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Advances in Psychiatric Treatment (2006), vol. 12, 173–181 Alcohol use disorders in elderly people: fact or fiction? Karim Dar Abstract The number of older people is increasing in populations throughout the world. Alcohol use disorders in elderly people are a common but underrecognised problem associated with major physical and psychological health problems. Owing to the negative attitudes and inadequate training of healthcare professionals, alcohol misuse is not always being detected or effectively treated. Current diagnostic criteria and common screening instruments for alcohol use disorders may not be appropriate for elderly people. Older people are as likely to benefit from treatment as younger people and the basic principles of treatment are much the same. Better integrated and outreach services are needed. Training of healthcare professionals in this area and pragmatic research should be prioritised to improve detection, treatment and service provision for this vulnerable and neglected population. In 2001, 16% of England’s population was over that it is easy to detect among elderly people and 65 years of age, and this proportion is forecast to that the amount an elderly person drinks in a single rise to 21% by 2026 (Falaschetti et al, 2002). In 1988, sitting is a good indicator of alcohol misuse. 13% of men aged 65 and over drank more than the weekly guideline of 21 units; the figure had increased to 17% in 2000. The number of women drinking over Patterns of alcohol use the recommended guideline (14 units per week) increased from 4% in 1988 to 7% in 2000 (Office for Alcohol use disorder may be described as being National Statistics, 2001). of early or late onset. Elderly people who fall into the Alcohol use disorders among older people are early­onset category have had a lifelong pattern of often described as a hidden problem, which may be problem drinking and have probably been alcoholics due to a number of factors. First, many elderly people for most of their lives (Menninger, 2002). American do not disclose information about their drinking studies suggest that this category comprises two­ because they are ashamed. Many are isolated, with thirds of elderly alcoholics (Gulino & Kadin, 1986; minimal social contact or networks, thereby making Atkinson et al, 1990). Typically, there is a family the problem more difficult to detect. It has also been history of alcoholism and these individuals had suggested that older people may significantly under­ drinking problems in their early 20s or 30s. They are report their drinking (Naik & Jones, 1994). Second, more likely to have psychiatric illness, cirrhosis and people in the helping professions seem reluctant to organic brain syndromes (Menninger, 2002). ask an older person about drinking, either because About one­third of elderly alcoholics fall into the it makes them feel awkward or because of the late­onset category (Adams & Waskel, 1991), first stereotypical image of alcohol use disorders as a developing drinking problems at 40–50 years of problem affecting mostly younger people (Deblinger, age. They tend to be highly educated and a stressful 2000). Third, alcohol problems often present in a life event frequently precipitates or exacerbates large number of non­specific ways such as accidents, their drinking. Brennan & Moos (1996) reported depression, insomnia, confused states and self­ that, in contrast to early­onset problem drinkers, neglect, many of which are linked to the ageing those in the late­onset category typically have fewer process. Finally, as Krach (1998) pointed out, Western physical and mental health problems. This group societies hold several misconceptions about alcohol is more receptive to treatment and more likely to use by elderly people, for example that alcoholism is recover spontaneously from alcoholism (Menninger, not a significant problem in the elderly population, 2002). A longitudinal study of the prognosis for Karim Dar is consultant psychiatrist in substance misuse at St Bernard’s Hospital (Uxbridge Road, Southall, Middlesex UB1 3EU, UK. Email: [email protected]). His clinical responsibilities include the Max Glatt Unit (a regional in­patient detoxification unit attached to the hospital) and a community alcohol team. His special interests include substance misuse problems in special populations and the economics of service provision. 