CARE OF THE OLDER PERSON

Older people and alcohol use Savita Bakhshi, Alison E. While

Savita Bakhshi, Research Associate, Alison E. While, Emeritus Professor, Florence Nightingale School of Nursing and Midwifery, King’s College London

Introduction The latest Chief Medical Officer’s annual report (Davies, 2014) identified excessive alcohol consumption, together with rising obesity levels, as contributing to increased cancer risk, liver disease and premature deaths from these causes. The report also noted how some undesirable health behaviours are becoming normalised, so that drinking excessive amounts of alcohol and being overweight are no longer considered as unusual. That said, alcohol consumption has generally been lower in older people compared with younger age groups, making the former less of a public health priority over time. However, recent data indicate that the proportion of older people drinking alcohol above the recommended levels has been increasing in the UK (Office for National Statistics, 2013).

Effects of alcohol misuse in older people Alcohol dependency and misuse in older people is associated with serious health, social and economic costs for individuals and societies. Tolerance to alcohol is also lower in older people compared with younger age groups, leading to a detrimental effect on an individual’s physical and psychological health (Hajat et al, 2004). For example, Alcohol Concern (2002) has highlighted how alcohol dependency and misuse can lead to various physical health problems for older people, such as increased risk of coronary heart disease,

Abstract

The proportion of older people drinking alcohol above the recommended levels has been increasing in the UK. Alcohol dependency and misuse can lead to various physical and psychological problems for older people. A range of factors can influence alcohol dependency and misuse among older adults, which need careful consideration when interventions are being developed to reduce consumption. Interventions to reduce alcohol consumption among older people can include: home visits, telephone support, mentoring, one-toone and group programmes, family and community engagement programmes, outreach programmes, and targeted support groups focused on education and social activities. There is a need for the training of community nurses focused on improving the detection (screening and assessment), treatment and service provision for older people.

Key Words

w Alcohol w Misuse w Dependency w Older people w Health behaviour

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hypertension, stroke, and increased risk of falls and accidents. Psychological conditions such as insomnia, memory loss, depression and dementia have also been seen in older people with high levels of alcohol dependency and misuse. High levels of alcohol consumption have also been noted among a significant proportion of health professionals, including nurses (Bakhshi and While, 2014), with some suggesting that alcohol consumption and the use of other substances arise due to unhealthy coping strategies in response to workload stress. These personal health behaviours and beliefs may impact upon the clinical practices of community nurses, especially if practitioners have limited training and confidence in their abilities to support those with an alcohol dependency or misuse. The aim of this article is to review the approaches to reducing alcohol dependency and misuse in older people, and the implications for clinical practice and research.

Defining alcohol dependency and misuse in older people The World Health Organization (2014: para 1) provides the following definition of harmful alcohol and other substance use: ‘A pattern of psychoactive substance

use that is causing damage to health. The damage may be physical (e.g. hepatitis following injection of drugs) or mental (e.g.  depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of harmful use’. Three types of older drinkers have been identified by the Institute of Alcohol Studies (2013): w Early-onset drinkers (‘survivors’) are those who have developed an alcohol problem early in life w Late-onset drinkers (‘reactors’) are those who begin drinking heavily later in life, often as a result of traumatic life events, retirement, loneliness and/or pain w Intermittent drinkers (‘binge drinkers’) are those who can drink alcohol occasionally or excessively, causing problems.

Prevalence of alcohol dependency and misuse in older people Alcohol misuse among older adults may go undetected for longer periods of time for various reasons (Hallgren et al,

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TOPIC HEADER CARE OF THE OLDER PERSON

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As older people generally have reduced social contact in comparison with younger age groups, their alcohol consumption may not be as noticeable.

2009). First, it is difficult to estimate the true prevalence of the problem in the UK as different terms are used for alcohol misuse. These include: ‘dependent’, ‘hazardous’, ‘harmful’, ‘alcoholism’, ‘alcohol addiction’, ‘alcohol abuse’ and ‘problem drinking’. Second, as with most self-report measures, older people under-report their drinking habits and/or misunderstand what is meant by a standard unit of alcohol (Merrick et al, 2008). Third, as older people have reduced social contact in comparison with younger age groups, their alcohol consumption may not be as noticeable. Fourth, the stigma associated with alcohol misuse can prevent people from asking for help (Holms and Currid, 2013; Wilson et al, 2013). Finally, alcohol misuse is related to incidents such as accidents, self-neglect, depression and/or confusion, which are also linked with the ageing process. Nevertheless, recent data have shown that 63% of men and 42% of women aged 65 years and over reported drinking at least once in the last week (Office for National Statistics, 2013). Furthermore, around a quarter (24%) of older men and 13% of older women reported drinking on 5 or more days in the last week. Hospital admissions relating to alcohol-related conditions are higher for older people compared with younger age groups, despite lower levels of alcohol consumption. For example, the number of alcohol-related admissions for people aged 65 years and over was 197 729 in 2002, rising to 520 950 in 2010 (Office for National Statistics, 2013). Alcohol-related death rates are also higher among older people compared with younger age groups. In 1991, 528 people aged 75 years and over in the UK died as a result

