Sammi: Good evening everybody and welcome to this evening’s Alcohol use in over 50s: A Management Approach in General Practice webinar. My name is Samantha and I am your host this evening. Before we get started I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.
Just some housekeeping quickly so you know how to interact with us and our control panel this evening. You should all be able to see a control panel like the image that is currently on the screen. If you cannot, have a look for a small red arrow in the top right-hand corner of your screen. If you click on that arrow, it will then pop out the rest of your control panel. Your control panel provides you with tools to select if you are listening in via your devices microphone and speakers, or if you have joined the audio via the telephone this evening. It also provides you with a place to ask questions. Okay. So everybody has been placed on listen-only mode. This is to make sure that learning is not disrupted by any background noise. As I said though, there is a chat box and we do encourage you to send us your comments and questions as they arise throughout the session. We will do our best to get back to everybody, but in the interests of time, it is not always possible. So at the end of the session we will post an email address where you can send any unanswered questions and we can get back to you off line.
Okay. So I would like to introduce our presenters for this evening. So we are joined by Associate Professor Apo Demirkol. He is a public health and addiction medicine physician. He works as a Senior Staff Specialist at the South Eastern Sydney Local Health District Drug and Alcohol Services, including La Perouse Aboriginal Community Health Centre, and Prince of Wales Hospital Pain Management Centre. He is the Medical Manager at the South Eastern Sydney Local Health District Drug and Alcohol Services that services an area with a population of 1.5 million people. Apo is also a Hearing Member at the Medical Council of New South Wales. Apo’s research and clinical interests are pharmaceutical opioid misuse, pain and addictions, substance use disorder among older people and indigenous communities. Apart from his clinical training, he participates in the supervision of PhD students at the University of New South Wales and the University of Sydney. So thank you for joining us, Apo.
I would also like to introduce our facilitator this evening, Dr Tim Senior. Tim is a GP at Thurawal Aboriginal Corporation at South Western Sydney. He is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and a Senior Lecturer in General Practice in Indigenous Health at UWS and also a Medical Educator. So thank you for joining us, Tim.
Tim: Good evening, everyone.
Sammi: That is great. So I will hand over to you now Tim to take us through the learning outcomes and then Apo will jump into our content for the rest of the evening.
Tim: Lovely. Thank you very much indeed. Good evening all of you. And these are the learning outcomes. So this education-speak for what we hope you will get out of the session this evening. So by the end of this online QI and CPD activity, we all should be able to be aware of the epidemiology of alcohol use problems among older Australians. We should be able to identify older patients with alcohol use disorder. We should be able to describe what can reasonably be done in general practice to address the needs of older people with alcohol use disorder. We should be able to list the referral pathways available to older patients that we can use to refer older patients with alcohol use disorder, and so I will pass over to Apo to start with. Good evening. Thank you very much.
Apo: Thank you, Tim. So I will just get this going, good evening everyone, with a case study. And a case study of a woman, Sarah, who has been your patient for a while. She is 52 years old and you have known her for five years now. She tells you that for the last two years or so she has been drinking two glasses of wine on a daily basis. That has increased from three to four times a week in the past. You are involved in the management of her DVT and mood disorder, for which you have prescribed warfarin 4 mg daily and quetiapine 150 mg twice a day. So with that, sorry, we are just going to do a quick poll and my question to you is, or proposition is that Sarah’s alcohol consumption is at a harmful level. So please chose what you think is applicable there. So she is a 52-year-old woman you have known for four to five years. She is drinking two glasses of wine daily for the last two years. She is on warfarin and quetiapine and is her drinking at a harmful level?
Sammi: Fantastic and we will give you another 10 seconds also to vote. We have got 45% of people voted at the moment, so let us see if we can get that up above 60, and then we will quickly share those responses. Just so everyone online can see what other people thought as well. Right, we have got 70% voted so I am going to close that off now and share it. So that will pop up on your screen there. You can see that 51% of people agree. 34 strongly agreed. 9% neither agreed nor disagreed, 6% disagreed and nobody strongly disagreed.
Apo: Yes. So look, you are on the money here with your responses. Those who agree and strongly agree. I mean, she is not by any means drinking at excessive level, but the medications she is on puts her at a harmful level. And we are talking about what is harmful drinking during this presentation. And she also increased her frequency at which she drinks and this is not really uncommon at this group and I will show you how it looks like in Australia and the United States in a few moments. And also, you know you can see that she has got a bit of a change over the last two years, and whether this change in frequency is masking another problem, whether it is about her mood because we do not know why she is on quetiapine and you know, that is really something to consider? And we will be sort of talking about similar issues. And here warfarin is one of those medications that is really effective, very sort of acutely and badly with alcohol consumption and I will try to show you some evidence that you know, alcohol is problematic with certain medications at this age group.
