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Older Adults and Alcohol Older Adults and Alcohol ProblemsProblems

NIAAA Social Work EducationNIAAA Social Work Education

Module 10CModule 10C

(revised 3/04)

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OutlineOutline

Prevalence Drinking guidelines Issues unique to older adults Co-morbid medical and psychiatric

conditions Screening and detection Prevention, brief alcohol intervention

and treatment Summary and recommendations

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Prevalence…Prevalence…

Depends on definition of at-risk or problem drinking: – 1-15% of older adults are

at-risk or problem drinkers Differs with sampling

approach Alcohol use problems are the

most common substance issues for older adults. Confounded by prescription, herbal, and over-the-counter medications

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Prevalence Prevalence (continued)(continued)

Older adults with Older adults with alcohol use problems alcohol use problems are not recognized by are not recognized by many professionalsmany professionals

Few older adults with Few older adults with alcohol abuse or alcohol abuse or dependence seek dependence seek help in specialized help in specialized addiction treatment addiction treatment settingssettings

©2002 Microsoft Corporation

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Drinking GuidelinesDrinking Guidelines No more than 1 standard No more than 1 standard

drink per daydrink per day No more than 2-3 drinks on No more than 2-3 drinks on

any drinking day (binge any drinking day (binge drinking)drinking)

Limits for older Limits for older women should women should be somewhat be somewhat less than for olderless than for oldermenmen

(Source: NIAAA, 1995; (Source: NIAAA, 1995;

Dufour & Fuller, 1995)Dufour & Fuller, 1995)

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Drinking Guidelines Drinking Guidelines (continued)(continued)

Recommendations consistent with Recommendations consistent with data on benefits/risks of drinking in data on benefits/risks of drinking in this age groupthis age group

Lower limits for older adults because: Lower limits for older adults because: IIncreased alcohol sensitivity with agencreased alcohol sensitivity with ageGreater use of contraindicated Greater use of contraindicated

medicationsmedicationsLess efficient liver metabolismLess efficient liver metabolismLess body mass/fat increases circulating Less body mass/fat increases circulating

levelslevels

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Defining Alcohol Use Defining Alcohol Use PatternsPatterns

AbstinenceAbstinence

Low riskLow risk

At-riskAt-risk

ProblemProblem

DependentDependent

No alcohol use for past yearNo alcohol use for past year

Alcohol use with no problemsAlcohol use with no problems

Alcohol use with increased Alcohol use with increased chance of problems/ chance of problems/ complicationscomplications

Experiencing adverse Experiencing adverse consequencesconsequences

Loss of control, drinking despite Loss of control, drinking despite problems, physiological problems, physiological symptoms (tolerance, withdrawal)symptoms (tolerance, withdrawal)

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Alcohol Use Patterns Alcohol Use Patterns (continued)(continued)

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Older Adults and Alcohol Older Adults and Alcohol UseUse

Increased risk of:Increased risk of:– Stroke (with overuse)Stroke (with overuse)– Impaired motor skills (e.g., Impaired motor skills (e.g.,

driving) at low level usedriving) at low level use– Injury (falls, accidents)Injury (falls, accidents)– Sleep disordersSleep disorders– SuicideSuicide– Interaction with dementia Interaction with dementia

symptomssymptoms ©2002 Microsoft Corporation

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Older Adults and Use Older Adults and Use (continued)(continued)

Other effects:Other effects:– Higher blood alcohol Higher blood alcohol

concentrations (BAC) from doseconcentrations (BAC) from dose– More impairment from BACMore impairment from BAC– Medication effects:Medication effects:

Potential interactionsPotential interactions Increased side effects Increased side effects Compromised metabolizing Compromised metabolizing

(especially psychoactive medications, (especially psychoactive medications, benzodiazepines, barbiturates, benzodiazepines, barbiturates, antidepressants, digoxin, warfarin)antidepressants, digoxin, warfarin)

©2002 Microsoft Corporation

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Social Work ScreeningSocial Work Screening

Who?Who?

What?What?

How?How?

– If aged 60 or overIf aged 60 or over– If physical signs are presentIf physical signs are present– If undergoing major life changesIf undergoing major life changes

– Screen for alcohol and Screen for alcohol and prescription drug use/abuseprescription drug use/abuse

– During any regular serviceDuring any regular service– Utilize brown bag approachUtilize brown bag approach– Ask direct questionsAsk direct questions– Avoid stigmatizing termsAvoid stigmatizing terms

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General Issues for Older General Issues for Older AdultsAdults

Loss (status, people, Loss (status, people, vocation, health, etc.)vocation, health, etc.)

