Identification and Treatment of the Geriatric Alcoholic Dental Patient

The Problem

Ethyl alcohol is the most widely used mood-altering substance in the United States and Europe.^1,2 This substance is a central nervous system depressant, although, when consumed, it initially has a transient stimulatory effect.¹ Alcohol abuse and dependence (alcoholism) are significant problems in the elderly population in the United States. While both conditions feature excessive use of alcohol, dependence is the more severe disease. Alcoholism has similar symptoms as aging: trembling, unsteady walking, sleep disturbances, inability to concentrate, hearing loss, and problems with driving. The number of elderly alcoholics is projected to double before 2030³ because of the aging of a younger population of heavy drinkers. Alcoholics are divided into two groups: those who currently use alcohol (active alcoholics) and those who abstain from alcohol use (recovered alcoholics). Each group presents a potential problem for dental treatment and postoperative care. In addition to identification of the active alcoholic patient, the dentist must be able to identify the recovering alcoholic patient to prevent a relapse into active alcoholism.

Abuse of Alcohol

The current elderly population (³ 65 years) has been reported to use alcohol more heavily (greater than two drinks per day) than previous generations did.4Within the elderly population, 13% of men and 2% of women are heavy users of alcohol⁵ and can be classified as alcoholics. Women usually begin heavy use of alcohol later in life than men do, and thus develop its health-related consequences at an older age.⁶ However, alcoholism progresses more rapidly in women than in men because women develop higher blood concentrations of alcohol than men do, when each consumes a similar volume of alcohol. This difference probably results from the lower percentage of body water and higher percentage of body fat in women.⁶

There are many medical complications of alcoholism including hypertension, malnutrition, neurological disorders, cirrhosis of the liver, aggravation of cardiovascular disease, and drug interactions.⁷ These adverse effects are often more severe in the elderly population because of the comorbid effects of aging and the coexistence of other diseases.^8,9 Elderly people metabolize and excrete alcohol more slowly than younger people do.¹⁰ Thus, they more likely will have adverse consequences of alcohol use, which probably will be more severe than in younger individuals.¹¹ In particular, chronic alcohol use in elderly individuals has more severe adverse effects on the brain, often impairing their coordination, and producing personality changes and memory loss.

Elderly people often use calories from alcohol as substitutes for food, which results in signs and symptoms of malnutrition. Heavy use of alcohol affects the digestion of food and absorption of minerals and vitamins. Thus, a marginally adequate diet becomes inadequate when alcohol replaces food energy and necessary nutrients.¹² Heavy use of alcohol also increases the usage requirements for a variety of nutrients including vitamins A, B-complex, C, D, and folic acid.¹³ The ingestion of trace metals (including iron, zinc, selenium, and magnesium) by the alcoholic patient may be deficient, which can adversely affect immune function. 1,^14-16 These nutritional deficiencies often are marked by changes in the oral mucosa, which are evident during a dental examination. Thus, the dentist may be the first health professional to suspect alcohol abuse in an elderly patient. When identified, these patients then can be referred for addiction treatment, which is very successful among the elderly.

Alcohol Abuse and Infection

Alcoholism has many adverse metabolic effects including significant increases in the susceptibility to infection,¹⁵ in particular, pneumonia, tuberculosis, and hepatitis.¹⁷ Alcohol abuse suppresses the immune system, which may be a direct result of its damaging effects on the liver.^15,18 The liver hepatocytes are affected adversely by alcohol ingestion and often are replaced by fibrous tissue (cirrhosis) and fat (fatty liver) in the livers of chronic alcohol abusers.^19,20

Liver dysfunction may affect clearance of very low density serum lipoproteins, placing the alcoholic at a higher risk for cardiovascular disease than the nonalcoholic.²¹ Alcoholics often have decreased numbers of blood platelets and prolonged bleeding times.^22,23 The production and function of both T- and B-lymphocytes are inhibited by alcohol. In addition, chemotaxis and adherence to capillary walls by macrophages and phagocytes become inhibited significantly in the alcoholic patient.

The cutaneous effects of alcoholism are side effects of liver disease, and nutritional and vitamin deficiencies. These effects include spider angioma (dilated subcutaneous arterioles on the face) and acne rosacea (flushing of the skin in the center of the face). The latter often affects the nose, creating a bulbous, flushed condition known as rhinophyma.²⁴

Clinical Characteristics

Geriatric alcoholics can be divided into two groups: early onset and late onset. One-third of older alcoholics are late onset and two-thirds are early onset, with specific differences noted between the groups.²⁵ Late onset alcoholism is associated more often with the loss of social support and increased environmental stress, such as a change in living arrangements, than is early onset alcoholism²⁶ (Table 1).

Identification

These patients can be identified using a health history that includes questions designed to determine whether an elderly patient could fall into either of the following categories:

• Bereavement following a loss—The death of a partner may cause mental distress, which is alleviated by drinking alcohol. In addition, alcoholism often occurs in elderly people stressed by the aging process, changes in personal relationships, and retirement, which often exacerbates anxiety, depression, and loneliness.^27-29
• Health problems—Individuals may use alcohol to reduce pain or assist sleep. However, most chronic health problems are exacerbated by alcohol.

