Unhealthy Alcohol Use in Older Adults E-Book

Erin L. Woodhead

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Seitenzahl: 219

Beschreibung

As our population ages, practitioners find themselves working with older adults more frequently. Alcohol use problems among older adults are often underdiagnosed and undertreated, and there are few treatments designed specifically for this client group. This practical guide provides practitioners with up-to-date information on assessing and treating unhealthy alcohol use among older adults. With a focus on evidence-based treatments, it is highly relevant to practitioners working across a variety of settings. Through the author's expertise, we learn about the prevalence of alcohol use among older adults, the models for understanding unhealthy use, and the different screening and assessment options as well as the treatment possibilities relevant to health care and social service providers. Assessment and treatment options highlight the need to consider lifespan development when providing care as well as the relevance of common life transitions and generational differences. Clinical pearls and vignettes illuminate treatment approaches and further sections discuss pharmacological interventions and cultural considerations. Printable tools are available in an appendix. This book is a must for practitioners from diverse settings who work with older adults. The materials for this book can be downloaded from the Hogrefe website after registration.

Leseprobe

Erin L. Woodhead

Unhealthy Alcohol Use in Older Adults

About the Author

Erin L. Woodhead, PhD, is associate professor of psychology at San José State University, California. She is a licensed psychologist who has published over 30 journal articles in the areas of substance use, mental health, and aging, as well as an edited textbook entitled Psychology of Aging. She teaches courses in clinical psychology, adult psychopathology, psychology of aging, addictions, and lifespan development.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the LC Control Number 2023939163

Library and Archives Canada Cataloguing in Publication

Title: Unhealthy alcohol use in older adults / Erin L. Woodhead.

Names: Woodhead, Erin L., author.

Description: Includes bibliographical references.

Identifiers: Canadiana (print) 20230467679 | Canadiana (ebook) 20230467741 | ISBN 9780889375109

(softcover) | ISBN 9781616765101 (PDF) | ISBN 9781613345108 (EPUB)

Subjects: LCSH: Older people—Alcohol use. | LCSH: Alcoholism—Treatment.

Classification: LCC HV5138 .W66 2023 | DDC 362.292/80846—dc23

© 2024 by Hogrefe Publishing

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Cover image: © miodrag ignjatovic – iStock.com

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Format: EPUB

ISBN 978-0-88937-510-9 (print) • ISBN 978-1-61676-510-1 (PDF) • ISBN 978-1-61334-510-8 (EPUB)

https://doi.org/10.1027/00510-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

|V|Acknowledgments

I would like to thank Jennifer K. Manuel, PhD, and Derek D. Satre, PhD, who spent a significant amount of time on earlier versions of this book, providing edits and content for the clinical cases and clinical pearls throughout the book. I would also like to thank my mentors throughout my career, including Steven Zarit, PhD, Barry Edelstein, PhD, and Christine Timko, PhD. Dr. Timko encouraged my interest in substance use research and continues to be an invaluable mentor. I am also appreciative of my colleagues at San José State University and the students who were part of my research lab while I was working on this book.