Social isolation, Social isolation, lonelinessloneliness

Major financial Major financial problemsproblems

Housing changesHousing changes Family concernsFamily concerns Time management Time management

burdenburden

Complex medical Complex medical issuesissues

Multiple medicationsMultiple medications Sensory deficitsSensory deficits Reduced mobilityReduced mobility Cognitive Cognitive

impairmentsimpairments Impaired self-care, Impaired self-care,

loss of independenceloss of independence

13Signs of Potential Alcohol Signs of Potential Alcohol ProblemsProblems

Anxiety, depression, Anxiety, depression, excessive mood excessive mood swingsswings

Blackouts, dizziness, Blackouts, dizziness, idiopathic seizuresidiopathic seizures

DisorientationDisorientation Falls, bruises, burnsFalls, bruises, burns HeadachesHeadaches IncontinenceIncontinence Memory lossMemory loss Unusual response to Unusual response to

medicationsmedications

New difficulties in New difficulties in decision makingdecision making

Poor hygienePoor hygiene Poor nutritionPoor nutrition Sleep problemsSleep problems Family problemsFamily problems Financial problemsFinancial problems Legal difficultiesLegal difficulties Social isolationSocial isolation Increased alcohol Increased alcohol

tolerancetolerance

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Special PopulationsSpecial Populations

Barriers to effective Barriers to effective identification exist for:identification exist for:– WomenWomen– Certain minority group Certain minority group

members/lack of members/lack of culturally competent culturally competent tools and interventionstools and interventions

– Individuals with physical Individuals with physical disabilities, comorbiditiesdisabilities, comorbidities

– HomeboundHomebound ©2002 Microsoft Corporation

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Co-morbid ConditionsCo-morbid Conditions

Impaired Activities of Impaired Activities of Daily Living (ADL’s)Daily Living (ADL’s)

Psychiatric symptoms, Psychiatric symptoms, mental disordersmental disorders

Alzheimer’s diseaseAlzheimer’s disease Sleep disordersSleep disorders ©2002 Microsoft Corporation

Co-morbidity is a serious, common Co-morbidity is a serious, common concern among older adults using concern among older adults using alcohol:alcohol:

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Screening for Alcohol Use Screening for Alcohol Use Problems in Older AdultsProblems in Older Adults

Goals

Identify Identify —at-risk drinkersat-risk drinkers—problem drinkersproblem drinkers—dependent dependent

drinkersdrinkers Determine the need Determine the need

for further diagnostic for further diagnostic assessment assessment

Rationale

Incidence is high Incidence is high enough to justify costsenough to justify costs

Adverse quality/ Adverse quality/ quantity of life effects quantity of life effects are significantare significant

Effective treatment Effective treatment existsexists

Valid and cost-Valid and cost-effective screening effective screening existsexists

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Screening InstrumentsScreening Instruments

Short Michigan Alcohol Screening Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G)Test-Geriatric Version (SMAST-G)

Health Screening Survey Health Screening Survey (quantity/frequency and CAGE (quantity/frequency and CAGE questions embedded in a general questions embedded in a general health survey) health survey)

CAGE (Cut down, Annoyed by CAGE (Cut down, Annoyed by others, feel Guilty, need Eye others, feel Guilty, need Eye opener)opener)

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S-MAST-GS-MAST-G

Yes or no answers to:Yes or no answers to:1. “When talking with others, do you 1. “When talking with others, do you

ever ever underestimate how much you underestimate how much you actually drink?”actually drink?”

2. “After a few drinks, have you 2. “After a few drinks, have you sometimes not sometimes not eaten or been able to skip eaten or been able to skip a meal because you a meal because you don’t feel hungry?”don’t feel hungry?”

3. “Does having a few drinks help 3. “Does having a few drinks help decrease decrease your your shakiness or tremors?”shakiness or tremors?”

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S-MAST-G S-MAST-G (continued)(continued)

4. “Does alcohol sometimes make it hard 4. “Does alcohol sometimes make it hard for you to remember parts of the day or for you to remember parts of the day or night?”night?”

5. “Do you usually take a drink to relax or 5. “Do you usually take a drink to relax or calm your nerves?”calm your nerves?”

6. “Do you drink to take your mind off your 6. “Do you drink to take your mind off your problems?”problems?”

7. “Have you ever increased your drinking 7. “Have you ever increased your drinking after experiencing a loss in your life?”after experiencing a loss in your life?”

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S-MAST-G S-MAST-G (continued)(continued)

8. “Has a doctor or nurse ever said they 8. “Has a doctor or nurse ever said they were worried or concerned about your were worried or concerned about your drinking?”drinking?”

9. “Have you ever made rules to manage 9. “Have you ever made rules to manage your drinking?”your drinking?”

10. “When you feel lonely, does having a 10. “When you feel lonely, does having a drink help?”drink help?”

2 or more positive responses = indicative of an alcohol abuse problem (range of scores of 0-10 possible)

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Quantity/Frequency Quantity/Frequency ScreenScreen

1. “Do you drink alcohol?”1. “Do you drink alcohol?”

2. “On average, how many days a week do you 2. “On average, how many days a week do you drink?”drink?”

3. “On a day when you drink alcohol, how many 3. “On a day when you drink alcohol, how many drinks do you have?”drinks do you have?”

4. “What is the maximum number of drinks you 4. “What is the maximum number of drinks you consumed on any given occasion in the past consumed on any given occasion in the past month?”month?”

8 or more drinks/week or 2 or more occasions of binge drinking in last month are indicative of alcohol use problems.

