JADA Continuing Education
Geriatric alcoholism
Pathophysiology and dental implications
Arthur H. Friedlander, DDS and
Dean C. Norman, MD
 |
ABSTRACT
|
|---|
Background. The authors reviewed the clinical features, epidemiology, diagnosis, medical treatment, orofacial findings and dental treatment of geriatric patients with alcoholism.
Types of Studies Reviewed. The authors conducted MEDLINE searches for the period 1995 through 2004 using the terms "alcoholism," "geriatric," "pathophysiology," "treatment" and "dentistry." They selected reports published in English in peer-reviewed journals for further review.
Results. Physiological changes associated with aging permit the harmful effects of drinking alcohol to arise at lower levels of consumption than in younger people. Excessive use of alcohol exacerbates the medical and emotional problems associated with aging and predisposes the person to adverse drug reactions with medications controlling these illnesses.
Clinical Implications. The incidence of dental disease in this population is extensive because of diminished salivary flow and a disinterest in performing appropriate oral hygiene techniques. Concurrent abuse of tobacco products worsens dental disease and heightens the risk of developing oral cancer. Identification of patients who abuse alcohol, a cancer-screening examination, preventive dental education, and use of saliva substitutes and anticaries agents are indicated. Clinicians must take precautions when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol.
Key Words: Alcoholism; aging; metabolism
Adults older than 65 years represent the fastest-growing segment of the U.S. population. The moderate intake of alcohol among people in this group is associated with cardioprotective effects and possible benefits relative to ischemic stroke, hypertension, bone density and cognitive function.1,2 Age-associated physiological changes, however, make this growing cohort vulnerable to developing medical and psychiatric illnesses because of excessive ingestion of alcohol.3,4 Exceeding certain drinking limits also worsens previously acquired age-related illnesses such as cardiovascular disease and may interact adversely with the medications used to treat them.5 Older people’s drinking of large amounts of alcohol also is associated with an increased presence of dental disease and a need to modify treatment of it.
|
AGE-RELATED ALCOHOL PHARMACOKINETICS
|
|---|
Older people are vulnerable to the adverse consequences of alcohol consumption because of the physiological changes associated with aging. Between the ages of 25 and 65, the proportion of total body weight represented by fat almost doubles in men and increases by 50 percent in women. As adipose tissue increases and lean body mass decreases, there is a reduction in total body water. Therefore, when an older person imbibes alcohol, a water-soluble compound, the alcohol is distributed in a smaller volume of body water, which results in a high blood alcohol concentration.6 Compounding the issue, the gastric enzyme alcohol dehydrogenase (ADH) may work less effectively in older people than in younger people. This could explain, in part, why elderly people develop higher blood alcohol levels than do younger people after imbibing similar amounts of ethanol.7 Because of these differences, older drinkers are more likely to have adverse consequences from drinking alcohol even at lower levels of consumption than are younger drinkers, and these consequences are likely to be more severe.8
Therefore, it has been recommended that all adults older than age 65 years limit their alcohol consumption to a maximum of one drink per day, in contrast to a recommended limit of two drinks per day for younger men and one to two drinks per day for younger women.9,10 These guidelines are based on defining a "drink" as 0.5 fluid ounces (12 grams) of pure ethanol, which may be obtained by imbibing 12 ounces of beer (4.5 percent alcohol by volume), 5 ounces of wine (12.9 percent alcohol), 1.5 fluid ounces (one "shot") of distilled spirits (40 percent alcohol or 80 proof) or one mixed drink.11
Many of the medical problems often seen in elderly populations may be caused or exacerbated by excessive drinking. Alcohol provides nonnutritional calories, and, in older people with age-associated decreases in appetite and food consumption, this can result in nutritional deficits. This is especially true in people who drink heavily, as alcohol inhibits the absorption of thiamine, riboflavin, niacin and folic acid from the intestine; impairs fat absorption; and promotes the loss of magnesium, calcium and zinc.12
Older people who have two or more drinks per day have an increased prevalence of hypertension.13 The mechanism by which alcohol causes hypertension is not understood completely, but it may arise from an increase in sympathetic nervous system activity. Accompanying this alcohol-induced hypertension is an increased risk of developing both cardiovascular and cerebrovascular disease.14
Chronic alcohol use is associated with decreased lymphocyte production and white blood cell function, which impairs the immune response. Coupled with age-related changes in the immune system, an increased susceptibility to infection such as pneumonia, tuberculosis and hepatitis exists.15
Alcohol also is an irritant to the gastrointestinal tract. It may cause gastritis, stomach ulcers, duodenal ulcers or any combination of the three. In 20 percent of people who have consumed alcohol for a long time, alcohol use can lead to cirrhosis and pancreatitis.16 Furthermore, heavy alcohol consumption is associated with cognitive problems and functional or motor impairment (for example, difficulty in eating, dressing, bathing, crossing a room, or getting in or out of bed). This is because of an excessive alcohol-to-brain-cell ratio that occurs because of age-associated neuronal cell loss, most noticeably in the basal ganglion, hippocampus, reticular activating system and neocortex.17,18
Long-term alcohol ingestion suppresses megakaryocyte maturation, which leads to decreased numbers of platelets, and it inhibits the release of thromboxane A2 and B2 which adversely affect platelet aggregation. The defects in hemostatic function are demonstrated by a prolonged bleeding time. Coagulation defects also may occur as the result of impaired vitamin K absorption, which affects the syntheses of clotting factors. This coagulopathy is worsened in patients with advanced liver disease, because a scarred, cirrhotic liver with relatively few hepatocytes is unable to synthesize fibrinogen, prothrombin and clotting factors V, VII, IX and X. These coagulation defects are demonstrated by an alteration in the prothrombin time.19,20 In the Dental Treatment section of this article, we describe the adverse effects of long-term alcohol abuse on the liver’s ability to metabolize medications.
