Competence: Is Senility Reversible?
By: Amos Goodall, Jr.
Older persons suffer a variety of conditions that may mimc senility or dementia. Some are potentially reversible. It may be that treating these conditions can restore competence and actually return years to the useful, productive life spans. Assuming that all persons who appear to be suffering from senility cannot ever recover can rob thema nd their family members. Identifying and treating these medical problems can actually restore confidence and add years of productive life. Elder lawyers are in a unique position to help.
This defines the problem: symptoms of hazardous drinking may mimic other irreversible conditions, such as Alzheimer's disease. Successful treatment may or may not reverse deterioration of brain function, but the absence of treatment will certainly lead in only one direction. It is our privilege to be alert to the problem in order to make a referral to a treatment professional, such as a certified addictions counselor or other geriatric specialist.
For some folks, patters of alcohol consumption that have continued without problems for years can result in a condition that appears to an uninformed world to be senility. This article examines one such alternative condition, called "hazardous drinking," for purposes of discussion. For physiological reasons, patters of alcohol consumption that complemented a healthy lifestyle for younger adults may itself result in deleterious consequences for older persons, beginning as early as age 60. Moreover, senoir citizens are often receiving medication that may itself interact negatively with even a small amount of alcohol, either separately or in unexpected combination with other prescribed substances. Finally, the lifestyle of a senior citizen may mask alcohol's cumulative toxic effects until too late.
Physical Response Differences Between Younger and Older Adults
Family members may be too close to notice critical changes. Other involved persons may not be sensitive to these subtleties until too late. Traditional screening tools may not disclose hazardous use, with the effect that family and person himself or herself may accept dementia, delirium, mood disorder, and personality problems as irreversible effects of aging when treatment could restore health. There is a window of ooportunity to reverse these toxic effects or at least to suspend further deterioration.
There are substantial differences between older and younger adults' physical responses to alcohol. Many of these differences are caused by the natural process of growing older. They body changes as it ages. Three characteristics seem naturally to occur:
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Decrease in metabolism of alcohol as part of the digestive process
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Decrease in body water
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Increased sensitivity and decreased tolerance to alcohol.
Indeed, it seems to be an international recommendation that older adults (over age 60) limit their routine consumption of alcohol to one drink per day (with allowance for up to two drinks on special "drinking" occasions, such as weddings), with some what lower levels for women. A "drink" is defined as 0.5 ounces of alcohol, 12 ounces of beer or 5 ounces of wine.
Metabolism is the major process by which drugs and alcohol are eliminated from the body. chimicals in the digestive system begin to break down alcohol when it is first ingested. An enzyme that plays a role in metablozing alcohol is gatric alcohol dehyrogenase. This substance, found naturally in the lining of the stomach, begins to break down alcohol in the stomach before it enters the bloodstream. As individuals age, this enzyme begins to disappear. Renal clearance rate changes also contribute to this efect, since elder persons may not eliminate alcohol fromthe system as efficiently. The result is that if an individual who is 60 years of age matches the drinks of an individual who is 30, more alcohol will be released into the body quicker and stay longer, producing a stronger effect and further taxing the liver, which may already be impaire das well.
Aging is often accompanied with a reduction in the body's muscle mass, body water, and lean body mass, as well as increase in fat. Since alcohol is a water-soluble substance,t his causes its concentration in the body to increase. As editorialized in Benshoff in the Journal of Rehabilitation, "The increased presence of substances in the body at higher concentration levels suggests that older adults may be significantly more susceptible to substance abuse problems at low dosage levels. The threshold between use and abuse for the average adult may simply be toohigh for the aging adult."
Medical Problems and Drug Abuse
As persons age, they tend to develop medical problems. Approximately 80-86 percent of persons over the age of 65 suffer from at least one chronic disease or condition, and an estimated 83 percent take at least one prescription drug. In our society, people tend to medicate themselves, and physicians often prescribe for these problems. Studies suggest that although in 1991, those over 65 made up less tahn 13 percent of the population, they received 25 to 30 percent of all prescriptions. Another study reported that 20 percent of older adults use a tranquilizer daily. In fact, one study suggested that 30 percent of those over 65 take eight or more prescribed drugs daily.
