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This page is primarily intended for health care professionals working with seniors.



Detoxification


When a person who is dependent on a drug such as alcohol, the person’s body can react adversely when the person stops taking it. Detoxification is the process by which a drug-dependent person withdraws from the effects of that drug in a supervised way, so that the withdrawal symptoms and the risks relating to withdrawal are minimised. (1)

Withdrawal can be thought of as the central nervous system rebounding against the depressant effects of alcohol.(2)

Medical detoxification reduces the dangers that can result from abruptly discontinuing use of alcohol or other drug.

Detoxification can take place in different locales and in several different ways. It can occur in hospital; in a free-standing clinic; or at home. Detoxification may be planned or unplanned. It may be initiated on one’s own or with the help of others.

In formal detoxification, the focus is usually on management of the physical aspects of withdrawal. The end point is when the person is physically stable and mentally alert enough to make an informed choice bout the next step. The process typically takes 5-7 days to achieve complete detoxification, but may take longer for other drugs such as benzodiazepines (3).

However, there has been an increasing recognition that detoxification is a part of a bigger  and more important process. Managing the physical aspects of withdrawal is only one component of it. Formal detoxification in many jurisdictions has changed over the years— for example, in British Columbia there has been a push for shorter stays; the focus is on poly-drug user; the push in some quarters has been for detoxification to be more limited (do less) not holistic (do more).

Alcohol Withdrawal in Seniors

Research indicates that alcohol withdrawal in seniors can be harder than for younger adults. (4) Seniors are more prone to the physiologic effects of withdrawal, e.g. seizures, cardiovascular problems, falls, delirium, and agitation. (5) Seniors show more withdrawal symptoms for a longer period of time. They show more symptoms of cognitive impairment, daytime sleepiness, weakness and high blood pressure.

Repeated episodes of alcohol withdrawal result in progressively more severe withdrawals for some seniors seniors, a phenomenon known as "kindling". (6)

Seniors and Detoxification

Substance abuse by seniors is considered as a serious public health concern. (7) Half of those dying from alcohol related deaths are seniors. (8) Seniors often have special needs during therapeutic detoxification. (9) Substance abuse counsellors believe alcohol withdrawal can happen at home if a physician is available. (10)

Barriers to Detoxification

Some community agencies working with seniors who have alcohol problems have noticed a big gap in the area of detoxification  when it came to seniors. The detoxification process was not readily accessible to seniors as to younger adults. Seniors were under-served.

Community agencies also see that the focus in detoxification tended to be on the physical aspects of detoxification and end in itself, rather than a step in the process of recovery. They note the need for a more comprehensive and less fragmented approach to detoxification of seniors. Otherwise there is  a significant  risk of relapse.

What are some of the barriers that seniors currently face in terms of being able to use detoxification services:

1. Location: There is the stigma of detoxification centres generally and where they are located. Detoxification centres tend to be located in the city core, close to urban poor, where a considerable part of alcohol or drug problems are located in many communities. The location can be convenient for those that lived in the area; but the location is a stigma for others coming in. As a result, it is common to hear seniors comment "Only losers go there". Often seniors, (particularly older women) feel "I don’t belong here"; "I don’t want others to know".

For many years, one  British Columbia  detoxification facility is located at an old institute which previously housed children with developmental disabilities (mental retardation). This is a negative association felt strongly by some seniors. In another community, alcohol detoxification takes place in the psychiatric ward of the hospital.

2. Past Detox Experience- If the senior's particular detoxification experience was bad-- with severe symptoms, the person may very well be reluctant and resistant to trying detoxification again. Some seniors who have had several experiences with detoxification find the staff at detoxification centres are less than helpful and may have condescending attitudes towards these "old pros". For the inexperienced senior, on the other hand, the prospect of detoxification can seem frightening and overwhelming.

3. Admission and Exclusion Criteria- Detoxification facilities have a number of criteria that can effectively exclude seniors

  • Require self care- staff do not have the time; so if there are five seniors there at one time, each with diarrhea or vomiting, staff would not be able to handle them. Clients in some facilities have to be able to do their own laundry. At night, one staff person may be the only person there- so cannot help with problems such a senior who becomes lost way to washroom
  • Exclude certain medical and/ or psychiatric conditions that cannot be managed at the detoxification centre (e.g. those who have diabetes)(11)
  • Exclude clients with physical disabilities (e.g. most are not wheelchair accessible)
  • Exclude clients who have had more than 4 admissions in a 12 month period and/ or the lapsed time since last discharge from a detoxification, residential treatment or supportive recovery program is less than 30 days. Because the senior may not have fully detoxified in the earlier detoxificationwas not sufficiently long or where the aftercare support were not there.

