Alcohol Use Disorder Among Older Adults
Publication Date: January 1, 2020
Last Updated: March 14, 2022
RECOMMENDATIONS
1. For women 65 years of age or older, no more than 1 standard drink per day with no more than 5 alcoholic drinks per week is recommended; for men 65 years of age or older, no more than 1–2 standard drinks per day, with no more than 7 per week in total is recommended. Non-drinking days are recommended every week. (Moderate, Strong)
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a. Depending upon health (i.e., dementia; Parkinson’s Disease; hemorrhagic stroke; epilepsy; cardiac dysrhythmias; hypertension; sleep apnea; COPD; liver disease; pancreatitis; GI and breast cancers; compromised balance or mobility), frailty, and medication use (i.e., benzodiazepines, opioids, gabapentinoids, sedating antidepressants) some adults should adhere to these recommended lower levels of alcohol consumption before they reach the age of 65.
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b. As the older adult ages, especially those with comorbidities (as above), alcohol should be further reduced to 1 drink or less per day, consumed on fewer occasions, and consideration should be given to abstaining from alcohol.
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c. It is recommended that older adults do not drink when operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or potentially dangerous physical activity; preparing for bed or having to arise at night; making important decisions; while responsible for the care of others; if living with serious physical or mental illness or a substance use disorder.
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d. Older adults who choose to drink alcohol should be advised to slow their pace of consumption and lower their total alcohol intake at each sitting in order to decrease the risk of harm. Alcoholic drinks are best taken with food and not on an empty stomach and should be alternated with caffeine-free, nonalcoholic beverages. They should be completely avoided in potentially risky situations or activities.
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2. Increase awareness of the risk of alcohol use through labeling that indicates:
a. Standard drink content of the product;
b. National Low Risk Drinking Guidelines for both adults and older adults; and
c. A warning of alcohol related risks and harms.
(, )b. National Low Risk Drinking Guidelines for both adults and older adults; and
c. A warning of alcohol related risks and harms.
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3. As a harm reduction strategy for chronic heavy drinkers, it is recommended that at least 50 mg of thiamine supplementation daily be used to prevent Wernicke-Korsakoff syndrome, progressive cognitive decline and increased frailty. (Low, Strong)
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4. All patients (including older adults) should be screened for alcohol use at least annually (i.e., as part of his or her regular physical examination) and at transitions of care (e.g., admission to hospital). Screening should be conducted more frequently if consumption levels exceed the low-risk drinking guidelines, there are symptoms of an AUD, there is a family history of AUD, the patient currently experiences anxiety and/or depression, caregivers express concern, or the older adult is undergoing major life changes or transitions. (Moderate, Strong)
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5. Older adults should be asked about alcohol use in all care settings including: hospitals, rehabilitation facilities, home health care, community services, assisted living and long-term care facilities, and specialized programs. (High, Strong)
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6. Ensure that screening for AUD in older adults is age appropriate and employs active listening, is supportive, accounts for memory impairment or cognitive decline, is non-threatening, non-judgmental, and non-stigmatizing, and recognizes that DSM–5 criteria will underidentify due to potentially reduced occupational or social obligations. (Moderate, Strong)
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7. Request consent to discuss the patient’s alcohol use and its impact with family, friends, and other caregivers. (Low, Strong)
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8. Older adults who screen positive for an AUD should be assessed by an appropriately trained health care provider. (Moderate, Strong)
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9. A comprehensive assessment is indicated for all older adults who have an AUD, have signs of harmful use, or who present with acute intoxication. The assessment should include: the use of a standardized alcohol use questionnaire to determine quantity and frequency of alcohol use and potential harms; a comprehensive assessment of medication and other substance use; determination of the presence of another substance use disorder; evaluation of physical, mental, and cognitive capacity, nutrition, chronic pain, social conditions, family/ social supports, and overall functioning; collateral history.The assessment should be performed regardless of physical, mental, or cognitive co-morbidities with modifications as deemed appropriate. (Moderate, Strong)
