Alcohol Misuse In Older Adults
Our invisible addicts
EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO
SELECTED LEADING RISK FACTORS (2000)
Blood pressure
Tobacco
Alcohol
Cholesterol
High Body Mass Index
Fruit and vegetable intake
Physical inactivity
Illicit drugs
0
5000
10000
15000
20000
Number of Disability-Adjusted Life Years (000s)
‘SENSIBLE LIMITS’ (‘HAZARDOUS/HARMFUL’)
(Royal Colleges 1995)
>21 Units per week (men) & >14 per week (women)
1990
% of men 65+
% of women 65+
2009
14
20
5
10
(Office of National Statistics)
ALCOHOL DEPENDENCE SYNDROME
Fewer than 5% of community residents
15% of older medical in-patients
42% of older homeless men
Alcohol-related mortality in men - London
(Office of National Statistics)
1991-1997
Men aged 75+
21.7/100,000
1998-2004
25.7/100,000
Alcohol-related mortality in men - Southwark
(Office of National Statistics)
2008-2010
Men aged 75+
64.9/100,000
LOCAL CMHT DATA
Prospective study of CMHT referrals from Jan - Dec 02
1 in 7 people with depression had alcohol dependence
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 A&E
PEOPLE AGED 65 AND OVER
PROJECTED POPULATION OF ENGLAND 2001-2031
25
22
20
19
17
16
15
2001
2011
2021
2031
12
10.2
10
8.6
7.8
5
0
Population of England (million)
% of Total
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
Characteristics of early vs late-onset problem drinkers
Early onset (65%)
Late onset (35%)
Age varies (<25, 40, 45)
Age varies (>55, 60, 65)
Men > women
Women > men
Lower socioeconomic statusHigher 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
Alcohol interactions in older adults
Warfarin
Antihistamines
Benzodiazepines
Aspirin
Acid reducing drugs
Opiate containing painkillers
Antibiotics
Drugs for diabetes
Paracetamol
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
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
Activities of daily living and alcohol misuse
Shopping
Using public transport/driving
Taking medication
Cooking
Other housework
Managing finances
Drinking > 8 units per week associated with
impairment in domestic activities
Chronic Alcohol Use
Cognitive disorders
CVA
Psychosis
Depression
Neuropathy
Anaemia
Nutritional Deficiencies
Liver Disease
Cirrhosis
Pancreatitis
Diabetes
Head, Neck, GI cancers
Coronary Artery Disease
Cardiomyopathy
Arrhythmia
Hypertension
Stroke
Stomach ulcer
Gastritis
Duodenal ulcer
NORMAL BRAIN
WERNICKE’S
ENCEPHALOPATHY
HIGH RISK GROUPS
• Homelessness
• Past harmful/hazardous drinking
• Recent bereavement
• Depression
• Social isolation
• Retirement
• Immobility
BARRIERS TO IDENTIFICATION AND TREATMENT
I
AGEISM
‘It’s 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
BARRIERS TO IDENTIFICATION AND TREATMENT
II
MIS-ATTRIBUTION Identifying alcohol-related
symptoms as physical illness/
depression/cognitive impairment
STEREOTYPING
Poorer detection of drinking in:
Women
Higher levels of education
Higher social class
Widows
MENTAL
DISORDER
SUICIDE
DRUG
INTERACTIONS
ALCOHOL
ELDER ABUSE
PHYSICAL
DISORDERS
ACCIDENTS
(FALLS)
SELF
NEGLECT
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
Alcohol Screening For Older Adults (SMAST-G)
1. Underestimates amount of alcohol
2. Misses meals
3. Uses alcohol to decrease tremors
4.
5.
6.
7.
Memory blackouts after drinking alcohol
Drinking to relax/calm nerves
Drinking to take mind off problems
Drinking after significant loss
8. Concern about drinking from doctor/nurse
9. Making rules to manage drinking
10.Drinking to ease loneliness
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
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