So for me to sort of deliver on my promise, I will just start with showing to you what has been happening in Australia. This is from the Institute, you know this is from our national drug strategy surveys from the Bureau of Statistics, and what you can see here is that you know, the number of abstainers is increasing and there is a decrease in risky drinking overall in the population. But, there is a but following this good news in terms of what is happening in Australia, and that is if you look at our local data from New South Wales and this is quite recent, It is a busy slide and I appreciate those who are looking at the screen right now, but what you can see here is that people who are 55 and over, there is a steady increase in their risky drinking consumption in New South Wales. And this is a terrific website but the way, HealthStats, so if you are wondering what is happening in the country, just in the state, just google HealthStats and put any condition that you want there, especially chronic ones and it just gives you a sort of bird’s eye view of what is happening around us. And I will just show you what is going on in terms of older people, and I do not mean that 50 is actually really an old age, but there are changes happening at the time you know from 50 onwards. And if you look at the left side of this slide, you are going to see that there is a decrease almost in every age group apart from the 25 to 29s, and they are the usual suspects in terms of drinking excessively, but please pay attention, these are females 50-59 and 60-69 year old females, and there is an increase in their drinking as much as those who are 30 or you know, younger than 30. And this is just to tell you that Sarah you know, was not an exception and this sort of risky drinking and the definition of risky drinking here is an NHMRC guideline, and is occurring at this age group. And if you look at the males, a similar pattern is occurring, but I want you to pay attention to the numbers. I am just going to go back to the previous slide. So females are, there is a pattern of increase, but the percentage of males who are drinking although it increases, is not that pronounced, it is quite significant, especially if you look at the you know, if you look at those who are 40 and over or 50 plus, you are going to see that you know, we are talking about 30% of the population that you are seeing. In that sense it is really important to make sure that you know, in this age group, you know, questioning alcohol is really, really important because we are not talking about an aberrant behaviour that is specific to a subpopulation group. We are talking about all of the people that we are encountering day to day.
And in terms of single occasion risk guidelines, this is binge drinking basically. You know, people are drinking more than four. Please have a look at the right side again. You know, especially the 50-59 year olds and the 60-69 year olds. There is a trend upwards there as opposed to those who are in the younger group. And admittedly, the younger group are consuming more in terms of percentage. But please do not underestimate the 50-59 year olds or the 60-69 year olds. So that is why in this talk we chose a cut-off point as 50. Other than the fact that you know, there are biological changes because you know, people over that age are consuming as much as they used to consume I guess when they were younger. And this effect is not really isolated to the Australian population.
And there is observation that you know, the baby boomers are carrying their habits forward. If you think about your medical training and if you are my age, you know in the group of people that we talking about, you know, we were told that people grow out of their habits, and you know they let go of you know, smoking or drinking and using drugs. It appears that you know, it is actually different with this current population and if you look at this, please pay attention to the number of drinks that they asked. Eleven or more drinks at least once in the last year. Eleven or more drinks in one sitting. It is quite a lot of alcohol. You know, it is one and a half bottles of wine. You know it is significant. And you can see of course the younger group is doing that more often but if you look at 40 onwards, that is the only group where there is an increase as the years go, you know when you look at the brownish orangish kind of column that is the most recent data that we have. And this data comes from a very large sample. This is not just a little Mickey Mouse survey, you know they went around and asked almost 21 thousand people in rural, regional, urban, male, female, all age groups. So it is pretty reliable data in terms of what is happening in the country.
And alcohol is not the exception. And remember alcohol is rarely sort of especially in younger groups, you know, you will find that people will be using other substances as well because you know, you may lose your inhibitions and then do things that you would not do and here is just a quick bird’s eye view of what other substances are sort of being consumed. And ecstasy is the exception in this community, in this age group that you know it is not really commonly used in older age groups but when it comes to cannabis, ice, cocaine and pharmaceutical opioids, you know, older people are, there is again an upward trend and so you know, it is just really important to make sure that you remember asking you know, your drug and alcohol history of everyone, regardless of their age. Because age is not protective when it comes to substance use. And I saw only a few days ago at Prince of Wales Hospital’s ED, and 81 year old man and was talking to his wife. And you know he said to me he was not doing any drugs. I asked the usual questions and then his wife reminded him of his special cigarettes, referring to the cannabis. So you know, that really happens and this data is telling us that you know, these are not sort of anecdotal sort of experiences, that this actually, that it would apply to the rest of the community. And the consequences are really not only for the individual but for the system and those around them.
