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Last December a seminar of stakeholders was arranged by Age Concern and the Institute of Alcohol Studies to discuss the development of national policy on alcohol and older people.

I attended the meeting as a representative of the BGS Policy Committee. It was chaired by Professor Ian Gilmore and included participants from the Department of Health, Royal Pharmaceutical Society, Age Concern and Institute of Alcohol Studies.

Alcohol abuse has attracted government and media attention in recent years, but the spotlight is dominated by younger people and associated binge drinking, public order and criminal justice issues. There is a large but under-detected group of older people with chronic physical and mental health problems misusing alcohol. This is a neglected area in research, policy and practice.

The size of the problem
22% of men and 11% of women over the age of 65 in the UK exceed government recommended “sensible limits” for regular alcohol consumption and these proportions are steadily rising.¹ There is a question whether these limits are appropriate for older people, as they are based on evidence for younger age groups. There is no consensus as to what are the safe levels of alcohol intake for older drinkers, who have increased risk of depression, dementia, falls and physical illness.

Current and future generations of older people may be relatively heavier drinkers than previous generations, perhaps with a larger proportion of problems related to long term moderate drinking.

Geriatricians are trained to recognise and treat physical illness and cognitive problems but receive little formal training in detecting and managing the alcohol problems that may underlie them.

Screening
Healthcare professionals caring for older people need to screen for alcohol misuse.

The “SMAST-G” screening tool is the most validated in the elderly population.²

However, to avoid confusion it is best to use one consistent tool for professionals targeting mixed groups of all ages; with the “AUDIT” tool most widely recommended.³

Specialists dealing with older people can then, if needed, use more specific tools.

When to screen?
It is difficult to target older people misusing alcohol as they present to many different services. Screening should be part of standard primary care review of older people but opportunistic screening should take place too, e.g. on admission to hospital. There is evidence that geriatricians are less likely to screen for alcohol abuse than general physicians.⁴ Other points in life that may represent a higher risk period where screening could occur include the transition from work to retirement, and after bereavement.

Evidence that alcohol screening alters the outcome for older people is limited, however this should not be used as an excuse that it is not effective. The few studies that have been done show that older people benefit from intervention and follow up to the same extent or better than younger people. There is some evidence that managing older people with alcohol problems can reduce length of stay, and improve physical and mental health.⁵

Outcomes
Participants developed a greater awareness of the difficulties facing healthcare professionals, not only in recognising and managing alcohol misuse in older people, but in promoting the issues at a national level.

Specifically for geriatricians there is a need to work more closely with old age psychiatrists and alcohol support workers.

Core components of a National strategy on alcohol use in older age:

i) Improving detection. Training and educating all care professionals working with older people; including community matrons, social workers, pharmacists, GPs, geriatricians and A+E staff.

ii) Promoting multi-disciplinary care. To involve psychiatrists, geriatricians, alcohol support workers, social workers and pharmacists; requiring collaboration between health, social care and the voluntary sector. This could include development of “local” champions with good clinical leadership promoting screening, brief intervention and follow up, and may not require a lot of additional resources.

iii) Research. There needs to be more extensive research into the effects of alcohol in older age.

Alison Cracknell

References:

1. General Household Survey 2006, Office of National Statistics.

2. Short Michigan Alcoholism Screening Test- Geriatric Version, University of Michigan Alcohol Research Centre 1991

3. The Alcohol Use Disorders Identification Test, World Health Organisation

4. Carrington Reid M et al. Physician awareness of alcohol use disorders among older patients. J Gen Intern Med 1998; 13(11):729-734.

5. Kominski G et al. UPBEAT: The impact of a psychogeriatric intervention in VA medical centers. Medical Care 2001; 39(5):500-512.

BGS Newsletter, March 2009
Issue 20 ISSN 1748-6343 20