Alcohol use disorders in elderly people–redefining an age old problem in old age
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.664 (Published 18 September 2003) Cite this as: BMJ 2003;327:664
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Dear Editor,
We welcome the rapid response of Dr. Rao (1) to our
clinical review paper on alcohol use disorders in the
elderly (2), and wish to address the points raised.
In particular, we welcome Dr. Rao’s ideas on how
mental health service planners deal with alcohol
related problems in the elderly. We wish to point out
that our paper was designed to provide a general
overview of the topic, with a view to encouraging
discussion among health care professionals from
different countries. The particular problems of the U.K.
Mental Health Service raised by Dr. Rao are important,
and highlight universal barriers to the treatment of
alcohol problems in older people, and indeed people of
all ages. We are not familiar with the ‘SIDD’ model for
severe mental illness proposed by Dr. Rao, but agree
that this appears to be a reasonable approach.
In relation to the issue of metabolism and excretion of
alcohol among the elderly we wish to reiterate our point
that, based on the limited number of studies in the
area, absorption, metabolism and excretion are not
appreciably altered in the healthy non-alcoholic elderly
(3,4). However, decreased lean body mass in the
elderly leads to an effectively smaller volume of
distribution and higher blood alcohol concentration.
Interestingly, even when Vogel-Sprott and Barrett (5)
controlled for blood alcohol concentration, they
demonstrated that alcohol-induced impairment in task
performance seemed to be age related.
Finally, Dr. Rao highlighted our omission of Naik and
Jones audit of alcohol history taking (6). We feel that the
principle involved, i.e. lack of documentation leading to
underdetection of alcohol problems, was more than
adequately illustrated with our reference to Callahan
and Tierney’s study (7).
1. Rao R, ‘Mental Health Services face tough
challenges’. BMJ rapid response, 19/09/03.
www.bmj.com
2. O’Connell H, Chin A, Cunningham C, Lawlor BA.
‘Alcohol use disorders in elderly people-redefining an
age old problem in old age’. BMJ: 2003;327:664-7.
3. Scott RB. Alcohol effects in the elderly. Compr Ther
1989;159:213.
4. Vestal R, McGuire EA, Tobin JD et al. Ageing and
ethanol metabolism. Clinical Pharmacology and
Therapeutics 1977:21;343-54.
5. Vogel-Sprott, Barrett P. Age, drinking habits and the
effects of alcohol. Journal of Studies on Alcohol.
1984;45:517-21.
6. Naik PC, Jones RG. Alcohol histories taken from
elderly people on admission. BMJ 1994;1308:248.
7. Callahan CM, Tierney WM. Health services use
among older primary care patients with alcoholism. J
Am Geriatr Soc 1995;43:1378-83.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
It was interesting to read the article of
O'Connell,Chin,Cunningham et al(BMJ 2003), alcohol use disorder in elderly
people-etc[1]. My comment is that still alcohol use disorder is under-diagnosed, whether in the elderly, or in younger generation. Also still
patients use their defence mechanisms, like denial and rationalization. Our
diagnosis depends on history from patients, relatives, police records, like
driving under the effect of alcohol, otherwise CAGE,MAST-G..etc depend on
cooperation of the patient. Biochemical investigations,like GGT,MCV,Hb
A1c..are not specific,but might help in the diagnosis in a patient who
might be alcoholic? It was mentioned that plasma level of acetate has
high level of sensitivity and specificity[2].
My concern as a Psychiatrist is that we ought to advise the alcoholic patient in
UK to report to DVLA (Driving & Vehicle Licensing Agency) in Swansea
about his drinking pattern[3]. In that case we are in difficult situation
with the possibility of under-diagnosis of alcoholic patients.
Thanking you,
Yours sincerely,
AK.Al-Sheikhli,MRCPsych,DPM
References,
1.O'Connell H,Chin Avi-Vyrn,Cunningham C etal,Alcohol use disorder in
elderly people-redefining an age old problem in old age,BMJ,2003;327:664-
667.
2.Girela E,Villanueva E,Hernadez-Cueto C,etal,Comparison of the CAGE
questionnaire versus some biochemical markers in the diagnosis of
alcoholism,Alcohol and Alcoholism,1994,Vol 29,337-343.
