Vol. XXIII. No. 12
·JOURNAL OF THE AMERlCAI\ GERIATRICS SOCIETY Copyright © 197~ bv the American Geriatrics Society
Printed in U.S.A.
A Treatment Typology for the Elderly Alcohol Abuser" ELOISE RATHBONE-McCUAN, PhD**
AND
JOHN BLAND, MSWt
Leuindale Geriatric Research Center, Baltimore, Maryland
ABSTRACT: Alcohol abuse is a serious, though often unrecognized and untreated, problem among the elderly. Treatment is handicapped by the clinician's frequent failure to understand all aspects of alcoholism, and by the lack of adequate treatment resources. Physical, mental and social problems complicate the situation. The Levindale Geriatric Research Center has developed a diagnostic and treatment typology which involves problems with alcohol, health, and the social support system in determining the appropriate environment and treatment resources for these patients. This method has immediate value for clinical practice, and has long-range value as a framework for planning integrated and comprehensive treatment services.
drinking problem in an elderly patient, and presents a treatment typology developed by the Levindale Geriatric Research Center for use in planning comprehensive treatment.
Alcoholism and other types of alcohol abuse constitute a major health and social problem for the elderly as well as for other segments of the population. Although the dimensions of this problem are just beginning to receive systematic attention and definition (1-;3), the need for effective treatment is immediate. The treatment of problem drinking in elderly patients is complicated by the sometimes overwhelming variety of physical, mental and social disturbances that go with the process of aging. Many elderly alcohol abusers are not receiving treatment for either their drinking or their other problems. These patients need a careful diagnostic work-up and a range of treatment resources. If they are already receiving some type of medical or social service for other disorders, the treatment of an alcohol-related problem must be coordinated with these other services. Otherwise, various agencies may duplicate treatment efforts or interfere with a satisfactory placement or other treatment plan. This paper concerns some of the factors which must be considered in diagnosing a
RECOGNIZING THE PROBLEM At present serious inadequacies exist, both in our system of identifying problem drinking among the elderly and in treating it. As the field of alcoholism research has matured, greater attention has been given to the relationship between age and alcoholism. Until quite recently, however, most studies focused on the youthful or middleaged drinker. Older subjects, if included at all, were likely to be lumped together in a "60 and over" category. The available data tend to support the general conception that there is a decreasing amount of drinking with advancing age. This does not, however, seem to be a linear relationship. The 1965 household survey of the Washington Heights section of Manhattan, for instance, showed a decrease in the prevalence of alchoholism in the age cohort 55 to 64 (17 per 1000) but an increase again in the cohort 65 to 74 (to 22 per 1000) (4). More recently, Johnson and Goodrich (3) found that 24 percent of their sample of 166 men and women aged 65 or over drank daily, and another 25 percent drank occasionally. The Rutgers Center of Alcohol Studies has estimated that alcohol
• Modified version of a paper presented at the 27th Annual Meeting of the Gerontological Society, Portland. Oregon, October 28-November I, 1974. •• Director, Levindale Geriatric Research Center. Belvedere and Greenspring Avenues. Baltimore MD 21215. t Chief of Alcoholism Programs. Division of Alcoholism Control, Maryland Department of Health and Mental Hygiene.
