Reaching out to older drinkers:

- a new practice model

Greg Scott

9 March 2010

An alcoholic is someone you don't like whoAn alcoholic is someone you don't like who

drinks as much as you do.drinks as much as you do.

Dylan Thomas

Every man desires to live long,Every man desires to live long,

but no man wishes to be old.but no man wishes to be old.

Jonathan Swift

Some basic background UK

Alcohol consumption rose by 60%: (1970 – 2006)

Affordability of alcohol doubled (1970 – 2001)

Most popular drinking venue is the home

ANARP (2004) excluded the over 65s

Models of Care for Alcohol Misusers

Review of Effectiveness: 1 reference for older people

Focus on Older People (65+)

Little published research or data

Demographic changes

Levels of alcohol related harm

Vulnerability to alcohol related harm

Alcohol & older people

“Wet Generation” born after World War II

Older men drink nearly as often as all adults

84% increase in cost of treating alcohol related harm

Currently > 50% total NHS spend on alcohol related

harm

75% increase alcohol related hospital admissions

ChangingChanging patterns of alcohol patterns of alcohol consumptionconsumption

Past experience indicates that alcohol Past experience indicates that alcohol consumption decreases with age, but recent consumption decreases with age, but recent patterns of behaviour may change due to patterns of behaviour may change due to ageing of the ‘baby boomers’ generation who ageing of the ‘baby boomers’ generation who have traditionally had more permissive have traditionally had more permissive attitudes towards alcohol and high level of attitudes towards alcohol and high level of consumption than earlier generations.consumption than earlier generations.

Changes in alcohol related admissions for 65+

% increase 2002 - 2007

Malignant neoplasm of oesophagus 6.6

Fall injuries 19.3

Liver disease 45.9

Epilepsy and Status epilepticus 51.8

Cardiac arrhythmias 70.9

Mental / behavioural disorders 76.9

Hypertensive diseases 119.4

Source: NHS Information Centre for Health & Social Care

Unique vulnerabilitiesUnique vulnerabilities Metabolism slows down with ageMetabolism slows down with age

Lower body massLower body mass

Lower proportion of water in a bodyLower proportion of water in a body

Decreased hepatic blood flow- liver will receive more damageDecreased hepatic blood flow- liver will receive more damage

Interaction with other medical conditions and interaction of alcohol Interaction with other medical conditions and interaction of alcohol with medication taken as a treatment of those conditionswith medication taken as a treatment of those conditions

Inefficiency of liver enzymes- alcohol broken down inefficientlyInefficiency of liver enzymes- alcohol broken down inefficiently

Vulnerability to alcohol related harm

Psycho- social challenges of ageing and impact of alcohol (isolation, Psycho- social challenges of ageing and impact of alcohol (isolation, depression, memory deterioration, change of role, food preparation skills, depression, memory deterioration, change of role, food preparation skills, opportunities, nutritional needs)opportunities, nutritional needs)

Shrinkage of cerebellum - posture and fallsShrinkage of cerebellum - posture and falls

Bones becoming more brittle – higher fracture risk- poorer nutrition- less Bones becoming more brittle – higher fracture risk- poorer nutrition- less chance of recoverychance of recovery

Mistaken for common physical or psychiatric conditions

Alcohol – medication interactions

Inadequate screening & reporting

Age group less likely to disclose

Risk of abuse and neglect

Early onset:

Describes those who have a lifelong pattern of drinking, have probably been alcoholic all their life, and are now elderly.

More likely to have chronic alcohol-related medical problems such as cirrhosis, organic brain syndrome, and co-morbid psychiatric disorders.

Late onset:

Describes those who have become alcoholic in their drinking pattern for the first time late in life.

Often triggered by a stressful life event.

Generally represented by milder cases with fewer accompanying medical problems.

More amenable to treatment, more likely to have spontaneous recovery

“Wiser Drinking”

Kensington & Chelsea pilot 2008/9

Aims:

Assess need for treatment services

Increase screening capacity in older persons services

Reduce alcohol related hospital admissions

Identify potential need for specialist alcohol service

Provision for treatment capacity

Service re-commissioned 2009/10

Older People’s Service

Specialist Service embedded in Tier 2 Alcohol Service

Providing training for other services

Outreach and site based

Working with local services to build capacity Raise awareness of alcohol and ageing

Training in use of screening tool

Individual case work Harm reduction advice and support

Pathways between geriatric & specialist alcohol services

Referral to treatment

Support accessing health & care services

Liaison with carers

The Pilot..

Referrals

70% women

Oldest: 87 years

All had their alcohol delivered to home

Half drinking 70+ units pw

40% drinking over 50 units

80% admitted to hospital in previous 6 months

80% treated by GP for depression

Previous contact with alcohol services: 3

ScreeningScreening

Identifying the problem is the first step towards Identifying the problem is the first step towards resolving itresolving it

Older people are at higher risk of harm and are better Older people are at higher risk of harm and are better respondents to treatment, but failure to screen may respondents to treatment, but failure to screen may lead to less frequent access to it.lead to less frequent access to it.

Low threshold interventions delivered early alongside Low threshold interventions delivered early alongside general health promotion and in conjunction with other general health promotion and in conjunction with other medical treatments are likely to be effective.medical treatments are likely to be effective.

AssessmentAssessment

Substance abuse screening instrumentsSubstance abuse screening instruments Special assessmentsSpecial assessments Functional abilitiesFunctional abilities Co-morbid disordersCo-morbid disorders Physical co morbiditiesPhysical co morbidities Psychiatric co-morbiditiesPsychiatric co-morbidities Cognitive impairments (dementia, delirium and other)Cognitive impairments (dementia, delirium and other) Affective disordersAffective disorders Sleep disordersSleep disorders

AssessmentAssessment

Substance abuse screening instrumentsSubstance abuse screening instruments Special assessmentsSpecial assessments Functional abilitiesFunctional abilities Co-morbid disordersCo-morbid disorders Physical co morbiditiesPhysical co morbidities Psychiatric co-morbiditiesPsychiatric co-morbidities Cognitive impairments (dementia, delirium and other)Cognitive impairments (dementia, delirium and other) Affective disordersAffective disorders Sleep disordersSleep disorders

Co-morbidityCo-morbidity

Hip fracturesHip fractures Blood pressureBlood pressure Gastric problemsGastric problems ConstipationConstipation MalnutritionMalnutrition StrokeStroke DepressionDepression Isolation and poor social functioningIsolation and poor social functioning Reduced/ impaired mobilityReduced/ impaired mobility DrivingDriving

Reasons for alcohol use

Unresolved emotional difficulties from past (53%)

Loneliness & isolation (23%)

Bereavement (10%)

Loss of status in the community (9%)

Ill prepared for retirement (9%)

Findings

Older people receptive to interventions

Enthusiastically received by fellow professionals, the

drinkers (and the media)

Need for health specialists in alcohol & ageing

Evidence of unmet demand for alcohol interventions

Implications

Evidence of significant unmet need for services

Demographic projections suggest rising need for

alcohol interventions with 65+ age group

Need to develop data and experience

Older people appear to welcome appropriate help

Alcohol related harms are often reversible

Next steps

More of the same

More similar

Partnership with a University & another charity

Replicate the pilot to see if findings confirmed

Development of evidence base

How should we address alcohol use amongst older people?

More research & better data

Guidance on development of local treatment pathways

Cross-authority co-operation to develop services

Greater awareness amongst health & social care staff

Greater attention to drinking habits

Some increase in treatment capacity

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