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Taking an alcohol history
Dr Tony Rao
Consultant Old Age Psychiatrist, SLAM NHS Foundation Trust
Visiting Researcher, Institute of Psychiatry, Neurology and Neuroscience
• ARBD shows better performance on semantic and verbal memory but poorer performance on visuospatial tasks vs Alzheimer’s disease (Ridley et al, Alzheimers Research and Therapy 2013)
• Evidence for partial reversibility of some ARBD such as white frontal white matter integrity, particularly for late onset alcohol misuse (Gazdzinski et al, Brain 2010)
• Alcohol use disorders frequently complicate primary dementia, increasing adverse effects and cognitive decline (Draper et al, International Psychogeriatrics, 2011)
• Cerebellar damage per se may disrupt frontal processes such as executive function and poor response inhibition (Pitel et al Neuroscience and Biobehavioral Reviews, 2015)
Alcohol related brain damage
Neuropsychological Impairment in Alcohol Related Dementia
(Rao, Advances in Dual Diagnosis 2016)
Rising “older” baby boomer” population of people aged 50+
Baby Boomer population most at risk (highest rise in
increasing/higher risk drinking; alcohol related admissions
and alcohol specific deaths)
Highest rises in accompanying substance misuse
(prescription and illicit drugs)
Older people show complex patterns and combinations of
substance use
In Europe, numbers requiring treatment will double in the
next 2 decades; in the USA, set to treble
Older People and Alcohol Misuse
1986
2011
The Baby Boomers
Turn 65
Non-judgemental approach
Presentations can be atypical
Under-reporting often occurs
Additional information from other sources invaluable
Assessment weighted towards co-morbidity, functional
abilities, influence of loss, cognitive state (including influence
of substances and physical disorders) and social support
Multiple assessments often required to build up clinical picture,
including the need for vigilance around safeguarding
GENERAL PRINCIPLES OF ASSESSMENT
• Sleep complaints
• Cognitive impairment, memory or poor concentration
• Liver-function abnormalities
• Incontinence
• Poor hygiene and self-neglect
• Unusual restlessness/agitation or persistent tiredness
• Unexplained nausea and vomiting
• Changes in eating habits
• Slurred speech, tremor, poor coordination
• Frequent falls and unexplained bruising
• Masking by other mental and physical disorders
TYPICAL PRESENTATIONS USUALLY ATYPICAL
AGEISM ‘It’s all he/she has in life’
UNDER-REPORTING Viewed as stigmatising
BARRIERS TO IDENTIFICATION AND TREATMENT
MIS-ATTRIBUTION Misidentifying as physical illness/
depression /cognitive impairment
STEREOTYPING Poorer detection of drinking in:
Women
Higher levels of education
Higher social class
Widows
ASSESSMENT OF ALCOHOL USE AND MISUSE
Age at first use
Age of onset of weekend use; weekly use; daily use
Pattern of use during each day
Age of onset of dependence syndrome
Current use over previous week (Quantity/Frequency)
Number of days of abstinence (reasons for this)
Periods of abstinence and triggers to relapse
Episodes of intoxication, withdrawal (including delirium
tremens)
Dates and length of contact with service
Nature and outcome of intervention
AUDIT (Alcohol Use Disorders Identification Test)
1. How often drinking alcohol per week
2. How many units of alcohol on a typical day
3. How often exceeded 6/8 units on single occasion in the last year
4. How often in last year unable to stop drinking once started
5. How often in last year failed to do what was expected because of
drinking
6. How often in last year needed an alcoholic drink in the morning
7. How often in last year had guilt or remorse after drinking
8. How often in last year unable to remember what happened night before
because of drinking
9. Injury to self or others as a result of your drinking
10. Relative or friend, doctor or other health worker concerned about your
drinking or suggested that you cut down
AUDIT
Score
Drinking categorisation
0-7
Lower risk (0-6 for men 65+, 0-4 for women 65+)
8-15
Hazardous/increasing risk
16-19
Harmful/higher risk
20+ Possible dependence
1. Underestimates amount of alcohol
2. Misses meals
3. Uses alcohol to decrease tremors
4. Memory blackouts after drinking alcohol
5. Drinking to relax/calm nerves
6. Drinking to take mind off problems