173 Dar older alcoholics found an overall stable remission & Bal (1990) found that, in general, African– of 21% in late­life drinking at 4 years, with late­ Caribbean, Muslim and Hindu women reported onset alcoholics almost twice as likely as those with drinking less than their White counterparts. Among early­onset alcoholism to have stable remission with Asian Muslims, Sikhs and Hindus, older men had treatment (Schutte et al, 1994). more alcohol problems than younger men. Key factors associated with heavy Genetic factors drinking There is substantial evidence that genetic factors are important in the development of alcohol problems. Cooper et al’s (1999) review and statistical analysis Some studies have suggested that, among men, of data from the 1992 and 1994 General Household genetics might play a greater part in early­ than Surveys and the 1993 and 1994 Health Surveys for in late­onset alcohol misuse (Atkinson et al, 1990). England looking at health­related behaviour in older Studies of older people in the USA have provided people revealed the following. strong evidence that drinking behaviour throughout the lifespan is greatly influenced by genetic factors Gender (Atkinson, 1984; Heller & McClearn, 1995). Men are more than twice as likely as women to exceed sensible guidelines for weekly drinking. In Causes and triggers of problem drinking terms of excessive drinking, 2% of men aged 70–74 Brennan et al (1999) have commented on the complex drank over 50 units per week, whereas less than 1% two­way relationship between stressors and of women over 70 drank 35 units or more per week. drinking behaviour, and a report by Alcohol Concern Older women were more likely to abstain than men (2002) lists a number of factors that commonly lead in all age bands between 55 and 85 years. to heavy drinking. These include bereavement – the death of a partner, family member or friend; mental Socio-economic group stress; physical ill health; loneliness and isolation; and loss – including loss of occupation, function, For both genders higher levels of drinking were skills or income. In elderly people the ageing process most prevalent among the higher social classes and itself can be a causative factor (Box 1). the most affluent. Living arrangements and partnerships Box 1 Life changes associated with alcohol misuse in elderly people Among older men, those who were married were least likely to drink heavily. Next came single (never­ Emotional and social problems married) men. Widowed or divorced men were • Bereavement most likely to engage in health­damaging behaviour • Loss of friends and social status such as smoking or excessive drinking. In contrast, • Loss of occupation among older women those married had the highest • Impaired ability to function levels of alcohol consumption. Other studies have • Family conflict commented on the following factors. • Reduced self­esteem Medical problems Social exclusion • Physical disabilities • Chronic pain A survey of older homeless people in London • Insomnia conducted about 15 years ago showed that around • Sensory deficits 30% were aged 50 and above, and of these a • Reduced mobility significant proportion had a drink problem (Kelling • Cognitive impairment (1991), cited in Ward, 1997). Practical problems • Impaired self­care Ethnic and religious origins • Reduced coping skills • Altered financial circumstances Drinking patterns vary considerably across ethnic • Dislocation from previous accommodation groups. A study carried out in England by Cochrane 174 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/ Alcohol use disorders in elderly people Alcohol-related health problems Estimates of the incidence of primary mood dis­ orders in older alcohol misusers vary from 12% to Alcohol use disorders in elderly people can cause 30% or more (Finlayson et al, 1988; Koenig & Blazer, a wide range of physical, psychological and social 1996). Depression in older alcoholics has a more problems. Excessive drinking puts older people at complicated clinical course, and older alcoholics increased risk of coronary heart disease, hypertension with depression have an increased risk of suicide and stroke (Department of Health, 1995). Alcohol and more social dysfunction than non­depressed adds to the risk accidents and has been identified as alcoholics; moreover, they are more likely to seek one of the three main reasons for falls, which are a treatment for their problems (Cook et al, 1991; significant cause of mortality and ill health in older Conwell, 1994). A history of alcohol use disorders people (Wright & Whyley, 1994). Alcohol misuse is an indicator of a poorer response to treatment can exacerbate insomnia and increase the likelihood of late­life depression. It has been reported that a of incontinence and gastrointestinal problems history of alcohol misuse predicted a more severe (Tabloski & Maranjian Church, 1999). The incidence and chronic course for late­life depression (Cook et of osteoporosis is increased and its progression al, 1991). The very high risk of suicide in this patient hastened in those who misuse alcohol. Alcohol group should always be borne in mind. may

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