English Bay, Vancouver, BC, Jan, 2003
Help with Alcohol Withdrawal
By Denise Bradshaw, Seniors Well Aware Program, Vancouver B.C. Canada, Email: email@example.com & Charmaine Spencer, Gerontology Research Centre, Simon Fraser University, Vancouver B.C. Canada, email: firstname.lastname@example.org
In Canada between 138,000 and 220,000 seniors currently experience problems with alcohol misuse or dependence which can significantly undermine their health and quality of life. Addiction research estimates that only 15% of people who need specialized treatment, will seek it during a given year. Of those seeking treatment, 40% will require detoxification (help with safe withdrawal from the alcohol or other drug).
First an illustration:
Mrs. Sutton is 69 years old. She first began drinking when she was training to be a nurse shortly after WWII. Her alcohol consumption only became a problem in her life during the last five years. Because of arthritis and surgery, she uses a walker to help her get around.
She tried to quit on her own on two occasions in the past. The first time, she ended up in hospital with pneumonia and severe dehydration. She did not mention the fact that she was trying to quit to anyone.
On the second occasion, her physician mentioned that there were two detoxification centres she might consider. When she phoned the first detoxification centre, they stated "Sorry, we can't take anyone using a walker". At the second centre, she was told she would have to wait up to two weeks because of the waitlist. Her response was: "I don't think I can hold out that long. I really need to quit now."
In the meantime, Mrs. Sutton was becoming increasingly apprehensive about going to the detoxification centre. Her drinking increased even further. She stayed at the centre two days. However, she was transferred to the hospital because she lost her balance, fell and injured herself getting up at night to go to the washroom.
Understanding What's Special
Alcohol withdrawal in seniors can be harder than for younger adults. Seniors show more withdrawal symptoms for a longer period of time, and more symptoms of cognitive impairment, daytime sleepiness, weakness and high blood pressure.
The rules at the detoxification centres (for example, the admission and discharge criteria, the process for getting a bed), as well as the misconceptions at centres and other service access points about older adults often result in these clients not being able to access the centres easily, if at all.
Alcohol Withdrawal Symptoms
Mild symptoms include insomnia, tremor, nausea, and sweating. Severe symptoms include hallucinations, seizures, and delirium tremens.
The level of (and extent of) the alcohol withdrawal symptoms will depend on many factors: length of use, amount of alcohol being consumed, whether the amount has been gradually reduced prior to detoxification or this is an abrupt withdrawal; person's overall health and; and the number of withdrawals they have had previously.
Use of Benzodiazepines
Benzodiazepines are commonly prescribed drugs for seniors (with some studies showing one in four seniors in the community having been prescribed it). The benzodiazepines are often prescribed for anxiety, difficulty sleeping. Benzodiazepines are intended for short term use (less than six months). Some older women have been on the drug for 20 or more years. Extended use can cause memory related problems in seniors (Rummans, Davis et al., 1993)
Rebound anxiety (anxiety, hysteria, abnormal illness) is very common in benzodiazepine withdrawal unless the drug is very slowly tapered (over months). This is caused by a neurotransmitter imbalance. (Higgits, Fonagy, Toone & Shine, 1990).
The need for home detoxification has been recognized in pilot projects in several communities across Canada (Victoria - the first, Vancouver, Burnaby, Toronto, small B.C. communities among others) The Vancouver & Burnaby programs have been operational for over 4 years and was evaluated in 1998.
Development of the Vancouver Program
A person does not necessarily have to go to a formal care setting in order to undergo safe alcohol withdrawal. Other locations are possible and may be advisable. Vancouver decided to try a "home detox concept" (HD) first introduced by D.B. Cooper in Britain.
Vancouver's program was part of a broader provincial recognition for alternatives to detoxification centres. Seniors were seen as having special needs and facing special barriers in the detox centres.
Prior to SWAP's involvement, seniors in need of detoxification were commonly experiencing repeated falls; hospital admissions/ readmissions; very poor nutrition and hygiene; and "not coping well". Other primary problems included repeat calls to other services and decreased supports or drop in the involvement of outside supports - "they felt had had itů" Frequently there had been evidence of decreased cognition, insight and judgment affected by the senior's long term alcohol use.
Here is an illustrative example
Mr. Hart is 74 years old and has never married. He currently lives in a small downtown apartment. He worked for 47 years selling heavy equipment, where he was expected to entertain potential clients. As a result of his work, he spent much of his life on the road, until his retirement, eleven years ago. He has a good pension from his company.
