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136 Substance Use in Older Adults
Table 5–2. Topics to inquire about when eliciting history of alcohol use
1. Age at onset of drinking
2. Age at onset of problematic drinking pattern
3. Past frequency of alcohol use, including highest frequency
4. Current frequency and amount of alcohol consumption
5. Any impairments in functioning (typically, impairments in relationships with others
or i
n ability to care for oneself)
6. Legal issues due to alcohol use
7. Previous attempts to reduce or quit alcohol use
8. Treatment history, including substance use disorder programs, 12-step programs,
ications for AUD
med
9. Any co-occurring substance use
10. Any history of alcohol withdrawal symptoms
health conditions, it is important to get a clear understanding about the
alcohol use itself. Table 5–2 lists the topics to cover when eliciting information specific to alcohol use from an older individual.
Laboratory tests such as complete blood count, complete metabolic
profile including liver function tests, and specific tests such as γ-glutamyl-
transferase (GGT), carbohydrate-deficient
transferrin (CDT), and ethyl
glucuronide (ETG) also have important roles in the management of alcohol misuse (Joshi et al. 2021). Macrocytosis, elevated liver enzymes,
and decreased albumin levels may denote excessive alcohol use (Nagao
and Hirokawa 2017). The ratio of aspartate transaminase (AST) to alanine transaminase (ALT) is generally ≥2:1 (Lala et al. 2022), so higher ratios should be investigated. GGT, CDT, and ETG have high specificity
in id
entifying recent alcohol use, which can be useful for monitoring abstinence. We believe it is reasonable to apply the above findings in the
general adu
lt literature to older adults with AUD.
Screening Instruments
Health care professionals should also consider using screening instruments to assess the intensity of alcohol use. Understanding the limitations of these screeners is important: for example, there is a risk of both
e positives and false negatives with respect to a diagnosis of AUD.
fals
The CAGE (cutting back, annoyance, guilt, eye-opener; see Table 2–4 on
page 34) questionnaire is a popular and easy-to-administer four-item
test that assesses attempts to cut down, annoyance at criticism, guilt
about alcohol use, and need for eye-openers (Ewing 1984). Because of
Alcohol Use and Use Disorder Among Older Adults 137
social changes with aging, some items may not be applicable to older
adults, limiting its use in the geriatric population. It also does not detect
binge drinking, which is common among older adults.
The Alcohol Use Disorders Identification Test (AUDIT) is a validated 10-item screening instrument developed by the World Health Organization (Saunders et al. 1993) that can be self-administered. Each
question has a Likert-style scale from 1 to 4, with higher scores indicating greater alcohol use. A recommended cutoff score typically is at 8,
but for older adults, a score of 5 or more should prompt further investigation. AUDIT-C uses only the questions related to consumption from
UDIT and has proved to be a good screener for AUD and at-risk
the A
drinking among older adults (Dawson et al. 2005; Gómez et al. 2006).
(At-risk drinking is drinking that increases the chances that an older
adult will develop problems and complications related to alcohol use.)
The Michigan Alcoholism Screening Test–Geriatric Version (MASTG) is a screening instrument specifically designed for older adults. It is
a 24-item questionnaire with “yes” or “no” responses and takes up to 10
minutes to administer. A shorter version, the Short Michigan Alcoholism Screening Test–Geriatric Version (SMAST-G), with 10 questions, is
suitable for quick screening in primary care settings. A score of two or
more “yes” responses indicates problematic alcohol use with a sensitivity of 91%–93% and a specificity of 65%–84% (Selzer et al. 1975).
T-G relies on older adults’ relationship to alcohol and its effects
SMAS
rather than quantifying the amount and frequency of alcohol use. We
recommend the use of either SMAST-G or AUDIT-C as brief and effective screeners that can be incorporated easily into the workflow of busy
clini
cians.
