GERO 522 Week 5: Alcohol Dependence in Older Adults

• Objectives
• Introduction
• Prevalence and Impact of Alcohol Use Disorders in Late Life
• Early- And Late-Onset Disorders.
• Comorbidity with Other Disorders
• Screening for Alcohol Problems Among Older Adults
• Theories of Etiology and their Relationship to Intervention
• Maximizing Effectiveness of Interventions with Older Adults
• Adapting Therapy to Older Adults
• Psychological and Biological Interventions
• Group Therapy
• Effectiveness of Treatment
• Biological Aspects
• Comparing Treatment Approaches in Younger Subjects
• Age-Related Treatment Approaches for Older Adults
• Conclusion
• Cyberclass
• References

Readings

• Knight (1992, on reserve) Lana
  
  Internet: see diagnostic criteria. Check sites for info and support.

• To understand the prevalence and impact of alcohol problems in the elderly.
• To recognize how alcohol problems of older people may differ from younger people.
• To gain familiarity with the possible causes of alcohol problems in the elderly, as well as the difference between early and late onset alcohol problems.
• To understand basic treatment approaches to alcohol problems in the elderly.

Introduction

This week's lecture was developed by Derek Satre, M.A.. Please click on his name to read his biosketch.

Aging and Alcohol Abuse

Although rates of alcohol abuse and dependence among older adults are lower than among younger adults, the negative effects of alcohol misuse among older adults remain substantial. This chapter summarizes what is currently known about alcohol dependence (alcoholism) in older adults, emphasizing recent research and clinical observations regarding the effectiveness of different treatment approaches. In the first sections, etiology, prevalence and impact of alcohol use disorders in older adults are discussed, including ways in which these problems may differ in older and younger adults. Differences between early- and late-onset alcoholism in older people, and comorbidity rates are also presented. Discussion of treatment begins with a consideration of how theories of etiology, including psychological and biological models, affect intervention. Treatment outcome studies are also presented. In this discussion, group treatments will be emphasized. Lastly, the issue of whether age-specific group treatment is more effective for older people than mixed-age treatment is addressed, and suggestions are offered for future directions in research.

Read the FAQ's on Alcohol Abuse and Alcoholism to gain an understanding of this issue for the general population. Then learn more about Aging and Alcohol Abuse at the National Institute on Aging web.

Prevalence and Impact of Alcohol Use Disorders in Late Life

Alcohol abuse and alcohol dependence (alcoholism), the two alcohol use disorders described in the DSM-IV, (see link below for criteria), , are significant problems among older adults in the United States.

What Is a Drink ? A standard drink is: One 12-ounce bottle of beer* or wine cooler One 5-ounce glass of wine 1.5 ounces of 80-proof distilled spirits. *Beer ranges considerably in its alcohol content, with malt liquor being higher in its alcohol content than most other brewed beverages.

Although both entail excessive use of alcohol, dependence is the more severe of the two diagnoses. (Alcohol dependence will be the main focus of this chapter, although some overlap in discussion will be necessitated by overlaps in the treatment literature). The distinguishing feature of alcohol dependence is "a cluster of cognitive, behavioral and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems" (American Psychiatric Association DSM-IV, 1994, p. 176).

The negative impact of the two disorders on health is significant. Excessive alcohol consumption has been associated with numerous physical and psychological problems in older people, including liver damage, heart disease, stroke, malnutrition, accidental injury, dementia, depression, and suicide. (see Bucholz, Sheline, and Helzer, 1995, for a review). Also, even small quantities of alcohol consumed may be dangerous if taken in conjunction with the wrong medications. Because older adults frequently take multiple medications, adverse drug and alcohol interactions are of special concern (see link below).

How Alcohol and Drugs Interact

Institute of Alcohol Studies

These problems provide a compelling reason to seek a greater understanding of the etiology, features and treatment of excessive late-life alcohol use. Although alcohol abuse and dependence have been widely studied in younger populations, relatively little attention has been paid to alcohol-related problems in late life. Fortunately, some aging organizations (e.g. American Society on Aging, National Council on Aging) have begun advocacy efforts to address the hidden problem of Substance Abuse Among Older Adults In addition, many studies have failed to compare younger drinkers to older ones (Bucholz et al., 1995). However, one difference has been observed repeatedly--older adults drink less than young adults. Rates of both alcohol abuse and dependence decreased with age (see figure below).

Among those who currently drink, data from the National Health Interview Survey (1990) indicate that 13.6 percent of men and 3.4 percent of women have had a heavy level of alcohol consumption in the past two weeks. The distribution of these heavier drinkers by sex and age is shown in the figure below.

