As the demographics of the U.S. change and a growing number of people are reaching older adulthood, the promotion of healthy lifestyles and primary disease prevention in this group is becoming a critical issue. Many acute and chronic medical and psychiatric conditions that lead to high rates of health care utilization in this age group are influenced by lifestyle choices and behaviors, such as alcohol consumption (Fuchs, 1999; Kropp, Powe, Weller, Shaffer, Saudek, & Anderson, 1998; Schneider & Guralnik, 1990; Waldo, Sonnefeld, McKusick, & Arnett, 1989). Older adults are more vulnerable to the effects of alcohol than their younger counterparts. Combined with their increased risk of comorbid diseases, and their frequent use of prescription and over-the-counter medications, many older adults seek health care for physical and mental conditions that are not immediately associated with increased alcohol consumption (Barry, Blow, Oslin, in press; Barry, Oslin, Blow, 2001). This is one reason why alcohol screening and intervention are particularly relevant to older adults.
Social workers provide services to older adults in a variety of settings, including primary health care, hospital, community-based housing, mental health, protective services, and senior program sites. Older adults with alcohol problems need elder-specific screening and intervention procedures that focus on the unique issues associated with drinking in later life. Social workers, because of their training and in-depth knowledge of the lives of older adults in their caseloads, can play a unique role in the detection and management of at-risk and problem alcohol use in this vulnerable population. Social workers are often the professionals who work most closely with older clients. Because of the profession's focus on social, family, and psychological health, there are great opportunities to both identify and work with alcohol-related problems as they occur or threaten to arise.
By the end of this module, learners should be able to:
A. Define low risk drinking, at-risk drinking, problem drinking, and alcohol dependence in older adults
B. Know drinking guidelines for adults age 65 and over
C. Understand the prevalence of at-risk drinking, problem drinking, and alcohol dependence among older adults
D. Identify signs and symptoms of alcohol problems in older adults
E. Know how to use brief alcohol interventions with older adults
F. Recognize barriers to intervention and treatment, and how to address them
The United States is experiencing dramatic and unprecedented increases in the number of individuals over age 65, especially those aged 85 and older (Administration on Aging, 2000). Estimates predict that over the next two decades these numbers will continue to rise by as much as 53% growth (Dill, 2001). By the year 2030, it is expected that one out of five Americans will be over age 65, and the number of individuals aged 85 and over will triple to 8.8 million (U.S. Bureau of the Census, 1996). These changes are expected to present new challenges to our nation's health care delivery systems (John A. Hartford Foundation, 2000) to preserve quality of life. Social workers are responsible for many of the issues facing older adults and their families, including case management, health care supports, navigating Medicare and other economic support systems, ensuring a continuum of housing options, fostering optimal mental health, fostering safety, preventing neglect and maltreatment, and providing services that delay or reduce the need for residential care/preserve least-restrictive environment options (Department of Health and Human Services, 1999; Schlarlach, Damron-Rodriguez, Robinson, & Feldman, 2000).
Community survey data indicate that the prevalence of problem drinking among older adults ranges from 1% to 15% (Adams, Barry, & Fleming, 1996; Fleming, Manwell, Barry, Adams, & Stauffacher, 1999; Gurland & Cross, 1982; Robins, Helzer, Weissman, Orvaschel, Gruenberg, Burke, et al.; Schuckit & Pastor, 1978). These rates vary widely depending on the definition of risk drinking or alcohol abuse/dependence, and the methodology used in obtaining samples. Among clinical populations, however, estimates of alcohol abuse/ dependence may be substantially higher. Problem drinkers of all ages are more likely to present in health care settings (Institute of Medicine, 1990b). In an exploratory study, Kunz (1997), found that visits to health care professionals generally increased with age and number of medical problems, and that abstainers and former drinkers were more likely to visit health care professionals than were current drinkers. This study points outs that the issue of prevalence is complex and requires more systematic research attention.
Most research conducted on substance use and misuse in older adults has focused on alcohol. Problems related to alcohol use are the largest class of substance use problems seen in older adults today. The rates of illegal drug abuse in the current elderly cohort are very low (Blow, CSAT, 1998b). Prescription drug misuse, however, is a broad issue with multiple determinants, causes, and consequences. Alcohol/medication interactions remain a significant concern.
Although epidemiological studies of alcohol use problems among older adults are limited, prevalence estimates and typical characteristics of older, at-risk problem drinkers are attracting attention (Adams, et al., 1996; Blow, Cook, Booth, Falcon, & Friedman, 1992b; Robins, et al., 1984). Physical and mental health care personnel do not recognize the majority of older adults who are at-risk or problem drinkers. Moreover, few elderly individuals with alcohol abuse or dependence seek help in specialized addiction treatment settings. Given the utilization of social and health care services by older adults, social workers in these settings can be crucial in identifying those in need of treatment and providing appropriate interventions based on clinical need.
Special concerns arise when developing alcohol consumption guidelines appropriate for the older adult population. Compared with younger people, older adults have an increased sensitivity to alcohol, as well as to over-the-counter and prescription medications. There is an age-related decrease in lean body mass versus total volume of fat. The resultant decrease in total body volume increases the circulating distribution of alcohol and other mood-altering chemicals in the body. Liver enzymes that metabolize alcohol and certain other drugs become less efficient with age. Central nervous system sensitivity increases with age.
