The number of elderly in populations across the globe is increasing and this trend is expected to continue over the coming years. [1] The number of people aged 65 and over in the UK was 16% in 2001 and is predicted to reach 21% by 2026 [2]. Alcohol abuse among elderly people is a common and underdiagnosed issue with deleterious impacts on physical and mental health. In 2008, 17% of men and 7% of women aged 65 and over exceeded the weekly recommended alcohol consumption limit and 9% of the elderly were involved in ‘heavy’ episodic drinking. [3] Despite the increase in harmful alcohol consumption and alcohol-related deaths among the elderly, it remains a hidden problem. There is a chance that a silent epidemic may be developing [4]. Whereas, the number of young adults binge drinking in the UK has been declining due to effective public health strategies and treatment, there is a pressing need for policy makers and health care professionals to target the older population [5]. This essay is going to explore the causes of alcohol addiction in the elderly and its effect on an individual’s mental and physical health. Furthermore, it will attempt to identify the barriers to treatment and age-specific challenges related to recognition and treatment of older alcoholics. The aim of the essay is to explore the issues closely related to the medical history of Mrs JR, a 72-year-old lady with a background history of alcoholism whom I interviewed after her alcohol-related hospital admission.
The literature on alcohol abuse identifies two types of alcohol use disorders among the elderly: early and late onset. People classified as early-onset drinkers have had a problem with drinking for the majority of their lives and account for two-thirds of elderly alcoholics [6]. The remaining one-third falls into late-onset category [7], which implies that people develop drinking problems after the age of 50. Importantly, late-onset drinking is set off by stressful life events in 70% of cases, compared with 25% of early-onset drinking [8]. Late-onset alcohol abuse is also thought to be associated with depressive personality types [9]. Mrs JR is an interesting case as she developed alcohol addiction and depression following death of her husband 13 years ago. Additionally, she acknowledges that alcohol misuse has to some extent been an issue throughout her life. According to the literature, the relationship between alcoholism and bereavement is multifactorial. A study comparing alcohol misuse in recently widowed and married elderly people showed that 19% of widowed and 8% of married people reported excessive drinking [10]. However, another study proved that the long-term alcohol abuse following bereavement is only likely in people with pre-existing alcohol consumption exceeding the safe levels [11]. It is therefore possible that Mrs JR developed an alcohol addiction due to bereavement which exacerbated a pre-existing alcohol misuse problem. She reported feeling ‘abandoned, lonely and overwhelmed with grief’ which was alleviated with alcohol consumption. She admits that had she received psychological help after her husband’s death she would of been more likely to avoid becoming an addict. I therefore believe that it is imperative to identify psychosocial factors including bereavement, retirement, social isolation and boredom as potential triggers of late-onset drinking, which should be explored by healthcare professionals. Involvement of healthcare professionals in patient care at critical points of patient’s life is particularly important, as it helps to spot and treat late-onset reactive drinkers.
Additionally, alcohol addiction in the elderly is often caused or complicated by mental health disorders, which adds complexity to alcohol-related disorders in this age group. The direction of causality with regards to mental health disorders and alcohol consumption requires further investigations. In 2009, 7% of population aged 65 and over reported co-existing alcohol misuse and mental health disorder [12]. Dual diagnosis of depression and alcoholism in older people is also associated with higher risk of suicide and more significant social dysfunction compared to alcoholics with no mental health disorders [13]. The phenomenon of ‘self-medication’ using alcohol is increasing common among the elderly, with 23% elderly people admitting the use of alcohol as ‘medication’ to cope with mental health problems. This negative method of coping with mental health issues has also been a long term struggle for Mrs JR. As the patient described, alcohol makes ‘all her worries go away and it always makes her feel better’. However, even though the direction of causality in her case is yet to be elucidated, it is crucial to appreciate that the close relationship between alcohol abuse and mental health in elderly patients cannot be overlooked.
As has been discussed thus far, there are numerous reasons for development of alcohol dependence in later stages of life. The current research identifies positive and negative factors leading to this change of behaviour including socialisation, depression, self-medication, social isolation, boredom, loss of function associated with ageing and bereavement, among many others. Even though, the direction of causality between these factors and alcohol abuse needs to be investigated further, deeper understanding of causes of alcohol misuse among elderly is a prerequisite for identifying suitable behaviour altering interventions.
Moreover, the cost to the NHS for alcohol-related hospital admissions of 55-74-year-olds is twelve times higher compared to the cost of admissions of the 16-24-year-old group [14]. Additionally, older people at risk of harm caused by alcohol misuse are less resilient to harmful effects of alcohol misuse. These significant risks associated with alcohol addiction in later stage of life calls for abandonment of age-blind approach to treatment of alcohol-related ill health. Increased alcohol consumption in the elderly puts them at higher risk of developing stroke, myocardial infarction and high blood pressure [15].
The increased risks of alcohol-related harm in elderly is closely linked to the physical changes associated with ageing. Alcohol also adds to the risk of accidents such as falls, which contribute to increased mortality and morbidity in elderly [16]. Older drinkers are also at higher risk of osteoporosis, liver cirrhosis and cancer. Furthermore, polypharmacy and numerous comorbidities, common in the elderly, increase the risk of alcohol-related harm and complicate the assessment of vulnerable patients [17].
