Evidence suggests that a significant and growing number of older people are at risk of alcohol-related harm:
- 20% of men and 10% of women aged 65 and over exceed recommended drinking guidelines and 3% of men and 0.6% of women aged 65-74 are alcohol dependent.
- There has been a steady increase in the amount of alcohol consumed by older age groups in recent years.
- Consumption patterns suggest that the ‘baby-boomer’ cohort is likely to have higher levels of alcohol consumption in old age than previous cohorts of older people.
Increased alcohol consumption coupled with the projected increase in the population of older people will place increasing pressure on substance misuse and health and social care services. However, little is known about the nature of the problem and what strategies and treatment approaches work best with older drinkers. The aim of this study was to address this deficit by synthesising relevant published literature, insight from substance misuse practitioners who specialise in working with older people and the perspectives of older people with alcohol problems.
Through our professional networks we identified five substance misuse treatment agencies that had a service specifically for older substance users, four of which agreed to take part in the study. The agencies had different age thresholds for eligibility for their older person’s service, ranging from 50 and over to 60 and over. A combination of one to-one interviews and focus groups were conducted with fifteen practitioners from these services to explore the nature of problem drinking in old age and the most effective strategies for working with older drinkers. Practitioners were asked to recruit clients to take part in the study. One-to-one interviews were carried out with 11 older clients aged between 55 and 73 and a further 15 clients aged 50 and over took part in a focus group. Questions were designed to elicit their experiences of drinking and needs in terms of intervention. A literature review was carried out to identify international research relating to the nature of the problem and strategies and interventions for working with older drinkers.
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.
- 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.
- 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.
- 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.
- Older drinkers often have different stressors, precipitating factors and risk factors for relapse than younger drinkers. They may also face a number of age-related barriers to treatment and are more likely to remain ‘hidden’ from services.
- Frontline health and social care staff may need to increase their competency in recognising and intervening with older people suspected of having an alcohol problem. Education and training for these workers should address attitudes and beliefs towards alcohol problems in old age.
- Substance misuse practitioners should understand the causes and consequences of alcohol problems in later life and the differing needs of older clients. Substance misuse services should take a flexible approach to providing treatment that is effective with older clients, ideally offering:
- a choice of venue, including domiciliary visits, for ease of access and to offer some form of anonymity for those who fear the stigma of having an alcohol problem.
- longer and more frequent sessions where there are complex needs or an extensive history of problem drinking.
- appointments at specific times or dates, perhaps coinciding with transport times or carer availability.
- outreach work with older people’s and caregiver groups and inreach into care homes and hospitals.
- Commissioners should consider commissioning local need assessments in relation to older peoples’ drinking and setting targets for numbers of older people attending substance misuse services.
- Prevention programmes should address risk factors and strengthen protective factors that can help older people weather the unique circumstances that contribute to the development and/or deterioration of alcohol problems.
Sarah Wadd, Kerry Lapworth, Donald Forrester and Sarah Galvani from the Tilda Goldberg Centre for Social Work and Social Care. Mary Sullivan from the Brunel Institute for Ageing Studies.
We are grateful to Alcohol Research UK for funding this research and to all those who took part in the study.