553
RATHBONE-MCCUAN AND BLAND
abuse affects 7.5 percent of the rural, suburban, and urban population aged 55 or older (5). Although the foregoing statistics confirm the existence of an alcohol problem among the aged they do not give a clear picture of which elderly persons are affected and how they are affected. The influence of alcohol abuse on the elderly patient's level of functioning and the bearing this has on the complexities of care have not been explored. In a paper presented at the Second Annual Alcoholism Conference, Pattison (6) pointed out that the first step in improving the alcoholism service network requires clear definition of the different subpopulations of alcoholics and a determination of the role that alcohol plays in the life of those populations. Determining the role of alcohol in the life of an older person requires studying the interaction of the drinking with other likely physical, emotional or social problems as well as studying the duration, type and severity of the excessive drinking. GAPS IN THE TREATMENT SYSTEM Once identified, the aged alcoholic or problem drinker encounters serious gaps and inadequacies in the various service systems available. Alcoholism services are not geared to aged alcoholics, and geriatric services usually have not faced up to the severity and prevalence of alcohol-related problems among their clientele. The geriatric alcoholic or problem drinker is often known to many different components of the community system for delivery of health and social services, receiving multiple but fragmented and often ineffectual interventions. The following is an example: Patient A, a white 65-year-old male, is known to a variety of Baltimore agencies. Through the alcoholism services he has been placed in several shelter facilities; thus he has been labeled an "alcoholic." At the Department of Social Services where he is a recipient of SSI, he has been labeled a "welfare client." He has been admitted to 3 of the 4 State mental hospitals, where he has been labeled a "mental patient." He has used a variety of health care facilities, including clinics and emergency rooms, becoming in the process a "chronic medical patient." The judicial and law enforcement agencies know him because he has undergone multiple dispositions in a period of a few months; here he is labeled an "offender." Because he has been a recipient of nutritional services through Meals-On- Wheels he has also been labeled an "isolated old man." The foregoing history is typical for the aged
554
Vol.XXlll
alcoholic who has become known to all aspects of the community service system, where he has probably been more effective at collecting labels than at securing treatment. Nowhere has he received the benefits of coordinated or preplanned services. In most such cases, the lack of integrated and coordinated services automatically produces ineffective and inefficient attempts at treatment. The public mental health system provides a good example of service fragmentation within a single system. State mental hospitals admit a disproportionate number of aged patients, many of whom are "repeaters" and many of whom carry a primary or secondary diagnosis of alcoholism. Aged alcoholics who are admitted to geriatric units have little chance of receiving treatment for alcoholism; those admitted to an alcoholism unit are not likely to receive treatment for the problems associated with old age. Once admitted, they may be victims of a "revolving door" policy or they may remain on the wards for an indefinite period. Despite increasingly well-organized efforts to keep the aged from improper placements in these institutions, the aged alcoholic often by-passes the geriatric screening process because of his involvement with the police and possibly the court system. Despite the problems noted in the State psychiatric hospitals, the nationwide trends to "deinstitutionalize" aged and long-term patients has had unintended adverse effects on many aged alcoholics. If the hospitals are ill-equipped to treat these patients, the providers of community care are even less well equipped. Once the alcoholic dries out, he or she is frequently discharged to a personal care setting, a domiciliary, or other "protective" milieu in the community. However, once the person loses the label of "patient," so few professional resources are available, and those that are available are so poorly coordinated, that community maintenance is often impossible. The emphasis of the alcohol abuse services in most States has been on developing services for a younger population of alcoholics. The currently popular residential facilities are geared to homeless males (and a few females) aged 30 to 50, with "shelters" designated specifically for the 3-5 percent classified as "skid row." State psychiatric institutions remain the dominant source of back-up service. For the aged drinker, alcoholism services need to be developed in conjunction with geriatric services so that treatment for the alcohol problem does not require the disruption of a positive residential or community placement.
December 1975
THE ELDERLY ALCOHOL ABUSER
