In March 2013, The General Lifestyle Survey showed that between 2005 and 2013, the percentage of men drinking 8 or more units of alcohol (the equivalent of 4 or more pints of normal strength beer) on any one day in the past week had changed by only 5% in the 65 and over age group. This compares to reductions of 30%, 19% and 12% in the 16-24, 22-44 and 45-64 age groups respectively. A clearly a worrying trend, helped little by the uncertainty over whether alcohol is friend or foe to public health.
Over the past 30 years, there has been much speculation over the putative protective effects of alcohol on health, much of which is based on a ‘J’ or ‘U’ shaped relationship between the amount of alcohol consumed and the presence of health problems or deaths associated with certain diseases. Nearly every day, the media is rife with stories about which type of alcohol and how much of it is ‘good for you’. Yet, the conclusion from what is out there within the higher levels of evidence is that an intake of between 1.5 and 3 UK units per day confers some protection from heart disease. However, if stroke, accidents and suicide are also considered, this figure goes down to 1.5 UK units per day. Although met with this some degree of trepidation, this upper limit was proposed for older people in Our Invisible Addicts, which is based not only on the above evidence but also on existing guidelines from the National Institute of Alcohol Abuse and Alcoholism in the United States. Future research will need to continue to navigate the complexities involved in exploring the relationship between alcohol and health, particularly if firm recommendations are to be made on the basis of robust methodology.
So, where do and should we go from here in changing practice and informing policy? Well, two major advances have already taken shape. The first is a major textbook with international collaboration, detailing advances in the clinical and public health aspects of addiction in older people; the second is an information guide for health professionals that build upon the recommendations from Our Invisible Addicts. Both are due for publication in the coming months.
Yet, there is still much more unfinished business. Firstly, there is a need to examine drinking trends among older people. Although there has recently been a real risk of losing national data on alcohol consumption, ‘high impact outputs’ will still include General Lifestyle Survey data on drinking and the annual statistical bulletin on alcohol-related deaths in the UK, although the former will report a smaller sample size.
Labeling of alcohol containing drinks has already been put in place, with calorific content likely to follow. However, it seems that minimum unit pricing (at least in England) remains a pipe dream, at least for the coming years.
Changes to clinical and public health guidance for older people remain hugely under-developed, but there is some positive movement in this area. A commissioning guide from the National Institute of Clinical Excellence in 20011 drew attention to the need for lower thresholds for high-risk groups (including older people) when commissioning inpatient and residential medically assisted alcohol withdrawal services. The commissioning guide was supplemented by examples of good practice when commissioning for older people, including community based interventions, addressing complex needs, equality of access to services and patient experience.
More recently in February 2014, DrugScope published It’s About Time, which should prove to be a key driver to policy change for those commissioning substance misuse and older people’s services; particularly in addressing age-related needs, barriers to treatment and age-appropriate interventions.
Now that responsibility for commissioning substance misuse services for health improvement under Directors of Public Health, only time will tell as to how effective these strategies will be in implementing and evaluating improvements in health and social outcomes for older people with alcohol misuse.
Informing and challenging doctors in psychiatry and public health with evidence of growing and significant public health and clinical problems in our older drinkers, is reasonably straightforward. What remains a significant challenge is how this message can be communicated to the public, for a substance that has formed a progressively greater role in our everyday lives for the past few decades. Therein lies the rub.
Doctor Tony Rao
Visiting Researcher at the Institute of Psychiatry and Consultant Old Age Psychiatrist
For more information about older people and alcohol, please visit www.alcoholandolderpeople.co.uk