Alcohol Abuse in Elderly Emergency Department Patients Wendy L. Adarns, MD, MPU,* Kath y n Magruder-Habib, PhD,t Sally Trued, MD, MPU,$ and Harry L. Broome, SS§ ______~
______
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Objectives: To determine the prevalence of alcohol abuse in elderly emergency department (ED) patients; to determine the prevalence of alcohol abuse for various categories of illness and injury among these patients; and to determine the frequency of detection of elderly alcohol abusers by ED physicians, Design: Cross-sectional prevalence study. Setting: The emergency department of a 625-bed university hospital that serves a mixed urban and rural population. Patients: 205 patients aged 65 and over who came to the ED during an 8-week period. Measures: A structured interview, which included the CAGE questionnaire and other questions regarding alcohol use, was administered. Emergency department records and past medical records were reviewed.
Results: The prevalence of lifetime alcohol abuse (CAGE positive or self-reported drinking problem) was 24%. The prevalence of current alcohol abuse (CAGE positive or selfreported drinking problem and alcohol use within the last year) was 14%. There was a particularly high prevalence (22%)among those presenting with gastrointestinal problems and a surprisingly low prevalence (7%) among those who presented with falls or other trauma. Physicians detected only 21% of the current alcohol abusers. Conclusions: Alcohol abuse is a prevalent and important problem among elderly ED patients. It is not well detected by physicians in this setting. Alcohol abuse appears to be less common among elderly trauma patients than their younger counterparts, but is very common among patients with gastrointestinal problems. ] Am Geriatr Soc 401236-1240,1992
lcohol abuse affects between 9% and 39% of emergency department (ED) patients and has an important impact on the medical care these people require.’-8 Most studies of the role of alcohol in emergency medical care, however, have included very few elderly patients4-*or have not reported the ages of their subjects.’-3 In a 1969 study of alcohol breath tests in ED patients, Wechsler et a19 found that positive alcohol breath tests were common in elderly trauma patients, especially home accident victims, as well as in their younger counterparts. More recently, 14% of elderly emergency department patients in Winnipeg screened positive for alcoholism.1° The prevalence and significance of alcohol problems among elderly patients in emergency departments have not, however, been studied otherwise. As the elderly population expands, the importance of understanding the emergency medical care needs of older adults will increase. Alcohol problems do play an important role in the emergency medical care of younger people, and so their prevalence and importance in elderly ED patients should be clarified. We studied the prevalence, illness categories, and physicians’ detection of alcohol abusers among elderly ED patients. Although there appears to be a decline in alcohol use and abuse with advanced age in the general pop-
ulation,”-’’ the consequences of heavy drinking remain important among hospitalized elderly people. The National Hospital Discharge Survey reports slightly higher rates of alcohol-related medical problems in elderly patients than in those 25-44 years old.’6 Interview studies of elderly inpatients show the prevalence of alcohol abuse between 15% and 50%.”-19 Since many elderly patients are admitted to the hospital through emergency departments, the high prevalence of alcohol abuse among elderly inpatients suggests that alcohol abuse may also be quite common in elderly ED patients. Elderly people in the ED have a different spectrum of clinical problems than their y o u n g . counterparts. They more commonly present with medical illness and less commonly with injurie~.’~-’~ Accidental falls, however, are also common precipitants of ED visits among elderly people.” Elderly ED patients have higher rates of urgent and “emergent” problemsz0, and are more likely to be admitted to the h~spital.’~-’~ Elderly alcohol abusers may also have a clinical profile quite different from that which we have learned to expect from studies of younger alcohol abusers. The clinical problems of elderly alcohol abusers in emergency departments have not yet been described. If alcohol abuse is to be addressed effectively, it must first be recognized. Physicians are well known for negative attitudes toward alcoholics and poor recognition of alcohol abuse.24 In one previous ED study, physicians recorded alcohol abuse in only 12% of those identified by study interviewers as alcoholic.’ Physician recognition of alcohol abuse in elderly ED patients has not been studied. We had the following objectives for this study: (1) To determine the prevalence of alcohol abuse in elderly emergency department patients. (2) To determine the prevalence of alcohol abuse for
