Alcohol and Aging - Do Ask, Do Tell
Social Work Today
By Leah Ruffin, MSW, and Lenard W. Kaye, DSW
Vol. 4 No. 4 p. 24

Retired college professor Dr. Franks lives alone in his quiet Vermont community. His service to the university was uneventful, although years ago, some rumors circulated about a drinking problem delaying tenure. After the death of his wife, his family notices that he has been more withdrawn and has begun having increasing short-term memory problems. His son wonders if he’s experiencing symptoms of dementia, although he seems fine when the family comes for extended visits. Last night, his daughter was called to the emergency department after a neighbor heard Dr. Franks’ cries for help. He had fallen in the kitchen. The hospital social worker detects a faint smell of alcohol on Dr. Franks’ breath and conducts an assessment of the retiree’s past and present alcohol use. His family is surprised when the social worker suggests treatment options, including an Alcoholics Anonymous group facilitated by other older adults.

Mrs. Winthrop has been at Sunset Assisted Living Center for the past six months. While she lived at home, she always enjoyed meeting her friends for afternoon cocktail hour; however, she always drank moderately. Since she moved to Sunset, Mrs. Winthrop has had several arguments with the staff, who want her to stop drinking completely. They claim she’d been found drunk several times, although Mrs. Winthrop denies the accusations. Her physician, apparently unaware of the drinking issue until recently, says Mrs. Winthrop should only drink moderately with her medications. She hasn’t asked her physician about, nor has he volunteered to discuss, the effects of alcohol on some of the antianxiety medications she brought with her from home. Her favorite nurse at the center made her an appointment to speak with the social worker last week. Mrs. Winthrop was surprised when the social worker gave her materials about the increased effects of alcohol on medication in older adults.

Older Adult Drinking
Although past research has long focused on the drinking habits of younger and middle-aged adults, older adult drinking is being reexamined as a growing area of concern. In general, the number of people in the general population who drink is known to decline with age (Health and Human Services, 2000). However, older adults are not immune to alcohol- and drinking-related problems. As the nation’s population ages, the number of older adults with alcohol problems and alcohol-related problems is expected to rise (Fink, et al., 2002; Hinkin, et al., 2001; Kraemer, Conigliaro, & Saitz, 1999). In fact, many anticipate an increase in later-life problem drinking based on the number of middle-aged adults currently using alcohol (Brennan & Moos, 1996; Klein & Jess, 2002). For many adults, even continuing moderate alcohol use may cause significant health-related problems as they age (Health and Human Services, 2000).

Reported rates of alcohol-related problems in older adults vary; however, a recent survey in the Journal of the American Geriatric Society reported a national prevalence between 20% and 22% (Fink, et al., 2002). Others report alcohol abuse and dependence rates of 5% to 10% among older primary care outpatients (Kraemer, et al., 1999) and up to 50% of older patients utilizing psychiatric hospitalizations (Hinkin, et al., 2001). Between 25% and 50% of nursing home residents display active symptoms of problem drinking (Klein & Jess, 2002).

Many attribute the wide range in the proportions of reported older problem drinkers to inconsistent definitions of problem drinking, including alcohol dependence and alcohol abuse. Alcohol abuse, as explained by the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) and the International Classification of Diseases, is distinguished by continued drinking despite negative effects on family, work, and personal health status or evidence of resultant trauma. Alcohol dependence is characterized by the person’s continued consumption of alcohol despite problems involving behavioral, cognitive, and physical symptoms. Craving, impaired control, physical dependence, and tolerance are often noted (Barrick & Connors, 2002).

Health Effects
Alcohol-related health consequences threaten older adults in unique ways. Physically, alcohol consumption may affect older adults differently than when they were younger, causing higher blood alcohol content in proportion to the amount ingested (Klein & Jess, 2002), increased risk of alcohol-related falls and hip fractures (Harvard Health Publications, 2001; Fink, et al., 2002), and potential medication complications. Alcohol-related hospitalizations are reported to rival the rates of hospitalization for myocardial infarction among older adults (Fink, et al., 2002), and the National Highway Traffic Safety Administration reports that 11% of all drivers aged 65 to 74 involved in fatal automobile crashes in 1994 were positive for alcohol use (Health and Human Services, 2000). Other health risks linked to alcohol abuse include hypertension, congestive heart failure, liver disease, stroke, and alcohol-induced dementia (Keren, 2003).