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Screening ResultsScreening Results

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Intervention with Older Intervention with Older AdultsAdults

1.1. Preventive education Preventive education for abstinent, low-risk for abstinent, low-risk drinkersdrinkers

2.2. Brief, preventive Brief, preventive intervention with intervention with at-risk and problem at-risk and problem drinkersdrinkers

3.3. Alcoholism treatment Alcoholism treatment for for abusing/dependent abusing/dependent drinkersdrinkers

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Brief InterventionBrief Intervention

Time-limited (5 mins, up to 5 brief Time-limited (5 mins, up to 5 brief sessions)sessions)

Targeted at a specific behaviorTargeted at a specific behavior Goal directedGoal directed

– Reducing alcohol consumption, and/orReducing alcohol consumption, and/or– Facilitating entry into formal treatmentFacilitating entry into formal treatment

Relies on negotiated goalsRelies on negotiated goals Empirical support with younger drinkers Empirical support with younger drinkers

across multiple settingsacross multiple settings

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Brief Intervention Brief Intervention (continued)(continued)

Project GOALProject GOAL (Guiding (Guiding Older Adult Lifestyles)Older Adult Lifestyles)

— Univ. of WisconsinUniv. of Wisconsin— Brief physician Brief physician

advice for at-risk advice for at-risk older drinkers older drinkers

— n=156n=156— Reduced Reduced

consumption at 12 consumption at 12 months by 35-40%months by 35-40%

Health Profile ProjectHealth Profile Project

— Univ. of MichiganUniv. of Michigan— Elder-specific Elder-specific

motivational motivational enhancement sessionenhancement session

— n=454n=454— Preliminary findings: Preliminary findings:

reduced at-risk reduced at-risk drinking at 12 monthsdrinking at 12 months

Empirical studies with older adults are limitedEmpirical studies with older adults are limited

26Brief Protocols with Older Brief Protocols with Older AdultsAdults

Brief intervention/motivational Brief intervention/motivational enhancement are effective enhancement are effective approachesapproaches

Accepted well by older adultsAccepted well by older adults Can be conducted at home or in clinicCan be conducted at home or in clinic Reduces alcohol useReduces alcohol use Reduces alcohol-related harmReduces alcohol-related harm Reduces health care utilizationReduces health care utilization

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Brief Protocols Brief Protocols (continued)(continued)

Ten components:Ten components:1.1. Identify future goals (health, activities, Identify future goals (health, activities,

etc.)etc.)

2.2. Customize feedbackCustomize feedback

3.3. Define drinking patternsDefine drinking patterns

4.4. Discuss pros/cons of drinking (motivation Discuss pros/cons of drinking (motivation to change)to change)

5.5. Discuss consequences of heavier drinkingDiscuss consequences of heavier drinking

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Brief Protocols Brief Protocols (continued)(continued)

Ten components:Ten components: 6.6. Identify reasons to cut down or quit Identify reasons to cut down or quit

drinkingdrinking7.7. Setting sensible limits, devising Setting sensible limits, devising

strategiesstrategies8.8. Develop a drinking agreementDevelop a drinking agreement9.9. Anticipate and plan for risky situationsAnticipate and plan for risky situations10.10. Summary of the brief sessionSummary of the brief session

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Other Treatment Other Treatment ApproachesApproaches

Cognitive-Cognitive-behavioral therapybehavioral therapy

Group-based Group-based counselingcounseling

Individual Individual counselingcounseling

Medical/Medical/psychiatric psychiatric approachesapproaches

Marital and family Marital and family involvement/family involvement/family therapytherapy

Case management/ Case management/ community-linked community-linked services & outreachservices & outreach

Formalized Formalized substance abuse substance abuse treatmenttreatment

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ConclusionsConclusions

Screening for alcohol use problems Screening for alcohol use problems among older adults is effectiveamong older adults is effective

Brief interventions are effectiveBrief interventions are effective Additional interventions complete a Additional interventions complete a

spectrum of effective approachesspectrum of effective approaches Treatment approach depends on client Treatment approach depends on client

background; assessment of needs, background; assessment of needs, goals, resources; and preferencesgoals, resources; and preferences

Intervention is availableIntervention is available

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Conclusions Conclusions (continued)(continued)

Older adults benefit from Older adults benefit from screening, assessment, referral, screening, assessment, referral, prevention, and intervention prevention, and intervention delivered by social workers who delivered by social workers who are sensitive to elder issues:are sensitive to elder issues:– Non-judgmental approachNon-judgmental approach– MotivationalMotivational– Supportive approachSupportive approach

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Recommendations Recommendations

Social workers in any setting with older Social workers in any setting with older adult clients should be prepared for:adult clients should be prepared for:Recognition and assessment of alcohol Recognition and assessment of alcohol

use problems (quantity and frequency; use problems (quantity and frequency; limits)limits)

Structured brief interventions when Structured brief interventions when appropriate appropriate

Initial management and referral for Initial management and referral for further assessment/treatment when further assessment/treatment when indicatedindicated