But I guess the most important thing for people who are, you know mid-fifties onwards, to remember that of course, you know, cannabis and other substances are there and depending on where you are you will probably be aware of it, but pharmaceutical opioids and sleeping tablets are the most commonly misused substances and they may not even know that they are misusing it because they take it in response to life’s unpleasant experiences. And we are talking about 8-10% of this age group. So I would highlight this. In terms of visualising who we are talking about, we are talking about really almost everyone who walks through your surgery and who are older than 50 years old when it comes to alcohol and other substances as well.
And in terms of its impact, look at the days that it has taken up in our hospitals, alcohol related hospital admissions and the cost. And this is unfortunately the only proper costing data that we have in Australia. When I say unfortunately, most countries do not have that, so I do not want to put this down. But nevertheless, I acknowledge that this is rather old, and for that reason I went back to our local data set and HealthStats, although it does not tell us the costing as you can see, you know, there is no decrease in terms of alcohol attributable hospital admissions. In fact, there is an increase in the number of admissions for both genders. So this tells me that the cost will be going up as well. And if you think about this, that this is a treatable, preventable condition, I think there are significant implications for us, you know, practitioners who are working day to day with people who may be misusing these substances.
So, you know what are the concerns? You know, what are we worried about? I think I made the point, I do not want to go over that again, but you know, local data, national data and international data is telling us that 50 plus, that group consumes alcohol more regularly than the younger people and at times, they actually consume at excessive amounts. So, you know this is one fact that we have been aware of for the last 8-10 years globally. And this may not have actually found its way to our medical training or speciality training, but this is I think a fact about the aging population and what we know about the population. And with that, what we know is that there is increasing biological sensitivity to alcohol as we age. And that is because you know, the change in the sort of the metabolism. You know fat to muscle ratio will change and how we metabolise alcohol will change. As a result you know, smaller quantities in this age group will sort of generate almost the same or more of intoxicating effects, especially on motor coordination and memory, than younger people. So this is to say, for someone who might have been drinking, let us say four to five beers a day for the last you know, 15 years with no problems. But there comes a time when they can no longer metabolise it. Not because you know, something dramatic happened, it is just a normal change as we age and our ability to metabolise this very complex toxic agent that is alcohol.
And also, you know for everyday life after 40, for all of us, you know it is likely that we are going to have one near-chronic disease. And especially for those who have substance use disorders, it is a subpopulation group, this cut off point is 30. So you know, you will find that people who struggle with you know, illicit substances you know, would have a biological age of 40 but they will have the comorbidities of someone who might be you know, 60 or 70. And of course the problem with chronic conditions is around the poly pharmacy and of course alcohol’s impact on certain conditions. If you think about how potent alcohol is when it comes for example to Krebs cycle, and you know its then effect on diabetes control you know, people might be doing everything right, but if they are not changing their alcohol intake their blood sugars may be all around the shop and you cannot even predict whether they are going to have hypoglycaemia or hyperglycaemia. And so the condition itself is affected by the alcohol consumption, but also the way that we treat. There is of course you know, an increasing number of medications for these conditions and alcohol is likely to interact with most of these medications. And it is quite likely that it will complicate most of these chronic, at times acute conditions.
So you know, these are you know not the only concerns. You know, if you look at again the population data and state wide data, we know that consuming alcohol is considered one of the three main risk factors for falls for people over 60. And this is not consuming excessive amounts of alcohol, this is just having alcohol on board that would increase the risk for falls. I think in terms of our risk mitigation strategies, it is really important to make that part of our conversation with our patients. And needless to say, there is accumulating evidence that you know, of association between increased alcohol consumption and certain chronic conditions such as coronary heart disease, hypertension and ischemic stroke. You know, alcoholic liver disease and a range of cancers. And the number of these conditions are sort of getting bigger and bigger and larger and larger the list. And also, you know, we now know that you know, early onset of dementia and excessive alcohol consumption here, not just you know, a moderate amount, excessive alcohol consumption are closely linked. And age related cognitive deficits. But also mood problems are significant, sort of associated. And needless to say, like in every other age group, you know it is implicated in suicides because people are you know, disinhibited. But in this age group, if you think about the other risk factors, you know, isolation, loss of status, loss of connections, through the sort of inhibition that comes with alcohol consumption, you know, one third of suicides in this age group are associated with alcohol.
So you know, you have seen the list. I mean there is not really one organ system that we do not actually sort of list here, and you know the reason that we are having this conversation is that you know, we do not normally talk about all of this when we sort of see people. Unless they are in emergency settings. You guys in general practice are actually quite thorough in you know, knowing your patients. Like you would know if someone like Sarah, but just you know, thinking about these individual concerns and I am going to talk about what we do with this in this sort of condition, alcohol use disorder. You know, just making it personal is really very important and the knowledge of where it might interact with the patients sort of overall wellbeing is the key to sort of get the message through.
