Challenges in Identifying and Treating Alcohol Use Disorder in the Elderly

Introduction

There is a rise in the number of mature people with alcohol misuse and such people have complex needs (Rao, Crome, Crome, & Iliffe, 2019). Some of these complex needs relate to the identification of the disorder and then providing interventions for the same. This essay discusses the difficulties in identifying alcohol use disorder in the elderly in the first part. The second part discusses the difficulties in treatment of people in the mature age group.

Difficulties in identification of alcohol use disorder

Professionals related factors

Certain reasons make it challenging for health professionals to identify alcohol use disorder in mature adults. These are discussed below.

Gilson (2015) reports that drinking generally decreases with age and this gives rise to a perception that alcohol use is not a condition that affects mature adults. However, for a small proportion of mature people, alcohol abuse may increase especially in affluent, unmarried, less religious, Caucasian, highly educated males who do not perceive higher risk with alcohol use(Barry & Blow, 2016). Health professions may not encounter mature adults with alcohol use disorder with the same frequency as in other age groups and thus may perceive that the amount of alcohol used is not harmful in reference to adult guidelines(Gilson, 2015).

One of the reasons why mature adults may evade early detection of alcohol use disorder is that many of such people live alone and are retired; DSM 5 criteria for substance use and the CAGE questions are effective in identifying those who live with someone and are working(Lehmann & Fingerhood, 2018). Lack of screening tools in elderly with cognitive impairment(O’Connell, 2003) and the inability of the screening tools to effectively evaluate and detect risks from previous level of drinking in mature persons(Abuse, 2020) means that many such people are not helped. Furthermore, mature people may also evade suspicion because they continue to function in the usual way (DiBartolo & Jarosinski, 2017 ).

Another possible reason for evasion of detection may be the practitioner’s assessment of health concerns associated with alcohol use disorder as a function of age and not alcohol use disorder. Thus, symptoms, such as, sleep disturbance, memory, falls or poor diet may be mistakenly assessed as age related issues (DiBartolo & Jarosinski, 2017 ). Furthermore, the practitioner may choose to pay more attention to the elderly person’s more urgent health issues rather than explore further if the person has alcohol use disorder(Gilson, 2015).

To summarise, ageism in health care practitioners, and numerous complaints at time constricted consultation in the elderly are also barriers to detection(Rao, Crome, & Crome, Managing older people’s alcohol misuse in primary care, ,2016).

Patient related factors

The 2016 National Drug Strategy Household Survey sampled 11886 Australians over age 50, and found that 17% older Australian drank at risky levels(Chapman, Harrison, Kostadinov, Skinner, & Roche, 2020). 39% males and 11 % of females were found to overestimate effects of long term low risk drinking, while 54% males and 20% females overestimate effects of short term low risk drinking(Chapman, Harrison, Kostadinov, Skinner, & Roche, 2020).

The University of Michigan National Poll 2021 on Healthy aging sampled 2023 adults aged between 50-80, and found that only 19% mature adults sought help when 23% drank 3 or more standard drinks a day and 1 in 10 were using marijuana, sedatives, pain medication or other illicit drugs(Healthy aging poll, n.d.).

A systematic quantitative study reveals several important themes or reasons that may contribute to elderly excess drinking(Bareham, Kaner, Spencer, & Hanratty, 2019). These themes include social reasons (desire to maintain social networks, fear of decrease of socialisation (Bareham, Kaner, Spencer, & Hanratty, 2019). Literature suggests that safe drinking levels for younger people may be higher as compared to the mature adults, but that the latter may be drinking the same levels without realising that these levels are unsafe for them (Barry & Blow, 2016); this could be because of physiological changes with age(DiBartolo & Jarosinski, 2017 ).

Known stressors associated with triggering alcohol misuse are often encountered in later life – loneliness, physical illness, retirement, losses (DiBartolo & Jarosinski, 2017). Mature adults may have more spare time, perceive themselves to be more responsible drinkers, and may mistakenly believe that they are drinking in responsible limits (Bareham, Kaner, Spencer, & Hanratty, 2019). Furthermore, like the health professionals, the elderly may attribute their health issues to other problems or they may not notice the health impact(Bareham, Kaner, Spencer, & Hanratty, 2019). Mature people may also deny known drinking problems due to generational stigma of shame thus fail to disclose (DiBartolo & Jarosinski, 2017). They may also choose to drink alone, thus escaping attention from their close friends and family members (Bareham, Kaner, Spencer, & Hanratty, 2019). Family members may also avoid disrespecting the older person and not raise the issue of alcoholism (DiBartolo & Jarosinski, 2017).