THE GERIATRIC ALCOHOL ABUSERDIAGNOSIS The physician (office, clinic or emergency room) is the professional who most regularly comes in contact with the geriatric alcoholic or problem drinker. Gerontologists estimate that about one-third of the noninstitutional over-65 population visits a physician during a four-week period. This means that in any given month some 6 million people over 65 see a physician, most frequently in his office or at a clinic (7). Physicians, therefore, playa key role in discovering the community's elderly problem drinkers and in making appropriate treatment referrals. This being the case, it is imperative for physicians to familiarize themselves with the various degrees and manifestations of problem drinking in the elderly in order to make a proper match between the patient and the treatment resource. Taking the time and effort to understand fully the interacting physical, mental and social problems of the geriatric drinker and to develop a treatment plan that relates to the whole complex of problems, should in the long run save time and lessen frustration for the physician in addition to providing more satisfactory treatment for the patient. The aged drinker suffers from a double stigma that may interfere with the professional's ability to treat him effectively. The clinician may regard both age and alcoholism as "incurable" and so devote little effort to distinguishing between levels and types of drinking in developing an appropriate treatment plan. The popular stereotype of the homeless "skid row" alcoholic also obscures the issue by diverting attention from the much larger group of problem drinkers who are less dramatically cut off from community ties. Failure to deal adequately with a drinking problem in an elderly patient can also stem from the clinician's natural reluctance to separate the patient from his one remaining source of pleasure. Rosin and Glatt (8) made a useful distinction between "primary" and "reactive" factors in diagnosing the geriatric patient's drinking problem. Primary factors are linked to the individual's personality and to the effects of longstanding heavy drinking; they include dementia, inveterate drinking and personality flaws. Reactive factors are associated with environmental influences and include bereavement, retirement, loneliness, infirmity, and marital stress. In order to determine which factors predominate, the history must include a thorough explora-
tion of the social and emotional as well as physical aspects, and a comparison of the person's past and present drinking habits. The history should provide information about physical symptoms and drinking patterns. This includes a record of the amount and type of beverage, frequency of use, situations in which alcohol is used, attitude toward alcohol, perceptions of drinking behavior, and the effects of alcohol on performance/behavior. It is important to assess the social situation (available family and friends, types of leisure activities, frequency and type of social contacts), the emotional status (presence of dissatisfaction, frustration, loneliness or anxiety, and the sources of these feelings),. and the coping mechanisms whereby the person handles these stresses. The clinician must avoid immediately labeling an older person with a drinking problem as an alcoholic. There is a strong possibility that a crisis situation such as death of spouse or a negative reaction to retirement is associated with the exacerbation of drinking, which can represent a coping response. Treatment should be directed toward helping the aged person work through the feelings of loss. Efforts will be less effective if the focus is solely on the coping behavior (drinking) and not on the source of emotional stress. In other cases, e.g., when the aged person is a long-term alcoholic, the treatment focus would quite properly be on the alcohol-related behavior. A TREATMENT TYPOLOGY The Levindale Geriatric Research Center has designed a simple typology that has potential value for the clinician in diagnosing the overall situation and in choosing the appropriate treatment for the elderly problem drinker (9). The diagnostic plan is based on the presence (p) or absence (a) of three variables: 1) Alcoholism or symptoms of problem drinking . (AI),
2) Health problems, with or without an impaired level of physical functioning (H). 3) Difficulties or inadequacies in the social network (N). A person with none of these problems would be designated Ala Ha SNA; a person with significant difficulties in all areas would be Alp Hp SNp. Most patients, however, are not "pure types" but present various combinations of factors and degrees of severity. These three variables determine the appropriate treatment plan. The presence or absence of
555
RATHBONE-MCCUAN AND BLAND
problems with alcohol, health, and the social network allow the clinician to determine the patient's functional state (independent, marginal, dependent), the environment in which he can be expected to function (community, sheltered, institution), and the appropriate treatment source for the drinking problem. The table shows how this diagnostic/treatment typology worked in 4 cases. Community environments include: 1) settings (home, apartment) which are not structured in any way to accommodate the special needs of the aged, and 2) settings referred to as "senior citizen housing projects." Sheltered environments are specialized and semiprotective; they include supervised boarding homes, domiciliary units and foster homes. Institutions include nursing homes and various types of hospitals (general, convalescent, mental). Alcoholism counselors are usually found either in special alcoholism service programs (city, county or private) or in health services (especially emergency rooms). Other needed services are found in health settings (inpatient, outpatient and emergency hospital services, clinics, private physicians), social agencies (family service agencies, public departments of social service), and to a lesser extent in mental health clinics. The following abstracts describe in more detail the 4 patients represented in schematic form in the Table: Patient 1 (Alp Ha SNa) has a history of alcoholism dating back 30 years. At age 67, he resides in a rooming house where he is in contact with his own neighborhood social network. His drinking pattern includes periodic binges that ultimately require placement in a State institution to "dry out," after which he returns to his regular routine and his small social niche. For this patient the treatment package would be alcoholism services (through the assignment of an alcoholism counselor) and effort directed toward an ideal goal of sobriety or a realistic goal of cutting down on the number of binges.