Several explanations have been offered for the apparent decline in alcohol consumption with age. The most prominent of these are: the mortality hypothesis, which states that heavy drinkers die earlier, and as a result do not appear in surveys of late-life drinking; the morbidity hypothesis, which holds that older adults limit their intake of alcohol due to increased medical problems that make drinking uncomfortable or unsafe; the biological hypothesis, which proposes that normal biological changes reduce the amount of alcohol that older adults can comfortably consume; the cohort hypothesis, which suggests that historical factors such as prohibition may make the current elderly cohorts less inclined to drink than later generations; the maturation hypothesis, which claims that alcoholism is a self-limiting disease and that with age heavy drinking goes into spontaneous remission; and the measurement hypothesis, which offers that prevalence rates in elderly samples may be artificially low due to problems in accurately measuring the drinking behavior of older adults (see Stall, 1987, for a review).

Among these theories, the issues of cohort and measurement effects highlight the difficulties inherent in obtaining a reasonably accurate prevalence estimate of late-life problem drinking. Addressing the measurement issue, Graham (1986) discusses the shortcomings of existing instruments used to measure alcohol use in older people. Graham points out that self-report measures require accurate memory for past consumption, the ability to do mental averaging, and a willingness to disclose information about personal behavior of which others may not approve. This may result in artificially low prevalence rates in epidemiological studies, and in clinical contexts may lead to underreporting of drinking behavior by older adult clients. Cognitive decline observed in clinical samples of older drinkers also compounds the difficulty of obtaining accurate self-reports, as well as the fact that older adults may need to drink less than younger adults to experience a comparable effect, due to physiological changes with age (Beresford & Lucey, 1995). Thus, even an accurate measurement of consumption does not provide a valid indicator of intoxication level. In clinical settings, this underreporting or inaccurate measurement of drinking may result in missed opportunities for intervention.

Evidence for the cohort hypothesis has been found in the results of three longitudinal studies indicating that drinking patterns are relatively stable over time, even into old age. (Christopherson, Escher, & Bainton, 1984; Glynn, Bouchard, LoCastro, & Laird, 1985; Fillmore & Midanik, 1983). Glynn and associates even found a slight increase in drinking problems over time, in a nine-year study with 2,100 community-dwelling men born between 1892 and 1945. One disturbing implication of these findings, when considered in light of the differences in consumption rates found in cross-sectional studies, is that rates of both alcohol abuse and dependence may be much greater in future cohorts of elderly if current heavy-drinking younger cohorts grow older while maintaining present consumption levels. Even if current alcoholism rates remain stable, however, the number of older alcoholics is projected to double between 1990 and 2030 (see chart below), from 1.5 million to 3.0 million older alcoholics (Beresford, 1995). Under either scenario, the increasing number of older alcoholics highlights the need for greater attention to treatment research.

 

Resource: National Center on Addiction and Substance Abuse (CASA)

As the prevalence rates cited above also make clear, rates of alcohol dependence are lower for women than for men, across all age groups. Reasons for this difference are not clear, but may include both biological and psychological factors: greater social stigma associated with female drinking, lower physiological tolerance for alcohol (Wilsnack, Vogeltanz, Kiers & Wilsnack, 1995), and sex differences in many of the risk factors (see table with risk factors below) associated with alcoholism such as aggressive and antisocial behavior, (Hawkins, Catalano & Miller, 1992). These difference in prevalence rates between men and women may have certain treatment implications, which will be considered later.

 

Risk Factors for Alcohol Abuse Among Older Adults
Risk Factor	Relationship
Gender	Studies consistently indicate that older men are much more likely than women to have alcohol-related problems.
Loss of Spouse	Alcohol abuse is more prevalent among older adults who have been separated or divorced and among men who have been widowed
Other Losses	Other losses of aging such as death of family members or friends, losses associated with retirement, chronic illness, or disability
Health care setting	The prevalence of alcoholism is between two and 15 percent among older adults living in the community but rises to between 18 and 44 percent for those in general medical and psychiatric inpatient facilities.
History of substance abuse	Those who have a substance abuse disorder earlier in life are more likely to experience a recurrence later in life.
Comorbid Psychiatric Disorders	Mood disorders may be precipitating or maintenance factors in late-onset drinking
Family History	Genetic factors are important in alcohol-related behaviors
Concomitant Substance Abuse	Older adults who use nicotine and psychoactive prescription medicines are more likely to abuse alcohol.

