Mohammed T. Abou-Saleh

ALCOHOL ABUSE 603elderly alcoholic to clinical attention. Laboratory results ofmacrocytosis, elevated mean corpuscular volume, and increasedliver enzyme levels, especially g-glutamyl transpeptidase, maycorrelate with alcohol abuse in the elderly. Blood alcohol levels,and urine or breath tests for alcohol, may be used to confirmalcohol intoxication.Assessment of tolerance, withdrawal, loss of control, socialdecline and mental and physical decline are useful clinicalparameters to recognize and diagnose alcohol addiction. Severalscreening instruments have been devised to help cliniciansrecognize alcoholism. These scales typically assess the quantityand frequency of drinking, social and legal problems resultingfrom alcohol abuse, health problems related to excessive alcoholuse, symptoms of addictive drinking, and/or self-recognition ofalcohol-related problems 57–59 . Many of these instruments havebeen validated for younger populations, but not specifically forthe elderly. The validity of the CAGE screen for alcoholism in theelderly has been examined empirically 60 . ‘‘CAGE’’ is a mnemonicfor the questions: Have you ever felt a need to Cut down ondrinking? Have you ever felt Annoyed by others inquiring aboutyour drinking? Have you ever felt Guilty about drinking? Do youever use alcohol for an Eye-opener? If two or more of thesequestions are answered positively, a need for more extensiveevaluation for alcohol abuse is indicated. Another more detailedscreen is the Michigan Alcoholism Screening Test–GeriatricVersion (MAST-G) 61 . In addition, the original MAST, scoredwith weighted (MAST) and unit scoring (UMAST), and twoshorter versions, the Brief MAST (BMAST) and Short MAST(SMAST), have been tested in the elderly 62 . Researchers foundthat the MAST and UMAST gave excellent sensitivity andspecificity for alcohol abuse in the study population of 52hospitalized elderly male alcoholics, matched with 33 nonalcoholiccontrols. The MAST and UMAST may be usefulscreening instruments to help recognize alcoholism in the elderly.THE TREATMENT OF ALCOHOL ABUSE IN THEELDERLYOnce the diagnosis of alcohol abuse is confirmed, the first step intreatment is a thorough evaluation to identify any other coexistingmedical or psychiatric problems. Treatment for these problemsmust be initiated at the same time as the patient is detoxified.Providing adequate nutrition and hydration is especially importantin the elderly alcoholic, due to increased nutritional problemsand impaired thirst mechanisms in the elderly. Benzodiazepinesare generally avoided in the detoxification of elderly alcoholics,due to their potential for causing delirium. However, if significantwithdrawal symptoms occur, benzodiazepines should be administered56,63,64 . Elderly patients may experience more severewithdrawals from alcohol and require higher doses of benzodiazepinesthan younger patients. In general, detoxification withbenzodiazepines with a short half-life is recommended in theelderly. However, these medications may not provide adequateanticonvulsant effect and the use of longer-acting benzodiazepinesmay be necessary 56 .Once the elderly alcoholic patient is detoxified, adequate relapseprevention and rehabilitative treatment is crucial for the patient tomaintain sobriety. The elderly alcoholic must first come to anacceptance of his/her alcohol abuse problem. Family members orothers who are close to the patient may be able to help the patientbreak through the denial regarding alcohol abuse seen in manyalcohol abusers. Family members may also be instrumental inmotivating the patient to stop drinking. Patient and familyeducation about the effects of alcohol must be provided, and theneed to abstain from alcohol must be stressed. A behavioral andself-management treatment module has resulted in marked successin treating alcohol use problems in the elderly 65 . This moduleeducates the elderly alcoholic about drinking behavior, theacquisition of self-management skills, and the re-establishmentof social networks.The elderly alcoholic patient’s recovery and rehabilitation is anongoing process. The patient needs to learn to readjust to lifewithout alcohol. The patient’s family and close relatives andfriends can help him/her in this endeavor by supporting sobrietyin the patient and incorporating the non-drinking patient intotheir lives without the presence of alcohol. Family members mayhave been ‘‘enabling’’ the patient to drink, and they need to bemade aware of these patterns of behavior and change themthrough family education and family therapy. If the elderlyalcohol abuser is a parent and the enablers are his children, therole reversal that is inherent in the children’s setting limits on theirparents may make this task especially difficult. Group therapymay help the patient adjust to a non-alcoholic lifestyle. In thissetting, he/she can develop non-alcohol-related social skills andlearn to bond with others in safe surroundings, free of the contextof alcohol. If elderly alcoholics can be treated in age-specificgroups, they may remain in treatment significantly longer and bemore likely to complete treatment than those treated in mixed-agegroups 65 . Involvement in Alcoholics Anonymous with people withwhom the patient feels comfortable and can consider his/her peersis important, especially if he/she has no close relatives or friends.The relationships with others that can be formed in these settingscan provide a replacement for the alcohol to which the patient wasbonded previously. Family involvement with the patient inAlcoholics Anonymous and in other affiliated groups such asAlanon, Alateen or Alatot is also important, as alcoholismadversely affects family members who also need support,education and treatment.Use of alcohol-deterrent medications, such as naltrexone ordisulfiram, may serve as adjunctive treatments. These drugs mayhelp motivated alcohol abusers to reduce the quantity of alcoholused or the number of drinking days. However, these medicationsgenerally are not effective unless prescribed and monitoredas part of an overall, multidisciplinary treatment and relapseprevention plan. Opioid receptor antagonists, such as naltrexoneor related compounds, may be less toxic than disulfiram in elderlypatients 66–68 .The cultural aspects of alcohol abuse intervention are alsoworthy of consideration. The above recommendations fortreatment are a description of treatment conceptualizations inthe USA. These interventions may need to be modified for othercountries. In instituting any type of treatment or intervention, it isimportant to consider the context of the problem being addressedand the context into which the treatment or intervention will beinstituted. The consumption of alcohol can take on a variety ofcultural meanings. To some groups, ethanol is a food or isassociated with religious rituals. For others, it is a means to relaxand calm one’s nerves. For still others, alcohol is considered to bea sinful intoxicant used by those of weak moral fiber. To intervenemost effectively with an aged person for whom alcohol consumptionhas become a problem, it is important to understand whatmeaning the use of the alcohol has for him as an individual, afamily member and as part of the greater society, including hiscultural group. The contextual meaning of the change in alcoholuse must likewise be considered. To understand these contextualmeanings most effectively, the clinician must be aware of what his/her inherent assumptions may be about these contextual meaningsand try not to confound with his/her own biases his/herunderstanding of the situation. Members of the patient’scontextual and cultural groups may be very helpful in providingmeaningful insights into these understandings. Once these culturalfactors are understood, interventions to reduce the problematicalcohol consumption to the desired outcome of abstinence or