Vol. XXIII
Patient 2 (Alp Ha SNp), aged 76, is widowed. He sold his business several years ago. His adult children are no longer in the city and his friends have all died. In recent years he began to drink and to seek companionship among others who drink. This man needs both treatment for his alcoholism and a change in social milieu. Treatment would consist of an alcoholism counselor and help with effecting needed changes in the living situation. Patient 3 (Alp Hp SNa), aged 74, has a history of chronic drinking. General physiologic deterioration had set in and during a binge she fell and broke her hip, resulting in impaired mobility. Her condition requires direct general health care and physical rehabilitation in addition to treatment for alcholism. She would receive alcoholism counseling either from the same health care facility in which she received primary and rehabilitative care or from another alcoholism service. Patient 4 (AlP Hp SNp), a 66-year-old woman, has been forced to retire. The loss of income, the involuntary change of lifestyle and the lowered social status has created serious depression. As a response to the multiple stresses of the retirement process, she withdrew from her social network, took to drinking, and suffered serious malnutrition and related medical consequences. Her alcoholism treatment would consist of placement in a long-term care setting. After an alcohol withdrawal period and regulation of diet, an alcoholism counselor would become involved. After restoration of health, she would be returned to the community where she would be linked to a mental health or family agency. The treatment typology developed at Levindale can be put to immediate use by the physician or other professional who is faced. with making or coordinating a treatment plan for an elderly alcoholic or problem drinker. However, since treatment resources at present are either nonexistent or scattered through a number of different service systems, the diagnosing clinician may have to use considerable ingenuity in ferreting out
Levindale Treatment Typology (Four examples) Variables Patient
Al
H
SN
Functional State
Environment
Treatment Source
1
Alp Alp Alp Alp
Ha Ha Hp Hp
SNa SNp SNa SNp
Independent Marginal Dependent Dependent
Community Community Sheltered Institution
Alcoholism counselor Ale. counselor and others Ale. counselor and others Ale. counselor and others
2 3 4
556
December 1975
THE ELDERLY ALCOHOL ABUSER
the appropriate resources. Ideally, one service system or agency would be designated responsible for coordinating the various services that are required. The coordinating agency could be an alcoholism service or geriatric service; it also could come from one of the other involved systems such as a family service agency, a community mental health center, a medical clinic, or a residential facility. What is critically important is that someone take responsibility so that the patient does not "fall between the cracks" of the various services. Regardless of the type of' agency that takes primary responsibility for coordinating services, the physician will continue to playa key role. The enormous task of identifying and treating the elderly alcoholic and problem drinker begins with the recognition that the problem exists. For too long the specialized needs of this group of alcohol abusers have been ignored by all levels of the service network ranging from high-level planning bodies and state agencies right down to the individual practitioner. However, ignoring the problem has not made it go away. Indeed, as the elderly population increases, the number of elderly alcohol abusers also increases. Professional recognition of the special problems presented by this group should lead to the development of more appropriate and more adequate treatment approaches and resources. have presented some of the factors which must be considered in understanding the elderly alcohol abuser's drinking in the context of his total life situation. The Levindale treatment typology shows how this understanding can be used to link the patient with 'appropriate treatment resource(s).
w:
All the understanding in the world, however, cannot make up for the absence of these resources. The effectiveness of traditional alcoholism/ aging services in treating these patients is drastically reduced by the lack of formal linkages between the two systems. A treatment typology which can be understood readily and applied by a wide range of service-givers can serve as the framework in which alcoholism and aging services, along with health, mental health and social services, and law enforcement, can develop a coordinated and comprehensive treatment system for this special subgroup of problem drinkers. REFERENCES 1. Baker F. Mishara BL, Kastenbaum R et al: A study of
2. 3.
4. 5.
6. 7. 8. 9.
alcohol effects in old age: phase II. Final report to National Institute on Alcohol Abuse and Alcoholism (NIAAA) under contract # NOI-AA-3-0I03, February 1974. Cahalan D and Room R: Problem drinking among American men. Monograph No.7, Rutgers Center of Alcohol Studies, New Brunswick, NJ, 1974. Johnson LA and Goodrich CH: Use of alcohol by persons 65 years and older, upper east side Manhattan. Report to National Institute on Alcohol Abuse and Alcoholism. January 1974. (HSM-43-73-38 NIA.) Bailey MB, Haberman PW and Alksne H: The epidemiology of alcoholism in an urban residential area. Quart Stud Alcohol 26: 19, 1965. Carruth B, Williams EP, Mypak P et al: Community care providers and the older problem drinker. Paper presented at the 24th Annual Meeting of Alcohol and Drug Problems Assoc. of North America, Minneapolis, Minnesota, September 1973. Pattison EM: Criteria in treatment evaluation. Proceedings of the Second Annual Alcoholism Conference, NIAAA, Washington, DC, June 1-2, 1972. Shanas E: Sociological factors of aging significant to the clinician, (in Seminar), J Am Geriatrics Soc 17:284, 1969. Rosin AJ and Glatt MM: Alcohol excess in the elderly, Quart Stud Alcohol 32: 53, 1971. McCuan ER: Working model for proposed intervention. Baltimore, Maryland, Levindale Geriatric Research Center, 1974.
