Taking an alcohol history

Dr Tony Rao

Consultant Old Age Psychiatrist, SLAM NHS Foundation Trust

Visiting Researcher, Institute of Psychiatry, Neurology and Neuroscience

• 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)

• Alcohol use disorders frequently complicate primary dementia, increasing adverse effects and cognitive decline (Draper et al, International Psychogeriatrics, 2011)

• Cerebellar damage per se may disrupt frontal processes such as executive function and poor response inhibition (Pitel et al Neuroscience and Biobehavioral Reviews, 2015)

Alcohol related brain damage

Neuropsychological Impairment in Alcohol Related Dementia

(Rao, Advances in Dual Diagnosis 2016)

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

Older People and Alcohol Misuse

1986

2011

The Baby Boomers

Turn 65

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

GENERAL PRINCIPLES OF ASSESSMENT

• 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

TYPICAL PRESENTATIONS USUALLY ATYPICAL

AGEISM ‘It’s all he/she has in life’

UNDER-REPORTING Viewed as stigmatising

BARRIERS TO IDENTIFICATION AND TREATMENT

MIS-ATTRIBUTION 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

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

Short Michigan Alcohol Screening Test-Geriatric Version (Short MAST-G)

Score of 5 or more suggestive of alcohol misuse

More suitable for screening dependence

Does not detect hazardous or at-risk drinking

Does not distinguish between current and prior alcohol problems

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

• 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)

ALCOHOL DEPENDENCE SYNDROME

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, self-

harm, 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

• 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

BRIEF INTERVENTION

Rao, R., & Crome, I. (2016). Alcohol

misuse in older people. BJPsych

Advances, 22(2), 118-126.

Further Reading

Rao, R., & Draper, B. (2015).

Alcohol-related brain damage in

older people. The Lancet

Psychiatry, 2(8), 674-675.

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.