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Harmful drinking among the elderly--a hidden problem: harmful drinking among the elderly is a growing problem but a nurse-led, home-based treatment programme in Christchurch is helping address the issue.

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"Addictions are repetitive behaviours in the face of negative consequences, the desire to continue something you know is bad for you." (1)

Stigma, myths and ignorance abound in the professional lives of clinical nurse specialists Chris Sinclair and Shirley McKinney. Their work at Christchurch Odyssey House outpatient community services treatment programme for harmful drinking in the elderly, called Sixty Five Alive, involves dispelling myths and challenging entrenched negative misconceptions. These include:

* The elderly are too old to change their drinking behaviour.

* It is wrong for families and health professions to interfere.

* They are entitled to consume what they want.

The most common myth by far, is that the elderly are happy in their drinking and shouldn't be robbed of their last pleasure in life. Both Sinclair and McKinney see scant evidence of this supposed happiness in the situations they encounter: the repetitively intoxicated man who called the ambulance up to 30 times a month; the semi-naked 80-year-old woman, eating off the floor at 11am; the man who broke his hip and lay undetected for six days; and those asked to leave rest homes because of their negative drinking behaviour.

Both nurses are aware of the positive effects of some alcohol consumption for the elderly. However, these beneficial aspects rarely feature in the scenarios they encounter. "By the time they come to us, they have a long history of alcohol dependence. Most health professionals have given up on them and others have exhausted all treatment options."

Sinclair and McKinney know hazardous drinking among the elderly is not just a blip, and that it will increase. In 2014, about 600,000 adults aged 65 and over were living in New Zealand. By 2024, there will be close to one million. (2) The burgeoning problem can be further explained by baby boomers, with their more permissive attitude to alcohol and drugs, now reaching retirement and old age.

The nurses say problematic drinking in the elderly is under-reported, under-diagnosed, under-treated and under-resourced. Lack of family can mean under-reporting or, if involved, families can sometimes brush over the problem, "especially if they have similar issues".

Many elderly drink alone at home and are less likely to visit their GP. (3) Health professionals, they say, are often reluctant to ask pertinent questions, fearing such questions will cause discomfort. Ignorance can prevail. They recently encountered a situation where a doctor insisted a frail woman, with compromised mobility, attend 90 Alcoholics Anonymous meetings in 90 days--"sadly, not all health professionals understand addiction".

The toll on the family and significant others can be heavy over time, with reactions ranging from frustration to helplessness to resentment. "They go through hell. Some are shocked when they find out the true extent of the drinking; others get burnt out from all the deceit. Some resort to manipulation, especially financial, to control the drinking and others simply give up and say they've had a gutsful."

Coping strategies

Coping strategies can include parental, punitive or chastising attitudes. Embarrassment, guilt and shame are common and often family members want to keep the problem secret. Teaching relatives effective communication skills, limit-setting techniques and how best to respond to confrontational, intoxicated behaviour can help. Occasionally, the elderly person prevents the nurses from talking to family members, which means significant parts of the clinical and social picture can be missed.

While loneliness is a common problem for the elderly, harmful drinking exacerbates it. "Their world can shrink. Sometimes we may be their only regular visitor," the nurses say. Comments like "Shall I start drinking again, so you will keep visiting me?" highlight the depth of aloneness felt by some. Stigma and fear of being judged often mean visiting professionals are hidden from neighbours and family. "If somebody pops in while we are visiting, we are often introduced as a friend," the nurses say.

About two thirds of those who Sinclair and McKinney see have early onset problematic drinking, ie they have drunk most of their life. The remaining third have late-life onset, ie mild/moderate levels of drinking when younger, but drinking to a harmful extent when older. In the latter group, loss of a loved one, death of children, financial issues, physical illness and pain, retirement and loss of mobility, status and independence can be key triggers. Some triggers, may not be so obvious, --"never underestimate the loss of a pet".

In-depth assessments are needed and are more time intensive than in general alcohol work because of co-morbidities. Sinclair and McKinney favour age-appropriate screening tools, such as the geriatric version of the Michigan Alcoholism Screening Test. (4) The "conversational model" is best for assessment. "We have to sieve through a lot of information so we can't rush it--we lose the person if we do." Assessing for co-existing mental health problems, in particular depression, is vital. Is the person drinking because of depression, or depressed because of their drinking is a question that must be answered.

Motivational interviewing is a core skill and Sinclair and McKinney debunk the myth that the elderly are too old to change their drinking habits. "They can be surprisingly motivated and grateful they have the opportunity to change," the nurses said.

Listening, understanding the person's ambivalence and dilemmas, evoking hope and confidence, strengthening and supporting commitment to change, and finding the person's own motivation to address harmful drinking are all required. "We use the skill of interweaving motivational questions with what we know about their lives. For example, a person who is not allowed by family to see his/ her grandchildren because of the risks associated with drinking may use this as motivation to make some changes".