3.Harris M,Psychiatric conditions with relevance to fitness to drive
,Advan. Psychiatr. Treat,2000,6,261-269.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
O’Connell and colleagues rightly highlight the ‘silent epidemic’ of
alcohol use disorders in elderly people (1), but the role of mental health
services may have been understated.
Services for older people with alcohol misuse face considerable
challenges. The United Kingdom 2001 General Household Survey found that
15% of men and 6% of women reported drinking above recommended ‘sensible’
limits of 21 and 14 units of alcohol respectively, during the previous
week (2). This may be an underestimate, given that the survey relies on
self report rather than other methods of obtaining information. As
parameters defining ‘sensible’ drinking do not fall with age, it is also
likely that older people may be at greater risk from the hazards from the
same levels of alcohol intake. As pointed out in the review, elderly
people are more sensitive to the harmful effects of alcohol than their
younger counterparts. However, it is inaccurate to state that metabolism
and excretion are ‘largely unchanged’, as it is known that there is a
reduced body water to fat ratio, decreased hepatic blood flow, a decreased
rate of hepatic alcohol metabolism and reduced renal clearance with aging.
Reasons for under-detection and misdiagnosis are explored, but one of
the landmark studies in this area has been left out. This was the striking
finding that a quantitative alcohol history was taken in only 2 out of 56
people aged 65 and over, admitted with an acute medical condition to a
Nottingham hospital(3). It is all the more relevant in light of alcohol
misuse being present in 15 per cent of liaison psychiatry referrals to an
inner city London teaching hospital, with 25 per cent of referrals with
alcohol misuse in the same study showing a depressive disorder (4).
Unfortunately, the review article does not do justice to the
implications of alcohol misuses for mental health services. Alcohol
remains a legal and readily available drug that is taken outside the
auspices of medical care; mental health problems such as harmful drinking
and alcohol dependence do not fall within the remit of the Mental Health
Act, unless accompanied by a comorbid mental disorder, commonly depression
or dementia.
Mental health service planners for older people who misuse alcohol
are left with a dilemma. One of the possible strategies is to incorporate
older people into dual diagnosis services, so that both alcohol misuse and
mental disorders can be treated together. The operational framework for
managing alcohol misuse could run along similar lines to severe mental
illness. A proposed model that is currently widely used in the United
Kingdom is the ‘SIDD’ definition, comprising dimensions of Safety,
Informal/formal care, Diagnosis, Disability and Duration (5). Sadly, such
services for older people are few and far between.
The road to planning, implementing and evaluating mental health
services for older people with alcohol misuse requires a clearer vision.
At present, vulnerable older people who require assessment and treatment
are stranded between parallel medical and mental health services.
At best, there is a limited place for them in whatever dual diagnosis
services exist. At worst, we have done no more than scratch the surface of
a problem that will continue to weigh heavily upon services that remain
ill equipped to meet its needs.
(1) O’Connell H et al. Alcohol use disorders in elderly
people—redefining an age old problem in old age. BMJ 2003;327:664-667
(2) Walker A et al. Living in Britain. Results from the 2001
General Household Survey. 2002; London:Office of National Statistics
(3) Naik PC, Jones RG. Alcohol histories taken from elderly people
on admission BMJ 1994;1308:248
(4) Rao R. ‘Sadly confused’: the detection of depression and dementia
on medical wards. Psychiat. Bull. 2001;25: 177-179
(5) Department of Health. Building Bridges: A Guide to Arrangements
For Inter-agency Working For the Care and Protection of Severely Mentally
Ill People. 1995;London: Department of Health
Competing interests:
None declared
Competing interests: No competing interests
Alcohol Detoxication among the Elderly
Editor- O'Connell et al* , in a literature review, claim that alcohol
use disorders are common in the elderly and advocate inpatient
detoxification, presumably for those dependent.However they do not
indicate where detoxification should be carried out. May I suggest that
this process take place, for reasons of clinical safety, in general
medical beds rather that in psychiatric units or hospitals as is still too
frequently the case, at least in Ireland.
*O'Connell H,Ai-Vyrn,Cunningham C, Lawlor B.Alcohol use disorders in
elderly people- redefining an old age problem in old age.BMJ 2003;327:664-
7
Competing interests:
None declared
Competing interests: No competing interests