ranging from 30 minutes to several
hours. Although 50 years of use and case reports suggest benefits,
research also
suggests that the
drug is
most useful when clients strictly comply with
the treatment protocol.
There is some limitation on prescribing disulfiram
to older adults with cardiovascular
disease.
- Naltrexone, a popular opioid receptor
antagonist, blocks the alcohol-induced release of dopamine. The primary
effect of
naltrexone appears to be its ability to reduce the patient’s emotional
response to alcohol consumption. Therefore, it may deter
patients who
sample alcohol from progressing
to heavy drinking or relapse and decrease alcohol
intake over time. The only
limitation
is that it may be inappropriate for patients
with painful conditions that require opiates for satisfactory
relief.
- Acamprosate, although not yet approved for use
in the U.S., has been shown to help patients achieve higher abstinence
rates and for those who resume drinking, significantly longer times to relapse.
It has
a benign
profile
of side effects and is not substantially
metabolized in the liver; therefore
patients with liver disease can use it.
- Few
studies have directly examined the effects of medicines as treatment
adjuncts to alcohol relapse-prevention programs
for older adults. Research generally supports the concept of using medications
as an
adjunct to
the
psychosocial therapy of alcohol abuse and
alcoholism. Additional clinical trials are needed but both naltrexone and acamprosate
appear to be attractive medications for potential use in older populations.
Strict
compliance
with
the treatment protocol is critical to their
effectiveness.
Clinical Implications
- Given current shifts in demographics
(e.g., aging trends and changing attitudes towards alcohol use),
the prevalence
of alcohol abuse in older adults is
expected to rise.
- Clinicians should carefully
screen older adult patients for alcohol abuse, and attend to issues
of isolation, loneliness,
and the stressors of aging.
- When identified and treated, older adults
with alcohol problems appear to benefit from psychological and pharmacological
management, thereby minimizing risk for relapse.
References
Bucholz, K., Sheline, Y., & Helzer, J. (1995). The epidemiology
of alcohol use, problems, and dependence in elders: A review. In T.
Beresford & E.
Gomberg (Eds.), Alcohol and aging (pp.
19-41). New York, NY: Oxford University Press.
Giordano, J., & Beckham,
K. (1985). Alcohol use and abuse in old age: An examination
of
Type II alcoholism. Journal
of Gerontological
Social
Work, 9, 65-83.
Gomberg, E., & Zucker,
R. (1998). Substance use and abuse in old
age. In I. Nordhus, G. VandenBos, S. Berg, & P.
Fromholt (Eds.), Clinical geropsychology (pp. 189-204).
Washington,
DC: American
Psychological Association.
Johnson, L.
(1989). How to diagnose and treat chemical
dependency in the elderly.
Journal
of Gerontological
Nursing, 15, 22-26.
Kranzler, H. (2000).
Pharmacotherapy of alcoholism: Gaps in knowledge and opportunities
for research.
Alcohol and Alcoholism,
35, 537-547.
National Institute on Alcohol
Abuse and Alcoholism. (1997). Ninth special report
to the United
States Congress on
alcohol and health.
Washington,
DC: U.S. Government Printing Office.
Schonfeld,
L., Dupree, L., & Rohrer,
G. (1995). Age-related differences between
younger
and older
alcohol abusers. Journal of Clinical
Gerontology, 1, 219-227.
Preparation of this manuscript
was supported, in part, with funding
awarded as part of
a grant from
the National
Institute
on Alcohol
Abuse and Alcoholism
(NIAAA) to the Research Institute on
Addictions, University at Buffalo (AA11529).
|