The above factors are also seen in another country; in a survey of 100 community living elderly in Brazil between age 60 to 79, the use of alcohol was found to cope with bereavement, loss of role in the workplace and in the family, financial and physical dependence with age (Garcia, Bassitt, & Pinto, 2020).

Difficulties in treatment

Health professions lack training in how to approach mature people on their drinking and may therefore fail to provide effective pathways for treatment(Gilson, 2015).

Yet, the elderly are more vulnerable to alcohol related adverse events. The likelihood of increase of comorbid physical conditions with age (Gilson, 2015), risk of conditions like fatty liver, alcoholic hepatitis, cirrhosis, certain cancers (DiBartolo & Jarosinski, 2017), and risk of cardiovascular conditions, make the elderly susceptible to alcohol related health problems (Alcohol and Cardiovascular Disease in the Geriatric Population, n.d.). Alcohol related harms exacerbate peripheral neuropathies, osteoporosis, hypotension and sleep difficulties which in turn increases potential complications from falls (Overview of the Chronic Neurologic Complications of Alcohol - UpToDate, n.d.).

Because of these comorbidities, alcohol withdrawal is best conducted in hospital. Cognition, lack of insight can affect the elderly’s agreement to be treated (Overview of the Chronic Neurologic Complications of Alcohol - UpToDate, n.d.).

The association of alcohol use and multiple physical conditions calls for multidisciplinary input– geriatrician to manage withdrawal and medical conditions; pharmacist might be needed to review interactions of medications (Lehmann & Fingerhood, 2018). Co-management is rare but necessary(Rao, Crome, & Crome, Managing older people’s alcohol misuse in primary care, ,2016).

Financial restrictions in retirement, loss of mobility and transport may preclude a mature person from accessing help(Bareham, Kaner, Spencer, & Hanratty, 2019). Community older adult psychiatric services with a home based model of care may be needed but often psychiatric services decline patients with primary substance misuse(Rao R. , Crome, Crome, & Iliffe, 2019).

Furthermore, psychiatric clinicians may not have the necessary addictions knowledge for mature adults alcohol misuse, while traditional addiction clinicians are not trained to recognise cognitive impairment or health impact in the elderly (Rao et al., 2016). The lack of integrated medical, addictions or psychiatric care makes difficult to provide for comprehensive care of the elderly (Abuse, 2020). The problem is compounded by the lack of peer support to find a cohort mature adults would feel comfortable to seek support from (DiBartolo & Jarosinski, 2017).

It is concerning that in a small study that provided training in screening and brief intervention for mature adults to 93 healthcare practitioners, found little difference in practitioner’s commitment or willingness to promote these interventions (Coogle & Owens, 2015). Clinicians should be mindful to avoid therapeutic nihilism. Barry and Blow (2016) report that intervention studies for mature adults from non-addiction specialists in social service settings have found screening and brief interventions led to reduction in sustained alcohol reduction from 2 to 18 months in mature adults. Of the few studies on alcohol treatment outcomes for mature adults, participants have been found to have better adherence to drinking goals than younger adults. Mature adults who have been through residential treatment had better long term outcomes than younger patients (Barry & Blow, 2016). Two systematic reviews have found that treatment of substance misuse in mature adults have better outcomes (Rao & Roche, 2017).

Finally, clinicians need to be aware that pharmacological treatments like naltrexone may have limited use if the elderly has pain conditions requiring opioids (MIMS , 2021). while Disulfiram may not be safe in elderly with cardiac conditions(MIMS , n.d.).

Conclusion

Clinician’s bias, lack of appropriate screening instruments, misconceptions of families and patients on safe drinking are some of the reasons why mature adult alcohol misuse may go undetected. Vigilance in emergence of stressors like bereavement, ill health, immobility and retirement should prompt clinicians and families to be more alert to the elderly’s substance use. Alcohol misuse has more severe health implications for the older adult, however, once the problem is identified, older adults respond well if not better, to treatment. Access to Coordinated multidisciplinary input to treatment of medical issues, social work, as well as motivational interviewing are effective in helping the elderly to overcome alcohol misuse in later life.

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