Alcohol Misuse in the Elderly

Ivan Saeger

M Aamer Sarfraz

Alcohol abuse in the elderly is a complex and important subject. The elderly population is increasing, and Alcohol Use Disorders (AUD) are an underrecognized problem associated with major physical and psychological health complications in this group. In addition to lack of awareness and changing guidelines, current services are not equipped to assess and treat this diverse population due to unenthusiastic attitudes and inadequate training of healthcare professionals, diverse diagnostic criteria, and unfit screening instruments.

We have reviewed various aspects of this complex topic with a view to highlighting the associated issues, apprehensions, and myths.

Definition

There are historical variations in the standards used to define normal and pathological drinking. International Classification of Diseases (ICD-11) divides “Disorders due to the use of Alcohol” into subsections of harmful use, acute intoxication, and withdrawal. For alcohol dependence, two of the following are required: impaired control over alcohol use, increasing precedence of alcohol use over other aspects of life and physiological features indicating neuroadaptation to the substance present over a period of 12 months; or should alcohol use be continuous, then diagnosis may be made over 3 months [1].

Diagnostic and Statistical Manual of Mental Disorders (DSM-V) utilises the term “Alcohol Use Disorder” as a pattern of alcohol consumption, leading to problems associated with two or more of the following: tolerance, withdrawal, difficulties in controlling drinking, neglect of activities, time spent drinking or recovering from effects of alcohol, drinking despite physical/ psychological problems, craving, alcohol consumed in larger amounts or over longer periods than was intended, failure to fulfil major role obligations, recurrent alcohol use in hazardous situations, and drinking despite social/interpersonal problems. Depending on the number of criteria met, Alcohol Use Disorder can be graded in severity as: 2-3 =mild, 4-5 =moderate and 6 or more = severe [2].

In addition to DSM-V and ICD-11, the American National Institute of Alcohol Abuse and Alcoholism (NIAAA) defines “at risk drinking” as consuming four drinks per day or 14 in a week for men, and more than three drinks a day or seven per week for women [3]. “Hazardous drinking” is the term favoured by the World Health Organisation (WHO), which broadly refers to a pattern of alcohol consumption that increases a person’s risk of harm to physical and mental health, and its social consequences [1].

In the UK, healthcare professionals and the public have been guided by publications about the safe limits of drinking. Drinking Sensibly (1981) advised sensible limits as 21 units a week for men and 14 for women [4]. In 1995, the Department of Health’s Sensible Drinking Report revised this to suggest that drinking less than four units for men and three for women per day, was the safe limit [5]. In 2016, there was a further revision in the Chief Medical Officer’s report, which set the same limit for men and women at 14 units per week.

Prevalence

Estimating alcohol abuse is complicated and depends on the methodology used. For example, in the UK, 65 years and above would be considered “elderly”, but global studies have used the age ranges of “50 and above” and “60 and above” [4,5]. Impairments in social, occupational, or recreational activities due to drinking can go undetected if the patient lives alone, has given up driving, and is retired with no risk of losing a job, and has no close family members. Moreover, AUD can mimic other common diagnoses in older adults, including depression and dementia. Stigma can also play a major role in the detection of AUD as many older individuals believe alcoholism to be a moral weakness, and denial is a common response to inquiry.

The amount of alcohol drunk per capita may have doubled over the last 50 years due to social values, individual freedom, and relatively cheap price of alcohol [6,7]. A recent survey in England [7], has highlighted the nation’s drinking habits – 20% of the population had not drunk in the 12 months, 19% drank at increased risk, and 4% were considered at higher risk (>50 units weekly for men and >35 units weekly for women).

The Health Survey (2019) highlighted that increased-risk or higher-risk drinking increased by age group until 65 years; from 65 years to 75 years there was a slight decrease and at 75+ this number fell off sharply [8]. This fits in with the well-documented pattern of alcohol consumption in later life [9] where heavier drinkers die earlier, leaving behind lighter drinking survivors (the mortality hypothesis); older adults reduce alcohol consumption due to deteriorating health (the morbidity hypothesis); due to physiological changes older adults cope with less alcohol (the biological hypothesis); a cohort’s drinking level is related to shared experiences and historical context rather than its stage of life (the cohort hypothesis); alcohol problems are self-limiting (the maturation hypothesis); and that it is difficult to measure accurately the drinking behaviour of older adults (the measurement hypothesis) [10].