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10. Assess older adults with AUD for cognitive impairment using a validated tool every 12 months or as indicated. In cases of cognitive impairment, repeat the cognitive evaluation at 6 and 12 months after a reduction or discontinuation of alcohol, to assess for evidence of improvement. The treatment plan should specify the timeline and procedure for ongoing evaluation of clinical outcomes and treatment effectiveness. (Moderate, Strong)
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11. The least intrusive or invasive treatment options, such as behavioural interventions, should be explored initially with older adults who present with a mild AUD. These initial approaches can function either as a pre-treatment strategy or as treatment itself. (High, Strong)
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12. Routinely offer alcohol behavioural intervention and case management with pharmacological treatment (e.g., anti-craving medication) as it may improve the efficacy of primary care treatment. (Moderate, Strong)
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13. Naltrexone and acamprosate pharmacotherapy can be used to treat AUD in older adults, as indicated, with attention to contraindications and side effects. Naltrexone may be used for both alcohol reduction and abstinence, while acamprosate is used to support abstinence. In general, start at low doses and titrate slowly, with attention to open communication with the patient. Initiation may be done in the home, hospital, during withdrawal management, or in long-term care with subsequent transition to an appropriate placement. (High, Strong)
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14. All older adults with AUD, and their caregivers and support persons, should be offered psychosocial treatment and support, as indicated, as part of a treatment plan. (Moderate, Strong)
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15. Use the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to screen for those requiring medical withdrawal management (prior delirium, seizures, or protracted withdrawal). Patients who are in poor general health, acutely suicidal, have dementia, are medically unstable, or who need constant one-on-one monitoring should receive 24-hour medical, psychiatric, and/or nursing inpatient care in medically-managed and monitored intensive treatment or hospital settings. (High, Strong)
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16. In the management of alcohol withdrawal in older adults, it is best to use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) symptom score with protocols using a shorter-acting benzodiazepine such as lorazepam. One should also pay close attention to comorbidities to avoid complications. (High, Strong)
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17. As a harm reduction strategy for older adults in controlled environments, where medical withdrawal is not available or deemed appropriate, it is recommended that a managed alcohol taper be considered. Individualize the taper by 1 standard drink every 3 days (aggressive tapering), weekly (moderate tapering), or every 2–3 weeks (mild tapering) with CIWA-Ar monitoring to keep the withdrawal symptom score < 10. The approach should be individualized, incremental, and with an indeterminate timeline. (, )
[Consensus]
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18. To prevent the development of Wernicke’s encephalopathy during withdrawal, at least 200 mg of parenteral thiamine (IM or IV) should be administered daily for 3–5 days. (Low, Strong)
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19. Health care practitioners, older adults, and their families should advocate for adequate access and funding for treatment for AUD, specifically access to pharmacotherapy (naltrexone and acamprosate) and psychosocial therapies. (, )
[Consensus]
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20. Treatment response for AUD should be monitored though laboratory measures such as gamma-glutamyl transferase (GGT) and Mean Cell Volume (MCT). (Moderate, Strong)
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21. The severity and management of concurrent physical and mental health conditions (including co-occurring psychiatric disorders, suicide risk, and cognitive disorders), as well as significant social transitions in the individual or family, should continue to be reviewed and monitored regardless of continuance, reduction, or cessation of alcohol use. (Moderate, Strong)
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22. Peri-operative elective surgical management should include medically supported withdrawal or alcohol use taper pre-operatively, with post-operative treatment and consideration of anti-craving medication. (Low, Strong)
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Recommendation Grading
Overview
Title
Alcohol Use Disorder Among Older Adults
Authoring Organization
Canadian Coalition for Seniors’ Mental Health
Publication Month/Year
January 1, 2020
Last Updated Month/Year
February 2, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Correctional facility, Hospital
Intended Users
Psychologist, addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D019973 - Alcohol-Related Disorders
Keywords
opioids, Alcohol Withdrawal, alcohol use disorders, benzodiazepines, cannabis
Source Citation
Butt PR, White-Campbell M, Canham S, Johnston AD, Indome EO, Purcell B, Tung J, Van Bussel L. Canadian Guidelines on Alcohol Use Disorder Among Older Adults. Can Geriatr J. 2020 Mar 30;23(1):143-148. doi: 10.5770/cgj.23.425. PMID: 32226573; PMCID: PMC7067152.