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It's a challenge on many fronts. Elderly are particularly vulnerable to the adverse effects of alcohol because of the physiological changes associated with ageing. Reduced tolerance to alcohol and poorer metabolism results in increased effects from alcohol. (5) Alcohol can negatively affect existing health conditions and alcohol's interaction with many types of medication can reduce their effectiveness or exacerbate negative effects. Gentle persistence is often required in guiding the person towards an awareness of their problem. To help with this awareness, the nurses highlight entrenched rituals around use, help identify high-risk situations for drinking and challenge post-retirement rationalisations.

Sinclair and McKinney say it helps they are both older nurses. "Patients' feedback is that they are able to relate to us because of our age. It's a big ask going into people's homes and talking about very intimate matters. Having life experience counts," they say. A sense of humour also helps, as does access to clinical supervision and knowing when to refer matters on to other agencies. Holding out hope is also essential.

Established in 2013 by addiction treatment facility, Odyssey House Trust, the Sixty Five Alive programme is anchored in a personalised approach and provides flexible treatment choices. Its services range from home-based one-on-one sessions to a therapeutic support group, facilitated by Veronica Higgins. "The interactive component of this group works well; results are better for those treated in same-age rather than mixed-age groups. Youth and the elderly are not a good mix--sometimes they don't even speak the same language," the nurses say.

An age-appropriate medical detoxification pathway has been set up, in co-operation with psychiatric services for the elderly, to provide more medical oversight in managing the increased risk of complications from co-morbidities. Harm minimisation/reduction interventions include keeping drinking diaries, negotiable verbal contracts, controlled drinking plans and alcohol-free days. Medications which inhibit alcohol consumption and reduce cravings are also treatment choices.

Dual case management

The programme offers dual case management with other agencies including GPs, mental and medical health services and various community organisations. On occasions, the nurses have advised Accident Compensation Corporation staff on how to manage abuse from drunk, elderly clients. The nurses educate rest-home staff, which can include advising on safe drinking measures, how best to manage risks associated with "happy hour" and getting staff to question their own perceptions of addiction.

When educating gerontology and practice nurses, they suggest a low threshold for suspicion of harmful drinking. Unexplained trauma --eg falls, burns and bruises--withdrawal from their usual social circle, a decline in personal hygiene and physical changes due to malnutrition, can be warning signs of hazardous drinking. Minor traffic accidents and frequent ambulance callouts can be other indicators. Alcohol use can mimic some medical problems, so the nurses advise asking an older person, presenting with any of the indicators, directly if alcohol or other substances have been used in the previous 24 hours or more.

McKinney says the engagement process with the older person is critical and she draws on her 30 years' working in addiction and mental health to meet this challenge. "People can be fragile because they have often isolated themselves over many years. They can be ashamed, particularly women, of their drinking behaviour and associated stigma and be very sensitive when we are attempting to engage them. We can be asked to leave as they sometimes change their minds about seeing us," she said.

Sinclair acknowledges the specialty is not everybody's cup of tea. "It's not viewed as an attractive career choice and the marginalisation of addiction and mental health issues puts it further out on a limb. It's an inspiring specialty, but you need to be open-minded to work in addiction.

A residential treatment centre specifically for the elderly, closer links with medical colleagues and increased public awareness of it being a community problem are all needed. Setting up a service from scratch has been a steep learning curve for both nurses but benefits have been many and varied. "We have a rewarding and refreshing client group, who bring life experiences that are never short on surprises and which can include sustained and solid recoveries. That's why we called the service Sixty Five Alive."

Bernie Burns, RN, is a staff nurse at Hillmorton Hospital, Christchurch, and is a regular contributor on mental health nursing issues.

References

1) Lemonick, M.D. (2007) How we get addicted. http://content.time.com/time/magazine/article/0,9171,1640436,00.html. Retrieved 19/10/15.

2) Hodges, I. & Maskill, C. (2014) Alcohol and older adults in New Zealand: A literature review. Wellington: Health Promotion Agency.

3) Khan, N., Davis, P., Wilkinson, T., Sellman, D. & Graham, P. (2002) Drinking patterns among older people in the community: hidden from medical attention. New Zealand Medical Journal; 115: 1148, pp72-75.

4) Edson, S. et al. (2001) Validity of the Michigan Alcoholism Screening Test (MAST) for the detection of alcohol related problems among male geriatric outpatients. The American Journal of Geriatric Psychiatry; 9:1, pp30-34.

5) Alcohol Advisory Council New Zealand. (2011) A hidden epidemic? Alcohol NZ; 1, pp22-24.
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Title Annotation:profile
Author:Burns, Bernie
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Nov 1, 2015
Words:1779
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