Mohammed T. Abou-Saleh

602 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYloss of appetite. If the elderly alcoholic’s impaired ambulationresults in a reduced capacity to obtain food, or if limitedfinancial resources are used to purchase alcohol instead offood, dietary intake may be restricted further.(b) The effect of alcohol on the gastrointestinal tract is toproduce malabsorption of fats, fat-soluble vitamins, calcium,magnesium, iron and zinc. The active transport of B vitaminsis also impaired.(c) Alcohol can contribute to increased losses of magnesium,phosphate, potassium and zinc through the urine. If vomitingand diarrhea occur, there may be increased loss of sodium,potassium and chloride.(d) Alcohol use increases the requirements for folate andpyridoxine.7. Alcohol use contributes to accidents and injuries that may leadto fractures or subdural hematomas. A study of accidentaldrowning in Denmark found that between one-third and onehalfof adult drownings were related to alcohol intake 47 .8. Alcohol use disorder has been associated with higher mortalityin a study of older public housing residents 48 .9. Alcoholism can disrupt the elderly alcoholic’s family structureand cohesiveness and may even lead to family violence. Thiscan result in dysfunctional family relationships, with consequentincreased difficulty in treatment of the alcohol-relatedproblems.Despite the many unfavorable effects of alcohol abuse in theelderly, researchers have also reported positive aspects of alcoholuse. Moderate alcohol consumption has been associated with adecreased risk of ischemic stroke in elderly subjects 49 . A study ofelderly Australians found that alcohol intake was associated witha significant increase in life expectancy 50 .CHARACTERISTICS OF ELDERLY ALCOHOLABUSERSElderly alcohol abusers differ from younger alcohol abusers in anumber of ways. Alcohol abuse in the elderly is often associatedwith a clustering of events, which are common in late life. Theseinclude such occurrences as job retirement, widowhood, thedeaths of close friends and relatives, more medical illness anddisability in oneself and one’s peers, and perceived loss of ameaningful role or function. Some authors consider late-onsetalcoholism to be ‘‘reactive alcoholism’’, where the dependence onalcohol is initiated by a need to alleviate the stresses of undergoingmultiple losses. However, the extent to which alcohol abuse in theelderly is precipitated by stress from these losses is unclear. Someresearchers have found little change in alcohol consumption ordrinking behavior due to life stressors 51,52 .The time of onset of alcohol abuse may also significantlydifferentiate the younger alcoholic from the older one. Early-onsetalcoholics have a greater amount of psychopathology and familyhistory of alcoholism than late-onset alcoholics. Early-onsetalcoholics are characterized by being male relatives of alcoholicmen with histories of violence with and without alcohol, legalproblems due to alcohol use, and illegal substance abuse. Lateonsetalcoholics are characterized by having isolated alcoholinducedproblems with health, marital relationships or self-care,and much reduced histories of arrests, violence or other substanceabuse. Many elderly people with alcohol problems fall into thelate-onset alcoholic group. These findings suggest that the etiologyand predisposition of a person to an alcohol use disorder maydiffer by onset age. If this is so, the treatments and interventionsfor an alcohol use disorder may also differ with age of onset andneed to be individualized accordingly 53,54 .Individual feelings towards alcohol use are affected by thecultural and historical attitudes one grows up with. For example,the experience of the American elderly alcoholic may differ fromthat of younger alcoholics in that the elderly alcoholic and hispeers may have been exposed to the turmoil of the Prohibitionera. The moral issues highlighted in this historical period mayinfluence the willingness that some elderly may have in recognizingand accepting a diagnosis of, and treatment for, alcoholism.THE RECOGNITION OF ALCOHOL ABUSE IN THEELDERLYAlcohol abuse in the elderly often comes to the attention of healthprofessionals through presentation with a non-specific medical orpsychiatric symptom, such as self-neglect, falls, confusion, lability,depression, unusual behavior, injuries, diarrhea, malnutrition,myopathy, incontinence or hypothermia. In cases where alcoholabuse is suspected, alcohol dependency must be considered.Alcohol dependency is suggested when there are: (a) tolerance; (b)withdrawal symptoms; (c) loss of control of use; (d) social decline;and (e) mental and physical decline.Tolerance to alcohol may be assessed by establishing a reliablehistory of the patient’s drinking pattern. Corroboration fromfamily members and others close to the patient may be crucial.Tolerance is suggested if the patient exhibits a quantity andfrequency of drinking which is increased over his baseline patternof drinking. A patient with tolerance to alcohol will require agreater quantity of alcohol to achieve the same amount ofinebriation that a lower quantity had been able to achievepreviously. Tolerance is strongly suggested if there has been atleast a 50% increase in the amount of alcohol required to attain agiven effect, a blood alcohol level of 150 mg without intoxication,or the equivalent use of one-fifth gallon (750 mg) of alcohol ormore in 1 day by a 180 pound person 55 .Withdrawal symptoms occur when a patient who is tolerant toalcohol experiences a rapid decrease in blood alcohol concentration.Symptoms of the alcohol withdrawal syndrome includetachycardia, with a pulse of greater than 110 beats/min, tachypnea,hypertension, low-grade fever, sweating, nausea, vomiting, handtremors and increased anxiety. In some cases, the patient maydevelop seizures or delirium tremens with confusion, agitationand visual hallucinations. An elderly patient undergoing withdrawalmay experience one or all of these symptoms 55,56 .Loss of control means that the patient is no longer ableconsistently to choose the amount of alcohol he/she will consumein a given situation. He/she may also experience blackouts andbehave and feel in unpredictable ways 55 .Social decline in the elderly alcoholic is assessed from a baselineof age-appropriate behaviors 55 . Many elderly people no longerhold a steady job, do not drive or hold a driver’s license, and havelost many of their close friends and associates with whom theyused to socialize. Thus, it may not be as appropriate to assess forsocial decline by investigating these areas of the elderly patient’slife as it would be in a younger patient. However, it is relevant andrevealing to ask elderly people whether they are in contact withtheir children or grandchildren, and to what extent. It is alsouseful to find out whether the patient’s relatives express anyconcern about the patient’s alcohol use. Investigating the patient’sfunctioning with respect to his/her hobbies or other enjoyedactivities can also be useful.Physical, psychological and laboratory findings may alsouncover problems with alcohol use 55 . Addictive alcohol use canlead to malnutrition, gastrointestinal upset and bleeding, delirium,falls, depression, hypertension and neglect of self. Recurrentdiseases of the stomach, pancreas or liver may also be caused byexcessive alcohol abuse. These medical conditions often bring the