Drummond et al [11], reported that 19.7% of the population drank at hazardous levels or above – in comparison with APMS data from 2007 and 2000, this was a stable level. However, compared to previous years, older adults aged 55-64 years were more likely to be drinking at harmful levels or above.

Nuevo et al [12] looked at data collected during 2002-2004 from 14 countries using the WHO World Health Survey about the alcohol consumption of adults aged 60 years and over. They found a pattern of decreasing alcohol consumption with increasing age – 10.2% were classified as heavy drinkers and a further 6.5% were heavy occasional drinkers.

In the US, the National Epidemiological Survey on Alcohol and Related Conditions III (NESARC-III) sampled over 36,000 people during 2012-2013. They reported a prevalence of 13.9% for all alcohol use disorders and 3.4% for severe alcohol use disorders. Consistent with comparable European research, they found age was inversely related to the 12 months’ prevalence of AUDs [13].

The Cost of Alcohol Consumption

Healthcare costs form almost half of the direct costs of alcohol consumption, including in terms of utilization of resources [14].

In recent years, the number of alcohol-related admissions in England rose with age up until 55-64 and then fell – 23% of admissions were people aged 55-64 and 31% those over 65 years [15]. If the criteria were expanded to include hospital admissions where the primary reason or a secondary diagnosis were linked to alcohol, then out of approximately 980 thousand admissions, 24% were for patients aged between 65 and 74 [16].  Similarly, Wadd et al [17] showed that the percentage increase for those over 65 was substantially greater than for those aged 25-64 and that alcohol-related age adjusted death rates were highest in the 55-74-year age group.

There is significant evidence for the causal role of alcohol for different cancers including oesophageal, liver, colon, rectum, and breast cancer and these show a dose-response relationship [18,19]. Alcohol has been shown to be a risk factor for cardiovascular disease and is one of 8 risk factors that account for 61% of cardiovascular deaths. It is also associated with fatty liver, alcoholic hepatitis and liver cirrhosis and the development of these diseases is related to both the duration and amount of heavy drinking [19].

The relationship between mental health and alcohol use is complicated. People with a mental health problem are more likely to misuse alcohol [31]. Alcohol misuse may physiologically cause mental health problems and hazardous drinking may lead to stress and subsequently poor mental health [20]. Mental health conditions may themselves influence changes in alcohol consumption. For example, individuals with personality disorder may be more likely to abstain entirely, whilst social anxiety disorder was chronologically associated with alcohol misuse [21,22,23].

Alcohol is the most used substance among adults aged 65 or older [24]. It is estimated that one-third of older individuals suffering from AUD developed the problem later in life [25]. In addition, some studies indicate that binge drinking among older adults has increased in recent years [26]. Among older men, those who were married were least likely to drink heavily followed by those who are single (never-married) men. In contrast, among older women, those married had the highest levels of alcohol consumption.

In general, African–Caribbean, Muslim, and Hindu women emigrated to the UK reported drinking less than their white counterparts. But among Asian Muslims, Sikhs and Hindus, older men had more alcohol problems than younger men. A combination of ‘Irish’ (greater number of drinks per drinking session) and ‘English’ (greater number of days engaged in drinking) drinking patterns may also be responsible for the greater risk of harmful drinking. This is further compounded by negative stereotyping and low rates of primary care consultation in the Irish population. These factors may influence their access to alcohol services [17]. 

According to the Office of National Statistics (2016), people aged over 65’s made up 18% of the total UK population and by 2066, this will increase to 26% [19]. Therefore, a focus on older adults and alcohol is justified not only for the benefit of the health of that community but also to mitigate an increasing financial and social burden to the state and healthcare provision [17].

Diagnosis and Management

There are several issues and myths about diagnosing and treating alcohol abuse in the elderly. The most important step in managing AUD starts with identification, followed by stabilizing the patient medically and psychiatrically by managing medical comorbidities, ensuring a safe detoxification, and addressing comorbid low mood, anxiety, psychotic, or cognitive issues.

As a cohort, older people may be vulnerable to alcohol because its harmful effects almost all occur in a dose-dependent relationship and are cumulative over time27. While physiological changes expose them to higher peak blood ethanol levels for a given amount of alcohol consumed [28], elderly may have several other factors which negatively interact with alcohol e.g., prescribed medications.