As stated before, the potential interaction of medications and alcohol is a particular concern in this age group. For some individuals, ANY alcohol use with specific over-the-counter or prescription medications can be problematic. Because of the age-related changes in how alcohol is metabolized, and the potential interactions between medications and alcohol, alcohol use recommendations for older adults are generally lower than those for adults under age 65. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 1995b) and the CSAT Treatment Improvement Protocol (TIP) on older adults (Blow, CSAT, 1998b) recommend that persons age 65 and older consume no more than one standard drink per day or seven standard drinks per week (Dufour & Fuller, 1995; Dietary Guidelines Advisory Committee, 2000, page 39). In addition, older adults should not consume more than 2 standard drinks on any drinking day. It is recommended that the limit for older women should be slightly less than one standard drink per day. To put these guidelines into perspective, the guidelines for younger men under 65 include no more than 2 standard drinks per day; and for younger women, no more than one standard drink per day. A standard drink contains about 14 grams (about 0.6 fluid ounces) of pure alcohol. Figure 2 depicts approximate standard drink equivalents.
Limits for Older Adults
- No more than 1 standard drink per day or 7 per week
- No more than 2 drinks on any drinking day
- Limits for older women should be less than 1 standard drink per day
Figure 2: What is a standard drink?
Note: People buy many of these drinks in containers that hold multiple standard drinks. For example, malt liquor is often sold in 16-, 22- or 40 oz. containers that hold between two and five standard drinks, and table wine is typically sold in 25 oz (750ml.) bottles that hold five standard drinks.
The drinking limit recommendations for older adults have been shown to be consistent with data regarding the relationship between consumption and alcohol-related problems in this age group (Chermack, Blow, Hill, & Mudd, 1996). Recommendations are also consistent with the current evidence on the beneficial health effects of drinking (Doll, Peto, Hall, Wheatley, & Gray, 1994; Klatsky, Armstrong, & Friedman, 1997; Poikolainen, 1991).
No alcohol use for past year
Alcohol use with no problems
Alcohol use with increased chance of problems/ complications
Experiencing adverse consequences
Loss of control, drinking despite problems, physiological symptoms (tolerance, withdrawal)
Definitions and examples of abstinence, low risk drinking, at-risk drinking, problem drinking, and alcohol/drug dependence can promote further understanding of the 'spectrum of use' seen in this age group. The spectrum-of-use categories are derived from both the clinical and research expertise of professionals in the field. Definitions for older adults regarding low risk, at-risk, and problem use focus primarily, but not exclusively, on alcohol (Barry, 1997; Barry, et al., 2001). Figure 3 illustrates the prevalence of each type of drinking.
Abstinence refers to no alcohol consumption during the previous year. Approximately 60-70% of older adults are abstinent. If an older person is abstinent, it is useful to ascertain why alcohol is not used. Some individuals are abstinent because of a previous problem with alcohol. Some are abstinent because of recent onset illnesses, while others have life-long patterns of low risk use or abstinence. Patients who have a history of alcohol use problems may benefit from "relapse prevention" monitoring and intervention to avoid aggravation of an old pattern.
Low risk drinking is alcohol use that does not lead to problems. Older adults in this category drink within recommended drinking guidelines, are able to employ reasonable limits on their alcohol consumption, and do not drink in risky situations (e.g., when driving a motor vehicle or boat), or when using contraindicated medications. Low risk use of medications would include using these drugs according to physician prescription or recommendations. Even among compliant individuals, a periodic careful check of the number and types of medications is important, since medication and alcohol interaction reactions are not uncommon among older adults. These persons can benefit from preventive messages and educational information, but may not need more intensive interventions (Barry, et al, 2001).
Figure 3: Prevalence of types of drinkers
At-risk drinking is characterized by alcohol use that increases the chances that a person will develop alcohol-related problems and complications. Persons over 65 who drink more than 7 drinks per week (one per day) are in the at-risk use category. Although they may not currently experience health, social, or emotional problems caused by alcohol, they may develop family and social problems. Furthermore, if this drinking pattern continues, health problems could be exacerbated over time. Brief interventions are useful for older adults in this group as means of preventing progression of alcohol-related problems (Fleming, Manwell, Barry, Adams, & Stauffacher, 1999.
Problem drinking among older adults is when alcohol is consumed at a level that has already resulted in adverse medical (e.g., injury, medication interactions), psychological, family, financial/economic, self-care, legal, or social consequences. It is important to reiterate that some older adults who drink even small amounts of alcohol can experience alcohol-related problems. Quantity and frequency of use may not be the only determinant of the need for social work intervention. The presence of consequences, whether or not the person is drinking above guidelines, should be a critical concern driving intervention plans.
Alcohol or drug dependence refers to a medical disorder characterized by loss of control over consumption, preoccupation with alcohol or drugs, continued use despite adverse consequences, and physiological symptoms such as tolerance and withdrawal (American Psychiatric Association, 1994). Formal specialized treatment is generally used for persons who meet criteria for alcohol abuse or dependence and who cannot discontinue drinking with a brief intervention protocol. Nonetheless, pre-treatment strategies are also appropriate for this most severely involved population. Brief interventions have been recommended by the Center for Substance Abuse Treatment (Barry, CSAT, 1999) for:
- use as a pre-treatment strategy to assist individuals on waiting lists for formalized treatment programs
- patients who meet abuse or dependence criteria with no signs of physical dependence or withdrawal
- use as an adjunct to specialized treatment to assist with specific issues, such as completing homework for treatment groups, attendance at work, or adherence to the treatment plan
Issues Unique to Older Adults
Research has suggested that elderly individuals have unique drinking patterns and alcohol-related consequences, social issues, and treatment needs (Atkinson, 1995). There is emerging evidence of the medical risks of even moderate alcohol use among older adults. Conflicting studies indicate a relationship between strokes and alcohol consumption. Some studies indicate that moderate alcohol consumption appears to increase the risk of strokes caused by bleeding. Other studies found that moderate consumption may decrease the risk of strokes caused by blocked blood vessels (Hansagi, 1995). Alcohol use has been demonstrated to impair driving-related skills, even at low levels of consumption, and it may lead to other older adult injuries, such as falls (Kivela et al., 1989). Of particular importance to the elderly population is the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants. Alcohol is also known to interfere with the metabolism of medications such as digoxin and warfarin (Adams, 1995; Fraser, 1997; Hylek, 1998).