Early and Late-Onset Disorders

In discussing causes, features and treatment approaches of alcohol dependence in late life, it is important to distinguish between late-onset and early-onset disorders. There is general agreement in the literature that approximately one-third of all older alcoholics are late-onset alcoholics, and two-thirds are early-onset, with certain differences noted between the two groups (Atkinson, Tolson & Turner, 1990). There is some suggestion in epidemiological studies that late-onset drinking may be an increasing problem in women. In one study which combined data from five Epidemiological Catchment Area sites, 28% of female alcoholics reported that their drinking problems began after age 49, compared to only 14% of male alcoholics in the same age group (Bucholz et al., 1995. For both males and females, the percentage of late-onset drinkers increased with age, with women showing a greater increase than men. While these findings may be partially explained by increased mortality of males in their seventies when compared to women, it also illustrates the magnitude of the problem of late-onset drinking in women. A study by Gomberg (1992) that compared older male and female alcoholics also suggests increasing alcohol problems for women in late life: 38% of females in treatment, but only 4% of males reported that their drinking problem began in the previous ten years. These studies suggest that the older the alcoholic is, the more likely the problem is of recent onset--an important consideration in treatment planning, as will be discussed further. If you are interested in substance abuse among older women you will want to read Under the Rug: Substance Abuse and The Mature Woman. This report was the first comprehensive analysis of substance abuse and addiction (e.g. alcohol, prescription drugs, tobacco) among American women age 60 and older. The report was issued by the National Center on Addiction and Substance Abuse (CASA) at Columbia University. CASA is a unique multidisciplinary think/action tank that seeks to assess the economic and social costs of substance abuse and identify what works in prevention, treatment, and law enforcement.

Early-onset drinkers are more likely to have had a family history of alcoholism and to have a history of arrests. Late-onset drinkers are more likely to suffer from serious health problems (Schuckit & Pastor, 1979). In a study of 170 older adults in a day treatment program for elderly alcoholics, Schonfeld and Dupree (1991) matched 23 early-onset subjects to 23 late-onset subjects by age and sex. They found that early-onset alcoholics reported being intoxicated twice as often as late-onset subjects, expected less success from the program, and were less likely to complete treatment.

 

Clinical Characteristics of Early and Late Onset Problem Drinkers
Variable	Early Onset	Late Onset
Age at Onset	Various, e.g., less than 45	Various, e.g., greater than 55
Gender	Higher proportion of men than women	Higher proportion of women than men
Socioeconomic Status	Tends to be lower	Tends to be higher
Drinking in response to stressors	Common	Common
Family history of alcoholism	More prevalent	Less prevalent
Extent and severity of alcohol problems	More psychosocial, legal problems, greater severity	Fewer psychosocial, legal problems, lesser severity
Alcohol-related chronic illness (e.g., cirrhosis, pancreatitis, cancers)	More common	Less common
Psychiatric comorbidities	Cognitive loss more severe, less reversible	Cognitive loss less severe, more reversible
Age-associated medical problems aggravated by alcohol (e.g., hypertension, diabetes, drug-alcohol interactions)	Common	Common
Treatment compliance and outcome	Probably less compliant	Possibly more compliant

Despite these differences, precipitating factors in problem drinking behavior appear similar for both late-onset and early-onset dependence. In the study cited above, Schonfeld and Dupree (1991) found that for both groups, depression, loneliness and lack of social support were the most frequently identified antecedents to pre-admission drinking. No gender differences were observed in either the late- or early-onset group. This study used a structured interview to assess drinking history and conditions that preceded initiation of drinking behavior, asking clients to focus on a "typical" day of drinking. These findings suggest that since early- and late-onset alcoholics of both sexes drink in response to stress, loneliness and depression, that treatment should focus on similar issues regardless of gender or time of onset. However, early-onset alcoholics are exhibiting an entrenched pattern of responses which may be more difficult to alter after many years of repetition, as well as a greater degree of physiological tolerance for alcohol.

Comorbidity with Other Disorders

A further treatment consideration is comorbidity: alcohol dependence frequently occurs in conjunction with other psychiatric disorders. In one study which examined comorbidity across the life span, in a cross-sectional study of 22,463 male veterans with a presenting diagnosis of alcoholism, 55% of the sample met criteria for at least one other psychiatric diagnosis (Blow et al., 1992). For older adults, 54.5% of the sample met criteria for at least one additional diagnosis, with the most common diagnoses being dementia, major depression, and anxiety disorders. 21% of the alcoholics in this sample also met criteria for affective disorders, most frequently major depression. This study had an impressively large sample size, including 3,986 alcoholic men aged 60 to 69. Although these findings are consistent with other studies showing high comorbidity rates, these figures must be interpreted cautiously. Blow's study used pooled data from VA facilities nationwide, with poor control for the uniform application of diagnostic criteria.

 

ACSH: Alcohol and Health

Many clinicians have also identified depression as a precipitating factor in alcoholism in older adults, and have suggested that effective treatment must address both issues (Zimberg, 1978; Atkinson, 1995). Brennan and Moos (1990) found that depression rates were higher in older females alcoholics than older males alcoholics. This finding is consistent with other studies that have generally found higher rates of depression in women than in men. Rosin and Glatt (1971) studied 103 older adults with alcohol problems, and found that in addition to bereavement and widowhood, loneliness was also predictive of late-onset alcoholism. However, most studies showing the association between alcoholism and depression, loneliness and isolation have not been able to determine whether these problems are a cause or an effect of excessive alcohol use, since they are cross-sectional rather than longitudinal in design.

