Taking an alcohol history Dr Tony Rao Consultant Old Age Psychiatrist, SLAM NHS Foundation Trust Visiting Researcher, Institute of Psychiatry, Neurology and Neuroscience
Alcohol related brain damage Alcohol use disorders frequently complicate primary dementia, increasing adverse effects and cognitive decline (Draper et al, International Psychogeriatrics, 2011) 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) Cerebellar damage per se may disrupt frontal processes such as executive function and poor response inhibition (Pitel et al Neuroscience and Biobehavioral Reviews, 2015)
Neuropsychological Impairment in Alcohol Related Dementia (Rao, Advances in Dual Diagnosis 2016)
Older People and Alcohol Misuse 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
1986 2011 The Baby Boomers Turn 65
GENERAL PRINCIPLES OF ASSESSMENT 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
TYPICAL PRESENTATIONS USUALLY ATYPICAL 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
BARRIERS TO IDENTIFICATION AND TREATMENT AGEISM It s all he/she has in life UNDER-REPORTING MIS-ATTRIBUTION Viewed as stigmatising 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
Short Michigan Alcohol Screening Test- Geriatric Version (Short MAST-G) 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 Score of 5 or more suggestive of alcohol misuse
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 More suitable for screening dependence Does not detect hazardous or at-risk drinking Does not distinguish between current and prior alcohol problems
ALCOHOL DEPENDENCE SYNDROME 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)
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, selfharm, 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
BRIEF INTERVENTION 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
Further Reading Rao, R., & Draper, B. (2015). Alcohol-related brain damage in older people. The Lancet Psychiatry, 2(8), 674-675. Rao, R., & Crome, I. (2016). Alcohol misuse in older people. BJPsych Advances, 22(2), 118-126. 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.