Journal of Gerontological Nursing

Discovering the Secret: Nursing Assessment of Elderly Alcoholics in the Home

Peg Krach, PhD, RN

Abstract

Estimates indicate that there are 3 million elderly alcoholics in the United States,1 and yet only 15% of this age group are receiving alcoholism treatment of any kind. The consequences of this disease are tragic for any age group, but they are especially destructive for the elderly who are more susceptible to the effects of the alcohol abuse because of existing problems and diminished resources.2 The problems presented by elderly alcoholics are an enormous nursing challenge, yet they are an all but ignored focus of study.3 American cultural ambivalence and misunderstanding about both alcoholism and old age not only contribute to a lack of interest in studying the problem, but also enable patterns of abuse to go uninterrupted.4 Generally, the health professions and other helping people, including family and friends, are overwhelmed by the multiplicity, chronicity, and confusing nature of the disorders of the elderly alcoholic.5

It is imperative for the nurse to consider every possible piece of information when working with the elderly alcoholic.6 Integration of data from the physical, mental, social, and economic dimensions of functioning must be used to determine an effective treatment plan.7 Nurses, more than any other professionals, have the ability to conduct multidimensional assessments due to their educational backgrounds and the quantity and quality of time that they spend with the elderly.

This investigation conducted functional assessments on older alcoholics in a home setting to provide data that will assist nurses to be better able to assess and intervene with elderly alcoholics.

THE STUDY

The aim of this study, which is part of a larger one, was to conduct functional assessments in face-to-face interviews with subjects living in a home setting to determine functioning in five dimensions: physical, mental, social, economic, and self-care capacity.

Subject Selection

Subjects were selected from the files of a mental health center and met the following criteria:

* Had a primary or secondary diagnosis of alcoholism.

* Were 55 years of age or older.

* Had a diagnosis of alcoholism for at least 5 years.

Fifteen individuals were contacted by phone and agreed to participate in the study. Each participant was given a cover letter that described the study and confidentiality. Also included were the investigator's name and telephone number in case the subject had additional questions regarding the research. The study was limited by the small sample size and lack of random assignment.

Instrument

The instrument for this study was the Older American Resources Survey (OARS), which measures physical, mental, economic functioning, and self-care capacity.8

The social and economic factors in the scale include basic demographic information. The mental health component of the index is comprehensive in its coverage of basic mental status factors of orientation and memory, measures of psychiatric symptomatology, and information about life satisfaction and perceived mental health.9 The physical health index attempts to identify various physical conditions and clinical symptoms, as well as information about the use of prescribed medications. Similarly, the section on activities of daily living measures instrumental functioning, as well as basic personal selfmaintenance capabilities.

The questionnaire is well-designed and carefully structured to yield meaningful answers. Inter-rater reliability for the instrument is high for all five dimensions, from 0.74 for psychological functioning to 0.88 for physical functioning. Limitations of the instrument are the average length of time it takes to complete the interview, which is 45 minutes, and the complexity of some items on the questionnaire.

Results

Fifteen subjects who were identified as alcoholic had a mean age of 64 years; 37% of the sample were women and 63% were men. The majority of the sample (75%) lived alone and 25%…

Estimates indicate that there are 3 million elderly alcoholics in the United States,1 and yet only 15% of this age group are receiving alcoholism treatment of any kind. The consequences of this disease are tragic for any age group, but they are especially destructive for the elderly who are more susceptible to the effects of the alcohol abuse because of existing problems and diminished resources.2 The problems presented by elderly alcoholics are an enormous nursing challenge, yet they are an all but ignored focus of study.3 American cultural ambivalence and misunderstanding about both alcoholism and old age not only contribute to a lack of interest in studying the problem, but also enable patterns of abuse to go uninterrupted.4 Generally, the health professions and other helping people, including family and friends, are overwhelmed by the multiplicity, chronicity, and confusing nature of the disorders of the elderly alcoholic.5

It is imperative for the nurse to consider every possible piece of information when working with the elderly alcoholic.6 Integration of data from the physical, mental, social, and economic dimensions of functioning must be used to determine an effective treatment plan.7 Nurses, more than any other professionals, have the ability to conduct multidimensional assessments due to their educational backgrounds and the quantity and quality of time that they spend with the elderly.

