Alcohol Use and Abuse- Alcohol abuse is a difficult disorder to identify among older adults. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV) refers to a maladaptive or destructive pattern of alcohol use measured over a 1-year period, leading to significant social, occupational, and/or medical impairment. Alcohol abuse is characterized by symptoms of dependence such as increased tolerance; diminished effect; withdrawal; consuming larger amounts; unsuccessful efforts to cut down; substantial activity involved in obtaining, using, or recovering from its effects; giving up on activities; and continued use despite knowledge of having persistent problems.
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The Treatment Improvement Protocol (TIP) expert panel convened by the Substance Abuse and Mental Health Services Administration stated that the DSM-IV classification of alcohol problems is largely irrelevant for older adults given changes in physiology, roles and responsibilities, and activities. The TIP panel recommended two terms to categorize older alcohol users: “problem drinkers” and “at-risk drinkers.” Problem drinkersrefers to heavy drinkers as well as those who meet the DSM-IV criteria for abuse and dependence. At-risk drinkersrefers to those exceeding recommended drinking limits, in recognition of the fact that the threshold decreases with advancing age. The TIP consensus panel recommended no more than one drink per day, a maximum of two drinks on special occasions (e.g., weddings, New Year's parties), and somewhat lower limits for women. A standard drink (standard ethanol unit) is defined as a 12-ounce can or bottle of beer or ale; a 1.5-ounce shot of spirits; a 5-ounce glass of wine; or a 4-ounce glass of sherry, liqueur, or aperitif.
Older adults are especially vulnerable to the deleterious effects of alcohol. Decreased muscle mass and increased body fat, changes in metabolism, medical comorbidities, and decreased body water all affect older adults' metabolism of alcohol. Higher blood alcohol concentrations can be observed in older adults in comparison with younger adults. Social indicators, such as arrests for driving under the influence (DUIs), absences from work, and family or marital problems, are common indicators of problems in younger people. In contrast, older adults are less likely to demonstrate these indicators; instead, they are more likely to drink in response to losses such as death of a spouse, divorce, retirement, infrequent driving, and diminished social support networks. Research indicates that older adults more often abuse alcohol at home and alone in response to negative emotional states and loneliness.
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Epidemiology
Estimates of alcohol abuse among elders vary according to survey methodology and age criteria used. Among community-based adults age 60 years and older, it has been estimated that 2% to 10% are problem drinkers. According to the National Household Survey on Drug Abuse, 9.4% of adults age 55 years and older are heavy drinkers and 2.3% are binge drinkers. Higher percentages have been noted among medical patients (e.g., 4% to 10% of older primary care patients, up to 14% of emergency room patients, and 23% of patients with substance abuse diagnoses at veterans hospitals).
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However, not included in these numbers are the many elders experiencing problems as a result of alcohol use but not meeting formal diagnostic criteria or those not identified and often referred to as “hidden abusers.” In the United States, few people in the older age groups receive treatment for alcohol abuse. The Drug and Alcohol Services Information System (DASIS) report noted that only 66,500 older adults were admitted to treatment in 2002. This suggests that approximately 0.1% of the more than 62 million people age 55 years and older receive substance abuse treatment. In Florida, the state with the highest median age where those age 60 years and older represent nearly 23% of the population, only 2% of older adults are in substance abuse treatment.
Two major categories of older alcohol abusers are typically described. Approximately two thirds of older alcohol abusers are believed to be “early-onset abusers” who have alcoholrelated problems carried over from earlier years. They often exhibit well-developed psychological problems, as well as more recent reactions to age-related stresses. The other third are believed to be “late-onset alcohol abusers” whose alcohol problems began later in life (e.g., in their 50s), often in response to recent losses or life changes. For this group, alcohol is used to soften the impact of negative emotions such as depression, grief, sadness, loneliness, and anxiety.
Screening and Case Finding
Identifying older alcohol abusers is a challenge. In 1989, L. W. Dupree compared different strategies for identifying and referring clients to an elder-specific treatment program. A community agency referral network strategy involved treatment program staff educating community agencies about the program's services and admission criteria. That strategy produced nearly twice as many referrals, more referrals meeting admission criteria, and at less cost when compared with either a public awareness/media campaign or treatment staff visiting health clinics to seek potential clients in need of treatment. “Gatekeeper” models, in which nontraditional referral sources (e.g., meter readers, mail carriers, phone company employees) are involved in case finding, have also been successful. Once referrals are made, age-appropriate screening tools such as the Short Michigan Alcoholism Screening Test–Geriatric Version can be helpful during the initial interview with the client. Screening for depression should be conducted given the relationship of depression and alcohol use in this age group.
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