Erin L. Woodhead, PhD

Table of Contents

Acknowledgments

1  Introduction

1.1  Defining Older Adulthood

2  Prevalence and Risk Factors

2.1  Common Terms to Describe Alcohol Use

2.2  Prevalence of Unhealthy Alcohol Use Among Older Adults

2.2.1  Prevalence of Unhealthy Alcohol Use Among Racial and Ethnic Minority Older Adults

2.2.2  International Studies on Prevalence of Unhealthy Alcohol Use Among Older Adults

2.2.3  Prevalence of Unhealthy Alcohol Use Among Sexual and Gender Minority Older Adults

2.2.4  Prevalence Conclusions

2.3  Comorbid Nicotine and Other Drug Use

2.4  Conclusions: Prevalence and Risk Factors

3  Conceptualizing Unhealthy Alcohol Use Among Older Adults

3.1  Age-Related Changes in Alcohol Processing

3.2  Early Versus Late Onset

3.3  Life Transitions and Unhealthy Alcohol Use

3.4  Biopsychosocial Model

3.5  Stress and Coping Framework

3.6  Cognitive Behavioral Model

3.7  Conclusions: Conceptualizing Unhealthy Alcohol Use

4  Diagnosing Unhealthy Alcohol Use Among Older Adults

4.1  DSM-5 Criteria for Alcohol Use Disorder

4.2  Identification of Unhealthy Alcohol Use and Diagnosis

4.2.1  Common Signs of Unhealthy Alcohol Use

4.3  Differential Diagnoses to Consider

4.3.1  Cognitive Changes With Age

4.3.2  Long-Term Alcohol Use and Cognitive Impairment

4.4  Comorbid Medical and Mental Health Conditions

4.4.1  Comorbid Mental Health Conditions

4.5  Conclusions: Diagnosing Unhealthy Alcohol Use

5  Screening and Assessment

5.1  Screening Recommendations

5.2  Assessment of Unhealthy Alcohol Use

5.2.1  Assessing Medically Complex Older Adults

5.3  Choosing Appropriate Assessment Tools

5.3.1  Alcohol Use Disorders Identification Test

5.3.2  Michigan Alcoholism Screening Test – Geriatric Version – and Short MAST-G

5.4  Conclusions: Screening and Assessment of Unhealthy Alcohol Use

6  Psychological Interventions

6.1  Care Coordination

6.2  Treatment Modifications for Older Adults

6.3  Harm Reduction Versus Abstinence-Based Treatments

6.4  Brief Interventions

6.5  Motivational Interviewing

6.6  Cognitive Behavioral Therapy

6.7  Mutual Help Groups

6.8  Family-Involved Treatments

6.9  Effectiveness of Treatments for Unhealthy Alcohol Use Among Older Adults

6.10  Conclusions: Psychological Interventions for Unhealthy Alcohol Use

7  Pharmacological Interventions

7.1  Disulfiram

7.2  Naltrexone

7.3  Acamprosate

7.4  Integrating Pharmacotherapy With Psychotherapy

7.5  Conclusions: Pharmacological Interventions

8  Cultural Adaptations

8.1  Cultural Adaptations to Treatment

8.2  Treatment Considerations for Sexual and Gender Minority Older Adults

8.3  Treatment Considerations for Older Women

8.4  Conclusions: Cultural Adaptations

9  General Conclusions

10  Further Reading

References

Notes on Supplementary Materials

|1|1Introduction

The proportion of older adults in the US population is increasing. Demographic trends indicate that by 2030, about 21 % of the US population will be 65 or older, compared with 16 % in 2019 (Administration of Community Living, 2021). This trend is also reflected internationally. In 2030, one in six individuals globally will be 60 years or older. Between 2020 and 2050, the world’s population of older adults is expected to double from 1 billion to 2.1 billion (World Health Organization, 2022). As the population of older adults grows, so does concern about the impact of unhealthy alcohol use in this population. 

This book highlights the unique concerns related to unhealthy alcohol use among older adults, and the clinical implications of the presented research. This book is intended for practitioners who are looking to expand their practice in this area, either toward expanding their work with older adults to include unhealthy alcohol use, or expanding work in the area of substance use to include older adults. Recommendations are offered throughout the book for ways to adapt diagnosis, assessment, and treatment to older adults; however, all of the recommendations need to be considered in the context of the individual client. Although older adults tend to be considered as one homogenous group, there are many differences between older adults, particularly those born in different generations. Some older clients may need treatment modifications to account for age-related cognitive changes, though caution is needed in assuming that all older adults need similar modifications.

This book offers a lifespan approach to understanding unhealthy alcohol use among older adults – that is, there are predictable shifts in alcohol use across the lifespan (Lee & Sher, 2018), particularly around common transitions points such as parenting and employment. Younger adults (ages 18 – 29) have the highest prevalence of drinking and alcohol-related problems (Barry & Blow, 2016). As individuals get older and gain more career and family-related responsibilities, they often reduce their alcohol consumption. Others, however, continue to drink at levels that put them at risk for health and psychosocial problems. For some groups, particularly women, new patterns of unhealthy alcohol use may emerge in middle age or later in life. These trends contribute to the increasing importance of better understanding unhealthy alcohol use among older adults, as well as appropriate psychological interventions. 

|2|This book reviews the prevalence of alcohol use among older adults, ways to conceptualize alcohol use among older adults, diagnostic considerations for alcohol use disorder among older adults, screening and assessment options, and treatment considerations relevant to health care and social service providers. Chapter 2 starts by summarizing the continuum of alcohol use, as well as epidemiological data on alcohol use among older adults. Chapter 3 presents common ways to conceptualize unhealthy alcohol use among older adults. Chapter 4 focuses on the diagnosis of alcohol use disorder among older adults, what to consider in the differential diagnosis of unhealthy alcohol use among older adults, and common comorbid conditions among older adults. Following this, recommendations for screening and assessing alcohol use among older adults are presented in Chapter 5. Chapter 6 describes psychological interventions, with a specific focus on how to consider lifespan development when providing care, as well as the relevance of common life transitions and generational differences. Case examples are used to demonstrate intervention approaches across a range of problem severity, highlighting treatment considerations relevant to health care professionals working with older adults. Chapter 7 provides a brief overview of pharmacological interventions. Finally, the role of culture in treatment, including race/ethnicity, gender, and sexual orientation are reviewed.