Some medications commonly prescribed by physicians for older people have the potential to interact adversely with alcohol. H2 histamine-receptor antagonists (for example, cimetidine [Tagamet, GlaxoSmithKline, Research Triangle Park, N.C.]) that are used to treat gastroesophageal reflux disease and ulcer disease inhibit ADH’s ability to metabolize ethanol. Thus, when a person who is being treated with these medications drinks alcohol, less of the alcohol is broken down in the stomach and a proportionally larger amount (30–40 percent) enters the bloodstream. Similarly, it may be difficult for a patient to obtain a proper level of anticoagulation with warfarin (Coumadin, DuPont, Wilmington, Del.) if he or she chronically imbibes alcohol, since alcohol may increase the medication’s rate of metabolism, which decreases its effectiveness.21,22
|
ASSOCIATED PSYCHIATRIC ILLNESSES
|
|---|
A significant minority of older adults receives the psychiatric diagnosis of "alcohol abuse" or "alcohol dependence" because of its markedly excessive ingestion of alcohol. Alcohol abuse occurs early in the disease process and consists of repeated episodes of intoxication that are severe enough to alter mood, impair judgment, slur speech and invariably prevent people from fulfilling personal responsibilities. Furthermore, a person who has received a diagnosis of alcohol abuse or alcohol dependence often continues to consume alcohol despite the knowledge that continued consumption poses significant medical and interpersonal problems such as acting inappropriately in social situations, which results in arguments with family or, occasionally, domestic violence.23 "Dependence" is an advanced stage of alcoholism and is distinguished by physiological dependence as evidenced by the presence of tolerance or symptoms of withdrawal. During this phase of the illness, the person progressively increases the amount of alcohol imbibed (tolerance) to achieve the same level of intoxication, and he or she may drink continuously so that blood concentrations remain high and so as to avoid withdrawal symptoms such as insomnia, sweating, rapid pulse, anxiety, nausea, vomiting and xerostomia. Excessive ingestion of alcohol in older people also is associated with the development of major depressive disorder and the concomitant abuse of or dependence on other drugs such as benzodiazepines.24,25
|
EPIDEMIOLOGY
|
|---|
More than 40 million Americans are older than 65 years.26 Approximately 13 percent of the men and 2 percent of the women in this cohort imbibe more than 1 ounce of alcohol per day.27 These rates are even higher among retirement community residents (31 percent of men and 22 percent of women), medical clinic outpatients (15 percent of men and 12 percent of women) and people being treated for major depressive disorder (between 15 and 20 percent of people).28 Of even greater concern are the data from the 2000 National Household Survey on Drug Abuse that noted that 9 percent of older adults reported "binge use" (five or more drinks on the same occasion for at least one day in the past 30 days) and 2 percent reported "heavy alcohol use" (five or more drinks on the same occasion for five or more days in the past month).29 The prevalence of alcohol problems in the elderly likely will increase further because of the alcohol consumption patterns of middle-aged baby boomers.30
Approximately two-thirds of elderly people who drink excessively developed the disorder early in life.31,32 They often had a positive family history for alcoholism, were socially disruptive when drinking, were cigarette smokers and were of lower socioeconomic status as determined by their income, educational attainment and occupation. These people also tended to have more alcohol-related declines in physical and mental health.33 The remaining one-third developed the disorder when they were older than 60 years as a method of coping with stressful life events such as retirement, declining health, chronic pain, disability, or death of a spouse and the resultant bereavement, loneliness and isolation. This latter group included people who often had higher incomes, were more psychologically stable and were better educated than those with an earlier onset of the disease.34
Epidemiologic studies have demonstrated that drinking more than two drinks per day is associated with an increase in all-cause mortality, stroke mortality, death from injury and an increased risk of death from cancer.1,35–37 Excessive ingestion of alcohol also elevates the risk of suicide. Those who are most at risk are white men older than age 75 who are depressed, medically ill and lack social support.38
|
DIAGNOSIS
|
|---|
The excessive use of alcohol is more difficult to ascertain in elderly people than in younger people because they are more reluctant to self-report abuse and because it can be masked by age-related medical, social or psychological conditions.39 Thus, physicians may misinterpret important signs and symptoms caused by alcoholism as normal consequences of the aging process; for example, attributing changes in eating habits to "fussiness about food" and confusion to "a bad night."40 These findings are consistent with research demonstrating that alcohol problems among women—widowed women in particular—is underrecognized, especially among those who are taking psychoactive medications or medications with sedative effects concomitantly.41
The presence of certain illnesses, however, may arouse the physician’s concern about an underlying problem with alcohol. These problems include frequent falls, fractures, peripheral neuropathy, insomnia, loss of libido, late-onset seizure disorder, incontinence, myopathy, hypertension, congestive heart failure, ulcers, cirrhosis, pancreatitis, bleeding diatheses, and cognitive and motor disorders.42
Biological markers of recent, excessive alcohol use also can be used to detect the illness. These markers include elevation in the level of the liver enzyme gamma-glutamyltransferase, increased mean volume of red blood cells (mean corpuscular volume), elevation in the level of high-density lipoprotein cholesterol and an increase in the level of carbohydrate-deficient transferrin. The sensitivity and specificity of these tests, however, is relatively low.43–45
A sizable number of physicians and some dentists use health questionnaires that are designed specifically to help identify older people who may be using excessive amounts of alcohol.46,47 A questionnaire that is applicable to the practice of dentistry is discussed in the Dental Treatment section of this article.
