Abstract
The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical, and psychosocial factors. The assessment, treatment, and aftercare of alcohol-related and other comorbid mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas such as alcohol-related brain damage and drug interactions with alcohol that deserve special attention.
Introduction
The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical, and psychosocial factors. The assessment, treatment, and aftercare of alcohol-related and other comorbid mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas such as alcohol-related brain damage and drug interactions with alcohol that deserve special attention.
In 2011, the Royal College of Psychiatrists published its first report on substance misuse and older people, Our Invisible Addicts.1 This set out key recommendations at the levels of policy, public health, service delivery, and treatment, as well as training and education. As a result of growing recognition of the nature and scale of the issues for policy relating to service development, workforce planning, and research, this report was extensively revised in 2018.2 Translating these needs into guidance is a key step in the process of achieving integrated care for older people with alcohol misuse and comorbid psychiatric disorder.3 This chapter details the rationale for nurturing this area of clinical practice in psychiatry by expanding on the main areas for development, with a clinical focus. These areas comprise the epidemiology of alcohol misuse in older people; assessment (including screening); psychosocial interventions; supporting families and carers; legal and ethical aspects; acute psychiatric presentations; drug interactions; alcohol-related brain damage; and the relevance of multi-agency working.
Epidemiology
There has been seen a sharp escalation in morbidity and mortality from alcohol misuse in older people. Between 2005 and 2013, the percentage of men in the UK drinking 8 or more units of alcohol on any 1 day in the past week fell by only 5% in those aged 65 and over, compared with a reduction of at least 12% in all other age groups.4 In the over-65s, the percentage of people who reported not drinking at all has fallen from 29.4% in 2005 to 24.2% in 2017.5 Risky drinking, which is falling in all other age groups, is increasing in the over-50s.5 This rise in drinking in ‘baby boomers’ (those born between 1946 and 1964) is of concern.6 The highest mortality rate for alcohol-related deaths was in men aged between 55 and 74.1 The number of people between the ages of 60 and 74 admitted to hospitals in England with mental and behavioural disorders associated with alcohol use has risen by over 50% since 2006, more than in the 15–59 age group. People aged 75 years and over with mental and behavioural disorders associated with alcohol experienced longer hospital admissions than their younger counterparts.7
These overall findings cannot be explained purely by rising numbers of older people in the general population, given that the population of people aged 65 and above in England and Wales increased by 11% between 2001 and 2011.8
Assessment
The assessment of an older person with alcohol misuse requires careful consideration (Box 6.1), taking into account age-specific factors that may influence the approach to interviewing, clinical presentation, and risks from the misuse. It is important to recognize that even low levels of alcohol use in older people can be harmful, so that dependence criteria do not necessarily have to be met to form a judgement as to whether alcohol is partly or wholly responsible for the clinical presentation.
Box 6.1 Assessment of an older person with alcohol misuse
General Principles
Respect dignity, individuality, values, and experiences
Take into account sensory and cognitive impairment
Be aware that atypical presentations and under-reporting are common
Use additional information from other sources
Be aware of psychiatric comorbidity, functional abilities, and loss events
Consider the influence of other substances, physical disorders, and social support
Special Areas for Consideration
Living arrangements
Other substance use and misuse (nicotine/over-the-counter/prescribed/illicit drugs)
Access to alcohol (e.g. relatives/formal carers/home delivery)
Drinking ‘environment’ (e.g. home drinking, drinking partners)
Medical history (physical complications from alcohol)
Mental capacity
Drug interactions (including other substances)
Risk of falls, social/cultural isolation, and elder abuse (including need for safeguarding vulnerable adults)
Level of nutrition
Social support from informal carers and friends
Social pressures from debt and alcohol-using carers
Comorbid psychiatric illness (mostly depression and alcohol-related brain damage)
In late-onset drinking the bias is towards women, whose problem drinking in later life is usually in reaction to a life crisis.9 Women are a particularly vulnerable group, as alcohol misuse is associated with depression and social isolation, both of which are more common in older women than in older men.10
Screening for Alcohol Misuse
The CAGE questionnaire screens for the core features of alcohol dependence, but it is insensitive to harmful and hazardous drinking in older people (it is further discussed in Chapter 7).11 The Alcohol Use Disorders Identification Test (AUDIT) has been validated in some older populations,12 with greatest sensitivity and specificity being shown with a cut-off point of 5 for older men and 3 for older women.
Shorter versions of the AUDIT include the AUDIT-5 (5 items) and the AUDIT-C (3 items). A cut-off point of 4 has been suggested for both the AUDIT-513 and the AUDIT-C.14 However, these studies have not undergone extensive replication in older people. The Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G) has shown the greatest validity and use in older populations.15
Given the lack of sensitive screening tools for alcohol problems in older people, tools for working-age adults need to be combined with quantity/frequency measures and a comprehensive assessment that incorporates the approach taken in Box 6.1.