Early identification and secondary prevention of alcohol problems in late life are likely to require elder-specific approaches. Older adults present challenges in applying brief intervention strategies for reducing alcohol consumption. Because drinking guidelines are lower for older adults, and because of historical and cultural factors that lead to feelings of shame or disgrace, older adult problem drinkers find it particularly difficult to identify their own risky drinking. In addition, chronic medical conditions may make it more difficult for clinicians to recognize the role of alcohol in decreased functioning and quality of life. Older adults may find that alcohol consumption is a pervasive element in many elder-available social activities. These issues present barriers to conducting effective brief interventions for this vulnerable population. Table 1 provides typical signs and symptoms of alcohol problems in older adulthood. Many of these signs can be related to other problems seen in later life, but it is important to determine if alcohol use is involved.
Table 1: Signs and Symptoms of Potential Alcohol Problems in Older Adults
excessive mood swings
falls, bruises, burns
(Adapted from Fleming and Barry, 1991; and Barry, Oslin, and Blow, 2001)
increased tolerance to alcohol
new difficulties in decision making
unusual response to medications
Special Populations of Older Adults
In addition to issues that are unique to older adults in general, there are specific barriers to recognition, intervention, and treatment for special populations of older adults. These include women, those with physical disabilities, and those who are homebound. The majority of older adults in our nation are women, but most research on older adults and alcohol has focused on men. This research bias occurs, in part, because the majority of older adults who abuse substances are men.
However, older women are more likely to be living alone and their alcohol use may be harder to detect (CSAT, 1998). Furthermore, older women are prescribed more psychoactive drugs, such as benzodiazepines, and are more likely to be long-term users of these medications (Gomberg, 1995). This factor, along with stereotypic misperceptions that older women do not drink, make it even more important to screen for alcohol use and combined alcohol/medication use in this group of potentially vulnerable individuals.
Barriers to effective identification exist for:
- Certain minority group members
- Individuals with physical disabilities
- People with comorbidities
Little research has been conducted with older minority populations, but the CSAT Consensus Panel on substance abuse in older adults (Blow, CSAT, 1998b) determined that these individuals face barriers to identification, intervention, and treatment. Data by Gomberg and Nelson (1995), and Gomberg (1995) indicated that older members of certain minority groups, African-Americans in particular, may be more vulnerable to late-life drinking than previously believed. Issues specific to older individuals from minority groups include lack of access to ongoing medical care, and language and cultural barriers for first generation immigrants.
Cultural competence is crucial when clinicians and clients have different racial and ethnic backgrounds. Clinicians need knowledge of culturally specific health care belief systems in order to effectively interview and interpret responses from their clients. Although progress is being made to improve cultural competence among clinical providers, there are many cultural and linguistic minorities about whom this information is less accessible (e.g. Eastern Europeans, Asians). Due to the type and intensity of services often provided by social workers, there is an opportunity to learn and subsequently to provide assistance to other clinicians working with clients from other cultures.
Clearly, the detection and treatment of alcohol problems among homebound older adults is more difficult than for more ambulatory older adults. Issues specific to this population include co-morbidities, isolation, transportation, safety, and handicapped accessibility (Dey, 1996). The populations of older adults who are restricted to their homes due to health problems (e.g. heart disease, diabetes, chronic lung diseases) are at particular risk for alcohol problems due to isolation, and their dependence on others to get out. Limited social contacts and lack of social support networks can make these individuals more susceptible to despair and depression, which can lead to alcohol use in an attempt to alleviate suffering (Blow, CSAT, 1998b). Since social workers frequently play an important leadership role in developing and/or conducting home health care assessments, they have a unique opportunity to address the troubling issues related to alcohol use problems in this special population.
Co-Morbid Medical and Psychiatric Conditions
The medical and emotional consequences of heavy or excessive alcohol consumption, as well as decreased consumption, have been well chronicled in most mental health texts. Although the impact of excessive alcohol use on Activities of Daily Living (ADL's) is not fully understood, several studies show a relationship between alcohol use and functional abilities, especially among older subjects. In a recent study by Ensrud and colleagues, a former history of alcohol use was associated with an odds ratio of 2.2 in predicting impairment in ADL's among older women (Ensrud, et al., 1994). Alcohol use was more strongly correlated with ADL impairment than smoking, chronological age, use of anxiolytics, stroke, or lower grip strength. In contrast to this finding, several authors have demonstrated that moderate alcohol use among older community-dwelling persons, compared to a group of non-drinkers, is associated with fewer falls, greater mobility and improved physical functioning (LaCroix, Guralnik, Berkman, Wallace, & Satterfield, 1993; Nelson, Sattin, Langlois, DeVita, & Stevens, 1992; 1994; O'Loughlin, Robitaille, Boivin, & Suissa, 1993). These studies did not include many heavy drinkers or individuals with alcohol use disorders. Together these studies suggest that alcohol consumption in older persons may exhibit a protective effect in moderate doses (similar to the protective effect on cardiovascular morbidity) and a detrimental effect with more excessive alcohol use (Scherr, LaVroix, Wallace, Berkman, Curb, & Cornoni-Huntley, et al., 1992).
