Sarah Wadd, Research Fellow and Donald Forrester, Director Tilda Goldberg Centre for Social Work and Social Care, University of Bedfordshire

Moderate drinking in old age has a beneficial effect on all-cause mortality (Paganini-Hill et al., 2007) and confers a number of psychological benefits, possibly through reduced stress and improved mood and sociability (Turner et al., 1981; Baum-Baicker, 1985; Cassidy et al., 2004; McPhee et al., 2004; Bond et al., 2005). However, survey data suggest that 20% of men and 10% of women aged 65 and over in the UK exceed recommended drinking guidelines (Robinson and Harris, 2011). To put this in perspective, the same survey indicates that in the 16-24 year age group, 21% of men and 23% of women exceeded drinking guidelines. In other words, older men are almost as likely to exceed drinking guidelines as young men. Older people are at increased risk for harm from alcohol, not only because physiological changes associated with ageing mean that they have a lower tolerance, but also because as people age they are more likely to have chronic illnesses, be on medications, or have functional impairments. This has recently led a working group for the Royal College of Psychiatrists to suggest that recommended drinking guidelines be reduced for older people (Royal College of Psychiatrists, 2011). Such guidelines already exist in the United States, where people aged 65 and over are advised not to drink more than seven drinks per week or more than three drinks on a single day (National Institute on Alcohol Abuse and Alcoholism, 1995).

There has been a steady increase in the amount of alcohol consumed by older people in the UK in recent years and this trend is consistent across different surveys and different consumption measures (Smith and Foxcroft, 2009). As the ‘baby boomers’ age, the prevalence of alcohol problems in older people is likely to increase because this age cohort has higher rates of use of alcohol consumption than previous cohorts. Furthermore, since the number of older people is increasing, even in the unlikely event that the prevalence of problem drinking remains the same, the absolute number will increase. Excessive alcohol use in older people is associated with a plethora of adverse consequences including falls and accidents (Wright and Whyley, 1994), insomnia, incontinence and gastrointestinal problems (Tabloski and Church, 1999), dementia (Hislop et al., 1995), Parkinson’s disease (Feuerlein and Reiser, 1986), memory loss, self-neglect, depression (Woodhouse et al., 1989) and suicide (Crome, 1991). Evidence from the United States suggests that older people are hospitalised for conditions associated with alcohol at approximately the same rate as for myocardial infarction (Adams et al., 1993).

Socio-demographic factors associated with alcohol problems in older people include being male (Illiffe et al., 1991; Saunders et al., 1991), socially isolated (Bristow and Clare, 1992; Ganry et al., 2000) and separated or divorced (Ekerdt et al., 1989). Some older people develop an alcohol problem for the first time in later-life (Adams et al., 1990; Liberto et al., 1992; Johnson et al., 1998; Moore et al., 2003; Moos et al., 2005). Known as ‘late-onset’ drinkers or ‘reactors’ because their drinking is often related to stresses associated with ageing such as retirement or bereavement (Graham et al., 1992), this group make up approximately one third of older drinkers (Dufour and Fuller 1995; Mellor et al., 1996). ‘Early-onset’ drinkers comprise the other two thirds of older drinkers and are considered to be problem drinkers who have aged. Late-onset drinkers are more receptive to treatment and more likely to recover spontaneously from an alcohol problem than early-onset drinkers (Menninger, 2002). A longitudinal study of the prognosis for older problem drinkers found an overall stable remission of 21% in late-life drinking at 4 years, with late-onset drinkers almost twice as likely as early-onset drinkers to have stable remission with treatment (Schutte et al., 1994).

