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Late-Onset Alcoholism: Gaining Understanding

Marie E. Cowart, Dr. P.H.
Professor of Urban and Regional Planning and Pepper Institute on Aging and Public Policy
Florida State University
Tallahassee, Florida

Mary Sutherland, Ph.D.
Professor of Curriculum and Instruction
Florida State University
Tallahassee, Florida
and

Principal Investigator
Jackson County Health Promotion Projects
Area Agency on Aging of North Florida
Tallahassee, Florida

An unexpected early evening fire in a high-rise apartment building for elders brought a serious health risk to our attention. The fire necessitated evacuating all residents to a nearby motel. By 9:30 p.m., assuming the residents were settled in their rooms, the staff felt free to retreat to their own homes. While the staff said thank you and good night to the manager, residents began to appear in the lobby from the elevator. The friendly manager inquired about what it was they needed—weren't their rooms satisfactory? It seems many residents were used to retiring to the privacy of their rooms for an evening of drinks. In leaving the apartment building hurriedly, they had not had time to bring their evening bottles and were looking for the bar. The residents we knew in daylight hours could not retire comfortably without their usual evening cocktails. Naturally, the manager reopened the bar for his unexpected guests. The staff tucked the observation away for future assessment.

Origins and Effects of Alcoholism Among Older Persons

Although little attention has been given to alcoholism among the elderly, more is becoming known about its origins and effects. In this paper, we discuss the natural history of late-onset alcoholism, focusing on information useful for practitioners and others who work with the elderly.

About 20 percent of all persons treated for alcoholism are older than age 55 (Petersen 1983), but since many drinkers are not known to health care providers and others, this number underrepresents drinking among older persons (Kermis 1986; USDHHS 1990). Most researchers report that there is a higher prevalence of drinking among men than women, but except for a few persons, the evacuated residents were women. We can assume that underreporting may pertain more to older women drinkers than to the older male population.

Alcoholism is a chronic, progressive, and potentially fatal disease with a progressive onset and hidden symptoms. It is also characterized by the need to drink alcohol on a continuous basis. Sometimes referred to as situational alcoholism, late-onset alcoholism may be associated with age-related stress and elimination of work expectations after retirement (Kermis 1986). This condition is defined as the onset of the first alcohol problem at or later than age 60 (Atkinson et al. 1990). When compared with early-onset or chronic alcoholics, the late-onset alcoholic consumes less alcohol and functions better (Brennan and Moos 1991). Parrella and Filstead (1988) recommend describing late-onset alcoholism as a developmental process.

Determinants of Late-Onset Alcoholism

Although research shows that alcohol consumption is lower and alcohol abuse is less prevalent among persons older than age 60 compared with younger persons, little attention has been given to the problem of heavy drinking among the elderly. In particular, the problem of late-onset alcoholism is little researched. While it is estimated that two-thirds of older drinkers begin their habit early in life, the remainder begin later as a response to stressful life experiences. This late-life onset of heavy drinking may occur more frequently among persons of high income levels (USDHHS 1990; Wade 1988). Because little is known about late-onset alcoholism, it presents a significant problem in how to prevent or intervene in these cases. This review begins with an examination of early determinants of the condition, using an epidemiologic framework as a basis for identifying some relevant risk factors.

Early factors in the etiology of late-onset alcoholism for older persons will include the situation in the physical and social environment. Access to alcohol may be considered the agent of the condition. Human factors are the third dimension of late-onset alcoholism in the elderly.

Environmental factors.

There are some differences in the prevalence of drinking alcohol that can be associated with geographic areas. Reported rates of alcohol consumption by geographic area are clouded by such anomalies as tourism or low tax rates on alcohol in neighboring States. The highest per capita consumption of alcohol is in the New England and Pacific States, and when considering the consumption per drinker, the highest consumption per drinker is in the mountain and southern states, or dry areas of the country (USDHHS 1990). Since these rates are for the general population, one cannot assume that higher late-onset alcoholism among the elderly follows the same pattern.

Persons living alone may be more prone to late-onset alcoholism, particularly if the individual has previously lived in a household with others. When the situation of living alone occurs late in life, the individual may resort to drinking to overcome loneliness.

