Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

18. Alcoholism and Substance Abuse in Older Adults 399There have been suggestions that people tend to drink less as they getolder, that alcoholism is a self-limiting disease, and that as people age, the alcoholproblems “burns out” (Drew, 1968). Those experiencing serious stresses ofaging may continue problematic drinking as a maladaptation to the stresses ofaging. With further study of the elderly alcoholic population, I noted a subgroupof early-onset alcoholics who had had alcoholism treatment when theywere younger and had experienced remissions, but relapsed as they got older.This group, also described by Carruth, Williams, Mysak, and Boudreau (1975),can be considered an early-onset group with late-onset relapse.DiagnosisPart of the resistance to developing programs for elderly alcoholics has been thedifficulties in making a diagnosis. There is often confusion regarding patientswith dementia, drug–drug interactions, greater denial by patients and family,and less acute medical problems associated with alcoholism. Graham (1986)noted that there are fewer social, legal, occupational, and interpersonal consequencesof alcoholism, because the elderly persons are often not working, livealone, and consume lesser quantities of alcohol, so that there is less alcoholdependence and withdrawal.In recent years, there have been advances in the diagnosis of alcohol problemsin the elderly population. A geriatric version of the Michigan AlcoholismScreening Test was developed (Blow et al., 1992). This 24-question screeninginstrument is reported to have good sensitivity and specificity. It can be usefulas a screening instrument in large populations, but it is cumbersome to use in aclinical interview.A useful and more practical tool, the CAGE Questionnaire (Ewing, 1984),has been found useful in diagnosing alcohol problems in general alcoholic populationsand also in the aged (Reid & Anderson, 1997; Rigler, 2000). A “yes”answer to any one of the four questions indicates a suspected alcohol problem;two “yes” responses are a strong indicator of an alcohol problem. I have usedthe CAGE (Zimberg, 1996) and have found it useful, with questions 1 and 3most commonly being answered positively among elderly alcoholics.Laboratory testing can assist in the diagnosis of alcohol problems in elderlypersons and includes liver function tests and elevated values of the mean corpuscularvolume (MCV) and mean corpuscular hemoglobin (MCH), which are partof the complete blood count (CBC). A newer test of the level of carbohydratedeficienttransferrin may prove useful as well (DuPont, 1999). Although, theselaboratory tests are by no means diagnostic in younger alcoholics, a study ofelderly alcoholics indicated that 70% of the 200 patients studied had abnormalitiesin the MCV, MCH, and liver function tests (Hunt, Finlayson, Morse, &Davis, 1988). This represented a much higher percentage of these abnormalblood studies in elderly alcoholics than in younger alcoholics.