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) suggests that older adults limit alcohol intake to one drink per day (Harvard Health Publications, 2002).

Problem Predictors
Several predictors of alcohol consumption and drinking problems are often highlighted in research. Although alcohol use by older adults declines in general, older men have been noted more likely to drink than older women, and more separated and divorced older adults have problem-drinking behaviors than widowed persons. Several studies have noted a rise in older-adult problem drinking occurring briefly after retirement (Barrick & Connors, 2002).

The link between stress and problem drinking in older adults is well-documented (Barrick & Connors, 2002; Brennan & Moos, 1996). Older men who experience increased stressors involving a spouse commonly report an increase in drinking-related problems, as do older women who experience negative life events or multiple financial stressors. It is noteworthy that many of those who drink heavily actually report an increase in certain life stressors as drinking behavior increases (Brennan, Schutte, & Moos, 1999).

Remarkably, not all life stressors are associated with increased older adult alcohol consumption. In fact, many older adult women with health-related stressors are less likely to consume alcohol than their healthier, more active counterparts, while older men living in poverty or being faced with financial stressors may also drink less than those who have a higher income (Welte, 1998; Brennan & Moos, 1996).

Looking at a person’s past response to stress and resultant alcohol use is likely to be a beneficial tool for the clinician. Current life stressors can be expected to play a factor in current drinking for those who experienced negative alcohol-related consequences in the past (Welte, 1998).

Commonly, older adults with drinking problems are described in terms of the age in which drinking began—that is, either as early- or late-onset drinkers. Late-onset drinkers, who typically begin drinking after retirement, are more likely to be older women, consume less alcohol, receive more emotional support from family and friends, describe less health-related stressors, and report fewer physical symptoms (Brennan & Moos, 1996). In contrast, early-onset drinkers describe an increased family history of alcohol abuse. They may also display the greater likelihood of co-occurring psychiatric disorders (Barrick & Connors, 2002).

A recent NIAAA report suggests that as the population ages, differences in drinking patterns between men and women may be lessening, particularly for those in the baby boomer cohort. Other projections show our nation’s Hispanic population is increasing, while noting that of those who drink, Hispanic men have the highest incidence of frequent heavy drinking among all racial/ethnic groups (Health and Human Services, 2000). Still, Caucasian men, slated to remain the largest subgroup of the elder population, have traditionally used alcohol as older adults. They will continue to have higher income and education levels of all older adult subgroups—demographic characteristics known to lead to a leisure-focused lifestyle more conducive to the use of alcohol.

Underdiagnosis
Alcohol use and alcohol-related problems unfortunately are often underdiagnosed by professionals in the geriatric field (Widlitz & Marin, 2002). Some clinicians are simply unaware of the prevalence of older problem drinkers. Often, older adults are less likely to seek treatment than younger problem drinkers (O’Connell, Chin, & Cunningham, 2003).

Many times, the symptoms of older problem drinking present differently than in younger clients, being masked by or resembling other medical conditions, leading to a misdiagnosis (Hinkin, et al., 2001). Common medical conditions associated with substance-use disorders include elevated liver function tests (including hepatitis and cirrhosis), pancreatitis, gastritis, arrhythmia, lower extremity neuropathy, alcoholic bowel disease, immunodeficiency, megaloblastic anemia, hypomagnesemia, hypophosphatemia, and new seizure activity (Widlitz & Marin, 2002).