A
~
~~
* Assistant Professor of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; t Assistant Chief, Services Research Branch, National Institute of Mental Health, Adjunct Assistant Professor of Epidemiology, University of North Carolina; $Assistant Professor of Medicine, University of North Carolina; 5 Medical Student, University of North Carolina, Chapel Hill, North Carolina. This work was done at the University of North Carolina, Chapel Hill, North Carolina, while Dr. Adams was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. This work was supported by The Robert Wood Johnson Foundation, The Pew Charitable Tmst/Rockefeller Foundation ”Healthof the Public”Grant, and the Department of Medicine, The University of North Carolina. Presented at the National Meeting of The Robert Wood Johnson Foundation Clinical Scholars Program, Fort Lauderdale, Florida, October 1991. ~
’*
~
1AGS 40:1236-1240, 1992 0 1992 by the American Geriutrics Society
0002-8614/92/$3.50
IAGS-DECEMBER 1992-VOL. 40, NO. 12
various categories of illness and injury among elderly ED patients. (3) To determine the frequency with which physicians in the ED detect alcohol abuse in elderly patients.
METHODS Subjects All persons age 65 and over who came to the University of North Carolina Hospital ED for care from June 11, 1990 to August 5, 1990 between the hours of 12 noon and 11 pm were eligible to participate if they were not living in an institution (eg, nursing home or psychiatric hospital), were able to speak English, and were able to give consent. Patients who were transferred from another hospital were excluded. A research assistant approached each patient, explained the study, and obtained informed consent. An interview was conducted in the ED as often as possible. For the few patients who were willing to participate but who could not complete interviews in the emergency department because of time constraints, interviews were completed by telephone for those discharged to their homes and in person for those admitted to the hospital. Measurements The interview was designed to measure quantity, frequency, and patterns of alcohol use, as well as medical history and functional status. The following information was collected: (1) Quantity of alcohol consumed within 24 hours of the visit to the ED. (2) Usual drinking practices, including quantity, frequency, and setting. (3) The CAGE Questionnaire to screen for alcohol abuse or dependence. A positive CAGE score was defined as two or more positive responses. (4) Self-report of a past or current "drinking problem." (5) Current medications. (6) Current medical illnesses. (7) The physical function scale from the Beth Israel/ UCLA Functional Status Q ~ e s t i o n n a i r e . ~ ~ (8) The Short Portable Mental Status Questionnaire from the Older Americans Research and Service Center Instrument.26 Emergency department records of all eligible patients, whether interviewed or not, were reviewed to extract data on blood alcohol levels, physician's recording of alcohol problems, medical conditions, disposition, demographics, and socioeconomic status. Medical conditions were coded by a physician using ICD-9 codes. All medical conditions addressed during the ED visit were recorded. For those patients who had received previous care at The University of North Carolina Hospitals or Clinics, past medical records were reviewed to determine if a history of alcohol-related problems had been recorded. Analysis We used four interview criteria to identify definite alcohol abusers and definite non-abusers: CAGE score, self-report of past or current "drinking problem," frequency of drinking in the last 6 months, and time since the last drink.
ALCOHOL ABUSE IN ELDERLY ED PATIENTS
1237
Those who were CAGE positive or reported a past or current "drinking problem" were categorized as "current alcohol abusers" if they acknowledged using alcohol within the last year. Those who were CAGE-negative or reported never having tasted alcohol were categorized as "definite non-abusers" if they did not report a current drinking problem and reported consuming one drink per day or less. People were excluded from the category of definite non-abusers if the medical record mentioned a drinking problem.