|
MEDICAL TREATMENT
|
|---|
The main components of treatment include confrontation, detoxification and rehabilitation. Confrontation involves overcoming patients’ denial, convincing them of the adverse consequences of continued drinking and motivating them to receive treatment.
Detoxification consists of removing alcohol from the patient’s body and protecting the patient from the serious effects of alcohol withdrawal, particularly delirium tremens. This process usually takes about five days and involves replacing alcohol with central nervous system (CNS) depressant medications such as lorazepam or diazepam in gradually reduced dosages to help the patient avoid withdrawal symptoms. Rest, adequate nutrition and the taking of multiple vitamins (especially those containing thiamine and magnesium) are vital to the process.48–52
Rehabilitation consists of continued efforts to increase and maintain high levels of motivation regarding abstinence and readjustment to an alcohol-free lifestyle. This aspect of treatment includes psychosocial interventions such as cognitive-behavioral therapy (CBT), which helps patients recognize that their beliefs and thinking styles are pathological and contribute to addictive behavior. CBT teaches people skills for coping with difficult and stressful situations, cravings and feelings that in the past would have forced them to drink alcohol.53 During the rehabilitative phase of care, many people are at high risk of experiencing relapse because they are preoccupied with thoughts of drinking. The medications naltrexone and acamprosate may be used to counteract the craving for and the positive-reinforcing properties of alcohol.54 It is believed that naltrexone, an opioid antagonist, works by blocking the dopamine in the nucleus accumbens (the brain’s reward center). The exact mechanism underlying the effectiveness of acamprosate, however, still needs to be defined.55
|
OROFACIAL FINDINGS
|
|---|
Salivary gland enlargement, usually in the parotid glands, may occur in some patients who ingest large quantities of alcohol on a long-term basis, with resultant liver damage. The condition is termed "sialosis" or "sialadenosis" and is thought to result from an ethanol-produced peripheral autonomic neuropathy that causes disordered salivary metabolism and secretion.56 A reduction in parotid gland salivary flow, a reduction in saliva-buffering capacity (that is, the ability to neutralize acid) and an alcohol-associated neglect of oral hygiene frequently give rise to extensive dental caries.57
People who drink more than 1 ounce of alcohol per day have an almost 20 percent greater likelihood of developing periodontitis.58,59 This also occurs because of an alcohol-associated neglect of oral hygiene and the consequent colonization of the periodontal tissues with pathogenic bacteria, as well as the associated presence of large amounts of lipopolysaccharide (LPS).60,61 This elicits an inflammatory response with multiple inflammatory cells infiltrating and populating the gingival tissues. The monocytes and macrophages of people with alcoholism are sensitive to LPS and produce large amounts of tumor necrosis factor-alpha, which may play a role in the destruction of the periodontal tissues.62–65
Oral signs and symptoms of alcohol-induced nutritional deficiencies include glossitis, angular cheilitis and gingivitis. In the early stages, the tongue is painful and the fungiform papillae are swollen, flattened and mushroom-shaped. As the deficiency progresses, the tongue begins to burn and becomes intensely red, and the filiform and fungiform papillae atrophy. Cheilitis is typified by ulcerations at the corners of the mouth, and the gingivitis manifests itself with necrotic areas at the tips of the interdental papillae.66–68 Oral candidal infections also may be present. The etiology of these infections has been attributed to alcohol-induced anemia, xerostomia and abnormalities in macrophage function.69–72
Poor wound healing, infection and osteomyelitis may develop after routine dental extraction. These complications can arise because people who abuse alcohol on a long-term basis are less able to accumulate protein and collagen at the surgical site and because ethanol suppresses activation and proliferation of T lymphocytes, as well as the mobilization and phagocytic capability of monocytes, macrophages and neutrophils.73,74
Almost 43,000 Americans are diagnosed annually with squamous cell carcinoma of the oral cavity, pharynx and larynx.75 The risk of developing these cancers increases when more than two alcoholic drinks per day are consumed; the risk continues to rise with increasing levels of alcohol intake. The development of these malignancies is abetted by the use of nicotine, the most commonly abused substance among older patients with alcoholism.76–78 Squamous cell carcinoma of the oral cavity, especially of the tongue and floor of the mouth, is thought to arise because the ethanol metabolite acetaldehyde promotes tobacco-initiated tumors by damaging DNA and altering oncogene expression in oral keratinocytes. The process is facilitated by the high and long-lasting concentrations of acetaldehyde that are present in the mouths of people who consume large amounts of alcohol and have poor oral hygiene.
|
DENTAL TREATMENT
|
|---|
Millions of older Americans drink excessive amounts of alcohol. In our experience, however, patients rarely disclose this information to their dentists, given the stigma associated with such actions. Similarly, dentists may be reluctant to ask about a patient’s alcohol use because it may seem intrusive or because they view the disorder as a moral shortcoming rather than as a medical disorder. This avoidance, however, presents a danger to the patient because of alcohol’s effects on oral and systemic health and because of an enhanced risk of medication-related adverse events and drug interactions.