Epidemiology studies have clearly demonstrated that co-morbidity between alcohol use and psychiatric symptoms is common in younger age groups. Individuals with mental disorders have an increased risk for substance use disorders, and persons with substance use disorders have an increased risk for mental disorders. For example, about one-third of individuals who have a psychiatric disorder also experience substance abuse, at some point in time (Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 1990). This rate is about twice that observed among people without psychiatric disorders. Also, more than 50% of individuals who use or abuse substances have experienced psychiatric symptoms significant enough to satisfy diagnostic criteria for a psychiatric disorder, although many of these symptoms may be alcohol and drug-related, rather than representing an independent condition.
Considerably less is known about co-morbidity between alcohol use and psychiatric illness in late life. A few studies indicate that dual diagnosis with alcoholism is important among the elderly (Blazer & Williams, 1980; Blow, Cook, Booth, Falcon, & Friedman, 1992b; Finlayson, 1988; Saunders, 1991). Co-morbid depressive symptoms are not only common in late life, but are an important factor in both the course and prognosis of psychiatric disorders. Older, depressed persons who are alcohol dependent have a more complicated clinical course of depression, an increased risk of suicide, and more social dysfunction than non-depressed alcoholics; moreover, they were shown to seek more treatment (Conwell, 1994; Cook, Winokur, Garvey, & Beach, 1991). Alcohol use prior to late life has also been shown to influence treatment of late-life depression. Cook and colleagues found that a prior history of alcohol abuse predicted a more severe and chronic course for depression (Cook, et al, 1991). However, relapse rates for older alcoholics did not appear to be influenced by the presence of depression.
Older, depressed persons who are alcohol dependent:
- Have a more complicated clinical course of depression
- Have an increased risk of suicide
- Seek more treatment
- Suffer more social dysfunction
A complex relationship exists between alcohol use and dementia disorders such as Alzheimer's Disease. Alcohol-related dementia may be difficult to differentiate from Alzheimer's Disease. Determining if alcohol use, especially heavy use, influences the emergence and progression of Alzheimer's Disease requires expensive and intensive autopsy studies to establish a neuropathologic diagnosis of Alzheimer's Disease. Although rates of alcohol-related dementia in late life differ according to the diagnostic criteria used and the nature of the population studied, there is a consensus that alcohol contributes significantly to the acquisition of cognitive deficits in late life. Among subjects over the age of 55 evaluated in the Epidemiologic Catchment Area (ECA) study, the prevalence of a lifetime history of alcohol abuse or dependence was 1.5 times greater among persons with mild and severe cognitive impairment than among those with no cognitive impairment (George, Landerman, Blazer, & Anthony, 1991).
Sleep disorders and sleep disturbances represent another group of co-morbid disorders associated with excessive alcohol use. Alcohol causes well-established changes in sleep patterns, such as decreased sleep latency, decreased stage IV sleep, and precipitation or aggravation of sleep apnea (Wagman et al., 1997). Age-associated changes in sleep patterns include increased REM episodes, a decrease in REM length, a decrease in stage III and IV sleep, and increased awakenings. The age-associated changes in sleep can be exacerbated by alcohol use and depression.
Co-morbidities are a serious, common concern when working with older adults. It is useful to keep potential co-morbid factors in mind when conducting health screening with older adults. The direction of causality between co-morbid conditions and alcohol is not always clear from the research, however the correlations and associations between these factors should always be considered.
Screening and Detection of Alcohol Problems in Older Adults
Physical health changes are often the first warning signs noted in older adults. A number of adverse health effects are associated with heavier alcohol use, including harmful drug interactions, injury, depression, memory difficulties, liver disease, cardiovascular disease, cognitive changes, and sleep problems (Barry, 1997; Barry et al., 2001; Finch & Barry, 1992; Gambert & Katsoyannis, 1995; Liberto, Oslin, & Ruskin, 1992).
Recent recommendations suggest that screening and interventions focused on lifestyle factors, including alcohol use, may be the most appropriate way to maximize health outcomes and minimize health care costs among older adults (Barry et al., 2001; Blow, CSAT, 1998b; Wetle, 1997). Recommendations from the expert panel on the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series no. 26, "Substance Abuse Among Older Adults" (Blow, CSAT, 1998b), include:
- Every person age 60 and over should be screened for alcohol and prescription drug use/abuse as part of any regular service
- Yearly re-screening is indicated if certain physical symptoms emerge or if the person is undergoing major life changes, stresses, or transitions
- These screening criteria apply to any social work setting in which older adults are served, and is not limited to health care and substance treatment settings
Table 2: Goals and Rationale for Screening Older Adults for Alcohol Abuse
- at-risk drinkers
- problem drinkers
- dependent drinkers
- Determine the need for further diagnostic assessment
- Incidence is high enough to justify costs
- Adverse quality/quantity of life effects are significant
- Effective treatment exists
- Valid and cost-effective treatment exists
The goals of screening are to: (1) identify at-risk drinkers, problem drinkers, or persons with alcohol dependence; and/or (2) determine the need for further diagnostic assessment. Routine screening for alcohol problems is justified by the observations that the high incidence justifies the cost, alcohol can adversely affect morbidity and mortality, there are effective treatments available, and there are valid, cost-effective methods for screening. In order for social workers to practice prevention and early intervention with older adults, they need to routinely screen for alcohol use (frequency and quantity), drinking consequences, and alcohol/medication interaction problems. Screening can be conducted as part of routine mental and physical health care and updated annually; before the older adult begins taking any new medications; or in response to problems that may be alcohol or medication-related. Clinicians can obtain more accurate histories by asking questions about the recent past; embedding the alcohol use questions in the context of other health behaviors (i.e. exercise, weight, smoking, alcohol use); and paying attention to nonverbal cues that suggest the client is minimizing use (e.g., blushing, turning away, fidgeting, looking at the floor, change in breathing pattern). The "brown bag" approach is recommended to determine medication use. Ask the client to bring a brown paper bag containing all prescribed and over-the-counter medications, including any herbal treatments, which they currently take. This provides an opportunity to assess the number and types of medications, the number of prescribing providers who work with the client, and the need for discussion among care providers.