And we talked about the importance of screening and identifying those who are at risk. And so you know, this is a recent data that came from our study group. Brian Draper is old age psychiatrist and has done several works. I really find this quite striking, that is they did routine screening of drug and alcohol issues with their clients, so everyone during the month they did look at it, and they had almost 30% of people were consuming alcohol at a risky level or using other substances. But there was not one clinical feature that would distinguish them from other patients. You know, so it is not about how they look, how they walk, because when it comes to that point, you know significant damage is done. It is about asking the question because quite honestly especially with your relationship, level of relationship that you have with your patients, it is a yes or no question if you ask the question how much do you drink, and do you use this and that? You know whatever the substance that you are interested in. It is just a matter of asking, because he found that in this age group, and remember this is in old age psychiatry and geriatric teams, you know how difficult it is to get patients in, we are talking about 75 plus age group, and here you know a routine screening just revealed that you know, there was a significant proportion of people who were consuming alcohol at a risky level. And the good thing is though, you know the tools that you are very familiar with and that are available to us are actually pretty good in assessing. So we do not need to use something special for this group. You know, you are all familiar with AUDIT or AUDIT-C and that it just works pretty well. It is just there is a debate whether we should use a sort of, we should adjust the upper limit for daily intake for older people in that should we reduce the sort of number of standard drinks to identify risky drinking. And I will show you what the suggestions are around the world. Just a reminder, this is the AUDIT-C questionnaire. Three questions and this would really tell you whether you know, someone is actually having a problem and you are all familiar with it. I am not going to bother you. But as you know, you know the A to E, it goes from zero to four in terms of marking and you can score zero to 12 and the suggestion here is for the older age group, you know, for females if it is three or more. For males, if it is four or more, then you may have someone who has an alcohol problem in terms of harms associated with alcohol. And the higher the score is, the most likely that the drinking would have an impact on their wellbeing.
And in the next slide, I really like this, this is Australian data. This is from Melbourne, Bright and his team did this. They actually sort of made, this is as you can recognise from the column, you can see that they are actually sort of correlating what we ask in AUDIT-C, but also they are adding another level that is you know, these certain medications that are listed there, you know the sedatives, antipsychotics, narcotic medications, nitrates, warfarin, anticonvulsants, antidepressants, and non-prescription antihistamines. Please keep you know, your Phenergan in mind, especially in here. And you can see here that what they did was, they sort of graded it and you can see the black bits there, it is about harmful, and the grey bits are for hazardous. So in the past what would have been you know, non-hazardous drinking if you do not take the medications into account, when you put the medications into account, you are going to find that you know, the risk is increasing. So for that reason, Sarah was at more risk. Because warfarin she was on, and you know, alcohol really plays with its metabolism, zero-order kinetic medications, and it just is really complicated. And also, sedating antipsychotics such as quetiapine, increases risks of fall, respiratory depression, so it is really important to sort of keep not only how much they are drinking, but what they are on and what their condition is, their physical condition is about. You know, it is really important to keep that in mind.
And you know, I think we know when we are talking about alcohol it will be remiss to sort of ignore the benefits of alcohol consumption. And you know, it may be a way of socialising. And it is really important to acknowledge that and to ask you know, what it is they get out of it. Because that might really help then to start a conversation as to whether there are other ways of socialising. But nevertheless, you know this social interaction you know, is a good thing but also we know that with alcohol consumption comes social harms. You know that is you know, domestic violence, brawls et cetera and you know it might have an impact on finances and you know their ability to drive, work et cetera. So I think it is important to explore potential social harms regardless. But as well, it is important to consider what they see as beneficial and I think you cannot deny that you know, it sort of connects people. It is a way that we socialise these days. I mean, how many of you know people who do not bring a bottle of wine when they come over to your place for dinner? Or think about yourself when you went to someone’s place last time, or gifted someone alcohol. Because I think this has become the norm you know, over the last 20 years. Prior to that, I do not think anyone was bringing sort of grog to dinner parties, it was more the salad with the stuff. So it is sort of changing.
But also, you know, there is this sort of misinformation about that a small amount of alcohol is beneficial for cardiovascular health. Well you know what? What we now know, is that all of those studies that were retrospective studies, they are talking about the selection bias in these studies because people who say they do not drink, they do not actually ask why they do not drink. You know, it included a group of people who were pretty sick and they could not drink or they decided to stop because they were pretty sick and as a result you know, the abstainers included a group that contained a group of people with significant health problems, especially cardiovascular problems compared to minimal drinkers. So the idea that you know, consuming one to two standard drinks of wine is good for your cardiovascular health comes from that sort of flawed study. So now we have evidence that you know, if you are sort of, if you are looking at people who cannot drink alcohol, you know who lack the enzyme alcohol dehydrogenase, if you use them as your control so the people who never truly had alcohol versus those who had alcohol, now we know that even minimal amounts of alcohol increase the risk. So, if you are suggesting or if you are, I am not saying that you would suggest them to consume alcohol, but if you are not challenging the idea that moderate alcohol consumption is beneficial for cardiovascular health, it may be misleading. And you know, that small amount, even if we take the face value of those studies suggesting that a small amount of alcohol is good for your heart, you know that amount of benefit can be obtained from a brisk 10 minute walk or just doing some home exercises in terms of cardiovascular benefit. So I guess you know, I do not have good news about the benefits of alcohol consumption, those who were planning to have a little glass of wine tonight, but you know it is just about knowing what the risk is I guess.
