Abstract:
The increased prevalence of alcohol use among U.S. older adults in the face of known consequences is concerning. Reducing acute and chronic risks associated with alcohol use is an important goal for this population. This article describes studies in which informational and educational interventions were provided with the goal of reducing alcohol use among older adults. A sample script is provided to guide healthcare providers and older adults’ significant others in a conversation to inform and educate elders on their risk related to alcohol use.
Keywords:
older adults, alcohol use, alcohol-interactive medications, brief negotiated interview
Alcohol use and alcohol use disorders (AUD) are a growing problem among U.S. older adults. Using data from the Treatment Episode Data Set for Admissions (TEDS-A), Huhn et al. (2019) reported a significant increase in the proportion of older adults seeking first-time treatment for AUD with an average annual percent change from 2004 to 2017 of 6.8 percent. Data from other national surveys inform the prevalence of alcohol consumption that does not reach the level of an AUD diagnosis, yet is considered risky alcohol use.
Risky alcohol use is defined as exceeding guidelines (i.e., four or more standard drinks on any day for women and five or more on any day for men) at least once a week in the past twelve months. Using two such national surveys, Grant et al. (2017) reported that the prevalence of high-risk drinking for the total U.S. population increased significantly from 9.7 percent in 2001–2002 to 12.6 percent in 2012–2013. The rate of high-risk alcohol use among older adults was 65.2 percent, noted by Grant et al., 2017, to be substantially higher relative to earlier surveys.
One point of consideration is how much alcohol is too much alcohol for older adults? Based on an analysis of eighty-three studies among people who consumed varying amounts of alcohol, Wood et al. (2018) identified the threshold for the lowest risk was about 100 grams of alcohol per week. In the United States, a standard drink is about 14 grams of pure alcohol; thus 100 grams would be about 7 standard drinks. To reduce the risks of alcohol-related harms, the 2015–2020 U.S. Dietary Guidelines for Americans recommends that if alcohol is consumed, it should be up to one drink per day for women and two drinks per day for men (U. S. Department of Health and Human Services [USDHHS] and U. S. Department of Agriculture, 2015). Women have a greater sensitivity to the toxic effects of alcohol, exhibiting decreased metabolism over the same amount of alcohol consumed by men (Erol and Karpyak, 2015), thus explaining the sex differences in alcohol limits.
Yet, the effects produced by alcohol are not the same for all people, and some should not drink alcohol at all. Older adults have lower lean body mass and less body water, less alcohol dehydrogenase (the enzyme in the stomach that breaks down alcohol), and an impaired ability to develop tolerance (Saitz, 2019). Given the physiological changes that come with aging, it may be best for older adults to limit alcohol consumption to up to one drink per day, and none for those at higher risk.
Those who are at higher risk may include those with conditions and illnesses that are common in older adults (He et al., 2018). Older adults are more susceptible to injury from motor vehicle accidents and falls and even more so when consuming alcohol (Saitz, 2019). Chronic alcohol consumption among older adults is also concerning because alcohol can contribute to liver disease, cardiovascular diseases, and cancers (Degenhardt et al., 2018). Alcohol interacts poorly with several medications, raising further concerns as 83.6 percent of adults in the United States ages 60 and older take at least one prescription medication and more than 34 percent take five or more (Hales et al., 2019).
The mortality associated with alcohol use among older adults is alarming. There has been a rise in alcohol-related deaths in the United States among people ages 16 and older, with the number doubling from 1999 to 2017 (White et al., 2020). Of the 2.8 million alcohol-related deaths in 2017, the rate among women was highest for ages 55 to 64, and the rate among men was highest for the same age bracket, followed by ages 65 to 74 (White et al., 2020). Acknowledging that alcohol-related mortality may be underreported on death certificates, White et al. (2020) reported that the rates of acute alcohol-related deaths (i.e., acute intoxication, alcohol poisoning, toxic effects of alcohol) increased more for people ages 55 to 62, compared with all other age groups.
The older adult population continues to grow and increasingly, alcohol use is a public health concern. Is there a way to affect the decision-making of older adults about their alcohol use? The purpose of this article is to examine the effect of informational and educational interventions on decisions older adults make about alcohol use. Guidance is provided for healthcare providers and significant others in having a conversation with older adults about their use.
