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How to diagnose pathologic gambling in older patients

Vol. 5, No. 12 / December 2006

Pathologic gambling among older patients causes more than financial losses; it also can lead to comorbid alcohol dependence, depression, anxiety disorders, and medical treatment nonadherence.1

Retirement, death of a spouse, “empty nest” syndrome, and other emotional, social, and financial stresses are common in later life. Some try to fill the gap with gambling, which can become pathologic. Early intervention and treatments addressing an older patient’s psychological and social needs can improve outcomes, however.

Screening for pathologic gambling

Late life pathologic gambling often goes undiagnosed but is thought to be on the rise. In a random sample of 843 older adults at scheduled primary-care appointments, 70% had gambled at least once in the past year and 11% were identified as at-risk gamblers.1

Diagnosing pathologic gambling requires a high degree of suspicion and inquiry. You must actively incorporate screening questions in the clinical interview to identify at-risk and pathologic gamblers in older patients.

Based on clinical experience and several DSM-IV-TR criteria,2 we developed a screening tool called PACE RULeS to identify pathologic gambling in this population (Box 1). A positive response to 5 or more of the 8 questions indicates a likely diagnosis of pathologic gambling. Lower scores may point to at-risk behavior and would require follow-up.

Box 1

8 questions to screen for pathologic gambling

Diagnose maladaptive or pathologic gambling if your patient answers yes to 5 or more of these “PACE RULeS” questions:

  • P—Are you often Preoccupied with thoughts of gambling?
  • A—Would you often gamble with increasing Amounts of money to achieve the same excitement?
  • C—Have you made repeated efforts to Control, cut back, or stop gambling?
  • E—Do you gamble to Escape daily problems and stresses?
  • R—After losing money, do you often Return another day to get even?
  • U—Have you ever committed Unlawful acts to finance gambling?
  • L—Have you Lost a significant relationship or job because of gambling?
  • S—Do you use your Savings to gamble?

Psychosocial intervention

After you make a diagnosis, manage your patient’s pathologic gambling with a comprehensive plan that includes family and community resources.3Box 2 shows interventions studied in the adult population that are appropriate for older patients.

Box 2

Interventions for older patients

  • Screen for active gambling
  • Intervene immediately if the patient is suicidal
  • Refer the patient to Gamblers Anonymous
  • Enlist family and friends to support treatment adherence and effectiveness. Be aware of confidentiality and ethical issues, however, especially during discussions with family members
  • Refer the patient to counseling
  • Actively participate in the treatment plan by assessing for relapses.


No psychotropics are FDA-approved for pathologic gambling, but adding medication to psychosocial interventions may help. Most medications studied in the general population are similarly efficacious in older adults. Slowly increase dosages, however, because of the greater risk of side effects in older patients.

Selective serotonin reuptake inhibitors help reduce gambling behavior, improve social and occupational functioning, and treat comorbid depression when used in relatively higher dosages. In anecdotal reports, the following medications have been found to be beneficial:

  • fluoxetine, 20 to 60 mg/d4
  • paroxetine, 20 to 60 mg/d5
  • fluvoxamine, 200 mg/d.6,7

Citalopram, 60 mg/d, also has shown efficacy in a single study of 15 adults ages 18 to 70.8 Similarly, clomipramine, 125 to 175 mg/d, has been effective in reducing gambling behavior. Naltrexone, 150 mg/d, appears to help individuals with intense urges to gamble, but liver function must be monitored.9 Anecdotal evidence also suggests that mood stabilizers including lithium, carbamazepine, and valproate may help treat impulsivity and comorbid bipolar disorder.

Although some medications treat pathologic gambling, others can cause it. Dopamine agonists such as pramipexole could cause reversible pathologic gambling in some older individuals who take it for Parkinson’s disease or restless legs syndrome.10

Drug brand names

  • Carbamazepine • Tegretol
  • Citalopram • Celexa
  • Clomipramine • Anafranil
  • Fluoxetine • Prozac
  • Fluvoxamine • Luvox
  • Lithium • Eskalith, Lithobid
  • Naltrexone • ReVia
  • Paroxetine • Paxil
  • Pramipexole • Mirapex
  • Valproate • Depakene, Depakote


1. Levens S, Dyer AM, Zubritsky C, et al. Gambling among older, primary-care patients: an important public health concern. Am J Geriatr Psychiatry 2005;13(1):69-76.

2. Diagnostic and statistical manual of mental disorders, 4th ed. text rev. Washington, DC: American Psychiatric Association; 2000.

3. Unwin B, Davis M, DeLeeuw J. Pathological gambling. Am Fam Physician 2000;61:741-9.

4. De la Gandara JJ. Fluoxetine: open-trial in pathological gambling. Paper presented at: Annual Meeting of the American Psychiatric Association; May 16-21, 1999; Washington, DC.

5. Kim SW, Grant JE, Adson DE, et al. A double-blind placebo-controlled study of the efficacy and safety of paroxetine in the treatment of pathological gambling. J Clin Psychiatry 2002;63(6):501-7.

6. Hollander E, DeCaria CM, Mari E, et al. Short-term single-blind fluvoxamine treatment of pathological gambling. Am J Psychiatry 1998;155(12):1781-3.

7. Hollander E, DeCaria CM, Finkell JN, et al. A randomized double-blind fluvoxamine/placebo crossover trial in pathological gambling. Biol Psychiatry 2000;47(9):813-7.

8. Zimmerman M, Breen RB, Posternak MA. An open-label study of citalopram in the treatment of pathological gambling. J Clin Psychiatry 2002;63(1):44-8.

9. Kim SW, Grant JE. An open naltrexone treatment study of pathological gambling disorder. Int Clin Psychopharmacol 2001;16(5):285-9.

10. Dodd ML, Klos KJ, Bower JH, et al. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62(9):1377-81.

Dr. Madaan is a fellow in child and adolescent psychiatry, Creighton University, Omaha, NE.

Dr. Padala is assistant professor, department of psychiatry, University of Nebraska Medical Center, Omaha, NE.

Dr. Sattar is assistant professor, department of psychiatry, Creighton University Medical Center, Omaha, NE.

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