This book addresses problems with alcohol use specifically. Although use of other drugs, particularly cannabis, appears to be increasing among older adults (Han & Palamar, 2020), alcohol remains by far the most commonly used and most problematic substance in this age group. When relevant, however, treatment considerations applicable to managing other comorbid substance use problems are noted.

1.1  Defining Older Adulthood

For the purposes of this book, the general assumption is that “older adult” is defined as a person aged 65 and older. It is worth noting, however, that the literature on alcohol use among older adults varies with regard to what age is used as a cutoff for older adulthood. Some studies of alcohol use among older adults use a cutoff of age 55 or older (French et al., 2014; Gell et al., 2015). The rationale for using a younger cutoff is related to the mortality hypothesis, which is that individuals with more severe alcohol use may die younger and therefore may not live to age 65 years or older. Additionally, there is the belief that chronic alcohol use ages individuals prematurely, therefore contributing to a need to expand the definition of older adulthood to a include a slightly younger age range. Throughout the book, studies that defined older adults to include ages younger than 65 are noted.

|3|2Prevalence and Risk Factors

This chapter reviews the prevalence of alcohol use disorder (AUD) and unhealthy alcohol use, as well as differences by generation or birth cohort, gender, race/ethnicity, and sexual and gender minority status. Before reviewing data on prevalence rates, it is important to define what is meant by unhealthy alcohol use and briefly review what is meant by a standard drink.

2.1  Common Terms to Describe Alcohol Use

Alcohol use occurs on a continuum ranging from low-risk or nonproblematic use, to substantial consequences that warrant an AUD diagnosis (Saitz, 2005). Many terms are used in the literature to describe the continuum of alcohol use, including:

Low-risk drinking: Patterns of use that fall below the recommended guidelines (for women, no more than three drinks on any 1 day and no more than seven drinks per week; for men, no more than four drinks per day and 14 drinks per week). This level of drinking typically does not meet criteria for an AUD diagnosis.

Risky drinking: Patterns of use that increase the chances of having adverse consequences. This level of drinking may meet criteria for an AUD diagnosis.

Problem drinking or hazardous drinking: A pattern of drinking that results in problems such as financial, health, or social consequences. This level of drinking typically does meet criteria for an AUD diagnosis.

Binge drinking: Alcohol use within a short amount of time, which results in elevated blood alcohol content (BAC) of 0.08 g/dl or above (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2021). This level of drinking typically does meet criteria for an AUD diagnosis.

The National Institute on Drug Abuse (NIDA) recommends that practitioners avoid the use of stigmatizing terms when talking about substance use (see Kelly et al., 2016). As an example, “hazardous alcohol use” is preferred over “alcohol abuse,” which may be an adjustment for practitioners trained under the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), when the terms “abuse” and “dependence” were more commonly used in clinical settings. In addition, terms such as “addict,” “alco|4|holic,” and “substance abuser,” have negative connotations. A descriptor such as “older adult with hazardous alcohol use” is preferable. This book uses the term “unhealthy alcohol use” as defined by Saitz (2005), including risky drinking and extending to severe AUDs.

Table 1 demonstrates the continuum of alcohol use ranging from abstinence to severe AUD. Defining different levels of alcohol use informs studies on the prevalence of alcohol use among older adults, and can inform the selection of an appropriate level of intervention. For example, the intensity of an intervention may vary depending on the individual’s drinking severity. Thus, defining alcohol use on a continuum can facilitate the selection of an appropriate level of intervention.

Table 1.  Alcohol use occurs on a continuum. Adapted from Saitz (2005).

Abstinence

Low-risk drinking

Risky use

Problem drinking

Severe AUD

Common definition

No current alcohol use

For women, no more than three drinks in a day and no more than seven drinks per week. For men, no more than four drinks in a day and no more than 14 drinks per week.

Drinking above the low-risk guidelines, with no consequences currently occurring. This level of drinking puts individuals at risk for adverse consequences in the future.

Drinking above the guidelines with consequences in one or more areas. May meet criteria for a mild or moderate AUD.

Six or more DSM-5 criteria met for AUD

Note. AUD = alcohol use disorder.