Also where the person re-presents at the facility, the attitudes of staff can become "He’s always in and out"; "she’ll never change"; and "alcoholics are all the same" (12)

4. Priority System- "he who knocks the loudest" Priority is given to referrals from services directly funded by Alcohol and Drug Services, as opposed to those indirectly funded sources. In many locations, it is "first come, first serve".

However, seniors with alcohol problems often lack people who can advocate on their behalf to get them in. Where there are waitlists, the person must phone (therefore the person must have a phone). The person then waits for the facility to call that there is a bed available. The senior must be ready to go at a moment’s notice (the person has between 1-4 hours to get there, or lose the bed). If the senior does not have no phone and wants to get this facility, she or he must go out in whatever the weather to a public phone. The facility has set times during which people cannot phone.

5. Physical environment - The physical environment at the facility can effectively exclude seniors. Many facilities have a number of steps, which make it hard if one uses a walker, or lack elevators. Some have been known to have pest infestations.

There is a lack of privacy. The typical facility requires people to share rooms (ward type bedrooms, separated by curtains as opposed to single or semi-private rooms). There is lack of accessibility for physically handicapped clients; and lack of bright, home like environment. (13)

Detoxing on One’s Own

Sometimes people go into withdrawal when the money runs out; or they force themselves self to stop drinking for a while (perhaps to deal with an ultimatuum from others). Others may try to withdraw "cold turkey". Some will ask and get aid from their family physician who provides medication to help the person deal with the withdrawal.

Unsupervised detoxification can be precarious for seniors, especially considering the health of older clients.

 

 

 

 


References

(1) http://www.health.gov.au:80/hfs/pubs/drug/alc_hand/alc_c14.htm#alcohol hbk ch. 14

(2) I. Davidson ( 1997) Older People and Alcohol : A Handbook for Community Health Nurses. Alcohol and Health Research Group University of Edinburgh , Edinburgh, Scotland. P.

(3) Comprehensive Review of Detoxification Facilities in British Columbia" (May 10, 1993) by Carol Blair, Mark Lazurko, & J. Skirrow for Alcohol and Drug Programs, Vancouver, B.C. (p9)

(4) K. J. Brower, S, Mudd, F.C. Blow, J.P. Young 7 E.M. Hill (Jan/ Feb. 1994)"Severity and treatment of alcohol withdrawal in elderly versus younger patients" Alcoholism: Clinical and Experimental Research 18 (1) 196-201

(5) Szwabo (Feb. 1993) "Substance abuse in older women" Clinics in Geriatric Medicine 9 (1) 1197-207 at 201

(6) Brown, M.E., Anton, R.F., Malcolm, R., Ballenger, JC (1988) "Alcohol detoxification and withdrawal seizures: clinical support for the kindling hypothesis" Biol. Psychiatry 23 507-514.

(7) D. Evans, S.D. Street, & D. J. Lynch (1996) "Alcohol withdrawal at home" Canadian Family Physician 42 937-945

(8) Division of Vital Statistics, B.C. Ministry of Health and Ministry Responsible for Seniors Selected vital statistics and health status indicators. Annual Report, 1994 Victoria: The Ministry.

(9) Evans, supra. N.7

(10) Alcohol and Drug Programs, B.C. Ministry of Health and Ministry Responsible for Seniors Report on Older Adults and Alcohol misuse. Victoria: The Ministry

(11) Supra, n. 3, p. 26

(12) D.B. Cooper (1994) Alcohol Home Detoxification and Assessment (New York: Radcliffe Medical Press) p. 27.

(13) Supra n. 3 at 35.

(14 Cooper, D.B. (1994) supra, n. 12.

(15) Notes from Senior Well Aware Program, Vancouver, B.C. Home Detoxification Training Materials.

(16) Cooper, D.B. (June, 1995) "Alcohol home detoxification." Canadian Nurse, 91(6), 35-9

(17) Stockwell, T., Bolt, L. Milner, I. Russell, G. Bolderston, H. Pugh, P.(1991) Home detoxification from alcohol: Its safety and efficacy in comparison with inpatient care . Alcohol and Alcoholism, 26(5/6):645-650.

(18) Stockwell, T. Bolt, L. Milner, I. Pugh, P. Young, I. (1990) Home detoxification for problem drinkers: Acceptability to clients, relatives, general practitioners and outcome after 60 days . British Journal of Addiction, 85(1):61-70.

(19) Ibid.

(20) Ibid.

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