Alcohol misuse is a growing problem for older people. But old age psychiatrist Dr Tony Rao believes all practitioners have a role to play in identifying those in need and ensuring they receive support without stigma or shame.
At the start of his consultant career, consultant psychiatrist Dr Tony Rao was co-ordinating the care of a retired teacher. She was socially isolated and living alone in a flat on the thirteenth floor of a tower block on a council estate. “She had no carers or family. There wasn’t even a lift to her flat. She was presenting with falls. I thought she had depression,” Dr Rao recalls.
For more than a year Dr Rao co-ordinated her care, during which time she was admitted to hospital twice for depression, and with each admission her mood quickly improved. “But she kept presenting with falls and depression and I thought: ‘What are we doing wrong here?’” says Dr Rao.
“After about a year, I happened to ask her: ‘Do you drink?’ And she said: ‘Yes – I drink a quarter of a bottle of whisky a day’.
“All those months of falling, of depression, were all part of her drinking.”
Dr Rao was able to give her the support she needed, and within three months she had stopped drinking. “Sadly, five years later I learned she had died of alcohol-related liver disease. Unfortunately services are just not geared towards supporting older people with alcohol misuse in the long term,” he says.
For more than 20 years, Dr Rao’s career has been dedicated to helping older people with alcohol misuse issues and to raising awareness that this is a growing problem that all practitioners should recognise.
Dr Rao is a consultant old age psychiatrist with a special interest in alcohol misuse in older people at south London and Maudsley NHS Foundation Trust. He began his career in 1998 as an old age consultant psychiatrist in Southwark, south London. “I soon realised that this area of London had a high rate of alcohol related harm in older people.
“This was mainly influenced by the combination of deprivation and a retired docking community with a culture of heavy drinking. Addressing their problems meant having to completely change my mindset in terms of how to meet their needs. And this meant doing a Masters in addictions,” says Dr Rao.
From starting out as “a one man band” focusing on alcohol misuse in older people, “over the last 20 years other mental health practitioners with a special interest in this area have joined me”.
During that time Dr Rao has covered “a wide range of areas” relating to older people and alcohol misuse, including workforce development, service development, policy change, research, teaching and training.
He has also been involved in public engagement and education, which included publishing a major report on Our Invisible Addicts which led to a parliamentary debate and a change to alcohol drinking limits.
By showcasing alcohol related harm in older people Dr Rao has also successfully campaigned to have alcohol and duel diagnosis included in the Community Framework for Adults and Older adults.
Alcohol misuse in older people: a growing problem
Twenty years ago Dr Rao was trying to convince colleagues that the problem of alcohol misuse in older people was not just “Tony’s problem in Southwark”. Now it is becoming seen as ‘everyone’s problem”, he says.
And it’s a growing problem. From 2012 to 2032 the populations of 65-84 year olds and the over 85s are set to increase by 39 and 106% respectively.
Alcohol is currently ranked the fifth highest risk factor of visibility in the UK for those aged 50-69 years. Within the last five years, the percentage of alcohol specific hospital admissions in England have risen by 22% in the over 50s. And between 2005/6 – 2020/21 there has been an 80% increase in the number of people aged 65 and over seeking treatment for alcohol addiction in England.
Cultural influence is one of the main reasons why alcohol misuse is a growing issue for older people, Dr Rao says. This generation of older people are the ‘post-war baby boomers’ born between the late 1940s and early 1960s. “They grew up during a time when advertising about drinking and the drinking culture was favoured and anti-drinking frowned upon,” he says.
Another factor, he says, is that alcohol remains “accessible and increasingly affordable”. And unlike other substances, alcohol continues to be socially acceptable and its use is not subject to stigma.
Misuse of alcohol among the older population has become even worse since the pandemic hit, Dr Rao suggests. He says some older individuals already susceptible to alcohol dependence are now drinking more heavily as a means of coping with social isolation, depression, anxiety and bereavement.
Dr Rao warns that with that “background of increasing risk of alcohol misuse among older people comes the problem of increasing harm”. Comorbidities are an issue for older people who misuse alcohol. “We know older people are more likely to have chronic health problems,” says Dr Rao. They are at risk of falls, and are also more likely to take medications that interact with alcohol, such as pain relief.
While misuse of alcohol by older people is a significant problem, individuals are less likely to seek treatment than younger generations, says Dr Rao. “There’s the ‘double whammy’ of older people being less likely to seek treatment for alcohol misuse because of the shame and stigma associated with it, and also because they don’t want to be a burden on the healthcare system.”
