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One out of 2 Americans report drinking on a routine basis, making the excessive consumption of alcohol the third leading cause of preventable death in America (CDC, 2012). Alcoholism and depression are common comorbidities that home healthcare professionals frequently encounter. To achieve the best patient outcomes, alcoholism should be addressed initially. Although all age groups are at risk, alcoholism and depression occur in more than 8 percent of older adults. Prevention through identifying alcohol use early in adolescence is vital to reduce the likelihood of alcohol dependence. This article provides an overview of the long-term effects of alcohol abuse, including alcoholic cirrhosis and hepatic encephalopathy. The diagnostic criteria for substance dependence and ideas for nonthreatening screening questions to use with patients who are adolescent or older are discussed. While providing patient care, home healthcare nurses share the patient's intimate home environment. This environment is perceived as a safe haven by the patient and home care nurses can take advantage of counseling and treatment opportunities in this nonthreatening environment.
For Amy, it began when her mother was working and she would just "hang out" with her older brothers. Even when she was only 10 years old her mother was rarely home. She never understood why her mother was gone so much, especially when the longer work hours never led to more money. It was just Amy and her two older brothers for as long as she could remember, and as long as she could remember, Amy battled her need for alcohol. At first her brothers would invite her to play cards with their friends on the weekends. This would end up with having a "good buzz" from beer. Amy quickly learned that the weekends would somehow pass more easily with less loneliness. Amy felt comfort with the alcohol fog because it helped her loneliness.
Marriage was neither the golden answer for happiness nor the cure for her alcohol dependency. She got married when she was 18 and newly graduated from high school. Her mother had warned her not to marry so young, but Amy thought this would help her persistent feeling of emptiness. Amy drank daily, slacking off slightly during her three pregnancies, but always routinely in some amount.
Eventually she found herself alone as a single parent, but she considered herself a "decent mom" who never missed a school function. She had graduated from high school with excellent grades and then after divorcing completed college on a Pell Grant. Amy worked in the field of Web design, which offered a flexible schedule and which she considered her job perfect for "her needs."
After 31 years of routine alcohol use Amy noticed some concerns. Her pale skin tones began to yellow. She was quickly diagnosed with alcoholic cirrhosis that seemed to progress overnight to hepaticencephalopathy. Amy was given the choice of stopping the alcohol and being placed on the liver transplant list, or continuing to drink and take medication to help slow the progression of the disease. Amy chose the latter. Unable to tolerate the medication by mouth, and with a weight loss of 40 lb (making her 20% below her ideal body weight), a gastrostomy tube was placed for enteral nutrition and medications. With her children grown and away, Amy opted to live at home and care for herself as best as she could. Her home care nurses were now her closest friends and helped ease the loneliness she had felt since childhood.
The association between alcohol and depression has long been acknowledged in literature (Conner et al., 2009; RxNews Health, 2009). An estimated 25% of males and 49% of females suffer from depression associated with alcohol abuse (Epstein et al., 2009; Hesselbrock et al., 1985). The lifetime rates of depression and alcoholism as comorbidites approach as high as 70% (Conner et al., 2009). The depression is great enough to make the lifetime risk of suicide 15% among alcoholics (Centers for Disease Control and Prevention [CDC], 2009; Kessler et al., 1999). In his book "Comfortably Numb," Barber (2008) emphasized that alcohol has been the "constant" for depressive disorders, long before any pharmaceutical products were developed. A study of 6,300 alcoholics supported findings that treating the comorbidity of alcoholism initially was more effective in recovery from depression than trying to resolve depression before alcoholism (Lejoyeux & Leher, 2010; Murphy et al., 2010).
Within the last 2 years more evidence has been identified concerning genetic links between the comorbidities of alcoholism and depression. Genetic markers for depression and alcoholism have been identified (Kertes et al., 2010; National Institutes of Health, 2011). Kertes and colleagues (2010) noted that if a person has depression or alcoholism, their risk for developing the other disorder is two to four times greater than the general population's risk. Additional research supports the genetic bases for alcohol dependence along with the value of medications that target-specific genes in alcoholism treatment (Moonat et al., 2009).
Depression affects a reported 21 million Americans (Mental Health America [MHA], 2011). Many people are undiagnosed, either by choice or due to lack of payment for care (MHA, 2011). Depression alone is reported less often among men than women. It is unknown if the incidence in men could actually be as high as in women due to the fact men do not seek healthcare services as often as women. Men may also deny their feelings. Males have a higher alcoholism rate than females. Males also have a higher mortality rate secondary to depression than females (Murphy et al., 2010).