While obtaining a medical history, dentists may uncover indicators that a patient is at risk of developing alcoholism. Historical factors that may indicate a problem include bleeding and coagulation disorders, headache, dyspepsia, diarrhea, palpitations, hypertension, anxiety, depression, recurrent falls and multiple visits to a hospital emergency department for any reason.
Dentists who believe that a patient has a history of or may be abusing or depending on alcohol can screen for the illness using the Short Michigan Alcoholism Screening Test-Geriatric Version questionnaire79 (Box
). This instrument is most effective (has a sensitivity of 89 percent and a specificity of 72 percent) when the questions are asked in a matter-of-fact way in a benign component of the medical history, such as the health habits review (for example, diet, exercise and smoking).79,80 A patient’s responding "yes" to two or more of these questions indicates that he or she may have a problem with alcohol use.4,81 The goal of this screening is not to make a medical diagnosis but to screen for indicators that point to a need for the patient to be referred to his or her primary care physician, a psychiatrist or a psychologist.
|
ALCOHOL’S EFFECT ON DENTAL THERAPEUTIC AGENTS
|
|---|
The safety and efficacy of many dental therapeutic agents is influenced by their concomitant ingestion with alcohol. Of greatest concern are the combined effects of alcohol and CNS depressants and the complex effects of alcohol on the liver’s ability to metabolize medications (Table).82–84 Acute ingestion of intoxicating amounts of ethanol (several drinks over several hours) depresses the respiratory center in the CNS in a dose-dependent fashion. Simultaneously, alcohol inhibits the liver’s ability to metabolize certain medications, resulting in elevated blood concentrations of the drugs. This presents a particular danger to patients who are taking medications that depress the CNS (sedatives, hypnotics, opioid analgesics), as they may experience a supra-additive increase in the drugs’ effects that can result in dizziness, drowsiness, loss of coordination, impaired judgment or respiratory depression. In turn, these effects increase the patient’s risks of falling and having other accidents.85–87
View this table:
[in this window]
[in a new window]
|
TABLE Adverse interactions between alcohol or resultant alcoholic liver disease and medications used in dentistry.
| |
Long-term ingestion of alcohol by a person who has yet to develop liver damage causes stimulation (induction) of the liver’s ability to metabolize certain medications, resulting in depressed and sometimes subtherapeutic blood concentrations of the drugs. This increased rate of drug metabolism may persist even in people who are recovering from alcoholism and may require a prescription for meprobamate, pentobarbital or diazepam in high dosages for the medication to be clinically effective.88 Some people also may develop cirrhosis, a disease associated with decreased rates of drug metabolism because of destruction of hepatocytes and impaired blood flow. Affected agents include local anesthetics, analgesics, sedatives and certain antibiotics. In view of the opposing effects of short-and long-term alcohol consumption, it is difficult to predict the net effect of concomitant alcohol and medication use in a person who has consumed alcohol long term.
Chronic consumption of large unspecified amounts of alcohol also has been shown to increase markedly the potential for repeated administrations of the maximum recommended daily dose or overdoses of acetaminophen to cause hepatotoxicity.89,90 Alcohol also inhibits the absorption and enhances the breakdown of penicillin in the stomach for up to three hours after ethanol intake. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) promote gastric bleeding when combined with ethanol and can cause gastric hemorrhage in people with alcoholism who have alcoholic gastritis. Clinicians should administer low dosages of acetaminophen alone or in combination with hydrocodone (Vicodin, Abbott Laboratories, Abbott Park, Ill.; Lorcet, Forest Pharmaceuticals, St. Louis) or oxycodone (Percocet, Endo Pharmaceuticals, Chadds Ford, Pa.) because of the danger of hepatocellular failure.
Many medications prescribed by dentists for older people have the potential to interact adversely with alcohol (Table
).82–84 Aspirin inhibits ADH’s ability to metabolize ethanol; thus, when a person being treated with aspirin drinks alcohol, less of the alcohol is broken down in the stomach and a proportionally larger amount enters the bloodstream.91,92 Aspirin and NSAIDs such as ibuprofen or naproxen, when used concurrently with alcohol, also may cause longer bleeding times and increase the likelihood of gastric inflammation by more than 10-fold.93,94 Narcotic analgesics and sedative hypnotics taken concurrently with alcohol can impair psychomotor skills and have been implicated in falls, broken bones and automotive accidents.95 When clinicians prescribe medications that may interact with alcohol, they should provide a warning about possible adverse effects resulting from concurrent use with alcohol and provide appropriate recommendations for modifying alcohol use.
|
DENTAL CARE
|
|---|
Preventive dental education and the maintenance of good oral health are paramount for people with alcoholism, particularly given the research findings that suggest that oral microflora may contribute to the development of intraoral carcinoma.96,97 Patients should receive instruction in proper toothbrushing and flossing methods that maximize removal of dental plaque. Artificial salivary products may be prescribed for patients who have signs of xerostomia. This therapeutic approach also is germane to this patient population, because a paucity of saliva is associated with increased concentrations of bacteria that are able to produce acetaldehyde.98 Dental treatment should consist of subgingival scaling, root planing and curettage; caries control; and restorative treatment. Profound local anesthesia is mandatory when patients who often are anxious are undergoing potentially painful procedures.