And in terms of safe amounts you know, in Australia our guidelines do not actually make a specific recommendation about older people and for everyone it is two standard drinks per day and no more than four standard drinks on each occasion. And I have listed here as you can see, US and IK suggestions, and both of them are talking about alcohol-free days which are not in our guidelines and they are suggesting one standard drink, or one or one and a half standard drinks being the safest amount and not more than seven standard drinks per week is the sort of suggested safe amount. So I like to sort of highlight that and NHMRC is in the process of updating the guidelines and also it commissioned a bunch of us who are writing the treatment guidelines as we speak. So towards the end of the year, we might have a different set of criteria, but I guess my suggestion to you is thinking about a bottle of wine throughout the week, and you know one to two standard drinks a day if they are not on those medications that I suggested. And if they are on those medications that are listed there, then you know, you really have to think about advising alcohol-free days when you see them.
So you know, this is the situation. So what works for older people with alcohol use disorder in primary care? The good news is that everything we know about the treatment of alcohol use disorders in younger people would apply to people with alcohol disorders in older age. So there is no difference. Whatever you think is working for younger patients would definitely work for this age group as well. And even better, they respond to treatment very favourably compared to their younger counterparts, and it improves their overall wellbeing and general health disproportionately compared to younger people, if you think about you know, the way that they metabolise alcohol and the harm that they were getting from it and also potential destabilisation of their general health.
And I am sure most of you are familiar with the importance of the GP letters to the individuals, or you know personalise information. There is really growing evidence not only in alcohol but in de-prescribing benzos or opioids, quite a significant proportion of people, if they receive a letter from their GP, that is addressing them, not one of those generic handouts, they change their behaviour very significantly because they, I think, take that to heart because you are making the effort. But also at times, people do not register things that they were not seeking information or advice from the very beginning. So if they came to see you for their blood pressure or other issues and you are talking about alcohol it may not register there and then. But your GP letters, your letter to them is just incredibly helpful and so it is you know, also in the letter if you advise certain things such as keeping an alcohol diary and just sort of tell them that you know, you will be talking about this next time. So that sort of future planning has proven to be quite effective in this age group compared to younger people. And in terms of motivational interviewing, this is one of the tools in chronic relapsing conditions that is very, very efficient and is quite effective. And motivational interview is really I think the epitome of what you can do here. Just rolling with the resistance and trying to get them to see what you think is not working for them. But get them to think what they can do. For example, if you are talking about alcohol-free days, encourage them to think when they can do it, what would be the most practical thing for them, and name the day. You know, just say it will be Thursday and on Thursdays I will not have any alcohol, rather than a day in the week that may never come. So it is really important to sort of make it practical and applicable to their condition.
And pharmacotherapies. You know, we know that naltrexone works in this group and it is really important that you know, it is effective and the others, we just do not know because they are not studied. I mean, we do not have any evidence that they are sort of harmful.
Tim I noticed that someone asked about the naltrexone.
Tim: That is right.
Apo: LFTs. So, look I think look in terms of naltrexone really you do not want them to have alcoholic hepatitis. So if their LFTs are sort of within the two to three times of the normal, naltrexone is pretty safe to use. And you just want to make sure that their synthetic function is also you know, not impaired. So make sure you know, that you are paying attention to their INR et cetera, so that you know, it is not a burden. But otherwise it is a pretty sort of reliable medication.
And I just noted the question about the confidentiality of the alcohol letter. I think in those studies it was actually given to the patients rather than just you know, getting something in the post or you know I guess it is addressed to them and marked as confidential would be the way to go to sort of part with that information.