Mr. Hart was well known in the community for his volunteer efforts, before and after retirement. However, he has not been volunteering for at least six months now, though he would like to resume. At best, Mr. Hart's health can be described as "fair". He injured his back in a car accident in 1981, and still has residual pain from the accident.
Issues in His Life
There are several important matters to take into consideration with Mr. Hart. He smokes heavily, particularly if he has been drinking. When he drinks, he usually does not eat.
The reason he is considering home detoxification is because of health and social problems. He has been experiencing incontinence in the last few months and neighbours have begun complaining about the smell. Home support refused to go in to clean his apartment anymore.
Currently, Mr. Hart faces being evicted from his apartment. Twice in the last year, he has fallen asleep, leaving supper on the stove to burn. Neighbours called the fire department because they thought there was a fire.
Stage One: The Development of a Home Detoxification Program in Vancouver
Purpose of Home Detoxification
The aim of home detoxification is safe withdrawal from a substance in an atmosphere which is familiar and comfortable to the client. This can be the person's own home, the home of a supportive relative or friend, or the home of a volunteer.
Home detoxification is planned, not crisis oriented. It is intended to be client driven (in the sense that this something the client wants, as opposed to what others may feel is needed). That means it often involves working with the client a considerable amount of time beforehand before the client decides that this is what he or she wants.
The main purpose of the detoxification is help prevent further deterioration in client status. The collateral purpose is to assist families.
Home detoxification involves:
Proper assessment of the senior's health and social situation before detoxification at home will be considered
Medical assessment (physician with program) and monitoring (by nurse) for safe withdrawal
Respect of the client (going at the client's speed, recognizing and respecting client's decisions, understanding client's fears or concerns about withdrawal and other matters)
Supports such as proper food, medications during withdrawal
Aftercare (appropriate support for
the person after the acute phases of the withdrawal)
Stage Two: Adapting the Program
Vancouver and Burnaby programs greatly modified the original HD approach to make it more suited to the social and medical realities of older adults. Part of the goal was to avoid the more paternalistic aspects of the original approach (for example, the original HD approach developed in Britain provided for alcohol testing to see if the person was "cheating", and this testing was seen as seriously undermining the trust needed in the relationship ).
Stage Three: Introduction of Withdrawal Management (WM)
Moving beyond a strictly a home detoxification approach, SWAP broadened its approach to withdrawal management. Home detoxification becomes one option of several. Withdrawal management aims at helping to reduce and eliminate the barriers that seniors can face in hospitals, detox centres, other related services. Thus, withdrawal management is a broader and more holistic approach. With withdrawal management, a senior may be detoxifying in a home, detox centre, or hospital depending on the circumstances.
In both HD and WM with seniors, the main objective is not just to focus on the acute withdrawal, but also to provide good support before and good "aftercare". This approach also means working well with community partners to identify and address barriers.
The Idea Behind the Withdrawal Management Concept
The main idea is to aid the older adult through withdrawal in a preparatory and after care manner. It is also to address barriers facing older adults in accessing services. That means working for changes in policies; providers' attitudes; seniors' fears; and medical issues.
SWAP's Goal with Home Detoxification & Withdrawal Management
The goal has been to help the person maintain independence in the community as long as possible. In other words, home detoxification was not a first step to going into a facility.
Types of Help that SWAP Clients Receive in the Withdrawal Management Program
rapport and building trust;
support and encouragement ("I can do this");
assessment (particularly health and social situation);
education around withdrawal (some do not know what to expect, or have had bad experiences previously) and
close monitoring during the
From a client's perspective, support
and encouragement is fundamental throughout the process. One of the greatest
issues around detoxification is "How will I live my life without alcohol or this
other drug. So much of my life currently centres around it."
Other types of help provided to the client also include
referrals when necessary;
harm reduction efforts;
help with instrumental activities.
Meeting the Need
Generally speaking, in the Vancouver downtown area, clients being referred during the first 18 months of the program were in a situation where their housing/ home environment was often less stable, so the focus was often more on withdrawal management. In Burnaby, there were more middle class clients with stable home, so focus was on home detoxification.
Who Does Best in these Kinds of Programs?
If the home environment is stable, and there is good support from family or friends, you will tend to get better results. It is important to recognize this is a slow process that involves a lot of support before and after to reduce the likelihood of relapse. If the seniors are involved with support groups before/after home detoxification, they also seem to do better. Both home detoxification and withdrawal management work well with older adults. Any approach taken must understand older adults' needs, and go at their pace.
References available on request.
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Last updated: April 14, 2001.