Alcohol screening questions can be asked by a verbal interview, a paper-and-pencil questionnaire, or a computerized questionnaire. All three methods are reliable and valid (Barry & Fleming, 1990; Greist, Klein, Erdman, Bires, Bass, & Machtinger, et al., 1987). Positive responses can lead to further questions about consequences. To successfully incorporate alcohol (and other drug) screening, the screening approach should be simple and consistent with other screening procedures already in place (Barry, Blow, & Oslin, in press).
Before asking any screening questions, the following conditions should be met:
- The interviewer and interview style need to be empathetic and non-threatening
- The purpose of the questions should be clearly relevant (i.e., to physical or mental health status)
- The respondent should be alcohol-free at the time of the screening
- The individual must be certain that all information is protected as confidential
- The questions need to be easily to understood
If the alcohol questions are embedded in a longer questionnaire or intake interview, a transitional statement is needed to move into the alcohol-related questions. The best way to introduce alcohol questions is to give the client a general idea of the content of the questions, their purpose, and the need for accurate answers (Blow, CSAT, 1998b). This statement should be followed by a description of the types of alcoholic beverages typically consumed, and if necessary, may include a description of beverages that are be considered alcoholic (e.g., cider, low alcohol beer). Determinations of consumption are based on 'standard drink' definitions and examples of these criteria should be provided, as well.
Screening for alcohol use problems is not always standardized, and not all standardized instruments have good reliability and validity with older adults. The following have good validity and reliability with older adults: the Short Michigan Alcoholism Screening Test-Geriatric Version (S-MAST-G) (Blow, Gillespie, Barry, Mudd, & Hill, 1992), and quantity/frequency questions. The CAGE, a widely used screening test, does not have high validity with older adults (Adams, et al, 1996) and, if used, should be part of a more extensive instrument that includes questions about quantity/frequency and consequences.
Table 3: Short Michigan Alcoholism Screening Test -Geriatric Version (S-MAST-G) The Regents of the University of Michigan, 1991. YES NO
1. When talking with others, do you ever underestimate how much you actually drink?
2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?
3. Does having a few drinks help decrease your shakiness or tremors?
4. Does alcohol sometimes make it hard for you to remember parts of the day or night?
5. Do you usually take a drink to relax or calm your nerves?
6. Do you drink to take your mind off your problems?
7. Have you ever increased your drinking after experiencing a loss in your life?
8. Has a doctor or nurse ever said they were worried or concerned about your drinking?
9. Have you ever made rules to manage your drinking?
10. When you feel lonely, does having a drink help?
TOTAL S-MAST-G SCORE (0-10)
Scoring: 2 or more "yes" responses are indicative of an alcohol problem.
Contact source: Frederic C. Blow, Ph.D., University of Michigan Alcohol Research
Center, 400 E. Eisenhower Parkway, Suite A., Ann Arbor, MI 48104, 734-998-7952
Alcohol screening with older adults suggests that:
- 15% of men regularly drink more than 14 drinks/week and 12% of women regularly drink more than 7 drinks per week (both above NIAAA guidelines)
- 9% of men regularly consume more than 21 drinks per week and 2% of women regularly consume more than 21 drinks per week (Adams, et al., 1996).
Prevention, Brief Alcohol Interventions, and Treatment with Older Adults
Specific treatment and intervention strategies for older adults who are alcohol dependent or hazardous drinkers are only beginning to be disseminated (Barry, et al, 2001; Blow, 1998a; Blow, CSAT, 1998b; Fleming, et al, 1999). For years, low intensity, brief prevention interventions have been suggested as cost-effective and practical techniques for an initial approach to at-risk and problem drinkers in primary care settings (Babor, Ritson, & Hodgson, 1986). Over the last two decades, controlled clinical trials have assessed the efficacy of early identification and secondary prevention using brief intervention strategies for treating problem drinkers. These trials focused on drinkers with relatively mild to moderate alcohol problems who are at risk for developing more severe problems (WHO, 1992; Barry & Fleming, 1994; Fleming, Barry, Manwell, Johnson, & London, 1997; Institute of Medicine, 1990a).
The spectrum of alcohol interventions for older adults include (Blow, CSAT, 1998b):
- prevention and education for persons who are abstinent or low risk drinkers
- minimal advice or brief, structured interventions for at-risk or problem drinkers
- formalized alcoholism treatment for those who meet criteria for abuse and/or dependence
BRIEF INTERVENTIONS WITH OLDER AT-RISK DRINKERS
The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), publishes a Treatment Improvement Protocol (TIP) Series. TIP no. 34, entitled "Brief Interventions and Brief Therapies for Substance Abuse" (Barry, CSAT, 1999), defined brief alcohol interventions as time limited (5 minutes to 5 brief sessions) and targeting a specific health behavior (at-risk drinking). Until recently, little attention has been given to brief intervention research with older adults. Formalized treatment is generally used with persons who meet criteria for alcohol abuse or dependence and cannot discontinue drinking with a brief intervention protocol. Pre-intervention strategies are also appropriate for this highest problem population.
