NICE Tools: Archive

Screening for Alcohol Issues in Older People


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).  


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.

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