RESULTS Four hundred sixty-one people who met eligibility criteria registered for care in the emergency department during our study period. Two hundred five (45%)were interviewed. The most common reason for not participating in interviews was the ED visit occurring during hours not covered by the interviewers. Some patients were deemed too ill to participate; 20 refused. Emergency Department records were available and reviewed for 96% of the sample and past medical records for 72%. One hundred forty-six of the 205 patients interviewed could be classified as either current alcohol abusers or non-abusers using the above criteria. Twenty patients could not be classified because of missing data. The remainder had some features suggestive of alcohol abuse but could not definitely be classified as alcohol abusers by our criteria. Sample Characteristics Table 1 shows selected characteristics of the entire sample. Sixty-two percent of patients were white, and 47% were male. The mean age was 74 years (range 65-99). Forty-seven percent were admitted to the hospital. Sixty-one percent came to the ED during the hours covered by interviewers. The most common presenting medical problems were abdominal problems (24%), CNS problems (16%), trauma (14%), chest pain (13%), and dyspnea (11%).
TABLE 1. CHARACTERISTICSOF THE STUDY SAMPLE (n = 461*) 74 & 7 Age (Mean yrs & SD) To
Sex (% Male) Race (% White) Admitted to hospital History of alcohol problem in medical record** Presenting medical problems Abdominal problems CNS problems Trauma Chest pain Dvspnea
47 62 47 22 24 16 14 13 11
* n varies slightly for different variables, but not by more than 10% for any variable with the exception of availability of medical record for review (see below). ** 331 of the 461 patients had records available for review.
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ADAMS ET AL
IAGS-DECEMBER 7992-VOL. 40, NO. 12
TABLE 2. CHARACTERISTICS OF PARTICIPANTSVS NON-PARTICIPANTS Participant Non-participant ( n = 205*) ( n = 256*) Age (mean yrs. f SD)
Race (% White) Sex (96 Male) Admitted to hospital History of alcohol problem in medical record** Alcohol problem recorded by ED phy-
74
2
7
74 k 7
76
76
p***
58 52 48 25
66 44
47 20
,078 ,119 ,907 .275
4
3
,879
sician
Prevalence of Alcohol Abuse Forty-nine people (24% of those interviewed) screened positive for alcohol abuse on the CAGE questionnaire and/or reported problem drinking on the interview. Thus the prevalence of lifetime alcohol problems was 24%. However, 20 of those who screened positive reported no alcohol use in the past year. Only 29 people, therefore, 14% of all interviewed, met the criteria described above for ”current alcohol abuser.” One hundred seventeen (57%) were classified as definitely not alcohol abusers. By interview criteria alone, 126 people would have been classified as definite non-abusers. However, nine of these had alcohol abuse mentioned in their medical records and were therefore excluded from that category. If these patients are added to the group of problem drinkers, the prevalence of lifetime alcohol problems increases to 26%. Table 3 shows a comparison of the characteristics of current alcohol abusers with those of non-abusers. Alcohol abusers were slightly younger (71 vs 74 years, P = 0.022) and were more likely to be male (86% vs 37%, P < 0.001). There were no significant differences in race, income, education, or mental status score. In the bivariate analysis, alcohol abusers in our study
Table 2 shows selected characteristics of participants vs non-participants. Participants were somewhat more likely to be black (42% vs 34%) and male (52% vs 44%), but these differences did not reach statistical significance. Participants were not significantly different from non-participants in age, likelihood of admission to the hospital, past history of problem drinking recorded in the medical record, or presenting medical problems. To determine whether bias was introduced by interviewing patients during restricted hours, we did 58 sample interviews during night and early morning hours. Those interviewed during the hours not usually covered were not significantly more or less likely to be CAGE-positive or to be classified as current alcohol abusers than those who came to the ED during the regularly covered hours. By medical record review, patients who came to the ED during the hours not usually covered by interviewers did not differ significantly from those who came during the hours usually covered with respect to age, race, sex, history of alcohol abuse in the medical record, or presenting medical problem. They were, however, more likely to be admitted to the hospital (51% vs 41%, P < 0.05).