Patients who require extensive surgery and have a long history of alcohol abuse require a comprehensive evaluation that includes a complete blood count (including platelet count), coagulation profile (including prothrombin time/international normalized ratio), liver function studies and a consultation with their treating physicians.99–101 The clinician also should discuss with the patient’s physician the advisability of prescribing prophylactic antibiotics before surgery. A review of the literature fails to reveal definitive guidelines relative to this issue; however, we do know that in this patient population the incidence of poor wound healing, infection and osteomyelitis occurs with great frequency after routine dental extractions.102
We recommend that dental professionals perform a clinical examination and oral prophylaxis at three-month follow-up visits and apply a fluoride gel with a fluoride concentration of at least 1.0 percent. Dentists also should correct any defects in the natural dentition or prostheses during these recall visits. Patients may experience enhanced self-esteem as a result of dental treatment, which may contribute to the psychotherapeutic aspect of management.
|
CONCLUSIONS
|
|---|
As the population of elderly Americans increases from the current 11 percent to more than 25 percent by 2030, dentists can expect to see an increasing number of older "problem drinkers" in their practices.9,10 Familiarity with the physiology of aging, the deleterious effects of alcohol on various organ systems (including the oral cavity) and adverse drug interactions with ethanol will permit dentists to treat this growing population safely.
|
FOOTNOTES
|
|---|
Dr. Friedlander is associate chief of staff and the director of Graduate Medical Education, VA Greater Los Angeles Healthcare System, the director of Quality Assurance, Hospital Dental Service, University of California Los Angeles Medical Center, and a professor of Oral and Maxillofacial Surgery, University of California Los Angeles School of Dentistry. Address reprint requests to Dr. Friedlander at VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, Calif. 90073, e-mail "arthur. friedlander{at}med.va.gov".
Dr. Norman is chief of staff, VA Greater Los Angeles Healthcare System, and a professor of medicine, David Geffen School of Medicine, University of California Los Angeles.
|
REFERENCES
|
|---|
- Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med 1997;337:1705–14.[Abstract/Free Full Text]
- de Lorimier AA. Alcohol, wine, health. Am J Surg 2000;180:357–61.[Medline]
- Adams WL, Cox NS. Epidemiology of problem drinking among elderly people. Int J Addict 1995;30:1693–716.[Medline]
- Moore AA, Seeman T, Morgenstern H, Beck JC, Reuben DB. Are there differences between older persons who screen positive on the CAGE Questionnaire and the Short Michigan Alcoholism Screening Test-Geriatric Version? J Am Geriatr Soc 2002;50:858–62.[Medline]
- Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and older: data from the established populations for epidemiologic studies of the elderly. J Gerontol 1992;47:M137–44.[Medline]
- Dufour MC, Archer L, Gordis E. Alcohol and the elderly. Clin Geriatr Med 1992;8(1):127–41.[Medline]
- Seitz HK, Simanowski UA, Waldherr R, et al. Human gastric alcohol dehydrogenase activity: effect of age, sex, and alcoholism. Gut 1993;34:1433–7.[Abstract/Free Full Text]
- Moore AA, Morgenstern H, Harawa NT, Fielding JE, Higa J, Beck JC. Are older hazardous and harmful drinkers less likely to participate in health-related behaviors and practices as compared with nonhazardous drinkers? J Am Geriatr Soc 2001;49:421–30.[Medline]
- National Institute on Alcohol Abuse and Alcoholism. The physicians’ guide to helping patients with alcohol problems. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism; 1995. National Institutes of Health publication 95–3769.
- National Institute on Alcohol Abuse and Alcoholism. Training physicians in techniques for alcohol screening and brief intervention. Bethesda, Md.: National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism; 1997.
