Clinical management of alcohol problems requires knowledge of and collaboration with community rehabilitation resources, and assessment and decision-making skills for early detection and prompt treatment. Gerontological nurses in the community are in a unique position to'aid in prevention, early detection, and treatment of alcohol problems. The purpose of this article is to review assessment and treatment of alcohol use in elderly women in communitybased settings.
Fifteen percent of the population older than age 60 are known to consume an average of four or more alcoholic drinks daily (Mackel, Sheehy, & Badger, 1994). However, alcohol misuse may be missed in women because of a number of factors. Women have a tendency to drink secretly at home and conceal their drinking behavior (Gearhadt, Beebe, Milhorn, & Meeks, 1991). Social stigma may reinforce women's tendency to hide alcohol and may contribute to the lack of questioning by health care providers about alcohol habits. In addition, health care providers may not ask about drinking habits of elderly women because of lack of awareness, embarrassment, discomfort, or time constraints. Older women may consider alcohol to be medicinal for their heart or to be helpful in coping with a loss, and may not report their drinking.
With fewer women abstaining from alcohol use during their earlier years, alcohol dependence may reappear or continue as they age. Early-onset alcoholism usually begins before middle age, while late-onset alcoholism usually begins after age 60 and often is a response to life events. Retirement, a pattern of heavy drinking with a husband, and widowhood are possible risk factors for alcohol abuse in older women. Late-onset alcohol abuse is more common in women than men (Gomberg, 1994).
EFFECTS OF ALCOHOL USE
The effects of alcohol use in elderly women can be considerable and may include physiological changes, physical injury, psychosocial changes, and financial stresses. Physiologically, women have increased susceptibility to alcohol's toxic effects, and they develop health problems sooner than men, although they may begin to drink at a later age (Breslin, 1993). Liver disease is a major concern, with hepatic changes and other serious disorders developing sooner after drinking less alcohol than men. Women have more serious liver disease, compared to men with similar drinking patterns (Wilsnack, Wilsnack, & HillerSturmhofel, 1994). Debate continues about the reasons for gender differences. Decreased alcohol dehydrogenase may make women more vulnerable to the effects of alcohol, compared to men of the same stature. Higher fat to body water proportions may result in a higher blood alcohol concentration for women when given the same volume of alcohol as men (Deal & Gavaler, 1994).
Elderly women who drink can experience development of new physiologic changes or worsening of previously existing conditions. Exacerbation of diabetes or peptic ulcers, cognitive deterioration, congestive heart failure, depression, and infections may occur because of alcohol abuse. Concomitant dependence on tobacco and use of prescription drugs may cause serious interactions. Women who drink may have a greater risk of falls and fractures if they have osteoporosis. Injuries may be a significant clinical indicator of alcohol abuse in elderly individuals (Israel et al., 1996).
Alcohol-related disorders in women consistently are linked to depression. Loss may precipitate alcohol use in elderly women. Women may lack the personal resources needed to help cope with life events associated with aging, which may contribute to drinking problems. Lasker (1986) found that elderly women offered numerous reasons for drinking including widowhood, marital and sexual problems, and stress from jobs.
The physical and psychosocial impact of alcohol use on health has a direct impact on economic costs. In the United States, it is estimated that more than $85 billion annually is spent in acute care and long-term care expenses and indirect expenses, such as lost work hours (National Institute on Alcohol Abuse and Alcoholism, 1991).
Evidence suggests elderly women who misuse alcohol may not be diagnosed and, thus, be placed at increased risk for physical and psychosocial health consequences. Assessment of women's pattern of alcohol use is a major issue for nurses because of these health consequences. Gerontological nurses in the community have the opportunity to identify and refer elderly women for alcohol treatment.
A thorough assessment is necessary to diagnose alcohol problems, and nurses in the community are in a unique position to note signs such as alterations in the performance of activities of daily living (ADL) or instrumental activities of daily living (IADL) that may aid in detecting alcohol problems. Signs that may indicate alcohol misuse include:
* History of falls.
* Family problems.
Problems such as a history of falls or small accidents, abdominal complaints, uncontrolled hypertension, weight loss, ecchymoses, depression, or loss of sleep may mask the underlying problem of alcohol abuse (Martsolf, Sedlak, Ludwick, & Doheny, 1999).
Vague physical complaints also may indicate alcohol misuse. Common medical symptoms individuals with alcohol problems may describe include (Barry & Fleming, 1994):
* Gastrointestinal (e.g., chronic diarrhea, abdominal pain).
* Neurological (e.g., tension headaches, insomnia, memory loss).
* Psychological (e.g., chronic depression).
* Less easily categorized complaints (e.g., fatigue, sexually transmitted diseases, accidents, trauma). Numerous medical problems result from alcohol abuse including complications in the esophagus, stomach, bowel, liver, pancreas, central and peripheral nervous system, and cardiovascular system (O'Connor, 1994).
