Alcoholism

Alcoholism is an illness that is a common form of chemical dependence, and is often referred to as a substance abuse disorder. As with any behavioral disorder, some people are predisposed to it, but there are also strong cultural and environmental influences. Alcoholism is associated with many poor health outcomes.

Alcoholism can be tricky to define, in part due to cultural variability in what is acceptable, both behaviorally and in the attribution of illness. Most definitions of alcoholism, as in the formulation of the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual, propose (1) that alcohol is taken more (in greater amounts or at more frequent intervals) than is personally or socially intended; (2) that seeking to use, using, and recovering from the effects of using take needed time from the fulfillment of personal, employment, or social obligations; and (3) that use persists despite advice to stop using. Such symptoms should occur repeatedly in order to meet most definitions of alcoholism. Definitions with a more medical orientation include features such as experiencing a physiological alcohol withdrawal syndrome (e.g., nervousness; agitation; increased heart rate, blood pressure, and sweating) when alcohol consumption ceases; requiring other medications (e.g., benzodiazepines such as diazepam or chlordiazepoxide); or marked tolerance to the effects of alcohol. Later, as liver function becomes compromised, older adults with alcoholism can show decreased tolerance (i.e., noticeable effects following comparatively little alcohol intake).

Alcoholism is not rare among older adults: most estimates range between 2 and 10 percent of that population. Understanding exactly how commonly it occurs can be difficult, because there are estimated to be many hidden drinkers, especially among those who are socially isolated. There is also some evidence that estimates might not be stable over longer periods, due to cohort effects; that is, attitudes toward alcohol, learned earlier, may change as young generations become older. When calculating how commonly alcoholism occurs among older adults, it is usual to distinguish two groups: alcoholics who have grown older and those in whom alcohol abuse emerges for the first time in old age. Among the latter, alcoholism can result from a combination of difficulty coping with losses (either feared or actual) and sometimes new social isolation.

Given that alcoholism is not uncommon among older adults and that it can be difficult to define without the presence of medical complications, strategies to recognize alcoholism have been proposed. A popular one is the so-called CAGE questionnaire: Have you felt the need to cut down on your drinking? Have you been annoyed by others' comments on your drinking? Have you felt guilty about drinking? Have you needed an "eye-opener"? Answering one of these positively suggests the need for further evaluation. A more detailed assessment is the twenty-five-item Michigan Inventory Questionnaire.

Another approach to identifying alcoholism is to screen for abnormalities that are detectable with standard blood tests, such as the red cell volume, the level of triglycerides or uric acid, and problems in the liver and biliary tree. Such an approach relies on a sympathetic physician who can introduce the fact that the constellation of such abnormalities is seen in people who have alcohol problems.

The medical consequences of alcoholism are legion, but a few are of special interest. Alcoholism often coexists with depression, and each exacerbates the other. Alcoholism is associated with memory impairment and even dementia. These cognitive effects can respond to cessation of alcohol consumption, and there is some evidence of amelioration with simple vitamin treatment. Alcoholism can be a cause of delirium in elderly people, especially when medical illness results in abrupt cessation of alcohol intake. Alcoholism is also implicated in falls and mobility impairment. Chronic alcohol use is well known to be associated with cirrhosis of the liver, which among its many complications includes inadequate metabolism of drugs processed by the liver or drugs bound to proteins. Drug interactions are also important. Social complications include (further) isolation, poverty, and legal difficulties.

Definitive treatment of alcoholism consists of the cessation of alcohol use. This is not commonly achieved without intense psychosocial support, such as is provided through Alcoholics Anonymous. Whether decreasing alcohol use to some minimal level can avert or militate the problems of alcoholism is a very controversial question. Supportive and nonjudgmental medical care can be a valuable aspect of the treatment of alcoholism. Physicians can judiciously prescribe medications for the treatment of anxiety and withdrawal. Access to treatment can be difficult for older alcoholics, however, especially those who are disabled or socially isolated. While the prognosis of untreated alcoholism in older adults is poor, treatment can potentially lead to amelioration. However, this is an area in need of further study.

Understood as a complex illness requiring medical and psychosocial support, and occurring often in a disadvantaged and isolated population, alcoholism in elderly people shares many features with other pervasive illnesses, such as dementia. Though treatment has proved difficult, the lessons learned from comprehensive care are likely to have resonance across a range of conditions that face an aging society. They suggest that systemic programs, individualized to accommodate varying needs and including intense psychological support, are needed to achieve effective outcomes in older adults.

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