Challenges in Assessment
AUD in later life is often underdiagnosed, underreported, or overlooked
and consequently is often not managed (Yarnell et al. 2020). Patients,
family members, and providers alike are predisposed to ageist beliefs,
posing additional barriers to diagnosis and treatment. For example, the
provider may believe that older adults are entitled to drink during their
later years. Or the provider may hesitate to ask pointed questions about
the person’s alcohol use, fearing compromised rapport if the individual
is offended. The likelihood that a patient’s primary care provider has an
alcohol-related discussion with the patient declines as the patient ages
(Duru et al. 2010). Not every patient with alcohol misuse needs treatment
at a specialized treatment center—screening and brief intervention at the
provider’s office or another clinical setting can be effective in reducing al-
138 Substance Use in Older Adults
cohol use and mitigating harm. SAMHSA recommends widespread
screening of older adults for alcohol misuse in all health care settings. A
multidisciplinary intervention is often required to address the psychosocial factors that accompany AUD.
MANAGEMENT
The management of alcohol misuse spans a myriad of health care settings, with multiple points of care along the continuum of disease presentation. Management can range from a primary care provider
conducting an annual visit
habilitation at specialized centers. Treatment of AUDs in older adults is
mostly
similar to that in younger adults, with some differences. Considering the changes in metabolism and polypharmacy among older
adults, care
treatment begins with medically supervised withdrawal and detoxification, requiring inpatient hospitalization. Others may go straight to
longer-term
cial interventions such as meetings and psychotherapy.
Interestingly, older adults have demonstrated treatment outcomes
just as good as or even better than those of younger adults. These outcomes are enhanced when the treatment plan is age sensitive and involves coordination among all professionals providing care (SAMHSA
2020). Older women tend to have better treatment outcomes related to
abstinence compared with men (Satre et al. 2004). The goals of care for
patients with misuse should include achieving abstinence and improving quality of life. The treatment should preserve the person’s dignity
ughout the continuum and encourage them to change risky behav-
thro
iors, thus reducing the chances of relapse (DiBartolo and Jarosinski
2017). Older a
and age sensitive. A consensus panel convened by SAMHSA (2020) recommends the following as key characteristics of age-sensitive alcohol
treatment regardless of the treatment setting:
ful selection of treatment options is necessary. For some,
approaches with maintenance medications and psychoso-
dults respond better when the treatment is age specific
providing brief interventions to inpatient re-
1. Supportive and nonconfrontational
2. Flexible
3. Sensitive to gender and cultural differences
4. Accommodating the client’s level of physical and cognitive func-
tioning
5. Holistic and comprehensive
6. Enhancing coping and social skills
Alcohol Use and Use Disorder Among Older Adults 139
Detoxification
Nearly half of patients with AUD experience alcohol withdrawal syndrome (AWS) when they reduce or stop drinking (Schuckit et al. 2003).
A history
sequent episodes (Goodson et al. 2014). Minor alcohol withdrawal is
characterize
tremors), anxiety, restlessness, alcohol craving, insomnia, loss of appetite, and nausea or vomiting. More severe syndromes (~5%) can present
with transient visual, tactile, or auditory hallucinations or illusions; delirium tremens (DTs); or grand mal seizures. Older adults often present
with confusion associated with functional decline rather than physical
symptoms like tremors and diaphoresis. They are also at higher risk of
DTs and longer hospital stays (Kraemer et al. 1997).
adults necessitate closer
Scientific Affairs 1996). Home or outpatient detoxification may be feasible in an older adult who is a reliable informant with good social support and medical stability (Rigler 2000). Readmission to inpatient
fa
cilities is common among older patients after detoxification (Van den
Berg et al. 2015).
sions, is important to prevent Wernicke’s encephalopathy, as well as
correction of any
stay for treatment of AWS, through either a fixed tapering schedule or
a sy
Assessment for Alcohol protocol. To prevent the risk of excessive sedation and residual effects, shorter-acting benzodiazepines such as lorazepam and oxazepam, which do not undergo oxidative metabolism in
the liver, are preferred over longer-acting agents (Guina and Merrill
2018). There is little evidence to support the use of antiepileptic drugs
(e.g., gabapentin, carbamazepine, or divalproex) for alcohol withdrawal in older adults (Montgomery et al. 2022).
of prior episodes of AWS is the most reliable predictor of sub-
d by autonomic hyperactivity (diaphoresis, palpitations,
Chronic medical comorbidities and increased frailty among older
monitoring during detoxification (Council on
Supplementation of thiamine, especially before any glucose infu-
electrolyte imbalances. Benzodiazepines are the main-
mptom-triggered protocol such as the Clinical Institute Withdrawal
Maintenance Pharmacotherapy
Long-term pharmacological treatment for AUD has not been studied
thoroughly in older adults but is imperative for risk mitigation (Kranzler and Soyka 2018). The SAMHSA consensus panel recommends using medications to treat AUD in older adults when necessary.