Further complicating the recognition of alcohol misuse may be the reluctance of individuals to volunteer information about alcohol use unless asked directly and specifically. Shame and hidden drinking may be barriers to overcome when asking individuals about alcohol intake (Lasker, 1986). Therefore, information may not be volunteered readily if nondirect questions are asked. Nurses should ask specifically, "Do you drink alcohol?". If a positive response is obtained then nurses must follow with questions aimed at frequency, amount, and duration. It is particularly important to clarify vague answers such as "once in a while," "occasionally," or "socially" when determining whether the women drink. Similarly, details about type of alcohol consumed, when it is consumed, and the amount consumed on a specific day are important to obtain a reliable account of consumption. From this information, the pattern of alcohol intake can be determined.
Nurses in the community who know the women well may be the best ones to ask about drinking habits because information about alcohol use is obtained most successfully when the nurses are trusted and exhibit a nonjudgmental attitude, and when the women are assured of confidentiality. A lessthreatening approach may be to begin with general medical questions or questions about stresses and lifestyles before asking the more sensitive questions about alcohol. After these questions have been addressed, nurses can ask a related question, "With your present problems, how does alcohol fit?". The answer will provide a basis for appropriate interventions.
History questions should be directed to elderly women as well as to their families or caregivers, as appropriate, to assess for subtle signs of misuse. Specific areas for questioning which may indicate drinking include:
* Have you experienced recent losses or changes in living arrangements?
* Are your grandchildren having trouble in school?
* Are your children living in a stable environment?
* Have you had financial problems?
* Do you have any new friends you have not spoken about?
Many alcohol abusers also abuse other drugs, and almost all individuals who abuse drugs other than alcohol also abuse alcohol. Polypharmacy is common in many older adults. Pre-existing disorders often present in elderly individuals make it likely they are taking mutual medications. Even if elderly individuals are not consuming alcohol at a high level (i.e., 60 to 80 g of ethanol daily), medications they take may interact with alcohol in harmful ways (Sullivan, 1995). These ways include inhibiting the breakdown of drugs, interacting additively, or enhancing the elimination of drugs. Thus, the individuals may receive more or less of a prescribed drug or may have more serious side effects because of concomitant use of alcohol and drugs. Therefore, a positive history of drinking requires a thorough medication assessment.
Physical signs and changes in functioning also may contribute clues that can alert nurses to alcohol dependence or abuse. Signs that may mimic other diseases and be overlooked as being alcohol-related include:
* Cognition changes, ranging from forgetfulness to delirium.
* Elevated blood pressure.
* Weight loss.
* Gait or balance abnormalities.
* Ecchymoses from poor nutrition, accidents, or both. Similar to other problems in older adults, functional assessment of ADLs may provide vital clues to alcohol misuse. Nurses should check for changes in hygiene, eating, mobility, or toileting. Assessing for changes in IADLs also is vital. Nurses need to assess whether the individuals can manage a checking account, do the grocery shopping, and prepare food. Legal issues such as driving under the influence or job-related problems may not be applicable in the elderly population if they have stopped driving or have retired.
When alcohol misuse is suspected, nurses can employ a screening tool specifically designed to detect problem drinking. These screening tools also can be used in situations when alcohol misuse is a potential problem (e.g., recent bereavement, loneliness, job stress). Routine use of these tools by nurses may bring awareness of alcohol problems to the attention of elderly individuals and eliminate the fear of discussing alcohol and its problems.
A variety of screening tools are available for detecting alcohol problems. Common tools are the Geriatric Michigan Alcohol Screening Test (G-MAST), the CAGE instrument, and the Alcohol Use Disorders Test (AUDIT). The G-MAST uses consequences of drinking to gauge drinking problems (Beresford, 1995), and the CAGE instrument, a brief fourquestion tool, focuses on alcohol dependence (Ewing, 1984). Both tools may be self-administered. The AUDIT, originally designed for interviews, contains questions related to consequences, consumption, and dependence, and incorporates guidelines for clinical screening including a clinical evaluation and a gamma-glutamyl transferase value. This secondary screening is suggested when clients may be "defensive or uncooperative" (Babor, de la Fuente, Saunders, & Grant, 1992, p. 5) . All three screening tests provide cutoff points for defining excessive drinking. However, none of these tools are intended to diagnose alcohol abuse but are used to aid in case finding.
Other screenings that may be helpful in detecting alcohol misuse include a depression screening and a trauma screening. Both depression and trauma have been linked to alcohol consumption. Two tools for depression screening are the Beck Depression Inventory (Beck, Steer & Brown, 1996) and the Geriatric Depression Scale (Sheikh et al., 1991). To assess trauma, a five-item Trauma Scale, originally developed by Skinner, Holt, Schuller, Roy and Israel (1984) and modified by Israel et al. (1996), can be used. The Scale contains questions such as:
* Have you had any fractures or dislocations to your bones or joints?
