Working with older drinkers

Key findings

Nature of the problem

• Moderate drinking in later life has a beneficial effect on all-cause mortality and confers a number of psychological benefits, possibly through reduced stress and improved mood and sociability.
• However multiple biological, psychological and social changes that accompany the ageing process make older people uniquely vulnerable to alcohol problems. These vulnerabilities can include loneliness, diminished mobility, multiple bereavements, chronic pain, poor physical health and poor economic and social supports.
• Many of the acute and chronic medical and psychiatric conditions that lead to high rates of health and social care use by older people are influenced by the consumption of alcohol. These conditions include harmful medication interactions, injury, depression, memory problems, liver disease, cardiovascular disease, cognitive changes and sleep problems.
• Most diagnostic and intervention strategies are neither age-specific nor sensitive to what is most effective in accommodating the unique biological and social condition of older age. This is also an issue in the area of prevention where the focus reflects the common age bias that alcohol problems occur in the young but not the old.

Detection

• Alcohol problems are less likely to be detected in older people. This may be because older people are more likely to try to hide the problem because of shame and embarrassment, because it can be difficult to distinguish the symptoms of alcohol problems in older people from the symptoms caused by the medical or psychiatric problems of ageing or because there is a lack of awareness amongst professionals that alcohol misuse is a potentially important problem for older people.

• Screening tools can be useful in identifying alcohol problems in older people. However, tools developed specifically for older people such as the Geriatric Version of the Michigan Alcohol Screening Test are preferable to generic screening tools such as AUDIT.
• Physical signs and symptoms that should trigger screening include sleep complaints, persistent irritability without obvious cause and frequent falls or unexplained bruising.

Assessment

• Developing a good rapport with an older person is very important when assessing them for alcohol problems. Ideally the information should be gathered informally once the relationship has been properly established.
• Assessments should be comprehensive and include physical and mental health, social activities, interpersonal relationships, the physical environment, competency with activities of daily living, safety needs, coping response and medication use. Assessment may take longer in older people where there is an extensive alcohol history, health problems or involvement of multiple agencies.
• Older people may find it hard to gauge how much they drink and have difficulty calculating alcohol units. Drink diaries and unit measuring cups may be particularly helpful for older people.

Intervention

• A growing body of evidence suggests that older drinkers are just as likely to benefit from intervention as younger drinkers but embarrassment, shame and the cultural inappropriateness of some mixed-age addiction services can deter older people from seeking alcohol treatment. Lack of transportation and mobility problems may prevent older people attending services.
• Older drinkers are likely to present with a great range and degree of challenges. A one-time brief encounter of 15 minutes or less can reduce non-dependent problem drinking in an older person by more than 20%. However, older people with more complex needs or an extensive history of problem drinking are likely to require more extensive specialist treatment with multiagency support.
• Interventions should focus on quality of life in addition to issues surrounding alcohol and aim to promote independence and reduce risk. Empirically supported interventions in adults are generally suitable for use with older people.
• Engaging the older person’s family in treatment may be helpful and they may feel more comfortable disclosing and discussing problems with same-age peers than participating in mixed-aged group work.