Unhealthy alcohol use can range from risky drinking to diagnosable conditions including AUDs (Saitz, 2005). NIAAA recommends that men limit their alcohol consumption to no more than four drinks on any 1 day and to no more than 14 drinks per week, whereas the recommendation for women is no more than three drinks per day and no more than seven drinks per week (NIAAA, 2018). Any amount less than this is considered low-risk drinking. Drinking greater amounts of alcohol increases the risk for significant health, social, and legal consequences. The 2020 – 2025 Dietary Guidelines for Americans differ from the low-risk drinking guidelines offered by the NIAAA, suggesting that adults limit their daily alcohol intake to two drinks |5|or fewer for men and one drink or fewer for women (US Department of Agriculture and US Department of Health and Human Services, 2020).

Internationally, countries differ on cutoffs for recommended drinking limits (Kerr & Stockwell, 2012). The UK guidelines recommend that adults limit their drinking to no more than 14 standard drinks in a week. Australia’s recommendation is to limit drinking to no more than two standard drinks per day. Unlike the US, these countries do not differentiate between drinking limits for men and women, though other countries do. For example, Ireland’s guidelines suggest no more than 17 standard drinks per week for men and 11 for women. This information is included here to note the variability both within the US and internationally, about recommended alcohol limits.

In the US, a standard drink is one that contains about 14 g of pure alcohol. This corresponds roughly to a 12-oz can of beer, a 5-oz glass of wine, or a 1.5-oz shot of liquor. The concept of a standard drink is meant to help estimate the alcohol content of different drink concentrations and serving sizes. It is important to note that the definition of a standard drink varies by country. For example, a standard drink in the UK is one that contains about 8 g of pure alcohol, whereas the definition in Ireland is 10 g of pure alcohol. It can thus be challenging to estimate the number of drinks accurately, since serving sizes and alcohol concentrations vary substantially (e.g., alcohol content in beer has increased in recent years). Many practitioners find it useful to use a visual aid such as a laminated card that illustrates what a standard drink is for different types of alcoholic beverages (see example in Table 2).

Table 2.  Standard drink equivalents. Adapted from the National Institute on Alcohol Abuse and Alcoholism (2018).

Drink type and standard size

Typical alcohol content

Approximate number of standard drinks

Beer or cooler (12 oz)

~5%

12 oz = 1

16 oz = 1.3

22 oz = 2

40 oz = 3.3

Malt liquor (8–9 oz)

~7%

12 oz = 1.5

16 oz = 2

22 oz = 2.5

40 oz = 4.5

Table wine (5 oz)

~12%

25-oz bottle = 5

80-proof distilled spirits (1.5 oz)

~40%

A mixed drink = 1 or more

A pint (16 oz) = 11

A fifth (25 oz) = 17

1.75 L (59 oz) = 39

Note. Standard drink amounts may not reflect customary serving sizes. Alcohol concentrations also vary significantly by brand.

|6|2.2  Prevalence of Unhealthy Alcohol Use Among Older Adults

This section presents the prevalence of AUDs and unhealthy alcohol use among older adults, as well as differences by generation or birth cohort, gender, race/ethnicity, and sexual and gender minority status. Also presented are the prevalence rates for nicotine and other drugs among older adults, since use of multiple substances is common (Crummy et al., 2020). Each generation, or birth cohort, has its own set of values and characteristics depending on larger societal conditions at the time of their childhood and entrance into adulthood. Although these generational characteristics are certainly not consistent across all individuals, the classification of specific birth cohorts and their traits has been used to understand broad differences in alcohol use norms, preferences, and attitudes (Slade et al., 2016). As each generation gets older, they bring with them a certain set of values and experiences typical of their generation, which may continue to influence their behavior during older adulthood. These values and experiences impact a range of health behaviors including diet, exercise, alcohol, smoking, and use of other substances.

Understanding the substance use patterns of each generation can help in predicting what the trends may be for future generations of older adults. For example, in an analysis of nationally representative data among three generations – Baby Boomers (born 1946 to 1964), Generation X (born 1965 to 1980), and Millennials (born 1981 to 1996) – Yang and colleagues (2018) found that between 2007 and 2016, binge alcohol use and cocaine use was highest among Millennials and lowest among Baby Boomers, with Generation X somewhere in between. However, the use of crack cocaine was highest in Generation X, with prevalence rates almost twice as high compared with both Baby Boomers and Millennials. Generation X was also more likely to report use of multiple substances (excluding alcohol) compared with Millennials. It is unclear if these substance use patterns will persist as each generation ages into older adulthood, particularly since Yang and colleagues (2018) found that there was a general decline in substance use with increasing age. Nonetheless, these data suggest that Generation X, typically defined as those born between 1965 and 1980, may bring different areas of concern to practitioners with regards to substance use when they reach older adulthood, and that practitioners may need to regularly assess for other substances besides alcohol and cannabis.