Depression is a serious concern of adolescents with suicide ranking as the third leading cause of death in people age 15 to 24 years (Health Resources and Services Administration [HRSA], 2009). Depression is associated with initial alcohol use during adolescence (Benton, 2009; Korkeila et al., 2010). Some adolescents began their alcohol use as a form of self-medication. The average age for first-time alcohol use in high-functioning alcoholics is reported to be between the ages of 13 and 15 years (Benton, 2009). Children who begin drinking before the age 15 are five times more likely to become alcohol-dependent than those who wait until age 21 (National Survey on Drug Use and Health, 2008).
Depression among elderly is common and associated with reduced quality of life and increased mortality (Lamers et al., 2010). Depression in elderly may be overlooked as a primary diagnosis leading to under treatment or no treatment at all. If depression or alcohol use disorders are recognized and treated, it is usually by primary care providers (Lamers et al., 2010). Heavy alcohol use and depression are reported to be as high as 8.2% among elderly. In his research published in Elder Law Weekly (2010), Lacks reported that elderly who continue to drink throughout their life span have more cognitive impairment and greater fall risks compared with those who do not abuse alcohol. Elders also binge drink more frequently than other age groups, making them at higher risk of injury (CDC, 2010).
There are two types of alcohol disorders: alcohol dependence and alcohol abuse (American Psychiatric Association [APA], 2000). To meet the criteria for alcohol dependence, the person must also meet the criteria for substance dependence (Table 1). The terms alcohol dependence and alcoholism are used interchangeably in the clinical setting. Alcohol abuse is not considered as severe as dependence, noting that withdrawal symptoms are not present if the person abstains. A summary of the diagnostic criteria for alcohol abuse is presented in Table 2.
To place the problem of alcohol use disorders into perspective, consider that alcoholism affects a minimum of 18 million people in the United States (U.S. Department of Health and Human Services, 2007), with the cost of all addictions to the United States estimated at $500 billion annually (Loomis et al., 2011). These sums would be even greater if 50% to 70% of alcoholics were not "high functioning."
The term "high-functioning alcoholic" is self-explanatory, with the person performing at a level where family and friends are able to deny their loved one might actually be alcoholic. The homeless older man on the street is the stereotype that seems to be more comfortably associated with alcoholism than a family member that "keeps their drinking to themselves." Similar to other psychologic disorders, many high functioning alcoholics were driven to be highly successful and nothing less than the best at everything they did (Benton, 2009).
Regardless of the classification of alcoholism, liver damage is a risk due to chemical toxicity.
Cirrhosis of the liver is an irreversible, chronic illness that is the result of damaged liver cells (hepatocytes). Over time alcohol promotes fat deposition, leading to fibrous tissue and nodule development. As functioning hepatocytes are gradually replaced with nonfunctioning tissue, liver dysfunction and failure ensue (Verrill et al., 2009). As liver dysfunction progresses to end-stage disease, the prognosis even with advanced treatment is usually poor. If, however, the patient abstains from alcohol within a month after receiving the cirrhosis diagnosis, long-term survival rates are greatly improved with up to a 77% survival rate in 7 years (Verrill et al., 2009). Alcoholic cirrhosis develops only in 20% of alcoholics, with women developing cirrhosis earlier and more often than men. Alcoholic cirrhosis is also more common in African Americans and Hispanics compared to other ethnicities (Chalassani, 2012). Classification of liver dysfunction is standardized with the use of the Laennec scoring system (Table 3). Diagnosis of cirrhosis is being made earlier in the disease process, making prognosis more favorable in patients willing to seek treatment for alcoholism (Fleming et al., 2010).
Hepatic encephalopathy (HE) is one consequence of the progression of liver dysfunction. HE can occur in up to 80% of patients with liver cirrhosis (Sargent, 2007). HE is a general term encompassing any neurodegenerative change. It would be the term to describe neurologic changes from mild memory impairments to a comatose state. Because of this loose definition, stages of encephalopathy are assigned: Grade I being episodic drowsiness through Grade IV indicating coma without response to pain (Sherlock & Dooley, 2002).
High ammonia levels causing neurotoxicity is the primary cause of encephalopathy. Most ammonia is produced in the gastrointestinal (GI) tract from bacterial synthesis. Only a small percentage of ammonia is due to the breakdown of dietary protein and glutamine in the kidneys and in muscles. The target organ for controlling ammonia levels is the GI tract.