This investigation conducted functional assessments on older alcoholics in a home setting to provide data that will assist nurses to be better able to assess and intervene with elderly alcoholics.

THE STUDY

The aim of this study, which is part of a larger one, was to conduct functional assessments in face-to-face interviews with subjects living in a home setting to determine functioning in five dimensions: physical, mental, social, economic, and self-care capacity.

Subject Selection

Subjects were selected from the files of a mental health center and met the following criteria:

* Had a primary or secondary diagnosis of alcoholism.

* Were 55 years of age or older.

* Had a diagnosis of alcoholism for at least 5 years.

Fifteen individuals were contacted by phone and agreed to participate in the study. Each participant was given a cover letter that described the study and confidentiality. Also included were the investigator's name and telephone number in case the subject had additional questions regarding the research. The study was limited by the small sample size and lack of random assignment.

Instrument

The instrument for this study was the Older American Resources Survey (OARS), which measures physical, mental, economic functioning, and self-care capacity.8

The social and economic factors in the scale include basic demographic information. The mental health component of the index is comprehensive in its coverage of basic mental status factors of orientation and memory, measures of psychiatric symptomatology, and information about life satisfaction and perceived mental health.9 The physical health index attempts to identify various physical conditions and clinical symptoms, as well as information about the use of prescribed medications. Similarly, the section on activities of daily living measures instrumental functioning, as well as basic personal selfmaintenance capabilities.

The questionnaire is well-designed and carefully structured to yield meaningful answers. Inter-rater reliability for the instrument is high for all five dimensions, from 0.74 for psychological functioning to 0.88 for physical functioning. Limitations of the instrument are the average length of time it takes to complete the interview, which is 45 minutes, and the complexity of some items on the questionnaire.

Results

Fifteen subjects who were identified as alcoholic had a mean age of 64 years; 37% of the sample were women and 63% were men. The majority of the sample (75%) lived alone and 25% lived with a spouse, Forty-two percent of the subjects had not graduated from high school, and 28% of the sample had a high school diploma.

An interesting finding was that 97% of the subjects were diagnosed primarily as depressed and alcoholism was a secondary diagnosis. This can be explained by the fact that depression often masks alcoholism, and thus older adults are often diagnosed for the secondary (depression) rather than the primary condition (alcoholism).10 Also, many health professionals are hesitant to diagnose alcoholism in older persons." The attitude of 'Tm not going to confront Grandpa" enables patterns of abuse to go uninterrupted.

Physical Health

The majority (90%) of the subjects was prescribed psychotropic medications. The most commonly prescribed psychotropic drugs were cyclic antidepressants and antianxiety agents.

One subject was taking 12 prescribed psychotropic drugs that were prescribed by three different physicians. This subject had a total of 25 prescribed drugs that she had filled at three different pharmacies. This finding should be noted in light of other investigations that have suggested that older adults who abuse alcohol will cross addict and abuse prescribed drugs.11,12 It is not surprising that prescriptions were written so frequently for this group, because 25% of all prescriptions in the US are written for the aged although they represent only 1 1% of the US population.2

A written inventory of all prescribed drugs was made. Subjects were asked to read the labels, open containers, and describe the actions and side effects of their medications. A mean of seven drugs was taken daily over the past month. The most commonly prescribed drugs included antihypertensive, cardiac, and diuretic medications (Table 1).

Table

TABLE 1MOST COMMONLY PRESCRIBED MEDICATIONS

TABLE 1

MOST COMMONLY PRESCRIBED MEDICATIONS

Table

TABLE 2MOST COMMON ILLNESSES

TABLE 2

MOST COMMON ILLNESSES

The majority of subjects (64%) experienced the following problems:

* Dosages of medications that do not reflect consideration of age of subject.

* Prescriptions prescribed by more than one physician.

* Inappropriate use of medications.

* Unaware of the purpose and adverse reactions of medications.

* Lack of motivation to learn about drugs.

* Unable to read labels.

