Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0109Alcohol Abuse in the ElderlyHelen H. Kyomen 1 and Benjamin Liptzin 21 McLean Hospital, Belmont, MA, and 2 Baystate Medical Center, Springfield, MA, USAAlcohol abuse in the elderly may be defined as the persistent andintended use of ethyl alcohol despite the problems caused by itsuse 1,2 . In the elderly, alcohol abuse usually presents clinically asself-neglect, falls, confusion, lability, depression, unusual behavior,injuries, diarrhea, malnutrition, myopathy, incontinence orhypothermia 3,4 . In fact, the elderly person with alcohol abuseproblems may be hospitalized for any one of these problems.During the course of the hospitalization, one may uncover signsof characteristic addictive use of ethyl alcohol, with: (a) tolerance;(b) withdrawal symptoms; (c) loss of control of use; (d) socialdecline; and (e) mental and physical decline 5 . Alcohol abuse in theelderly is an under-recognized problem that has become increasinglyimportant due to the growing numbers of elderly people 6–10 .Prevalence estimates of alcohol-related problems are in the range1–6% in community-dwelling elderly, 7–22% in medicallyhospitalized elderly, and 28–44% in elderly psychiatric inpatients 1,4 .In one study of older primary care outpatients, 15% of men and12% of women regularly drank in excess of limits recommendedby the National Institute of Alcohol Abuse and Alcoholism (>7drinks/week for women and >14 drinks/week for men) 11 .EFFECTS OF ALCOHOL IN THE ELDERLYOlder people are at greater risk and more vulnerable to the toxiceffects of alcohol for three main reasons:1. A smaller volume of alcohol is required to produce the sameeffects as in a younger person. The elderly have a decreasedvolume of distribution due to decreased muscle mass, a greaterproportion of fat and a smaller water compartment. These allresult in a higher blood alcohol level than in a younger adultfor the same amount of alcohol consumed 12–16 . This suggeststhat the elderly person’s brain, liver, cardiac and other organsystems are subjected to a greater toxic effect from a givenamount of alcohol. In a younger person, larger amounts ofalcohol consumption may be necessary before detrimentaleffects from alcohol abuse become grossly evident. An elderlyperson may reach this threshold for hazardous use of alcoholafter drinking a relatively small amount 17 .2. The general decrease in the capacity to withstand stress andmaintain homeostasis, as well as a higher risk for medicalillness and disability in elderly people, can magnify the effectsof alcohol abuse in the elderly.3. Some organ systems may be especially susceptible to alcohol inthe elderly. For example, the central nervous system appears tobe more sensitive to alcohol in the older person 18–21 , and bonefractures are much more frequent among elderly who usealcohol than in those who do not 22 .The interaction of these three main factors places the elderlyalcohol-using person at greater risk for multiple impairmentsresulting from the use of alcohol.There are many possible detrimental effects from alcohol abusein the elderly. Among them are the following:1. Driving ability can be adversely affected with the consumptionof minimal amounts of alcohol. Relatively small amounts ofalcohol can lead to confusion, visuospatial impairment,problem-solving deficits and motor impairment in theelderly 23–25 , which can inhibit the continuous attention andquick responses needed for driving. If the elderly person alsohas cognitive or sensory deficits, then the additional insultsfrom alcohol use may make driving considerably moredangerous 17,20 .2. Cognitive impairments suggesting dementia may be caused byalcohol abuse 26,27 . Although some cognitive impairment canresult from even social drinking, chronic alcohol consumptionhas been shown to cause marked cognitive deficits, withassociated cortical atrophy and ventricular dilatation on brainscan 19,28,29 . Some researchers have suggested that alcoholismcontributes to accelerated mental aging, but this is stillcontroversial 19,30 .3. Elderly alcoholics have a higher prevalence of alcohol-relatedmedical conditions than the elderly population at large. Suchconditions include alcoholic liver disease, alcoholic cardiomyopathy,hypertension, chronic obstructive pulmonarydisease, neurologic diseases (including cognitive brain syndromesand peripheral neuropathy), malnutrition, osteopenia,psoriasis, peptic ulcer disease and various cancers 22,31–36 .4. Alcohol use can adversely affect the elimination of some drugsand add to the toxicity of others. This places an elderly personwith medical illness or disability who is taking prescriptionmedication at great risk for having subtherapeutic or adverseeffects from the medication 37,38 . The magnitude of thisproblem is evident when one considers that the elderly receive25% of all drugs prescribed in the USA, while comprising onlyapproximately 12% of the population 6,39,40,41 .5. The depressant effects of alcohol on the central nervous systemmay mimic or contribute to depression in the elderly 42,43 . Someelderly with depressed mood may resort to drinking in order to‘‘self-medicate’’ themselves. This may alleviate the depressivesymptoms initially, but later lead to an increase in depression,anxiety, sleep disturbances and impotence 40,44 .6. Alcohol can contribute to malnutrition in the elderly.Malnutrition can result from the interaction of the followingfactors 45,46 :(a) Food intake can be hindered if the elderly alcoholicdevelops depressed mood, becomes apathetic and experiencesPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd