Return to List of Archived Questions

Geriatric Dual Diagnosis What treatments are currently most recommended to address dual diagnosis issues in the elderly? Are you aware of any alcohol detox programs that specialize in serving the needs of the elderly? Thank-you for your question. It's hard to answer it briefly, so please bear with me. In general, we tend to describe an overall approach, rather than specific treatments for this group. Elderly patients with alcohol or other substance use disorders, with or without co-morbid psychiatric diagnoses, are first screened for the quantity and frequency of drinking or other substance use, and for the level of risk this behavior poses. The need for detoxification and the potential for DTs should be considered immediately. An elderly person with sensory or cognitive impairments who drives while intoxicated or takes medications wrongly would be an example of the highest level of chronic risk. For the elderly especially, risk has to be assessed in the context of co-morbid medical and psychiatric conditions. Another area to be assessed would be the functional consequences of drinking or drug use for the individual-i.e, in the elderly one must consider the effects on ADLs, health-related activities, maintenance of a safe home environment, financial stewardship, etc. Then, before deciding on a treatment strategy and setting, motivational factors and social supports should be assessed: Is the condition acknowledged by the patient? Is complete abstinence a realistic goal, or should in the case of alcohol use, should the aim be reduction of drinking? Regarding dual diagnoses in the geriatric population, it has been estimated that up to 25% of elderly adults with alcohol use disorders have major depression; 10-15% have anxiety disorders, and a similar percentage have cognitive impairment of at least mild severity. Most also have chronic medical conditions, particularly pain syndromes. These co-morbid conditions are viewed as risk factors for alcohol use disorders in old age, or aggravating factors which worsen the course or complicate the treatment. General treatment Considerations for Elderly Patients with Substance Use Disorders For alcohol use and substance use disorders in general, treatment settings and modalities are chosen based on the severity of the condition, the degree of risk and the level of functional impairment. Outpatient medical and psychiatric services which provide informal counseling would be the least intensive level. More specialized treatments would more likely be offered at rehabilitation programs, but still on an outpatient level. These interventions include various forms of psychotherapy, from "motivational interviewing (MI)," which aims to shore up the individual's resolve to modify behavior, to cognitive behavioral therapy (CBT). In CBT, the individual is helped to recognize warning signs for risky behavior and the thought patterns associated with it, thereby interrupting the sequence which automatically leads to drinking or drug use. Sometimes these treatments are offered in groups as well as one-on-one therapy. AA, of course, is a group intervention, occasionally started during inpatient rehabilitation but by definition an outpatient maintenance program. While detoxification is sometimes offered on an outpatient basis, this is more likely to require hospitalization, especially for elderly patients in whom complications are more likely to occur. Medications to modify problem drinking are used cautiously if at all in the elderly, but can be administered either on an inpatient or outpatient basis. Naltrexone, an opiate antagonist, has recently been approved for use in the US to reduce craving, and seems to have had a good record of safety with older patients in Europe. Ondansetron, a 5-HT3 receptor antagonist, also may be promising; this suggests that Mirtazapine, an antidepressant with similar properties, may be a good choice for some patients with co-morbid depression and alcohol abuse. On the other hand, Disulfiram (Antabuse¨) is not considered safe for use in the elderly. Whatever the setting and whichever treatment is chosen, geriatric patients fare better with gentler, less aggressive approaches and in specifically geriatric, or "geriatric-friendly" settings where their needs and life circumstances can be taken into consideration. Treatment of Elderly Dual-Diagnosis Patients Regarding dual diagnoses (your original question!), I would again say that the treatment setting and modality may be determined by considerations of severity, risk and functional impairment. For example, severe or psychotic depression with risk of suicide may require inpatient psychiatric admission, just as if there were no co-morbid substance use disorder. As a rule, the psychiatric component is addressed first, or at least simultaneously. Overall, the acute treatment of the co-morbid psychiatric disorder, especially the psychopharmacological component, does not differ substantially from that of other elderly patients with the same condition. An exception may be the use of benzodiazepines, or other anti-anxiety drugs, for elderly substance use patients with co-morbid anxiety disorders. Use of benzodiazepines in this group is controversial, since these drugs are "cross-reactive" with alcohol and therefore easily abused; benzodiazepines are also notorious for causing confusion and ataxia in elderly clients with mild cognitive impairment. I mentioned earlier that Mirtazapine may be especially useful for depressed patients with alcohol abuse disorders, but some elderly patients may not tolerate this medication, and other antidepressants would serve equally well in addressing depression symptoms. Availability of Treatment in the New York City Area. A partial list of outpatient facilities that have dual diagnosis and or geriatric programs includes: the Mid-Town Center (56 West 45th St.; 212-764-5178); the Realization Center (19 Union Sq. West; 212-627-9600); the Freedom Institute (515 Madison Ave.; 212-838-0044), and another program administered by the department of psychiatry at St. Vincent's Hospital on West 12th St. and Seventh Ave. Smithers (now known as The Addiction Institute of New York) has extensive outpatient rehabilitation programs, including ones for older and dual diagnosis clients, at St. Luke's-Roosevelt Hospital. ElderCare Outpatient Services (953 Southern Blvd. in the Bronx; 718-860-2994) has outpatient dual diagnosis programs geared specifically to seniors. Inpatient rehabiliation is available at most psychiatric hospitals in the area, such as Payne Whitney Manhattan, St. Vincent's and others. You should probably investigate the extent to which any of these programs serves geriatric clients before making a referral. Private-pay settings include Four Winds Hospital in Katonah, New York, or Silver Hill Hospital in Connecticut. You should be aware that most of the inpatient programs do not also do detoxification. Reference Atkinson, RM: Substance abuse. In Comprehensive Textbook of Geriatric Psychiatry. Edited by Sadavoy J, Jarvik LF, Grossberg GT, et al. New York, W.W. Norton and Company, 2004, pp 723-762