TABLE 3. CHARACTERISTICS OF CURRENT ALCOHOL ABUSERS VS NON-ABUSERS Current Alcohol Definite Non-abuser Abuser (n = 29) ( n = 117) P* Race (%White) Sex (% Male) Admitted to hospital Income
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Objectives: To determine the prevalence of alcohol abuse in elderly emergency department (ED) patients; to determine the prevalence of alcohol abuse for various categories of illness and injury among these patients; and to determine the frequency of detection of elderly alcohol abusers by ED physicians, Design: Cross-sectional prevalence study. Setting: The emergency department of a 625-bed university hospital that serves a mixed urban and rural population. Patients: 205 patients aged 65 and over who came to the ED during an 8-week period. Measures: A structured interview, which included the CAGE questionnaire and other questions regarding alcohol use, was administered. Emergency department records and past medical records were reviewed.
Results: The prevalence of lifetime alcohol abuse (CAGE positive or self-reported drinking problem) was 24%. The prevalence of current alcohol abuse (CAGE positive or selfreported drinking problem and alcohol use within the last year) was 14%. There was a particularly high prevalence (22%)among those presenting with gastrointestinal problems and a surprisingly low prevalence (7%) among those who presented with falls or other trauma. Physicians detected only 21% of the current alcohol abusers. Conclusions: Alcohol abuse is a prevalent and important problem among elderly ED patients. It is not well detected by physicians in this setting. Alcohol abuse appears to be less common among elderly trauma patients than their younger counterparts, but is very common among patients with gastrointestinal problems. ] Am Geriatr Soc 401236-1240,1992
lcohol abuse affects between 9% and 39% of emergency department (ED) patients and has an important impact on the medical care these people require.’-8 Most studies of the role of alcohol in emergency medical care, however, have included very few elderly patients4-*or have not reported the ages of their subjects.’-3 In a 1969 study of alcohol breath tests in ED patients, Wechsler et a19 found that positive alcohol breath tests were common in elderly trauma patients, especially home accident victims, as well as in their younger counterparts. More recently, 14% of elderly emergency department patients in Winnipeg screened positive for alcoholism.1° The prevalence and significance of alcohol problems among elderly patients in emergency departments have not, however, been studied otherwise. As the elderly population expands, the importance of understanding the emergency medical care needs of older adults will increase. Alcohol problems do play an important role in the emergency medical care of younger people, and so their prevalence and importance in elderly ED patients should be clarified. We studied the prevalence, illness categories, and physicians’ detection of alcohol abusers among elderly ED patients. Although there appears to be a decline in alcohol use and abuse with advanced age in the general pop-
ulation,”-’’ the consequences of heavy drinking remain important among hospitalized elderly people. The National Hospital Discharge Survey reports slightly higher rates of alcohol-related medical problems in elderly patients than in those 25-44 years old.’6 Interview studies of elderly inpatients show the prevalence of alcohol abuse between 15% and 50%.”-19 Since many elderly patients are admitted to the hospital through emergency departments, the high prevalence of alcohol abuse among elderly inpatients suggests that alcohol abuse may also be quite common in elderly ED patients. Elderly people in the ED have a different spectrum of clinical problems than their y o u n g . counterparts. They more commonly present with medical illness and less commonly with injurie~.’~-’~ Accidental falls, however, are also common precipitants of ED visits among elderly people.” Elderly ED patients have higher rates of urgent and “emergent” problemsz0, and are more likely to be admitted to the h~spital.’~-’~ Elderly alcohol abusers may also have a clinical profile quite different from that which we have learned to expect from studies of younger alcohol abusers. The clinical problems of elderly alcohol abusers in emergency departments have not yet been described. If alcohol abuse is to be addressed effectively, it must first be recognized. Physicians are well known for negative attitudes toward alcoholics and poor recognition of alcohol abuse.24 In one previous ED study, physicians recorded alcohol abuse in only 12% of those identified by study interviewers as alcoholic.’ Physician recognition of alcohol abuse in elderly ED patients has not been studied. We had the following objectives for this study: (1) To determine the prevalence of alcohol abuse in elderly emergency department patients. (2) To determine the prevalence of alcohol abuse for
A
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* Assistant Professor of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; t Assistant Chief, Services Research Branch, National Institute of Mental Health, Adjunct Assistant Professor of Epidemiology, University of North Carolina; $Assistant Professor of Medicine, University of North Carolina; 5 Medical Student, University of North Carolina, Chapel Hill, North Carolina. This work was done at the University of North Carolina, Chapel Hill, North Carolina, while Dr. Adams was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. This work was supported by The Robert Wood Johnson Foundation, The Pew Charitable Tmst/Rockefeller Foundation ”Healthof the Public”Grant, and the Department of Medicine, The University of North Carolina. Presented at the National Meeting of The Robert Wood Johnson Foundation Clinical Scholars Program, Fort Lauderdale, Florida, October 1991. ~
’*
~
1AGS 40:1236-1240, 1992 0 1992 by the American Geriutrics Society
0002-8614/92/$3.50
IAGS-DECEMBER 1992-VOL. 40, NO. 12
various categories of illness and injury among elderly ED patients. (3) To determine the frequency with which physicians in the ED detect alcohol abuse in elderly patients.