Some of your clients may ask about the positive health benefits of drinking alcohol. Therefore you may want to click on the links to read about Moderate Alcohol Consumption And Health or Does Moderate Alcohol Consumption Prolong Life? These reports were published by the American Council on Science and Health (ACSH) which is an independent, non-profit consortium of scientists providing consumer education.

Screening for Alcohol Problems Among Older Adults

As noted above, prevalence of alcohol abuse and dependence are relatively high in clinical populations such as general hospital and psychiatric settings. Therefore, it is important that physicians and other health care professionals screen their patients for possible alcohol problems. The Physicians' Guide to Helping Patients with Alcohol Problems provides an overview on how to assess, intervene, and monitor patients with alcohol-related problems.

A number of brief instruments have been developed for this purpose (see below), including some specifically created for older adults. Perhaps the shortest and most widely used screening tool is the CAGE questionnaire, a four-item scale of common alcohol related problems (Ewing, 1984). This instrument has been validated for use with older adults. Another, longer instrument specifically designed for use with older adults is the Michigan Alcohol Screening Test-Geriatric Version (see example below) (MAST-G, Blow et al., 1992). This instrument has high sensitivity and specificity among older adults recruited from a wide range of clinical settings, including nursing homes and primary care clinics.

Theories of Etiology and Their Relationship to Intervention

In addition to risk factors, it is useful to consider different conceptualizations of alcoholism, including popular theories of etiology, and the impact that these theories have had on intervention (Miller & Hester, 1995). Excessive alcohol use and its associated problems have been observed since antiquity. The moral or ethical model of alcoholism proposed by early writers such as Aristotle (Aristotle, 1954) viewed alcohol as a bad choice by an individual to drink excessively, rather than a medical or psychiatric disorder. From this perspective, alcohol problems are viewed as willful violations of the norms of society and deserving of punishment rather than treatment. The dominance of the moral perspective during prohibition in the United States (1920-1933), a time period that many of the current elderly cohort remember, may contribute to the sense of guilt and shame that older alcoholics often feel.

Somewhat related to the moral model is the spiritual model of alcoholism, which holds that excessive alcohol use is sinful and derives from alienation from the proper spiritual path. This view has roots in many of the world's religions which either forbid or limit alcohol consumption. Treatment thus involves a spiritual process. Alcoholics Anonymous (AA) is based on this perspective, and holds that only through a spiritual connection with a higher power can alcoholics hope to remain sober.

Biological models of alcoholism place strong emphasis on genetic predisposition and physiological processes as determinants of alcoholism. These theories draw on empirical studies of increased risk for alcoholism in those with alcoholic relatives, including adoption and twin studies (Heller & McClern, 1995). It has been suggested that those with a genetic predisposition to alcoholism may have unique physiological sensitivity which makes addiction more likely. This model has also been referred to as a "dispositional disease" model (Miller & Hester, 1995). Intervention strategies that follow from this model include identifying those who may be at risk for alcoholism due to family history, and advising complete abstention from alcohol. Among older adults, as was noted above, early-onset alcoholics report greater family history of alcoholism that late-onset alcoholics (Schuckit & Pastor, 1979). One possible implication of biological models, with importance for younger as well as older adults (among older adults, particularly those classified as early-onset), is that limited or controlled drinking as a treatment goal is ill-advised, given an innate predisposition to addiction.

Among the perspectives which inform intervention efforts by mental health professionals, behavioral models and theories are prominent. These include conditioning, social learning, and cognitive models (Miller & Hester, 1995). The conditioning model emphasizes the role of alcohol consumption as a behavior that has been reinforced by its consequences, including tension reduction and other pleasurable physiological sensations, time out from social rules, and positive reinforcement from companions. Because drinking behavior is assumed to be essentially learned, intervention involves teaching new patterns of behavior to replace drinking. Treatment may include classical conditioning strategies, such as aversion therapy, or operant learning principles, such as the community reinforcement approach present in group therapy.

The social learning model emphasizes how others in the environment may influence drinking behavior, including the role of modeling of drinking behaviors and peer pressure. Reliance on alcohol as a coping strategy is another important element of this model. Interventions from a social learning perspective focus on changing the client's relationship to his or her environment, such as finding new non-drinking friends and new ways of handling stress (Miller & Hester, 1995).

Cognitive models emphasize the role of internal thought processes in initiating and maintaining behavior. In the case of drug and alcohol use, these thoughts may include expectancies (beliefs) about intoxication. Positive beliefs about the effects of alcohol have been correlated with heavier and more frequent drinking (Leigh, 1989). In treatment, cognitive restructuring may be used to reduce positive expectancies and to increase negative expectancies regarding the effects of alcohol.

