The aim of this presentation is to summarize and critically evaluate the recent literature on methods to better identify AUD in older adults, including instruments specifically developed or modified for this age group, as well as, delineate targeted treatment strategies which may be more effective in achieving and maintaining sobriety in this population.
Background:
Alcohol Use Disorder (AUD) has been identified as a significant, under-recognized, underreported and hidden epidemic in the U.S. (Alpert, 2014). The prevalence is expected to rise dramatically as the number of adults aged 65 and older increases to one in five by 2030. Worldwide, older adults aged 60 and older are currently at 800 million and this figure is expected to climb to over two billion in 2050 (World Health Organization [WHO], 2012). With this escalation in the number of older adults comes a concomitant increase in those struggling with AUD, where the health consequences can be significant. According to WHO (2016), 5.9% of all global deaths are attributable to alcohol consumption.
Challenges in assessment include acknowledging differences in drinking patterns, onset (early vs. late onset), symptom presentation, difficulties in differentiating symptoms of AUD from other health complaints associated with aging, as well as the denial, shame, and stigma which can present major barriers to prompt identification. In the care setting, busy practitioners with limited resources and time often confine screening to persons with a known history. However, complex comorbidities that usually present in older adults can delay assessment and subsequent treatment. A latent missed diagnosis fails to capture individuals who may have AUD and may preclude or delay appropriate interventions, and ultimately, the goal of sustained sobriety. The inconsistent use of evidence-based screening instruments to identify those at risk is an obstacle to successful diagnosis and treatment.
With regard to management, older adults do achieve equivalent or better results than younger counterparts when they enter treatment (Bakhshi & While, 2014; Yasamy, Dua, Harper, & Saxena, 2013), especially when interventions are focused on the needs of this specific age group. Furthermore, a substantial “treatment gap” exists brought about by the inability to access and/or afford care. The literature also highlights treatment modalities as part of the alcohol screening and brief interventions (ASBI) model, such as cognitive-behavioral therapy (CBT) and mutual help (aid) groups (MHGs). There is emerging evidence that interventions must be both engaging and tailored to this specific age group to enhance compliance and optimize probability of ongoing recovery.
The issues surrounding the assessment and management of older adults with AUD are complex and poorly understood. Furthermore, both the literature and research on older adults with AUD has been minimal given the growing prevalence of this population. Nurses have the potential to enhance awareness, initiate screening with appropriate instruments, participate in treatment plans that are individualized to achieve treatment success and play a key role in advocacy for this underserved and vulnerable group.
Methods:
An in-depth review of the literature was conducted to ascertain the state-of-the science related to instruments used in screening older adults for AUD, as well as, age-appropriate interventions. Key words included: alcohol use disorder (AUD), alcoholism, older adults, elderly and substance abuse. Articles on substance use disorder (SUD) were excluded unless there was a significant or updated component related to AUD. In addition to integrative reviews, an emphasis was on primary sources incorporated from the last decade to identify more recent trends and obtain the most pertinent and comprehensive information.
Results:
A total of 36 articles were found within the past decade, with four of those being integrative reviews. As far as AUD assessment instruments, the CAGE is considered a primary screening instrument because of its ease of use; its drawbacks include failure to identify binge drinking and separating a drinking history from current use. The MAST-G scale is specifically formulated for geriatric patients and has been gaining substantial support in the literature. Treatment approaches include inpatient detoxification followed by targeted interventions to maintain sobriety. Detoxification can be more problematic in the older adult population, with confusion rather than tremors being the predominant sign. The subsequent phase of implementing Alcohol Screening and Brief Interventions (ASBIs) is increasingly recognized in the literature as both a screening strategy and supportive treatment. ASBIs can include mutual help groups, cognitive behavioral therapy, motivational interviewing, the FRAMES model, and other related approaches (Blow & Barry, 2012). The literature specifically highlights mutual health groups, such as Alcoholics Anonymous (AA), as most beneficial when comprised primarily of older adults who have similar issues of retirement, loss, physical co-morbidities, diminished self-esteem, shame and stigma. The literature strongly supports that for the older adult, ASBIs should be both engaging and tailored to enhance compliance and optimize treatment success and sustained recovery.
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