Abstract Alcohol consumption constitutes a substantial burden of disease. Older people are being admitted to hospital for alcohol problems in increasing numbers. A recent systematic review reports cautious supportive evidence for primary prevention interventions in reducing excessive alcohol consumption in older drinkers, but does not focus on treatment of dependent drinkers. The evidence base for treatment interventions for dependent drinkers is comparatively limited, but it is growing. In addition to brief interventions, specialist outpatient treatment and inpatient treatment have been evaluated. The responses of older people to treatment are promising: they want to abstain, they have the capacity to change, they respond well to brief advice and motivational enhancement therapy, they achieve improvements at least as comparable to younger counterparts—and sometimes better—and they do have the prospect of long-term recovery. There is a need to develop services tailored to the needs of older substance misusers. Education of the workforce, including medical students and other health care professionals, is the key. Collaboration and coordination of services, training, research and policy are essential. There are very few designated services for older substance misusers in the UK and only 7% of older people who need treatment for alcohol problems access them. There is a massive gap in the whole gamut of research from basic to clinical research in this vulnerable patient population: this has to be developed if management is to be effective and up to date. alcohol, brief interventions, dependence, older people Introduction Alcohol consumption constitutes a substantial burden of disease and in older people is increasingly being recognised as a major public health issue in older people [1, 2]. It is estimated that by 2050 one in four people in Europe will be over the age of 60 . Projections in Europe and the USA are that the number of people over the age of 65 requiring treatment for substance misuse will have doubled or tripled over the period 2001–20 [4, 5]. In the UK over the last 10 years, alcohol consumption has been rising in older people. For example, those aged 65 and over have shown a 20% increase in the proportion exceeding recommended drinking limits on any 1 day over the previous week . This is reflected in hospital admissions; whereas in 2010/11 this age group comprised 14% of hospital admissions related primarily to alcohol, between 2015 and 2016 this had more than doubled to 29% [7, 8]. Alcohol-related deaths are increasing and the greatest increase and the highest risk is in the 55–64 age group . Mortality rates from substance misuse in the over 65 are nearly twice that of the general population . ‘Recommended’, ‘safe’, ‘sensible’, ‘low risk’ or no drinking? Given this background of serious complications from alcohol consumption in older people the study by Kelly et al.  is instructive. Their systematic review focuses on primary prevention rather than the treatment of dependent drinkers. They reported cautious supportive evidence for interventions in reducing excessive alcohol consumption in older drinkers. They have pointed to some of the difficult methodological issues in reviewing this area. Not only was there a considerable heterogeneity in the study populations but different assessment instruments were used. Thus, direct comparison between individual studies was difficult. Further issues include the definition of when someone becomes older. Is it someone over 50, 55, 65 or 75 years? Does this make a difference in terms of sensitivity to the effects of alcohol on physiological function in that older people are likely to be more susceptible to the equivalent dose of alcohol consumed by younger people? The studies reviewed appeared not to include the very old. There was variation in how alcohol consumption was measured. For example, ‘drinks per week’ may equate to different amounts in different countries. In the USA, a ‘drink’ is equivalent to 14 g alcohol whereas in the UK, a ‘unit’ is equivalent to 8 g of alcohol. In addition, definitions or descriptions of alcohol consumption varied, e.g. hazardous, harmful, at risk, heavy, excessive and did not describe the quantity and frequency of use in the subjects studied. Are the instruments used to screen and assess younger adults, e.g. AUDIT, appropriate for older people? Most of the instruments used to measure alcohol consumption and dependence were developed in younger people. Furthermore, the assessment instruments used in the studies reported by Kelly et al. differed, e.g. AUDIT, CARET, TLFB and only SMAST-G is specifically for older people. They acknowledged that data generated by self-report are likely to be unreliable as people may underestimate their consumption. There are also issues with diagnostic criteria, e.g. International Classification of Diseases or Diagnostic and Statistical Manual, in an older population. Reduced tolerance, changing social roles and less exposure to legal consequences may lead to dependence being underestimated. Interventions are diverse and not described in detail. Follow-up periods were relatively short, particularly for a condition that may be long term. How do we account for any differences in the definition of ‘brief’ intervention? Other interventions including control interventions, usual care, can be very variable. As the authors state, although there are several reviews of the effectiveness of brief