The elderly may have diminished pedal stability and are at higher risk of falls, with estimates suggesting that alcohol may be a factor in approximately 10% of those presenting to the emergency department [29]. While falls and delirium were more frequent presenting symptoms when compared with controls, several other factors including cardiovascular disease, gastrointestinal problems, sleeping difficulties and depression can mask a presentation of AUD [30, 31, 32].

All types of dementia, except Alzheimer’s Disease, occur more commonly in the elderly with alcohol use disorders. The reasons for this are not clear, as the relationship between alcohol use and dementias is very complex. Cognitive impairment stemming from alcohol misuse has been flagged as a silent but approaching epidemic.

Attempts to investigate this relationship, however, been hampered by confounding factors that may accompany the lifestyles of alcohol abusers, such as head injury, psychiatric and other substance abuse co-morbidities, and a higher rate of vascular risk factors [33]. The term ‘alcohol related dementia’ has been suggested to describe 10% of all dementias; this figure is based upon a population where 700,000 people had dementia, with lower levels of alcohol use than in younger cohorts [7, 11].

Alcohol misuse and psychiatric illness may coexist in late life, and dual diagnosis is not uncommon. Some studies found that the elderly were more likely to have the triple diagnosis of alcoholism, depression, and personality disorder [34]. Estimates of primary mood disorders in older alcohol misusers vary from 12% to 30% [35]. Coexisting depression has a more complicated course in alcohol users, and older people abusing alcohol have an increased risk of suicide and greater social dysfunction than non-depressed alcoholics. A history of AUD is also an indicator of a poorer response to treatment of late-life depression. More infrequently, other psychiatric disorders such as schizophrenia may coexist with alcohol problems and complicate the treatment of both.

Services should consider motivations for drinking in the elderly population, which may differ from those of their younger counterparts. When Wadd et al (2020) surveyed approx. 16,000 adults aged over 50, they found that over half of those drinking at a hazardous level identified a loss of sense of purpose in life as a reason for drinking, and the most common reason for drinking amongst both low risk and hazardous drinkers was retirement [5].

Regarding detoxification, withdrawal symptoms may vary in severity and the elderly should be monitored closely for delirium or seizures. Benzodiazepines are used for detox because they are more effective due to simpler hepatic degradation. If benzodiazepines do not control the symptoms and severe agitation continues, haloperidol may be used with caution. In addition, β-blockers are shown to be effective in controlling tachycardia and hypertension, but they must be monitored due to risk of hypotension in older adults. In addition to using a suitable setting (community, inpatient, or rehab), a combination of cognitive behavioural therapy and support groups, such as Alcoholics Anonymous, are effective when combined with pharmacotherapy [36].

Pharmacotherapy options includes naltrexone, which is recommended for relapse prevention. Acamprosate has shown similar results as naltrexone but has not been studied specifically in older adults. The use of combined naltrexone and acamprosate may produce slightly better results in certain cases. Disulfiram must be used with caution in older adults due to an increased risk of adverse effects like tachycardia and hypotension. Finally, providing structure to an older person’s daily routine and removing access to alcohol are strategies known to improve outcomes.

There is evidence that healthcare professionals are less adept at detecting alcohol use disorders in older populations, however, it has been found that alcohol history is less likely to be taken with increasing age of the patient [37]. Results from work carried out among social workers similarly found that it was difficult to identify alcohol and drug misuse among the elderly [38, 17].

Age Concern [39] have highlighted difficulties in identification and onward referral of older adults with AUDs. In a report published in 2003, they suggested that the reasons for this may include ageist assumptions about the lifestyles of this population, a lack of knowledge of safe-drinking limits, and individuals’ reluctance to ask for help [39]. Wadd et al discussed that the elderly struggled to access available and effective treatment, which was more tailored towards a younger population [17, 40].

Primary Care is the intended gateway to services for alcohol use disorders in the UK. General Practitioners (GPs) screen for AUD, offer interventions and advice, and refer to specialist alcohol services when needed [41,42]. GPs were identified as the primary source of help for alcohol problems in some studies, with some evidence that people might cut down drinking in response to their advice [43]. This pathway, however, belies a radical shift over the last 20 years in the way that drug and alcohol services are funded and provided in the UK.