 

Dental management of the geriatric alcoholic patient requires the clinician to be aware of the possibility of alcohol abuse in this population. Alcoholism is a psychiatric disease, and as healthcare providers, dentists must treat it as a specific disease without moral implications. Alcohol abuse often occurs in individuals who are financially solvent and lead reasonably normal lives. Many patients try to mask the addiction, but the alert clinician often can detect the signs and symptoms of substance abuse.³⁰ A comprehensive health questionnaire with follow-up questions usually provides an opportunity for the patient to indicate either a previous or existing alcohol problem. Then, the dentist can inquire about past and current use of alcohol and other mood-altering substances. In addition, if patients reveal use of multiple and/or expired medications, pharmacy and dental provider shopping, concealing the smell of alcohol by the use of mints or perfume, and impaired coordination, the dentist should consider more focused screening tests.⁹ Based on the results of a preliminary health history, the dentist can screen further for alcoholism or alcohol abuse using either the Short Michigan Alcoholism Screening Test—Geriatric Version³¹ (Table 2) or the CAGE Questionnaire³² (Table 3). These tests can indicate individuals in need of treatment for alcohol abuse. A recent study suggested that most patients do not object to alcohol screening and alcohol counseling by dentists.³³ This report also suggested that dentists should not be concerned about adverse patient attitudes about counseling for behavioral change.³⁴

Because of the difficult diagnosis, alcoholism is often underdiagnosed in older adults. However, not only can undetected alcoholism make the last years of life miserable, but it also could take away those years because suicide risk is higher in the alcoholic population.

Dental Management

It is incorrect to assume that the alcoholic patient cannot be treated by the general dentist. Anxiety levels often are elevated in elderly alcoholic patients,³⁵ and they may drink alcohol before the appointment to alleviate anxiety. The dentist should consider pretreatment relaxation techniques for management of these patients. Close monitoring of the patient's health status during treatment can result in successful dental therapy without undue stress for the patient.

Alcoholics (and recently recovered alcoholics) have a high incidence of the following oral conditions compared with nonalcoholics:

• Decayed, missing, or filled teeth^36-38
• Periodontitis^38-40
• Enlarged parotid glands and xerostomia⁴¹
• Carcinoma⁴²

 

Preventive dental education and maintenance of good oral health are important for these patients, particularly given the research findings that suggest that oral microflora may contribute to the development of intraoral carcinoma.^43,44 Artificial salivary products may be prescribed for patients who have signs of xerostomia.⁴⁵ Recovering alcoholic patients should not use mouthwashes containing ethanol because these agents might precipitate relapse into alcohol abuse.

Alcoholic patients should receive a clinical examination and oral prophylaxis at 3-month intervals and a fluoride gel (at least 1%) should be applied after the prophylaxis.⁴⁶ Otherwise, dental treatment usually does not differ for the alcoholic than for the nonalcoholic patient, except for surgical procedures.

Surgery for the alcoholic patient is complicated by problems with anesthesia and postoperative bleeding and wound healing. The alcoholic patient usually has increased tolerance for drugs and anesthetics,⁴⁷ so use of lower dosages for surgical procedures may be appropriate. Delayed blood clotting, wound healing, and osteomyelitis are often reported after routine oral and periodontal surgical procedures.^48,49 Thus, before surgical procedures, the clinician should consider use of a preoperative antibiotic regimen.⁵⁰

During the surgical procedure, the dentist should protect the airway because the gag and cough reflexes may be depressed in the alcoholic patient.⁵¹ Intravenous sedation and nitrous oxide should be avoided because of the potential for cardiovascular or respiratory depressive events^52-54 and for initiating relapse in the recovering alcoholic. In general, postoperative pain medication should be avoided in both the active and recovering alcoholic patient. If pain medication is required, a minimal amount should be prescribed and the medication controlled by a reliable family member or friend to minimize the chance for abuse by the patient.

The US Food and Drug Administration has estimated that of the most commonly prescribed drugs, more than 50% have at least one ingredient that could react with alcohol. When prescribing medications for the active alcoholic, the dentist should be aware that ethanol ingestion may be associated with either enhanced or inhibited effects, and possible enhanced toxic effects of some drugs.^47,55 Alcohol inhibits the absorption and enhances the breakdown of penicillin within the stomach for up to 3 hours after ethanol intake. Aspirin and nonsteroidal anti-inflammatory drugs promote gastric bleeding when combined with ethanol and can cause gastric and esophageal hemorrhage in alcoholic patients.^56,57 When a dentist prescribes medications that may interact with alcohol, he or she should provide a warning about possible adverse effects of the combination and provide appropriate recommendations for modifying alcohol use. The dentist also should be aware that the active alcoholic likely will ignore these warnings.

Additionally, the dentist should consider the consequences of suggesting use of over-the-counter (OTC) medications for postoperative pain and infection. Alcohol is present in many OTC drugs, including mouthwashes, liquid analgesic preparations, liquid vitamin preparations, and liquid sleep-enhancing medications.⁴² The small amount of alcohol ingested through these medications possibly could trigger a relapse in a recovering alcoholic, therefore, extreme care must be taken when prescribing drugs for this group. In the active alcoholic patient, use of these medications in combination with alcohol greatly enhances their effects.

Conclusion

The dentist is in an ideal position in the healthcare environment to provide initial identification of the geriatric alcoholic individual. These individuals often exhibit oral consequences of their addiction, which require initial treatment and close follow-up monitoring by the dentist. Referral of geriatric active alcoholics for treatment should be a priority for health professionals, so that the individual can enjoy the remainder of his or her life without the burden of addiction.

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