interventions in adults, this is not the case for older people. Support for brief interventions has been demonstrated in a meta-analysis of 22 RCTs including 7,619 adult patients across the age range showed that participants receiving brief intervention had lower alcohol consumption than the control group after follow-up of 1 year or longer, although there was substantial heterogeneity between trials and studies were not restricted to older people . Kelly et al.  had intended to investigate cognitive outcomes but were unable to identify relevant studies. What guidance should be given to older people? Whatever intervention is implemented, what should the goal be? Fundamental to knowing what advice to give older drinkers is knowing what quantity constitutes hazardous or harmful drinking. Since this not well defined, should the advice be to drink within the 2016 Department of Health Guidance, i.e. no more than 14 units (112 g alcohol) per week ? It should be noted that this guidance differs from the USA, which indicates that up to 7 US drinks units per week (equivalent to 98 g or 12 units) is safe for healthy older people . Whatever a ‘safe’ ‘recommended’ limit, ‘sensible’, ‘low’ risk or at an ‘acceptable’ risk of consumption is, this will differ from individual to individual. The UK alcohol guidelines of 14 units a week for both men and women may still be too generous for older people. Vigilance is needed due to the possibility of interactions with prescribed and over the counter medications, as well as comorbid disorders including suicidal risk. Physiological changes related to ageing may make alcohol consumption much more risky than in younger adults. There are those who would argue that for some, particularly older, individuals with physical and mental health comorbid disorders, there are no ‘safe limits’ for alcohol consumption . Recent studies on the relationship between alcohol consumption and mortality and cognitive outcomes are enlightening. Shield et al.  estimated the risk of mortality based on different levels of average alcohol consumption in seven European countries and concluded that a higher rate of mortality occurred if alcohol consumption exceeded more than 7–13 g (approximately 1–1.6 units) per day for women and 7–20 g (approximately 1–2.5 units) per day for men. Topiwala et al. , in a longitudinal 30-year cohort study of cognitive decline, concluded that moderate levels of alcohol consumption are associated with adverse brain outcomes derived from imaging. Brain structure was affected at 14–21 units per week. Their conclusion is that if alcohol is a modifiable risk factor for cognitive decline, preventive interventions should not be delayed. These recent studies seem to suggest that the range for ‘low’ risk drinking is approximately 1–1.6 units and 1–3 units a day for women and men, respectively. Treatment Kelly et al.’s restrained conclusion that alcohol interventions in older people may be effective is to be welcomed. This should be interpreted positively but trial methodology needs to be strengthened and extended. For instance, concerns has been raised by McCambridge and Saitz  about the reasons for the low uptake of brief interventions in primary care, a point also raised by Kelly et al. . Fortunately, there are those older people who are drinking in a risky or hazardous fashion and for whom brief interventions are effective. However, we should not ignore those drinkers who are alcohol dependent with mental illness and physical comorbidities, who require more intensive interventions, and who do not present or receive treatment. The evidence base for treatment interventions for this group is comparatively limited, but it is growing. In addition to brief interventions, specialist outpatient treatment and inpatient treatment have been evaluated. Two systematic reviews on treatment interventions demonstrated that most studies were undertaken in developed countries [19, 20]. Subjects were categorised as heavy drinkers or at risk or alcohol dependent. The interventions for alcohol problems were very mixed and include information, education, advice, personalised feedback, drinking diaries, counselling, brief motivational intervention and telephone booster sessions. Thus, as in Kelly et al.’s review, there were methodological limitations in that there was little standardisation of type, duration and intensity of treatment. Few studies systematically devised and evaluated age-specific components. Sample sizes were relatively small and follow-up short. As with Kelly et al.’s findings, recognition of the wide age range, standardisation of diagnostic tools and assessment instruments, detailed description of treatment options and style of delivery tailored to older people, would enhance comparability. Despite these limitations, it is encouraging that the overall trend of the results pointed to a greater response to treatment, greater treatment adherence and supportive social networks than in younger adult populations. Treatment in specialist units also has positive outcomes similar to those in younger adults Overall, the Moy and Bhatia studies demonstrated that older adults with alcohol problems can benefit from treatment [19, 20]. The responses of older people are promising: they want to abstain, they have the capacity to change, they respond well to brief advice and motivational enhancement therapy, they achieve improvements in the domains (mental and physical health, relationships, legal, occupational