Co-existing Mental Health and Alcohol Issues Among Older Adults. Dr Martin Morrissey Old Age Psychiatrist DHHS

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2 Co-existing Mental Health and Alcohol Issues Among Older Adults Dr Martin Morrissey Old Age Psychiatrist DHHS

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4 Why worry about it? The absolute number of elderly folks with alcohol misuse will increase as the population ages Relatively little attention has been paid to management and treatment specifically in older age groups There are physical and social consequences of ageing that need to be considered when dealing with alcohol use in older people

5 Risky/High risk alcohol consumption

6 For long term risk for males an average daily consumption of up to four standard drinks is considered 'low risk', five to six 'risky' and seven or more 'high risk'; for long term risk for females, an average daily consumption of up to two standard drinks is considered 'low risk', three to four 'risky' and five or more 'high risk'. For short term risk the consumption of 11 or more standard drinks for males or seven or more for females on any one day is considered 'high risk'. A standard drink is any form of beverage that contains 12.5mL or 10 grams pure alcohol (NHMRC 2001).

7 Risky/High risk alcohol consumption by age

8 Drinking patterns and ageing Abstainers and light drinkers tend to have stable consumption into older age Heavy drinkers tend to reduce consumption with age.

9 Assessing Alcohol Use in Older People Ask routinely Non-judgmental manner/questioning Think about potential exacerbating factors Corroborative History

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11 Be suspicious Declining self care Falls Squalor Cognitive impairment

12 Reported Benefits of mild/moderate alcohol use in the elderly Protective re ischaemic heart disease especially in males Reduced osteoporosis in post-menopausal women Improved cognitive functioning compared to those who abstain or heavy users

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14 I spent a lot of money on booze, birds and fast cars. The rest I just squandered. -George Best

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16 Patterns of problem drinking in Elderly The Graduates many don t make it that far The reactors response to life events The bingers

17 Health, Alcohol and Ageing Elderly more likely to suffer adverse effects of alcohol than younger people due to - declining physical health -interaction with medications prescribed for physical illness -physiological changes( metabolism)

18 National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the United States recommends that people older than 65 consume no more than one drink per day

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20 Alcohol and depression Drinking excessively causes depression and anxiety symptoms (via biological, psychological and social consequences) Rates of depression approximately 3x greater in context of alcohol misuse Alcohol often used as self medication for depression and anxiety disorders Must ask about alcohol intake as part of depression assessment Importance of treating both problems

21 Alcohol and cognitive impairment Direct toxic effects Acquired brain injury Neglect of health care Alcohol misuse compounding cognitive impairment from other causes

22 Alcohol, Thiamine (Vit B1) and brains Thiamine is required for carbohydrate metabolism A reduction in thiamine can interfere with the production of brain chemicals Alcohol abuse can result in decreased availability of thiamine by inadequate nutritional intake, decreased absorption of thiamine, impaired utilisation of thiamine by cells This is the primary mechanism involved in Wernicke s-korsakoff syndrome

23 Alcohol and driving MVA risk 3x higher in elderly even after small amount of alcohol than elderly with zero BCA Physical sequelae of MVA more pronounced in elderly

24 Points of intervention Primary prevention alcohol advise as part of community health/healthy ageing strategy Recognising at risk individuals,eg single/ separated males living alone Assertive management of those present with alcohol related health problems eg post alcohol related fall/fracture

25 Mr Unsteady 68 year old male Multiple presentations to DPM with falls Prolonged admission with impaired mobility, neglect, pneumonia, delirium Long history of alcohol misuse

26 Practical advice Set yourself a target to reduce the amount of alcohol you drink. Avoid high-risk drinking situations. Drink lower-strength beverages. Work out other things you can do instead of drinking. Involve your partner or a friend. They can help to agree a goal and keep track of your progress. Talk it over with your GP. For many people this simple step helps them to cut down their drinking.

27 Some good news Most alcoholics with cognitive impairment show at lease some improvement in brain structure and functioning within a year of abstinence. Older people appear may be more responsive to education/counselling regarding alcohol misuse Age group targeted strategies probably most effective

28 Medication and alcohol dependence in elderly Naltrexone- 1 pilot study suggested well tolerated, may decrease craving in elderly Acamprosate no evidence in elderly but some reported benefit in younger age groups Disulfiram not recommended

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30 A herd of buffalo can only move as fast as the slowest buffalo. And when the herd is hunted, it is the slowest and weakest ones at the back that are killed first. This natural selection is good for the herd as a whole, because the general speed and health of the whole group keeps improving by the regular killing of the weakest members. In much the same way, the human brain can only operate as fast as the slowest brain cells. Excessive intake of alcohol, as we know, kills brain cells. But naturally, it attacks the slowest and weakest brain cells first. In this way, regular consumption of beer eliminates the weaker brain cells, making the brain a faster and more efficient machine. That's why you always feel smarter after a few beers. Cheers