Maximizing Effectiveness of Interventions with Older Adults

The theories described above have informed alcohol treatment approaches for adults of all ages. In order to apply these theories to successful programs for older adults, several aspects of aging must be taken into account: social factors such as widowhood and isolation, physical infirmities, and comorbidity with other psychological problems. These considerations have given rise to a variety of recommended modifications to treatment protocols, which are summarized here. Physical accessibility. As noted above, comorbidity with other physical and psychological disorders is a common aspect of alcohol dependence in older adults. To the extent that these problems decrease mobility and increase frailty, appropriate adjustments must be made. In terms of location, it is important that treatment centers be located somewhere convenient to older adults who may not drive and may have disabilities that limit their physical mobility. For outpatient treatment, a possible location that may meet these requirements is an adult day health center or a senior center. Senior center locations are advantageous because clients are already familiar and comfortable with the surroundings. This seems to reduce potential stigma associated with seeking treatment for an alcohol problem. Other possible settings include retirement housing centers and Veterans Administration hospitals.

Adapting Therapy To Older Adults

A number of authors have remarked on useful adaptations of psychotherapy in general to working with older adults, no matter what issues are the focus of therapy. These changes include using a slower tempo of speech; slower pace of therapy; speaking louder; more frequent repetition of material covered to assist in learning; and use of simpler language with elders, who tend to have less years of education than younger adults (Knight, 1996). Although these modifications are not difficult to employ, they may require practice on the part of therapists not used to working with older people.

In a group setting, it may be necessary for group leaders to be more active and to provide more structure than they might with younger adults. Leaders may need to make greater efforts to initiate group activities and discussion (Leszcz, 1996). It has been suggested that older adults have decreased energy reserves to handle the anxiety brought on by participating in group therapy, but that this anxiety may be allayed if greater group structure is provided by the leader (Burnside, 1984).

As was noted earlier, cohort effects may help to explain differing patterns of drinking across the generations. Cohort issues must also be considered in treatment. With older adults raised during the prohibition era, in which drinking was considered evil or sinful as well as illegal, cohort effects may appear in greater feelings of guilt or shame regarding drinking behavior. This sense of shame may be particularly acute among older women drinkers (Wilsnack et al., 1995). Additional cohort effects may include greater perceived stigma in seeking out treatment from a mental health professional, and reluctance to discuss personal problems with a stranger (Knight, 1996).

Psychological And Biological Interventions

According to Zimberg (1984), effective treatment of older alcoholics requires that therapy address the many stresses associated with aging. These problems include widowhood, increased physical disability, chronic illness, retirement and social isolation. Treatment Referral Information is provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) which maintains a toll-free number (1-800-662-HELP) for alcohol and drug information/treatment referral assistance

Group Therapy

For both inpatient and outpatient treatment settings, group therapy may be one of several components of the overall program. Other aspects include individual therapy, case management with social workers, and family counseling and follow-up regarding the patient. In outpatient group treatment programs, members may also be encouraged to attend AA (Vannicelli, 1982; Willenberg, Olson, Bielinski & Lynch, 1995). Zimberg (1985) has described a successful program for treating older alcoholics which includes age-homogeneous peer groups and social/recreational activities. Through these different treatment components, the program aims to create a "therapeutic community" in which clients communicate freely with each other and with treatment staff.

There may also be multiple groups as part of treatment, with each group serving a different purpose. Dupree (1994) has described such a "modular" treatment program specifically designed for older adults, called the Gerontology Alcohol Project (GAP), developed at the Florida Mental Health Institute. In this cognitive-behavioral program, groups are defined according to content and are designed to be both manualized and complementary with other groups. The specific groups are:

1. A-B-C's of Drinking;
2. Alcohol Self-Management in High Risk Situations;
3. Alcohol Information and Education;
4. General Problem Solving;
5. Social Support Network Development.

Resource: Alcoholics Anonymous

In group sessions, addressing these issues requires familiarity and sympathy on the part of the group leader, as well as a willingness to allow time to discuss concerns that may not appear directly related to drinking behavior. Group members may be encouraged to empathize over their common concerns and life experiences, and to offer suggestions and problem-solving advice when appropriate. Attention to aging issues may be particularly important for those clients identified as late-onset alcoholics, whose drinking may be "reactive" to stresses of late life.

One of the major features of group treatment for alcohol dependence is encouragement that the members provide to each other regarding abstaining from alcohol. Members of the group generally take turns sharing their successes and relapses with other group members. Success is positively reinforced, and relapses are ideally met with sympathy and the encouragement to keep trying. There are a number of recovery method for alcoholics who are uncomfortable with the spiritual content of widely available 12-Step programs. Rational Recovery was one of the first secular groups. It was founded to provide an alternative to the 12-step, spiritual healing program of Alcoholics Anonymous. Other secular support groups include SMART Recovery and Secular Organizations For Sobriety (SOS).