What is more, physiological changes which are considered to be a part of the ageing process, reduce one’s capacity to metabolise alcohol, making elderly people more susceptible to alcohol-related harmful effects [18]. This has been an issue for Mrs JR, whose number of alcohol-related admissions correlates with the increase in age. Being an alcoholic for 13 years, she has had numerous episodes of falls, broken bones and head trauma. What repercussions has she had to deal with? Excessive drinking contributed to exacerbation of her osteoporosis and incontinence, but most importantly it lead to a deterioration of her relationship with her family. Mrs JR herself admitted that because of alcohol, she destroyed her health and failed as a mother and grandmother.
Furthermore, alcohol abuse of Mrs JR was only acknowledged by healthcare professionals after ten years of lonely futile struggle with this dreadful disorder. She experienced extreme loneliness and felt abandoned by the medical professionals. This begs a question of why are older adults falling through the net and what should be done to improve treatment and recognition of alcoholism in elderly? Currently, its been shown that healthcare workers recognise alcohol addiction in as little as one-third of cases of older addicts being hospitalised [19]. Some factors that impede the recognition of alcohol abuse in older patients include societal myths, lack of awareness among healthcare professionals, shame and denial of an addict, shared features between alcoholism and conditions attributed to ageing and finally screening instruments that are not age specific and don’t work for older people [20]. Thus alcohol abuse takes a greater toll on the elderly compared to the younger population, in which the problem is more easily recognised. As people grow older, they tend to suffer from a wide spectrum of psychosocial, physical and mental sequels of alcohol abuse and early problem recognition is vital to improve the general condition of health among the elderly [21].
Moreover, as mentioned before, the screening tools available, such as the widely used CAGE questionnaire prove to be ineffective in older people. One study investigated its validity in a community sample of elderly people and it was shown to be negative in 60% of the elderly at risk of alcohol dependence [22]. Other tests such as Alcohol Use Disorders Identification Test (AUDIT) has not been validated with regards to its usefulness among elderly patients. The main causes of failure of currently available tools include: focus on lifetime drinking rather than current alcohol consumption and lack of age-specific recommended alcohol limits. As discussed before, as people age they develop higher sensitivity and reach higher alcohol levels in the blood at lower levels of alcohol ingestion [23].
Additionally, older drinkers tend to develop dependency at significantly lower levels of consumption [24]. What seems to be a clearer indicator of alcohol misuse is the health and behavioural effect of alcohol on elderly individuals [25]. Therefore, healthcare professionals should strive to investigate recurrent unexplained hospital admissions in the elderly in depth. This could potentially be an aid in recognizing vulnerable elderly people with alcohol dependence. A possible solution to this issue could also be the implementation of age-sensitive recommended limits of alcohol consumption, in keeping with ageing physiology. On top of that, screening tools dedicated to the older population should be developed and validated.
Currently, each potential stage of recognition of alcohol abuse among the elderly including public health initiatives, primary care and acute hospital setting overlooks the role old age can have. Recognition of the problem is further impeded by the clinicians’ attitudes which are too often borderline ageist. The barriers to treatment also include gaps in treatment and service provision. The ageist attitude can also affect the quality of treatment received by elderly. Some alcohol treatment centres even introduced upper age limit of 65 to be a cut off for admission. Furthermore, the preconception that the elderly are ‘too old to change their habits’ continues to have a negative effect on the treatment of alcohol abuse in elderly people. Older addicts tend to be less knowledgeable with regards to harmful effects of alcohol, more affected by increased availability and reduced price of alcohol and often too ashamed to seek help. All of the aforementioned issues need to be addressed for the successful detection and treatment of elderly alcohol addicts to become a possibility.
The public health policy in the UK aimed at alcohol-related harm in the elderly, lacks consistency and needs to be improved. Taking into consideration the significant increase, of 150% within a decade from 2002, in alcohol-related mental health issues in elderly in the UK, there is a pressing need for development of joint strategies for mental health and alcohol-related harm [26]. Moreover, there is a lack of UK-wide data on the topic and no changes can be implemented without consistent research.
As discussed above, the alcohol addiction in elderly people is an increasing and under recognised problem which may become a silent epidemic in the very near future if no action takes place. There is a need to increase the awareness of the problem among the general public and healthcare professionals. Additionally, new age-sensitive policies and screening tools should be developed to aid recognition and treatment. Clinicians need to change their approach from ageist, to proactive in order to tackle the problem effectively. Thus, a great amount of training is a prerequisite to introduce change and better identify at risk individuals. The literature provides evidence that elderly people do benefit from treatment, as much as younger adults do. However, the sources of support and type of help available is not well-placed.
In conclusion, alcohol abuse among elderly patients tends to be multifactorial and complicated by comorbidities which often cloud recognition of the problem. Alcohol use disorders are often associated with stressful life events such as bereavement, retirement or precipitants such as boredom, loneliness and psychiatric disorders. The patient’s case discussed in this essay underlines the flaws of the current system, showing the complexity of the issue and drawing attention to the deleterious effects of a lack of recognition of the extent of the problem. Even though the harm to Mrs JR has already been done, the improvements suggested here could have a significant impact on the life of elderly patients at risk of developing alcohol addiction in the future.