METHODS Subjects All persons age 65 and over who came to the University of North Carolina Hospital ED for care from June 11, 1990 to August 5, 1990 between the hours of 12 noon and 11 pm were eligible to participate if they were not living in an institution (eg, nursing home or psychiatric hospital), were able to speak English, and were able to give consent. Patients who were transferred from another hospital were excluded. A research assistant approached each patient, explained the study, and obtained informed consent. An interview was conducted in the ED as often as possible. For the few patients who were willing to participate but who could not complete interviews in the emergency department because of time constraints, interviews were completed by telephone for those discharged to their homes and in person for those admitted to the hospital. Measurements The interview was designed to measure quantity, frequency, and patterns of alcohol use, as well as medical history and functional status. The following information was collected: (1) Quantity of alcohol consumed within 24 hours of the visit to the ED. (2) Usual drinking practices, including quantity, frequency, and setting. (3) The CAGE Questionnaire to screen for alcohol abuse or dependence. A positive CAGE score was defined as two or more positive responses. (4) Self-report of a past or current "drinking problem." (5) Current medications. (6) Current medical illnesses. (7) The physical function scale from the Beth Israel/ UCLA Functional Status Q ~ e s t i o n n a i r e . ~ ~ (8) The Short Portable Mental Status Questionnaire from the Older Americans Research and Service Center Instrument.26 Emergency department records of all eligible patients, whether interviewed or not, were reviewed to extract data on blood alcohol levels, physician's recording of alcohol problems, medical conditions, disposition, demographics, and socioeconomic status. Medical conditions were coded by a physician using ICD-9 codes. All medical conditions addressed during the ED visit were recorded. For those patients who had received previous care at The University of North Carolina Hospitals or Clinics, past medical records were reviewed to determine if a history of alcohol-related problems had been recorded. Analysis We used four interview criteria to identify definite alcohol abusers and definite non-abusers: CAGE score, self-report of past or current "drinking problem," frequency of drinking in the last 6 months, and time since the last drink.
ALCOHOL ABUSE IN ELDERLY ED PATIENTS
1237
Those who were CAGE positive or reported a past or current "drinking problem" were categorized as "current alcohol abusers" if they acknowledged using alcohol within the last year. Those who were CAGE-negative or reported never having tasted alcohol were categorized as "definite non-abusers" if they did not report a current drinking problem and reported consuming one drink per day or less. People were excluded from the category of definite non-abusers if the medical record mentioned a drinking problem.