When it comes to pharmacotherapies I do not know that we need to medicalise or prescribe medications for everything, especially in this age group. Really the first three bits are really effective and I am not talking about you know, touchy feely, Mickey Mouse kind of, sort of efficiency here. It is significantly improved outcomes are achieved through this psychoeducation, personalised feedback and motivational interviewing. And when you introduce these medications, please be aware of polypharmacy. I am not going to go into details of all the medications and interactions, but you know, at DASAS there are drug and alcohol specialists or your local drug and alcohol people will be your source to sort of check the practical aspects of whether this medication is actually appropriate. You know your naltrexone, Campral or disulfiram will be appropriate for that particular patient. So keep the polypharmacy and drug interactions in mind in this age group of course. And if there is consent, and also you would know the family dynamics. Involving family members is effective, because I think it introduces a level of accountability and also building on their past achievement is effective. So as their GP, you know what worked for them in the past and if they lost a bit of weight, if they, whatever they achieved in the past. And if you just try to extrapolate from that, you know look you have done this and as a result I know that you can do this as well, is very positive feedback. Because you know, changing behaviour is tricky and it has certain sort of difficulties about it, but if you ty to build on what you know about them, it is all about making it personal, it really works in this age group, especially in primary care very, very efficiently.
But of course you know, there is this small number of patients where you know, alcohol use will be very problematic. That is dependent drinking. And in this age group it is not sort of disappearing and going anywhere. So these people are still sort of problematic. So I guess you know, asking them how often they drink and what happens to them when they stop drinking is really important. And asking about the history of you seizures is important. But whether they get the shakes and you know, what are they like before their first drink, especially the time to first drink is important and you know, their last drink is important. I just put the symptoms of alcohol withdrawal there. You are all familiar with it. But just to use it as a prompt in terms of exploring that. And here are the sort of pointers about who may be drinking dependently, especially in this age group, that if they had been drinking heavily for the last six years or more, so there is no interruption, and it is daily 10 standard drinks or more, or if you have more than 10 standard drinks even shorter periods may actually mean, that is you know, a couple of years. It may mean that they develop some level of tolerance that could be harmful in this age group. And early morning drinking is really important. Unless they are shift workers, you know for the rest of the population, early morning drinking is often about getting over the withdrawal symptoms. And if they had a past history of severe alcohol withdrawal syndrome, you know it is just really a sign that they will definitely have something like that next time they stop, if they have actually had a significant break. And if there is concomitant drug use, especially benzodiazepines, that is really a tricky sort of issue and as we know, alcohol reduces your seizure threshold and if they have severe hepatic conditions then their metabolisation is impaired. And of course head injury is a major problem.
So if you have these sorts of issues, then I guess referral to an inpatient detoxification is really a good idea because you know, for younger people even with that sort of history, you can do that potentially as an outpatient. But you know, we do not want to give a lot of benzodiazepines to manage the alcohol withdrawals in this age group. We do it through a symptom triggered approach. And of course in certain settings, especially in the country, you know inpatient detoxification is not a sort of option, but really local hospitals should support this, because as you know, severe alcohol withdrawal is a medical emergency. It needs to be managed accordingly. And outpatient detoxification can be done if you have like a chance to daily review them and if you have sort of a trusting, someone that you can trust managing their medications and if you can use the support of community nursing or community pharmacy. But the key message is the same. No one needs more than five days of benzodiazepines for the management of alcohol withdrawal symptoms. Okay? So if you prolong it, then you are treating something else, it is not withdrawal. And the combination of benzodiazepines and alcohol, you know that is a sort of very tricky combination and there are serious comorbidity and increased risk of mortality in this group. And you know, none of the medications that we know of for the management of alcohol use disorder, such as Campral, naltrexone or anti-epileptics, you know, the Epilim and all that sort of stuff, they are not efficient in the management of alcohol withdrawal symptoms. So only benzos would work, but you need to use them efficiently and cautiously just for a short period of time. Because alcohol is a short-acting substance, so the withdrawal period is also short. So three to five days.
And there will be quite a lot of people who are not ready to change. So I will talk to you about what works and if you have patients who are not interested in changing their alcohol intake, that is okay. Because you know, their contact with you is really sort of important. And it is important that you know, they actually linked in with you and if they are interested in something else like smoking cessation, and especially you know, your five phases and it is really important to apply all of them and making sure that you do a nutrition and physical activity assessment in this age group, especially with the alcohol that they are not trying to give up. Because we know that thiamine deficiency is really a significant problem in this age group. And if you think about you know, I mentioned it before to you, that you know individualising the advice in terms of harm is really important. And if you think about the medications and you know, their sleep and motivation, you know falls, you know risk of losing independence, that is really an efficient tool in older people. Risk of losing independence more than any other health problem that you can think of would worry them. In fact maybe relationships or maybe finances. So you know, you will know this because they are talking to you about other issues.