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of alcohol-related causes. This figure increased by 58% to 834 deaths in 2011 (Office for National Statistics, 2013).

Factors associated with alcohol dependency and misuse in older people The Institute of Alcohol Studies (2013) has suggested that older people living in the UK may be heavier drinkers than previous generations, due to various social, lifestyle and demographic factors such as the affordability, availability and acceptability of alcohol, as well as longer life expectancy (Hallgren et al, 2009). Reports examining the impact of demographic factors on alcohol dependency and misuse have found that older men are more likely to exceed weekly drinking guidelines than women of a similar age group (Hallgren et al, 2009; 2010). Widowed or divorced men are also likely to engage in health-damaging behaviour, such as excessive drinking, compared with married older men (Merrick et al, 2008). A sudden disruption in lifestyle and other changes can also lead to heavy drinking among older people (Hallgren et al, 2010; Royal College of Psychiatrists, 2011). For example, retirement can lead to decreased social activity, which in turn can be a major contributory factor towards alcohol dependency and misuse (Mental Health Foundation, 2006; Hallgren et al, 2009). Emotional and social factors, such as bereavement, loss of occupation, functions, skills, income, friends and social status, family conflict, psychological ill-health, mental stress, reduced self-esteem, loneliness and isolation, can act as triggers for alcohol dependency and misuse (Dar, 2006). Similarly,

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CARE OF THE OLDER PERSON

Approaches to reducing alcohol dependency and misuse in older people The organisation and delivery of public health varies across the UK depending upon the country, with Public Health England being the executive agency responsible for oversight and monitoring in England. The Health and Social Care Act 2012 (UK Government, 2012) transferred some responsibility for health improvement, namely, health promotion to local authorities with misuse treatment and disease screening alongside health protection remaining the responsibility of NHS organisations. Thus, public health initiatives for the prevention of alcohol dependency and misuse, and the reduction of alcohol consumption among older people while clearly needed, now straddle local authorities and NHS provision, and need good partnership-working across both agencies and teams. Indeed, personnel with different skills are essential to meet the needs of older people with alcohol dependency who are likely to have additional health and social needs. The efficacy of individual treatments may be dependent upon the type of drinker. That is, late-onset drinkers appear to be more likely to adhere to treatments compared with early-onset drinkers (McKee, 2000). Interventions to reduce alcohol consumption among older people can include home visits, telephone support, mentoring, one-to-one and group programmes, family and community engagement programmes, outreach programmes and targeted support groups focused on education and social activities. However, existing research investigating the effectiveness of these interventions in older people living in the UK is limited, with the Royal College of Psychiatrists (2011) noting that the majority of current research is focused on white, American men attending veterans’ hospitals, which limits the generalisability of these studies’ findings to other populations.

‘5 As’ framework A number of frameworks have been proposed to guide health professionals in their efforts to help patients address their risk behaviours and to promote healthy behaviours. The ‘5 As’ behavioural counselling framework (Glasgow et al, 2006) is popular and widely used to address a range of risk behaviours including alcohol use, substance use and smoking. The framework recommends that clinical practice should comprise five components: assess, advise, agree, assist and arrange. Thus, if the patient is found to be at risk, then the practitioner should advise them to change their behaviour, assess their interest in changing their behaviour, assist them in their behavioural change efforts and arrange appropriate follow-up (Dosh et al, 2005). The applicability of this framework to

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various disease states is useful, as is its flexibility of use, which enables a responsive approach on a case-by-case basis. However, this flexibility does not always enable the replicability and generalisability of the data collected for research purposes.

