Considerations with the older client
Adrienne Withall and Samaneh Shafi ee
The global population is ageing. By the year 2030, the total number of older people worldwide is expected to exceed 1 billion, accounting for one in every eight persons (National Institute of Aging and US Department of State, 2007 ). Alcohol misuse in older adults presents unique challenges to clinicians and health professionals. It rep- resents a growing but relatively neglected public health problem and it has been predicted that the number of older people requiring treatment for alcohol-use dis- orders (AUDs) will increase substantially in coming years (Han et al ., 2009 ). This is considered to be due partly to the size of the “Baby Boom” cohort (born after World War II, between 1946 and 1964) – particularly the higher rate of alcohol and other substance use among this group due to social acceptability and affordability, as well as the greater observed inclination of baby boomers to discuss personal and mental health concerns (Patterson and Jeste, 1999 ; Wang and Andrade, 2013 ).
However, research into populations engaging in risky or problematic alcohol use has largely neglected those aged over 60 (Patterson and Jeste, 1999 ). There also remains a lack of awareness among primary health care, drug and alcohol, aged care and general practitioners about the extent and impacts of alcohol use and misuse in people aged over 60, possible impacts on cognition especially in midlife and a general reluctance to screen for alcohol-use disorders in this group.
In fact, older people are likely to have a greater sensitivity to cognitive impair- ment as a result of alcohol use, partly through the increased risk of cognitive impairment as a result of increasing age (Kumar et al ., 2005 ). Although alcohol- related brain damage (ARBD) is more common in midlife than later life (MacRae and Cox, 2003 ), alcohol use may complicate neurodegenerative and vascular dementias, and is the second most common cause of delirium and confusional states in older people (Kales et al ., 2003 ). Paradoxically, moderate alcohol intake may actually be neuroprotective (Collins et al ., 2009 ), highlighting the need for alcohol use guidelines specific to this age group.
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Given the heightened effects of alcohol in late life due to poorer metabolism of alcohol, general frailty, physical health comorbidity, the potential for impaired vitamin absorption, prescribed medication interactions and the high risk of comorbid neu- ropsychiatric disorders, new strategies are needed in order to address safe drinking levels, as well as suitable assessment and treatment protocols.
Prevalence of alcohol-use disorders in older people
In developed countries, there is a growing body of epidemiological evidence indi- cating that alcohol (and other drug) abuse is a current public health concern in the older population (Wang and Andrade, 2013 ). It is further anticipated that this effect will spread to developing regions over the next few decades (Wang and Andrade, 2013 ). In general, the prevalence of alcohol-use disorders declines with increasing age and they are more common in men than women (Coulton, 2009 ), although many diagnostic methods do not have age-specific criteria (see later, this chapter). Estimates for the number of older people drinking at risky levels vary widely: mostly from 1 to 15 per cent (Blow and Barry, 2012 ) although higher rates have been reported in Europe. For example, data from Belgium indicated that 20.5 per cent of people aged 65 years and over drank in excess of the NIAAA guidelines (Hoeck and Van Hal, 2012 ).
An Australian national community survey found that older adults in fact drink more frequently than younger age groups, albeit at lesser levels (Australian Institute of Health and Welfare, 2011 ). This same trend was shown in data from participants in the Netherlands Twin Register between 2009 and 2012. Daily alcohol use was mark- edly higher in the 55–64 year age band and highest in the 65 and over group; it was ten fold lower in prevalence in the 18–24 year age group (Geels et al ., 2013 ). Men drank more than women across all age groups and hazardous drinking occurred in 12.7 per cent of men aged 65 years and over and 5.5 per cent of women, which was less than for younger age groups (Geels et al ., 2013 ). Data from the 2001–2002 National Epidemiologic Survey of Alcohol and Related Conditions indicated that 16 per cent of participants aged 65 and over had a lifetime diagnosis of alcohol-use disorder and fewer than 2 per cent had this diagnosis during the past 12 months (Lin et al ., 2011 ). Alcohol-use disorders were diagnosed with the Diagnostic and Statistical Manual of Mental Disorders (4th edn, DSM-IV; American Psychiatric Association, 1994 ).
Blazer and Wu ( 2009 ) examined pooled data from nearly 11,000 participants in the 2005 and 2006 US National Surveys on Drug Use and Health. Overall, 60 per cent of adults aged 50 or over had used alcohol in the past year, with elevated rates in the 50–64 year age band as compared to those aged 65 years and over. Further work indicated that the rate of past year alcohol-use disorders was twice as common in the 50–64 than the 65 and over age band (approximately 7 per cent vs 3.3 per cent;
Blazer and Wu, 2011 ). This suggests that there is a cohort effect consistent with the observation of increased alcohol intake in the Baby Boomer generation (Patterson and Jeste, 1999 ).
