Author: David V. Flores, PhD, LMSW, MPH
Alcohol Use Disorder (AUD) among older adults is on the rise and is poised to overwhelm our national resources (Institute of Medicine, 2012). Individuals 65 and older are projected to increase from 40.3 million in 2010 to 72.1 million by 2030, a 56% increase, and will double to 88.5 million by 2050 (U.S. Census Bureau, 2010). Moreover, those 85 and older are projected to triple from 5.4 million to 19 million by 2050 (Kalapatapu & Sullivan, 2010).
Concomitant with this dramatic population growth is the expected rise in AUD and need for substance use treatment among older adults. This increase in alcohol abuse is directly associated with the retiring "baby boomer" generation (Gfroerer, 2003; Institute of Medicine, 2012). The "baby boomer" generation maintains the highest prevalence of substance use compared to other cohorts (Wang & Andrade, 2013). One in five older adults currently has a mental health or substance abuse condition and healthcare institutions are unable to meet the needs of this population (Institute of Medicine, 2012). Older adults with substance abuse disorders (4.8 million) are projected to double by 2020 and those in need of treatment will escalate to almost 6 million.
The Committee on the Mental Health Workforce for Geriatric Populations assessed the current and future needs of older adults and found significant deficits in geriatric training among healthcare providers and insufficient community resources. Further, the Committee also found a significant lack of specialists engaged in the detection, diagnosis, treatment, care, and management of geriatric conditions (Institute of Medicine, 2012). The lack of a prepared workforce is projected to continue and burdens on the local, state, and national resources will increase exponentially.
The health consequences of long-term AUD for older adults are significant and include both physical and socioeconomic consequences (Substance Abuse and Mental Health Services Administration, 2009). Potential physical consequences include cirrhosis of the liver, cancer, immune system disorders, cardiomyopathy, cerebral atrophy, and cognitive deficits (National Institute on Aging, 2013). Alcohol use also exacerbates preexisting conditions such as osteoporosis, diabetes, high blood pressure, and ulcers (National Institute on Aging, 2013). Older adults seeking hospitalization for alcohol-related conditions do so at rates similar to those admitted for myocardial infarction (Merrick et al., 2008).
Blazer and Wu conducted a secondary analysis of the National Survey on Drug Use and Health in order to assess prevalence, distribution, and correlates of at-risk alcohol use in the United States among older adults (2009). Researchers found that at risk alcohol misuse and binge drinking are more frequent among individuals 50 to 64 years of age compared to those 65 and older. Furthermore, among those 65 and older, 13% of men and 8% of women were at-risk drinkers and 14% of men and 3% of women were binge drinkers. The study also found that binge drinking among males was associated with higher income, being separated, divorced, or widowed, and being employed. Binge drinking among women was associated with non-medical use of prescription drugs. The use of tobacco and illicit drugs was also associated with binge drinking for both men and women (Blazer & Wu, 2009).
In the Netherlands, Geels and colleagues (2013) found that age, sex, and initiation of cigarette and cannabis use were significant predictors of AUD. For men, frequency of alcohol misuse was highest for older adults aged 65 and over (30.6-32.7% of men and 20.2-22.0% of women). For women, the highest prevalence of excessive drinking (14 and more glasses per week) was reported for those between 55 to 60 years of age. For both men and women 65 years and older, significant factors for abuse included early initiation of regular alcohol use and early age at first intoxication (Geels et al., 2013)
Health care providers should follow clinical guidelines defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2005) and the National Institute on Aging (2013) . These organizations suggest that more than seven drinks per week or more than three drinks on any single day is considered "risky drinking" for individuals over 65; women's alcohol intake should be less than men (National Institute on Aging, 2013; National Institute on Alcohol Abuse and Alcoholism, 2005).
Alcohol use is considered contraindicated for older adults who have health conditions requiring complex medication regimes; thus, abstinence is recommended (Merrick et al., 2008).
The most straightforward method for assessing at-risk drinking or alcohol use disorders is to ask the patient how much they drink and how often the daily maximum number of drinks has been exceeded. This straightforward screening method has been found to be as sensitive and as specific as other alcohol screening methods (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009; Willenbring, Massey, & Gardner, 2009). This method provides an educational opportunity to discuss appropriate alcohol limits (Willenbring et al., 2009).