557
·JOURNAL OF THE AMERlCAI\ GERIATRICS SOCIETY Copyright © 197~ bv the American Geriatrics Society
Printed in U.S.A.
A Treatment Typology for the Elderly Alcohol Abuser" ELOISE RATHBONE-McCUAN, PhD**
AND
JOHN BLAND, MSWt
Leuindale Geriatric Research Center, Baltimore, Maryland
ABSTRACT: Alcohol abuse is a serious, though often unrecognized and untreated, problem among the elderly. Treatment is handicapped by the clinician's frequent failure to understand all aspects of alcoholism, and by the lack of adequate treatment resources. Physical, mental and social problems complicate the situation. The Levindale Geriatric Research Center has developed a diagnostic and treatment typology which involves problems with alcohol, health, and the social support system in determining the appropriate environment and treatment resources for these patients. This method has immediate value for clinical practice, and has long-range value as a framework for planning integrated and comprehensive treatment services.
drinking problem in an elderly patient, and presents a treatment typology developed by the Levindale Geriatric Research Center for use in planning comprehensive treatment.
Alcoholism and other types of alcohol abuse constitute a major health and social problem for the elderly as well as for other segments of the population. Although the dimensions of this problem are just beginning to receive systematic attention and definition (1-;3), the need for effective treatment is immediate. The treatment of problem drinking in elderly patients is complicated by the sometimes overwhelming variety of physical, mental and social disturbances that go with the process of aging. Many elderly alcohol abusers are not receiving treatment for either their drinking or their other problems. These patients need a careful diagnostic work-up and a range of treatment resources. If they are already receiving some type of medical or social service for other disorders, the treatment of an alcohol-related problem must be coordinated with these other services. Otherwise, various agencies may duplicate treatment efforts or interfere with a satisfactory placement or other treatment plan. This paper concerns some of the factors which must be considered in diagnosing a
RECOGNIZING THE PROBLEM At present serious inadequacies exist, both in our system of identifying problem drinking among the elderly and in treating it. As the field of alcoholism research has matured, greater attention has been given to the relationship between age and alcoholism. Until quite recently, however, most studies focused on the youthful or middleaged drinker. Older subjects, if included at all, were likely to be lumped together in a "60 and over" category. The available data tend to support the general conception that there is a decreasing amount of drinking with advancing age. This does not, however, seem to be a linear relationship. The 1965 household survey of the Washington Heights section of Manhattan, for instance, showed a decrease in the prevalence of alchoholism in the age cohort 55 to 64 (17 per 1000) but an increase again in the cohort 65 to 74 (to 22 per 1000) (4). More recently, Johnson and Goodrich (3) found that 24 percent of their sample of 166 men and women aged 65 or over drank daily, and another 25 percent drank occasionally. The Rutgers Center of Alcohol Studies has estimated that alcohol
• Modified version of a paper presented at the 27th Annual Meeting of the Gerontological Society, Portland. Oregon, October 28-November I, 1974. •• Director, Levindale Geriatric Research Center. Belvedere and Greenspring Avenues. Baltimore MD 21215. t Chief of Alcoholism Programs. Division of Alcoholism Control, Maryland Department of Health and Mental Hygiene.