Medications can be prescribed in general health care settings, not just
specialized treatment centers. Medications may be necessary for pa-
140 Substance Use in Older Adults
tients in whom psychosocial interventions have not been successful or
who continue to struggle with cravings and return to alcohol use. Treatment planning for the older adult should also include consideration of
age-
related factors such as cognition, hearing impairment, or any phys-
ical or functional decline (SAMHSA 2020). If cognitive impairment is
sent, the extent of impairment should be assessed, and treatment
pre
planning may need to involve family members or legal guardians.
Factors to consider when prescribing for older adults include evaluating for potentially harmful drug–drug interactions, using lower doses
of medications, ensuring
supports (SAMHSA 2020). Medication management should be closely
linked with behavioral interventions, including linking older adults to
12-step programs such as AA.
Currently, three medications are approved by the FDA to treat AUD:
naltre
xone, acamprosate, and disulfiram. Two additional medications
with off-label use for AUD are gabapentin and topiramate (Winslow et
al. 2016). None of these medications are specifically contraindicated for
use in older adults, but caution should be exercised nonetheless. Table
5–3 compares agents with respect to some key clinical attributes.
medication adherence, and planning recovery
Naltrexone
Naltrexone is a nonselective opioid antagonist that is available as a
once-daily oral tablet or once-monthly intramuscular injection. It curbs
the craving for alcohol and therefore reduces alcohol consumption predominantly by dampening the dopamine-mediated reward and pleasurable effect of alcohol. Naltrexone has proven to be an effective and
reatment for AUD in younger adults, reducing the risk of heavy
safe t
drinking and resulting in decreased drinking days in the general adult
population (Rösner et al. 2010b).
Although evidence in older adults is minimal, two small randomized, controlled trials (RCTs) showed reduced rates of relapse with naltrexone
subjects ages 50–70 years for 12 weeks, demonstrating safety (Oslin et
al. 1997). The second study involved subjects 55 and older with depression and AUD, evaluating sertraline-placebo versus sertralinenaltre
adding naltrexone to sertraline, it did show that relapses were correlated with ineffectively treated depression (Oslin 2005; Oslin et al.
1997).
patient is
treatment. The first study compared naltrexone with placebo in
xone. Although the second study showed no significant effect of
Naltrexone is especially useful because it can be started while the
still drinking, providing a key advantage among patients who
Table 5–3. Comparison of medications available for maintenance treatment of alcohol use disorder
Need to be
abstinent on
Medication
FDA-approved agents
Acamprosate Yes 333 mg tid 666 mg tid Diarrhea
Naltrexone No 25–50 mg/day PO
Disulfiram Yes 125 mg/day PO 250–500 mg/day PO Diarrhea (dose-related, transient), weakness,
Non-FDA-approved agents
Gabapentin Yes 300 mg/day PO 600 mg tid Dizziness, sedation, ataxia or gait disturbance,
Topiramate No 25 mg/day PO 300 mg/day PO,
Baclofen Yes 5 mg PO tid 10 mg PO tid Drowsiness, dizziness, headache, confusion, muscle
Source. Kranzler and Soyka 2018.
initiation
Initial dosing
400 mg/month
or
IM
Maximum
dosing Adverse effects
100 mg/day PO Sedation, nausea, vomiting, decreased appetite,
titrated over
8 weeks
abdominal pain, insomnia, dizziness
periphera
peripheral ed
Paresthesia, dysgeusia, anorexia, impaired attention,
nervousness, dizziness, pruritis
stiffnes
speech
l edema, insomnia, anxiety
ema
s, excessive perspiration, numbness, slurred
Alcohol Use and Use Disorder Among Older Adults 141
142 Substance Use in Older Adults
have had difficulty cutting down in the past. Eventually, the patient has
the option to transition from daily oral dosing to a monthly injection
(Kranzler and Soyka 2018). Patients who receive prescription opioids
for pain relief are not good candidates for naltrexone, as it may cause
significant opioid withdrawal symptoms (SAMHSA 2020). Common
adverse effects of naltrexone include dizziness, nausea, reduced appetite, and increased daytime sleepiness. Because of transient elevation of
liver enzymes, hepatic
within a few weeks of initiating treatment. Liver enzymes should also
be checked every 6 months after that for the duration of treatment. Naltrexone should be avoided in patients with acute hepatitis, liver failure,
or elevated liver enzymes (Reus et al. 2018).