Alcohol Consumption Limits and Alcohol-Medication Interaction
Mixing alcohol with some prescription and over-the-counter medications can be harmful, potentially leading to falls and serious injuries, especially among older people (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2014). Commonly used medications that interact with alcohol include those for medical conditions common in older adults such as diabetes (e.g., metformin), high cholesterol (e.g., lovastatin, simvastatin), pain (e.g., ibuprofen, aspirin, acetaminophen), and depression (e.g., paroxetine, sertraline) and more listed in this pamphlet (NIAAA, 2014).
Given the concerns about alcohol-interactive medications, Zanjiani et al. (2018) provided a pharmacy-based intervention to older adults ages 59 to 94. The intervention included an informational poster about alcohol-interactive medications, a more detailed informational brochure, and a 60-second public service announcement that focused on risks associated with alcohol-interactive medications. Questionnaires were administered prior to and immediately after the information was provided to the 134 adults, and to ninety-seven of those who were able to be contacted three-months after the intervention. Awareness of alcohol interactive medications (i.e., whether medications and alcohol can be used safely together and which level of alcohol consumption is safe) significantly increased across the three timepoints. Older adults in this study were asked to identify medications that are potentially dangerous when taken with alcohol and asked about seventeen possible alcohol-medication interaction (AMI) side effects, including vomiting, falls, and shortness of breath.
‘The mortality associated with alcohol use among older adults is alarming.’
Across the three timepoints, there was a significant linear trend in the number of dangerous medications and the mean number of side effects identified. At each time point about 80 percent of participants correctly indicated that alcohol consumption with medication can be dangerous at any level. Endorsement of a key message, “It is important to drink no more than one drink a day,” increased from 59 percent of the sample on the pre-test to 93 percent on the post-test, decreasing to 81 percent for the ninety-seven older adults who responded at the three-month follow-up (Zanjiani et al., 2018).
In the same study, Zanjiani et al. (2018) evaluated the intentions of older adult regarding talking with a doctor or pharmacist about alcohol-interactive medication risk; changing the amount of alcohol consumed; talking with friends or family about alcohol-interactive medication risk; and being an advocate for safe alcohol and prescription drug use.
For those reporting alcohol use in the past month, at each time point, about 90 percent were willing to talk to their doctor about alcohol-interactive medications. On the pre- and post-test, about 70 percent of participants were willing to change their alcohol consumption to prevent an alcohol-interactive medication risk, yet at three-month follow-up only 47 percent were willing to do so. At each time point, nearly 90 percent were willing to talk with family or friends about alcohol-interactive medication risk (Zanjiani et al., 2018).
The results of the study by Zanjiani et al. (2018) suggest that in providing information to older adults, it is important to reinforce important messages over time. The intervention had positive effects in the short-term for a prominent message of the intervention that older adults should consume no more than one drink per day, but the effects were not sustained at three-month follow-up. Providing the evidence for, and the impact of consuming more than one drink per day may be helpful in promoting that message.
Older adults in this study had high endorsements at baseline for messages related to harms and consequences associated with the consumption of alcohol with medications, responses that remained high immediately after the intervention and at three-month follow-up. For older adults on prescribed medications, there are multiple opportunities for reinforcing messages about alcohol-medication interactions, including with those who prescribe medications, pharmacists who dispense medications and counsel patients, and healthcare providers and family members who are in positions to administer those medications. Also along this chain of custody are opportunities to reinforce the message that for some older adults, consuming any amount of alcohol is unsafe, and for healthy older adults the daily limit should be no more than one standard drink a day.
Alcohol Risk Education
Education entails more than just providing information—it needs to be applied to everyday life. A study conducted by Ettner et al. (2014) aimed to examine the effectiveness of a patient-provider educational intervention in reducing at-risk drinking among older adults. Physicians and their patients were randomly assigned to usual care (n=640 patients) or the Project SHARE (Senior Health and Alcohol Risk Education) intervention (n=546 patients). All patients completed surveys at baseline and at three, six, and twelve months. Older adults in the usual care group completed the surveys and received standard care, which could have included alcohol counseling.