* Unable to open containers.

Assessment also included the presence or absence of a variety of illnesses and the extent to which individual subjects found these disabling. All subjects had at least one physical problem that required ongoing medical treatment. Physical illnesses most commonly identified were cardiac disease, arthritis, and respiratory disease (Table 2). Twenty-five percent of subjects were sick in bed over the past 6 months, 20% were hospitalized for a physical illness, and 75% had seen a physician for a physical problem over the past 6 months.

Finally, individuals were asked for an overall assessment of their own physical health. None of the subjects perceived that they were in good physical health. Ninety-five percent of the subjects were satisfied with their medical care (Table 3).

Mental Health

The present level of intellectual intactness or deterioration was assessed by using the Short Portable Mental Status Questionnaire,13 which is part of the OARS. This is a 10-item test of orientation, recent memory, long-term memory, and the capacity for serial calculation. Three clinical subtypes of alcoholic disorder can theoretically be distinguished: alcoholism with no chronic brain damage; alcoholism with brain damage caused by alcohol abuse; and alcoholism existing along with other disorders, such as Alzheimer's disease.14 One subject exhibited marked intellectual deterioration (Table 4).

Table

TABLE 3RESPONSES RELATED TO PHYSICAL HEALTH

TABLE 3

RESPONSES RELATED TO PHYSICAL HEALTH

Table

TABLE 4RESPONSES RELATED TO MENTAL HEALTH

TABLE 4

RESPONSES RELATED TO MENTAL HEALTH

Three of the subjects appeared superficially to be demented, but through additional assessment were found to be depressed. St. Pierre et al15 suggest that part of the difficulty in evaluating the older individual for depression is that depressed elderly may appear to be demented. What has been called "pseudodementia" actually refers to cognitive deficits of psychogenic origin that were identified in this study .

The second area evaluated was concerned with the presence or absence of functional psychiatric symptomatology. Other mental health measures included an interviewer rating of participants, a self-rating of mental ami emotional health, and a mental health inventory from the Minnesota Multiphasic Personality Inventory (MMPI).16 This inventory consists of 15 true-false items derived from MMPI scales pertinent to the problems of the elderly. Five items are from Scale 1 (hypochrondriasis), five are from Scale 2 (depression), and five are from Scale 3 (hysteria), Scale 6 (paranoia), or Scale 7 (schizophrenia). AU subjects were rated by the investigator as having moderate to severe impairment of mental health. The majority of subjects (65%) rated their mental health as poor and declining over the past 5 years. Hypochondriasis was common among the subjects (75%).

Fifty percent of the subjects exhibited signs of depression. Three of the subjects had been hospitalized previously for suicide attempts. This finding is not surprising because depression is the most common psychiatric disorder of the elderly population.15,17

All subjects were asked, "Do you have a problem with your health because of drinking, or has your physician advised you to cut down on drinking?" Although 15 subjects had long histories of alcoholism, only two responded positively to this question. This denial or masking was expected in this population; Hughes et al have observed that persons who feel the most vulnerable and threatened also feel the greatest need to deny . 18

Social Functioning

Systematic inquiry was made into the extent, quality, and availability of social interactions. This included a focus on marital status, on living arrangements, on the availability of a confidant in whom subjects could trust and confide, and finally on the presence, availability, and willingness of someone in the environment to provide some kind of ongoing care in case of illness or disability.

Seventy-five percent of the subjects had at least one phone call and visitor each week (Table 5). Ninety percent of subjects knew of at least one person who they could visit in their homes.

Thirty percent of the sample felt lonely most of the time and described their social relationships as unsatisfactory and of poor quality. Ninety-two percent of the subjects had at least one person in whom they could confide. An adult child was the most commonly identified confidant. Half of the subjects visited a senior citizen center and participated in a group activity at least once a week; 40% of these subjects reported that they did not enjoy the activities. At least once a week, 95% of the subjects leave their houses for other activities, such as food shopping and attendance at church; 40% of the subjects use transportation provided by the agency for these trips whereas 17% of the sample need transportation.