Studies of brief interventions for alcohol problems have employed various approaches to change drinking behaviors. Studied strategies include relatively unstructured counseling and feedback, as well as more formal structured therapy (Chick, Lloyd, & Crombie, 1985; Fleming et al., 1997; Kristenson, Ohlin, Hulten-Nosslin, Trell, & Hood, 1983; Persson & Magnusson, 1989). These strategies have relied heavily on concepts and techniques from the behavioral self-control training (BSCT) literature (Miller & Heather, 1986; Miller & Munoz, 1976; Miller & Rollnick, 1991; Miller & Taylor, 1980). A number of brief alcohol intervention studies have been conducted in primary care settings, with primarily positive results among younger adults (Chick et al., 1985; Fleming et al., 1997; Kristenson et al., 1983; Persson & Magnusson, 1989). Brief interventions and brief therapies each have been shown to be effective across a range of clinical settings (Barry, CSAT, 1999). Brief alcohol interventions have particular usefulness with older adults (Blow, 1998a; Fleming et al, 1999).
To date, two randomized clinical brief intervention trials have been conducted with older adults. Along with their colleagues, Fleming (1999) and Blow (in progress) assessed the efficacy of brief advice protocols to reduce hazardous drinking among older adults in primary care settings. These studies show that: (1) older adults can be engaged in brief intervention protocols, (2) the protocols are acceptable to this population, and (3) there is a substantial reduction in drinking among older at-risk drinkers receiving the interventions compared to a control group.
The first study, Project GOAL-Guiding Older Adult Lifestyles (Fleming, et al, 1999), was a randomized, controlled clinical trial conducted in Wisconsin with 24 community-based primary care practices (43 practitioners) located in ten counties. Of the 6,073 individuals screened for problem drinking, 105 males and 53 females met inclusion criteria (N=158) and were randomly assigned to a control (n=71) or intervention group (n=87). One hundred forty-six subjects participated in the 12-month follow-up procedures. The intervention consisted of two, 10-15 minute, physician-delivered counseling visits that included advice, education, and contracting using a scripted workbook. No significant differences were observed between groups at baseline on alcohol use, age, SES, depression, onset of alcohol use, smoking status, activity level, or use of mood-altering drugs. At baseline, both groups consumed an average of 16-17 drinks per week. At the 12-month follow-up, the older adults who had received the brief clinician intervention demonstrated a 34% reduction in alcohol use (p<.001). In contrast, the control subjects demonstrated minimal changes in alcohol use.
The second, larger elder-specific study, the Health Profile Project is currently being finalized in primary care settings located in Southeast Michigan (Blow, in progress). The elder-specific intervention contains both brief advice discussions conducted by either a psychologist or social worker (as in the World Health Organization studies), and motivational interviewing techniques (Miller & Rollnick, 1991), including feedback. A total of 452 subjects were randomly assigned to groups in this trial. Over 26% of the participants are African American. Follow-up rates of 92% were obtained at the 12-month follow-up. The preliminary results of this study are similar to the prior study (Fleming, et al, 1999) in terms of 7-day alcohol use and binge drinking at the 12-month follow-up. These randomized, controlled clinical trials extend the positive results of brief intervention trials with younger at-risk drinkers to the vulnerable older adult population.
Brief Intervention Protocols with Older Adults
As stated above, brief alcohol screening and intervention techniques can be particularly useful with older adults who are at-risk and problem drinkers. The brief alcohol intervention is designed for use in busy clinical settings. The negotiated drinking goals are flexible, allowing the individual, with guidance from the clinician, to choose between goals of drinking moderation or abstinence. The goal of brief counseling is to motivate problem drinkers to change their behavior, not to label themselves. Studies of brief interventions have avoided labeling individuals as alcoholic or as suffering from alcoholism; the use of such "charged" terms might be inappropriate for at-risk drinkers (Babor, et al., 1994). Brief intervention generally has one or two main goals: (1) to reduce or stop alcohol consumption, and/or (2) to facilitate entry into formalized treatment if warranted. Auxiliary issues included in the brief alcohol intervention for older adults vary based on individual client issues and the time available for the intervention.
The actual steps and guidelines for brief alcohol intervention can be adapted from those recommended in recent reports (Barry, et al., 2001; Blow, Barry, & Walton, (unpublished); Fleming et al., 1997; Wallace, Cutler, & Haines, 1988). With older adults, a semi-structured brief intervention can be conducted following a positive screen for at-risk or problem drinking. The content of the intervention must be elder-specific and include:
1. Identifying future goals for health, activities, hobbies, relationships, and financial stability. This activity makes issues that are affected by alcohol use salient, and may help to initiate a discrepancy between current drinking behaviors and valued goals.
2. Giving customized feedback on screening questions. During this summary of health habits, clients are provided with information about their physical and mental health functioning, and their health habits including alcohol consumption. This provides an opportunity for the social worker to give feedback that may facilitate the client's self-reflection regarding his/her health status and alcohol use.
3. Defining drinking patterns. This includes discussing types of older drinkers in the population, where the individual's drinking pattern fits into the population norms for a matched age group, and definitions of standard drinks. This assists individuals to understand that the effects of alcohol are similar across beverage groups and puts their drinking into perspective.
4. Weighing the pros and cons of drinking. This step is particularly important as it helps the social worker to understand the role of alcohol in the older patient's life. For example, alcohol may be used to cope with loss and loneliness. Similar to a cost-benefit analysis, this activity can be used to motivate changes in drinking behaviors.
5. Exploring the consequences of heavier drinking. Some older individuals experience problems with physical, psychological, or social functioning even though they are drinking below cut-off levels.
6. Exploring reasons to cut down or quit drinking. This activity is also part of the motivation process. Maintaining independence, preserving physical health, and protecting mental capacity can be key motivators in this age group. Older adults are asked to identify positive and negative aspects of their alcohol use, and to identify both benefits and barriers to change. This discussion assists the client to weigh the issues, and hopefully "tips the decisional balance" in favor of changing drinking habits.
