Treating alcohol problems in older adults​

When to recommend treatment to older adults

Use SBIR (Screening, Brief Intervention and Referral) with all older patients who experience problems related to their alcohol use (College of Family Physicians of Canada [CFPC] & Canadian Centre on Substance Abuse [CCSA], 2012). This ranges from patients who consume relatively small quantities of alcohol to those with a severe alcohol use disorder.

SBIR website

Alcohol Screening, Brief Intervention and Referral: Helping Patients Reduce Alcohol-Related Risks and Harms is a resource for Canadian family physicians, nurse practitioners and other healthcare professionals developed by the CFPC and the CCSA. The website provides access to evidence-informed guidance and resources to assist healthcare providers in helping patients manage their alcohol consumption. It includes an SBIR protocol.

Brief interventions for older adults with alcohol problems

Brief interventions are one-on-one counselling sessions that may include:

• motivation-for-change strategies [link to Fundamentals/motivation and change]
• patient education
• assessment and direct feedback
• contracting and goal setting
• behavioural modification techniques
• written materials such as self-help manuals.

The intervention may involve a single meeting or a series of two to four meetings. It can be as simple as expressing concern about the amount of alcohol a patient is consuming and suggesting that the patient abstain or reduce their drinking.

The U.S. Center for Substance Abuse Treatment (1998) lists the following steps for brief interventions with older adults:

1. Customized feedback about the patient's responses to screening questions about drinking patterns and other health habits such as smoking and nutrition.

2. Discussion of types of drinking and where the patient's drinking patterns fit into the population norms for that age group (e.g., "Thinking about Drinking").

3. Reasons for drinking. Identifying why the patient drinks is particularly important because the practitioner needs to understand the role of alcohol in the context of the older patient's life, which may include coping with pain, loss and loneliness.

4. Consequences of heavier drinking. Some older patients may experience problems with physical, psychological or social functioning even though they are drinking below cut-off levels.

5. Reasons to cut down or quit drinking. A desire to maintain independence, physical health, financial security and mental capacity can be key motivators in this age group.

6. Sensible drinking limits and strategies for cutting down or quitting. Useful strategies with this age group include developing social opportunities that do not involve alcohol, getting reacquainted with hobbies and interests from earlier in life and pursuing volunteer activities.

7. Drinking agreement in the form of a prescription. Agreed-upon drinking limits that are signed by the patient and the practitioner are particularly effective in changing drinking patterns

8. Coping with risky situations. Social isolation, boredom and negative family interactions can present special problems in this age group.

9. Summary of the session.

Considerations in treating older adults with alcohol problems

When treating older adults with alcohol use problems, consider:

• counselling patients about the low-risk drinking guidelines (These do not apply to patients diagnosed with an alcohol use disorder, only to "problem drinkers.")
• medical withdrawal management for patients who meet criteria for alcohol dependence (Inpatient withdrawal is recommended for people who are frail and elderly.)
• recommending pharmacotherapy
• thiamine supplementation
• a consultation with an occupational therapist to determine whether in-home safety adaptations are needed to allow the patient to remain safely at home or whether the patient needs to be institutionalized.
• reporting to the ministry of transportation if you believe the patient has a condition that may make it dangerous to operate a motor vehicle.

Be aware of two other issues:

• The patient may have heard that moderate alcohol consumption can reduce cardiovascular and dementia risk, which may complicate the patient's acceptance of treatment recommendations for alcohol use disorders.
• Capacity to consent to or refuse treatment may be an issue with older adults. You may want to consult with a psychiatrist or geriatrician with expertise in this area if, for example, a patient refuses treatment and is incapable of safe independent self-care.

Managing older patients who refuse treatment for an alcohol problem

Some older patients may not be ready to accept treatment for their alcohol use problems.

A harm reduction approach allows primary care providers to work with people to moderate their drinking or to develop a healthier lifestyle, without demanding that they become abstinent.

Use the following strategies to reduce the harms of drinking in older patients:

• Provide health education about the connection between specific health problems and alcohol use and about the risks of falls and injury.
• Help the patient connect with appropriate medical help.
• Encourage the patient to eat something throughout the day when drinking.
• Recognize and address the patient's mental health needs (e.g., untreated depression or anxiety).
• Recognize and address the patient's pain management needs.
• Explore non-drug alternatives to manage pain (e.g., heating pads, relaxation therapies, massage, swimming, tai chi).

A harm reduction approach can help older patients who drink to become more stable, making it possible for them to address their alcohol use problem more definitively.