Alcohol abuse

Definition

Alcohol abuse occurs when individuals clearly drink too much on a regular basis and their alcohol use causes poor health and is self-destructive or can present a danger to others. People who abuse alcohol are usually able to set limits and establish some measure of control over their drinking. Rather than deny the excessive nature of their alcohol use, they usually listen to friends and family members who express concern and suggest that they need help in stopping their abuse. Alcohol abuse can lead to alcohol dependence or alcoholism, in which the drinker loses control of the amount he or she drinks.

Health risks include:

• high blood pressure and increased risk of stroke.
• increased risk of cancer of the head, neck, or esophagus.
• increased risk of cirrhosis of the liver.
• increased risk of falls and fall-related injuries, particularly in women. Studies indicate that heavy drinking in older women increases the risk of osteoporosis.
• decline in cognitive function. Some researchers think that alcohol abuse increases a senior's risk of Alzheimer's disease, although further research is needed.
• increased risk of malnutrition.
• high risk of interactions with prescription drugs that the senior may be taking.

Description

Alcohol abuse among older persons is often called an invisible epidemic because researchers and health practitioners believe it is under-recognized, under-diagnosed, misdiagnosed for another condition, and under-treated. Alcohol abuse in older adults often is hidden and, consequently, overlooked. For example, many older adults drink in the privacy of their homes and are less likely to be disruptive in public or arrested for driving while intoxicated. Further, even when family, friends, and professionals recognize an alcohol problem exists, they are reluctant to confront an older person. This reluctance may be related to a fear of making the older person angry, a lack of knowledge about alcohol problems in later life, or the older person's denial of having drinking behavior. Alcohol abuse is different than alcoholism in that alcoholics cannot stop using alcohol despite the severe physical and psychological consequences of excessive drinking. They stop listening to people who complain about their drinking. They make promises they do not keep. They keep drinking and drinking just as much, no matter what their drinking does to themselves and to others.

Limited research suggests that sensitivity to alcohol's health effects may increase with age. One reason is that the elderly achieve a higher blood alcohol concentration (BAC) than younger people after consuming an equal amount of alcohol. The higher BAC results from an age-related decrease in the amount of body water available to dilute the alcohol. Therefore, although they can metabolize and eliminate alcohol as efficiently as younger persons, the elderly are at increased risk for intoxication and adverse effects. Aging also interferes with the body's ability to tolerate and adapt to the presence of alcohol. Through a decreased ability to develop tolerance, elderly persons consistently exhibit certain adverse effects of alcohol—such as decreased coordination—at lower doses than younger subjects whose tolerance increases with increased consumption. Thus, elderly persons can experience the onset of alcohol problems even though their drinking pattern has remained unchanged over the years.

Aging and alcohol misuse produce similar deficits in intellectual and behavioral functioning. Alcohol abuse may accelerate normal aging or cause premature aging of the brain. In addition, older people who abuse alcohol exhibit more brain tissue loss than younger subjects who abuse alcohol, often despite similar total lifetime alcohol consumption. These results suggest that aging may make a person more susceptible to alcohol's effects. The frontal lobes of the brain are especially vulnerable to longterm heavy drinking. Research shows that shrinkage of the frontal lobes increases with alcohol use and is associated with intellectual impairment in both older and younger subjects who abuse alcohol. Also, older persons who abuse alcohol are less likely to recover from cognitive deficits during abstinence than are younger persons with a drinking problem. Age-related changes in volume also occur in the cerebellum, a part of the brain involved in regulating posture and balance. Thus, long-term alcohol abuse can accelerate the development of age-related balance and posture problems, increasing the likelihood of falls.

Combined effects of alcohol and aging

Many medical, emotional, and other problems are associated with both aging and alcohol abuse, but the extent to which these two factors may interact to contribute to certain diseases and disorders in unclear. Examples of alcohol-aging interactions include:

• The incidence of hip fractures in older persons increases with alcohol use. This increase is due to falls while intoxicated and a significant loss of bone density in older persons who are alcohol abusers, compared to older people who do not drink or drink in moderation.
• Studies of the general population suggest that consuming one or two alcoholic drinks per day for men and one per day for women may reduce the risk of heart disease, including persons 65 and older. However, because of age-related body changes in older men and women, the National Institute on Alcohol Abuse and Aging (NIAAA) recommends people aged 65 and older consume no more than one drink per day.
• Alcohol-related traffic accidents are a significant cause of injury and death among all age groups, including the elderly. A person's crash risk per mile increases starting at age 55 and exceeds that of a young, beginning driver by age 80. Alcohol abuse increases the risk factors, especially since older drivers tend to be more seriously injured than younger drivers in crashes of equal magnitude.
• Long-term alcohol use activates enzymes in the body that break down toxic substances, including alcohol. When activated, these enzymes can also break down some common prescription medicines, reducing their effectiveness. These include the anxiety and sleeping disorder drugs called benzodiazepines (e.g., Valium, Ativan, and Librium) and anti-seizure medications, including phenytoin (Dilantin), clonazepam (Klonopin), and carbamazepine (Tegretol). Alcohol-drug interactions are especially common among the elderly.
• Depressive disorders are more common in the elderly than among younger people and often coincide with alcohol abuse. Depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in activities that were once pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment. In a national survey, persons older than 65 who abused alcohol were found to be three times more likely to have a major depressive disorder than those who were not alcohol abusers.

Alcohol and suicide among seniors

Research shows a growing need for suicide prevention programs targeted at older adults who abuse alcohol, according to the American Association of Suicidology. Research suggests that increased age could serve as a marker for more chronic alcoholism, which is associated with greater risk for suicide. Alcohol abusers who commit suicide are older and more likely to be male, have a mood disorder, and relationship difficulties than older adults who do not abuse alcohol. Some researchers recommend enhanced suicide-prevention efforts for older individuals who abuse alcohol that include a focus on depression and interpersonal factors, such as partner-relationship difficulties. Among persons older than 65, moderate and heavy drinkers were 16 times more likely than non-drinkers to die of suicide, according to the NIAAA.

Demographics

As the older population grows, increasing numbers of older alcohol abusers will require health care. Although alcohol problems are often underreported, alcohol use remains common among older persons. It is difficult to estimate the scope of the problem because there is little significant statistical data available, especially prior to 2000, in the United States, and even less worldwide. In a study of community-dwelling persons 60–94 years of age, 62% of the subjects were found to drink alcohol, and heavy drinking was reported in 13% of men and 2% of women. Overall, about 6% of older adults are considered heavy users of alcohol, according to a study in Erie County, New York. Heavy drinking is defined as having more than two drinks per day.

Surveys of different age groups in the U.S. population suggest that the elderly, generally defined as persons older than 65, consume less alcohol and have fewer alcohol-related problems than younger persons. However, some surveys that track individuals over time suggest that a person's drinking pattern remains relatively stable with age, perhaps reflecting social norms that prevailed when the person began drinking. For example, persons born after World War II may show a higher prevalence of alcohol problems than persons born in the 1920s, when alcohol use was stigmatized. In addition, some people increase their alcohol consumption later in life, often leading to late-onset alcohol abuse. In contrast to most studies of the general population, surveys conducted in healthcare settings have found increasing prevalence of alcoholism among the older population. Surveys indicate that 6–11% of elderly patients admitted to hospitals exhibit symptoms of alcoholism, as do 20% of elderly patients in psychiatric wards and 14% of elderly patients in emergency rooms, according to the NIAAA. In acute-care hospitals, rates of alcohol-related admissions for the elderly are similar to those for heart attacks. Yet hospital staff is significantly less likely to recognize alcoholism in an older patient than in a younger patient, the NIAAA reports. The prevalence of problem drinking in nursing homes is as high as 49% in some studies, depending in part on survey methods. The high prevalence of problem drinking in this setting may reflect a trend toward using nursing homes for short-term alcoholism rehabilitation stays. Late-onset alcohol problems also occur in some retirement communities, where drinking at social gatherings is often the norm, according to the NIAAA.

Causes and symptoms

Each older person who develops an alcohol problem has a unique set of circumstances. It often is difficult to identify one event that led to the problem. However, excessive use of alcohol in later life often is triggered by changes in work status, family relationships, and health. To the older person, these changes typically represent a loss that produces emotional and/or physical pain.

Retirement

Many people welcome retirement, but for some individuals, work has been a primary source of identity. Work has given their lives purpose, structure, and meaning. For people who have not developed other interests and relationships, retirement can usher in many losses: routine, co-workers, activity, income, and feelings of productivity. Some older people drink in reaction to the loss of self-worth, responsibility, and income following retirement. Others cannot adjust to the lack of structured activity and drink out of boredom. Still others may find themselves in new leisure situations where they believe “social” drinking is expected.