Alcohol Use Disorders Identification Test Some prefer to use the 10-item Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al, 1993), which is a screening tool that has been widely used to identify those with at-risk behaviours so that appropriate interventions may be initiated. The first three items (AUDIT-C) are also commonly used to assess whether a patient’s alcohol use suggests hazardous drinking. However, the administration of this tool may lead to response bias due to factors such as a lack of understanding and/or stigma related to heavy consumption. Furthermore, different approaches to assessing alcohol use appear to result in variations in the data collected (Bradley et al, 2011), both reflecting issues related to the person or health professional collecting the data and different screening tools. Older adults with increased-risk (hazardous) drinking may be treated with a brief intervention (a short counselling session) which lasts around 5–10  minutes (Royal College of Psychiatrists, 2011) or up to 30  minutes (National Institute for Health and Care Excellence (NICE), 2014). Brief interventions can involve multicomponent one-to-one or group counselling, motivational interviewing, cognitive behavioural therapy, family therapy and/or self-help groups (Royal College of Psychiatrists, 2011). Topics covered during the sessions may include drinking patterns, advice about reducing consumption, support networks, and any psychological issues that may impact upon the success of the brief intervention (NICE, 2010). If a formal screening tool is not used to understand an older person’s alcohol consumption, asking the older person to maintain a daily drinking diary—in which information such as the number of alcoholic drinks consumed as well as the time and location of drinking should be recorded—may help to identify the extent of alcohol dependency and misuse. The diary may also form the basis for asking the older person to use problem-solving techniques to address their alcohol-related issues, sometimes with the help of their family and friends who may be useful in assisting with behaviour change. It is difficult to conclude which of these approaches should be recommended over others, as each has their own strengths and limitations. The selection of the appropriate approach should be dependent on factors such as the older person’s condition, the aim of the intervention, and situational facilitators and constraints. Reviews of research studies have shown that prevention and educational interventions focused primarily on improving knowledge, awareness and understanding of alcohol-related behaviour and associated potential problems may not necessarily lead to sustained changes in alcohol consumption (Anderson et al, 2009; 2012). Such interventions can, however, help to educate older people

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medical-related factors, such as physical ill-health, insomnia, sensory deficits, reduced mobility and cognitive impairment, can also contribute to heavy consumption of alcohol (Dar, 2006).

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TOPIC HEADER CARE OF THE OLDER PERSON about sensible drinking habits, the prevalence and causes of alcohol dependency and misuse in their age group, alcohol-related harm, preventative actions, and provide a sense of support that help is available should they require it.

Causes of alcohol dependency The causes of alcohol dependency and misuse could also be addressed in order to prevent regular consumption. For example, interventions targeting social isolation and loneliness in older people have been found to be effective (Dickens et al, 2011). It is equally important to design and implement interventions that aim to overcome the barriers associated with failing to ask for assistance with alcohol-related concerns and behaviours. For example, older people with long-term chronic conditions that limit their physical functioning and mobility could be given alcohol dependency and misuse-related assistance as part of their ongoing care package, either in their homes or when they visit the GP surgery or hospital clinics. Additionally, transport issues need to be addressed for vulnerable older people if community engagement and outreach programmes form part of public health initiatives or therapy for those with alcohol dependency. As stigma is associated with alcohol misuse and can prevent people from asking for help, educational material with details about the type of assistance that is available should be made easily accessible (Alcohol Concern, 2002). In some circumstances, home visits by community nurses may be more appropriate in order to maintain privacy. Specialist multi-component treatment interventions tailored to the specific needs of older people should also be made available.

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Implications for clinical practice and research Community nurses are in a good position to help develop and implement alcohol-related initiatives to help reduce the prevalence of alcohol dependency and misuse among older people with whom they have contact. In order for this to happen, community nurses need to understand their own attitudes towards alcohol use together with their clients’ motivations, attitudes and beliefs that impact upon their behaviour (Royal College of Psychiatrists, 2011; Holms and Currid, 2013) and be confident in their skill and knowledge base. This requires relevant training focused on improving the detection of alcohol misuse, including screening and assessment, treatment and service provision for this group (Dar, 2006; Dyson, 2006; Wilson et al, 2013). Professional education should enable community nurses to be able to identify alcohol dependency and misuse that is not part of the ageing process, and whether it is interrelated with personal problems such as social isolation, loneliness, housing, finances and health status. This training could begin within initial professional education and be continued within specialist district nurse education and thereafter as part of continuing professional development (Royal College of Psychiatrists, 2011) so that practitioners are capable of delivering the necessary

