Alcohol Abuse in an Older Widow
Mrs. V is a 70-year-old woman who regularly attends a senior center in her neighborhood. She is very social and often arranges to meet groups of friends for dinner. She also actively goes on bus trips to casinos and is often viewed as being one of the liveliest members of the group. Mrs. V has a daughter and several close friends who are relieved that she is socializing again. For the past two years, Mrs. V had been the primary caregiver of her husband, who died of pancreatic cancer. Mr. V underwent several courses of chemotherapy and grew progressively weak until he became bedridden. Mrs. V wanted to care for him at home, and spent all of her time devoted to his care until he passed away. For several months following his death, Mrs. V stayed at home and had little contact with her friends. Her daughter encouraged her to go out to dinner, and Mrs. V slowly became more active. Mrs. V found that it was easier to socialize if she had a glass of wine before leaving her home. Mr. V used to collect wines, and it was common for Mrs. V to have a glass of wine with dinner. Her daughter viewed her mother’s drinking as a return to a normal routine and was relieved to see her socialize with friends again.
For many months Mrs. V seems to be doing well. She goes out daily and volunteers one day each week at the hospital that provided care to her husband. She makes arrangements to have her apartment painted. Her daughter visits and helps to clear out Mrs. V’s apartment in preparation for the painting. Her daughter is perplexed when she finds many bags of empty wine bottles in the cabinets. Mrs. V tells her that her father always saved these bottles and she did not want to throw them away. Since Mrs. V seems to be doing so well, her daughter helps clean the apartment and thinks little of the wine bottles.
The director of the senior center asks to speak with Mrs. V in private after one of her many trips to the casino. Several members of the center have expressed concern about Mrs. V’s drinking while on trips, and report that at the last outing she became angry when no one wanted to have “one last round” of drinks with her before leaving. Others have reported that she often wants people to spend most of the trip drinking with her in various bars. The director tells Mrs. V that she has much to offer people and suggests that she participate in a reading program for children in lieu of going to the casinos for a few months. Mrs. V becomes angry and states that she is simply trying to be a good friend. She stops attending the senior center and refuses to take calls from any of the friends who complained about her. She finds another group that takes frequent day trips, and resumes going to casinos in addition to comedy clubs.
Several weeks later, Mrs. V falls while getting off of the bus after a trip to a casino. She is taken to the hospital and is found to have a left hip fracture. She is noted to have slurred speech with alcohol on her breath in the emergency room, and her blood alcohol level is found to be 110 mg/dL. Her daughter comes to the hospital and realizes that her mother has been drinking much more than she had thought. Mrs. V is admitted to the hospital in order to have surgery to repair her hip. She reports having had “only a glass of wine” on the trip. The patient is placed on alcohol withdrawal precautions, and the orthopedic surgeon arranges for consultations with Internal Medicine, Psychiatry, and Neurology prior to surgery.
Older adults with alcohol abuse and dependence problems are far less likely to be identified as having substance use disorders than younger persons.1 Unfortunately, older adults are at high risk of serious medical and psychiatric consequences from the consumption of alcohol. These include cardiac events, stroke, peptic ulcer disease, falls, fractures, memory loss, and uncontrolled hypertension.2
It is important to recognize the diagnostic criteria for alcohol dependence, alcohol abuse, and the clinical entity referred to as problematic drinking.3,4 Alcohol dependence refers to a maladaptive pattern of drinking that results in distress, causes a significant impairment in functioning, and is accompanied by at least three symptoms from a list that includes tolerance, withdrawal, drinking more than intended, unsuccessful efforts to reduce use, spending large amounts of time drinking, reducing activities due to substance use, or persistent use despite the occurrence of problems.3 Alcohol abuse refers to a condition that involves a maladaptive pattern of use with impairment and distress, but the patient has only one complicating factor, such as persistent social, physical, or interpersonal problems, without meeting the criteria for dependence.3 Problematic drinking is a clinical term used to identify those who may be at risk for developing abuse or dependence but do not yet meet the criteria.4 For older adults, problematic drinking should be considered when the patient drinks more than one drink per day or more than seven drinks per week. Consumption of more than three drinks at one time, often referred to as binge drinking, is also cause for concern.4,5
The prevalence of alcohol abuse and dependence among older adults is difficult to identify, as many clinicians do not screen for alcohol problems and patients often minimize and deny their drinking behaviors.1,4 Several studies have shown that 2-4% of those over age 65 years suffer from either alcohol abuse or dependence. Problematic drinking occurs in up to 15% of older adults.6 Studies of hospitalized elderly persons often show rates as high as 20% for alcohol abuse and dependence.6,7 This is often identified when an older patient is admitted to the hospital for another reason but shows signs of alcohol withdrawal during his or her stay. While all pathologic patterns of drinking are cause for clinical concern, patients who meet criteria for alcohol dependence often need inpatient treatment due to the high risk of serious medical sequelae and life-threatening withdrawal.7
Risk factors for alcohol abuse and dependence in the older adult include any past history of alcohol or substance use problem.4 Recent emotional stressors including loss, bereavement, social isolation, loneliness, and boredom are associated with an increase in alcohol use that may become problematic.1,2 Many older adults with chronic pain, depression, insomnia, or anxiety are at risk for abusing alcohol.4 Medical problems and use of multiple medications are often a complex factor, as many medications interact negatively with alcohol. Older adults achieve higher blood alcohol levels and become clinically intoxicated after drinking smaller amounts than younger persons.5 This is due to a decrease in the metabolism of alcohol and the lower percentage of total body water that older adults have as compared to when they were younger. Older adults often do not realize that the two to three drinks they could once consume in the past now contain enough alcohol to cause overt intoxication, particularly confusion and poor motor coordination.4-6
Screening for problematic alcohol use is a vital part of the assessment of an older adult. A simple and direct means is to start by asking the patient directly, “How often do you have a drink containing alcohol such as wine, beer or liquor?”2 This is often perceived as nonthreatening and can be followed up with more direct questions regarding daily use, amounts, and problems related to drinking, such as falls, impairment in activity, mood, and anxiety.4,5 The clinician should be concerned about any patient who arrives for an appointment with the smell of alcohol on his or her breath, as it correlates highly with alcohol abuse or dependence. Patients with unexplained declines in hygiene, appearance, poorly controlled chronic conditions such as diabetes, hypertension, nutritional deficiencies, falls, and cognitive loss should be screened for alcohol abuse and dependence.3-6
Interventions for the older drinker range from brief supportive interventions provided in the physician’s office for the at-risk patient to inpatient treatment for acute intoxication and withdrawal.7,8 It is very important for the physician to establish an open dialogue with the patient about the health benefits of reducing or stopping drinking early, before serious problems arise. As denial is a common feature among all patients who abuse substances, interventions must be tailored to fit the needs of the individual.6-8 Medications such as naltrexone, disulfiram, and acamprosate may be helpful in some patients6,7 (Table).