The ability to metabolize ammonia is dependent primarily on the health of the liver and a small percentage on muscle (Zafirova & O'Connor, 2010). If the liver is unable to metabolize ammonia, levels increase until symptoms occur. In patients with cirrhosis, bowel motility is sluggish causing a higher level of ammonia production from bacteria. Cirrhosis is also associated with muscle wasting, making muscle unable to excrete ammonia either. As ammonia levels rise and cross into the blood-brain barrier, neurotoxicity occurs. Ammonia levels are normally 15 to 45 mg/dL, but may increase 20 times in patients with HE (Butterworth, 2004). Symptoms of HE are presented in Table 4. Encephalopathy may range from unnoticeable to full comatose state. Signs and symptoms of HE may progress at various rates according to the patient's bowel motility and muscle mass.
Treatment options for encephalopathy are presented in Table 5. Lactulose remains the least expensive treatment for encephalopathy. Its effects cause acidification of the GI lumen reducing the production of ammonia. A second mechanism of action is a cathartic, reducing the amount of bacterial/ammonia formation in the gut due to increased transit time (Schiano, 2010). Lactulose may be administered by mouth, enteral feeding tube, or rectally.
A second option for treatment (used primarily in resistant cases of HE) is the nonabsorbable antibiotic Rifaximin. Rifaximin (brand name Xifaxan), when combined with lactulose, reduces recurrence of HE and hospitalizations by 50% (Prescriber's Letter, 2010). The cost of Xifaxan treatment is prohibitive, however, at $1,200.00 a month. Rifaximin may be administered by mouth or by feeding tube.
The implications for home healthcare and hospice nurses are numerous. Large research-based studies from numerous countries support that priority should be in identifying and challenging patients to seek help for alcoholism. Local chapters of Alcoholics Anonymous can be located easily with Internet searches. Assisting patients in admitting their dependence is not easy, even when they are faced with losing their families, their possessions, and sometimes their lives. Providers of primary care services should make depression screening universal for all patients, and communities should have outreach services for diagnosis and treatment of depression and alcoholism. Family members should encourage patients to seek treatment for alcoholism initially, then secondly for their depressive symptoms (Lejoyeux & Leher, 2010).
During counseling sessions patients will be encouraged to consider what happens when drinking (the consequences of their drinking). A list of consequences for patients to consider is provided in Table 6. If patients are open to dialogue about their drinking experiences, home healthcare nurses may discuss these topics with patients during clinical encounters (McCrady & Epstein, 2009).
Both patients and healthcare providers, including home healthcare nurses, need to keep in mind that alcoholism is a chronic condition and that therapy in some form needs to continue throughout life (McKay & Hiller-Sturmhofel, 2011). Table 7 lists barriers to the continued care of alcoholism, and Table 8 lists ideas to support adherence to continuing therapy. If patients choose to continue drinking and HE occurs, survival rates are poor. Only 42% have survived after the first year of diagnosis dropping to a 23% survival rate at Year 3 (Bismuth et al., 2010).
Although many patients served in home care may be closer to the end of life, home care and hospice nurses should still consider that excessive consumption of alcoholic beverages is the third leading cause of preventable death in America (CDC, 2012). One out of two Americans reports drinking on a routine basis (CDC, 2011). Identifying risks for alcoholism, or helping patients recognize their excessive use in order to motivate them into treatment, should be a goal. Although it is easier to turn a "blind eye," knowing that alcoholism is responsible for approximately 2.3 million years of life lost annually in the United States is a great reason to discuss alcohol use with patients (CDC, 2012). The earlier that overconsumption is recognized, the more positive the health outcomes. If a nurse could have intervened earlier in Amy's case, her liver damage might have been prevented.
Nurses are the largest body of healthcare providers and can make a difference in early intervention. Because of the close relationships home care nurses share with patients and families, they especially have opportunities to discuss dependency issues and treatment options.
Using an empathetic approach to the patient also predicts more successful outcomes (Barber, 2008). Active listening to the patient's reasons for initially using alcohol or other chemical substances helps patients sort through the reasons they are fighting treatment. Motivating patients to change cannot be accomplished usually by one individual, but comes from the support of family and friends (Alcoholics Anonymous, 2011; Miller & Heather, 1998). Home healthcare nurses have professional and personal relationships often with the patients and families they serve. Encouraging patients to be open to change to improve and maintain their health is an important role of home care professionals.
