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Alcohol maybe putting elderly woman at risk

Mrs Brown is 78, lives alone and keeps falling. You discover she has atrial fibrillation, and a raised MCV and gamma-glutamyl transferase; you suspect alcohol may be a major factor. Dr Melanie Wynne-Jones offers advice.

How common is alcohol consumption in the elderly?

One in six men and one in 14 women over the age of 65 exceed 'sensible drinking limits', but many (28 per cent of men and 55 per cent of women) drink less than one drink a week.

Up to 5 per cent of elderly people who drink more than occasionally are problem drinkers with significant physical or psychological dependence on alcohol; the figure may be as high as 12 per cent in men in their 60s(1).

Some will be long-term problem drinkers, but affluence, loneliness, boredom, pain, insomnia and depression, together with the increased social acceptability and availability of alcohol are additional factors in old age. Numbers have also risen with increased life expectancies and demographic changes.

What are the alcohol risks in old age?

There is a J-shaped relationship between alcohol consumption and mortality, with moderate drinkers faring better than teetotallers and heavy drinkers. An elderly person who drinks excessively risks liver failure, pancreatitis, heart disease and neurological damage, but safe limits for the over-65s may actually be higher than for younger drinkers(2).

However, up to two-thirds of accidental deaths in women over the age of 65 are caused by falls(3) and alcohol may be an aetiological factor in up to a third of falls by elderly people(4).

How can you establish whether Mrs Brown is in fact drinking heavily?

She may tell you if you ask her as part of your history taking, but like many problem drinkers, she may be adept at hiding the evidence and simply deny that she is drinking. Her family may have their suspicions, although they may have turned a blind eye to her adding a 'nip' to her tea, or have even bought alcohol for her. Some housebound people use an extended network of friends and neighbours to bring them alcohol, so that no one gets the full picture. Mrs Brown may even have been tempted to drink and drive if her mobility is poor.

It is important to take a psychosocial history, particularly looking for depression and other conditions in which alcohol may be used as a coping strategy. Sensitive discussion of these areas may help Mrs Brown to reveal her true level of alcohol consumption.

A nutritional history is important , as people who drink excessively often neglect their diet. Physical examination may reveal signs of chronic liver disease, and a mini-mental state examination will determine whether she has any cognitive impairment.

Should the falls be investigated further?

Intoxication is a common cause of falls, and may exacerbate other conditions or medication which affect mobility, balance, blood pressure or consciousness. A full history and examination should provide pointers to other reasons why Mrs Brown may be falling, although alcohol and cardiovascular causes are most likely.

Should Mrs Brown be anticoagulated?

Both atrial fibrillation and heavy alcohol consumption are risk factors for stroke, and for someone aged 78, anticoagulation is the most effective treatment for stroke prevention in atrial fibrillation.

Treatment is always a trade-off between risks and benefits, and anticoagulation could put Mrs Brown at significant risk if she fell. It is quite likely she might forget to take this and other medication properly; error, as well as the alcohol itself, could have devastating effects on her anticoagulant control.

Anti-platelet therapy may be a safer, though less effective alternative. Discussion with the local consultant is likely to be helpful here.

What if Mrs Brown refuses to give up drinking?

If Mrs Brown has full insight into the dangers of falling or continuing to drink heavily, she is entitled to accept as much or as little help as she chooses; this is true for problem drinkers of all ages.

But if she has significant cognitive impairment, this may be caused by the alcohol, neurodegenerative disease, or treatable psychiatric illness. A psychiatric opinion will help to establish the diagnosis and whether Mrs Brown is competent to make her own decisions on the safety aspects of remaining at home.

Key points

lExcessive drinking by elderly patients is common, but safe limits may be higher than for young adults

lA drinking history should be routinely taken in the elderly, but the patient may deny consumption

lAlcohol is an aetiological factor in many physical and psychiatric illnesses but can also be a coping mechanism

lAlcohol may be implicated in a third of falls by the over-65s

lExcessive drinking may threaten the safety of elderly people living alone, and compromise anticoagulant or other medication

clinical casebook

References

1. Institute of Alcohol Studies. www.ias.org.uk

2. White I et al. Alcohol consumption and mortality: modelling risks for men and women at different ages.

BMJ 2002;325:191

3. Office for National Statistics. 1997 Mortality statistics: injury and poisons. London: Stationery Office, 1999.

4. Rapid Response to (2) above, www.bmj.com Robert Patton, Research Associate Department of Psychological Medicine, Imperial College. July 30, 2002

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