Since drinking is a learned behavior, patterns of association with others may have a relationship to late-onset alcoholism. There is some risk of drinking problems in older women experiencing situations of having husbands with drinking problems, entering the empty nest period, and of employment (USDHHS 1990). In other instances, family or social contacts may reinforce the older person's drinking (Bienenfeld 1987).

For younger persons, local attitudes and norms about drinking influence acquired patterns of alcohol usage ((USDHHS 1989; USDHHS 1990). Related to these norms are the marketing of alcohol and the way use of alcohol is portrayed in the media (for example, television and movies). Whether these values have an effect on the prevalence of late-onset alcoholism is not known.

Agent factors.

Accessibility to alcohol has a logical relationship to late-onset alcoholism. To cite an extreme example, an older person who is institutionalized in a nursing home or adult congregate living facility may not have ready access to alcohol and therefore would have difficulty consuming alcoholic beverages. Another access constraint might be lack of transportation to the store that sells alcohol. However, the older person might be able to circumvent this obstacle by engaging home delivery or having a friend or relative obtain a regular supply of alcohol for consumption. A very real obstacle is money, since regular use of alcohol can be costly (USDHHS 1990).

Host factors.

Human factors play a central role in late-onset alcoholism. Alcohol often becomes the means for coping with the stress of loss experiences in later life. Thus, dealing with stress becomes the basis for the onset of late life alcoholism. Elders face certain common experiences that lead to late life stress and can precipitate late-onset alcoholism.

Common stressors experienced late in life are related to loss situations (Finlayson 1988; Kermis 1986; Young 1988). Therefore, persons who have had family members, in particular children, leave home may be prone to this form of alcoholism. Loss of a spouse is another common loss. Persons who divorce will experience loss and may cope with their new role by drinking. For older persons whose life work provided meaning to their lives, retirement or job loss may trigger late-onset alcoholism. Some elders may find themselves experiencing financial difficulties or reduced income, another loss that can initiate drinking.

Loss of good health, particularly the onset of chronic conditions or the experiencing of chronic pain or disability, are other causes of stress leading to situational or late-onset alcohol misuse. While alcoholism often leads to depression (Bienenfeld 1987; Fries 1989), the depressed older person may be predisposed to misuse alcohol, thus further aggravating the depression—a chicken-egg situation.

Younger alcoholics may exhibit such personality traits as neuroticism, self-centeredness, or deviant behavior. Longstanding or chronic alcoholics may be depressed and have a history of marital, work, or police problems. In contrast, the late-onset alcoholic has experienced loss or trauma, but does not exhibit the personality traits of the earlier onset conditions (Kermis 1986).

Contributions to Other Health Risks

Major distinguishing characteristics between late-onset alcoholism and chronic alcoholism are the effects that occur to body systems from years of abuse. Longstanding abuse of alcohol behaves like a toxin to multiple body systems. It primarily affects the cardiovascular, digestive, neurological, and skeletal systems. These changes rarely occur in the late-onset alcoholic—unless the habit begins in the early elder years and persists as heavy drinking.

Perhaps the most common side effect of late-onset alcoholism is malnutrition. Since overuse of alcohol provides calories but no nutrients, malnutrition often accompanies alcohol use without weight loss or other overt signs. Alcohol also interferes with absorption of vitamins and minerals. Impairment of vitamin B metabolism is the major effect that occurs, resulting in tremors and cerebral deterioration, including clouded consciousness, memory impairment, and imagining (Kermis 1986; Dychtwald 1986).

Depression is common in heavy drinkers. Incompatibility of alcohol and drugs can further exacerbate signs of depression (Busse and Blazer 1980; Fries 1989). Memory impairment, confusion, or mood swings are other common mental health effects of this and other forms of alcohol overuse (Bienenfeld 1987; USDHHS 1990).

In addition to contributing to the development of unwanted chronic conditions in the individual, late-onset alcoholism can have serious effects on the family and on society. The single most hazardous risk is drinking while driving (Fries 1989). When driving under the influence of alcohol is compounded with poor night vision, slowed reaction time, and other impairments of the elderly, increased risks of automobile or even pedestrian accidents are a probable outcome.

Once the abuse of alcohol is established, the natural history of the condition progresses and evidence of the abuse can be discerned. The effects of the condition are often insidious but the impacts can be serious. Yet many persons with the condition go unrecognized.