Although controversy surrounds the "controlled drinking" approach to treating alcohol dependence, this may also be an agreed-upon goal for individuals in group treatment (Dupree, Broskowski, & Schonfeld, 1984). However, it may be appropriate to exclude these clients from groups designed to encourage complete abstinence. Moderation Management is a self-help group for individuals who have decided to cut back or quit drinking. Older adults who feel uncomfortable with the reliance on a "higher power" prescribed by Alcoholics Anonymous or who desire to reduce rather than eliminate alcohol consumption may be more comfortable with this approach (Miller et al., 1995).

Is AA for you? Click on the link to find out if you or your clients would benefit from this self-help group which calls for reliance on a "higher power" to quit drinking. The " Big Book" is the "bible" for AA which lays out the 12 step program and how it works. You can obtain information on AA meetings through out the United States by clicking on the link. Those who have alcoholic parents should know that they are at greater risk for alcoholism themselves.

Individual Psychotherapy

Resource: National Institute on Alcohol Abuse and Alcoholism

Individual cognitive and behavioral treatment for a variety of disorders have been developed for use with the elderly (Gallagher-Thompson & Thompson, 1996). Cognitive behavioral approaches to treating alcoholism in older adults focus on improving the client's life in a variety of ways in addition to merely abstaining from drinking (see example of treatment objectives and approaches below) . Glantz (1995) recommends that it is important to establish a collaborative relationship with the client in which goals are set for each of the following areas: (1) social life and friends; (2) family; (3) intimate or romantic relationships; (4) employment or practical achievement; (5) recreation or avocation; and (6) drinking. Clients may also identify additional goals. A mandatory goal in the treatment plan described by Glantz is to stop drinking completely, or at least to achieve a period of abstinence followed by very limited and controlled drinking.

The drinking behavior itself is analyzed with the client to determine the maladaptive purpose underlying the drinking behavior. The client is also helped to study his or her pattern of drinking, and to identify the circumstances in which the urge to drink arises. Coping skills and behavior alternatives are then developed and rehearsed in therapy to address these difficult situations.

Irrational thinking in any of the six goal areas is likely to arise in the course of therapy. Older alcoholics frequently have maladaptive thoughts concerning their own guilt, thinking that they deserve to be punished, wanting not to live (though not necessarily wanting to die) and thinking that they deserve the bad things that have happened to them (Glantz, 1995). Addressing the irrationality of these thoughts in the course of treatment can have a beneficial effect on the mood and self-esteem of the client, which helps to control drinking behavior. However, Schonfeld and Dupree (1995) point out that cognitive behavioral treatment does have drawbacks: it requires adequate cognitive functioning in order to identify high risk situations, learn new coping skills and self-monitor behavior. Older alcoholics may not be able to cooperate effectively in their treatment if they do not meet these requirements.

Effectiveness of Treatment

Unfortunately, few empirical studies have specifically examined treatment outcomes for older adults with alcohol dependence. In the discussion below, I review the few existing studies and also draw on studies comparing treatment modalities studied extensively in younger populations. While it may not be the case that what works for younger adults will work for older ones, interventions that consistently fall short of success in younger populations may suggest which treatment techniques are unlikely to be effective.

Individual psychotherapy. Although individual psychotherapy is widely recommended in the clinical literature, with clinicians such as Glantz (1995) offering detailed recommendations, outcome studies to date have only addressed effectiveness of group treatment programs. While some authors have claimed that behavioral and cognitive behavioral treatment models are basically the same in individual or group settings (Schonfeld and Dupree, 1995), this has not been established empirically.

Group Psychotherapy. As noted above, group therapy is often incorporated as one component of treatment for alcohol dependence. As a result, the effectiveness of specific group treatment modalities with older alcohol-dependent elders has not been established empirically. However, outcome studies of programs that rely heavily on groups have shown favorable results. In the Gerontology Alcohol Project (Dupree, 1994), described above, results were measured at intervals of one month, three months, six months and twelve months. Seventeen clients followed in this study had chosen abstinence as a goal, and fourteen of them had maintained this goal at the twelve month evaluation. Seven others had chosen a goal of responsible, limited drinking. Less than half of these clients reached their goal, although one client died following the three-month assessment. As was noted previously, early-onset drinkers were more likely to drop out of this treatment program than late-onset drinkers (Schonfeld, (1991), and thus are not represented in follow-up data. If they had been, success rates would obviously be further reduced.

