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The National Institute of Alcohol Abuse and Alcoholism (NIAAA) developed drinking limit recommendations for younger and older adults: The following are the drinking limits by age group.
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Younger than age 65 years: No more than 7 standard drinks/week for women (no more than 1 drink/day), and no more than 14 standard drinks/week for men (no more than 2 drinks/day).
For men and women age 65+: At risk drinking is no more than 1 drink/day. The limits are the same for both men and women in this age group.
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The World Health Organization defines alcohol use in 3 major categories: nonhazardous, hazardous, and harmful use. This categorization allows for variation based on individual differences in metabolism, response, history, and use patterns. It fits particularly well when working with older adults because it avoids stigmatizing terms such as “alcoholic” and “addict.”
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Nonhazardous or Low-Risk Use
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Alcohol use or short-term psychoactive medication use that does not lead to problems is called nonhazardous or low-risk use (see Case 58–1, adapted from Barry and Blow, 2010). People who use alcohol and/or medications at a low risk level can set reasonable limits on alcohol consumption and do not drink when driving a car or boat, operating machinery, or using contraindicated medications. They also do not engage in binge drinking. Among older adults, low-risk use of medications could include short-term use of an antianxiety medication for an acute anxiety state during which the physician’s prescription is followed and no alcohol is used, or drinking 1 drink 3 times/week without the use of any contraindicated medications.
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Case 58–1
Jenny Martin is a 68-year-old retired social worker who drinks 1 glass of wine when out to dinner or playing bridge with friends, no more than 3 times/week. She does not take any psychoactive medications. She has no family history of alcohol abuse or dependence, and does not take other medications that would interact with alcohol. She receives routine health care from a primary care physician and attends a senior center. A clinician could provide prevention messages regarding her alcohol use in the context of her overall health.
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Hazardous Use or At-Risk Use
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Hazardous or at-risk use is use that increases the chances that a person will develop problems and complications related to the use of alcohol. These individuals have more than 7 drinks/week or drink in risky situations (see Case 58–2). They do not currently have health problems related to alcohol, but if this drinking pattern continues, problems may result. Misuse of psychoactive medications includes taking more or less medication than prescribed; hoarding or skipping doses of a medication; using medication for purposes other than those prescribed; and using medications in conjunction with alcohol or other contraindicated medications.
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Case 58–2
John Fogarty is a 64-year-old marketing executive. He works long hours with few interests outside of work. He drinks 2 drinks/day during the week and 3 or 4 drinks/day on the weekends. His wife has been concerned about his drinking. She would like him to spend more time in activities with her that do not involve drinking. He has gone to a counselor to help him start to plan for retirement. He completed some health and social history questionnaires for the counselor. The message from the counselor included a statement regarding his use of alcohol and concern about potential problems. “You said that, on average, you drink alcohol every day and drink 2 drinks at a time during the week and drink more than that on the weekends. You and I have talked about your stresses at work, your wife’s concerns about your use of alcohol, and your own worries about retirement. I am concerned that your pattern of alcohol use could put you at risk for other problems. How do you see this?”
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“Harmful use” includes both “problem use” and “dependence.”
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Problem use refers to a level of use that has already resulted in adverse medical, psychological, or social consequences (see Case 58–3). Although most problem drinkers consume more than the low-risk limits, some older adults who drink smaller amounts may experience alcohol-related problems. As mentioned above, medication misuse can also fit into the problem use category. Assessment is needed by the clinician to determine severity.
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Case 58–3
Marina Holbrook is a 70-year-old widow living alone in a small apartment in a medium-size city. Her husband died 3 years ago and she has “felt lost” since then. In a routine visit to her primary care clinic, the nurse practitioner asked some questions about her general health and Mrs. Holbrook said that she is tired all the time and, because she does not sleep well, she is using nonprescription sleeping pills. When asked, she said that she generally drinks 1 glass of wine a day before dinner just as she and her husband did when they were younger, and 1 glass of wine before bed “to help me sleep.” She had been taking a prescription medicine for stomach pain for 6 months, but the pain has not improved. Her nurse practitioner discussed with her the potential problems of mixing some medications with alcohol, provided information about the senior center in her neighborhood, suggested she try the center for some activities and that she try to stop the use of alcohol, since it could be starting to cause problems that would get worse with time. “I am concerned about your use of alcohol with the medications for your stomach and the sleeping pills. The stomach medicine you take and the sleeping pills can increase the effect of the alcohol. I’m also concerned that you may not have a lot of opportunities to get together with other people. Would you like me to give you the phone number for the Senior Center in your neighborhood and the name of the person to call at the Center? She is very nice and I know would be happy to hear from you. Ideally, it may be best to discontinue both alcohol and the sleeping pills. You said that you did not want to do that. So do you think that, for the next month, you could stop using the sleeping pills or stop the use of alcohol? It is more dangerous to use them both at the same time. We can talk again about what works and what does not work in 1 month and reassess what to do next.”