553
RATHBONE-MCCUAN AND BLAND
abuse affects 7.5 percent of the rural, suburban, and urban population aged 55 or older (5). Although the foregoing statistics confirm the existence of an alcohol problem among the aged they do not give a clear picture of which elderly persons are affected and how they are affected. The influence of alcohol abuse on the elderly patient's level of functioning and the bearing this has on the complexities of care have not been explored. In a paper presented at the Second Annual Alcoholism Conference, Pattison (6) pointed out that the first step in improving the alcoholism service network requires clear definition of the different subpopulations of alcoholics and a determination of the role that alcohol plays in the life of those populations. Determining the role of alcohol in the life of an older person requires studying the interaction of the drinking with other likely physical, emotional or social problems as well as studying the duration, type and severity of the excessive drinking. GAPS IN THE TREATMENT SYSTEM Once identified, the aged alcoholic or problem drinker encounters serious gaps and inadequacies in the various service systems available. Alcoholism services are not geared to aged alcoholics, and geriatric services usually have not faced up to the severity and prevalence of alcohol-related problems among their clientele. The geriatric alcoholic or problem drinker is often known to many different components of the community system for delivery of health and social services, receiving multiple but fragmented and often ineffectual interventions. The following is an example: Patient A, a white 65-year-old male, is known to a variety of Baltimore agencies. Through the alcoholism services he has been placed in several shelter facilities; thus he has been labeled an "alcoholic." At the Department of Social Services where he is a recipient of SSI, he has been labeled a "welfare client." He has been admitted to 3 of the 4 State mental hospitals, where he has been labeled a "mental patient." He has used a variety of health care facilities, including clinics and emergency rooms, becoming in the process a "chronic medical patient." The judicial and law enforcement agencies know him because he has undergone multiple dispositions in a period of a few months; here he is labeled an "offender." Because he has been a recipient of nutritional services through Meals-On- Wheels he has also been labeled an "isolated old man." The foregoing history is typical for the aged
554
Vol.XXlll
alcoholic who has become known to all aspects of the community service system, where he has probably been more effective at collecting labels than at securing treatment. Nowhere has he received the benefits of coordinated or preplanned services. In most such cases, the lack of integrated and coordinated services automatically produces ineffective and inefficient attempts at treatment. The public mental health system provides a good example of service fragmentation within a single system. State mental hospitals admit a disproportionate number of aged patients, many of whom are "repeaters" and many of whom carry a primary or secondary diagnosis of alcoholism. Aged alcoholics who are admitted to geriatric units have little chance of receiving treatment for alcoholism; those admitted to an alcoholism unit are not likely to receive treatment for the problems associated with old age. Once admitted, they may be victims of a "revolving door" policy or they may remain on the wards for an indefinite period. Despite increasingly well-organized efforts to keep the aged from improper placements in these institutions, the aged alcoholic often by-passes the geriatric screening process because of his involvement with the police and possibly the court system. Despite the problems noted in the State psychiatric hospitals, the nationwide trends to "deinstitutionalize" aged and long-term patients has had unintended adverse effects on many aged alcoholics. If the hospitals are ill-equipped to treat these patients, the providers of community care are even less well equipped. Once the alcoholic dries out, he or she is frequently discharged to a personal care setting, a domiciliary, or other "protective" milieu in the community. However, once the person loses the label of "patient," so few professional resources are available, and those that are available are so poorly coordinated, that community maintenance is often impossible. The emphasis of the alcohol abuse services in most States has been on developing services for a younger population of alcoholics. The currently popular residential facilities are geared to homeless males (and a few females) aged 30 to 50, with "shelters" designated specifically for the 3-5 percent classified as "skid row." State psychiatric institutions remain the dominant source of back-up service. For the aged drinker, alcoholism services need to be developed in conjunction with geriatric services so that treatment for the alcohol problem does not require the disruption of a positive residential or community placement.
December 1975
THE ELDERLY ALCOHOL ABUSER