RESULTS Four hundred sixty-one people who met eligibility criteria registered for care in the emergency department during our study period. Two hundred five (45%)were interviewed. The most common reason for not participating in interviews was the ED visit occurring during hours not covered by the interviewers. Some patients were deemed too ill to participate; 20 refused. Emergency Department records were available and reviewed for 96% of the sample and past medical records for 72%. One hundred forty-six of the 205 patients interviewed could be classified as either current alcohol abusers or non-abusers using the above criteria. Twenty patients could not be classified because of missing data. The remainder had some features suggestive of alcohol abuse but could not definitely be classified as alcohol abusers by our criteria. Sample Characteristics Table 1 shows selected characteristics of the entire sample. Sixty-two percent of patients were white, and 47% were male. The mean age was 74 years (range 65-99). Forty-seven percent were admitted to the hospital. Sixty-one percent came to the ED during the hours covered by interviewers. The most common presenting medical problems were abdominal problems (24%), CNS problems (16%), trauma (14%), chest pain (13%), and dyspnea (11%).
TABLE 1. CHARACTERISTICSOF THE STUDY SAMPLE (n = 461*) 74 & 7 Age (Mean yrs & SD) To
Sex (% Male) Race (% White) Admitted to hospital History of alcohol problem in medical record** Presenting medical problems Abdominal problems CNS problems Trauma Chest pain Dvspnea
47 62 47 22 24 16 14 13 11
* n varies slightly for different variables, but not by more than 10% for any variable with the exception of availability of medical record for review (see below). ** 331 of the 461 patients had records available for review.
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ADAMS ET AL
IAGS-DECEMBER 7992-VOL. 40, NO. 12
TABLE 2. CHARACTERISTICS OF PARTICIPANTSVS NON-PARTICIPANTS Participant Non-participant ( n = 205*) ( n = 256*) Age (mean yrs. f SD)
Race (% White) Sex (96 Male) Admitted to hospital History of alcohol problem in medical record** Alcohol problem recorded by ED phy-
74
2
7
74 k 7
76
76
p***
58 52 48 25
66 44
47 20
,078 ,119 ,907 .275
4
3
,879
sician
Prevalence of Alcohol Abuse Forty-nine people (24% of those interviewed) screened positive for alcohol abuse on the CAGE questionnaire and/or reported problem drinking on the interview. Thus the prevalence of lifetime alcohol problems was 24%. However, 20 of those who screened positive reported no alcohol use in the past year. Only 29 people, therefore, 14% of all interviewed, met the criteria described above for ”current alcohol abuser.” One hundred seventeen (57%) were classified as definitely not alcohol abusers. By interview criteria alone, 126 people would have been classified as definite non-abusers. However, nine of these had alcohol abuse mentioned in their medical records and were therefore excluded from that category. If these patients are added to the group of problem drinkers, the prevalence of lifetime alcohol problems increases to 26%. Table 3 shows a comparison of the characteristics of current alcohol abusers with those of non-abusers. Alcohol abusers were slightly younger (71 vs 74 years, P = 0.022) and were more likely to be male (86% vs 37%, P < 0.001). There were no significant differences in race, income, education, or mental status score. In the bivariate analysis, alcohol abusers in our study
Table 2 shows selected characteristics of participants vs non-participants. Participants were somewhat more likely to be black (42% vs 34%) and male (52% vs 44%), but these differences did not reach statistical significance. Participants were not significantly different from non-participants in age, likelihood of admission to the hospital, past history of problem drinking recorded in the medical record, or presenting medical problems. To determine whether bias was introduced by interviewing patients during restricted hours, we did 58 sample interviews during night and early morning hours. Those interviewed during the hours not usually covered were not significantly more or less likely to be CAGE-positive or to be classified as current alcohol abusers than those who came to the ED during the regularly covered hours. By medical record review, patients who came to the ED during the hours not usually covered by interviewers did not differ significantly from those who came during the hours usually covered with respect to age, race, sex, history of alcohol abuse in the medical record, or presenting medical problem. They were, however, more likely to be admitted to the hospital (51% vs 41%, P < 0.05).
TABLE 3. CHARACTERISTICS OF CURRENT ALCOHOL ABUSERS VS NON-ABUSERS Current Alcohol Definite Non-abuser Abuser (n = 29) ( n = 117) P* Race (%White) Sex (% Male) Admitted to hospital Income
