Assessing Alcohol and Substance Abuse in the Elderly

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In the late 1960s Cahalan and his associates developed a survey assessment instrument for alcohol consumption and problems. It assessed alcohol consumption using three different scales: (1) the usual number of drinks of beer, wine, and distilled spirits consumed "nowadays," as reported in drinks per day, week, month, or year; (2) the number of drinks of beer, wine and distilled spirits consumed the day before completing the questionnaire; and (3) the regularity of alcohol consumption on specific days of the week. For example, a respondent may indicate that, in a typical week, he or she drinks one glass of wine during the evenings and two drinks each on Friday and Saturday night. Thus, this individual, on average, drinks nine drinks a week, which then usually is translated into drinks per year.

Independently of consumption, respondents indicate the frequency (e.g., never, once per week, month, or year) of experiencing alcohol problems. These items assess the frequency with which alcohol affects physical, psychological, or social functioning. In general, convictions for drunk driving and alcohol-related traffic accidents are weighted more heavily than other types of problems. Although they reflect some components of a DSM-IV diagnosis of alcoholism, they do not permit such a diagnosis, which requires the use of a diagnostic interview.

The shortest and simplest self report of alcohol abuse is the four-item CAGE instrument, in which a positive response to two or more of the items suggests alcohol abuse. The items assess feeling that one should drink less, being annoyed by others' criticizing one's drinking, feeling guilty about drinking, and drinking in the morning. The items have good face validity, yet this instrument does not appear to be sensitive in older populations. The Michigan Alcoholism Screening Test (MAST) for older adults is a much longer (24-item) instrument that has been validated on the hospitalized elderly but may not be practical for screening outside hospitalized populations. It should be noted that other versions of the MAST have not been equally valid in all populations tested.

The use of self-report surveys of alcohol consumption and problems may prove difficult, especially with the elderly. However, for the general population, Mi-danik concluded in 1988 that ''the validity of self-

Assessment of Mental Health in Older Adults reports is not an either/or phenomenon." There is no "gold" standard against which to compare self-reports, only a variety of "lead" standards such as collateral reports, diaries, official records, laboratory tests, or interviews. All of these methods assess overlapping but nonisomorphic aspects of an individual's alcohol use. Sobell and Sobell noted in 1990 that the relevant issue is the extent of discrepancy among sources of information that are being used to investigate a given research question. The latter observation may be especially relevant for the elderly.

Tobacco, alcohol, and prescription drugs (usually anxiolytics) are the most abused drugs in the elderly. Indeed, alcohol consumption both reduces thiamine uptake and interacts with prescription drug use, a fact that is further complicated by the reduced capacity of elderly persons for clearing such drugs. Thus, use of both types of substances may carry a risk for health problems that increases with age. Moreover, the elderly may not recognize that their relatively nonprob-lematic levels of consumption at younger ages may cause problems in later life.

While drinking has been shown to decline with age, this may not be a reliable predictor of future trends since recent research has shown that changes in drinking patterns appear to be more closely associated with period rather than age effects. These considerations may render assessment of risk for problem drinking (with its attendant drug interactions) more difficult in the elderly.

In 1997, Atkinson argued that the relatively low reported rates of alcoholism in those over the age of 60 (no more than 2% in men and less than 1% in women) may underestimate the actual prevalence of problems) largely due to a failure to accurately report consumption and problems in surveys. The "discrepancy problem'' may be more pertinent among the elderly than in younger populations. Thus, there may be special difficulties with self-report in the elderly, with a problem/reported problem ratio perhaps increasing with age. This is further complicated by cohort effects, with younger cohorts more willing to acknowledge problems than older ones, if such cohort differences are maintained in later life.

Excluding daily blood alcohol level testing, there are several reasonable supplements to self-report in the elderly. First, there is a pattern of cognitive deterioration associated with alcohol abuse in the elderly that is distinct from that associated with senile dementias such as Alzheimer's and even Korsakoff's Syndrome (which involves irreversible brain damage due to long-term severe alcohol abuse). This pattern is summarized in DSM-IV as involving deficits in memory, language, motor functions, object recognition (without organic motor or sensory impairment), and abstract thinking and planning. Evidence has supported this diagnostic approach with an additional strong finding that name-finding was almost completely spared in alcohol-related dementias, in contrast to Alzheimer's Disease, in which dysnomia is pronounced.

Second, and perhaps most helpful, are in-home assessments. In addition to standard consumption interviews and listing the prescriptions and home remedies that the elderly use, other data and relatively unobtrusive observations can be employed. These include a history of falls, grooming, odors present in the house (also, obviously, useful for an assessment of tobacco use), bruises at the level of furniture, tremors, incontinence, and many others (many of which could be associated with non-alcohol-related dementias or depression). Naturally, such an assessment would require considerable training and would obviously be available only for that minority of the elderly who receive home care from outside agencies.

Unfortunately, there is no good way of assessing the dependence on prescription tranquilizers (principally benzodiazepines) in the elderly unless withdrawal symptoms, such as extreme anxiety and irritability, occur since dependence is not typically associated with dose increase. Such dependence is more frequent among elderly women than men. Signs of toxicity from long-term use are easily mistaken for other disorders of the elderly, such as memory loss and other cognitive impairments, as well as problems with mobility. It is likely that alcohol and drug abuse may reflect the levels of stress in elders' lives.

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