Alcohol Use Screening and Assessment for Older Adults
Issue #17 of General Assessment Series
Older adults are diagnosed with fewer alcohol use disorders (AUDs) than young and middle aged adults (Grant et al. 2015). The number of AUDs in older adults, however, are second only to prescription medication disorders. Importantly, harmful alcohol use increases the risk for non-communicable disease (WHO, 2017) and contributes to morbidity and mortality. Aging increases vulnerability to the effects of alcohol used alone and in combination with illicit drugs and medications. Alcohol use contributes to diabetes, cancer and cardiovascular disease. Risk further increases in the presence of co-morbid conditions. The National Institute of Alcohol Abuse and Alcoholism (NIAAA,2017), therefore, recommends that alcohol consumption for adults age 65 and older be limited to 1 standard drink (12 ounces of beer, 4-5 ounces of wine or 1 ½ ounces of distilled spirits) per day or 7 standard drinks per week and no more than 3 drinks per occasion. Lower limits or abstinence are recommended for those taking medications that interact with alcohol and conditions exacerbated by its use. In 2008, it was estimated that 40% of persons over 65 drank alcohol (NIAAA, 2017), a number which rose by 65% from 2002 to 2013. About 19% of older drinkers meet criteria for “at risk” drinking (alcohol consumption above NIAAA levels, likely to increase health risks). Additionally, 23% report binge drinking [4-5 drinks per occasion] (Grant et al., 2015). More than 50% of late middle-aged men and women (50-64), are drinking alcohol and 14% are drinking heavily. Many do not recognize related health risks of risky/harmful amounts of alcohol and do not reduce their drinking with age. These data portend growing numbers of alcohol related problems with an increase in the number of older adults (NIAAA, 2015).
BEST TOOL: The U.S. Preventive Task Force recommends that all adults be screened for alcohol use and that “risky” drinkers be provided with counseling (USPTF, 2017). The first step is to ask “Do you drink alcohol?” and if so, “How much alcohol do you drink?”. If the patient reports regular alcohol consumption, The Short Michigan Alcoholism Screening Instrument–Geriatric Version (SMAST-G), should be used. It is a short-form alcohol screening instrument tailored to the needs of older adults. Two or more “yes” responses suggest an alcohol problem (Blow et al., 1992). Brief behavioral counseling has been demonstrated to reduce alcohol misuse among older adults for whom the severity of alcohol disorder is generally lower than younger adults. The Substance Abuse and Mental Health Services Administration Guidelines now recommend that a screening test like the SMAST-G be the first step in SBIRT, a process of Screening, Brief Intervention, Referral to Treatment. Nurses should follow the first questions about drinking using the SMAST-G with health teaching and counseling as need indicates. Nurses can then discuss the desirability/need to cut down on alcohol use if the patient scores positively and/or reports drinking above the NIAAA recommendations. If the patient does not see a need for change, the first two questions should be asked at every visit. When the screening score indicates a moderate to severe alcohol problem, referral to a mental health or geriatric nursing practitioner, a geriatric psychiatrist, or another professional specializing in substance use disorders is indicated.
TARGET POPULATION: Older adults who consume alcohol in any amount. The goal of screening is to identify “at risk” drinkers, persons drinking at levels linked with negative outcomes for physical and mental health like falls, stroke, depression, hypertension, and/or gastrointestinal problems. Introducing the topic, however, provides opportunity for health teaching about alcohol use and precautions to reduce its risks. Older drinkers taking prescription medications are at greatest risk as use of prescription or illicit drugs and alcohol in combination is common. SBIRT is an appropriate intervention for combinations of medication/drugs and alcohol use as well, although it is less effective for illicit drugs.
VALIDITY AND RELIABILITY: The MAST-G, the original instrument from which this measure was derived, has a sensitivity of 93.9%, specificity of 78.1%, a positive predictive value of 87.2%, and a negative predictive value of 88.9%.
STRENGTHS AND LIMITATIONS: The instrument serves as a screening tool only. A second instrument with good validity and strong reliability useful for its brevity is the AUD-C. Translated into several languages and tested across populations, the 3 question AUD-C is used in all adult primary care populations to screen for risky drinking and active alcohol use disorders (SAMHSA, 2017). Sensitivity ranges from 0.66-0.95 in the identification of risky drinking by men and women. A more comprehensive assessment for an alcohol or drug use disorder requires that the clinician collect data using a Quantity/Frequency Index. Questions about the quantity and frequency of use, the social and health consequences of drug use, including nicotine, prescription, over-the-counter, herbal and food supplements, recreational drugs, and alcohol provide a full profile to inform a discussion and/or referral.
FOLLOW-UP: Brief interventions by health care providers following positive screening of older adults have been shown to be useful in reducing alcohol consumption (Schonfeld et al., 2010; Moore, 2011). See SAMHSA for the SBIRT steps and tools for learning this technique. Older adults with Alcohol Use Disorders respond to treatment with rates comparable to younger adults (Kuerbis & Sacco, 2013) Nurses in all health care settings serving older adults should screen for alcohol use.
MORE ON THE TOPIC:
Blow, F.C., Brower, K.J., Schulenberg, J.E., Demo-Dananberg, L.M., Young, J.P., & Beresford, T.P. (1992). The Michigan Alcoholism Screening Test – Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research, 16, 372.
Blow, F.C., & Barry, K.L. (2012). Alcohol and substance misuse in older adults. Current Psychiatry Report, 14,310-319.
Grant, B.F., Goldstein, R.B., Saha, T.D., Chou, S.P. Jung. J., Zhang, H., Pickering, R.P. Ruan, J., Smith, S.M., Huang, B., & Hasin, D.H. (2015). Epidemiology of DSM-5 Alcohol use disorder. Journal of the American Medical Association, Psychiatry, 72(8), 757-766.
Kuerbis, A., & Sacco, P. (2013). A review of existing treatment for substance abuse among the elderly and recommendations for future directions. Substance abuse research and treatment, 7, 13-37. doi: 10.4137?SART.S7865.
Substance Abuse and Mental Health Services Administration (SAMHSA): Screening, Brief Intervention and Referral to Treatment: Home Page: https://www.samhsa.gov/sbirt.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). AUDIT-C Overview. Available at: https://www.integration.samhsa.gov/images/res/tool_auditc.pdf.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). SBIRT: Training & Other Resources - SAMHSA-HRSA
Center for Integrated Health Solutions. Available at: https://www.integration.samhsa.gov/clinical-practice/sbirt/training-othe...
U.S. Preventive Services Task Force. Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care. (2013; Update in progress as of Dec 2017) Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummar...alcohol-use-in-adolescents-and-adults-screening-and-behavioral-counseling-interventions.