In the Bloom County cartoon strip, Binkley approaches his closet of neurotic fears much as we, in the health professions, approach elderly alcoholics. Compelled, yet tentative, we extend a hand hoping not to make things worse. Possible outcomes to an intervention can run the gamut of simple to very complex problems in areas of health, interpersonal relationships, housing, finances, and mental health. When caretakers are then confronted by limited or nonexistent resources appropriate for continuing work begun in hospitals and mental health settings, the picture of underdiagnosis and failure to treat becomes clearer.
Alcoholism treatment facilities that work primarily with elderly alcoholics don't exist. Older alcoholics are traditionally assigned to heterogenous treatment groups that may be irrelevant to their developmental and chronic physical concerns. Little, if any, attention is given to distinguishing and working with their unique needs.
Alcoholism is reported to affect from 2% to 48% of the over-60 populalion.1-2 Some studies report that alcoholism increases with age; other studies report that alcoholism tapers off.3·4 Lasker reports that there are an estimated 3 million alcoholics over 55 years of age in the United States, while very little information is available about aging women.4
There is general agreement that the occurrence of alcoholism in the elderly population is lower in the community and highest in nursing homes, hospitals, and psychiatric settings. This has been explained, in part, by the invisibility, underdiagnosis, and camouflaging by families and friends of the elderly living in the community, and the higher visibility and physical problems detected in professionally monitored settings.5 7 However, underdiagnosis continues to occur in health-care settings.
By the time the elderly alcoholic comes to the attention of treatment agencies, their support systems and resources are gone or seriously eroded. Compromises in social, physical, and psychological functioning accompany alcoholism in the elderly, increasing the problems of loneliness, depression, boredom, accidents, interpersonal conflict, loss, and biological changes that attend aging.
The Alcoholism Day Treatment Center
These and other issues have come to our attention at the Day Treatment Center (DTC), part of the Alcoholism Program located in a northeast Veterans Administration (VA) medical center. Three years ago, the Alcoholism Program staff identified the need for special treatment of the aging and disabled alcoholic populations. The many and varied needs of these groups require a disproportionate amount of clinician time for counseling, crisis intervention, and developing individual resource networks to help maintain sobriety. It was thought that a "sub" program, focused on the issues of aging and disabilities, would reduce the time spent in telephone hours and crisis management with these patients; it would additionally offer on-going support, cornpanionship, and fun.
Thus far, all of our patients have been men, most of them over 55, and all having some form of impairment as a result of their long-time alcohol abuse. The majority have been referred by the medical service and each patient has been through the alcohol program's 28day inpatient rehabilitation treatment program, or the 3-to-14-day Short-Term Alcoholism Rehabilitation Treatment (START). Through this system, patients arrive at the Day Treatment Center with some understanding of their alcoholism.
The DTC is coordinated by a clinical specialist in psychiatric-mental health nursing and staffed by students from the allied health disciplines, nursing, occupational therapy, and psychology. Nurses in this setting have the advantage of providing continuous physical and mental assessments of these highrisk, vulnerable patients.
The DTC Structure
The DTC is an outpatient clinic that meets daily, Monday through Friday for l'/2 to 3 hours. One meeting a week is a "how-to" group, with lessons in ceasesmoking, cooking, assertiveness training, etc. Two meetings a week are for alcohol education, using films, lectures, and discussions. On-going educational seminars deal with issues of health, social support agencies, and behavioral psychology. There is also a weekly social meeting in which we play games, or just chat.
Members are initially assigned to one or more groups, based upon the evaluation of community, social, and physical functioning. After attending for a few months, patients may add or delete groups based upon their own interests and needs. These changes are negotiated with the DTC coordinator.
Each meeting format has a distinct purpose, fulfilling the different needs of individual members. For instance, if the patient appears to have a high level of denial about his alcoholism and does not understand some of the basic concepts of treatment and maintaining sobriety, he may be assigned to the educational groups. Or, if the patient lives alone but doesn't know how to cook, eating expensive fast foods that are high in sodium and cholesterol , he may need a cooking group, a nutrition group, and a financial planning group. Loneliness is an enormous problem for most elderly people and can be magnified when alcoholism is involved. Simply having a group meeting to attend each day may be more important than the content.