Low and moderate alcohol consumption among older adults who are otherwise healthy has been associated with some potential benefits in cardiovascular status, and perhaps delaying the onset of cognitive loss.9 However, due to the large number of elderly persons at risk for problematic drinking, those who have suffered from family problems related to alcohol, and the expense related to drinking, there is no evidence to support the recommendation that older adults use alcohol for any type of therapeutic purpose.4-6
Information on alcohol and aging for clinicians and patients may be downloaded from the National Institute on Aging website at www.nia.nih.gov. The Substance Abuse & Mental Health Services Administration maintains a telephone hotline (1-800-662-4357) and a website (http://findtreatment.samhsa.gov) to assist in finding treatment providers.
Outcome of the Case Patient
Mrs. V was monitored for signs of alcohol withdrawal. She displayed a mildly elevated blood pressure of 150/85 mm Hg but did not require any medications for withdrawal symptoms. She was evaluated by an internist who noted that she was mildly anemic with a hematocrit of 30% and had mild elevations in her liver function tests (aspartate aminotransaminase 77 U/L, alanine aminotransaminase 54 U/L). These test results were attributed to her alcohol use, and it was recommended that they be repeated after a period of sobriety. Mrs. V was started on enalapril 10 mg daily for her hypertension and was medically cleared for hip surgery.
She was evaluated by a psychiatrist, who found that she initially denied that alcohol was involved in her fall and blamed the bus company for “bad service.” When asked about her husband’s death and her role as a caregiver, the patient became tearful and discussed how the couple had had a nightly ritual of choosing one of her husband’s favorite wines. They each drank one glass, often over several hours while talking or watching a movie. Mrs. V felt that drinking a glass of wine was a remembrance of her husband. She later admitted that drinking helped her feel more at ease going out. She felt embarrassed that the director of the senior center spoke to her about her drinking but felt that she could control it. She admitted during the interview that she knew she was drinking a lot, often regretting it later. Mrs. V said that she wanted to stop drinking, but felt that socializing with her friends was all related to activities involving alcohol. Mrs. V admitted to feeling lonely and felt that she would have no one to do things with. She was willing to change her pattern of use and appeared to meet criteria for alcohol abuse.
Mrs. V underwent a successful open reduction and internal fixation of her left hip and received intensive physical therapy. During her 2-week stay in the orthopedic rehabilitation unit, Mrs. V’s daughter brought an old friend, Mrs. F, to see her. Mrs. F is a widow and also openly describes herself as an alcoholic in recovery. She spoke to Mrs. V about a variety of activities that she attended that do not involve alcohol, and offered to take her out whenever she was physically ready. Mrs. F visited Mrs. V daily in the orthopedic rehabilitation unit and they made plans to socialize after discharge. Mrs. V recovered well and was discharged home. Prior to her discharge, she asked her daughter to remove all of the wine bottles from her husband’s collection so that no alcohol was in her apartment. She agreed to return to see the psychiatrist periodically due to concerns that she may have a mood or anxiety disorder.
At a 3-month follow-up visit with the psychiatrist, Mrs. V appeared neatly dressed and groomed. She had been attending a support group for widows and also volunteering at a shelter for teenage runaways. Mrs. V reported that she had not had any alcohol since the day of her hip fracture. Mrs. F had introduced her to a group of older adults in recovery from alcohol problems that visits museums and art galleries and goes to theaters. Mrs. V showed no signs of depression or anxiety and stated that she felt fortunate to have stopped drinking “with only a broken hip and a bruised ego.” After discussion with the psychiatrist, Mrs. V went back to the senior center and told the director that she was thankful for her help. Mrs. V was welcomed back by her friends at the senior center, but she told them that she felt she needed to stay with her new routine. At a 6-month follow-up visit with the psychiatrist, Mrs. V was doing well and continued to remain sober. She was offered referrals to 12-step programs while in the hospital and at follow-up visits but declined, stating that she was able to stop drinking with the support of her “sober friends.”
The author reports no relevant financial relationships.
Author Affiliations: Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: email@example.com.