Alcohol Misuse In Alcohol Misuse In Older AdultsOlder Adults
Our invisible addicts
0 5000 10000 15000 20000
Illicit drugs
Physical inactivity
Fruit and vegetable intake
High Body Mass Index
Cholesterol
Alcohol
Tobacco
Blood pressure
EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000)
Number of Disability-Adjusted Life Years (000s)
1990 2009
% of men 65+ 14 20
% of women 65+ 5 10
(Office of National Statistics)
>21 Units per week (men) & >14 per week (women)
‘SENSIBLE LIMITS’ (‘HAZARDOUS/HARMFUL’) (Royal Colleges 1995)
42% of older homeless men
15% of older medical in-patients
Fewer than 5% of community residents
ALCOHOL DEPENDENCE SYNDROME
1991-1997 1998-2004
Men aged 75+ 21.7/100,000 25.7/100,000
Alcohol-related mortality in men - London (Office of National Statistics)
2008-2010
Men aged 75+ 64.9/100,000
Alcohol-related mortality in men - Southwark (Office of National Statistics)
LOCAL CMHT DATALOCAL CMHT DATA
1 in 7 people with depression had alcohol dependence
Prospective study of CMHT referrals from Jan - Dec 02
OBSERVATIONS IN PEOPLE OBSERVATIONS IN PEOPLE DRINKING ABOVE ‘SENSIBLE’ DRINKING ABOVE ‘SENSIBLE’
LIMITSLIMITS
• 43% showed ICD ‘alcohol dependence syndrome’
• 71% had suffered physical problems
• 57% admitted to MH Ward or presented to A&E
• 21% showed ‘harmful use of alcohol’
PEOPLE AGED 65 AND OVER
PROJECTED POPULATION OF ENGLAND 2001-2031
7.8
16
8.6
17
10.2
19
12
22
0
5
10
15
20
25
Population of England (million) % of Total
2001
2011
2021
2031
Gender differences in Gender differences in older peopleolder people
Women with alcohol misuse more Women with alcohol misuse more likely to:likely to:
Be widowed/separated/divorcedBe widowed/separated/divorced Have spouse with alcohol misuseHave spouse with alcohol misuse Have history of depressionHave history of depression More negative effects from alcoholMore negative effects from alcohol Take psychotropic medicationTake psychotropic medication
Early onset (65%) Late onset (35%)
Age varies (<25, 40, 45) Age varies (>55, 60, 65)Men > women Women > menLower socioeconomic status Higher socioeconomic status Stressors common
Stressors common Family History likely Family History unlikelyLegal/Work problems Problems with daily routineChronic medical illness Acute medical illnessAmnestic Syndrome Alcohol-related dementiaLess treatment compliance Greater treatment compliance
Characteristics of early vs late-onset problem drinkers
Warfarin
Antihistamines
Benzodiazepines
Aspirin
Acid reducing drugs
Opiate containing painkillers
Antibiotics
Drugs for diabetes
Paracetamol
Alcohol interactions in older adults
Alcohol and the body- consequences for Alcohol and the body- consequences for older peopleolder people
Decreased lean body mass Decreased lean body mass
Decreased total body waterDecreased total body water
Decreased level of liver enzyme that breaks Decreased level of liver enzyme that breaks down alcoholdown alcohol
Higher blood alcohol concentration Higher blood alcohol concentration than younger people, for given than younger people, for given number of unitsnumber of units
Effect of physical health Effect of physical health statusstatus
Threshold for ‘at risk’ use decreases Threshold for ‘at risk’ use decreases with agewith age
Higher risk of other diseases Higher risk of other diseases
(e.g. hypertension, diabetes, dementia)(e.g. hypertension, diabetes, dementia)
Body sway increases with ‘sensible Body sway increases with ‘sensible drinking’ drinking’ and normal blood alcohol and normal blood alcohol levellevel
Shopping Using public transport/driving Taking medicationCooking Other houseworkManaging finances
Activities of daily living and alcohol misuse
Drinking > 8 units per week associated with impairment in domestic activities
Chronic Alcohol UseChronic Alcohol Use
Liver DiseaseLiver DiseaseCirrhosisCirrhosis
Coronary Artery DiseaseCoronary Artery DiseaseCardiomyopathyCardiomyopathyArrhythmiaArrhythmiaHypertension Hypertension StrokeStroke
Duodenal ulcerDuodenal ulcer
Cognitive disordersCognitive disordersCVACVAPsychosisPsychosisDepressionDepression
PancreatitisPancreatitisDiabetesDiabetes
Head, Neck, GI cancersHead, Neck, GI cancers
Stomach ulcerStomach ulcerGastritisGastritis
NeuropathyNeuropathyAnaemia Anaemia Nutritional DeficienciesNutritional Deficiencies
NORMAL BRAIN WERNICKE’S ENCEPHALOPATHY
• Homelessness
• Recent bereavement
• Depression
• Social isolation
HIGH RISK GROUPS
• Past harmful/hazardous drinking
• 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’
UNDER-REPORTING Seen as a moral weakness
Stigmatising
Care of the Elderly physicians less likely than general physicians to screen for alcohol use
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 educationHigher social classWidows
SUICIDE
ACCIDENTS(FALLS)
SELF NEGLECT
PHYSICALDISORDERS
MENTALDISORDER
ALCOHOL
ELDER ABUSE
DRUGINTERACTIONS
RATING SCALES
Commonly not used in primary Commonly not used in primary AND secondary care, because ofAND secondary care, because of
• Time constraints/competing Time constraints/competing demandsdemands• Insufficient TrainingInsufficient Training• Limited evidence for treatmentLimited evidence for treatment
‘‘Traditional Rating Scales’ lack Traditional Rating Scales’ lack sensitivity and validity, particularly sensitivity and validity, particularly in the elderlyin the elderly
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
IMPLICATIONS FOR EXISTING IMPLICATIONS FOR EXISTING SERVICESSERVICES
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 Recommendations from Our Our Invisible AddictsInvisible Addicts
Improved detection by primary and secondary careImproved detection by primary and secondary care Improved access to treatmentImproved access to treatment Improved training of health professionals Improved training of health professionals Better partnerships between statutory and Better partnerships between statutory and
voluntary sectorsvoluntary sectors Better provision, e.g. for alcohol related brain Better provision, e.g. for alcohol related brain
injuryinjury Prioritisation in government policyPrioritisation in government policy Prioritisation for research into extent of problem, Prioritisation for research into extent of problem,
detection, treatment and health/social care detection, treatment and health/social care outcomesoutcomes
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