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support to enable behaviour change (NICE, 2014) and working in partnership with other alcohol dependency services. Good liaison and referral systems also need to be put into place so that people with alcohol-related concerns are able to obtain help as and when needed. Bakhshi and While’s (2014) systematic review noted that much of the limited published research relating to professionals’ alcohol-related clinical activity has focused upon the first component of the 5 As framework, namely, assessment (with or without the use of a validated assessment tool) to the relative neglect of the other components, which are essential if people are to be enabled to change their alcohol-related behaviour. In the second strand of their review they also noted that two studies reported a positive association between health professionals’ personal alcohol use and their professional alcoholrelated health promotion practices, with another two studies reporting a positive association between health professionals’ personal attitudes towards alcohol and their professional practices. While these few studies cannot yield firm conclusions, Bakhshi and While (2014) have highlighted how health professionals’ personal alcohol use and attitudes may play a role in their professional practices with their clients—as seems to be the case in relation to other health behaviours, such as smoking (Vogt et al, 2005), seasonal influenza vaccination (Zhang et al, 2012) and weight management (Zhu et al, 2013; 2014). This raises a challenge for the community nursing workforce, especially in light of increasing levels of alcohol consumption across the general population (Davies, 2014) and the concomitant likelihood that some community nurses will also have high levels of alcohol consumption. Further research is required on the prevalence, nature and causes of alcohol consumption, dependency and misuse within the older adult population living in the UK so that preventative strategies can be put into place. Studies also need to investigate and develop appropriate assessment tools and outcome measures specific to this group with the aim of improving detection rates at an early stage. It will be beneficial to include older adults from the target population as well as community nurses in the development of such assessment tools and outcome measures, so that the acceptability and feasibility of the instruments can be properly tested. In addition, existing prevention and education interventions need to be strengthened and new programmes developed, tested and implemented while keeping in mind the specific needs of older people (Royal College of Psychiatrists, 2011).

Conclusion High levels of alcohol consumption are an increasing public health problem across all population groups including older people. A range of factors can influence alcohol dependency and misuse among older adults, which need careful consideration when interventions are being developed to reduce consumption in this age group. The existing research also indicates various challenges relating to the definitions and measurement of alcohol dependency

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and misuse among older people, as well as the interpretation and generalisability of the findings across cultures and countries. Community nurses are ideally positioned to support older people to reduce their alcohol consumption, not only by identifying those at risk and delivering interventions, but also by helping them to overcome some, if not all, of the factors that may lead to dependency and misuse (i.e. visits and other inclusion strategies for housebound people to prevent social isolation and loneliness). Additionally, there is a need to educate community nurses to enable them to identify at-risk drinkers, and provide them with the competencies to address alcohol-related issues in older people effectively. Perhaps more challenging is the issue of high levels of alcohol consumption present in some of the health-care workforce, not only as an occupational health issue, but because of its potential association with alcohol-related professional activities.  BJCN The authors declare that there is no conflict of interest. Alcohol Concern (2002) Factsheet: Alcohol Misuse among Older People. http:// tinyurl.com/p6c5fxj (accessed 29 April 2014) Anderson P, Chisholm D, Fuhr DC (2009) Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 373: (9682): 2234–46. doi: 10.1016/S0140-6736(09)60744-3 Anderson P, Scafato E, Galluzzo L; VINTAGE project Working Group (2012) Alcohol and older people from a public health perspective. Ann Ist Super Sanita 48(3): 232–47 Bakhshi S, While A (2014) Health professionals’ alcohol-related professional practices and the relationship between their personal alcohol attitudes and behavior and professional practices: a systematic review. Int J Environ Res Public Health 11(1): 218–48 Bradley KA, Lapham GT, Hawkin EJ et al (2011) Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med 26(3): 299–306. doi: 10.1007/s11606-010-1509-4 Dar K (2006) Alcohol use disorders in elderly people: fact or fiction? Adv Psychiatric Treatment 12: 173–81. doi: 10.1192/apt.12.3.173 Davies SC (2014) Annual Report of the Chief Medical Officer. Surveillance Volume 2012: On the State of the Public’s Health. Department of Health, London.

KEY POINTS

w Alcohol dependency and misuse in older people is associated with serious health, social, economic costs for individuals and societies

w Demographic, emotional, social and medical factors can contribute to high levels of alcohol consumption among older people

w The ‘5 As’ framework (assess, advise, agree, assist and arrange) is a useful guide to practice

w Interventions to reduce alcohol consumption among older people can include: home visits, telephone support, mentoring, one-to-one and group programmes, family and community engagement programmes, outreach programmes, and targeted support groups w Community nurses are in a good position to help develop and implement practices to help reduce the prevalence of alcohol dependency and misuse among older people

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CARE OF THE OLDER PERSON

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Older people and alcohol use.

The proportion of older people drinking alcohol above the recommended levels has been increasing in the UK. Alcohol dependency and misuse can lead to ...
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