The 10 item Alcohol Use Disorders Identification Test (AUDIT) is also a useful method for assessing alcohol consumption behaviors and for educating patients (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). You can access this instrument at http://www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf
Alcohol Assessment Questions for the Healthcare Practitioner from the Clinical Guidelines of Alcohol Use Disorders (Society of Hospital Medicine, 2004)
Alcohol Use Disorder
Alcohol abuse and dependence are now considered Alcohol Use Disorder--a subcategory under Substance Related and Addictive Disorders in the DSM 5 (APA, 2013). AUD is defined as a clinically significant impairment or distress due to maladaptive patterns of substance use that often results increased tolerance, increased time spent on substance use activities, withdrawals, craving, increased amounts of the substance, unsuccessful efforts to control use, continued usage despite adverse consequences, and a decrease in social, occupational, or recreational activities.
The health care provider should first assess the patient's motivation for treatment-- "Are you willing to consider changing your drinking habits at this time?" This is important for appropriate referral to treatment.
NIAAA suggests that a combination of medication with a disease management approach has been an effective as alcohol intervention (Smith et al., 2009). If an alcohol problem is suspected the health care provider should clearly communicate consequences of continued alcohol use and recommendations for treatment, and explain the comorbidity of alcohol use with other medical conditions (Willenbring et al., 2009).
The following interventions have been shown to be effective for treating alcohol abuse disorders in older adults:
American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th. Retrieved September 20, 2013, 2013, from http://www.dsm5.org/Documents/Substance Use Disorder Fact Sheet.pdf
Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., & Monteiro, M.G. . (2001). AUDIT: The alcohol use disorders identification test, guidelines for use in primary care Paper presented at the World Health Organization, 2 ed., Geneva, Switzerland.
Blazer, Dan G., & Wu, Li-Tzy. (2009). The Epidemiology of At-Risk and Binge Drinking Among Middle-Aged and Elderly Community Adults National Survey on Drug Use and Health. American Journal of Psychiatry, 166(10), 1162-1169. doi: 10.1176/appi.ajp.2009.09010016
Geels, L.M., Vink, J.M., vanBeek, H.D.A.J., Bartels, M., Willemsen, G., & Boomsma, D. (2013). Increases in alcohol consumption in women and elderly groups: evidence from an epidemiological study. BMC Public Health, 13, 207. doi: 10.1186/1471-2458-13-207
Gfroerer, J. (2003). Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort. Drug and alcohol dependence, 69(2), 127-135. doi: 10.1016/s0376-8716(02)00307-1
Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press.
Kalapatapu, Raj K., & Sullivan, Maria A. (2010). Prescription Use Disorders in Older Adults. American Journal on Addictions, 19(6), 515-522. doi: 10.1111/j.1521-0391.2010.00080.x
Merrick, Elizabeth L., Horgan, Constance M., Hodgkin, Dominic, Garnick, Deborah W., Houghton, Susan F., Panas, Lee, . . . Blow, Frederic C. (2008). Unhealthy Drinking Patterns in Older Adults: Prevalence and Associated Characteristics. Journal of the American Geriatrics Society, 56(2), 214-223. doi: 10.1111/j.1532-5415.2007.01539.x
National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people.
National Institute on Alcohol Abuse and Alcoholism. (2005). Helping Patients Who Drink Too Much. A Clinician's Guide 2005 Edition. Rockville, MD: National Institutes of Health.
Smith, P.C., Schmidt, S.M., Allensworth-Davies, D., & Saitz, R. . (2009). Primary Care Validation of a Single-Question Alcohol Screening Test. Journal of general internal medicine, 24(7), 783-788. doi: 10.1007/s11606-009-0928-6
Society of Hospital Medicine. (2004). Clinical guidelines for alcohol use disorders in older adults. http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clinical_guidelines_alcohol.pdf
Substance Abuse and Mental Health Services Administration. (2009). The NSDUH Report: Illicit Drug Use among Older Adults. Rockville, MD: SAMHSA.
U.S. Census Bureau. (2010). The next four decades: The older population in the United States: 2010 to 2050, current population reports. Washington DC.
Wang, Yuan-Pang, & Andrade, Laura Helena. (2013). Epidemiology of alcohol and drug use in the elderly. Current Opinion in Psychiatry, 26(4), 343-348.
Willenbring, M.L., Massey, S.H., & Gardner, M. (2009). Helping Patients Who Drink Too Much: An Evidence-Based Guide for Primary Care Physicians. Am Fam Physician(80), 44-50.