1. What signs does the woman exhibit that might indicate a potential alcohol problem?
Based on the description, the signs that this elderly woman might be abusing alcohol are social isolation (Mayo Clinic, n.d.). She mentions that she has drifted apart from her friends and she has lost contact with her daughter. The more direct indications are information from her housekeeper. The housekeeper reported that the woman regularly sent her out to buy scotch, and she frequently found her passed out drunk on the couch when she arrived in the morning.
2. Why do you think the emergency staff did not suspect an alcohol problem when the woman was admitted?
If the emergency staff had asked her about alcohol consumption, the description of the patient indicates that she would have responded that she “had the odd cocktail”, but was not a regular drinker. Another reason that the emergency staff may not suspect alcoholism is that the great majority of alcoholics are male and seniors have fewer psychosocial signs of alcohol use disorder than do middle-aged adults (Pabst & Kraus, 2008; Rincon-Hoyos, Castillo, & Prada, 2016). A previous study investigating staff attitudes to alcohol use disorder among an older population showed that emergency personnel are less suspicious of seniors, or more tolerant, than they are of middle-aged adults and therefore there is a lower level of identification of alcohol use disorder and referral in this population (Janik & Dunham, 1983). Also, alcohol use disorder is a well-studied phenomenon among adolescents and adults, but not as well understood among the aging population and therefore be less easily recognized (Guidolin, Gomes da Salva Filho, Nogueira, Ribeiro, Neto, 2016).
3. What is the best way to assess an older adult for alcohol abuse?
In the U.S., those over the age of 60 tend not to seek addiction treatment in specialty clinics (Andersen, et al., 2015). Therefore, primary care settings can be a good choice for the detection and treatment of alcohol use disorder among the elderly (Andersen, et al., 2015). A battery of tests to be used to assess alcohol use disorder could be Form-90, Alcohol Dependence Scale, Brief Symptom Inventory, Penn Alcohol Craving Scale, and the WHO Quality of Life Scale (Andersen, et al., 2015). As for an emergency setting, current practice in the UK is to routinely screen for alcohol use in the Accident and Emergency Department using the Fast Alcohol Screening Test (Knightly, et al., 2016). Knightly, et al. (2016) compared the routine Fast Alcohol Screening Test with the Michigan Alcoholism Screening Test – Geriatric Version and found that the test designed specifically for older patients identified significantly more elders with a history of alcohol use disorder. The study suggests that alcoholism among elders is underdiagnosed in an emergency setting.
4. What recommendations would you have for the woman?
Some of the causes of late-onset alcohol use disorder can be difficulty coping with loneliness and bereavement (Chen, et al., 2011). The patient appears to be socially isolated as she stared that she has lost contact with her daughter and friends. A therapy plan that included dealing with social isolation would be appropriate. Andersen et al. (2015) used a 12-session outpatient therapy for alcohol abuse, which consists of four sessions of Motivational Enhancement Treatment, extended by eight sessions of Community Reinforcement Approach. The Motivational Enhancement Treatment consists of three sections: functional assessment, motivational interviewing, and developing a plan for change. The Community Reinforcement Approach is a further development of developing a plan for change. The therapist and the patient work together through modules that are specific to older alcohol use abusers. Such modules include how to cope with cravings and the social pressure to consume alcohol, how to cope with aging, training for managing moods, developing a network of non-drinkers, and recreation and social counselling (Andersen et al., 2015).
5. What are some of the concerns when referring older adults for alcohol treatment?
In this particular case, the problem with referring this patient for alcohol treatment is that she is denying that she has a drinking problem. Guidolin, et.al. (2016) suggest that alcohol use may be more difficult for women to admit to due to socio-cultural norms of women not drinking. Oslin et al. (2006) found a lack of engagement regarding alcohol treatment among older adults. However, research suggests that treatment can be successful (Oslin, et al., 2006). Study results from a multi-site randomized trial among individuals age 65 and over, and identified as at-risk alcohol use disorder, found that seniors can modify their drinking habits over a six-month period.
References
Anderson, K., Bogenschultz, M. P., Buhringer, G., Behrendt, S., Bilberg, B. B., Eksstom, C. H., Nielsen, A. S. (2015). Outpatient treatment of alcohol use disorders among subjects 60+ years: design of a randomized clinical trial conducted in three countries (Elderly Study). BMC Psychiatry, 15, 280. DOI 10.1186/s12888-015-0672-x
Chen, Y. C., Prescott, C. A., Walsh, D., Patterson, D. G., Riley, B. P., Kendler, K. S., et al. (2011). Different phenotypic and genotypic presentations in alcohol dependence: age at onset matters. Journal of Studies on Alcohol and Drugs, 72(5), 752–762.
Guidolin, B. L., Gomes da Salva Filho, I., Nogueira, E. L., Ribeiro, F. P., Jr., Neto, A. C., (2016). Patterns of alcohol use in an elderly sample enrolled in the Family Health Strategy program in the city of Porto Alegre, Brazil. Ciênia Saude Coletiva, 21(1), 27-35. DOI: 10.1590/1413-81232015211.10032015
Janik, S. W, Dunham, R. G. (1983). A nationwide examination of the need for specific alcoholism treatment programs for the elderly. Journal of Studies of Alcoholism and Drugs, 44, 307.
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Alcohol screening for older adults in an acute general hospital: FAST v. MAST-G assessments. BJPsych Bulletin, 40, 72-76, doi: 10.1192/pb.bp.114.049734
Mayo Clinic (n.d.). Alcohol Use Disorder: Symptoms. Retrieved on June 23, 2016 at http://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/basics/symptoms/con-20020866
Pabst, A, & Kraus, L. (2008). Alcohol consumption, alcohol-use disorders and trends.
Results of the 2006 epidemiological survey of substance abuse. IFT Munchen: Institut für Therapieforschung.
Oslin, D. W., Grantham, S., Coakley, E., Maxwell, J., Miles, K., Ware, J., Blow, F. C., Krahn, D. D. PRISM-E group. (2006). PRISM-E: Comparison of Integrated Care and Enhanced
Specialty Referral in Managing At-Risk Alcohol Use. Psychiatric Services, 57(7), 954–958. doi:10.1176/appi.ps.57.7.954.
Rincon-Hoyos, H. G., Castillo, A. & Prada, S. I. (2016). Alcohol use disorder and psychiatric diseases in Columbia. Colombia Med 47(1), 31-37.