The Cooking Group
Ostensibly, this group meets specific needs like learning to cook quick, easy, and healthy meals for one or two people. Recovering elderly alcoholics often don't have the social skills necessary to reach out and re-establish interpersonal bonds. Comfortable familiarity and trust gradually develop when the same people meet weekly, over a long period of time, to accomplish specific tasks. Learning cooperation and developing more satisfactory communication skills are the rewards of this experience, and, they learn to cook.
Early in his recovery, Mr. M was a highly anxious, rigid individual. His behavior in his primary therapy group was pressured and controlling, alienating him from other group members. The cooking group was considered as one possible avenue to relieve tension and as an opportunity for relaxation and fun.
The cooking group is highly structured and goal-oriented. Participation encourages mutual cooperation, and at times, non-active involvement (sitting and "smoozing"). We predicted that both aspects would raise Mr. M's anxiety. Hopefully, however, preparing and eating the food would moderate it.
Mr. M's first group was difficult for everyone. He entered the kitchen with a purposeful stride; he began to take over the food preparation, cooking, serving and, finally, cleanup. The two occupational therapy students who co-led the group were stunned. They were unable to dissuade Mr. M from taking over, and their efforts increased his anxiety and thus, his loud, pressured speech and controlling behavior.
I met with the ,students in supervision and discussed the situation. We explored interventions that might effectively decrease Mr. M's tension and increase his cooperation and enjoyment. The students began by helping the group assign a few, limited tasks to Mr. M. They then made sure he did no more. Group members spent time sitting and talking with him when he was not actively involved.
Initially, Mr. M became more anxious. He followed the new rules, but during the meal, bolted down enormous amounts of food, which mildly repelled everyone. The group maintained their plan and Mr. M gradually began to respond. He relaxed somewhat and tentatively began to talk about himself. One early topic he discussed was his critically limited income and how worried he was about managing his daily needs. He was worried about further illness and the loss of even some of his meager income. Alcohol had taken the edge off of these pressing concerns in the past.
Now they were frequently on his mind. Other members of the group had similar situations and shared their shortcuts and "freebees" with Mr. M. The fact that others shared his concerns was tremendously comforting.
At the last cooking group that I attended, Mr. M appeared relaxed and was enjoying the activity and company. He still attempts to control the group, but often, these days, catches himself and is less defensive if others comment on his behavior.
The cooking group has become an important vehicle for working with problems of budgeting, nutrition, and reinforcing eating and socializing without alcohol.
General Education Group
General education meetings encourage discussion of current life issues (eg, health, social service agencies for the elderly) or just getting to know themselves better now that they are sober. This knowledge gives them a greater sense of control over their lives. Elderly people frequently voice their feelings of vulnerability in approaching a social services agency. Since approximately 80% of the elderly have chronic conditions that require attention, teaching them about their illnesses, treatments, and available, appropriate resources increases their coping abilities and feelings of order.
Mr. O is a frightened, frail man with multiple physical problems. His sobriety has, in large part, been dependent on his frequent visits to the DTC since his wife's death. At home he is lonely, isolated, and chronically afraid. His biggest fear is of becoming ill with no one near. Whenever he knows he will miss a DTC meeting, he notifies us ahead of time, otherwise we will call him at home to inquire about his missed meeting.
As his health has deteriorated, his ability to use public transportation has diminished. He is frightened about calling the wrong agency for help, being rejected, and not accurately hearing what they might tell him. These are all common concerns of the elderly.
In the education group we discussed this situation, what we knew of available resources and decided to invite Info-Line, an elderly advocacy group, to speak to us at one of our meetings. As a result of that meeting, Mr. O now has enlisted transportation for the disabled to pick him up at home, deliver him to the clinic, and return him home each day.
The Alcohol Education Group
Alcohol education meetings provide an opportunity to talk about current problems and old, alcohol-related conflicts from the perspective of sobriety.
Working is no longer a major part of the patients1 lives in the DTC. Most have been unemployed for many years. Unresolved conflicts linger from the days of working and drinking, however, and surface in conversations about work.
Mr. B is a retired businessman. He was, during his lengthy career, successful. During the latter years of his career, his drinking became progressively alcoholic in nature. Conflicts arose with peers and supervisors.
Resentments emerge when he talks about work or retirement. Other DTC members had similar alcohol-related work problems; most have accepted that period of their alcoholism and the impact it had on their vocational life. Mr. B is thoughtful and intelligent, but continued to ruminate about the old injuries. He was somewhat surprised to learn that his experience was not uncommon; he also observed that others had resolved or accepted their work past.
