Diagnosing Alcohol User Disorders in Older People

The International Classification of Diseases-10th Edition (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-V) are currently used to diagnose alcohol use disorders. Both of these diagnostic systems are developed in and for younger adults and some aspects of the criteria may not appropriately apply to older people. In diagnosing older patients with AUD, a multidisciplinary team that includes an addiction specialist and an old age psychiatrist/geriatrician may help in negotiating the intricacies of some of these incompatibilities in these diagnostic systems.

What Is Effective in the Management of AUD in Older Adults?

Older adults benefit from treatment, and in some cases, tend to have better outcomes than younger people. Older adults may respond well to brief interventions (see Chapter 6), motivational interviewing and enhancement approaches as well as personalized feedback from their treating doctors. Drinking diaries, psychoeducation and follow-up letters or phone calls specifically addressing alcohol intake are effective tools in reducing the amount or the frequency of alcohol consumption.

Chapter Recommendation Grade of recommendation
18.5 Brief interventions should be employed for older people drinking at risky levels or experiencing alcohol-related harms (such as falls, driving impairment, drug interactions). A

Withdrawal Management for People with Alcohol Dependence

Comorbid physical illness and associated infirmities among older people increase the risk of a complicated alcohol withdrawal experience (see Chapter 8), and as a result it is important to carefully assess and closely monitor older patients who are at risk of developing alcohol withdrawal complications, ideally in an inpatient setting.  

Appropriate management of the nutritional status as well as the optimal management of comorbid physical and mental health problems will likely to ensure a shorter admission and reduce the risk of major alcohol withdrawal complications such as delirium tremens. 

Lorazepam and oxazepam clearance are minimally affected by age, hence these two medications are recommended for the management of alcohol withdrawal symptoms. Older people are likely to require lower doses of benzodiazepines for the management of their withdrawal symptoms and as a result a symptom triggered approach is recommended for this group.  

Thiamine deficiency is common among people with severe alcohol use disorders. There is good empirical evidence to support the use of thiamine intravenously (at least 500 mgs, two or three times a day) during the admission for alcohol withdrawal management.  

Chapter Recommendation Grade of recommendation
18.6 Withdrawal management of people who are older with alcohol dependence requires close monitoring, nutritional supplements especially IV thiamine, careful use of sedative medication, and management of comorbid conditions. GPP
18.7 Caution should be exercised when prescribing medications to people who are older that drink. Short-acting benzodiazepines (such as oxazepam, lorazepam) are preferred for alcohol withdrawal management over long- acting benzodiazepines (such as diazepam). D

Relapse Prevention

The use of pharmacotherapies in relapse prevention for in older adults is an area for further research (see Chapter 10). There is some evidence for the efficacy of Naltrexone use in older people with AUD. As older patients tend to be on a variety of medications, a careful consideration needs to be given in order to avoid the complications related to polypharmacy prior to commencement of any additional medication.

Chapter Recommendation Grade of recommendation
18.8 Psychological and pharmacological treatment approaches should be tailored to physical, cognitive and mental health of older patients with a special attention to complications of polypharmacy. D