Psychosocial Interventions
Only 6–7% of high-risk substance misusers over the age of 60 receive the treatment that they require.16 However, since older people are likely to be in contact with the healthcare system, there are significant opportunities to identify problems associated with substance misuse.
Recent studies have shown positive outcomes from psychosocial interventions. Although there is relatively little research in this age group, consistently positive findings emerged from those studies in which psychosocial treatment for alcohol problems in the older patient was investigated. The studies demonstrated that older people want to abstain; have the capacity to change; can be successfully offered help by physicians; respond well to brief advice and motivational enhancement therapy; do not necessarily need age-specific treatment programmes; can achieve improvement in outcomes across a range of domains (mental and physical health, relationships, legal, occupational, and financial issues) comparable to that in younger adult populations; and have the prospect of long-term recovery. Although more research needs to be done, older adults should not be barred from treatment because of age.
The Brief Intervention and Treatment for Elders (BRITE) project reported a reduction in alcohol use and problems from 80% to 18%, but there was no control group in this study.17 The Healthy Living as You Age (HLAYA) study found improvement in both controls (advice only) and intervention (integrated care) groups at 12 months.18 This is in keeping with the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study, which found that patients did better in integrated mental health and substance misuse care in primary care compared with referral to specialist providers.19
Box 6.2 outlines some of the challenges to recovery faced by people with alcohol misuse.
Recovery can be a lengthy process and its particular challenges include:
Supporting access to specialist services (e.g. overcoming stigma)
Mobilising personal and social resources (e.g. contact with family and friends, buddying and befriending, attendance at Alcoholics Anonymous)
Changing social contacts (e.g. avoiding drinking partners)
Achieving controlled drinking, rather than abstinence
Patient’s ownership of the care plan
Emotional factors (e.g. bereavement, loss, sexuality, history of abuse, relationship problems, past traumatic experiences)
Practical considerations (e.g. diet, sleep, hazardous prescribed drug interactions, physical health, drinking and driving, fall hazards, safe storage of medications)
Managing setbacks and not seeing them as failures
Managing harm reduction using the community reinforcement approach
Supporting Families and Carers
Little is known about formal interventions for supporting families and carers affected by the lives of older people with alcohol misuse.20 Families often take a long time both to identify drinking problems and to seek help.21 Fewer than 1% of alcohol services in England provide a service specifically for older people.22
Ageism from family members not appreciating the likelihood of alcohol problems in later life, together with the stigma of being labelled an ‘alcoholic’ and subsequent under-reporting of alcohol intake, can both influence the detection of alcohol misuse.23 Concern from carers (commonly family members and friends) is the most common factor motivating older people to seek treatment for alcohol problems.24 Receiving help from family and friends to cut down drinking lowers the likelihood of alcohol problems in older people.25
The Stress-Strain-Coping-Support (SSCS) model offers a practical approach to understanding the effects of substance misuse on family and carers,26 with interventions centred on building resilience in individuals and a family/social structure.
Legal and Ethical Aspects
Alcohol misuse in older people can present unique legal and ethical challenges. The complexity of dependence accompanied by age-related impaired decision-making results in a conflict between encouraging controlled drinking or abstinence and continuous alcohol misuse that is influenced by a lack of mental capacity. Using the core feature of harm awareness, an assessment of mental capacity in substance use can help to distinguish an unwise decision from a lack of mental capacity per se.
Capacity can also vary over time and change in relation to different decisions. In alcohol misuse, mental incapacity may fluctuate according to level of intoxication or delirium and may be associated with a revolving-door phenomenon of hospital discharge and readmission. This is further complicated by the observation that cognitive impairment may improve within the first 60 days of abstinence.27 Capacity should be seen as decision-specific. If a person is deemed to be ‘lacking capacity’, it means that they lack capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken.
Although older people with alcohol-related brain damage can often be treated under the Mental Capacity Act 2005, it should be acknowledged that the Mental Health Act 1983, as amended in 2007, can also be used if there is evidence of a mental disorder such as dementia and if the criteria for using this Act are satisfied (for further discussion of capacity and mental health legislation, see Chapters 21 and 22).
Acute Presentations of Alcohol Misuse
As signs and symptoms of alcohol misuse can be very non-specific, under-reported, and under-recognized, alcohol misuse may remain undetected in many patients in an acute setting.