Economic

An assessment of economic functioning included employment status and current earnings, amount and sources of income, home ownership, and subjective financial evaluations (Table 6). The majority of subjects (90%) perceived themselves as being severely financially stressed. They lived below the poverty line ($5,999 annual income) and felt that their financial resources did not provide the basic necessities of life. The majority (57%) of subjects expressed the need for food stamps, medical care, home health services, and nursing services.

Self-Care Capacity

Information in the area of self-care capacity was divided into two segments. The first of these concerned the performance of a variety of activities necessary in maintaining an independent household. These included the independent use of the telephone and the capacity to use public transportation, go shopping, prepare meals, do routine housework, take one's own medication, and handle one's own money. All subjects had difficulty in the area of self-care. The most common problems related to shopping and meal preparation (Table 7). Twenty-five percent regularly require assistance with activities of daily Jiving, and 26% of the subjects feel they need additional help. Ten percent of the sample has the assistance of home health aides for at least 4 hours a week. Seven percent of the subjects had meals delivered daily by an agency.

The second area of functioning that was assessed concerned an individual's capacity to take care of bodily functions. This included an assessment of the subjects' capacity to eat by themselves, dress and undress themselves, take care of their own appearance, walk, get in and out of bed, take a shower or bath, and be continent of bowel and bladder. All subjects stated they could carry out these activities without assistance. However, it was noted by the investigator that all subjects over-rated their self-care capacity.

DISCUSSION

The data from this investigation suggest that comprehensive functional assessment of the older alcoholic rather than a symptom-oriented search is needed.19 Signs of alcohol abuse may be more obscure for older drinkers than for younger age groups.3 20 For example, self-neglect, confusion, or repeated falls are often accepted as the vicissitudes of aging rather than signs of alcohol abuse.' One third of elderly alcoholics are late-onset abusers who drink in reaction to losses.5 These reaction drinkers tend not to manifest the severity of cognitive and somatic problems common to early-onset alcoholics.14 Volume and frequency of drinking are less significant indicators of alcoholism for the aged.1,21 The older drinker will consume less alcohol per drinking occasion than younger drinkers, but older drinkers are more likely to drink on a daily basis.22,23

Table

TABLE 5RESPONSES RELATED TO SOCIAL FUNCTIONING

TABLE 5

RESPONSES RELATED TO SOCIAL FUNCTIONING

Table

TABLE 6RESPONSES RELATED TO ECONOMIC DIMENSION

TABLE 6

RESPONSES RELATED TO ECONOMIC DIMENSION

Table

TABLE 7RESPONSES RELATED TO SELF-CARE CAPACITY

TABLE 7

RESPONSES RELATED TO SELF-CARE CAPACITY

FIGURERECOMMENDED READINGS FOR OLDER ADULTS

FIGURE

RECOMMENDED READINGS FOR OLDER ADULTS

Older drinkers also remain socially isolated more often than younger drinkas. This social isolation is promoted by a lack of interest of health-care providers, who believe that older adults are not treatable or teachable.19 This study suggests that there is a knowledge deficit among the aged in regards to what factors constitute abuse. This finding has implications for interventions, because many older posons will eliminate or moderate their drinking once they understand how alcohol abuse will affect thenwell-being.22 Connecting me impact of drinking to five levels of functioning can be a powerful motivating force to change.4

Functional assessments need to be conducted in a home setting for several reasons. Older alcoholics have difficulty participating in community services due to cost, age, health, location of service, and relevance of service for their age group. Second, they can remain isolated because conventional means to motivate alcoholics to enter treatment often lack meaning for the elderly, ie, fear of loss of job or family. Lastly, the home setting allows for more comprehensive assessments and interventions. The nurse is better able to determine other signs of alcohol abuse, such as deterioration of the physical environment, personal neglect, and social isolation.

Nurses must also be aware of special interviewing techniques when working with this population, for example, it is helpful to ask non-alcohol specific questions when taking an initial drinknig history. It must be kept in mind that this age group grew up in a time when alcoholism carried a greater moral stigma. Frequently the word "alcoholic" will arouse hostility, so the term "drinking problem" should be substituted. Questions about the older person's familial, social, employment, legal, and health circumstances often give cues to alcohol abuse. Focusing initially on these areas can be a valuable starting point for later discussion of drinking patterns.