Loss of relationships

As people grow older, they often lose many of the relationships they have had for years. Children leave home, a spouse dies, friends move away or die, and their circle of relationships grows smaller. Physical problems may limit mobility, making it difficult or impossible to travel. The sense of isolation and lone-liness may become unbearable. Unlike younger people, who often begin drinking to be with friends, older persons often drink because they feel or are alone. Older people frequently are devastated by the loss of a spouse and sometimes turn to alcohol to block the pain of their bereavement. Widowers appear to be particularly vulnerable.

Poor health

Loss of physical health can be very stressful, especially to older persons. Poor health can limit mobility and lead to a negative self-image for some older adults. Alcohol may be used to block the emotional pain caused by the loss of physical capabilities. Other older people experience serious and chronic pain and sometimes use alcohol as a sedative to lessen the physical pain, eventually becoming dependent on alcohol.

Symptoms

Not everyone who drinks regularly has a drinking problem, and not all problem drinkers drink every day. Help might be warranted when the following circumstances are present:

• Drinking to calm nerves, forget worries, or for depression.
• Losing interest in food.
• Gulping down drinks.
• Frequently having more than three drinks in a day.
• Lying about or trying to conceal drinking habits.
• Drinking alone.
• Hurting oneself or someone else while drinking or under the influence of alcohol.
• Being drunk more than three or four times in a year.
• Feeling irritable, resentful, or acting unreasonable while not drinking.
• Being physically or emotionally abusive while drinking or under the influence of alcohol.
• Having medical, social, or financial problems caused by drinking.

Diagnosis

Identifying alcohol-related problems among older persons is often more challenging than with other age groups. Because of retirement or other lifestyle changes that limit older persons' interaction with social and other networks, there are fewer opportunities for the alcohol abuse to be observed. However, older persons are likely to visit a primary healthcare unit in which conditions can be identified that may be the consequence of alcohol abuse or dependence. These symptoms include depression, malnutrition, insomnia, cognitive problems, and loss of interest in life.

Because alcohol problems among older persons often are mistaken for other conditions associated with growing old, alcohol abuse in this population may go undiagnosed and untreated or may be treated inappropriately, according to the NIAAA. Healthcare providers should discuss alcohol use with their older patients as a part of routine care. Advice to older patients should include telling them that the medical conditions common to older people, such as high blood pressure and ulcers, can be worsened by drinking. Also, mixing alcohol with over-the-counter and prescription drugs can be dangerous or fatal. Where there is no medical condition that would preclude the use of alcohol, older patients should be advised to limit their alcohol intake to one drink per day. Healthcare providers, including emergency room personnel and admitting physicians who suspect an alcohol problem in their elderly patients, should refer such patients to treatment. It is a mistaken belief that older persons have little to gain from treatment for alcohol misuse; each stage of life has its own rewards for sobriety, and they are all valuable.

Treatment Studies indicate that elderly persons with alcohol problems are at least as likely as younger persons to benefit from alcoholism treatment. The outcomes are more favorable among persons with shorter histories of alcohol abuse. Additionally, although evidence is not entirely consistent, some studies suggest that treatment outcomes may be improved by treating older patients in age-segregated settings. The use of medications to promote abstinence has not been studied extensively in elderly subjects. However, one study has suggested that naltrexone (ReVia) may help prevent relapse to alcohol abuse in subjects ages 50–70. Results of research in animals suggest that age-related alterations in specific chemical messenger systems in the brain may alter the effectiveness of medications used to treat alcohol abuse.

Nutrition/Dietetic concerns

Older adults who abuse alcohol frequently display changes in their dietary habits, such as having a poor diet, missing meals, or eating irregularly. Heavy drinking can cause an older person to feel full, even after two or three drinks, so the diet can become unbalanced as foods that would normally be chosen are not eaten. Hangovers can also lead to poor food choices the next day in an attempt to try to feel better. Alcohol abuse also depletes certain vitamins and minerals in the body, so supplementation is often recommended. These typically include vitamin C , vitamin B complex, L-glutamine, lecithin, and chromium. A high-potency multi-vitamin, multi-mineral supplement, containing magnesium (400 mg) and the antioxidants beta carotene and d-alpha tocopherol, is also recommended to help in the short term.