and financial issues) at least as comparable to younger counterparts—and sometimes better—and they do have the prospect of long-term recovery. Although there are potential benefits of age-specific treatment programs, it does appear that older people can respond to treatments that have been developed and tested in younger populations In these reviews, psychosocial treatments predominated. Pharmacological treatments are available and should be carefully administered, always together with psychological interventions and within a multidisciplinary context. As some of the studies reported by Moy et al. and Bhatia et al. were undertaken in primary care, this has significant implications for practice [19, 20]. Much can be delivered by generalists and integration of mental health with substance misuse in primary care has also been shown to be advantageous [21, 22]. The use of standardised training and materials can aid implementation of treatment approaches. However, the role of specialists should not be downplayed; this group can be very complex to manage and require the experience, expertise and clinical judgement of addiction psychiatrists and geriatricians and their teams. Studies have not yet tested specific effective components of interventions or the barriers and facilitators of positive outcomes, despite the fact that some studies were undertaken on older people only. However, some elements that can enhance treatment were identified and can be incorporated in service provision. Service provision Notwithstanding the advances in understanding the development of addiction along the life course, and a more extensive choice of treatment interventions, there remains a critical need to develop services tailored to the needs of older people suffering from alcohol and other substance misuse. There are very few services in the UK that are designated for older substance misusers. It has been estimated that only 7% of older people who need treatment for alcohol problems access them [23, 24]. If patients who present with physical or psychiatric problems related to alcohol are not identified and treated appropriately, the potential for good outcomes will be jeopardised. In order to offer the optimal care, highly qualified and experienced staff are needed [25, 26]. Over the last 5 years, addiction services in the UK have been reduced and the situation can be described as precarious at best and dire at worst. There have been reductions in training posts and consultant numbers. Hospital-related admissions have risen inexorably due to cuts in community services. In what way should the delivery of interventions take account of the distinctive condition of the older person? There remains a degree of stigma about addicts and therapeutic nihilism reading the effectiveness of treatment. As a result, patients are not prescribed those medications that are effective and are not given access to the psychological therapies that should accompany them. For those accessing services, it makes sense to aim to adapt them to the specific needs of older people such as working at a slower pace, non-confrontational, peer support, promotion of self-esteem, life stage transitions, e.g. grief, loss, leisure, recreation, and physical abilities, sensory losses and communication difficulties. Older people may not engage with after care or 12-step approaches, so different options may need exploration. Studies in older people have not evaluated cost-effectiveness in older alcohol misusers, though findings in the adult population do point to savings from interventions . The future The numbers of older alcohol misusers are likely to increase. There are treatments, which if made available, are highly likely to be of benefit. At the same time, there are seemingly insuperable difficulties in ensuring the effective interventions are delivered in coordinated services, agencies and professionals at this time in the UK. Education of the workforce, starting with medical students and other health care professionals in training, is the key. Collaboration and coordination of services, training, research and policy are essential. Denial of alcohol-related problems in older people is not a solution. Crucially, a change in culture is needed so that older people are not be prevented from alcohol treatment because of age. For these reasons, the Royal College of Psychiatrists have embarked on a range of activities to raise awareness, improve clinical skills and foster research. Invisible addicts is published in 2011 . In 2015, an information guide to assist practitioners in clinical work was produced . A book which collated national and international research was published in 2015 . Invisible addicts is currently being revised. In the UK, there is a massive gap in the whole gamut of research from basic to clinical research in this vulnerable patient population: this has to be developed if management is to be effective and up to date. Key points There is evidence that interventions are effective in older drinkers. There is uncertainty as to what guidance older people should be given about alcohol consumption. Alcohol consumption and associated harm are rising in older people. There are very few treatment services for older drinkers in the UK. Conflict of interest None. Funding None. 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Age and Ageing – Oxford University Press
Published: Mar 1, 2018
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