As the weeks and groups went by, he began to reveal concerns about his son. This initially seemed unrelated to his career issues. His son, it turned out, has a similar job with many of the same pressures Mr. B had. With job pressures and encouragement to drink at work functions, Mr. B noticed his son's escalating drinking with growing alarm. The fear of history repeating itself was stirring up old conflicts.
Discussions about work reminded him of his son's situation, increasing his anxiety. His fears and anger were being displaced on his old work issues, avoiding the confrontation with his pressing, current dilemma.
Over-determined, emotional responses to a topic in the alcohol education group needs more investigation. Sometimes current problems can be complicated by old, similar issues. At other times, unresolved issues continue to haunt and give pain. Mr. B was suffering from both. The alcohol education group offers a safe setting to rework old, and understand new, problems.
Our social meetings are most important. The goal of this group is simple - having fun. Games that emphasize and value long-term memory are invariably the most popular. The sense of mastery in remembering old dates, events, and people renews self-confidence and increases self-esteem unlike any other clinic activity. Camaraderie, feelings of warmth, closeness, and cooperation are always present during these activities. Formerly productive men who have been neglected and ill for years sparkle and become quite lively. Inhibitions diminish; laughter booms along the hallways. This is a wonderfully healing group.
This type of treatment for alcoholism has the flexibility to attend to individual issues of the aging alcoholic population. Much of the effectiveness is based in the simplicity of the design.
A hospital setting is ideal for this program with immediate and direct access to patients. Nursing homes, senior centers, and senior housing can benefit enormously from incorporating this type of program into their settings. The presence of an alcoholism day treatment program heightens awareness of the existence of this disease in the aging population, allowing easier identification of those who suffer from it. This, then, can lead to earlier treatment.
A nurse directing this program, with expertise in gerontology and substance abuse, covers the range of needed services: medication management, medical problems, social agency familiarity, issues of aging, and knowledge of the acute and chronic effects of alcoholism. Using the services of students from graduate and undergraduate programs has been effective, economical, and well-received.
Elderly alcoholics tend to be more passive than younger alcoholics and benefit from more interpersonal involvement with professional health-care personnel.8 Students fill this role perfectly; they are eager and energetic and the patients respond positively to the time, attention, and enthusiasm.
A limitation of this program is the few hours it is open. Ideally, the program would run 20-30 hours a week. Or, it could be combined with other on-going programs for the elderly such as Masson9 describes in her article on adult day care. There should be additional group activity periods exclusively focused on alcohol and alcoholism.
Much of the aging alcoholic's anguish can be alleviated by treating the acute problems of alcoholism in hospitals, alcoholism rehabilitation programs, and psychiatric settings.10,11 Once the acute phase has been resolved, long-term maintenance supports sobriety and enriches daily living during recovery. This phase is well served by alcoholism day treatment centers.12,13
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- 3. Atkinson RM. Kofoed LL: Alcohol and Drug Abuse, in Cassel C, Walsh J (eds): Geriatrie Medicine New York, SpringerVerlag, 1984. vol II.
- 4. Lasker MN: Aging alcoholics need nursing help. J Gerontol Nurs 1986; I2(I):I6-I9.
- 5. Gulino C, Kadin M: Aging and reactive alcoholism. Geriatric Nursing 1986; 7(3):148-151
- 6. Schuckit MA: Geriatric alcoholism and drug abuse. Gerontologist Ì977; 17(2): 168-174,
- 7. Butler R, Lewis M: Aging and Mental Health ed 3- St Louis: CV Mosby Co, 1982.
- 8. Linn MW: Attrition of older alcoholics from treatment. Addictive Diseases 1978; 3:437-447.
- 9. Masson V: How nursing happens in adult day care. Geriatric Nursing 1986; January/February 18*21.
- 10. Rosin AJ, Glatt MM: Alcohol excess in the elderly. Quarterlv Journal of Studies of Alcohol 1971; 32:53-59.
11. Swanson DW, Weddige RL. Morse RM: Abuse of prescription drugs. Mayo Clinic ofProc 1973; 48:359-367.
- 12. Peppers LG, Stover RG: The elderly abuser: Challenge for the future. Journal of Drug Issues 1979; 9:73-83.
- 13. Zung BJ: Sociodemographic correlates of problem drinking among DWI offenders. J Stud Alcohol 1979; 40:1064-1072.