Signs and symptoms of alcohol misuse
To help ensure this patient group receives the necessary support and treatment, it is important for practitioners to be aware of the signs and symptoms of alcohol misuse – many of which are subtle or could be easily mistaken for other issues.
The most significant presentation for alcohol misuse is falls, says Dr Rao. “However, when, say, an older, respectable retired doctor or teacher falls and presents in casualty, you tend not to ask them whether they have been drinking or not. So despite this common presentation practitioners tend not to ask about alcohol use,” he says.
Then there are non-specific presentations, where having excluded long-term conditions such as depression or diabetes, the clinician may find the “harbingers of alcohol misuse”, says Dr Rao.
These symptoms include poor sleep, nausea, vomiting, depression, and problems with memory and concentration. Practitioners should also be aware of the symptoms of mild alcohol withdrawal in these patients, which could be agitation, a fast heart rate, or even delirium.
Screening people for alcohol use is a vital way of identifying individual problems so that they can then get support, says Dr Rao. “I ask people how they spend their day and then whether part of that day is drinking, as a way of starting a conversation about alcohol misuse.” He also uses the Alcohol Use Disorders Identification Test (AUDIT) - a ten minute test to establish an individual’s level of risk as a drinker. AUDIT also offers interventions tailored to four different risk levels – from lower risk to probable dependence.
Practitioners should not make assumptions that the way a patient presents means they do not drink. “It may surprise you when you start screening how much people do drink and they themselves may be surprised about their level of alcohol consumption,” says Dr Rao.
Focus on ‘harm reduction” in alcohol misuse
Treating these patients is not the same as treating someone for a medical condition like high blood pressure, where treatment is prescribed, hopefully the individual complies, and their prognosis improves. Instead, typically the focus is on “harm reduction”, says Dr Rao.
“Often you’re not going to be able to get someone to stop drinking completely. ‘Harm reduction’ means using all the different means - screening assessment, psychological, social, and family support to reduce an individual’s alcohol intake to improve their quality of life,” he says.
Dr Rao also warns that lecturing patients who misuse alcohol to change their behaviour can “make them more intransigent”, and that instead practitioners should take “a non-judgemental, non-confrontational approach” to support them to drink less alcohol. “The key to success in any change in substance misuse behaviour is motivational enhancement – where you encourage individuals to reflect on the behaviour changes they want to make, rather than telling them what they should change,” he says.
Dr Rao advises practitioners to make sure they understand the “ unique needs” of older people who misuse alcohol, addressing age specific problems. This could include giving more time during a consultation, speaking more slowly, spreading out an assessment over a higher number of visits, and taking into account the impact of alcohol misuse on people’s finances, social situation, and every day activities.
He points out that helping these patients is not just about medical support but that there is also a psychological and social dimension to their care, which involves different health and care agencies. “What I have learned over the years is the importance of integrated care for these patients. What tends to happen with older people with alcohol problems is that their care is confined to old age psychiatry, geriatrics and general practice.
“But one size doesn’t fit all and different presentations of alcohol misuse need to be addressed in different ways,” says Dr Rao. “Maybe the older person presents with a mental health problem which can be best managed in general practice, or they may be socially isolated, which could be addressed by the voluntary sector. Clinicians need to be aware of the different range of services out there, including social housing, the voluntary sector, social care enterprises and charities such as Age UK.”
All practitioners can make a difference to older people’s care by taking the time to check if alcohol misuse could be the reason for their ill health. “Screening only takes a few minutes – but it will be of immense benefit and can pay dividends in improving clinical outcomes. Which is why alcohol screening should be a part of every single routine mental and physical health consultation,” says Dr Rao.
But it is also essential that practitioners conducting such screening should do so with sensitivity and understanding. As Dr Rao says: “Alcohol misuse is hugely stigmatised, particularly when it comes to older people. So it’s important they shouldn’t be made to feel ashamed – or they will never open up about having an alcohol problem.”
- Improving care for older people with co-existing mental disorders and alcohol misuse https://www.nice.org.uk/sharedlearning/improving-care-for-older-people-with-co-existing-mental-disorders-and-alcohol-misuse
- Substance misuse in Older People: an information guide https://www.researchgate.net/publication/278779731_Substance_misuse_in_Older_People_an_information_guide
- Interview with Dr Tony Rao on alcohol related cognitive impairment https://www.youtube.com/watch?v=0N1YlfQY1rU
- Catch Me When I Fall by Dr Tony Rao is a novella based on 20 years of community-based experience in the field of old age psychiatry. It was based on a real patient but anonymised and highlights the challenged faced by services in the detection and treatment of older people with alcohol misuse. https://www.amazon.co.uk/Catch-Me-When-I-Fall/dp/1398406473. All profits go to charity.