Since alcohol is the most commonly used and most problematic substance among older adults, it can be helpful to know what is considered “normative” drinking for older adults. Chan and colleagues (2007) found that, among a national sample of men aged 65 and older, 29 % had zero drinks |7|per week in the past week, 32 % had one drink per week, 8 % had two to three drinks per week, and 31 % had more than five drinks per week. A similar pattern was observed for older women: 41 % had zero drinks per week, 40 % had one drink per week, 6 % had two to three drinks per week, and 13 % had more than two or three drinks per week. Understanding normative drinking among older adults can help practitioners compare the drinking levels of older adult clients versus these normative levels. As noted in Chapter 6, practitioners can also provide feedback to older adult clients about normative drinking levels as part of a brief intervention.

The results of the Chan and colleagues (2007) study suggest that a minority of older adults are engaging in unhealthy alcohol use. However, longitudinal data suggest that rates of unhealthy alcohol use and AUDs have increased among older adults in recent years (Breslow et al., 2017; Han et al., 2017). Han and colleagues (2017) found that participants between the ages of 50 and 64 had a 23 % relative increase in past-month binge alcohol use (defined as five or more drinks on one occasion) between the years of 2005 and 2014. Adults aged 65 and older had an 11 % relative increase during the same time frame. Women reported a 44 % increase in past-month binge alcohol use, compared with a 9 % relative increase among men, and had an 85 % increase in past-month AUDs, compared with a 2 % relative increase among men. Breslow and colleagues (2017) also noted increasing rates of alcohol use among adults aged 60 and over between 2007 and 2014. Specifically, the prevalence of current drinking, defined as more than one drink in the past year, increased 1 % per year for men and 2 % per year for women. Binge drinking, defined as five or more drinks in the same day, was stable among men but increased an average of 4 % each year for women. The results of these large, national survey studies suggest that there are steady increases in drinking among older adults, and that this trend is particularly pronounced among older women. The authors noted older women’s increasing use of alcohol as an emerging public health concern and encouraged regular screening in this group. Chapter 8 provides more information on unhealthy alcohol use among older women. 

2.2.1  Prevalence of Unhealthy Alcohol Use Among Racial and Ethnic Minority Older Adults

White and Latinx older adults are at higher risk of unhealthy alcohol use compared with older adults from other racial/ethnic backgrounds (Assari et al., 2016; Assari et al., 2019; Han et al., 2017; Rao et al., 2015). For example, Han and colleagues (2017) found that binge alcohol use in the past |8|month (five or more drinks on one occasion) increased significantly between 2005 and 2014 among White participants but not among participants who identified as Black, Latinx, or Asian. At the final follow-up point in 2014, Latinx participants reported the highest rate of unhealthy alcohol use in the past month (17 % of participants) compared with non-Hispanic White participants. White participants also had a significant increase in past-year AUD diagnosis, defined as meeting DSM-IV criteria for either alcohol abuse or alcohol dependence, whereas no significant changes were reported for participants who identified as Black, Latinx, or Asian. In multivariate models, Asian participants were significantly less likely than White participants to endorse unhealthy alcohol use in the past month and self-reported past-year AUDs. Latinx participants were more likely to report unhealthy alcohol use in the past month compared with White participants. 

Black older adults tend to drink at lower levels than other racial/ethnicity groups. In a study of Black adults 65 or older living in the Los Angeles area, 70 % reported that they currently did not drink alcohol (Assari et al., 2019). In this sample, drinking alcohol was associated with financial difficulties in multivariate models controlling for other demographic and health variables. In a separate study of Black and White older adults who were part of the Religion, Aging, and Health Survey, Black and White participants had similar levels of unhealthy alcohol use (five or more drinks in a day), at around 1 % of the sample. White participants were more likely to report any alcohol consumption in the past month compared with Black participants (27 % vs. 15 %; Assari et al., 2016). 

2.2.2  International Studies on Prevalence of Unhealthy Alcohol Use Among Older Adults

A small number of international studies have examined unhealthy alcohol use among older adults. Results from the Australian National Health Survey of adults ages 55 and older indicated that abstinence from alcohol increases with age (Australian Bureau of Statistics, 2009