THE GERIATRIC ALCOHOL ABUSERDIAGNOSIS The physician (office, clinic or emergency room) is the professional who most regularly comes in contact with the geriatric alcoholic or problem drinker. Gerontologists estimate that about one-third of the noninstitutional over-65 population visits a physician during a four-week period. This means that in any given month some 6 million people over 65 see a physician, most frequently in his office or at a clinic (7). Physicians, therefore, playa key role in discovering the community's elderly problem drinkers and in making appropriate treatment referrals. This being the case, it is imperative for physicians to familiarize themselves with the various degrees and manifestations of problem drinking in the elderly in order to make a proper match between the patient and the treatment resource. Taking the time and effort to understand fully the interacting physical, mental and social problems of the geriatric drinker and to develop a treatment plan that relates to the whole complex of problems, should in the long run save time and lessen frustration for the physician in addition to providing more satisfactory treatment for the patient. The aged drinker suffers from a double stigma that may interfere with the professional's ability to treat him effectively. The clinician may regard both age and alcoholism as "incurable" and so devote little effort to distinguishing between levels and types of drinking in developing an appropriate treatment plan. The popular stereotype of the homeless "skid row" alcoholic also obscures the issue by diverting attention from the much larger group of problem drinkers who are less dramatically cut off from community ties. Failure to deal adequately with a drinking problem in an elderly patient can also stem from the clinician's natural reluctance to separate the patient from his one remaining source of pleasure. Rosin and Glatt (8) made a useful distinction between "primary" and "reactive" factors in diagnosing the geriatric patient's drinking problem. Primary factors are linked to the individual's personality and to the effects of longstanding heavy drinking; they include dementia, inveterate drinking and personality flaws. Reactive factors are associated with environmental influences and include bereavement, retirement, loneliness, infirmity, and marital stress. In order to determine which factors predominate, the history must include a thorough explora-
tion of the social and emotional as well as physical aspects, and a comparison of the person's past and present drinking habits. The history should provide information about physical symptoms and drinking patterns. This includes a record of the amount and type of beverage, frequency of use, situations in which alcohol is used, attitude toward alcohol, perceptions of drinking behavior, and the effects of alcohol on performance/behavior. It is important to assess the social situation (available family and friends, types of leisure activities, frequency and type of social contacts), the emotional status (presence of dissatisfaction, frustration, loneliness or anxiety, and the sources of these feelings),. and the coping mechanisms whereby the person handles these stresses. The clinician must avoid immediately labeling an older person with a drinking problem as an alcoholic. There is a strong possibility that a crisis situation such as death of spouse or a negative reaction to retirement is associated with the exacerbation of drinking, which can represent a coping response. Treatment should be directed toward helping the aged person work through the feelings of loss. Efforts will be less effective if the focus is solely on the coping behavior (drinking) and not on the source of emotional stress. In other cases, e.g., when the aged person is a long-term alcoholic, the treatment focus would quite properly be on the alcohol-related behavior. A TREATMENT TYPOLOGY The Levindale Geriatric Research Center has designed a simple typology that has potential value for the clinician in diagnosing the overall situation and in choosing the appropriate treatment for the elderly problem drinker (9). The diagnostic plan is based on the presence (p) or absence (a) of three variables: 1) Alcoholism or symptoms of problem drinking . (AI),
2) Health problems, with or without an impaired level of physical functioning (H). 3) Difficulties or inadequacies in the social network (N). A person with none of these problems would be designated Ala Ha SNA; a person with significant difficulties in all areas would be Alp Hp SNp. Most patients, however, are not "pure types" but present various combinations of factors and degrees of severity. These three variables determine the appropriate treatment plan. The presence or absence of
555
RATHBONE-MCCUAN AND BLAND
problems with alcohol, health, and the social network allow the clinician to determine the patient's functional state (independent, marginal, dependent), the environment in which he can be expected to function (community, sheltered, institution), and the appropriate treatment source for the drinking problem. The table shows how this diagnostic/treatment typology worked in 4 cases. Community environments include: 1) settings (home, apartment) which are not structured in any way to accommodate the special needs of the aged, and 2) settings referred to as "senior citizen housing projects." Sheltered environments are specialized and semiprotective; they include supervised boarding homes, domiciliary units and foster homes. Institutions include nursing homes and various types of hospitals (general, convalescent, mental). Alcoholism counselors are usually found either in special alcoholism service programs (city, county or private) or in health services (especially emergency rooms). Other needed services are found in health settings (inpatient, outpatient and emergency hospital services, clinics, private physicians), social agencies (family service agencies, public departments of social service), and to a lesser extent in mental health clinics. The following abstracts describe in more detail the 4 patients represented in schematic form in the Table: Patient 1 (Alp Ha SNa) has a history of alcoholism dating back 30 years. At age 67, he resides in a rooming house where he is in contact with his own neighborhood social network. His drinking pattern includes periodic binges that ultimately require placement in a State institution to "dry out," after which he returns to his regular routine and his small social niche. For this patient the treatment package would be alcoholism services (through the assignment of an alcoholism counselor) and effort directed toward an ideal goal of sobriety or a realistic goal of cutting down on the number of binges.