- Dufour MC. If you drink alcoholic beverages do so in moderation: what does this mean? J Nutr 2001;131:552S–561S.[Abstract/Free Full Text]
- Lieber CS. Relationships between nutrition, alcohol use, and liver disease. Alcohol Res Health 2003;27:220–31.[Medline]
- Kiyohara Y, Kato I, Iwamoto H, Nakayama K, Fujishima M. The impact of alcohol and hypertension on stroke incidence in a general Japanese population: the Hisayama Study. Stroke 1995;26:368–72.[Abstract/Free Full Text]
- Holman CD, English DR, Milne E, Winter MG. Meta-analysis of alcohol and all cause mortality: validation of the NHMRC recommendations. Med J Aust 1996;164(3):141–5.[Medline]
- Chang MP, Wang Q, Norman DC. Diminished proliferation of B blast cell in response to cytokines in ethanol-consuming mice. Immunopharmacol Immunotoxicol 2002;24(1):69–82.[Medline]
- Falck-Ytter Y, McCullough AJ. Nutrition effects of alcoholism. Curr Gastroenterol Rep 2000;2:331–6.[Medline]
- Perreira KM, Sloan FA. Excess alcohol consumption and health outcomes: a 6-year follow-up of men over age 50 from the health and retirement study. Addiction 2002;97:301–10.[Medline]
- Thomas VS, Rockwood KJ. Alcohol abuse, cognitive impairment, and mortality among older people. J Am Geriatr Soc 2001;49:415–20.[Medline]
- McGarry GW, Gatehouse S, Vernham G. Idiopathic epistaxis, haemostasis and alcohol. Clin Otolaryngol Allied Sci 1995;20(2):174–7.[Medline]
- Zaman A, Hapke R, Flora K, Rosen HR, Benner K. Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease. Am J Gastroenterol 1999;94:3292–6.[Medline]
- Adams WL. Alcohol and the health of aging men. Med Clin North Am 1999;83:1195–211.[Medline]
- Cropp JS, Bussey HI. A review of enzyme induction of warfarin in metabolism with recommendations for patient management. Pharmacotherapy 1997;17:917–28.[Medline]
- Grant BF. Theoretical and observed subtypes of DSM-IV alcohol abuse and dependence in a general population sample. Drug Alcohol Depend 2000;60:287–93.[Medline]
- Atkinson RM, Misra S, Ryan SC, Turner JA. Referral paths, patient profiles and treatment adherence of older alcoholic men. J Subst Abuse Treat 2003;25(1):29–35.[Medline]
- Rigler SK. Alcoholism in the elderly. Am Fam Physician 2000;61:1710–6, 1883–4.[Medline]
- Adams WL, Barry KL, Fleming MF. Screening for problem drinking in older primary care patients. JAMA 1996;276:1964–7.[Abstract]
- Adams WL, Cox NS. Epidemiology of problem drinking among elderly people. Int J Addict 1995;30:1693–716.[Medline]
- Devanand DP. Comorbid psychiatric disorders in late life depression. Biol Psychiatry 2002;52:236–42.[Medline]
- Sattar SP, Petty F, Burke WJ. Diagnosis and treatment of alcohol dependence in older alcoholics. Clin Geriatr Med 2003;19:743–61.[Medline]
- Reid MC, Anderson PA. Geriatric substance use disorders. Med Clin North Am 1997;81:999–1016.[Medline]
- Demir B, Ulug B, Lay Ergun E, Erbas B. Regional cerebral blood flow and neuropsychological functioning in early and late onset alcoholism. Psychiatry Res 2002;115(3):115–25.[Medline]
- Blow FC, Walton MA, Chermack ST, Mudd SA, Brower KJ. Older adult treatment outcome following elder-specific inpatient alcoholism treatment. J Subst Abuse Treat 2000;19(1):67–75.[Medline]
- Schutte KK, Byrne FE, Brennan PL, Moos RH. Successful remission of late-life drinking problems: a 10-year follow-up. J Stud Alcohol 2001;62:322–34.[Medline]
- Brennan PL, Moos RH, Mertens JR. Personal and environmental risk factors as predictors of alcohol use, depression, and treatment-seeking: a longitudinal analysis of late-life problem drinkers. J Subst Abuse 1994;6(2):191–208.[Medline]
- Banks SM, Pandiani JA, Schacht LM, Gauvin LM. Age and mortality among white male problem drinkers. Addiction 2000;95:1249–54.[Medline]
- National Institute on Alcohol Abuse and Alcoholism. Tenth special report to the U.S. Congress on alcohol and health: Highlights from current research. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism; 2000. NIH publication 00-1583.
- Camargo CA Jr, Hennekens CH, Gaziano JM, Glynn RJ, Manson JE, Stampfer MJ. Prospective study of moderate alcohol consumption and mortality in US male physicians. Arch Intern Med 1997;157(1); 79–85.[Abstract]
- Blow FC, Brockmann LM, Barry KL. Role of alcohol in late-life suicide. Alcohol Clin Exp Res 2004;28(5 supplement):48S–56S.[Medline]
- Graham K. Identifying and measuring alcohol abuse among the elderly: serious problems with existing instrumentation. J Stud Alcohol 1986;47:322–6.[Medline]
- Holroyd S, Duryee JJ. Substance use disorders in a geriatric psychiatry outpatient clinic: prevalence and epidemiologic characteristics. J Nerv Ment Dis 1997;185:627–32.[Medline]
- Arndt S, Schultz SK, Turvey C, Petersen A. Screening for alcoholism in the primary care setting: are we talking to the right people? J Fam Pract 2002;51(1):41–6.[Medline]
- Dufour M, Fuller RK. Alcohol in the elderly. Ann Rev Med 1995;46:123–32.[Medline]
- Conigrave KM, Davies P, Haber P, Whitfield JB. Traditional markers of excessive alcohol use. Addiction 2003;98(supplement 2): 31–43.[Medline]
- Golka A, Wiese A. Carbohydrate-deficient transferrin (CDT): a biomarker for long-term alcohol consumption. J Toxicol Envrion Health B Crit Rev 2004;7:319–37.
- Di Bari M, Silvestrini G, Chiarlone M, et al. Features of excessive alcohol drinking in older adults distinctively captured by behavioral and biological screening instruments: an epidemiological study. J Clin Epidemiol 2002;55(1):41–7.[Medline]
- Lento J, Glynn S, Shetty V, Asarnow J, Wang J, Belin TR. Psychological functioning and needs of indigent patients with facial injury: a prospective controlled study. J Oral Maxillofac Surg 2004;62:925–32.[Medline]
- Turner JA, Dworkin SF. Screening for psychosocial risk factors in patients with chronic orofacial pain: recent advances. JADA 2004;135:1119–25.