Alcohol problems in older people frequently remain undiagnosed. A British study reported that doctors are less likely to request an alcohol use history from older patients (Naik and Jones, 1994) while an Australian study found that only a third of older problem drinkers were diagnosed following hospital admission (McInnes and Powell, 1994). In a general hospital in the United States, over a 6 month period, medical staff correctly diagnosed only 37% of older patients with an alcohol problem compared to 60% of younger patients (Curtis et al., 1989). There are a number of possible reasons for this low level of detection. Firstly, the symptoms of alcohol problems in older people are not specific and therefore difficult to distinguish from the symptoms caused by the medical or psychiatric problems of ageing (Thibault and Maly, 1993). Secondly, older people may be reluctant to reveal alcohol problems and cognitive decline and memory impairment may make self-reports less reliable. Thirdly, standard alcohol screening instruments have low sensitivity in older populations (Graham, 1986; Beullens and Aertgeerts, 2004). And finally, there may be lack of awareness amongst professionals that alcohol misuse is a potentially important problem for older people or a reluctance to ask embarrassing questions of older people. Research suggests that health and social care workers frequently take the view that older people are too old to learn something new (‘you can’t teach an old dog new tricks’) particularly when this requires a change in behaviour (Tabisz, 1993; Mellor et al., 1996; Wadd et al., 2011). This attitude may prevent older people being offered a full range of treatment options. In the United States, older people are less likely to have specialist alcohol treatment recommended by physicians and initiated when it is recommended (Curtis et al., 1989) and more likely to receive medical management for health problems caused by alcohol use rather than treatment for the alcohol problem itself (Moos et al., 1993). This is despite the fact that older people are more adherent to alcohol treatment than younger adults (Oslin et al., 2002) and are just as likely to benefit from it (Oslin et al., 2002; Lemke and Moos 2003).

In recent years there has been a debate as to whether older people should be provided with alcohol treatment or even services specifically tailored to the needs of their age group. Theoretical concerns that seem to support the idea of age-specific treatment include: differing age-associated stresses, perpetuating factors and risk factors for relapse; aspects of treatment for older adults that may require specialized training of staff; beneficial effects of social bonding with same-age peers may enhance group cohesiveness and treatment compliance; health status of older people may preclude certain components of treatment employed with younger adults, such as use of disulfiram (Atkinson, 1995). On the other hand, many researchers have noted that older people are more diverse in terms of their backgrounds, education levels, and level of cognitive ability than younger people (Knight, 1996) therefore older service users may have little in common in terms of needs. Current opinion is that age-specific treatment may improve older adults’ compliance and outcomes (Slaymaker and Owen, 2008). As a result, treatment facilities across the US have implemented age-specific programs and we have recently carried out a study of specialist older people’s alcohol services in the UK (Wadd et al., 2011). Typical UK services include smaller caseloads, lengthy assessment process, a slower pace of treatment, the option of home visits, a high level of multi-agency working, outreach and advocacy, family involvement and a focus on age-specific issues such as grief, loneliness, boredom and retirement.

Peterson and Zimberg (1996) highlighted three steps to an age-specific approach for treatment for older people:

• The stresses associated with ageing must be identified and dealt with.
• An accurate diagnosis must be made in order to rule out the existence of other factors that could affect treatment outcome. For example, depression and alcohol dependence often co-exist and the depression must be treated with an integrated treatment plan with the substance use problem
• Older people should be encouraged to find activities and interests and create a new social support structure. Family members and other caregivers should be involved and age-specific support groups and treatment programs should be used.

Blow et al. (2000) and Schonfeld et al. (2000) found that cognitive–behavioural approaches were successful in treating alcohol problems amongst older people. These included teaching older people the skills necessary to rebuild social support networks and to use self-management to overcome depression, grief and loneliness. Studies suggest that brief interventions are effective with older people. Fleming et al. (1999) and Blow et al. (2000) used brief intervention in randomised clinical trials in primary care settings to reduce hazardous drinking among older people. These studies found that older people can be engaged in brief interventions, that they find the technique acceptable and that it can substantially reduce drinking among at-risk drinkers. As in younger age groups, other treatment interventions that are commonly used include group and family approaches, detox, rehabilitation and health promotion.

To conclude, whilst there is evidence of an emerging epidemic of alcohol problems amongst older people, media attention revolves around young people, binge drinking and antisocial behaviour. Alcohol problems amongst older people are largely overlooked or ignored in research, policy and practice. Research has demonstrated that older people can be successfully treated for alcohol problems – you can ‘teach an old dog new tricks’. The key to tackling the epidemic is likely to lie in providing training and improving awareness among professionals, ensuring that the needs of older people are highlighted in strategy and policy documents, developing specialist services that have expertise in attending to the age-specific needs of older people and the development of screening tools which include more reliable markers of harmful alcohol use in old age such as medication use, co-existing disease and decreased ability to function effectively.

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