Longitudinal data from the General Lifestyle Survey (Great Britain) cited in a paper by Knott and colleagues ( 2013 ) showed that between 1998 and 2010 daily
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alcohol consumption exceeding recommended limits has decreased in the 16–24 year age group (from 50 to 34 per cent for men and 41 to 31 per cent for women), while it has increased in those aged 65 and over (from 17 to 22 per cent for men and 4 to 11 per cent for women). This trend for a change in drinking habits in older adults is reinforced by the data modeled by Han and colleagues ( 2009 ) that indicated a conservative doubling in the number of adults aged 50 years and over diagnosed with substance use disorder by the year 2020.
In summary, there is variation between studies regarding the prevalence of harmful alcohol use and alcohol-use disorders in late life. This is often due to differ- ences in methodology between studies (definition of an older person, community vs hospital or institution setting and diagnostic criteria) and a key challenge is the lack of any gold standard definition for alcohol-use disorders in older people (Coulton, 2009 ; Gilson, Bryant and Judd, 2014 ). However, it is evident that rates are increasing substantially, consistent with the increasing number of older people in the population and different drinking habits of the Baby Boomer generation. This increase in prev- alence rates will put significant pressure upon health services and emphasizes the importance of developing diagnostic tools and treatment protocols that are suitable for this group.
Identifi cation and assessment of alcohol-related issues in older people
The identification of alcohol-use disorders among the older population is generally quite poor. This is due to a wide range of issues including difficulties with defining hazardous drinking in the elderly, a lack of age-appropriate clinical guidelines, a reluctance of health professionals to screen for alcohol misuse and abuse in older people (due to insufficient knowledge about this group, as well as time constraints and competing demands), the misapprehension that alcohol-use disorders are not common in ageing, a reluctance by patients to report alcohol-use levels to their clinician, the potential for atypical presentations triggered by accidents, confusion or self-neglect and a lack of knowledge regarding the interplay between alcohol and cognitive impairment in late life (Dar, 2006 ; O’Connell et al ., 2003 ).
Identifi cation of alcohol-use disorders in older people
There are challenges associated with defining an alcohol-use disorder in older people. Even the definition of “older” in the literature varies and this can depend on the clinical context. For example, drug and alcohol services can view older clients as those aged 40 to 50 and above; however, this cut-off usually increases to 65 years in an aged-care context. Furthermore, standard diagnostic criteria may not apply to this population. Given that older adults are often retired and may be socially isolated, it can be difficult for older people to meet DSM-IV diagnostic criteria (Patterson and Jeste, 1999 ). Tolerance can also be difficult to establish given biological changes with age that mean older people require less alcohol to achieve the same effects
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(Patterson and Jeste, 1999 ). The newer DSM-5 (American Psychiatric Association, 2013 ) now utilizes a single diagnostic category, “alcohol-use disorder”, which has 11 criteria that the person may meet to be diagnosed with an AUD (two symptoms minimum). While some of the same difficulties with older patients persist, the newer criteria provide a broader range that may be more inclusive of this group.
This issue is intended to be addressed with the new revision of the International Classification of Diseases (ICD), which will include age-specific diagnostic criteria (B. Draper, personal communication, July 2014 ).
There is also a lack of clarity in clinical guidelines with respect to safe drinking levels for older adults, with considerable variation across countries. The majority of current guidelines are based on work in young adults and do not provide a recom- mended daily or weekly intake for older people. This is relevant since older people do not metabolize alcohol as efficiently and have the competing effects of frailty and concomitant medication use (prescribed and/or illicit) interacting with alcohol consumption (Ridley, Draper and Withall, 2013 ). The guidelines are also very country specific, with respect to the fact that different countries vary greatly in the grams of alcohol included in a standard drink and this needs to be considered.
In particular, the highest per-capita alcohol consumption in the world is reported in Europe and accordingly alcohol-related deaths among older people in this region has markedly increased over the past decade (Hallgren, Hogberg and Andreasson, 2009 ). However, the majority of countries in the European Union do not have age-specific guidelines (Hoeck and Van Hal, 2012 ).
