Alcohol and older people: the Ghost of Christmas future?

It was just over 10 years ago, after getting to the point where nearly half the older patients on my ward had mental disorders that were related to their unhealthy use of alcohol that I said to myself ‘enough is enough’. But what did I have to offer them?  I had no doubt that the answer was very little, either as in-patients or after they had been discharged to their own homes, from where they were often then re-admitted. The only previous specialist experience in this area of expertise was 9 years previously as a houseman on a medical unit in West London that had a particular interest in alcohol misuse. Even then, it was more a question of assisting withdrawal from alcohol and then seeing many patients being re-admitted some weeks later.

Luckily for me, there was help at hand in the form of the opportunity to pursue a postgraduate degree in the Clinical and Public Health aspects of Addiction. This was not going to be a straightforward undertaking as a full time consultant in charge of a busy inner-city service and having to pay for the course mostly out of my own pocket. Many of my colleagues were sceptical as to whether this would really be a worthwhile undertaking. After all, who was ever going to believe that alcohol would ever end up being a problem at this stage of life? Even if it was, what we could we do about it anyway? Surely it was too late for older people to stop drinking and is it not, after all, their one last pleasure in life?

After gaining the necessary knowledge and skills in the area of addiction in older people, it was as if a door had opened into another land. Not only did I suddenly find how considerably under-detected alcohol misuse was in older people (largely through stigma and a fear of being labelled an ‘alcoholic’), I also found that even if detected, there was widespread ‘therapeutic nihilism’ to address alcohol related problems in older people. Much of this was a judgemental approach where the view was of being ‘too late to change’, but it was largely a matter of many health professionals having neither the skills nor the time to intervene and make a difference. When the positive outcomes from developing a service to meet the needs of older people with alcohol misuse can be highlighted through research, this is indeed a golden moment. This has finally happened in the form of the first UK outcomes study of older people with alcohol misuse discharged and followed up from in-patient wards into services within my own NHS Trust [1]

Informing and challenging doctors in psychiatry and public health with evidence of a growing and significant public health and clinical problem in our older drinkers is reasonably straightforward. What remains a significant challenge is how this message can be communicated to the public. Therein lies the rub.

There are 4 main obstacles to public education around alcohol. Firstly, alcohol has been part of UK culture for over 500 years and the UK continues to show a pattern of ‘Scandinavian’ drinking behaviour that it characterised by drinking to intoxication. For every one comment made about the harmful effects of increasing and higher risk drinking, there is a plethora of comments about the ‘Nanny State’, often backed up by anecdotes of how ‘drinking never did me any harm and I’ve been drinking X amount of pints (or some other measure) for X years…’.  Secondly, there is little acknowledgement that alcohol is a drug. If we went into a bar and asked for diazepam, we would be surprised if this request was not met with the retort ‘Sorry, we don’t do drugs here!’ Yet alcohol is equally addictive and acts within exactly the same part of the brain as diazepam and is associated with a much wider range of harmful effects on health. Thirdly, there is a general lack of awareness (particularly in older people) about risky patterns of alcohol intake and how these can be quantified. In 15 years, I have yet to come across an older personwho is able to estimate their daily or weekly alcohol consumption in units. Lastly and perhaps most relevant of all is the awareness that alcohol can be harmful. To the general public, the health risks from smoking are reasonably straightforward. Smoke passes into the lungs and is associated with diseases of this organ that are directly related to disability and death. Alcohol is a little more complicated. It passes into the bloodstream, there is evidence that drinking in moderation is not necessarily associated with some worse outcomes for some areas such a cognitive function. It is also associated with a number of physical and mental disorders where it contributes towards ill health but there may also be additional contributions from other lifestyle factors. Yet, is it also known that alcohol is directly associated with a numbers of cancers, cirrhosis of the liver and brain injury.

From my own clinical and research experience of older people with alcohol misuse, I have little doubt that there is a fine line between drinking within safe limits as part of a lifestyle which is healthy and independent on the one hand, and on the other, crossing this line where drinking at increasing or higher risk not only starts to affect physical and mental health but also later becomes the sole purpose in life.  This risk is only added to by the increased likelihood of older people taking medication and having health problems that interact adversely with alcohol.

There are likely to be a higher number of older people ‘crossing the line’ over the next two to three decades. The evidence for this is robust. Older people are more likely than any other age group to drink on 5 or more days per week. Between 2000 and 2012, the percentage of men and women in England drinking over recommended limits increased by 50% and 100% respectively.  Even using the most conservative estimate, the number of people aged 65 and over admitted for alcohol specific disorders has increased by 40% over the past 6 years. Alcohol related deaths also remain highest in the 55-74 age group. In people aged 60 and over in England, hospital admissions for mental and behavioural disorders associated with alcohol use outnumber those with alcohol related liver disease. The number of people aged 60 and over admitted to hospitals in England with alcohol related brain injury has risen by over 140% over the past 10 years, with an almost static rise in the 15-59 age group. These overall findings cannot be explained purely by rising numbers of older people in the general population given that the population of people aged 65 and above in England and Wales increased by 11% between 2001 and 2011.

So what of the Ghost of Christmas Future for older people’s drinking? The spectre looms large, but unlike Dickensian fiction, the shape of things to come remains very real and we need both public health and clinical interventions to curtail what may have once been a ripple, but now a tidal wave that we can no longer ignore. Both minimum unit pricing and considering different safe limits for older people are not going to be popular, but may be a step in the right direction, if the public uses the available information in making informed choices about their own health.

[1] Rao, R. (2013). Outcomes from liaison psychiatry referrals for older people with alcohol use disorders in the UK. Mental Health and Substance Use, 6(4), 1-7.

Posted in Uncategorized