7. Drinking after significant loss
8. Concern about drinking from doctor/nurse
9. Making rules to manage drinking
10.Drinking to ease loneliness
Short Michigan Alcohol Screening Test-Geriatric Version (Short MAST-G)
Score of 5 or more suggestive of alcohol misuse
More suitable for screening dependence
Does not detect hazardous or at-risk drinking
Does not distinguish between current and prior alcohol problems
CAGE screening instrument
Felt that you should Cut down on your drinking
Annoyed by others criticising your drinking
Feel Guilty about your drinking
Have Eye-opener on waking to get rid to steady nerves
• A strong desire or compulsion to drink alcohol
• Difficulties in controlling use in terms onset, termination or
levels of use
• Physiological withdrawal state when use ceases or reduces
• Evidence of tolerance (increased amounts required to achieve
effects originally produced by lower amounts)
• Progressive neglect of alternative pleasures or interests
because of increased amount of time necessary to obtain
alcohol or to recover from its effects
• Persisting with substance use despite clear evidence of overtly
harmful consequences (physical or mental)
ALCOHOL DEPENDENCE SYNDROME
Family and Past Psychiatric History
• Alcohol and substance misuse in parents, siblings,
grandparents, aunts, uncles, wife, husband, partner,
children, including possible association with death
(including suicide)
• Personal history of delirium tremens, detoxification, self-
harm, depression, anxiety, psychotic illness, alcohol
related brain damage/dementia
Personal History
• Educational attainment
• Psychosexual history, including nature and quality of
relationships (e.g. domestic abuse, carer alcohol misuse)
• Occupational history
• Retirement
Past Medical History
• Ongoing medical disorders
• Mobility, hearing and eyesight
• Hepatic, cardiovascular, respiratory, gastro-intestinal,
neurological complications
• Blood borne viruses (hepatitis B, C and HIV)
• Falls, pain, sensory impairment
• Admission to hospital, dates, problems, treatment, length
of admission and outcome
• GP contact, health checks and opportunistic interventions
Social History
• Social vulnerability: risk of falls, social/cultural isolation,
financial abuse
• Social function: activities of daily living/statutory/voluntary/
private services
• Social support: informal carers and friends,
• Social pressures: debt, substance using ‘carers’
• Collateral information
Relatives
GP consultations
Hospital discharge summaries
Home carers
Day centres
• Housing officers/Wardens of Sheltered accommodation
• Criminal justice agencies
• Consent and Capacity
• Investigations (including cognitive testing & neuroimaging)
Forensic History
• Cautions, charges, convictions
• Types of offences (e.g. offences against the person)
• Imprisonment at any time
• Ongoing contact with forensic services
Personality
• Anxious or emotionally unstable personality traits
• Stress, coping mechanisms and resilience
• Cultural and spiritual values
• Interests and hobbies
DISTINCTIVE ASPECTS OF ALCOHOL MISUSE IN
COGNITIVE IMPAIRMENT
MENTAL CAPACITY
• Often conflict between capacity and the role of practitioner in
addressing Substance Misuse
• Assessing mental capacity helpful in distinguishing an unwise
decision from lack of capacity-centres around awareness of
harm
• Mental capacity in SM can vary over time and affected by
intoxication, withdrawal, mood state and cognitive state
ELDER ABUSE
• Substance misuse abuse more likely in perpetrators of abuse
• Older women with neurological or mental disorder who misuse
drugs or alcohol, are at highest risk of experiencing elder abuse
• Structured advice taking no more than 5 minutes
• Not effective for dependent drinkers
• Mostly opportunistic
• Effective in lower and increasing risk drinking
• Persist, need boosters, reduce mortality
• Effective in reducing alcohol related problems
• Cost saving of £10 for every £1 spent
BRIEF INTERVENTION
Rao, R., & Crome, I. (2016). Alcohol
misuse in older people. BJPsych
Advances, 22(2), 118-126.
Further Reading
Rao, R., & Draper, B. (2015).
Alcohol-related brain damage in
older people. The Lancet
Psychiatry, 2(8), 674-675.
Rao, R. (2016). Cognitive impairment
in older people with alcohol use
disorders in a UK community mental
health service. Advances in Dual
Diagnosis, 9(4), 154-158.