Another program specifically designed for older recovering alcoholics is "The Class of '45," a system of support groups patterned on the social support model of Zimberg (1984). These support groups, conducted at the Portland, Oregon VA Medical Center, are open to veterans who were on active military duty before 1945 (Atkinson, 1987). This outpatient group meets once a week, incorporates humor, and frequently uses reminiscence including telling old war stories. Although the outcome measures used to evaluate the effectiveness of the program are not precise, this group showed an 81% attendance rate and an average length of stay of ten months, as compared to the average outpatient treatment attendance of 51% with a 5.8 month length of stay. While this study does not demonstrate effectiveness in terms of abstention, it shows that if treatment is adapted to the specific needs and cohort features of an older population, dropout is reduced and increased success becomes possible.

Biological Aspects of Treatment

While the field of psychology has developed effective methods of intervention, particularly in group settings, the contribution of biology is much more limited. Unlike depression, anxiety or schizophrenia, in which biological treatments challenge or even surpass the effectiveness of psychological interventions, the cravings associated with alcoholism as yet have no medical treatment. The biological sciences have made some contribution to current understanding of etiology and the effects of alcohol on the body, and to a more limited extent the neurochemical mechanisms of addiction itself. Although this knowledge has yielded few practical applications for treatment settings, biological understanding of alcoholism has provided additional "ammunition" for those psychological interventions, such as cognitive psychotherapy, that seek to increase the alcoholic's awareness of the negative effects of alcohol. For older adults, providing feedback from neuropsychological assessment, medical evaluation of heart, and liver functioning may help to build motivation to reduce alcohol intake (Miller & Rollnick, 1991). Offering concrete evidence of the real physical damage caused by the addiction over time may help addicts to realize that they have a serious problem.

Direct biological components of intervention may be divided into two parts: treatment of withdrawal and treatment of addiction. It has been consistently found that the symptoms of withdrawal associated with detoxification may be more severe in older adults. In one study, Brower, Mudd, Blow, Young, and Hill (1994), conducted a retrospective chart review of older and younger patients admitted for inpatient detoxification and alcoholism treatment. They found that the older group had significantly more withdrawal symptoms over a longer period of time than the younger group. Another study by Liskow, Rinck, Campbell and DeSouza (1989) also found that symptoms of detoxification for older adults were more severe, and that more chlordiazepoxide (a drug administered to temper the effects of withdrawal) was given to older subjects. These studies suggest that the process of detoxification is likely to be longer and more difficult for older alcoholics than for younger ones.

In treating actual addiction, as opposed to withdrawal symptoms, two biological strategies have been employed: Antabuse (disulfiram) and antidepressant medication. Neither has been studied in older populations. Among younger samples, disulfiram, a drug that makes patients sick if they drink alcohol while taking the drug (and hence is more properly understood as a psychological (behavioral) intervention rather than a strictly biological one), has been moderately successful (see Miller et al., 1995, for a review). However, disulfiram is contraindicated for patients with heart problems, psychosis, brain damage, and other serious illnesses, so may be of limited use in older populations (Gulino & Kadin, 1986).

Among younger adults, the few studies available suggest that antidepressants are not effective in treating alcoholism (Reinert, 1958; Charnoff, 1963). It should be noted, however, that these two studies investigate the effectiveness of older tricyclic antidepressants rather than the newer SSRI's (selective serotonin reuptake inhibitors), which are currently under evaluation. Given the high rates of comorbid depression in both older and younger alcoholics, antidepressants remain viable for treating the depression that often accompanies alcoholism. In such situations, clinicians must be aware that medication is addressing only one of the client's diagnoses. For older adults, the combination of alcohol and antidepressants can be dangerous, leading to an exaggerated response to alcohol including impaired motor skills and depression of the central nervous system. The result could range from drowsiness to coma (Korrapati & Vestal, 1995). Clearly, clinicians prescribing antidepressants to alcoholic older adults should be aware that a relapse to drinking behavior could have very serious consequences.

Comparing Treatment Approaches in Younger Subjects

In a meta-analysis of 219 published outcome studies of treatment for alcohol dependence, Miller and his colleagues (1995) rated intervention strategies according to their likelihood of effectiveness. Although these studies do not specifically focus on older subjects, the results are instructive. Behavioral group and individual treatment approaches were generally superior to other treatments, and include brief interventions, social skills training, motivational enhancement, community reinforcement, behavior contracting and aversive conditioning. Unsuccessful interventions include relaxation training, confrontational counseling, psychoanalytic therapy and general educational counseling. In Miller's meta-analysis, treatment approaches were evaluated according to the number of positive and negative study findings (whether the treatment in question was successful or unsuccessful) and studies were weighted for comparison according to a measure of methodological quality. Although direct inferences regarding older adults cannot be made from this analysis, Miller's work provides possible direction for future treatment innovations with older adults, as well as additional evidence for the soundness of cognitive and behavioral treatments that other researchers such as Schonfeld and Dupree (1995) have endorsed.