Older adults in Project SHARE received a personalized report following the completion of their alcohol risk evaluation and again at six months. The report relayed specific reasons for the identified risk classification and potential harms that could result. The older adults also received an educational booklet on alcohol and aging, a diary to track alcohol consumption, and up to thirteen informational sheets depending on their reported alcohol-associated risks, such as moderating alcohol consumption, sleep, preventing falls and fractures, and gout. The physicians were asked to use the information in the patient personalized report to discuss the patient’s alcohol consumption and associated risks and advise the patient to reduce alcohol use if they were still at risk. The Project SHARE older adults were contacted three times, two weeks after receiving the baseline report, three months after sending the baseline report, and two weeks after sending the six-month personalized patient report.
Most of the patients (61 percent) in the Ettner et al. (2014) study were at risk because of their alcohol use combined with medications; there were no significant differences between the usual care and the intervention groups in the alcohol-associated risk levels (which ranged from 1 to 7 and averaged 2.6 risks). At-risk alcohol use declined in both groups at six and twelve months; significantly greater declines were observed in the intervention group. Notably, by twelve months there was a 20 percent dropout rate in the intervention versus 5 percent in the control. When all dropouts were assumed to remain at risk and retained in the analyses, at six months, 67 percent of the Project SHARE patients versus 72 percent of usual care patients were predicted to remain at risk (p=.05) and by twelve months, the difference remained at 5 percentage points (63 percent vs. 69 percent), but no longer significant (p=.12).
Motivational interviewing has demonstrated success in improving treatment engagement and outcomes.
Older adults who engaged in Project SHARE successfully reduced their alcohol use-related risk, an effect that persisted over twelve months. The higher dropout in the intervention versus the control raises questions about how physicians engaged in conversations with the older adults. For example, motivational interviewing, developed for use with people who have substance use disorders, has demonstrated success in improving treatment engagement and outcomes (Miller and Rollnick, 2013). Motivational interviewing is a collaborative approach to resolving ambivalence and enhancing motivation to change. The brief negotiated interview (BNI) is a semi-structured interview based on motivational interviewing and is a best practice for this person-centered conversation (D’Onofrio et al., 2005). The next section illustrates how the brief negotiated interview (BNI) framework can be used to guide a conversation with an older adult who is at risk because of alcohol use and alcohol-medication interactions.
Talking with Older Adults About Alcohol and Alcohol-Interactive Medications
Using the BNI, the emphasis is on respectful listening, open-ended questions (versus closed questions with yes/no responses), choice, and negotiations (Bernstein, Bernstein, and Levenson, 1997). As shown in the script, the steps of the brief negotiated interview are to: raise the subject; provide feedback; enhance motivation; and negotiate and advise. These steps are intentionally designed to elicit reasons for change and action steps from the older adult, thus giving them voice and choice in making the changes they elect to make. Examples are shown in the script to illustrate how to have a conversation with an older adult—whether as a healthcare provider, friend, or significant other. Relevant information that can be provided to the older adult is included or cited in the script (click here to download the PDF).
Conclusion
Providing information to older adults about alcohol use, recommended limits for an older adult, and the associated risks for older adults with comorbid health conditions and those taking alcohol-interactive medication, may be helpful in the short-term. Yet, it is important to reinforce important messages over time. Providing education based on personalized reports, such as with Project SHARE, was effective in reducing alcohol consumption, yet that was not sustained in the long term. Thus, it may be necessary to reinforce education over time. Engaging with older adults guided by the BNI framework entails providing information and education in a way that is motivational and person-centered. Such a conversation can take place by using carefully phrased questions at key points in the process of working toward a negotiated plan—one developed in concert with the older adult with the goal of reducing the harms associated with alcohol use.
Deborah S. Finnell, DNS, CARN-AP, FAAN, is professor emerita at the Johns Hopkins School of Nursing in Baltimore, MD. She can be contacted at dfinnell@jhu.edu.
References
Babor, T., et al., 2001. “UDIT. The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care.” 2nd Ed. Geneva: World Health Organization.
Barry, K. L. and Blow, F. C. 2016. “Drinking Over the Lifespan: Focus on Older Adults.” Alcohol Research. 38(1): 115–20.
