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

18. Alcoholism and Substance Abuse in Older Adults 401coexisting psychiatric disorders, particularly depression, cognitive impairment,and prescription drug misuse. I have found that at least 50% of the elderly alcoholicsI have treated are clinically depressed and in need of antidepressanttreatment (Zimberg, 1996).Engaging in TreatmentTREATMENTOnce the diagnosis of an alcohol problem has been made and problems associatedwith the stresses of aging and any coexisting psychiatric problems determined,the patient should be told about these problems, including an alcoholproblem. The other problems should be indicated along with the alcohol problemas requiring treatment. This contrasts the confrontation necessary with ayounger alcoholic, where often the alcohol problem is the major concern thatmust be dealt with first.Elderly individuals have greater denial of an alcohol problem, and dealingwith the alcohol problem in the context of stresses of aging is more readilyaccepted and often engenders a willingness to accept treatment. Labeling anelderly patient an “alcoholic” will often result in the patient refusing to engagein treatment.DetoxificationMost elderly people with alcohol problems do not consume large amounts ofalcohol that will result in withdrawal if the drinking stops. However, somepatients may require detoxification. The patient should have a medical evaluation,or his or her primary care physician should be contacted. If the patient isnot suffering from serious medical problems, outpatient detoxification is oftenpossible (Evans, Street, & Lynch, 1996). Benzodiazepines are the drugs ofchoice (Kraemer, Conigliaro, & Saitz, 1999; Saitz & O’Malley, 1997).I prescribe diazepam, 10–15 mg daily, with a reduction of half a tabletevery other day, while monitoring blood pressure and pulse. The patient shouldbe seen at least three or four times during this period of ambulatory detoxification.A long-acting benzodiazepine is preferred because of its built-in taperingeffect after the last dose.If the patient has serious medical problems, the detoxification should bedone in a hospital. Patients dependent on benzodiazepines, or a combination ofalcohol and benzodiazepines, should be detoxified in a hospital setting. Mostelderly people find it more acceptable to be detoxified on a general medical servicerather than a specialized inpatient detoxification unit, and will often refuseto be admitted to such a unit.