* Have you been injured in a road or traffic accident?
* Have you injured your head?
* Have you been injured in a fight or assault?
* In the past year have you had repeated small accidents at home?
After a thorough assessment, treatment options can be explored. Treatment includes detoxification, referrals to either addiction programs or Alcoholics Anonymous (AA), and follow-up care. A commonly held myth related to alcohol abuse in elderly individuals is the various treatment strategies are not efficacious in this population. Lichtenberg, Gibbons, Nanna, and Bluemthal (1993) criticize belief in this myth and cite at least six studies that report findings to the contrary. According to this research, there is hope for recovery for elderly alcohol abusers who typically will complete treatment more successfully and maintain sobriety longer than their younger counterparts.
While description of vague symptoms may be the clue that alerts nurses that alcoholism is a problem, elderly individuals occasionally may be in an intoxicated state requiring detoxification. If an older adult is in this state, treatment for alcohol dependence cannot be initiated effectively until detoxification has been accomplished. Elderly alcohol abusers are detoxified most safely and effectively in the hospital because of the need for close supervision of the physiologic symptoms of withdrawal (Dufour & Fuller, 1995).
After diagnosis, one of the central roles for nurses in the community working with elderly women who are alcohol abusers is working with the interdisciplinary team to make referrals. Unfortunately, denial plays a major role in preventing elderly individuals from engaging in the rehabilitative process. Breaking through denial is difficult. After a thorough assessment in which alcohol misuse has been identified as a problem for an elderly woman, the interdisciplinary team needs to confront the woman with the facts about and consequences of her behavior. Health practitioners may need to repeat the facts patiently as part of the process of breaking through the denial (Eastland, 1995). This confrontation should be marked by both concern and a nonjudgmental attitude on the part of practitioners and should be conducted in a supportive atmosphere.
Historically, the social stigma of alcohol abuse in women has increased the difficulty women experience in acknowledging their problem. Women are drinking more, but the stigma remains. Women's denial of problem drinking and delay in seeking assistance can be attributed to their perception that drinking is a coping strategy. The belief is the drinking is not the problem but rather a response to situations and life changes, such as the maturing of children (Beckman, 1994). Denial may be intensified because alcohol-related problems may be attributed to the aging process.
Denial on the part of health practitioners is a common reason for the lack of adequate assessment of the alcohol intake patterns in elderly women. Some health care providers and alcohol abusers and their families believe alcohol abuse is not a problem for elderly individuals because of their own stereotypical beliefs or the value they place on drinking. It is not uncommon to hear expressions of acceptance because the elderly individuals "only have a few short years left. So let them enjoy themselves" (Dufour & Fuller, 1995, p. 129).
Israel et al. (1996) suggest alcohol recovery often begins with confrontation by a concerned individual. The individuals and even their families may react in anger. Nurses should be aware that a frank yet sensitive discussion of these negative behaviors and any concurrent physiologic changes related to alcohol abuse presents a challenge.
After denial has been addressed, instructing individuals who are not alcohol dependent to cut down on drinking can be highly effective (Israel et al., 1996). Alcohol treatment approaches are generally of two types: an addiction program or AA. In either case, the goal of treatment usually is abstinence (Dufour & Fuller, 1995; Eastland, 1995). Choice of one approach instead of another often is related to:
* Patient preference.
* Onset of alcohol abuse (i.e., early versus late).
* Ability to pay and health care benefits.
* Comorbidity of acute or chronic medical or psychiatric problems.
Furthermore, the difference in treatment between early-onset and lateonset alcohol abuse is important. Interventions addressing the social and psychological stresses that accompany the aging process are appropriate. These stresses often are associated with late-onset alcohol abuse.
Economic constraint is one barrier experienced by some women attempting to seek treatment (Beckman, 1994). Women may have low incomes or third party payment coverage which does not adequately provide for alcohol treatment in addiction programs. However, AA is a free, community-based, selfhelp program where cost is not an issue.
Alcoholics Anonymous may be a treatment choice for elderly aleoholies (Dufour & Fuller, 1995; Eastland, 1995; Mackel et al., 1994). Although AA is not a recovery program necessarily geared for older alcohol abusers, one third of all AA members are older than age 50 (Egbert, 1993). Group support in AA provides the opportunity for regular exposure to other alcohol abusers who acknowledge their disease and who extol both abstinence and sobriety as a path to wholeness.