Implications for Those Who Work With the Elderly

For those who work with the elderly, even on a day-to-day basis, the recognition that an individual has late-onset alcoholism is frequently a surprise; the condition is often identified during a contact with the older individual for some other reason. Just as the high-rise apartment staff were caught off guard when the displaced residents sought their evening drinks, many cases of late-onset alcoholism are found during hospitalization for an unrelated condition. Because of the associated hazards of the condition, it is important that health providers and others who work with the elderly on a regular basis identify persons with late-onset alcoholism, so that the underlying causes for this means of coping with stress can be identified and treated. Assessments of the elderly will need to include observations for the subtle behaviors that are associated with the condition, so that monitoring for other effects and treatment of the underlying cause of the problem can begin.

Assessment

Some research has found that health care practitioners often overlook problems with alcohol in clients who do not fit the stereotypic profile of a male of lower socioeconomic status, with acknowledged alcoholism as a problem. Moore et al. (1989) compared newly admitted adult hospitalized patients for the presence of alcoholism with the findings of the admitting physician; they learned that admitting physicians significantly underdiagnose alcoholism findings. The highest correlation was for psychiatric patients, while the lowest correlations were for surgical and gynecological patients. Thus, practitioners and others working with the elderly have a need to improve their assessment skills for alcoholism and, in particular, for late-onset alcoholism. Lack of such skills can mean a lack of recognition of signs of alcohol abuse or an interpretation of such signs as changes related to aging (USDHHS 1990).

Researchers indicate that late-onset alcoholism may be a response to stressful life experiences (e.g., bereavement, poor health, economic change, retirement) and may occur more frequently among elders of higher socioeconomic status and higher educational levels (Atkinson 1988; Schoenfeld et al. 1987). Such knowledge indicates that persons experiencing loss are at risk for this condition and should be regularly screened. An exception to the prevalence of late-onset alcoholism in higher income groups is the homeless. Since the homeless are more likely to exhibit chronic rather than late-onset alcoholism, screening for late-onset problems in this group would be productive in those who are recently displaced or unemployed.

In addition to health providers who may initiate screening during a regularly scheduled office visit or hospital admission, persons who are in regular contact with elders in the community must also learn to observe for signs of alcohol abuse. Such individuals may be housing managers, service providers, pharmacists, ministers, and others in regular contact with the elderly.

Components of the assessment.

Routine assessments for late-onset alcoholism will need to determine the stressors that are of concern to the elderly, and how the older person is coping with the stress. Identification of personal confidants and social supports are important dimensions of coping.

The most common assessment approach to determining heavy drinking is to ask the individual about his or her alcohol consumption (USDHHS 1990). However, self-reported information about drinking may omit such sources of alcohol as liquid medicines or tonics, and may be distorted because of poor memory or the hesitancy to accurately report because of perceived or actual social values about drinking. Denial is another factor that can affect the accuracy of self-reporting on the quantity of alcohol consumed.

Indirect approaches to identifying problems.

Because of the frequency of denial in admitting a problem with heavy drinking, an indirect approach is needed to gain knowledge about the prevalence of late-onset alcoholism. Less direct approaches that can point to problems with drinking may include difficulty in interpersonal relationships and in performing employment, volunteerism, or decisionmaking activities of daily living. Repeated falls are another indicator. The older person presenting in the local emergency room or clinic may exhibit bruising that would indicate both falling and increased peripheral vascular permeability. Self-neglect is another common sign of late-onset alcoholism. This sign can occur as a result of the accompanying depression, isolation, or malnutrition of late-onset alcoholism (Fries 1989). If the older person is alone much of the time or tends to isolate one's self, such factors may not be recognized as being related to the person's alcohol intake (USDHHS 1990).

One approach to assessment may be to ask elders to complete a self-rating form. Questions that may be included are morning drinking, driving while drinking, receiving a traffic ticket for drinking and driving, automobile accidents related to drinking, drinking to forget problems, drinking that worries relatives and friends, stomach ulcer or gastritis, interference with sleep, and drinking alone (Fries 1989). Such an approach can help combat denial and promote the individual's self-recognition of problems with alcohol.

Early physical signs to look for include tremors, anxiousness, or memory impairment (Kermis 1986; Bienenfeld 1987). The individual who bruises easily may have peripheral vascular changes.