- Oslin DW. Late-life alcoholism: issues relevant to the geriatric psychiatrist. Am J Geriatr Psychiatry 2004;12:571–83.[Abstract/Free Full Text]
- Satre DD, Mertens JR, Weisner C. Gender differences in treatment outcomes for alcohol dependence among older adults. J Stud Alcohol 2004;65:638–42.[Medline]
- Sim MG, Hulse G, Khong E. Alcohol and other drug use in later life. Aust Fam Physician 2004;33:820–4.[Medline]
- Soyka M, Horak M. Outpatient alcohol detoxification: implementation efficacy and outcome effectiveness of a model project. Eur Addict Res 2004;10(4):180–7.[Medline]
- Davidson D, Saha C, Scifres S, Fyffe J, O’Connor S, Selzer C. Naltrexone and brief counseling to reduce heavy drinking in hazardous drinkers. Addict Behav 2004;29:1253–8.[Medline]
- Lemke S, Moos RH. Prognosis of older patients in mixed-age alcoholism treatment programs. J Subst Abuse Treat 2002;22(1):33–43.[Medline]
- Oslin DW, Pettinati H, Volpicelli JR. Alcoholism treatment adherence: older age predicts better adherence and drinking outcomes. Am J Geriatr Psychiatry 2002;10:740–7.[Abstract/Free Full Text]
- Barrick C, Connors GJ. Relapse prevention and maintaining abstinence in older adults with alcohol-use disorders. Drugs Aging 2002;19:583–94.[Medline]
- Carda C, Gomez de Ferraris ME, Arriaga A, Carranza M, Peydro A. Alcoholic parotid sialosis: a structural and ultrastructural study. Med Oral 2004;9(1):24–32.[Medline]
- Novacek G, Plachetzky U, Potzi R, et al. Dental and periodontal disease in patients with cirrhosis: role of etiology of liver disease. J Hepatol 1995;22:576–82.[Medline]
- Tezal M, Grossi SG, Ho AW, Genco RJ. The effect of alcohol consumption on periodontal disease. J Periodontol 2001;72(2):183–9.[Medline]
- Pitiphat W, Merchant AT, Rimm EB, Joshipura KJ. Alcohol consumption increases periodontitis risk. J Dent Res 2003;82:509–13.[Abstract/Free Full Text]
- Williams RC. A century of progress in understanding periodontal disease. Compend Contin Educ Dent 2002;23(5 supplement):3–10.[Medline]
- Page RC. The etiology and pathogenesis in periodontitis. Compend Contin Educ Dent 2002;23(5 supplement):11–4.[Medline]
- Khocht A, Janal M, Schleifer S, Keller S. The influence of gingival margin recession on loss of clinical attachment in alcohol-dependent patients without medical disorders. J Periodontol 2003;74:485–93.[Medline]
- Felver ME, Mezey E, McGuire M, et al. Plasma tumor necrosis factor alpha predicts decreased long-term survival in severe alcoholic hepatitis. Alcohol Clin Exp Res 1990;14:255–9.[Medline]
- Bird GL, Sheron N, Goka AK, Alexander GJ, Williams RS. Increased plasma tumor necrosis factor in severe alcoholic hepatitis. Ann Intern Med 1990;112:917–20.[Medline]
- Schafer C, Schips I, Landig J, Bode JC, Bode C. Tumor-necrosis-factor and interleukin-6 response of peripheral blood monocytes to low concentrations of lipopolysaccharide in patients alcoholic liver disease. Z Gastroenterol 1995;33(9):503–8.[Medline]
- Gambert SR. Alcohol abuse: medical effects of heavy drinking in late life. Geriatrics 1997;52(6):30–7.[Medline]
- Schottenfeld RS, Pantalon MV. Assessment of the patient. In: Galanter M, Kleber HD, eds. The American Psychiatric Press textbook of substance abuse treatment. 2nd ed. Washington: American Psychiatric Press; 1999:109–19.
- Dreizen S. Dietary and nutritional counseling in the prevention and control of oral disease. Compendium 1989;10:558–64.[Medline]
- Bagasra O, Howeedy A, Kajdacsy-Balla A. Macrophage function in chronic experimental alcoholism, part I: modulation of surface receptors and phagocytosis. Immunology 1988;65:405–9.[Medline]
- Lorenz R, Jorysz G, Tornieporth N, Classen M. The gastroenterologist’s approach to dysphagia. Dysphagia 1993;8(2):79–82.[Medline]
- Fernandez-Sola J, Junque A, Estruch R, Monforte R, Torres A, Urbano-Marquez A. High alcohol intake as a risk and prognostic factor for community-acquired pneumonia. Arch Int Med 1995;155:1649–54.[Abstract]
- Golin V, Mimica IM, Mimica LM. Oropharynx microbiota among alcoholics and non-alcoholics. Sao Paulo Med J 1998;116:1727–33.[Medline]
- Davies HT, Carr RJ. Osteomylelitis of the mandible: a complication of routine dental extractions in alcoholics. Br J Oral Maxillofac Surg 1990;28(3):185–8.[Medline]
- Tønnesen H, Kehlet H. Preoperative alcoholism and postoperative morbidity. Br J Surg 1999;86:869–74.[Medline]
- Forastiere A, Koch W, Trotti A, Sidransky D. Head and neck cancer. N Engl J Med 2001;345:1890–900. (Published erratum appears in N Engl J Med 2002;346:788.)[Free Full Text]
- McInnes E, Powell J. Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed? BMJ 1994;308: 444–6.[Abstract/Free Full Text]
- Talamini R, Barzan L, Franceschi S, Caruso G, Gasparin A, Comoretto R. Determinants of compliance with an early detection programme for cancer of the head and neck in north-eastern Italy. Eur J Cancer B Oral Oncol 1994;30B(6):15–8.
