Alcoholism in the elderly. How to spot and treat a problem the patient wants to hide

Alcoholism is a disease that warrants a complete medical workup and vigorous intervention in all age-groups, including the elderly. Increased awareness of the problem, with early diagnosis and treatment, can reduce mortality and morbidity. Alcoholics are at risk for relapse, so physicians should be patient and positive in their approach. Especially in the elderly, obtaining a list of all prescribed and over-the-counter medications used is an important starting point. Nonessential drugs should be discontinued and use of any others closely monitored. If a withdrawal syndrome results from discontinuation of alcohol, thiamine, multivitamins, and sedatives should be prescribed as clinically indicated. Treatment of any underlying psychiatric disorder is important. Psychosocial intervention is essential in dealing with recovering elderly alcoholics to overcome loneliness and to enhance sobriety. A formal rehabilitative effort is mandatory. Long-term rehabilitation focuses on group support and may include use of disulfiram (Antabuse).

Fluoxetine: prescribing guidelines for the newest antidepressant

Fluoxetine is an antidepressant drug with a unique chemical configuration which enhances serotoninergic transmission by inhibiting serotonin uptake. The chronic presence of serotonin in the synaptic cleft reduces postsynaptic receptors, a postulated explanation for its antidepressant efficacy. Comparative studies show that the therapeutic effectiveness of fluoxetine is equal to that of imipramine, amitriptyline, and doxepin. A 20 mg morning dose alleviates most depressions. The long half-life of one to three days for the parent compound and seven to 15 days for the active metabolite, desmethylfluoxetine, is largely unaffected by age or renal impairment. Nausea, nervousness, insomnia, and headache are the most common side effects. Therapeutic doses do not affect cardiac conduction or cause orthostasis. A primary benefit of this drug is its significant relative safety in overdoses as compared to other antidepressants.

Depression and alcoholism: clinical considerations in management

When alcohol abuse occurs with depression, both the substance abuse and the mood disorder necessitate treatment. These conditions may have some similar manifestations, making differential diagnosis difficult. Depressed alcoholics report more previous treatment for substance abuse, withdrawal symptoms, and marital problems than those without depression. They also incur greater loneliness, unemployment, and social ineptness. Depressive symptoms found commonly in this group include work inhibition, guilt, self-disgust, dissatisfaction, and social disinterest. A history of depression among relatives favors a dual diagnosis of alcoholism and depression. Distinguishing those alcoholics with specific depressive illness enhances the therapeutic efficacy. Alcohol abusers need treatment, but those with concomitant depression persisting well beyond detoxification often require antidepressant medications. In long-term care, lithium may reduce alcohol-related rehospitalizations. A strong doctor-patient relationship with or without pharmacotherapy promotes continuation in a therapeutic regimen. Involvement in Alcoholics Anonymous and disulfiram maintenance therapy are other deterrents to drinking relapse.

Evaluation and management of self-mutilation

Instances of deliberate self-injury are observed in both psychotic and nonpsychotic individuals. Patients with command hallucinations, religious preoccupations, substance abuse, and social isolation are the most vulnerable. Persons who request unnecessary surgical procedures for bizarre reasons also are at high risk. Such behavior constitutes a medical, surgical, and psychiatric emergency. A thorough psychiatric evaluation is mandated in every case. Vigorous psychiatric treatment and follow-up care involving the full range of pharmacologic, somatic, and psychologic interventions are indicated.

Detection of unknown early pregnancy. A matter of safety

Almost 2% of females admitted as accident victims to a general hospital-teaching facility were pregnant without their physicians knowing it. Emergency treatment of such patients may overshadow other aspects of holistic care and have adverse consequences when a pregnancy is unrecognized. These cases illustrate the importance of always performing a complete physical examination and obtaining a good history that includes menstrual data. When appropriate, we recommend routine use of the serum human chorionic gonadotropin test for pregnancy. It is a simple and reliable means of detecting pregnancy by ten days after nidation, and its use protects the patient, physician, and unborn child. Safer health service is the result.