After the above areas are assessed, it is important for the nurse to move on and complete a drinking history, keeping in mind that the interview must be conducted at a slower pace, because the elderly person needs time to adjust to sharing personal issues. Confrontation needs to be less aggressive, and acceptance of the older person as a fellow human being needs to be fostered.24 The drinking history should include questions on the amounts and types of beverages consumed, attitudes toward alcohol situations when drinking arises, perceptions of drinking behavior, and the effects that alcohol has on overall behavior and life. It should be kept in mind that persons who do have a drinking problem are not likely to admit to excessive consumption of alcohol.

The drinking history should also include the use of prescription drugs that may exacerbate the problems of alcohol abuse. Completion of a drug history is essential in the assessment process. This step can never be eliminated in a total assessment; it is estimated that 73,000 older Americans die each year from taking the wrong medicine or dose, or from two or more drugs interacting.23 This statistic is especially alarming in light of the multiple drug use in the present investigation. Assessment of drug use should be ongoing and evaluated periodically.

NURSING INTERVENTIONS

The first step that nurses must take to successfully work with elderly alcoholics is to explore personal attitudes towards aging and alcoholism.24 Lasker states that an honest and thorough appraisal of prejudices, judgments, and values is essential.6 As the nurse's self-awareness increases, it then becomes possible to control and modify negative or ambivalent attitudes. Nursing must also develop a thorough understanding of the aging process and alcoholism to determine alcohol-related changes from those related to normal aging. This understanding leads to an ability to conduct comprehensive assessment, which in tum generates appropriate interventions.

The data from this study suggest that the following interventions are effective when working with an older alcoholic in a home setting.

* Point out the relationship of functional problems to alcohol abuse.

* Discuss actions, effects, and consequences of alcohol intake and drugalcohol interactions.

* Identify benefits to be derived from abstinence or reduced alcohol intake.

* Confront less aggressively.

* Avoid use of terminology such as alcoholic or alcoholism.

* Negotiate for a period when alcohol use is eliminated or moderated.

* Encourage the completion of drug assessment guides and discuss them monthly with the client.

* Contact the physician and pharmacist if there are medication-related problems.

* Use whatever is important in the person's life as a possible motivating force for change.

* Offer alternative methods of "feeling good," ie, prayer, exercise.

* Encourage completion of reading assignments (Figure).

* Familiarize yourself with the approach used by Alcoholics Anonymous.

* Encourage participation in Alcoholics Anonymous.

* Establish a "buddy system" to provide support, ie, another member of Alcoholics Anonymous, a church member, a neighbor.

* Teleconference on a consistent basis.

* Assist in providing life necessities by identifying and coordinating community services.

* Conduct ongoing systematic functional assessments to evaluate status.

* Include significant others in treatment plan.

* Build on strengths; remember that you are working with survivors.

SUMMARY

Learning more about the disease of alcoholism and its implications for the elderly is the responsibility of every nurse. We must be skilled at conducting comprehensive, functional assessments if interventions are to be successful. Working with the elderly alcoholic provides the nurse the opportunity to offer preventive measures, health teaching, and treatment. Helping the elderly find sobriety and quality in life will be one of the most rewarding experiences in nursing practice. Individual and societal attitudes that older persons are too old to change, learn, and recover needs to be challenged on all fronts.