So if you bring that back potentially to their drinking, the chances are that you are going to get a hook there and work with the patient. And not only harms of consuming alcohol, but also benefits of reducing alcohol is important to be mentioned. So that they can actually see where that sort of goes and these are some aspects that I have put there that you use in your motivational interviewing, you know, improved health, sleep, you know their mood, memory and sexual performance. You know older people are sexual beings and it matters to them, so it is really important to sort of bring that into the talk as well because just because they are older does not mean that they have given up on other aspects of life. And you know, weight loss and improved relationships, independence. I have listed them in here for you. You are going to get these slides. And these are some pointers that perhaps you can use when you give advice.
And when it comes to people who are drinking regularly, I think it is important to sort of give some practical advice about the alcohol and the harm reduction. It is about the limit and whether they are drinking alone or whether they are drinking with people and if they are going to the pub and there are shouts and that is the reason that they are drinking a lot, perhaps you can sort of get them to think about other ways of socialising with their mates. And you know, setting limits and trying to stick to them. You know, starting with non-alcoholic drinks and alternating their alcoholic drinks with non-alcoholic drinks. So these are some practical aspects, you know, in terms of you know driving safety is there as well, and especially eating while they are drinking is really important, because when you have something in your tummy the metabolisation of alcohol will be slower. So you know, this is some advice that we can give.
And in terms of nutritional status, you know thiamine, very cheap, no harm is associated with it. It does not interact with other medications, and you know, over the counter bottles have more than 50 tablets some of them in them. So if you advise and give them daily 100 mg thiamine, at least you know it will protect them in terms of other related concerns that we have with alcohol and cognition.
And that you know, change is possible. First of all it is important for us to accept this. But for people, just because they have been doing it for years, it does not mean that nothing is going to change. It is important to put that positive angle, and if you know, they do not want to talk to you more if they want to talk to some other people, it is important to give them maybe the support services numbers and encourage them. And I will give you some examples of what they are towards the end of the slides. And if you see them regularly, and if you are seeing them regularly rather, and keeping alcohol on the agenda, it is really a very helpful thing to do. And for those who are not stopping drinking, please keep in mind that just because they are older, you know some of the safety aspects are still there and they are not exempt from that. Especially if they are driving and if you think they are at risk, you know make sure that you know, you talk to your MDO and consider whether you need to actually make a notification to RMS. And this is really sort of a significant issue that older people who are drinking have fitness to drive assessment. And if you think, you know they are intoxicated and they have got the keys with them, they are not leaving it with you or they do not have anyone to drive and they are going to hop in the car, regardless of their age by the way, you better call the police because if you think about the latest cases. So it is just really important to keep driving safety in mind. But also child protection issues. I am not going to go into detail much here, but remember older people are involved in child care. And keep in mind whether they are putting anyone at risk, and I am talking about here excessive drinking of course.
And here is a sort of stepped care approach. If you have someone who is 50 years old and they scored more than eight. This is really serious drinking. I think just start with initial brief personalised advice you know in terms of behavioural change. And then try you know, two or three sessions of motivational interviewing and introduce a pharmacotherapy, and I think naltrexone is the first choice in this age group, if they do not have any contraindications. And then I think, refer on if this is not working, because it is not really good to sit on these patients, especially you with the comorbidities. So my suggestion to you is that most of the evidence comes from the stepped care in the UK, and what they suggest is that if you do it for four to six weeks in between your steps, you know early referral is probably a good option and keeping the referral on the agenda is important with this age group.
So, I have got another case for you. This is Thomas. He is a 63-year-old and he has been coming to your surgery for quite a long time. He had a fall and he was admitted briefly to a local hospital and his blood pressure was poorly controlled. He says he takes his ACE inhibitor regularly and has been struggling with insomnia and takes temazepam 10 mg tablets two or three times a week. And you have got no evidence whatsoever that he is misusing the tablets. He does not run out of scripts et cetera, but he takes them you two or three times a week. He tells you that he has been drinking up to five standard drinks, two to three times a week and since he cut down on work 18 months ago. So he is not drinking daily, but he drinks five standard drinks two to three times a week. So with this, we have got a poll and the assumption is that Thomas’s alcohol consumption is at a harmful level, and you will see the options there. See what you think.
Sammi: And we will wait until we have got about 70% of people voted. We have currently got 45, so we will give you another 10 seconds or so to click away and then we will quickly pop those results up so you can all see what the group said. 58, 59, 60. Another 10%. Click away. I will give you another couple of seconds before we close that off. Alrighty, lets close that off now and we will share those results. So, 39% strongly agreed and 58% agreed. 3% disagreed. Nobody was neutral and nobody strongly disagreed.