Therapy

Once individuals have their alcohol abuse under control, a lifetime of support therapy is usually needed and may include regularly attending a 12-step support group, such as Alcoholics Anonymous. Abstinence is necessary for successful treatment of heavy drinkers. These individuals cannot resume social drinking without risking a return to excessive consumption. Many feel they are the exception to the rule; however, for every 10 people who say they will stop drinking, only four do.

Prognosis

Motivation and intervention by family and friends can help the older alcohol abuser to achieve abstinence in heavy drinkers or normal drinking patterns in alcohol abusers. Recovery from alcohol dependence is possible. One study reported 65% of patients who abused or were dependent on alcohol abstained for at least a year following treatment. Another study showed 40% to 60% of alcoholics abstained for more than a year.

KEY TERMS

Cerebellum —The part of the brain that serves to control and coordinate muscular activity and control balance.

Cognitive —Relating to the process of acquiring knowledge by the use of reasoning, intuition, or perception.

Depressive disorders —Mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in activities that once were pleasurable.

Twelve-step program —A program that uses a set of 12 defining and guiding principles in alcohol abuse recovery.

QUESTIONS TO ASK YOUR DOCTOR

• What type of treatment would benefit me most?
• Are there medications available than can help me?
• How has alcohol abuse affected my general health?
• Will my health improve after I stop my alcohol abuse? If yes, what are the likely improvements?

Prevention

The best prevention of alcohol abuse is to not drink at all. Otherwise, older persons should limit their alcohol intake to no more than one drink a day. It is also advisable not to drink when feeling upset or depressed.

Caregiver concerns

Alcohol abuse should be recognized as a family problem. The best time to take action is when the caregiver suspects there is a problem with alcohol abuse. Not only the caregiver but the alcohol abuser's entire network of family and friends needs to show concern, compassion, and understanding. They should encourage the alcohol abuser to seek help and offer support while the older alcohol abuser is undergoing treatment. It is also important for the caregiver and others not to use alcohol in the presence of the person getting help if that person is a heavy drinker or is trying to abstain from alcohol use.

Resources

BOOKS

Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

Levkoff, Sue E., et al., eds. Evidence-Based Behavioral Health Practices for Older Adults: A Guide to Implementation. New York: Springer, 2006.

PERIODICALS

Greenfield, Shelly F. “Drinking and Older Adults.” Alcohol Use and Abuse (Harvard Special Health Report) (2007), 25.

Mahoney, Diana. “Curbing Alcohol Misuse in the Elderly.” Clinical Psychiatry News (April 2007): 27.

McPhillips, Mike. “Alcohol Misuse in Older Patients.” Update (April 1, 2006): 81.

Oslin, David W. “The Challenging Face of Substance Misuse in Older Adults.” Psychiatric Times (November 1, 2006): 41.

Stevenson, Joanne Sabol, and Joan A. Masters. “Predictors of Alcohol Misuse and Abuse in Older Women.” Journal of Nursing Scholarship (Winter 2005): 329(7).

Watts, Malcolm. “Incidences of Excess Alcohol Consumption in the Older Person.” Nursing Older People (January 2007): 27(4).

ORGANIZATIONS

Al-Anon Family Group Headquarters, 1600 Corporate Landing Parkway, Virginia Beach, VA, 23454-5617, (757) 563-1600, (800) 425-2666, (757) 563-1655, wso@al-anon.org, http://www.al-anon.org.

Alcohol and Drug Foundation of Queensland, PO Box 332, Spring Hill, Queensland, Australia, 4004, 07-3831-5355, 07-3832-2527, adfq@adfq.org, http://www.adfq.org.

Alcohol Concern, 64 Leman St., London, United Kingdom, E1 8EU, 020-7264-0510, 020-7488-9213, contact@alcoholconcern.org.uk, http://www.alcoholconcern.org.uk.

Alcoholics Anonymous, PO Box 459, Grand Central Station, New York, NY, 10163, (212) 870-3400, (212) 870-3003, http://www.aa.org.

National Institute on Aging, 31 Center Dr., MSC 2292, Bldg. 31, Room 5C27, Bethesda, MD, 20892-2292, (301) 496-1752, (800) 222-2225, (301) 496-1072, niainfo@mail.nih.gov, http://www.nia.nih.gov.

National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Lane, MSC 9304, Bethesda, MD, 20892-9304, (301) 443-3860, (301) 480-1726, niaaa@nih.com, http://www.niaaa.nih.gov.

Ken R. Wells