REFERENCES

  • 1. Edwards D. An investigation of the use and abuse of alcohol and other drugs among 50 aged male alcoholics and 50 aged female alcoholics. Journal of Alcohol and Drug Education. 1985; 30(2):24-30.
  • 2. Caroselli-Karinja M. Drug abuse and the elderly. / Psychosoc Nurs Ment Health Serv. 1985; 23(6):25-30.
  • 3. Estes N, Heinemann M. Alcoholism Development, Consequences, and Interventions. St. Louis: CV Mosby Co; 1986.
  • 4. Kinney J. Seaton G. Loosening the Grip: A Handbook of Alcohol Information. St Louis: Times Mirror Mosby College Publishing; 1987.
  • 5. Valanis B, Yeaworth R, Mullins M. Alcohol use among bereaved and non-bereaved older persons. Journal of Gerontological Nursing. 1985;13(5):25-32.
  • 6. Lasker M. Aging alcoholics need nursing help. Journal of Gerontological Nursing. 1984; 12(1): 16- 19.
  • 7. Krach P. Chemical dependency in the aged: Nursing assessment and intervention. Proceedings of the 35th International Congress on Alcoholism and Drug Dependency; 1 989; Oslo. Norway.
  • 8. Duke University Center for the Study of Aging and Human Development. Multidimensional Functional Assessment Methodology. 1976.
  • 9. Pfeiffer E. A short psychiatric evaluation scale: A new 15-item monotonie scale indicative of functional psychiatric disorder, in: Hoffmeister P, Muller C. Brain Functions in Old Age. Bayer Symposium VH. Berlin: Springer-Verlag; 1979.
  • 10. Daley D, Moss H, Campbell F. Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness. Center City, MN: Hazelden foundation; 1987.
  • 11. Miller F, Whitcup S, Sacks M, Lynch P. Unrecognized drug dependence and withdrawal in the elderly. Drug Alcohol Depend. 1985; 15:177-179.
  • 12. Malcolm M. Alcohol and drug use in the elderly visited at home. Int J Addict. 1984; 19(4):4 11-418.
  • 13. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficits in elderly patients. J Am Geriair Soc. 1975;23:443-450.
  • 14. Simon A. The neuroses, personality disorders, alcoholism, drug use and misuse and crime in the aged. In: Birren JC, Sloan RB, eds. Handbook of Mental Health Aging. Englewood Cliffs, NJ: Prentice Hall, Ine; 1980.
  • 15. St. Pierre J, Craven R, Brono P. Late life depression: A guide for assessment. Journal of Gerontological Nursing. 1984; 13(5):2532.
  • 16. Blazer D. Description and application. In: Multidimensional Functional Assessment the OARS Methodology: A Manual, 2nd ed. Durham, NC: Center for the Study of Aging and Human Development, Duke University Medical Center; 1978.
  • 17. Ronsman K. Therapy for depression. Journal of Gerontological Nursing. 1985; 12(12):18-25.
  • 18. Hughes C, Blackburn S, Wargo M. On masking among clients. Topics in Clinical Nursing. 1 986; 8( I ):83-89.
  • 19. Bower F, Patterson J. A theory-based nursing assessment of the aged. Topics in Clinical Nursing. 1 986; 8( I ): 1 1 -32.
  • 20. Porterfield L. Geriatric pharmacology: Therapeutic rationale. Home Healthcare Nurse. 1984;March/April:33-35.
  • 21. Salzman C. Geriatric psychopharmacology. J Geriatr Psychiatry. 1987; 20(1):1 1-27.
  • 22. Beckman L. Treatment needs of women alcoholics. Alcoholism Treatment Quarterly. 1984;19:101-113.
  • 23. Fielo S, Rizzolo M. The effects of age on pharmacokinetics. Geriatr Nurs. 1985; Nov/Dec:328-331.
  • 24. Naegle M. Theoretical perspectives on the etiology of substance abuse. Holistic Nursing Practice. 1988; 2(40): 1-1 3.
  • 25. Wolfe S, Rigate L, Hulstrand E, Kamimoto L. Worst Pills, Best PUL·. Washington, DC: Public Citizen Health Research Group; 1988.

TABLE 1

MOST COMMONLY PRESCRIBED MEDICATIONS

TABLE 2

MOST COMMON ILLNESSES

TABLE 3

RESPONSES RELATED TO PHYSICAL HEALTH

TABLE 4

RESPONSES RELATED TO MENTAL HEALTH

TABLE 5

RESPONSES RELATED TO SOCIAL FUNCTIONING

TABLE 6

RESPONSES RELATED TO ECONOMIC DIMENSION

TABLE 7

RESPONSES RELATED TO SELF-CARE CAPACITY

10.3928/0098-9134-19901101-09

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