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

18. Alcoholism and Substance Abuse in Older Adults 405abstinence, motivating them to increase their activities and get involved instimulating and worthwhile efforts that will enhance their self-esteem. Both thedepression and the alcohol use are thus effectively treated.In some cases of elderly alcoholics who appear severely depressed, it maybe possible to establish a differential diagnosis in a shorter period of time thanthe 2–3 weeks indicated. A dual-diagnosis typology has been developed, with aquestionnaire that can determine whether the depression is alcohol-induced orindependent of alcohol use (Zimberg, 1999a).The questions involve determining the presence of depression during periodsof sobriety, whether depression occurs after the onset of drinking, but not atother times, and whether there is a previous history of depression. This informationcan lead to a determination of coexisting depression and the start ofantidepressant medication sooner. The patient should be alcohol-free at thetime the antidepressant medication is started.Disulfiram has been available for the treatment of alcoholics for 50 years.Its value in controlled studies has been found to be equivocal. However, studiesusing disulfiram with observed administration or under the supervision ofemployee assistance programs, or with patients on probation or on parole, hasbeen found useful (Brewer, Meyers, & Johnsen, 2000). The conventional wisdomregarding the use of disulfiram in elderly alcoholics has been that the drugis too dangerous to use. However, in my experience, in elderly alcoholics whohave proved resistant to other treatment efforts and are not suffering from significantcardiovascular or liver disease, and who do not have serious cognitiveimpairment, the smaller dose of disulfinam (125 mg/day) given under supervisionhas been safe and effective.The long-acting opiate antagonist naltrexone has been found to be effectivein reducing craving and alcohol use in the alcohol-dependent patient(Weinrieb & O’Brien, 1997). A study of naltrexone in elderly alcoholics hasshown a similar beneficial effect (Oslin, Liberto, O’Brien, Krois, & Norbeck,1997). I have used this drug at a dose of 50 mg/day and have given patients acard to warn about the use of opiates for pain. In patients who have intensecraving and have not responded to the psychosocial treatment of the stresses ofaging, naltrexone can be safely used.Another drug that decreases craving, acamprosate, functions as a modulatorof glutamate in the central nervous system (Zornoza, Cano, Polache, &Granero, 2003). It has been used extensively in Europe and received Food andDrug Administration (FDA) approval for this indication in mid-2004. No studieson the elderly have been done. If effective, this may be an additional pharmacologicaltreatment (Whitworth et al., 1996).It should be noted that most elderly alcoholics respond to the agingspecificapproach, often with the use of antidepressants. For the minority ofpatients who are treatment-resistant, usually the early-onset type, the pharmacologicaloptions discussed should be considered.