- Vacher C, Legens M, Rueff B, Lezy JP. Screening of cancerous and precancerous lesions of the oral mucosa in an at-risk population [in French]. Rev Stomatol Chir Maxillofac 1999;100(4):180–3.[Medline]
- Blow FC, Brower KJ, Schulenberg JE, Demo-Dananber LM, Young JP, Beresford TP. The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): a new elderly-specific screening instrument (abstract). Alcohol Clin Exp Res 1992;16:372.
- Saitz R. Clinical practice: unhealthy alcohol use. N Engl J Med 2005;352:596–607.[Free Full Text]
- Barry KL, Blow FC. Screening and assessment of alcohol problems in older adults. In: Lichtenberg PA, ed. Handbook of assessment in clinical gerontology. New York: Wiley; 1999:243–69.
- Kittelson L. Substance abuse. In: Ciancio SG, ed. ADA guide to dental therapeutics. 2nd ed. Chicago: ADA Publishing; 2000:560.
- Yagiela JA, Picozzi A. General mechanisms of drug interactions. In: Yagiela JA, Neidle EA, Dowd FJ, eds. Pharmacology and therapeutics for dentistry. 4th ed. St. Louis: Mosby; 1998:61–8.
- Rizack MA, ed. The Medical Letter handbook of adverse drug interactions. New Rochelle, N.Y.: Medical Letter; 1998:5–19.
- Lieber CS. Mechanisms of ethanol-drug-nutrition interactions. J Toxicol Clin Toxicol 1994;32:631–81.[Medline]
- Miller WR, Heather N, eds. Treating addictive behaviors. 2nd ed. New York: Plenum Press; 1998.
- Henderson-Martin B. No more surprises: screening patients for alcohol abuse. Am J Nurs 2000;100(9):26–32.[Medline]
- Mason BJ. Dosing issues in the pharmacotherapy of alcoholism. Alcohol Clin Exp Res 1996;20(7 supplement):10A–16A.[Medline]
- Dart RC. The use and effect of analgesics in patients who regularly drink alcohol. Am J Manag Care 2001;7(19 supplement):S597–S601.[Medline]
- Zimmerman HJ, Maddrey WC. Acetaminophen (paracetamol) hepatotoxicity with regular intake of alcohol: analysis of instances of therapeutic misadventure. Hepatology 1995;22:767–73. (Published erratum appears in Hepatology 1995;22:1898.)[Medline]
- Adams WL. Potential for adverse drug-alcohol interactions among retirement community residents. J Am Geriatr Soc 1995;43:1021–5.[Medline]
- Gentry RT, Baraona E, Amir I, et al. Mechanism of the aspirin-induced rise in blood alcohol levels. Life Sci 1999;65:2505–12.[Medline]
- Tsuda T, Okamoto Y, Sakaguchi R, et al. Purpura due to aspiring-induced platelet dysfunction aggravated by drinking alcohol. J Int Med Res 2001;29:374–80.[Medline]
- Neutel CI, Appel WC. The effect of alcohol abuse on the risk of NSAID-related gastrointestinal events. Ann Epidemiol 2000;10:246–50.[Medline]
- Stenbacka M, Jansson B, Leifman A, Romelsjo A. Association between use of sedatives or hypnotics, alcohol consumption, or other risk factors and a single injurious fall or multiple injurious falls: a longitudinal general population study. Alcohol 2002;28(1):9–16.[Medline]
- Boffetta P, Ye W, Adami H-O, Mucci LA, Nyrén O. Risk of cancers of the lung, head and neck in patients hospitalized for alcoholism in Sweden. Br J Cancer 2001;85:678–82.[Medline]
- Maier H, Zoller J, Herrmann A, Kreiss M, Heller WD. Dental status and oral hygiene in patients with head and neck cancer. Otolaryngol Head Neck Surg 1993;108:655–61.[Medline]
- Moreno-López LA, Esparza-Gómez GC, González-Navarro A, Cerero-Lapiedra R, González-Hernández MJ, Domiínguez-Rojas V. Risk of oral cancer associated with tobacco smoking, alcohol consumption and oral hygiene: a case-control study in Madrid, Spain. Oral Oncol 2000;36(2):170–4.[Medline]
- Talamini R, Vaccarella S, Barbone F, et al. Oral hygiene, dentition, sexual habits and risk of oral cancer. Br J Cancer 2000;83:1238–42.[Medline]
- Schreiber A. Alcoholism. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(2):127–31.[Medline]
- Meehan S, Schmidt MC, Mitchell PF. The International Normalized Ratio as a measure of anticoagulation: significance for the management of the dental outpatient. Spec Care Dentist 1997;17(3):94–6.[Medline]
- Koorbusch GF, Fotos P, Goll KT. Retrospective assessment of osteomyelitis: etiology, demographics, risk factors, and management in 35 cases. Oral Surg Oral Med Oral Pathol 1992;74(2):149–54.[Medline]
TOP
ABSTRACT
AGE-RELATED ALCOHOL...
