Alcohol Misuse In Older Adults

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Alcohol Misuse In Older Adults
Our invisible addicts
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EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED
LEADING RISK FACTORS (2000)
Number of Disability-Adjusted Life Years (000s)
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SENSIBLE LIMITS (HAZARDOUS/HARMFUL)
(Royal Colleges 1995)
gt21 Units per week (men) gt14 per week (women)
1990 2009
of men 65 14 20
of women 65 5 10
(Office of National Statistics)
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ALCOHOL DEPENDENCE SYNDROME
Fewer than 5 of community residents
15 of older medical in-patients
42 of older homeless men
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Alcohol-related mortality in men - London
(Office of National Statistics)
1991-1997
1998-2004 Men aged 75 21.7/100,000
25.7/100,000
Alcohol-related mortality in men - Southwark
(Office of National Statistics)
2008-2010 Men aged
75 64.9/100,000
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LOCAL CMHT DATA
Prospective study of CMHT referrals from Jan -
Dec 02
1 in 7 people with depression had alcohol
dependence
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OBSERVATIONS IN PEOPLE DRINKING ABOVE SENSIBLE
LIMITS

• 43 showed ICD alcohol dependence syndrome

• 21 showed harmful use of alcohol

• 71 had suffered physical problems

• 57 admitted to MH Ward or presented to AE

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PEOPLE AGED 65 AND OVER PROJECTED POPULATION OF
ENGLAND 2001-2031
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Gender differences in older people

• Women with alcohol misuse more likely to
• Be widowed/separated/divorced
• Have spouse with alcohol misuse
• Have history of depression
• More negative effects from alcohol
• Take psychotropic medication

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Characteristics of early vs late-onset problem
drinkers
Early onset (65) Late onset (35) Age varies
(lt25, 40, 45) Age varies (gt55, 60, 65) Men gt
women Women gt men Lower socioeconomic
status Higher socioeconomic status Stressors
common Stressors common Family History
likely Family History unlikely Legal/Work
problems Problems with daily routine Chronic
medical illness Acute medical
illness Amnestic Syndrome Alcohol-related
dementia Less treatment compliance Greater
treatment compliance
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Alcohol interactions in older adults
Warfarin Antihistamines Benzodiazepines Aspirin
Acid reducing drugs Opiate containing
painkillers Antibiotics Drugs for
diabetes Paracetamol
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Alcohol and the body- consequences for older
people
Decreased lean body mass Decreased total body
water Decreased level of liver enzyme that breaks
down alcohol
Higher blood alcohol concentration than younger
people, for given number of units
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Effect of physical health status

• Threshold for at risk use decreases with age
• Higher risk of other diseases
• (e.g. hypertension, diabetes, dementia)
• Body sway increases with sensible drinking and
  normal blood alcohol level

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Activities of daily living and alcohol misuse
Shopping Using public transport/driving Taking
medication Cooking Other housework Managing
finances
Drinking gt 8 units per week associated with
impairment in domestic activities
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Chronic Alcohol Use
Cognitive disorders CVAPsychosis Depression
Head, Neck, GI cancers
Neuropathy Anaemia Nutritional Deficiencies
Coronary Artery Disease CardiomyopathyArrhythmia
Hypertension Stroke
Liver Disease Cirrhosis
Stomach ulcer Gastritis
Pancreatitis Diabetes
Duodenal ulcer
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NORMAL BRAIN
WERNICKES ENCEPHALOPATHY
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HIGH RISK GROUPS

• Homelessness

• Past harmful/hazardous drinking

• Recent bereavement

• Depression

• Social isolation

• Retirement

• Immobility

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BARRIERS TO IDENTIFICATION AND TREATMENT
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AGEISM
Its all he/she has in life
Always been a poor sleeper
Can be a bit fussy with food
Care of the Elderly physicians less likely than
general physicians to screen for alcohol use
UNDER-REPORTING
Seen as a moral weakness
Stigmatising
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BARRIERS TO IDENTIFICATION AND TREATMENT
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MIS-ATTRIBUTION
Identifying alcohol-related symptoms as physical
illness/ depression/cognitive impairment
Poorer detection of drinking in Women Higher
levels of education Higher social class Widows
STEREOTYPING
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MENTAL DISORDER
SUICIDE
DRUG INTERACTIONS
ALCOHOL
ELDER ABUSE
ACCIDENTS (FALLS)
PHYSICAL DISORDERS
SELF NEGLECT
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RATING SCALES

• Commonly not used in primary AND secondary care,
  because of
• Time constraints/competing demands
• Insufficient Training
• Limited evidence for treatment
• Traditional Rating Scales lack sensitivity and
  validity, particularly in the elderly

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Alcohol Screening For Older Adults (SMAST-G)
1. Underestimates amount of alcohol
2. Misses meals
3. Uses alcohol to decrease tremors
4. Memory blackouts after drinking alcohol
5. Drinking to relax/calm nerves
6. Drinking to take mind off problems
7. Drinking after significant loss
8. Concern about drinking from doctor/nurse
9. Making rules to manage drinking
10.Drinking to ease loneliness
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IMPLICATIONS FOR EXISTING SERVICES
Extrapolating prevalence data for people aged 65
and above
OVER 500 men and 300 women in both Lewisham and
Southwark
with a diagnosis of Alcohol Dependence Syndrome
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Recommendations from Our Invisible Addicts

• Improved detection by primary and secondary care
• Improved access to treatment
• Improved training of health professionals
• Better partnerships between statutory and
  voluntary sectors
• Better provision, e.g. for alcohol related brain
  injury
• Prioritisation in government policy
• Prioritisation for research into extent of
  problem, detection, treatment and health/social
  care outcomes

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