cont. from

Age:

The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.

Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.

History:

The diagnosis of an alcohol problem is best made by the history. Laboratory tests have a sensitivity of no better than 50%, and physical examination is helpful only after the consequences of alcoholism are apparent. Early diagnosis based on a careful history can prevent such consequences. Physicians should use terms such as "person with an alcohol problem" rather than "alcoholic," which is a commonly used but demeaning shorthand term.

• Although the dangers of alcoholism are well known, data suggest that physicians frequently fail to make the diagnosis. Less than 50% of people who went to their doctor because of alcohol-related issues were asked about the problem. Multiple studies on medical inpatients and surgical patients in university and community hospitals, as well as outpatients in internal medicine and family medicine practices, show a low recognition rate and an even poorer treatment rate. The following are possible reasons that alcohol-related problems are missed during diagnosis:
  • Patient factors contribute to the failure to diagnose alcohol problems. Patients frequently deny they have a problem. They might not link alcohol with its consequences. Patients may be unaware that a positive family history increases their risk for the disease. They might fear being reported to their employers. Patients might be too ashamed to report their problem.
  • Physicians frequently share the responsibility for the failure to diagnose alcoholism. Many physicians have a negative attitude toward alcoholic persons. They view alcoholic patients as demanding and feel that they waste society's resources.
  • Recognized substance abuse patients tend to have an antisocial personality disorder (type 2 alcoholism, characterized by an association with criminal behavior [sociopathy], onset in teen years, and drinking to get high), while those whose diagnosis is missed tend to have depression or anxiety. During residency training, physicians see a fair number of persons with type 2 alcoholism; these patients are often not truthful and have a poorer prognosis. This contributes to the belief among many physicians that alcoholism is not treatable, despite good evidence to the contrary (see Treatment). Also, physicians might hesitate to label a patient as alcoholic because of negative consequences. Physicians who have a problem with alcohol themselves are less likely to discuss alcoholism and its consequences with patients.
  • Finally, physicians might not know how to screen for and diagnose alcoholism. However, screening for alcoholism is important (see CAGE questionnaire, AUDIT, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).
  • "How much do you drink?" is probably the question asked most commonly by doctors. This question has less than 50% sensitivity for alcohol problems. Blood tests, such as liver function tests and mean corpuscular volume, are not particularly effective; even the best test, gamma glutamyl transferase, has a sensitivity of only approximately 50%. Recently, sialic acid and carbohydrate-deficient transferrin levels have been touted as possible tests, but the sensitivities of both appear to be too low to be useful.
• The CAGE (need to cut down on drinking, annoyance, guilt about drinking, need for eye-opener) questionnaire is the best-known and most-studied short screening test.
  • The following 4 questions make up the CAGE questionnaire:
• Have you ever felt the need to cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

• Patients who answer affirmatively to 2 questions are 7 times more likely to be alcohol dependent than the general population. Those who answer negatively to all 4 questions are one-seventh as likely to have alcoholism as the general population.
• The sensitivity of the CAGE questionnaire was thought to be 75%. More recent studies, however, show that the sensitivity is lower, particularly in populations with a lower prevalence, such as among female and elderly populations. The CAGE questionnaire also may fail to identify binge drinkers and cannot identify those who have not experienced the consequences of alcoholism. Nevertheless, the CAGE questionnaire is brief and easy to administer.
• The AUDIT (alcohol use disorders identification test) is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

continue page 4

top . pages 1 2 3 4 5 6 7 8 9 10  . send to friend . addictions site map

Reviewed: 04/2006