Blow, F. C. and Barry, K. L. 2012. “Alcohol and Substance Misuse in Older Adults.” Current Psychiatry Reports 14(4): 310–9.
Bernstein, E., Bernstein, J., and Levenson, S. 1997. “Project ASSERT: An ED-based Intervention to Increase Access to Primary Care, Preventive Services, and the Substance Abuse Treatment System.” Annals of Emergency Medicine 30(2): 181–89.
Degenhardt, L., et al. 2018. “The Global Burden of Disease Attributable to Alcohol and Drug Use in 195 Countries and Territories, 1990–2016: A Systematic Analysis for the Global Burden of Disease Study 2016.” The Lancet Psychiatry 5(12): 987–1012.
D’Onofrio, G., et al. 2005. “Development and Implementation of an Emergency Practitioner–performed Brief Intervention for Hazardous and Harmful Drinkers in the Emergency Department.” Academic Emergency Medicine 12(3): 249–56.
Erol, A. and Karpyak, V. M. 2015. “Sex and Gender-related Differences in Alcohol Use and its Consequences: Contemporary Knowledge and Future Research Considerations.” Drug and Alcohol Dependence 156(2015): 1–13.
Ettner, S. L., et al. 2014. “The Effect of an Educational Intervention on Alcohol Consumptions, At-risk Drinking, and Healthcare Utilization in Older Adults: The Project SHARE Study.” Journal of Studies on Alcohol and Drugs 75(3): 447–57.
Grant, B. F., et al. 2017. “Prevalence of 12-month Alcohol Use, High-risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001–2002 to 2012–2013: Results from the National Epidemiologic Survey on Alcohol and Related Conditions." JAMA Psychiatry 74(9): 911–23.
Hales, C. M. 2019. “Prescription Drug Use Among Adults Aged 40–79 in the United States and Canada.” National Center for Health Statistics Data Brief 347. Retrieved December 4, 2020.
He, Z., et al. 2018, “Prevalence of Multiple Chronic Conditions Among Older Adults in Florida and the United States: Comparative Analysis of the OneFlorida Data Trust and National Inpatient Sample." Journal of Medical Internet Research 20(4): e137.
Huhn, A. S., et al. 2019. “Trends in First-time Treatment Admissions for Older Adults with Alcohol Use Disorder: Availability of Medical and Specialty Clinical Services in Hospital, Residential, and Outpatient Facilities.” Drug and Alcohol Dependence 205: 107694.
Kantor, E. D., et al. 2015. “Trends in Prescription Drug Use Among Adults in the United States from 1999-2012. JAMA 314(17): 1818–31.
Miller, W. R., and Rollnick, S. 2013. Motivational Interviewing: Helping People Change. NY: Guilford Press.
National Institute on Alcohol Abuse and Alcoholism. 2014. “Harmful Interactions: Mixing Alcohol with Medicines.” Retrieved May 29, 2020.
Saitz, R. 2019. “Medical and Surgical Complications of Addiction.” In S.C. Miller, D.A. Fielin, R.N. Rosenthal, and R. Saitz, eds., The ASAM Principles of Addiction Medicine. Philadelphia: Wolters Kluwer.
Smith, P. C., et al. 2009. “Primary Care Validation of a Single-Question Alcohol Screening Test.” Journal of General Internal Medicine 24(7):783–8.
U.S. Department of Health and Human Services and U. S. Department of Agriculture. 2015. “2015–2020 Dietary Guidelines for Americans.” Retrieved May 4, 2020.
White, A. M. , et al. 2020. “Using Death Certificates to Explore Changes in Alcohol-related Mortality in the United States, 1999 to 2017.” Alcoholism: Clinical and Experimental Research 44(1): 178–87.
Wood, A. M., et al. 2018. “Risk Thresholds for Alcohol Consumption: Combined Analysis of Individual-participant Data for 599 912 Current Drinkers in 83 Prospective Studies.” The Lancet 391(10129): 14–20.
Zanjiani, F., et al. 2018. “Sustained Intervention Effects on Older Adults’ Attitudes Towards Alcohol and Medication Interactions.” American Journal of Health Education 49(2): 66–73.