Alcohol Withdrawal Syndrome
The clinical response to symptoms of alcohol withdrawal will depend on the extent of alcohol use, the degree of dependence (if any), general health, and social circumstances. Treatment may include supervised care by health and social care staff or family, and home visits. However, if older people do demonstrate alcohol withdrawal syndrome, the threshold for admission to hospital may have to be lower because of the greater seriousness of medical complications such as neurological and hepatic disorders in this age group. Furthermore, a clinical judgement needs to be made about the patient’s ability to make decisions about detoxification, since this may be impaired owing to cognitive dysfunction directly as a result of substance misuse or indirectly as part of a co-occurring mental or physical disorder.
Although long-acting benzodiazepines are the treatment of choice for alcohol withdrawal syndrome in adults, older people should start with a lower dose. It is important to strike a balance between a dose sufficient to alleviate the symptoms but not enough to result in intoxication. It may be preferable to consider shorter-acting medications such as lorazepam or oxazepam, especially if there is hepatic dysfunction. It is important to ensure that the dose takes account not only of the patient’s age (older people should have roughly half the dose given to a working-age adult), but also physical conditions (e.g. if the patient has liver disease, accumulation may be more likely) and mental state (the patient may have a co-occurring depression, anxiety, or psychosis).
An effect on memory can be detected even within the normal dose range of prescribed benzodiazepines and a dependence syndrome may result from low-dose prescription, so withdrawal with confusion may further complicate the clinical picture.
The starting dose is often related to the score on the Severity of Alcohol Dependence Questionnaire (SADQ), although this scale has been developed in younger people and should be translated cautiously. The regime consists of medication in 3 or 4 doses divided over 24 hours and, following stabilization over 3 or 4 days, reduction usually takes place over 7–10 days. Other prescribed and over-the-counter medication, illicit drugs, and existing health conditions must be considered when formulating the dosage regime. Patients may already be on benzodiazepines or be using medications (including opiate analgesia) that are not prescribed.
Convulsions and the possibility of Wernicke–Korsakoff syndrome should be considered, but patients should routinely be treated with vitamins B and C by intramuscular or even intravenous administration to avoid malabsorption. Emergency treatment for anaphylaxis must be available as, although this is very rare, it can be fatal. Anti-craving agents (such as acamprosate and naltrexone) and aversive medications (such as disulfiram) should be considered, but the evidence base in older people is sparse and a clinical decision needs to be based on the condition of the patient and the adverse effects profile.
Wernicke’s Encephalopathy
Acute intoxication may mask the development of the potentially life-threatening Wernicke’s encephalopathy, which can present during alcohol withdrawal or can be misdiagnosed as alcohol withdrawal. Wernicke’s encephalopathy is a spectrum of disease resulting from thiamine deficiency, usually caused by alcohol misuse. There is a greater risk in those who drink continuously rather than binge drink, and the condition has a peak onset in men aged 40–59 and in women aged 30–49. It is usually described in terms of the classic triad of confusion, ataxia, and ophthalmoplegia and is a medical emergency.28 It is important to maintain a high level of suspicion for the possibility of Wernicke’s encephalopathy, particularly if the person is intoxicated.
The condition can be reversed if detected and treated promptly with parenteral (intramuscular or intravenous) thiamine. Untreated Wernicke’s encephalopathy may lead to Korsakoff’s psychosis, in which there is lasting damage to areas of the brain involved with memory.29 It is important to differentiate Wernicke–Korsakoff syndrome from delirium and from other conditions that cause a thiamine deficiency, including thyrotoxicosis, metastatic cancer, long-term dialysis, and congestive heart failure.
Delirium Tremens
Delirium may be associated with intoxication or withdrawal states. Recognizing delirium tremens in acute hospital settings is especially important as it has a high morbidity and mortality but is treatable. It is characterized by hallucinations, disorientation, tachycardia, hypertension, fever, agitation, convulsions, and diaphoresis (sweating) and typically sets in following acute reduction and/or cessation of alcohol. It typically begins 48–96 hours after the last drink and, in the absence of complications, can last for up to 7 days.30
Elderly patients and those with concurrent medical conditions, both acute and chronic, are at higher risk of complications. Concurrent medical conditions are common and may include dehydration, unrecognized head trauma, electrolyte abnormalities, infections (including meningitis), gastrointestinal haemorrhage, pancreatitis, liver disease, and myocardial infarction. These conditions may neither be obvious nor self-reported in delirious patients. Close monitoring by nursing staff is critical for the patient’s protection. A quiet room for rehydration and nursing is essential.
Related posts:
Chapter 7 – Drug Misuse in Older People
Chapter 9 – The Home Assessment in Old Age Psychiatry
Chapter 13 – To Scan or Not to Scan
Chapter 15 – What Can Person-Centred Care in Dementia Learn from the Recovery Movement?
Chapter 22 – Deprivation of Liberty
Chapter 19 – Reducing the Healthcare Burden of Delirium
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