functioning should be monitored before and
Acamprosate
Acamprosate reduces craving for alcohol and the pleasurable effects associated with alcohol by modulating glutaminergic transmission (Wit-
itz et al. 2012). Substantial evidence demonstrates the safety and
kiew
efficacy of acamprosate, as it reduces the risk of any drinking and significantly increases cumulative abstinence duration among younger
adults (Rösner et al. 2010a). The FDA approved acamprosate for maintenance of abstinence from alcohol in patients with alcohol dependence,
but there is limited evidence of effectiveness in older adults. Acamprosate is likely to be better tolerated than naltrexone in patients with hepatic impairment (Scott et al. 2005).
Ideally, the patient must be abstinent from alcohol for 5 days before
starting a
is associated with stronger medication effect and better abstinence outcomes (Maisel et al. 2013).
rhea. Considering that older adults are at higher risk of renal impairment, baseline renal function and frequent monitoring of renal function
should accompany treatment with acamprosate (SAMHSA 2020). The
three-times-daily dosing can lead to nonadherence.
camprosate. Studies show that detoxification before initiation
The most common side effects are gastrointestinal, especially diar-
Disulfiram
Disulfiram, an acetaldehyde dehydrogenase inhibitor, precipitates an
acute physical reaction due to the accumulation of acetaldehyde. Side effects upon consuming alcohol on this medication include diaphoresis,
flushing
firam (disulfiram ethanol reaction) could happen due to topical exposure
to alcohol such as hand sanitizers, aftershave lotions, or mouthwashes
, and hypotension. The physical reactions characteristic of disul-
Alcohol Use and Use Disorder Among Older Adults 143
(Ghosh et al. 2021). Disulfiram has demonstrated efficacy and safety in
open-label studies, but its effect has been difficult to replicate in blinded
RCTs. It works better in supervised settings (Skinner et al. 2014).
Drug interactions and coexisting medical conditions limit the use of
disulfiram, especially in older adults. The physical reaction of disulfiram and alcohol can be harmful in older adults, which makes it less recommended in the geriatric population (Le Roux et al. 2016). It should be
discont
thermore, use of disulfiram requires patients to adhere to strict medication protocols and monitoring of compliance (Skinner et al. 2014). For
these r
line agent in older adults.
inued if the patient continues to drink while being treated. Fur-
easons, we would avoid using disulfiram as a first- or second-
Gabapentin
Gabapentin is FDA approved for post-herpetic neuralgia and adjunctive therapy for focal (partial) seizures, through enhancement of GABAerg
ic neurotransmission. It can be used off-label for AUD, as studies
have found that it helps with mild AWS and reduces the percentage of
heavy drinking days (Kranzler et al. 2019; Mason et al. 2014). Also, gabapentin has been associated with improving sleep during withdrawal,
promoting complete abstinence, and reducing cravings (Leung et al.
2015). There is no evidence thus far to support its use in older adults,
especially given its common side effects such as sedation, dizziness,
and gait problems (Anton et al. 2020).
Topiramate
Topiramate is an anticonvulsant that has FDA-approved indications for
migraine prevention and seizures. It can be used off-label in AUD for
craving and withdrawal symptoms. It is hypothesized to exert this effect through modulating GABA
and kainate subtypes of glutamate receptors (Shank and Maryanoff
2008). There is some evidence that topiramate reduces heavy drinking
and promotes abstinence (Johnson et al. 2003). Topiramate is associated
with cognitive impairment and weight reduction. Short- and long-term
cognitive dysfunction occur even at low doses (De Sousa 2010). Weight
loss may not be a desirable side effect in older patients, which makes
topiramate less than ideal as a first-line treatment for AUD. Headaches,
insomnia, nausea, hypotension, urinary frequency, and cognitive impairment are common adverse effects with use of topiramate (Johnson
2010; Pennington et al. 2020).