7. Setting sensible drinking limits and devising strategies for cutting down or quitting. This step sets an action plan in motion. Strategies useful for this age group include developing social opportunities that do not involve alcohol, getting reacquainted with hobbies and interests from earlier in life, and pursuing interesting volunteer activities, if possible.
8. Developing a drinking agreement. A formal written agreement helps to solidify the plan of action and reinforces commitment. Negotiated drinking limits, signed by the client and the practitioner, are particularly effective in changing drinking patterns. Older adults are asked to choose: (1) their drinking goal (reduction vs. abstinence), (2) a start date for addressing their drinking, (3) their rate of reduction, and (4) a target date for achieving their goal. This provides the client with a menu of options. The social worker may offer additional feedback and/or advice. Goal choice increases a sense of personal responsibility in the client.
9. Anticipating and planning for coping with risky situations. This step is critical to empower the individual for change. Common risky situations include social isolation, boredom, sleeplessness, grief, physical pain, and negative family interactions. These all present special challenges to this age group. Social workers should ask their older clients about the situations and environmental cues that may trigger drinking. This step increases insight into consumption, allows the individual to identify personal strengths and strategies for cutting down, and supports the individual's self-efficacy.
10. The brief intervention ends with a summary of the session.
Brief intervention protocols often use a workbook following these ten steps. Workbooks provide the opportunity and tools for the client and practitioner to discuss, negotiate, and follow-up on drinking changes. Workbooks often have pages where the clinician and client can list information about drinking cues, reasons for drinking, and reasons to cut down or quit. A drinking agreement in the form of a contract, and drinking diary cards for self-monitoring are often included. Providers are trained to administer the intervention protocol through role-playing and general skills training techniques employed in educational programs. The approach with clients is non-confrontational and generally follows motivational interviewing principles as described by Miller and Rollnick (1991).
Example of a drinking agreement:
I, _________________________________________________ agree to the following drinking goal:
_____Number of drinks ____________________________ Frequency OR _____ Abstinence
Starting date: _______________________________
Participant signature: _________________________________________
Clinician signature: ___________________________________________
Other Treatment Approaches for Older Adults
As with all other clinical issues, no approach fits every client. Treatment should be individualized and tailored for the specific needs of each client. Tailoring takes into account the medical, psychiatric, social, emotional, safety, legal, and cultural needs of that client. A number of general approaches for the treatment of older adults with alcohol problems are recommended by the CSAT Consensus Panel on substance abuse in older adults (Blow, CSAT, 1998b) and the CSAT Consensus panel on brief interventions and brief therapies for substance abuse (Barry, CSAT, 1999). These include cognitive behavioral approaches, group-based approaches, individual counseling, medical/psychiatric approaches, marital and family involvement/family therapy, case management/community-linked services and outreach, and formalized alcohol treatment. Each has been used with older adults who have problems related to alcohol or combined alcohol and medication use. However, most of these approaches have been more widely studied with younger adults (Blow, CSAT, 1998b).
Very few studies have examined other interventions for older drinkers (Atkinson, 1995). Cognitive-behavioral approaches have been used successfully to teach individuals the necessary skills for rebuilding social support networks and for using self-management approaches to overcome depression, grief, and loneliness (Dupree, Broskowski, & Schonfeld, 1984; Schonfeld & Dupree, 1991). Involving supportive family members in the treatment process, particularly a spouse, has been shown to increase treatment compliance in older, married men (Atkinson, Tolson, & Turner, 1993). Finally, case management services have been found to be helpful for older adults receiving alcoholism treatment, and may be the best way to provide outreach services (Graham, Saunders, Flower, Timney, White-Campbell, & Pietropaolo, 1995). CSAT Treatment Improvement Protocol no. 26 (Blow, CSAT, 1998b) includes an extensive discussion of these and other methods.
The study of treatment outcomes for older alcohol abusing/dependent adults has become a critical issue because of their unique needs for targeted treatment intervention. Because traditional residential alcohol treatment programs generally serve very few older adults, small sample sizes have presented a formidable barrier to the systematic study of formalized treatment outcomes for older adults. The development in recent years of elder-specific treatment programs has resulted in sufficiently large numbers of older adults being served to begin promoting empirically based treatment of this special population (Atkinson, 1995). The lack of longitudinal studies on treatment outcomes remains a major limitation in our knowledge base. More work is needed to determine: (1) if elder-specific formalized treatment is effective; (2) if clients in an elder-specific program show better outcomes than clients in a mixed-age program; and (3) the effectiveness of alternative treatment approaches.
Summary and Recommendations
A spectrum of approaches exists for intervening with problems related to alcohol and combined alcohol-medication use in older adults. The chosen approach should be tailored to the characteristics of the individual client, taking into account:
- the nature of the alcohol use problem, alcohol-related symptoms, age of onset, patterns of use, and readiness to change
- cultural background
- medical, mental health, and social needs
- the availability of, or barriers to, resources
Changes in managed health care environments affect social work practice. Ideally, these changes will contribute to improved intervention, in terms of cost, effectiveness, and innovative techniques/technologies. A full continuum of prevention/intervention strategies for older adults includes:
- prevention/education for persons who are abstinent or low risk drinkers
- minimal advice and structured brief intervention protocols for problem drinkers
- formalized treatment for older persons with alcohol abuse/dependence
This range of service options provides social workers with the tools essential for providing badly needed, high quality care to older adults across the spectrum of alcohol use disorders.