Alcoholics Anonymous. (2011). Information on alcoholics anonymous. Retrieved from http://www.aa.org/pdf/products/f-2_InfoonAA.pdf[Context Link]
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR (4th ed.). Washington, DC: American Psychiatric Press. [Context Link]
Barber, C. (2008). Comfortably numb: How psychiatry is medicating a nation. New York, NY: Pantheon. [Context Link]
Benton, S. A. (2009). Understanding the high-functioning alcoholic: Professional views and personal insights. Westport, CT: Praeger. [Context Link]
Bismuth, M., Funakoshi, N., Cadranel, J. P., & Blanc, P. (2010). Hepatic encephalopathy: From pathophysiology to therapeutic management. European Journal of Gastroenterology & Hepatology, 23(1), 8-22. doi:10.1097/MEG.0b013e3283417567 [Context Link]
Butterworth, R. F. (2004). Heatic encephalopathy: National Institute on Alcoholism Addiction & Alcoholism/National Institutes of Health. Retrieved from http://pubs.niaaa.nih.gov/Publications/arh27-3/240-246.htm[Context Link]
Centers for Disease Control and Prevention. (2009). Alcohol and risk of suicide: Suicide and alcohol among racial/ethnic populations. Retrieved from http://www2c.cdc.gov/podcasts/player.asp?f=13037#transcript[Context Link]
Centers for Disease Control and Prevention. (2010). Adult and public health fact sheets: Binge drinking. Retrieved from http://www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm[Context Link]
Centers for Disease Control and Prevention. (2011). Fast stats: Alcohol use. Retrieved from http://www.cdc.gov/nchs/fastats/alcohol.htm[Context Link]
Centers for Disease Control and Prevention. (2012). Adult and public health fact sheets: Alcohol use and health. Retrieved from http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm[Context Link]
Chalassani, N. P. (2012). Alcoholic and nonalcoholic steatohepatitis. In L. Goldman & A. I. Schafer (Eds.). Goldman's cecil medicine (24th ed., pp. 996-999). Philadelphia, PA: Elsevier. [Context Link]
Conner, K. R., Pinquart, M., & Gamble, S. A. (2009). Meta-analysis of depression and substance use among individuals with alcohol use disorders. Journal of Substance Abuse Treatment, 37(2), 127-137. [Context Link]
Deglin, Vallerand, &Sanoski, C.A. (2012). Davis drug guide for nurses (12th ed.). Philadelphia, PA: Elsevier. [Context Link]
Elder Law Weekly. (2010). Alcoholism: Alcohol use and cognitive decline among the elderly. (15515117), 16. Retrieved from http://search.proquest.com/docview/208901769?accountid=14752[Context Link]
Epstein, J. F., Induni, M., & Wilson, T. (2009). Patterns of clinically significant symptoms of depression among heavy users of alcohol and cigarettes. Preventing Chronic Disease, 6(1), A109. Retrieved from http://www.cdc.gov/pcd/issues/2009/jan/08_0009.htm[Context Link]
Fleming, K. M., Aithal, G. P., Card, T. R., & West, J. (2010). The rate of decompensation and clinical progression of disease in people with cirrhosis. Alimentary Pharmacology & Therapeutics, 32(11-12), 1324-1350. [Context Link]
Foster, K. J., Lin, S., & Turck, C. J. (2010). Current and emerging strategies for treating hepatic encephalopathy. Critical Care Nursing Clinics of North America, 22, 341-350.
Germani, G., Hytiroglou, P., Fotiadu, A., Burroughs, A.K., & Dhillon, A. P. (2011). Assessment of fibrosis and cirrhosis in liver biopsies. Seminars in Liver Disease, 31(1), 82-90.