The non-health professional who is in regular contact with elders in the community may look for the purchase of alcoholic beverages or the practice of requesting others to purchase alcohol. Routine inspections of apartments or other living quarters for fire code compliance can include observation for signs of excessive consumption of alcohol.

Monitoring Alcohol and Other Conditions

Once individuals are identified as late-onset problem drinkers, regular monitoring of drinking patterns is important. Observing for alternative coping patterns may indicate that the individual is lessening their drinking practices. On the other hand, isolation, a lack of interest in outgoing behaviors, and depression may point to continued alcohol abuse. Routine monitoring can be a part of routine health checkups.

Treatment Choices

Treatment of the late-onset alcoholic may be a matter of personal choice for the person whose habit does not have an impact on others (Dychtwald 1986). Since self-choice plays a large part in the decision to change coping behaviors or to receive treatment, addressing awareness can play a large part in late-onset alcoholism. Such awareness can occur at two levels: general public information and individual teaching and counseling.

Effective treatment must address the source of the alcohol abuse, loss, and coping. Counseling that assists the individual to understand the relationship between the stress of loss and his or her pattern of drinking will help in achieving a first step toward combating the problem. In group living settings, staff can build elements into the social and physical environment that will reinforce stress reduction activities, promote discussion, and encourage group activities and gatherings rather than isolation. Persons who do not join in on group activities may be called on to contribute in meaningful ways to lessen their isolation. Late-onset alcoholism can respond positively to preventive approaches directed at stress reduction and coping skills (Lawson 1989).

Because of the nature of the cause of late-onset alcoholism, individuals with this condition may respond to health promotion approaches. Such approaches include:

• Assuming individual responsibility for personal lifestyle
• Substituting improved nutrition, exercise and fitness, and stress control for current behavior patterns
• Reducing alcohol intake for improved overall health and well-being (Dychtwald 1986)

The late-onset alcoholic may have an occasional episode of intoxication or uncontrolled drinking. In that case, it is important to provide medical care or brief inpatient therapy to withdraw the toxin and restore fluid and electrolytes, including B complex vitamins (Busse and Blazer 1980).

Health professionals and persons in regular contact with older adults who have late-onset alcoholism play an important role in detecting the condition. Regular monitoring and preventive interventions can do much to reduce the risks associated with this condition.

Conclusions and Recommendations

Over the past 20 years, the number of older persons living alone has increased by 20percent, so that in 1990 more than 30 percent of persons older than age 65 were living alone. There is a wide disparity between men and women, since 16.2 percent of men and 40.6 percent of women reside alone (U.S. Bureau of the Census 1981, 1991). Rural elders tend to stay in their own housing, even when younger family members leave for more urban areas (Krout 1986), implying that there may be greater numbers of elders living alone in nonmetropolitan areas. With the population aging both by actual numbers and by longevity, this trend is expected to increase. Long-term policy that emphasizes home and community-based care will further encourage older persons to remain at home in their later years. While at home, they will be coping with chronic conditions and other losses associated with aging that predispose one toward late-onset alcoholism. From these trends, one can infer that the prevalence of this condition will become more widespread, with the third of the older population who live alone being at particular risk.

The small amount of research and clinical literature on late-onset alcoholism points to the need for research about the condition. Prospective study approaches can expand the understanding of the etiology of the condition, as well as the effectiveness of various interventions (Atkinson 1987). Certainly the absence of knowledge also raises concerns about how practitioners and others who work with the elderly will be educated and learn about the condition. Only with awareness will such workers be alerted to the subtle signs that point to late-onset alcoholism.

Often, reported data about drinking habits are based on the total or younger population and may not apply to the elderly (USDHHS 1990). Much late-onset drinking is underreported. Yet, as the percentage of the population who are older increases, health practitioners and persons who work with the elderly will need to learn to recognize problems associated with this age group. Late-onset alcoholism is a preventable condition. When brought to the attention of the older adult by sensitive persons who regularly work with the elderly, it is a condition that can be corrected by self-awareness and changes in lifestyle.

References

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Atkinson, R.M.; Tolson, R.L.; and Turner, J.A. Late versus early onset problem drinking in older men. Alcoholism: Clinical and Experimental Research 14(4):574-579, 1990.

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Last Updated 11-7-02