Vol. XXIII
Patient 2 (Alp Ha SNp), aged 76, is widowed. He sold his business several years ago. His adult children are no longer in the city and his friends have all died. In recent years he began to drink and to seek companionship among others who drink. This man needs both treatment for his alcoholism and a change in social milieu. Treatment would consist of an alcoholism counselor and help with effecting needed changes in the living situation. Patient 3 (Alp Hp SNa), aged 74, has a history of chronic drinking. General physiologic deterioration had set in and during a binge she fell and broke her hip, resulting in impaired mobility. Her condition requires direct general health care and physical rehabilitation in addition to treatment for alcholism. She would receive alcoholism counseling either from the same health care facility in which she received primary and rehabilitative care or from another alcoholism service. Patient 4 (AlP Hp SNp), a 66-year-old woman, has been forced to retire. The loss of income, the involuntary change of lifestyle and the lowered social status has created serious depression. As a response to the multiple stresses of the retirement process, she withdrew from her social network, took to drinking, and suffered serious malnutrition and related medical consequences. Her alcoholism treatment would consist of placement in a long-term care setting. After an alcohol withdrawal period and regulation of diet, an alcoholism counselor would become involved. After restoration of health, she would be returned to the community where she would be linked to a mental health or family agency. The treatment typology developed at Levindale can be put to immediate use by the physician or other professional who is faced. with making or coordinating a treatment plan for an elderly alcoholic or problem drinker. However, since treatment resources at present are either nonexistent or scattered through a number of different service systems, the diagnosing clinician may have to use considerable ingenuity in ferreting out
Levindale Treatment Typology (Four examples) Variables Patient
Al
H
SN
Functional State
Environment
Treatment Source
1
Alp Alp Alp Alp
Ha Ha Hp Hp
SNa SNp SNa SNp
Independent Marginal Dependent Dependent
Community Community Sheltered Institution
Alcoholism counselor Ale. counselor and others Ale. counselor and others Ale. counselor and others
2 3 4
556
December 1975
THE ELDERLY ALCOHOL ABUSER
the appropriate resources. Ideally, one service system or agency would be designated responsible for coordinating the various services that are required. The coordinating agency could be an alcoholism service or geriatric service; it also could come from one of the other involved systems such as a family service agency, a community mental health center, a medical clinic, or a residential facility. What is critically important is that someone take responsibility so that the patient does not "fall between the cracks" of the various services. Regardless of the type of' agency that takes primary responsibility for coordinating services, the physician will continue to playa key role. The enormous task of identifying and treating the elderly alcoholic and problem drinker begins with the recognition that the problem exists. For too long the specialized needs of this group of alcohol abusers have been ignored by all levels of the service network ranging from high-level planning bodies and state agencies right down to the individual practitioner. However, ignoring the problem has not made it go away. Indeed, as the elderly population increases, the number of elderly alcohol abusers also increases. Professional recognition of the special problems presented by this group should lead to the development of more appropriate and more adequate treatment approaches and resources. have presented some of the factors which must be considered in understanding the elderly alcohol abuser's drinking in the context of his total life situation. The Levindale treatment typology shows how this understanding can be used to link the patient with 'appropriate treatment resource(s).
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All the understanding in the world, however, cannot make up for the absence of these resources. The effectiveness of traditional alcoholism/ aging services in treating these patients is drastically reduced by the lack of formal linkages between the two systems. A treatment typology which can be understood readily and applied by a wide range of service-givers can serve as the framework in which alcoholism and aging services, along with health, mental health and social services, and law enforcement, can develop a coordinated and comprehensive treatment system for this special subgroup of problem drinkers. REFERENCES 1. Baker F. Mishara BL, Kastenbaum R et al: A study of
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alcohol effects in old age: phase II. Final report to National Institute on Alcohol Abuse and Alcoholism (NIAAA) under contract # NOI-AA-3-0I03, February 1974. Cahalan D and Room R: Problem drinking among American men. Monograph No.7, Rutgers Center of Alcohol Studies, New Brunswick, NJ, 1974. Johnson LA and Goodrich CH: Use of alcohol by persons 65 years and older, upper east side Manhattan. Report to National Institute on Alcohol Abuse and Alcoholism. January 1974. (HSM-43-73-38 NIA.) Bailey MB, Haberman PW and Alksne H: The epidemiology of alcoholism in an urban residential area. Quart Stud Alcohol 26: 19, 1965. Carruth B, Williams EP, Mypak P et al: Community care providers and the older problem drinker. Paper presented at the 24th Annual Meeting of Alcohol and Drug Problems Assoc. of North America, Minneapolis, Minnesota, September 1973. Pattison EM: Criteria in treatment evaluation. Proceedings of the Second Annual Alcoholism Conference, NIAAA, Washington, DC, June 1-2, 1972. Shanas E: Sociological factors of aging significant to the clinician, (in Seminar), J Am Geriatrics Soc 17:284, 1969. Rosin AJ and Glatt MM: Alcohol excess in the elderly, Quart Stud Alcohol 32: 53, 1971. McCuan ER: Working model for proposed intervention. Baltimore, Maryland, Levindale Geriatric Research Center, 1974.
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