Treatment of alcohol use disorders in the elderly: an overview of RCTs.

In this issue of International Psychogeriatrics, our research group published a paper on alcohol use disorders (AUD) in elderly adults (Kist et al., 2014). According to different authors, age of onset is an important characteristic to distinguish subgroups of patients with AUD, similar to, for example, late-onset depression (LOD) and lateonset schizophrenia (LOS). The cut off age to discriminate between early and late-onset AUD varies but is often 25 years, which is substantially younger than the cutoffs to discriminate LOD or LOS. However, in AUD, many patients started having alcohol problems much later in life, for example, after 45, 50, or even after 60 years. These very late onset patients are almost completely ignored in research. In a group of older inpatients with AUD, we found that those who started drinking heavily after 25 and after 45 years of age have similar cognitive impairments compared with their peers who started drinking before 25 years of age. Our results are counter-intuitive at first instance, but some other authors have found the same results. However, several potential limitations may also account for this result, and replication is needed before conclusions that are more definite can be drawn. In the preparation of this editorial, we found a lack of research in patients who started drinking excessive amounts of alcohol very late in life. This is in contrast with, for example, a fair amount of research in LOD and at least some research in LOS. The lack of research cannot be explained by a low frequency or importance of AUD in the elderly using mental health care. The 12-month prevalence of AUD was 1.5% in a large epidemiological study of adults aged 65 years and older (N > 8,000), with a lifetime prevalence of 16.1% (Lin et al., 2011). Another recent large epidemiological study (N > 16,000) has found an estimated 12-month prevalence of alcohol dependence of 0.6%, with a 0.9% prevalence of alcohol abuse in community-living elderly adults aged 65 years and over (Blazer and Wu, 2011). However, not only AUD may be relevant, sub-threshold disorders and at-risk or binge drinking should also be taken into account. The 12-month prevalence of subthreshold dependence was 5.2% in the study done by Blazer and Wu (2011). In the same study population, at-risk drinking was reported by 13% of men and 8% of women, and more than 14% of men and 3% of women reported binge drinking (Blazer and Wu, 2009). In general hospitals up to 30% of older patients and in psychiatric hospitals up to 50% of older patients were diagnosed with AUD (Caputo et al., 2012). In nursing homes, the prevalence of AUD or drinking problem varies between 8% and 53% (Johnson et al., 2000). Chronic alcohol use is associated with multiple physical diseases and psychiatric disorders, including depression, anxiety, and dementia (Caputo et al., 2012). Alcohol causes approximately 3.8% of all deaths and 4.6% of the global burden of disease worldwide (Rehm et al., 2009). These papers on prevalence were published in major (geriatric) psychiatric journals, and many healthcare workers will be familiar with the results. If we were not be aware of how to screen or diagnose elderly patient with AUD, then this could be a potential explanation for lack of research in this field. Excellent systematic reviews have been published on the screening instruments for AUD in elderly people (Berks and McCormick, 2008; O’Connell et al., 2004), both suggesting the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001) as a useful screen, especially to detect harmful and hazardous drinking in the elderly. With regard to CAGE (Cut down, Annoyed, Guilty and Eye-opener), there was no agreement between the above-cited two reviews. Another potential explanation would be that healthcare workers are not aware of treatment studies, and consider elderly patients with AUD as hopeless. Personally, I was also not aware of any systematic review of treatment studies on AUD in the elderly, and was familiar with only a few randomized controlled trials (RCTs) published in (geriatric) psychiatric journals. A literature search revealed two recent reviews of treatment studies, but neither of these was published in a (geriatric) psychiatric journal, and the same is valid for many for the RCTs that were included in aforementioned reviews. Perhaps old age psychiatrists and psychologists treating elderly adults with AUD are not aware of these reviews and RCTs. The first of the aforementioned reviews is, according to its title, a systematic and narrative review of treatment for older people with substance problems (Moy et al., 2011). This review found only six studies with an extensive research strategy,