The violent patient: what to do?

Violence is a common clinical problem that must be quickly assessed to be properly managed. The examiner should keep at a safe distance from the patient and conduct the interview in a firm but nonthreatening manner. Verbal intervention, pharmacotherapy, and occasionally, physical restraints are indicated as a first-line approach while treatment of the underlying medical or psychiatric abnormality is initiated. Once the violent patient is under control, management includes thorough diagnostic assessment, pharmacotherapy, careful psychotherapy, and mobilization of community resources.

Psychiatric disorders in the elderly. Psychopharmacologic management

Psychiatric management of elderly patients is a challenging task because of the many age-related physiologic changes and medical problems in this population. Thorough patient evaluation is essential to rule out somatic disorders and determine underlying causes. Somatic complaints must be taken seriously, even if a patient is receiving treatment for a psychiatric disorder. Psychotropic therapy is used mainly for controlling depression, agitation, and psychotic symptoms. If psychiatric symptoms persist or become worse, psychotropics should be discontinued to prevent possible drug toxicity (eg, anticholinergic delirium) and psychiatric consultation should be requested.

How do eating disorders affect thyroid function?

Abnormal thyroid function in patients with eating disorders can result from malnutrition. A low serum triiodothyronine (T3) level is commonly noted in starvation states and is caused by reduced peripheral conversion of thyroxine (T4) to T3. Diminished T4 concentrations are also observed. Adequate nutrition normalizes this type of aberrant laboratory profile. Thyroid function tests that give results below the normal range are best repeated initially for verification of results and again after adequate nutrition is reestablished. If no primary endocrinopathy is present, spontaneous correction of these laboratory values can be expected with conventional dietary habits.

Use of magnesium sulfate in alcohol withdrawal

Magnesium deficiency plays an important role in alcohol withdrawal syndromes. Parenteral replacement of magnesium in the form of magnesium sulfate is safe and diminishes the severity of withdrawal symptoms in recently alcohol-abstinent patients. Early diagnosis of withdrawal illness and institution of magnesium replacement therapy decrease the need for benzodiazepines, diminish withdrawal complications and reduce the length of hospital stay. Testing for serum magnesium levels is useful, but experience supports the empiric use of magnesium replacement therapy in alcohol withdrawal.

Depression in alcoholics by the NIMH-Diagnostic Interview Schedule and Zung Self-Rating Depression Scale

Depression was prominent among 40 alcoholics in an alcohol treatment program. Untreated depression may increase risk for relapse to problem drinking. The structured diagnostic interview schedules, DIS and Zung, showed good agreement and were effective instruments in the detection of depression in alcoholics.

Monoamine oxidase inhibitors

Monoamine oxidase inhibitors offer effective treatment opportunities to an expanded range of depressed and anxious patients, particularly those with atypical depression. The use of these drugs requires heightened physician awareness and patient education, but the risks are less pronounced than was previously thought. Hypotension is the main side effect. Hypertensive reactions can be avoided by strictly proscribing congestion of MAO inhibitors with indirect-action sympathomimetic substances that occur in certain drugs, foods and beverages.

Metrizamide myelography risk factors: a pseudopsychiatric case presentation

A case of neurologic sequelae from intrathecal metrizamide is presented. The patient had a convulsion, became comatose, and transiently developed mutism and hemiparesis, with eventual full recovery. Metrizamide is generally safe, but side effects do occur, and they may require clinical attention and follow-up.

Acutely psychotic patients: a treatment approach

Treating acute psychosis by rapidly producing a neuroleptic state is safe and effective. Getting psychotic patients quickly out of the hospital, keeping them out, and enabling them to function maximally are the treatment goals. Many such patients respond to a trial of lithium therapy; responders are usually better able to work or attend school and to live independently, and they less often show the degree of personality deterioration present in classical schizophrenia. Patients with schizophrenic, schizoaffective disorder, or bipolar illness should receive trial lithium therapy. Responders to lithium treatment are found in all three diagnostic categories.