Over half of the adverse drug reactions requiring hospitalization take place among 65 or older persons. Benzodiazepines, sedative, and hypnotics users are particularly susceptible to abuse - Diazepam, Codeine, Meprobamate, and Flurazepan are the most commonly abused agents. From 17 to 23 percent of drugs prescribed to older adults are benzodiazepines, including Xanax, Librium, Valium, and Atavan. These agents, especially those that may be more slowly eliminated from the body, often interact with each other and with alcohol to change the person's apparent functional capacity and cognition. Two of the most commonly prescribed, Temazepam and Lorazepam, have a half-life of 10-20 hours; another, Quazepam, has a half-life of 25-41 hours, with long-acting active metabolites. Older users experience greater effects.
Traditional screening techniques may not be effective. On the other hand, and educated, concerned third party who does not interact with the older person on a daily basis - such as an elder lawyer - acutally may be the person best equipped to begin the analysis, even though there may be a tendency to want to avoid doing so. A well-dressed elder does not fit the classsic misconception that alcoholics are "bums" or "homeless." The professional may feel uncomfortable prying into a client's "personal" life, even though this may affect the efficiency of the professional's advice. Finally, the professional may feel uncomfortable commenting on a drinking style that may seem - in the professional's own more youthful experience - to be conservative. "If he drinks like I do, he couldn't have a problem, could he?"
Classic testing instruments (including the ubiquitous "Ann Landers" questions) may not disclose hazardous drinking. The client is likely to be retired and not engage in as many activities as a younger adult. Substance use may not interfere with social or occupational functioning. Widows and widowers may not have close family members who observe behavioral changes; other relatives may be biased against recognizing that drinking or prescription drugs, rather than age or disease, may be a cause or cheif contributor to mood changes, memory deficits, sleep problems, falls, anxiety, or confusion.
In recent proceedings of the Philip E. Heckerling Institute on Estate Planning, Professor Lawrence Frolik wrote:
Be alert to the possibility of depression or dementia.... Dementia'a most common symptom is diminished short-term memory.... Dementia is also characterized by mood swings, changes in personality, uncharacteristic acts and exhibiting greater confusion when placed in new surroundings.
These observations are also consistent with the effects of hazardous drinking.
As trust and estate professionals, we are not equipped to give definitive diagnoses of hazardous drinking. We do have a duty to preserve the sanctity of the estate plans we suggest and implement. Attorneys, under Rule of Professional Responsibility 1.14, have a duty to maintain the traditional attorney-client relationship as long as possible, and a number of ethics committee interpretations, as well as recent modifications tot he Rule contemplate an active role. Here indeed, an older person's lawyer may be the only professional who has had a continuing confidential relationship with the older person who does not have the potential for ulterior motives in advising the older person.
Screening for Alcohol and Drug Abuse
A variety of fairly simple screening test instruments are available. While these may not provide a definitive diagnosis, they may assist the estate planner in focusing the client and family on the problem. In fact, the Department of Health and Human Services ("HHS") recommends that ever 60-year-old be screed for alcohol and prescription drug abuse as part of his or her regular physical examniation - and more often if suggested by circumstances of the patient's life. A screening test simply suggests the need for further professional help. Its results do not, by themselves, allow any conclusions to be drawn. The test is no substiture for a form assessment, if needed.
Three popular tests are known by their acronyms: CAGE, MAST-G and AUDIT. The CAGE consists of four questions, can be self-administered, and is suitable even for persons with low reading skills. It can also be modified to screen for other drugs. It is considered less effective for female drinkers then males. Although two or more positive responses are considered indicative of an alcohol problem, recognizing that denial is a symptom of the disease, even if one positive response should be grounds for further exploration.
The MAST-G, a modification of the Michigan Alcohol Screening Test, was specifically developed for older adults. It has a high sensitivity and specificity among adults in a variety of settings, including primary care clinics, nursing homes, and living environments.
Developed by the World Health Organization, the AUDIT (Alcohol Use Disorders Indentification Test) is not specifically designed for older adults. However, it has been validated cross-culturally. Because there are few culturally-sensitive screening instruments, the AUDIT is recommended by the HHS as useful for identifying alcohol problems amoung older ethinic minority individuals.
Conclusion
Elder law practitioners should consider keeping a copy of these tests on hand so that clients can take them on their own or have them administered. Symptoms of hazardous drinking may mimc other irreversible conditions, such as Alzheimer's disease. While successful treatment may or may not reverse deterioration of brain function, the absence of treatment will certainly lead in only one direction. It is our privilege to be alert to the problem in order to make a referral to a treatment professional, such as a certified addictions counselor or other geriatric specialist. We may be able to add years to our clients' lives and help them to return from the abyss.
**The endnotes have been removed from this article