Screening for Alcohol Issues in Older People
WHY DO WE NEED LIFE STAGE SPECIFIC ASSESSMENT TOOLS FOR OLDER ADULTS?
It is important to ask about alcohol use. Remember, alcohol is a drug! As we age there are inevitably changes particularly in older women in the ability to metabolize substances, even when used in moderation. We need to ask about the quality and type of substance in addition to quantity and frequency (including substances not intended to be imbibed.) We need to inquire about concurrent physical health (such as diabetes) and mental health conditions (such as depression) as well as other substances, prescribed and non-prescribed including over the counter, herbal, and shared medications. Increasingly, it is important to ask about recreational drugs as well.
To be useful, questions need to be appropriate for the individual’s life stage. It’s not just about asking the questions regarding alcohol and substance use but the context and sequence of the questions. A confident, simple and direct approach is important in clarifying information relevant to the client in their immediate situation. (We recognize that there may be limitations associated with language and cultural concerns.)
And the risks are greater. Be aware that the life threatening consequences of alcohol similar to benzodiazepine withdrawal (National Initiative for the Care of the Elderly,
2012) are more frequent in later life and require careful monitoring with concern for other medical conditions and consequences. In particular watch for tremulousness, palpitations, shaking, seizures; nausea, vomiting, diarrhea, sweating, agitation, anxiety, hallucinations; disorientation, and alteration of consciousness (Sullivan et al, 1989).
STANDARD DRINKS AND LOW RISK GUIDELINES FOR ALCOHOL
Alcohol is still the most widely used problem substance encountered by clinicians. In working with clients, it is important to have a shared understanding of “one drink”. According to the Canadian Council on Substance Abuse: “In Canada, a standard drink of alcohol (ethyl alcohol or ethanol) contains 13.6 grams or 17 ml of absolute alcohol - the amount contained in a 12-ounce (341ml) bottle of regular (5%) beer, five ounces (142 ml) of (12%) table wine or 1.5 ounces (43 ml) of 80-proof liquor. Definitions of standard drinks are different in other countries” (Canadian Centre for Substance Abuse, 2011). Although the recently adopted national guidelines for low risk drinking are somewhat higher, research supports lower recommended limits for older adults of one drink per day for men and less than one drink per day for women, and no more than two drinks on any drinking day (National Institute on Alcohol Abuse and Alcoholism, 2005).
Older adults may have cognitive issues which may interfere with their insight into the risks of alcohol. It is important to frame the screening tools in context. Here is a sequence of screening tools you may find helpful:
Short Michigan Alcohol Screening Test – Geriatric Version (SMAST-G) (Blow, 1991): this will help you assess whether there is alcohol dependence.
Senior Alcohol Misuse Indicator (SAMI) (Busto, Flower, and Purcell, 2003): offers you a route to exploring the risk of a developing problem along with health impacts.
Geriatric Depression Scale, short version (GDS) (Yesavage et al, 1982-83): It is not uncommon for depression to be present when there is alcohol misuse. Alcohol has a depressant effect on the body. It is important to screen for depression, but beyond this, we need to explore the interactions of alcohol and depression.
Montreal Cognitive Assessment (MoCA) (Nasreddine et al, 2005): this is your opportunity to have a baseline of cognitive function, which will influence the treatment plan, and can also be helpful in demonstrating later that things have improved when alcohol or substances are no longer part of the picture. Alcohol induced memory impairment is not necessarily permanent.
• For older adults, consequences of substance use and withdrawal are often more immediate and intense than in the general adult population.
• Questions need to be appropriate for the life stage and the context and sequence of questioning are important.
• Going beyond substance use to assess mental health and cognitive status can provide a context for the information gathered and clarify the treatment plan.
1 National Initiative for the Care of the Elderly (NICE), (March
For more information on NICE or any of the 2012), Medication Utilization: Understanding Potential
March 15, 2013
2 Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C.A. & Sellers, E.M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar).
3 Canadian Centre of Substance Abuse (2011), Alcohol Overview, Available: http://www.ccsa.ca/Eng/Topics/Substances AndAddictions/Alcohol/Pages/AlcoholOverview.aspx
4 National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2005). Module 10 C Older Adults and Alchohol Problems in Social work education for the prevention and treatment of alcohol use disorders. Available at: http://pubs. niaaa.nih.gov/publications/Social/Module10COlderAdults/ Module10C.html
5 Blow, Frederick C. (1991), Michigan Alcohol Screen Test – Geriatric Version (MAST-G), Available at: http://www.ssc.
National Initiative for the Care of the Elderly wisc.edu/wlsresearch/pilot/P01-R01_info/aging_mind/Aging_ AppB5_MAST-G.pdf
6 Busto, U., Flower, M.C., & Purcell, B. (2003), cited in Centre for Addiction and Mental Health, 2008, Improving Our Response to Older Adults with Substance Use, Mental Health and Gambling Problems.
7 Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982-1983; 17(1):37-49, Available at: www.chcr.brown. edu/GDS_SHORT_FORM.PDF
8 Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. (2005) The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. Journal of the American Geriatrics Society 53:695-699, Available: www.mocatest.org
Prepared by: The EENet Community of Interest for Specialized Geriatric Addictions, supported by Geriatric Mental Health, Addictions, and Behavioural Issues Community of Practice, The brainxchange (formerly the Seniors Health Knowledge Network (SHKN) & Alzheimer’s Knowledge Network (AKE))
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