The current Australian guidelines do not have any specific recommendations for older adults (National Health and Medical Research Council, 2009 ). All adults aged 18 and over are advised to consume no more than two standard drinks on any single day (1 drink = 10g) in order to reduce the lifetime risk of harm from alcohol-related disease or injury. These guidelines, however, acknowledge that people aged 60 years and older are at an increased risk of harm from consuming alcohol and that, while less likely to binge drink, they are more likely to drink smaller quantities more regu- larly and are at risk of cumulative harm. The recent Invisible Addicts report released by the Working Group of the Royal College of Psychiatry in the UK (Crome et al ., 2011 ) advocates that the upper “safe limit” for older people is 1.5 units per day or 11 units per week (1 drink = 8g). The NIAAA guidelines (National Institute on Alcohol Abuse and Alcoholism, 1998 ) are comparable, recommending that healthy adults over 65 years who are not taking any medications should not exceed one drink on a given day and seven drinks in total over the course of a week (1 drink = 14g).
Interestingly, a recent analysis of nationally representative data from the Health Survey for England indicated that if the guidelines of the Working Group of the Royal College of Psychiatry were to be adopted then there would be a greater number of drinkers at risk of alcohol-related harm in the community in the 65+ age band than in the 16–24 year group (Knott et al ., 2013 ). Furthermore, the number of older, at-risk drinkers would increase by 2.5 fold to exceed 3 million cases in England alone. This is a dramatic increase and caution needs be used in applying such criteria until we have a better grasp of the true impact of low-level daily drinking in late life.
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Given that older people may also show more complex patterns of substance use (e.g., alcohol plus inappropriate use of prescribed medications) and need clear guid- ance on cognitive and physical comorbidities, the development of further age-specific guidelines, as well as research to prove their validity, is imperative. The impact of these lowered drinking levels, in particular how best to manage the number of people who would screen positive, also needs to be considered.
Tools to identify alcohol-use disorders in older people
Common screening tools to assess alcohol use and misuse in older clients currently screen for risky intake levels and alcoholism only. The Short Michigan Alcoholism Screening Instrument – Geriatric Version (SMAST-G) (Blow et al ., 1992 ) is a short form of the Michigan Alcoholism Screening Instrument that is specifically tailored to older adults. The Substance Abuse and Mental Health Services Administration (SAMHSA) Guidelines now recommend that a screening test like the SMAST-G be the first step in “SBIRT”, a treatment protocol consisting of screening followed by brief intervention and referral to treatment as needed (Naegle, 2007 ). Scores on this scale can be a useful starting point to instigate a discussion with those who screen positive about the need to reduce their levels of alcohol consumption. The Alcohol-Use Disorders Identification Test (AUDIT) was developed by the World Health Organization as a brief screening tool mainly for use in primary care settings (Babor et al ., 2001 ). It consists of ten questions regarding both the quantity and frequency of alcohol use in adults, with the aim of identifying those drinking at hazardous or harmful levels. The screening cut-point for hazardous drinking and where brief intervention is indicated is a total score of eight or higher, although it is acknowledged that the elderly constitute an at-risk group and therefore a reduced score of six or seven might be more sensitive. The scale has also been further refined to briefer, three-item (AUDIT-C) and five-item versions (AUDIT-5) that have been shown to reliably identify heavy drinking and/or active alcohol abuse or dependence and to out-perform other scales (Bush et al ., 1998 ; O’Connell et al ., 2004 ). Though not developed specifically for an older population, the shortened versions of this scale have been shown to have good utility for both males and females in this age group (Bradley et al ., 2004 ; Bush et al ., 1998 ). The other common detection tool is the CAGE (Ewing, 1984 ), which screens for alcohol abuse or dependence. This tool is brief and is the most commonly administered; however, its main target is identifying alcoholism rather than current or shorter-term hazard- ous use (Crome et al ., 2011 ) and its performance in the elderly has been shown to be variable (O’Connell et al ., 2004 ).
A newer test developed by Fink and colleagues ( 2002a ) is the Alcohol-Related Problems Survey (ARPS). The aim of this comprehensive 60-item tool is to provide a sliding threshold scale according to comorbid medical conditions and concomitant medications and it categorizes patients into non-hazardous, hazardous or harmful drinking. There is also a shortened version (Fink et al ., 2002a ). Both versions of this scale have been shown to perform better than the AUDIT and the SMAST-G in
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older people and to have excellent sensitivity; however, both have poorer specificity (Moore et al ., 2002 ). Unlike the other scales, the ARPS is able to identify a cohort of people at risk of alcohol-related harm due to their comorbid medical illnesses or concomitant medications (Fink et al ., 2002b ). While broad and comprehensive, a key disadvantage of the ARPS is its long length, which may serve as a deterrent to its use in clinical care.
