Review
Alcohol use disorders in the elderly: A brief overview from epidemiology to treatment options

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Abstract

Alcohol-use-disorders (AUDs) afflict 1–3% of elderly subjects. The CAGE, SMAST-G, and AUDIT are the most common and validated questionnaires used to identify AUDs in the elderly, and some laboratory markers of alcohol abuse (AST, GGT, MCV, and CDT) may also be helpful. In particular, the sensitivity of MCV or GGT in detecting alcohol misuse is higher in older than in younger populations. The incidence of medical and neurological complications during alcohol withdrawal syndrome in elderly alcoholics is higher than in younger alcoholics. Chronic alcohol abuse is associated with tissue damage to several organs. Namely, an increased level of blood pressure is more frequent in the elderly than in younger adults, and a greater vulnerability to the onset of alcoholic liver disease, and an increasing risk of breast cancer in menopausal women have been described. In addition, the prevalence of dementia in elderly alcoholics is almost 5 times higher than in non-alcoholic elderly individuals, approximately 25% of elderly patients with dementia also present AUDs, and almost 20% of individuals aged 65 and over with a diagnosis of depression have a co-occurring AUD. Moreover, prevention of drinking relapse in older alcoholics is, in some cases, better than in younger patients; indeed, more than 20% of treated elderly alcohol-dependent patients remain abstinent after 4 years. Considering that the incidence of AUDs in the elderly is fairly high, and AUDs in the elderly are still underestimated, more studies in the fields of epidemiology, prevention and pharmacological and psychotherapeutic treatment of AUDs in the elderly are warranted.

Introduction

Around 2 billion people worldwide consume alcoholic beverages. It has been shown that alcohol causes approximately 3.8% of all deaths worldwide (6.3% of men and 1.1% of women) and accounts for 4.6% of the global burden of disease (7.6% of men and 1.4% of women) (Rehm et al., 2009). In most European countries, alcohol consumption was responsible for 14.6% of all premature adult mortality (17.3% for men and 8.0% for women); moreover, in Eastern Europe, particularly in some industrialized cities of Russia, alcohol has been shown to be responsible for more than half of all deaths in younger men (15–54 years), and was a major cause of death in older men (55–74 years) and in women.

Over 76 million people have alcohol-use disorders (AUDs) consisting in alcohol dependence, alcohol abuse and dependence or harmful drinking. This latter definition consists of alcohol intake > 14 drinks per week or > 4 drinks per occasion for men and > 7 drinks per week or > 3 drinks per occasion for women, where a drink corresponds to 10–12 g of pure alcohol (Schuckit, 2009). AUDs are commonly found in all developed countries, and prevail in men; namely, AUDs were frequently found in Chinese, German, Thai, and US men, and in Brazilian and US women (Rehm et al., 2009). The lifetime risk of AUDs in men is more than 20%, with a risk of about 15% for alcohol abuse and 10% for alcohol dependence (Schuckit, 2009).

Almost 50% of the elderly (aged over 65) and almost 25% of subjects over 85 years old drink alcohol. AUDs afflict 1–3% of elderly subjects, and represent a cause of physical and psychiatric morbidity and social distress (Blazer and Wu, 2009). In addition, up to 30% of older patients hospitalized in divisions of general medicine, and up to 50% of those hospitalized in psychiatric divisions present AUDs.

The aim of the present review is to briefly analyze AUDs in the elderly population (> 65 years old). A detailed discussion of prevention, epidemiology (that would imply the distinction between alcohol dependence, alcohol abuse and harmful drinking), pathogenesis, diagnosis and treatment, including psycho-pharmacological and social interventions, would go beyond the limits of this mini-review. Therefore, we mainly focused on alcohol-related disease that follows chronic misuse, even though other issues have been briefly dealt with.

Section snippets

Pathogenesis of alcohol related damage

After its ingestion, ethanol (almost 10%) is metabolized by the alcohol-dehydrogenase (ADH) in the gastric mucosa, undergoing the so called “first-pass metabolism”. The remaining amount leaves the stomach and is rapidly absorbed by the upper small intestine. Then, via the portal vein, it reaches the liver, where it is largely metabolized to acetaldehyde by ADH in cytosol, and by cytochrome P-450-IIE1 in microsomes (Lieber, 2005). Acetaldehyde is quickly converted to carbon dioxide and water,

Diagnosis of AUDs

Several epidemiological studies have shown that the diagnosis of AUDs in the elderly is underestimated (Moore et al., 2002). This represents a worrying bias, as AUDs in the elderly have a greater probability to respond to treatment than those developed at an earlier age (6). There is a variety of conditions whose evaluation should include screening for a potential AUD such as: a) worsening of a chronic disease (hypertension, diabetes mellitus, osteoporosis, macrocytic anemia,

Alcohol related diseases

The adverse effects of short-term (acute alcohol intoxication) and long-term (chronic alcohol abuse) excessive drinking outweigh its reputedly beneficial effects. Even an isolated episode of acute ethanol intoxication prior to another insult (i.e., traumatic injury resulting from driving under intoxication, burns) may exacerbate the suppression of the host defense and increase susceptibility to infections. Chronic alcohol abuse is associated with multiple diseases, involving liver, pancreas,

Detoxification

The incidence of medical (myocardial ischemia, aspiration pneumonia, arrhythmias, orthostatic hypotension) and neurological complications (hallucinations, delirium tremens, dizziness, convulsions) during alcohol withdrawal syndrome (AWS) in elderly alcoholics is higher than in their younger counterpart (Letizia and Reinbolz, 2005). Controlled clinical studies evaluating the efficacy of medications for the treatment of AWS in elderly patients are not available. However, in order to avoid any

Conclusions

The incidence of AUDs in the elderly is fairly high; however, AUDs in the elderly are underestimated, and data collection of alcohol-related harm in older adults by the European Union and also by the World Health Organization is incomplete and sparse (Lee et al., 2008). Filling this scientific gap may identify cost-effectiveness intervention for AUDs in older adults, improving the sustainability of public finances and reducing health inequalities (Scafato, 2010); additional research is needed

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