Health Resources and Services Administration. (2009). Child health USA: Adolescent mortality. U.S. Department of Health and Human Services. (2007). Retrieved from http://mchb.hrsa.gov/chusa08/hstat/hsa/pages/225am.html[Context Link]
Hesselbrock, M. N., Meyer, R. E., & Keener, J. J. (1985). Psychopathology in hospitalized alcoholics. Archives of General Psychiatry, 42(11), 1050-1055. [Context Link]
Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence and risk factors for suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56(7), 617-626. [Context Link]
Kertes, D. A., Kramer, J., Edenberg, H. J., Nurnberger, J. I., Hesselbrock, V, & Schuckit, M. A. (2010, November 3). Gene variant linked to depression in alcohol-dependent individuals. Presentation, American Society of Human Genetics (ASHG) 60th Annual Meeting, Washington, DC. [Context Link]
Korkeila, J., Vahtera, J., Nabi, H., Kivimaki, M., Korkeila, K., Sumanen, M., & Koskenvuo, M. (2010). Childhood adversities, adult life events and depression. Journal of Affective Disorders, 127, 130-138. doi:10.1016/j.jad.2010.04.031 [Context Link]
Lamers, F., Jonkers, C. C., Bosma, H., Kempen, G. I., Meijer, J. A., Penninx, B. W., ..., van Eijk, J. T. (2010). A minimal psychological intervention in chronically ill elderly patients with depression: A randomized trial. Psychotherapy and Psychosomatics, 79(4), 217-226. doi:10.1159/000313690 [Context Link]
Lejoyeux, M., & Lehert, P. (2010). Alcohol use disorder and depression: Results from individual patient data meta-analysis of the Acamposate-controlled studies. Alcohol & Alcholism, 46(1), 61-67. [Context Link]
Loomis, D. M., Griswold, K. S., Pasatore, P. A., & Dunphy, L. M. (2011). Psychosocial problems. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter, & D. J. Thomas (Eds.). Primary care: The art and science of advanced practice nursing (3rd ed., pp. 1003-1098). Philadelphia, PA: F. A. Davis. [Context Link]
McCrady, B. S., & Epstein, E. E. (2009). Overcoming alcohol problems: Therapist guide. Oxford, England: Oxford University Press. [Context Link]
McKay, J. R., & Hiller-Sturmhofel, S. (2011). Treating alcoholism as a chronic disease: Approaches to long term continuing care. Alcohol Research and Health, 33(4), 356-370. [Context Link]
Mental Health America. (2011). Ranking America's mental health: An analysis of depression across the states. Retrieved from http://www.nmha.org/go/state-ranking[Context Link]
Miller, W. R., & Heather, N. (Eds.), (1998). Treating addictive behaviors (2nd ed.). Washington, DC: Library of Congress. [Context Link]
Moonat, S., Starkman, B. G., Sakharkar, A., & Pandey, S. C. (2009). Neuroscience of alcoholism: Molecular and cellular mechanisms. Cellular and Molecular Life Sciences, 67, 73-88. doi:10.1007/s00018-009-0135-y [Context Link]
Murphy, J. M., Gilman, S. E., Lesage, A., Horton, N. J., Rasic, D., Trinh, N.-H., ..., Smoller, J. W. (2010). Time trends in mortality associated with depression: Findings from the Stirling COUNTY study. Canadian Journal of Psychiatry, 55(12), 776-783. [Context Link]
National Institutes of Health. (2011). Gene variants predict treatment success of alcohol medication. National Institutes of Health. NIAAA Press Office. doi: 301 443 3860. [Context Link]
National Survey on Drug Use and Health. (2008). Alcohol dependence or abuse and age of first use: Substance Abuse and Mental Health Services, U.S. Department of Health and Human Services. Retrieved from http://www.oas.samhsa.gov/2k4/agedependence/agedependence.htm[Context Link]
Prescriber's Letter. (2010, June). Gastroenterology. Prescriber's Letter, 17. Detail-Document 260608. [Context Link]
RxNews Health. (2009). Alcoholism: Mean vulnerability for major depression and alcohol dependence. NewsRx Health, 32. Retrieved from http://search.proquest.com/docview/211568815?accountid=14752[Context Link]
Sargent, S. (2007). Hepatic encephalopathy. British Journal of Nursing, 16(6), 335-339. [Context Link]
Schiano, T. D. (2010). Treatment options for hepatic encephalopathy. Pharmacotherapy, 30(5), 16S-21S. [Context Link]
Sherlock, S., & Dooley, J., (2002). Diseases of the liver and biliary system (11th ed.). London, England: Blackwell Science. [Context Link]
U.S. Department of Health and Human Services. (2007). News release: Acting surgeon general issues national call to action on underage drinking. U.S. Department of Health and Human Services. Retrieved from http://www.hhs.gov/news/press/2007pres/20070306.html[Context Link]
Verrill, C., Markham, H., Templeton, A., Carr, N., & Sheron, N. (2009). Alcohol-related cirrhosis: Early abstinence is a key factor in prognosis, even in the most severe cases. Addiction, 104(5), 768-774. doi:10.1111/j.1360-0443.2009.02521.x [Context Link]
Zafirova, Z., & O'Connor, M. (2010). Hepatic encephalopathy: Current management strategies and treatment, including management and monitoring of cerebral edema and intercranial hypertension in fulminant hepatic failure. Current Opinion in Anaesthesiology, 23(2), 121-127. [Context Link]
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