Currently, the most commonly used tools for an older population are aimed at identifying cases of alcoholism. It would be beneficial if there were specific tools to identify a broad spectrum of AUDs in older adults and if these could distinguish between symptoms observed in “normal ageing” and those associated with alcohol misuse. To have optimum utility, this tool would be brief and able to be administered across a range of clinical settings. Another current gap in this literature is the older population presenting with cognitive impairment. There is currently no gold standard screening instrument to detect AUDs in this population and they constitute a particu- larly vulnerable group to the effects of alcohol, particularly as regards their clinical course (O’Connell et al ., 2004 ). Older people presenting to some memory clinics may be excluded if there are signs of AUDs, but may also struggle to engage with alcohol treatment services (where these are available for older groups) due to cognitive impair- ments (Wadd et al ., 2013 ). However, existing alcohol screening measures can be adapted for individuals presenting with cognitive impairment and recommendations suggest supplementing screening performance feedback with alcohol diaries and col- lateral information from family members and carers to provide accurate information on alcohol use (Wadd et al ., 2013 ). Our multidisciplinary, memory clinic in the Aged- Care Psychiatry service at Prince of Wales Hospital (NSW, Australia) accepts all refer- rals, regardless of age and aetiology, and we are currently working collaboratively with local drug and alcohol services (who are now cognitively screening all clients) to trial this clinic as a means of providing more in-depth assessment of ageing drug and alcohol patients who present with cognitive impairment. One gap that persists in the literature, however, is that more information is required regarding the differences in presentation of older people with cognitive impairment with comorbid alcohol misuse (or, more broadly, substance abuse) compared to those with common types of dementia.
Cognitive assessment of older adults with alcohol-use disorders
There is, likewise, currently no cognitive tool advocated for the older population to assess the impact of alcohol on cognitive performance although anecdotal evidence in our clinics suggests that the Montreal Cognitive Assessment (MoCA) has good acceptability and utility and is preferable to the Mini-Mental State Examination (MMSE). The MoCA was also highlighted as a quick, easy to administer and accept- able tool to use in substance misuse services to screen for cognitive impairment among older clients (Wadd et al ., 2013 ). This type of assessment is vital as cognitive capacity is a sensitive predictor of engagement in treatment (Bates and Pawlak, 2006 );
identifying cognitive deficits allows treatment to be modified to optimise outcomes for the patient (Wadd et al ., 2013 ).
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The MoCA has been shown to be effective in distinguishing those with mild cognitive impairment (MCI) from control participants with intact cognition and from patients with conditions associated with impaired cognition in ageing, such as mild Alzheimer’s disease (Lee et al ., 2008 ) and Parkinson’s disease (Hoops et al ., 2009 ). It correlates well with the domains of a broad neuropsychological assessment, particularly memory, executive function and visuo-spatial function, and it can have particular utility in directing further in-depth assessment (Lam et al ., 2013 ). The strength of the performance of the MoCA on these domains makes it particularly suitable for differentiating between some of the difficulties observed in patients with many types of early dementia and those with alcohol-induced cognitive impairment.
There is also evidence of the utility of the MoCA as a cognitive screen in younger adults with substance abuse. The utility of this test has been compared to the full Neuropsychological Assessment Battery-Screening Module (NAB-SM), which assesses cognitive functioning across the five domains of attention, language, memory, visuo-spatial function and executive function (Stern and White, 2003 ) and has been used previously in drug and alcohol settings. The MoCA was shown to have criterion-related validity and good accuracy in correctly distinguishing cases of alcohol-related cognitive impairment (Copersino et al ., 2009 ). A weakness of the MoCA is that it does not examine psychomotor speed, visual learning or delayed recognition, although it is only a screening measure and as such cannot be expected to examine all cognitive domains. The study did also support the clinical utility of the test and showed that the patient acceptability was good. Within the group with ARBD, the MoCA memory sub-domain in particular has also been shown to be able to distinguish between those with Korsakoff ’s Syndrome and patients with alcohol-related cognitive impairment (non-Korsakoff ’s: Wester et al ., 2013 ).
The MoCA appears to be a useful brief screening tool to evaluate cognitive impairment in older people and in those with AUDs. This test should not be used as a substitute for further neuropsychological assessment but rather to complement this process and indicate patients where further evaluation is warranted.
Barriers to screening older people
A difficulty for clinicians as regards the diagnosis and assessment of AUDs is that the medical comorbidities that can be warning signs for alcohol misuse and abuse can also present as symptoms of medical illnesses associated with ageing. Examples of this include cognitive impairment, confusion and disorientation, gastrointestinal tract problems and falls. However, these conditions do provide an important opportunity for screening. The primary care setting in particular is a key environment for the screening of AUDs in older people since this age group is known to visit their physician regularly, on average at least six times each year (Schappert, 1999 ). Key opportunities for alcohol-use screening in primary care include at the initial con- sultation, if the patient has a fall, or when a new medication is commenced or existing medications are reviewed (Hunter and Lubman, 2010 ). Screening should