Historically in England, most commissioned drug and alcohol services were provided by NHS providers. However, since the Drug Strategy (2010) that encouraged competitive tendering, there has been an increase in voluntary sector organisations providing these services. In addition to this, following the Localism Act (2011), local authorities have been responsible for commissioning drug and alcohol services and receive their funding through public health grant from Public Health England [46].

The changes mentioned above have amounted to an overall disinvestment in drug and alcohol services. Roscoe et al reported that between 2013/2014 to 2018/19, £212.2 million was disinvested [46]. This is a 27% decrease in funding, albeit less than 1% was disinvested from alcohol treatment [46]. Whilst disinvestment was perceived as contributing to fewer people accessing drug and alcohol services, it was not found to be related to increases in alcohol-specific hospital admissions or mortality [46].

Miscellaneous Issues

There is no strong evidence that alcohol causes premature ageing, but there are some suggestions regarding alcohol’s role in creating signs of ageing. For example, American Academy of Dermatology Association has highlighted environmental and lifestyle choices e.g., consumption of alcohol, as contributors to premature aging of skin [18]. A study between 1976-2003 discovered that women who drank 28 or more alcoholic beverages per week were 33% more likely to develop arcus senilis, a grey or white arc above or below the outer part of the cornea; and 35% of men who consumed more than 35 drinks per week developed the condition [47]. Other evidence of alcohol-related signs of aging is anecdotal and includes narratives of alcohol leading to wrinkles and inflammation.

The elderly are at increased risk of dehydration because the sense of thirst diminishes, renal function declines, and the balance of water and sodium in the body changes [44]. One study found that approximately 38% of its 30,000 participants were dehydrated, and another discovered that 4 in 10 older adults admitted to hospitals showed signs of dehydration [45]. Compounding these problems is the fact that alcohol can result in frequent urination, which can lead to dehydration [44].

Drinking alcohol compounds the risk of driving at older ages, because it impacts reaction time, coordination, eye movement, and information processing abilities [48]. One study in 2012, found that 21% of the drivers involved in fatal car crashes had a blood alcohol concentration (BAC) of 0.08 or higher; 14% of those drivers were aged 65 or older [49].

Several self-report questionnaires have been designed for detecting AUD, which include the Short Michigan Alcoholism Screening Test–Geriatric Version [50] and the Alcohol Use Disorders Identification Test (AUDIT) [51]. AUDIT and its short-form AUDIT-C [52] are also useful tools for screening for harmful and hazardous drinking in elderly patients. AUDIT has superior validation cross-culturally but less evaluation in the elderly age group. CAGE is widely used in clinical settings – it comprises 4 items that ask about cutting down, annoyance at criticism, guilty feelings, and the use of eye-openers [53]. It does not have high validity with older adults, especially with older women. It is limited as it assesses lifetime alcohol use and does not enquire about current drinking habits. In a large study involving more than 5000 consecutive primary care patients aged 60 and older, the CAGE identified fewer than 50% of the heavy or binge drinkers. MAST–G has high specificity and sensitivity with older people in a wide range of settings, including primary care clinics and nursing homes [54].

There has not been much research within mental health services exploring the changes in drinking behaviour among older people during the COVID-19 pandemic. A few studies used AUDIT to identify risky drinking in the elderly in large samples. They found that compared with before lockdown, those who abused alcohol were more likely to be female, had less severe cognitive impairment, and showed morning-drinking and feelings guilt over their drinking [55].

Conclusions

Alcohol consumption constitutes a substantial burden of disease and is being recognised as a major public health issue in the elderly. It is, therefore, important that the needs of this population are highlighted in national health service frameworks and strategies. There have been some efforts at the Department of Health and the Royal Colleges to address the issue through an overall increase in funding, more training posts, and a plan to bring drug and alcohol services back into psychiatric services. Let us see how long it takes for these changes to trickle down to meeting the needs of the elderly by overcoming wider issues of ageism and the reluctance of some specialist alcohol services to open their doors. There is an urgent need for UK-based research to help treatment services determine the exact extent of the problem and to develop effective screening methods and interventions to provide optimal care for this vulnerable, growing, and under-recognised group.

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About the authors

Dr Ivan Saeger is a Higher Trainee (ST4) in psychiatry working at Oxleas NHS Trust

Dr M Aamer Sarfraz is a Consultant Psychiatrist, and visiting professor at the Canterbury Christ Church University.