Introduction

While the stereotype of an alcoholic is generally one of an unkempt, "down and out" man on Main Street or Skid Row, researchers have discovered an "invisible epidemic" of drinking problems among older men and women living in the community ¹

There is a paucity of research on substance abuse among the elderly, but it is estimated that as many as 17 per cent of all adults age 60 years or older have a drinking problem ². One study of seniors between the ages of 60 and 94 living in the community, found that 62% consumed alcohol and that six per cent consumed more than two drinks per day ³. Surveys suggest that the prevalence of problem drinking in nursing homes may be as high as 49 per cent ⁴.

A range of different drinking problems is found among seniors. Some of these individuals have been drinking excessively for most of their lives; others use relatively small amounts of alcohol, but mix alcohol with prescribed medication in harmful ways; still others develop alcohol problems during their senior years.

Beyond the Stereotype: Late-onset Alcoholism

Late-onset alcoholism is defined as a drinking problem that begins at or later than age 60 ⁵. Because late-onset drinkers tend to consume less alcohol and generally function at a higher level than individuals whose drinking is chronic, the problem is one that isn't always readily apparent.

It is estimated that approximately one-third of seniors who drink, begin to do so late in life, usually in response to age-related stressors ³. When older people find themselves in the position of feeling alone with nothing to do and no place to go, alcohol can become a cheap and easy companion. A glass of inexpensive wine at lunch and then again at dinner, or a few bottles of beer in front of the TV may seem like a "quick fix"---to relax, to get comfortable, to mask a pain, to get a good night's sleep, or to recreate warm memories of times once spent with a spouse or good friend.

The fact that it is generally considered socially acceptable for adults to drink alone, especially within the confines of their own home, makes it even easier for older people to seek comfort in alcohol. As opposed to the club and bar settings that attract our youth, drinking among seniors takes place in private homes and apartments and at retirement communities where drinking at social gatherings is often the norm. Because most seniors don't have to get to work at a regularly specified time, and may not have the same number of social ties as younger people, it is a problem that often goes unnoticed by family members, close friends, and even professionals.

The Dangers of Late-onset Drinking

While chronic alcohol abuse often affects multiple body systems, the most common side effect of late-onset alcoholism is malnutrition. Alcohol provides few nutrients and also interferes with the absorption of vitamins and minerals. But since alcohol provides "empty" calories, the older drinker may be malnourished without any obvious weight loss.

The first signs of a drinking problem may include tremors, depression, mood swings, or problems with memory or cognition. Other problems associated with problem drinking among seniors include a pattern of repeated falls and injuries or involvement in vehicular and/or pedestrian traffic accidents. Driving under the influence of alcohol is particularly dangerous for seniors who tend to have slower reaction time and poorer night vision.

Clearly, the combination of age, medication, medical problems and alcohol use can cause serious problems for seniors. When mixed with prescribed and over-the-counter medications, which are commonly used by seniors, alcohol greatly increases the potential for adverse interaction effects that may even prove deadly. Alcohol can negatively affect compliance with treatment, because during bouts of drinking, people often forget to take prescribed medications that are essential to their well-being.

Many seniors also have misperceptions about possible beneficial effects of alcohol use. Because sleep patterns change as people age, seniors may mistakenly use alcohol as a sleeping aid. In truth, alcohol actually makes insomnia worse by causing increased wakefulness during the night.

How much is too much?

Put simply, older people are less able to tolerate the effects of alcohol. Adults over the age of 65 are more likely to have one or more chronic health problems and are more likely to take multiple medications, making them especially vulnerable to the effects of alcohol. For these reasons, the same standards that are used to define "moderate drinking" in a 40 year-old do not apply to someone over the age of 60.

The National Institute on Alcoholism and Alcohol Abuse (NIAAA) defines "moderate" drinking for seniors as more than 12 ounces of beer, or 5 ounces of wine, or 1.5 ounces of hard liquor per day ⁴. In other words, that means more than one beer, or one glass of wine or one shot of hard liquor per day. The World Health Organization uses a term called "hazardous drinking" to describe alcohol use with negative consequences that falls short of the criteria for alcohol dependence or abuse ³.