A report by the Institute of Medicine (1990a) found that, across age groups, most alcohol-related problems occurred in non-dependent drinkers. This is particularly true in older adulthood. Screening, brief intervention protocols, and brief therapies can be inexpensive and less costly than a single emergency room visit for an alcohol-related injury, regardless of age. The implementation of alcohol screening and brief intervention strategies can be enhanced by the development of systematized protocols that provide easier service delivery in a milieu where clinicians see more and more clients with less and less time available per client. Both from a public health standpoint and from a clinical perspective, there is a critical need to implement empirically proven, effective intervention strategies with a variety of older drinkers who are at risk for more serious health, social, and emotional problems.
While substantial progress has been made in our understanding of the effectiveness of alcohol screening, brief interventions, and treatments with older adults, it remains to be determined how these protocols fit into the broad spectrum of health care settings and how to target specific interventions/treatments to appropriate subgroups of clients. Social work training, which integrates mental and physical health care perspectives, provides a strong and ideal basis to incorporate effective screening, interventions, and treatments for alcohol problems in the older adult population. Effective integration can lead to state-of-the-art 'best practices' care for a vulnerable and growing population.
Professional social workers, preparing for practice in a variety of clinical settings that serve older adults, should be prepared for (1) recognition and assessment of alcohol use problems and (2) initial management and referral. Emerging educational and certification programs are including recommendations in these domains to enhance prevention and treatment efforts with older adults who are at-risk for, or currently have, alcohol or other substance use problems. Several critical core competencies are relevant to these recommendations:
- All social workers should know how to screen for the quantity and frequency of alcohol and other drug use among older adult clients. Approximately 8-15% of older adults (Adams et al., 1996) are at-risk drinkers or drink at relatively low levels that still compromise cognitive and/or physical conditions. Additionally, some older adults also use prescription, over-the-counter, and/or herbal medications that may have a negative outcome if used in combination with alcohol. Social workers need to systematically address alcohol and other substance use as part of routine practice with older adults. Far too few clinicians are trained in appropriate, empirically supported screening approaches that are effective with older adults.
- All social workers should be knowledgeable about the recommended upper limits of moderate drinking for all age groups. (This includes knowledge about standard drink measurement.) Social work curricula seldom include study of such materials as the USDA (Dietary Guidelines Advisory Committee, 2000, p. 38) and the NIAAA (1995b) guidelines for alcohol consumption. (This is equally true of many other helping disciplines, including psychology and medicine.) To effectively assess at-risk or problem drinking among older adults, including alcohol-other substance interactions, social workers should become familiar with up-to-date guidelines and research evidence.
- All social workers practicing with older adults should have a comprehensive working knowledge of the physical, emotional, and social problems associated with alcohol use, abuse, and dependence in relation to older adults and aging processes. This must include familiarity with current knowledge concerning medication misuse and alcohol/medication interactions. It is important that social workers be able to discern symptoms of physical, cognitive, mental health, or social problems from symptoms of alcohol use disorders, and to recognize how these disorders and symptoms may interact. Many signs and symptoms among older adults are complex, subtle, and easily confused. Proper differential diagnosis is essential to creating relevant and effective treatment plans.
- All social workers should be competent and comfortable in providing structured, targeted, brief interventions to assist older adults to reduce or eliminate alcohol use. Advice and brief interventions can be delivered as part of early detection programs in a wide variety of clinical settings. Brief alcohol interventions have been demonstrated to be effective with older at-risk drinkers and those who drink at lower levels that still compromise cognitive or physical conditions. These interventions require short, concentrated training sessions that include motivational interviewing and the use of structured materials to support the interventions. Examples of these types of materials are available through the National Institute of Alcoholism and Alcohol Abuse (http://www.niaaa.nih.gov/publications) and through the Center for Substance Abuse Treatment (CSAT) in the Treatment Improvement Protocols (TIP) series (e.g., Blow, 1998b; Barry, 1999). Training can be made available to professionals who work with older adults through pre-clinical, clinical, continuing education, professional organization, and other personnel development opportunities. Such training is necessary because brief, effective methods of dealing with alcohol use disorders are both clinically and cost effective.
- Access, read, and report on at least one of the following recommended reference materials: NIAAA alcohol use guidelines, including older adults (1995); Treatment Improvement Protocol on Brief Interventions and Brief Therapies in Substance Abuse Treatment (Barry, CSAT, 1999); or each of the websites discussed in this module.
- Read and report on the following book: Barry, K.L., Oslin, D., & Blow, F.C. (2001). Alcohol problems in older adults: prevention and management. NY: Springer Publishing Co. (including workbooks in English and Spanish).
- Select 3 aging-related physical and/or psychological changes described in this unit. Develop a means of mimicking the effects in a person your own age (e.g., vision changes may involve a light layer of Vaseline on sunglasses lenses; mobility restriction may involve borrowing a walker and/or wheeled office chair; loss of smell may involve nose plugs; hearing loss may involve noise/ear plugs, etc.) Spend some time experiencing these changes and discuss, as a group, how these changes might affect the social work process. Also discuss how a social worker might tell the difference between changes due to these processes and changes that might be tied to alcohol use problems.
- Develop an eco-map for an elderly client or a fictional character. Analyze its strengths and limitations. Pay particular attention to elements that might support the emergence and persistence of alcohol use problems and elements that might support efforts to change or prevent alcohol use problems.
- Find out the legal blood alcohol level for driving in your community (e.g., .08 in many states). Consider the implications of having this level apply to older drivers. What are the ethical and practical implications? Can and should anything be done to change this situation?
- Discuss the elements of a media campaign designed to prevent low-risk and moderate older drinkers from becoming high-risk or dependent drinkers. What would be special about a campaign targeting this age group versus all age groups?
- Discuss the recommendations for social work training in this module and consider a variety of options and plans for becoming well-prepared for professional practice with this population.
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Updated: March 2005