Whether an addiction program or AA is the treatment strategy, several factors are related to treatment success. Strategies for treatment need to be tailored to specific patient needs. Age of onset of abuse problems, gender, and current age are factors to consider. For example, the difference between appropriate treatment strategies for early-onset and late-onset alcohol abuse is an important distinction. Chronic alcohol abusers and reactive abusers typically are dissimilar and benefit from differing treatment approaches (Graham, Zeidman, Flower, Saunders, & White-Campbell, 1992). Some approaches suggested for chronic abusers are reduction of drinking, discussions related to use of leisure time, and resolution of housing and financial problems. Approaches for reactive abusers include grief counseling and education about the effects of alcohol on health.
A final factor related to the selection of a treatment approach is the coexistence of medical and psychiatric conditions. Comorbid psychiatric disorders exist in approximately two thirds of alcohol-abusing and problem-drinking women (Beckman, 1994). As a result, a wide range of medical and psychiatric services must be made available to women.
Addiction programs can be structured in a variety of ways. Elements that exist in most programs include some form of group therapy or individual counseling; family and marital therapy; medical and psychiatric services or referrals; vocational rehabilitation; and aftercare placement. Issues related to problems of daily living, use of leisure time without alcohol, stressful life events, and resocialization are addressed throughout the program. Alcoholics Anonymous meetings also may be included in the treatment approach in an addiction program.
The literature presents conflicting views of the importance of treatment groups that are age or gender specific. However, when the factors of older age and gender are considered, prevention and treatment of alcohol abuse warrant distinctive approaches with elderly women (Wilsnack et al, 1994).
Beckman (1994) argues for women-oriented treatment programs that have at least four essential characteristics:
* Delivery in a setting compatible with women's interactional styles and personal orientations.
* Consideration of gender roles, female socialization, and women's status in society.
* Avoidance of exploitation of women.
* Focus on women-specific treatment issues such as sexual problems, assault and abuse, development of social support systems, and development of adequate coping mechanisms.
In addition to suggesting women benefit from gender-specific treatment strategies, Beckman (1994) adds that age is a factor affecting the content of treatment programs. Few studies have examined outcomes for elderly patients in different forms of treatment (Liberto, Oslin, & Ruskin, 1992). However, a study conducted by Kofoed, Toison, Atkinson, Toth, and Turner (1987) showed that 1-year treatment success rates for older patients in homogenous-age treatment groups were four times the rates for patients in mixed-age group therapy. Findings of that study suggest older patients stay in treatment more readily when they are in groups composed solely of older individuals. Age-related topics that may need to be addressed include losses in later life, boredom, and loneliness related to decreased socialization, problems related to rebuilding social support networks, and community involvement (Mackel et al., 1994).
The recovery process is time consuming, and a referral by the interdisciplinary health care team does not signal the end of the nurseclient relationship. Subsequent contacts with the individuals provide opportunities for nurses to treat ongoing medical problems which may be related to the alcohol abuse and to provide encouragement to continue with treatment.
IMPLICATIONS FOR GERONTOLOGICAL NURSING
Gerontological nurses based in all settings are pivotal in identifying alcohol abuse, advising about alcohol use, and referring elderly women for alcohol treatment. As the aging population increases, the problems associated with drinking also are on the rise; yet, the problem of alcohol misuse often is unrecognized. Nurses in the community are in an ideal setting to observe and interact with elderly women in their own neighborhoods, while they relate with significant others and perform ADLs. This provides nurses the challenge and opportunity to identify elderly women with alcohol problems. Nurses can have an impact on the community by providing education and educational programs; disseminating literature; and conducting alcohol screenings.
Assessment of alcohol intake should be routine for all elderly women and should include examining changes in behavior, appearance, social interaction, financial status, and health, as well as direct questioning about alcohol intake. Assessment should be ongoing rather than solely in an initial history intake. Periodic assessment is essential because circumstances may change, alcohol intake may increase, and as the relationship grows between client and nurse, disclosure may become easier.
After the topic of alcohol habits is approached, advice should address the effects of alcohol use on existing medical conditions, interactions with medications, and increased risk of injuries. Gordis (1998) emphasized that most elderly individuals who do not have major health problems should be instructed to limit daily alcohol consumption to one drink daily. These effects should be discussed because the media gives mixed messages about alcohol use (Eliason, 1998). The media relates that alcohol protects the heart; drinking is bad when you are driving; it is helpful for relaxation and can stimulate a waning appetite; and yet, alcohol can be hazardous if used more than moderately. In response, people often do not know what to believe.
If alcohol abuse is suspected, referral is a priority. When patients are in recovery, nurses can instill hope for recovery in elderly alcohol abusers by openly debunking myths and discussing research findings that support recovery success with these individuals and their families. In this discussion, nurses need to address the fears held by many elderly alcohol-dependent individuals.
Although there is hope for successful alcohol treatment with elderly women, they frequently will have relapses in drinking behavior. Nurses should view these relapses as part of the recovery process rather than as failures and should follow up on missed appointments in this population by invitations to reschedule and reactivate a treatment program.
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