Alcohol Misuse In Older Adults Alcohol Misuse In Older Adults Our invisible addicts

EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000) Number of Disability-Adjusted Life Years (000s)

% of men % of women (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

Men aged /100, /100,000 Alcohol-related mortality in men - London (Office of National Statistics) Men aged /100,000 Alcohol-related mortality in men - Southwark (Office of National Statistics)

LOCAL CMHT DATA 1 in 7 people with depression had alcohol dependence Prospective study of CMHT referrals from Jan - Dec 02

OBSERVATIONS IN PEOPLE DRINKING ABOVE ‘SENSIBLE’ LIMITS 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

Gender differences in older people Women with alcohol misuse more likely to: Be widowed/separated/divorced Be widowed/separated/divorced Have spouse with alcohol misuse Have spouse with alcohol misuse Have history of depression Have history of depression More negative effects from alcohol More negative effects from alcohol Take psychotropic medication Take psychotropic medication

Early onset (65%)Late onset (35%) Age varies ( 55, 60, 65) Men > women Women > men Lower socioeconomic statusHigher socioeconomic status Stressors common Stressors common Family History likelyFamily History unlikely Legal/Work problemsProblems with daily routine Chronic medical illness Acute medical illness Amnestic Syndrome Alcohol-related dementia Less 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 older people Decreased lean body mass Decreased total body water Decreased level of liver enzyme that breaks down alcohol Higher blood alcohol concentration than younger people, for given number of units

Effect of physical health status Threshold for ‘at risk’ use decreases with age Threshold for ‘at risk’ use decreases with 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 drinking’ and normal blood alcohol level Body sway increases with ‘sensible drinking’ and normal blood alcohol level

Shopping Using public transport/driving Taking medication Cooking Other housework Managing finances Activities of daily living and alcohol misuse Drinking > 8 units per week associated with impairment in domestic activities

Chronic Alcohol Use Liver Disease Cirrhosis Coronary Artery Disease Cardiomyopathy Arrhythmia Hypertension Stroke Duodenal ulcer Cognitive disorders CVA Psychosis Depression PancreatitisDiabetes Head, Neck, GI cancers Stomach ulcer Gastritis NeuropathyAnaemia Nutritional 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 education Higher social class Widows

SUICIDE ACCIDENTS (FALLS) SELF NEGLECT PHYSICAL DISORDERS MENTAL DISORDER ALCOHOL ELDER ABUSE DRUG INTERACTIONS

RATING SCALES Commonly not used in primary AND secondary care, because of Time constraints/competing demands Time constraints/competing demands Insufficient Training Insufficient Training Limited evidence for treatment Limited evidence for treatment ‘Traditional Rating Scales’ lack sensitivity and validity, particularly in 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 SERVICES 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 Our Invisible Addicts  Improved detection by primary and secondary care  Improved access to treatment  Improved training of health professionals  Better partnerships between statutory and voluntary sectors  Better provision, e.g. for alcohol related brain injury  Prioritisation in government policy  Prioritisation for research into extent of problem, detection, treatment and health/social care outcomes