Etiology and Pathophysiology
Alcohol activates gamma amino butyric acid-mediated inhibition of the central nervous system (CNS). Concurrent use of benzodiazepines, tricyclic antidepressants, opioids, and monoamine oxidase inhibitor (MAOI) antidepressants can increase the CNS depression associated with alcohol impairing cognition and motor function and can also result in respiratory depression (Sproule, 2002).
Significant alcohol abuse or alcoholism can be associated with a number of comorbidities such as depression, falls, amnesia, anxiety, trauma, neuropathy, insomnia, anorexia, malnutrition, and cirrhosis. Elderly persons with alcohol difficulties may not be identified easily because they may be retired and isolated socially. The rehabilitation therapist should rule out alcohol difficulties, particularly in patients who frequently experience falls or have malnutrition issues (Jacobson et al., 2007).
Patient Case 1
S.J. is a 74-yr-old alcoholic. He has been living in a skilled-nursing facility for the past 15 mo and has not had access to alcohol. During lunch hour one day, the speech–language pathologist attempts to evaluate S.J. for possible dysphagia. However, the pathologist is having difficulty performing the evaluation because S.J. refuses to sit down. Instead, S.J. runs around and steals packets of sugar and then hides in the corner of the dining room with his back to the others and quietly opens the packets. Once he finishes eating the sugar, he laughs almost uncontrollably and begins to run around the dining room again, looking for and stealing more packets of sugar.
The speech–language pathologist is bewildered by S.J.’s behavior and frustrated that she cannot get him to sit down for the evaluation. Why is S.J. exhibiting this behavior?
S.J.’s alcoholic past can explain his behavior. In his mind, S.J. is stealing drinks and running off to a corner to consume his alcohol in a hidden fashion. The sugar in the packets may help remind S.J. of alcohol. The speech–language pathologist spoke with a nurse who had considerable experience dealing with alcoholics. The nurse provided very direct and consistent instructions and suggested a reinforcement structure that solved the problem.
Alcohol, opioids, sedative hypnotics, and stimulants all present dependence, abuse, intoxication, and withdrawal issues. Hallucinogens and phencyclidine present dependence, abuse, and intoxication issues but not withdrawal issues. The rehabilitation therapist should be aware that substance-related disorders can mimic other disorders, such as delirium, psychotic disorders, and mood disorders. In addition, disorders related to alcohol and sedative–hypnotic substances can mimic dementia, amnesia, and anxiety disorders, and disorders related to stimulants can mimic anxiety disorders (Preston et al., 2008; Sproule, 2002).
SUD can lead to cognitive disorders, withdrawal, intoxication, and mood disorders (Jacobson et al., 2007). Impaired cognition, mental clouding, and sedation can present a significant safety risk for the patient and can complicate the therapeutic process. For example, the patient may show decreased ability to follow instructions during therapy sessions, low motivation, and impaired psychomotor performance. SUD can result in restricted function in activities of daily life (ADL) and can be associated with compulsive behaviors and symptoms of tolerance or withdrawal (Jacobson et al., 2007). Associated inability to function in ADL increases the burden of care for caregivers.
Patients with SUD may have accompanying psychiatric problems and substance-related difficulties. For example, antisocial personality disorder and depression disorders are frequently found in patients with substance abuse. Remediating the substance-related difficulties may actually precede the development of these psychiatric problems (Epstein et al., 1994).
Upon admission to rehabilitation services patients should be screened for substance-use disorders. Several tools are available for screening and identifying SUD. One can use simple questions to screen for problems with alcohol use. For example, asking a man “During the past year, on how many occasions have you had five or more drinks?” (or asking a woman “During the past year, on how many occasions have you had four or more drinks?”) may identify whether further inquiry is needed. A second tool called CAGE consists of 4 questions: 1) Have you ever felt you should Cut down on your drinking? 2) Have people Annoyed you by criticizing your drinking? 3) Have you ever felt bad or Guilty about your drinking? and 4) Have you ever felt that you needed a drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover? (Kenna, 2007a; Sproule, 2002).
Tools that screen for drug abuse include the Drug Abuse Screening Test (DAST), which is a 28-question screen; the DAST-10, which is an abbreviated 10-question screen; and the CRAFFT, which is intended for use in adolescents. CRAFFT is a mnemonic acronym of the first letters of key words in the screening questions. Laboratory urine testing can also confirm use of alcohol or drugs (Sproule, 2002).
Patients should also be monitored for symptoms of acute intoxication and for symptoms of acute alcohol withdrawal syndrome. Early withdrawal symptoms peak 24 h after alcohol cessation, although withdrawal can also emerge several days after cessation of alcohol use. Symptoms of withdrawal can resolve in a few hours or persist for up to 2 wk. Symptoms of alcohol withdrawal syndrome can range from mild tremor to delirium, hallucinations, seizures, and death (Jacobson et al., 2007). The effects of alcohol withdrawal in the elderly are similar to the effects of alcohol withdrawal in the middle-aged patient. The rehabilitation therapist may suspectacute withdrawal if a patient exhibits unexplained symptoms ofrespiratory depression, hypotension, hypertension, trauma, seizure, ataxia, arrhythmia, psychiatric disorders, or other changes in mental status (Jacobson et al., 2007).
In an alert patient who is acutely intoxicated, referral to the acute care setting for supportive and protective management may be indicated. The physician and members of the health care team should assess the hydration status, electrolyte levels, and nutritional status of patients being treated for alcohol intoxication or withdrawal. Patients who have lost fluids from vomiting, sweating, or hyperthermia may need intravenous fluid replacement. Magnesium deficiency is commonly seen in alcoholic patients. Thiamine deficiency is also common. Thiamine can be administered as 100 mg IM for the initial dose and then 100 mg 3 times/day for 3 to 4 wk. Thiamine should be administered before dextrose is administered in order to prevent Wernicke’s encephalopathy, which includes symptoms of ataxia, acute confusion, and ophthalmoplegia. Long term impairment of cognition following Wernicke’s encephalopathy is termed the Wernicke-Korsakoff syndrome (Kenna, 2007a; Sproule, 2002).
A short-acting benzodiazepine such as lorazepam (Ativan) 1 to 2 mg or haloperidol (Haldol) 2 to 5 mg intravenously can be used to treat acute violent behavior or severe agitation associated with acute alcohol withdrawal. Benzodiazepines are the preferred agents for managing these symptoms. Antipsychotic agents should be used with caution because they can lower seizure threshold, and patients experiencing alcohol withdrawal are already at risk for developing seizures.
The most reliable tool for assessing the extent of withdrawal and guiding treatment is the Clinical Institute Withdrawal Assessment of Alcohol—Revised (CIWA-Ar), which is a 10-item scale used for grading the severity of withdrawal symptoms. A maximum of 67 points can be assigned; a score of 8 or less indicates mild withdrawal, a score of 9 to 15 indicates moderate withdrawal, and a score of 16 or more indicates severe withdrawal. This tool also provides guidelines for managing withdrawal symptoms based on the continued reassessment of the severity of symptoms. The Sedation Agitation Scale can be used in combination with the CIWA-Ar to determine the appropriate benzodiazepine dosing for managing symptoms. Long-acting benzodiazepines are frequently used because their sedative effects fluctuate less and they are easier to wean with a self-tapering effect. Patients who have liver disease or are elderly should be treated with short-acting benzodiazepines in order to prevent oversedation and adverse events (Kenna, 2007b).