receptors and inhibiting the AMPA
A
144 Substance Use in Older Adults
Baclofen
Baclofen is an agonist at the presynaptic GABAB receptors that suppresses cortico-mesolimbic dopaminergic activity. It has some efficacy
in the general adu
tive among patients with liver impairment (Addolorato et al. 2007). A
Cochrane Review did not find any dif
cebo; the reason stated was the heterogeneity among studies (Minozzi
et al. 2018). The most common adverse effects include vertigo, somnolence, paresthesia, and muscle spasms (Minozzi et al. 2018). No studies
have ev
aluated baclofen in the treatment of AUD among older adults.
lt population with AUD and serves as a key alterna-
ference between baclofen and pla-
Psychosocial Interventions
Nonpharmacological interventions are highly effective as either standalone treatments or, more commonly, treatments adjunctive to medication management. These interventions can vary from brief interventions
in the pr
residential settings. Like management of other chronic medical conditions, shared decision-making is a cornerstone for any intervention, including medication management. Emphasizing the patient’s preference
and inclu
interventions improves the chances of compliance with the plan and
outcomes of the intervention (Friedrichs et al. 2016).
ovider’s office to more structured programs in ambulatory or
ding the patient, along with any social support, in planning the
Inpatient Treatment
Older adults who meet criteria for AUD and have significant medical or
psychiatric comorbidities requiring medically supervised detoxification need inpatient treatment. The scope of these programs can be limited to detoxification followed by referral to ambulatory treatment
centers for further management. Alternatively, these programs may include a residential treatment program that follows medically supervised withdrawal.
Brief Interventions
Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive public health approach to provide early intervention for
people wi
compasses quick screening, short interventions to promote awareness
and be
SBIRT is a cost-effective tool to prevent alcohol misuse and reduce risk
for older adults (Moore et al. 2011). Brief interventions are suitable in
th substance use disorders or at risk of developing them. It en-
havior change, and appropriate referrals for specialty care.
Alcohol Use and Use Disorder Among Older Adults 145
primary care offices, emergency departments, and outpatient behavioral health service programs. They can be delivered by health care providers from a wide range of professional backgrounds (Wamsley et al.
2018). For example, pr
effects of alcohol on aging bodies and advise directly about the need to
change. Older adults are open to this approach and likely to participate
in the intervention. See “Brief Interventions” in Chapter 3 (page 62) for
a more
detailed discussion of SBIRT.
oviders can lead a discussion emphasizing the ill
Motivational Interviewing
Motivational interviewing is a client-centered psychotherapeutic approach that promotes shared decision-making and guides the patient
ward desired outcomes. It addresses the ambivalence among patients
to
about entering treatment, evaluates their perception of behavior
change, and encourages them to formulate reasons and plans to change
dysfunctional behaviors (Westra and Aviram 2013). Motivational interviewing has been successful in treating older adults with substance
misuse. The ELDERLY study showed that patients with mood disorders
drank more at baseline; they also cut down consumption of alcohol using short interventions based on motivational interviewing and cognitive-behavioral therapy (CBT) elements (Behrendt et al. 2020).
tivational interviewing can be used in a variety of treatment set-
Mo
tings—as brief as a conversation in a primary care office or as intensive
as an intervention in a residential treatment center. Being a flexible,
nonconfrontational, and nonjudgmental approach, it aligns well with
the age-sensitive approach outlined earlier in “Management.”
Cognitive-Behavioral Therapy
CBT is a leading intervention for AUD or other drug use disorders. It is
a time-limited treatment with multiple sessions focused on achieving
and maintaining remission by addressing cognitive, behavioral, and environmental triggers for relapse. Multiple studies over decades have
demonstrated its effectiveness compared with no treatment, minimal
treatment, or nonspecific control treatment (Magill et al. 2019). Geriatric
Evaluation Team: Substance Misused Abuse Recognition and Treatment (GET SMART) at the Department of Veterans Affairs uses a set
curriculum, based on cognitive-behavioral and self-management tech
niques, to prevent relapse among older veterans (Schonfeld et al. 2000).
Desp
ite a high dropout rate, the program demonstrated efficacy in veterans with significant medical, social, and drug use problems (Schonfeld et al. 2000).
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