Older adults with drinking problems may present with symptoms that can be confused as common signs of aging. Substance abuse disorders may influence the elder’s mental health, manifesting as mood swings, depression, irritability, insomnia, or hypersomnia. Increasing social and family isolation is often typically associated with substance abuse disorders. The person may experience loss of physical mobility or begin to have unexplained accidents and falls. They may have deterioration in hygiene, increasing chronic pain, or declining cognitive functioning (Widlitz & Marin, 2002).

Screening Tools
Typical screens for problem drinking may not be appropriate for use with older adults because of their reliance on work and family problem-related questioning (Fink, et al., 2002). Several short screening instruments have been shown to be useful when working with older adults. The 10-question Brief Michigan Alcoholism Screening Test is recommended as reliable with older adults (Cherpitel, 1997) and the widely used CAGE, recently tested with adults over the age of 60, showed moderate sensitivity and specificity when a cut-off score of 2 was used to define problem drinking (Hinkin, et al., 2001). (Sensitivity is defined as the number of participants with a condition that the instrument identifies as having the condition while specificity is the number of participants without a condition that the instrument correctly identifies [Cherpitel, 1997].)

The CAGE test is an acronym for the following questions: (1) Have you ever felt you should Cut down on your drinking?; (2) Have people Annoyed you by criticizing your drinking?; (3) Have you ever felt bad or guilty about your drinking?; and (4) Have you ever had a drink first thing in the morning (i.e., as an eye-opener) to steady your nerves or get rid of a hangover (Cherpitel, 1997; Hinkin, et al., 2001)? CAGE may work well because of a lack of age-specific questions and because it provides the clinician with the opportunity to follow up with detailed questions; however, limitations include the instrument’s limited ability to screen for multiple substance abuse disorders (Hinkin, et al., 2001) and active drinking vs. inactive drinking (Widlitz & Marin, 2002). Modifications to the CAGE might include beginning the screen with instructions to answer within the context of the last year (Widlitz & Marin, 2002). Clinicians should also gather information from all available sources, including family, friends, and caregivers, whenever possible.

The vital lesson, no matter the preference of screen, is to ask older adults about their alcohol consumption so treatment can begin. Frequent clinical recommendations include treatment tailored to the needs of older adults in the same age settings (O’Connell, et al., 2003).

Work and social skills development, often the focus of younger adult treatment programs, are not as applicable to older problem drinkers. A study of older VA patients showed improved results in programs with more structured policies, flexible discharge procedures, in-depth assessments, and increased postprogram mental health treatment (Brennan & Moos, 1996).

Many older adults may respond to treatment practices that are nonconfrontational, focus on coping skill building, and offer health links (Barrick & Connors, 2002). Group therapies and self-help groups may also be particularly effective for older adults who express the presence of significant social stressors.

Implications for Social Work Practice
Social workers who work with older adults must be aware of the possibility of alcohol-related problems present in their clients. Even moderate amounts of alcohol consumption can play an important role in increasing health risks. Social workers need to help educate their clients that what might have been a safe amount of alcohol use in the past may now cause significant problems. Depression, compounded by alcohol-related problems, is a major concern for older adults, as is increased risk of falling and complications with medications.

Screening should not be limited to assessing disruptions in work responsibilities or family status. Furthermore, it is important to keep in mind that physical symptoms may often go undetected or mirror other health problems. Because many older adults may see more than one physician or primary care practitioner and use more than one pharmacy, clinicians need to conduct a comprehensive assessment, including obtaining input from as many sources as possible.

It is also important to understand that there are treatment options for older adults struggling with alcohol-related problems. Many self-help group programs focus on older drinkers, and many treatment facilities are offering age-specific programs.

While the likelihood of alcohol abuse may decline as people age, alcoholism remains a serious, life-threatening problem for significant numbers of older adults. Social workers should see themselves as a critical force in assessing for abuse and promoting treatment for those elders at risk.

— Leah Ruffin, MSW, is coordinator of the University of Maine Center on Aging.

— Lenard W. Kaye, DSW, is a professor and director at the University of Maine School of Social Work and Center on Aging.

Due to space limitations, we were unable to include this article’s references. However, the references are available upon request by e-mailing SWTeditor@gvpub.com.