Apo: Yes, so I am with the group here. It is really important to sort of look at what is happening and his age is a problem and you know, the issue is to think about is he is drinking at a risky level because you know, it is more than five. Although it is two to three times a week, it is really more than the weekly safe amount in terms of what is happening. And he takes sleeping pills and also you know, why he fell. Did he drink on the day? You know was that a function of it? And what is happening with his blood pressure, because you know, alcohol really creates a havoc with control of blood pressure. So there are lots of things that could be mentioned here and if you look at the table that I had right after the AUDIT-C slide, he would fall into the harmful, not hazardous, but harmful drinking group. So I think you know, here it is just a great opportunity to talk about sort of the psychoeducation and setting goals for him. And naltrexone is potentially a good sort of option here, and there is a question from Louise about the Sinclair method. For those who do not know what the Sinclair method is, rather than taking it daily, to take the medication on the days that they drink. And it is really a good way of thinking about it, because naltrexone basically kills the joy out of drinking. So they do not drink as much. But remember, the Sinclair method is for those who are drinking six standard drinks or more, not those who are sort of around two. So, I think you know, Thomas drinks harmfully and it would be good to talk about all of these things. And if you have any problems in terms of the medications or practicalities, we have got DASAS which is going through a change and you know, it will be really mainly sort of manned by people from St. Vincent’s and other local drug and alcohol services, so I think there will be more consistent advice from DASAS.
And also, I do not know whether you are aware of this, Get Healthy information and coaching service. You know we put all the details here in their website if you have people that you are worried about. And all you have to do is fill in this form, a general practitioner form, and send it over, email or fax it to the Get Healthy Service, and they get 10 coaching sessions over six months. And this is a really very helpful sort of intervention for this age group. And you know, HealthPathways, are if you are in your PHN, if you have them. In ours we really have the sort of contact details so it is really important to remember HealthPathways there. And Yourroom is a great resourced for your patients to have a good look and you know you can print out some of the resources for them. I put my references in here.
That was the talk that I had for you today and so I am hoping we covered all the things that we said we were going to cover. We have got a few minutes and if you have any questions I will be very happy to try to answer them.
Sammi: Fantastic. So maybe while Tim reviews those learning outcomes for us, if anyone has got any questions, if you want to type them through to us now, that would be great.
Tim: Thank you very much. If we just go over the learning outcomes as well. So during the evening we have covered the epidemiology of alcohol use problem among older Australians. That was the slide at the beginning. We have covered how to identify older patients with alcohol use disorder, with the AUDIT-C questionnaire. We have described what can easily be done in general practice to address the needs of older people with alcohol use disorder. It is quite comprehensive. And we have listed the referral pathways that are available to older patients with alcohol use disorder. I think you will get a copy of the slides and you will have local referral pathways available to you, particularly through HealthPathways as well.
Sorry, just looking to see if there is any questions coming through, with two minutes left to go. You will get an evaluation survey as well and we really value your feedback on how the evening has gone. We certainly do look at all of those. And Sammi has sent through the email address to you all so if you do have any questions that do come up after, you can send those through to us and we will do our best to cover those off as well. It looks like there are no questions coming through, so thank you very much indeed. I think that was a really good comprehensive session. Thank you very much, Sammi for your coverage. I am just wondering if that is someone coming through with a question now. One question. Just a question about Antabuse.
Apo: One question about Antabuse. I love Antabuse. I can see that. But you need to be very careful in this group, because you know cardiovascular events especially if they had stents et cetera. It is not the medication itself, it is the reaction that can cause trouble in this age group. So please watch out for the interactions and I think maybe if you go to MIMS you are going to see that that is listed there. And also, remember to assess their cognition, because if they have memory problems they may forget they have taken the medication and then they drink on it and then they get that awful reaction. But for people between 50 and 65, if they do not have any problems, Antabuse is pretty safe if they take it. You know, it is a good medication if they take it, if you know what I mean. So you need to maybe have an allied pharmacist or someone from home to support it.
And someone is asking about the maximum dose of diazepam. Our suggestion is, that we do not give more than 40 mg daily for anyone in the community. For this age group, I would tell you that unless you know they are drinking really excessively, that is more than six standard drinks on a daily basis, I would not go beyond 25 mg a day and I would taper it off over the course of five days.
And how long would you give naltrexone? Well there is not really a limit, and I think so long as you are regularly reviewing it, you know you should give it a go for at least three months. Re-evaluate it and then see what happens, whether you want to give it another three months. I hope that answers your question.
Sammi: That is fantastic. Thanks so much, Apo.
Tim: Thank you very much.
Sammi: And that looks like the end of the questions, but as Tim said, we have posted that email address so if anything else arises, please do send it through. I would like to thank our presenter, Apo and also Tim, our facilitator and also everybody that joined us on line. As Tim mentioned, there is an evaluation survey that follows the webinar. You do need to complete it to receive your CPD points. It will pop up on your screen automatically when we close down the webinar software. If it does not, do not stress, there is an email going out in one hour’s time that will contain a link to that survey. So, that is it from us for this evening, so thank you and good night everybody.