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Dependence is part of the World Health Organization (WHO) “harmful use” category and is a medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite adverse consequences, and, sometimes, physiologic symptoms such as tolerance and withdrawal as in Case 58–4.
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A wide range of legal and illegal substances can be abused. Medication abuse involves medication use that results in diminished physical or social functioning, medication use in risky situations, and continued medication use despite adverse social or personal consequences. Dependence includes medication use that results in tolerance or withdrawal symptoms, unsuccessful attempts to stop or control medication use, and preoccupation with attaining or using a medication.
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Case 58–4
Leon Culver is a 68-year-old retired electrician. He has had chronic abdominal pain and unresolved hypertension for the past 12 years. He has a history of alcohol problems and had an admission to alcohol treatment 15 years ago. About 4 years ago, after having withdrawal symptoms during a hospital admission for a work-related injury, he again entered an alcohol treatment program. He was abstinent for 2 years and then started drinking again after he retired. He now drinks approximately 5 beers a day plus some additional liquor once a week. His physician and social worker in the primary care clinic are aware that this is a chronic relapsing disorder and continue to work with Mr. Culver to help him stabilize his medical conditions and find longer term help for his primary alcohol dependence. “Mr. Culver, your high blood pressure and stomach pains don’t seem to be getting better. The amount you are drinking could interfere with them getting better. I know you’ve tried hard to deal with your alcohol problems and you really kept those problems in check for a very long time, but now they seem to be getting in the way of your health and well-being again. Would you be willing to talk to someone from the alcohol program here at the medical center to assess whether or not it is time to get some extra help to prevent further problems?”
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Because of the relationship between the amount of alcohol consumed and health problems, questions about consumption (quantity and frequency of use) provide a method to categorize patients into levels of risk for alcohol use. The traditional assumption that all patients who drink have a tendency to underreport their alcohol use is not supported by research. People who are not alcohol dependent often give accurate answers. To assess for misuse of psychoactive medications, key questions include amounts used, other medications taken, and any concomitant use of alcohol.
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Clinicians can attain more accurate histories by asking questions about the recent past; embedding the alcohol use and psychoactive medication questions in the context of other health (ie, health history, exercise, nutrition, smoking, medications used, alcohol use). Screening questions can be asked by verbal interview, by paper-and-pencil questionnaire, or by computerized questionnaire. All 3 methods have been shown to have equivalent reliability and validity. To successfully embed alcohol and medication misuse screening into clinical practices, the screening needs to be simple and consistent with other screening procedures already in place.
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Potential Prescreening Questions
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Prescreening question: Do you drink beer, wine, or other alcoholic beverages?
Follow-up: If yes, how many times in the [past year; past 3 months; past 6 months] have you had 4 or more drinks in a day (for older men)/3 or more drinks in a day (for older women)?
On average, how many days/week do you drink alcoholic beverages? If weekly or more: On a day when you drink alcohol, how many drinks do you have?
Prescreening questions: Do you use prescription medicines for pain? Anxiety? Sleep? Do you use any of these prescription drugs in a way that is different from how they were prescribed?
Follow-up: If yes, follow up with additional questions regarding which substances, frequency and quantity of use.
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Screening instruments exist that can be used with older adults: the Alcohol Use Disorders Identification Test (AUDIT) developed by the WHO (Table 58–1), the Short Michigan Alcoholism Screening Test–Geriatric Version (SMAST-G) (Table 58–2), and ASSIST, a drug use questionnaire developed by the National Institute on Drug Abuse (NIDA) and modified for older adults to assess misuse of psychoactive prescription medication.
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The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) developed a series of treatment improvement protocols (TIPs), including TIP #26, “Substance Abuse in Older Adults.” The expert panel recommended that all adults age 60+ years should be screened on a yearly basis (generally, embedded with other health-screening questions) and rescreened if there are major life changes that could precipitate increased use and problems (eg, retirement, death of a partner/spouse, etc).