Age-Specific Treatment Programs for Older Adults

In addition to the few studies have examined outcomes for older adults in treatment for alcohol dependence in geriatric settings, several studies have examined how older adults have fared in mixed-age programs. One issue raised by these studies is whether older adults can succeed in such programs, or if age-specific treatment is warranted. Theoretical concerns that seem to support the idea of age-specific groups include: differing age-associated stresses, perpetuating factors and risk factors for relapse; aspects of treatment for older adults that may require specialized training of staff; beneficial effects of social bonding with same-age peers may enhance group cohesiveness and treatment compliance; health status of elders may preclude certain components of treatment employed with younger adults, such as use of disulfiram (Atkinson, 1995). On the other hand, many researchers have noted that older adults are more diverse in terms of their backgrounds, education levels, and level of cognitive ability than younger adults (see, e.g., Knight, 1996). Because of this variability, age-specific screening cannot guarantee that members of older treatment groups will be similar in these respects.

In a survey of age effects on alcoholism treatment, Janik and Dunham (1983) compared outcomes across age groups from data acquired from the National Alcoholism Program Information System. In this study, age was the independent variable, and mode of treatment and outcome measures were the dependent variables. No differences were found between outcomes of older and younger adults, although no data from age-specific treatments were included. Since older adults did not perform worse than younger adults, the researchers concluded that age-specific treatments were unnecessary. However, a more reasonable conclusion to be drawn from this study is that while older and younger adults perform equally well in a mixed-age treatment setting, the success of age-specific treatment was untested and therefore remains unknown. Unfortunately, the study also did not investigate the interaction between age and the effectiveness of different treatment modalities. Thus it is impossible to show whether older adults performed better in one form of treatment than another.

Some clinicians have suggested that outpatient treatment aimed specifically at older women may be useful in enhancing treatment response. Wallace (1995) has argued that because women are in the minority in many mixed-sex treatment settings, facilities and recreational activities may be less suited to their needs. Unfortunately, the empirical literature on older female alcoholics is extremely sparse. Describing an outreach program targeting older low-income women, Fredrikson (1992) suggests that having women-only groups may facilitate increased self esteem and social connectedness between women in treatment. Fredrikson also observes that in this program, entry into treatment was slow and incremental for some participants and seemed to be facilitated by non-threatening group activities with other women. Treatment goals included controlled drinking as well as complete abstention. Although the methodology used in this report to measure treatment outcomes is somewhat vague, Fredrikson states that 60% of participants in the program abstained from alcohol for at least three months of the year after entering treatment.

Conclusion

Alcohol dependence in older adults appears to be associated with particular antecedents and comorbid features. These include losses and stresses associated with aging, social isolation and comorbid psychiatric disorders. Treatment must take account of these issues in order to be successful. Other useful adaptations to treatment include greater attention to accessibility and the physical limitations of older adults, a slowed pace of therapy, an emphasis on building social support networks, and sensitivity to cohort effects such as stigma surrounding both drinking and seeking treatment.

Unfortunately, most of the evidence for the effectiveness of treatment for older adults with alcohol dependence is anecdotal in nature. While the observations of those working in the field are valuable, much work remains to be done to investigate the effectiveness of all treatment modalities with elders. Unlike the recent burgeoning of outcome studies for psychological interventions for depression (Scogin & McElreath, 1994), there are no published empirical studies comparing one treatment modality to another for older adults, and no studies comparing treatment to a no-treatment control. No controlled studies of individual psychotherapy have been conducted to date, although group interventions using cognitive and behavioral techniques appear effective. Supportive age-specific group therapy also appears more effective than supportive mixed-age group treatment.

The few studies of treatment effectiveness that have been conducted are largely limited to male, mostly white veteran populations in VA hospital settings. Studies of more diverse populations are needed. Although some researchers have begun to investigate issues of race and ethnicity in treatment of older alcoholics (Gomberg & Nelson, 1995), very little work is currently being conducted in this area. Studies investigating treatment of older alcoholic women are virtually non-existent. The distinction between early- and late-onset disorders has not been adequately investigated in terms of treatment implications. While there is some indication that late-onset dependence has a better prognosis in treatment, the differences between the two groups have not been studied systematically

Although many criticisms may be leveled at the current state of research into psychological interventions for alcoholism in older adults, the field remains very promising. Biological/medical interventions for alcoholism, on the other hand, lag behind the significant contributions made to the treatment of other psychiatric disorders such as schizophrenia, anxiety and depression: disulfiram and antidepressants, the only medications associated with alcoholism treatment, are inadequately investigated at the present time and may be contraindicated in older populations due to medical risks. The biological sciences have contributed greatly to the understanding of how alcohol negatively impacts the body, and have made theoretical contributions to the understanding of addiction, but have yet to enter the field of treatment. In the future, it is hoped that more effective medical interventions for alcoholism may be developed to complement existing psychological approaches.

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