Alcoholism and American healthcare: The case for a patient safety approach

Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.

Late-Onset Alcohol Abuse as a Presenting Symptom of Neurodegenerative Diseases

BACKGROUND

The association between lifetime alcohol abuse and a higher risk to develop dementia is well known. However, it is unknown whether older adults who begin abusing alcohol late in life have an underlying neurodegenerative disease.

OBJECTIVE

Identify the frequency of lifelong alcohol abuse (L-AA), late-onset alcohol abuse (LO-AA), and alcohol abuse as a first symptom of dementia (AA-FS) in patients with neurodegenerative diseases.

METHODS

Cross-sectional retrospective study of patients evaluated at an academic referral center with a clinical diagnosis of behavioral variant frontotemporal dementia (bvFTD), Alzheimer-type dementia (AD), and semantic variant primary progressive aphasia (svPPA) (n = 1,518). The presence of alcohol abuse was screened with the National Alzheimer's Coordinating Center questionnaire. L-AA was defined as onset < 40 years, LO-AA as onset ≥40 years, and AA-FS was defined when the abuse started within the first three years from symptom onset.

RESULTS

The frequency of LO-AA was 2.2% (n = 33/1,518). LO-AA was significantly more frequent in patients with bvFTD than AD (7.5%, n = 13/173 versus 1.3%, n = 16/1,254, CI:1.0;11.4%), but not svPPA (4.4%, n = 4/91, CI: -4.4;10.7%). Similarly, AA-FS was more frequent in bvFTD patients than AD (5.7%, n = 10/173 versus 0.7%, n = 9/1,254, CI:0.5%;9.5%), but not svPPA (2.2%, n = 2/91, CI:-2.4;9.1%).

CONCLUSION

LO-AA can be a presenting symptom of dementia, especially bvFTD. Alcohol abuse onset later in life should prompt a clinical investigation into the possibility of an underlying neurodegenerative process because delay in diagnosis and treatment may increase patient and caregiver burden. The results need to be interpreted with caution due to the limitations of the study.

The Experiences of Clinicians Caring for Older Adults with Dual Diagnosis: An Exploratory Study

Dual diagnosis has been identified as a significant challenge to mental health services, resulting in higher rates of psychiatric relapse and greater illness severity. Much research explores dual diagnosis in the adult mental health cohort, however little research attention has been paid to older adults with dual diagnosis. Far from being a trivial issue, preliminary studies have shown that dual diagnosis in older adults is under diagnosed and poorly identified by clinicians with few specific treatment options available. In addition, studies of the ageing baby boomer cohort demonstrate a potential for dual diagnosis presentations to increase in the coming years. This article explores the experiences of a clinical team providing care to older adults with dual diagnosis in Melbourne, Australia, through a semi-structured interview process. The participants described a number of systemic barriers to providing care to the older adults with dual diagnosis presenting to the mental health service, in addition to feeling poorly prepared and expressing a degree of clinical helplessness. Additionally, the participants described service improvement, which included a strong dual diagnosis culture in the leadership team of the mental health service and role modelling dual diagnosis competent practice among clinicians.

Maturing out, natural recovery, and dual diagnosis: What are the implications for older adult mental health services?

In 1962, Charles Winick proposed that addiction was a self-limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance-using populations. As more consumers present to adult mental health treatment settings with co-occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance-using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies.

Acceptance and Commitment Therapy with Older Adults: Rationale and Considerations

Older adults are the fastest growing segment of the population. With these changing demographics, mental health professionals will be seeing more older clients. Additionally, older adults are an underserved population in that most older adults in need of mental health services do not receive treatment. Thus, it is essential that treatments for mental and behavioral health problems are empirically supported with older adults and that mental health professionals are aware of the special needs of older adult populations. Acceptance and Commitment Therapy (ACT) is an emerging approach to the treatment of distress. The purpose of this article is to provide a rationale for using ACT with older adults based on gerontological theory and research. We also review research on ACT-related processes in later life. We present a case example of an older man with depression and anxiety whom we treated with ACT. Finally, we describe treatment recommendations and important adaptations that need to be considered when using ACT with older adults and discuss important areas for future research.

Alcohol, ageing and dementia: A Scottish perspective

There are complex relationships between alcohol use; processes of ageing both social and biological; and cognitive impairment. This paper takes Scotland as a case study to begin to unpick and explore these relationships and their implications for people who drink as they age. In recent years several policy documents have been published in Scotland that acknowledge the increasing prevalence of alcohol problems among people as they age. This paper is based on a review of the literature, analysis of recent Scottish policy documents and two research projects undertaken by the author. The links between alcohol use and dementia are discussed, focusing on biological and social implications for individuals as they age. Current responses in Scotland to these different issues are examined from individual, cultural and policy perspectives. Despite efforts in Scotland the needs of ageing and older individuals who experience alcohol-related morbidity are not sufficiently addressed.

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.

Alcohol use disorders in geriatrics

Alcohol use disorders cause significant morbidity and mortality in the geriatric population. This review article begins with a hypothetical case for illustration, asking what the primary care physician could do for a geriatric patient with alcohol abuse over a course of four office visits. Various aspects of alcohol use disorders in the geriatric population are reviewed, such as range of alcohol use, epidemiology, medical/psychiatric impact, detection, comprehensive treatment planning, modalities of psychotherapy, medication management, and resources for clinicians/patients.

Treatment of addiction in the elderly

Although it is often not considered and frequently undiagnosed, addiction disorders are a significant problem in the elderly. Elders are at a higher risk for the consequences of abuse or addiction owing to changes related to aging, multiple medications and chronic illness. The consequences of addiction disorders in this population include delirium, memory loss, suicide, falls and fractures, as well as drug–drug or drug–disease interactions. Abuse or addiction to alcohol or prescription or illicit drugs often presents differently in the elderly, may be inadvertent or prescriber-related and requires a different approach to assessment. Coexisting psychiatric or physical disorders together with addiction need to be considered in the overall functional status of the elderly. Treatment should be individualized based on the patient’s needs, readiness for change and available resources, and should vary from brief outpatient intervention to inpatient care. Treatment outcomes for elders are as good as or better than the outcome of younger adults. With an increasing proportion of the population becoming elders and the aging of ‘baby boomers,’ an increase in addiction in this population, including to illicit drugs, is expected in the near future. Education of the public, as well as healthcare professionals, along with reassessment of the prevalence of these disorders in this population using age-appropriate criteria, are needed, since more resources will be required in order to treat these individuals in the near future.

Poor sleep quality and alcohol use problems among elderly Taiwanese aboriginal women

BACKGROUND

Little is known about sleep quality and alcohol use problems in the elderly minority population. This study aimed to identify a one-month prevalence of poor sleep quality and alcohol use problems among elderly Taiwanese aboriginal women and to examine the association between them.

METHODS

A cross-sectional survey with stratified random sampling was conducted in eight aboriginal communities in Taiwan. The 1261 elderly aboriginal women (response rate 84%) completed all assessments. Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), while the CAGE questionnaire was used to evaluate alcohol use problems.

RESULTS

Of the study participants, 20.54% and 25.59% had poor sleep quality and alcohol use problems, respectively. Controlling for confounding factors, alcohol use problems were a risk factor for poor sleep quality (AOR = 1.44, p = 0.0433). Alcohol use problems were associated with three components of PSQI: sleep disturbances, subjective sleep quality, and daytime dysfunction.

CONCLUSIONS

The elderly Taiwanese aboriginal women with problematic alcohol drinking experienced poorer sleep quality. Development of a program to reduce alcohol use problems might improve sleep quality among elderly Taiwanese aboriginal women.