Because seniors span more than four decades in age and differ from one another on a range of other dimensions (including medical conditions and medications used), physicians must carefully interpret the appropriateness of these guidelines for each patient. Certain qualitative screening tools, such as the CAGE, may help physicians in this regard ³.

Problems in Detection

While research suggests that late-onset alcoholism is more common among seniors of higher educational levels and higher socioeconomic status, health care practitioners typically overlook problem drinking in this group ⁵. Even though these seniors visit their family practitioner several times a year, their doctors generally fail to recognize drinking problems when they occur. One explanation for this phenomenon is that seniors often make efforts to hide their alcohol use from their doctors.

Many doctors are simply not attuned to the symptoms of problem drinking in older persons and may erroneously attribute falls, mental confusion, lapses in self-care and other problems resulting from alcohol use to illness or the aging process itself. And even when physicians suspect that an older person has a drinking problem, doctors may be too embarrassed or too busy to do anything about it. In some cases, they are simply too forgiving. They don't think of older persons as problem drinkers and may say to themselves, "So what if an older person gets some enjoyment from drinking?"

The U.S. Department of Health and Human Services recommends that all 60 year-olds should be screened for alcohol and/or prescription drug abuse by their primary care doctors as part of a routine physical. Re-screening should occur as the individual undergoes key life transitions.

This may entail taking extra time to talk with the patient in order to determine how the individual is coping with stressful life experiences, such as poor health, bereavement, or retirement. In addition, because of memory impairment and denial, it is essential to ask the patient pointed questions about the extent of their alcohol use. Do they drink in the morning? Do they drink when they are alone? Do they drink to calm their nerves? Do they ever get hurt or injured as a result of drinking? Do they "drink their meals" instead of eating? Do they drink when they feel depressed? Do they drink when they feel lonely?

Treatment Options

Some practitioners don't take late-onset drinking seriously because they assume that the problem will not respond to treatment. However, this assumption is inconsistent with empirical research. A longitudinal study comparing the treatment outcomes of older alcoholics vs. older persons with problems of late-onset, found that the latter group was almost twice as likely to respond favorably to treatment ⁶. In addition older adults have treatment outcomes that are as good or better than those of younger people ¹.

Since most older individuals see their family doctors at least several times a year, these visits should be viewed as an opportunity for the physician to initiate a frank and open discussion about drinking habits. Studies show that older individuals with late-onset alcoholism can benefit from brief, targeted counseling from their physicians concerning the dangers of alcohol and can be encouraged to make positive changes in their lifestyle. Supportive family members can also play an important role in assisting the individual to comply with recommended lifestyle changes.

Some seniors find that Alcoholics Anonymous (A.A.) meetings offer them strength and support to overcome drinking problems. Other seniors feel these groups are stigmatizing and find it more comfortable to seek support from their age peers at senior citizen programs. Effective programs treat the "whole person", making sure that their health, housing, financial, and social needs are met. Because late-onset alcoholism is often associated with stress, isolation, loss, and loneliness, effective substance abuse treatment for the elderly should address these underlying issues.

Towards the Future

In a recent article in American Family Physician, Dr. Sally K. Rigler of the University of Kansas School of Medicine writes, "Physicians must maintain a high index of suspicion and a nonjudgmental attitude, and should be able to recognize patient defenses and effectively support the patient's family members". When late-onset drinking disorders are recognized and treated, the outcomes benefit patients, families, and communities.

There are several epidemiological studies that show that a glass or two of wine (or indeed equivalent amounts of alcohol in other drinks) have been associated with reductions in the frequencies of cardiac events, cardiac mortality, and stroke ⁷,⁸. For this reason, older persons who drink in moderation without signs or symptoms of excess intake do not need to be urged to stop drinking entirely.