By 2030, one-third of the U.S. population will be age 55 or older. There is no reason why elder adults should not be able to drink responsibly as they age. However, excessive alcohol abuse, known as Alcohol Abuse Disorder (AUD) is a growing problem in the elderly across the United States. Alcohol abuse adversely affects both physical and cognitive functions of elder adults. This blog is intended to provide information and a legal resource to family members and friends of an elderly adult who is suffering from physical and/or mental problems resulting from AUD.
How do you know if an elder parent, spouse or family member is abusing alcohol, especially in a baby boomer generation that consumed alcohol as part of most normal social activities?
According to the Dietary Guidelines for Americans, moderate alcohol consumption is defined as having up to 1 drink per day for women and 2 drinks for men. Heavy drinking is defined as more than 15 drinks a week for men. For women, heavy drinking is typically considered to be 8 drinks or more a week.
In the past, individuals who suffered from excessive or problem drinking were simply called alcoholics. However, the word “alcoholic” is now considered to have negative and harmful connotations. More recently, the health profession has begun to use the term alcohol use disorder (AUD).
Until several years ago, there was no single diagnosis for alcohol abuse or alcohol dependence. However, that changed in 2013 when the American Psychiatric Association produced the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as DSM-V. For the first time, DSM-V combined two disorders, alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD). Under the guidelines in DSM-V, a diagnosis of AUD is made by asking the following questions:
In the past year have you?
1. Had times when you ended up drinking more, or longer than you intended?
2. More than once, wanted to cut down or stop drinking but couldn’t?
3. Spent a lot of time drinking, or getting over other aftereffects?
4. Wanted a drink so badly, you couldn’t think of anything else?
5. Found that drinking, or being sick from drinking, often interfered with taking care of your home or family?
6. Continued to drink, even though it was causing trouble with family or friends?
7. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
8. More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, using machinery, walking in a dangerous area)
9. Continued to drink, even though it was making you feel depressed or anxious or adding to another health problem? Or after having a memory blackout?
10. Had to drink more than you once did to get the effect you want? Or found that the usual number of drinks had much less effect than before?
11. Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such a trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?
The presence at least 2 of these symptoms indicates AUD. The severity of AUD is defined as the following:
1. Mild - The presence of 2-3 symptoms.
2. Moderate - The presence of 4-5 symptoms.
3. Severe - The presence of 6 or more symptoms.
According to the National Council on Alcoholism and Drug Dependence, 8 million older adults abuse alcohol and drugs. 6-11% of elderly adults admitted to hospital exhibit symptoms of alcoholism and 20% of all elderly patients admitted to psychiatric services exhibit symptoms of alcoholism. Widowers over the age of 75 have the highest rate of alcoholism in the U.S.
AUD is also prevalent in assisted living and nursing home settings. In some studies, it is thought up to 49% of elderly people living in nursing homes are thought to suffer from alcoholism.
There are a number of causes of AUD in elder adults. Isolation and loneliness represent a significant factor in elder alcohol abuse. The death of a spouse and resultant grief and depression can be obvious triggers for excessive drinking. Demographic trends mean that adult children often move away from their parents to live and work in different states. Supports provided by friends and neighbors may be weakened by death, moving and health problems. Boredom and health problems restricting an elder’s activities and independence are other prevalent factors in alcoholism.
In general, alcohol effects elderly adults more than younger adults because aging lowers the body’s tolerance for alcohol. Specifically, elder adults have less muscle than younger adults. This means that the elder body takes longer to absorb the alcohol and the elder adult feels the effects of alcohol for a longer period of time. In addition, as we age, our bodies have less water to aid in kidney function. In addition to the longer lasting effects of alcohol, elder adults with chronic AUD can suffer from a number of serious physical and mental problems:
Research has indicated that long-term alcohol consumption can raise blood sugar levels and can contribute to the development of type 2 diabetes.
Excessive alcohol is often linked to the development of hypertension in elder adults. In addition, medications directed specifically for high blood pressure are affected by alcohol. Often an elder drinker will mix medications and alcohol, leading to significant risks associated with high blood pressure.
Alcohol and related dehydration can irritate the urinary tract causing bladder inflections, sometime called cystitis. Also known as urinary tract infections (UTI), these infections are not only painful, but they can cause confusion and delirium if left untreated.
In the elderly, the prevalence of dementia is almost 5 times higher in alcoholics than non-alcoholics.
Wernicke Encephalopathy - Korsakoff Syndrome (WKS) are a set of two separate brain disorders that are caused by a severe deficiency of vitamin B1 (Thiamine). These two conditions can appear separately or together but are almost always associated with chronic AUD.
Wenicke Encephalopathy is an acute condition that consists of the sudden onset of confusion, loss of muscle coordination (axia) and abnormal eye movements such as back and forth movement, eye lid drooping and double vision. Korsakoff syndrome is a chronic condition that often develops after the symptoms of Wenicke Encephalopathy have diminished. Korsakoff syndrome is characterized by severe memory impairment.
One of the peculiar symptoms associated with Korsakoff syndrome is the fabrication or distortion of memories, known as confabulation. Elder adults with confabulation create memories that are completely untrue. However, the made up memory is not intentional and the elderly adult is not aware that he or she is not telling the truth.
Dehydration in elderly adults is common even without the complication of alcohol. Kidney function decreases with age, most noticeably over the age of 70. Certain medications have diuretic effects, which increase the likelihood of dehydration. Dehydration can cause confusion, dizziness and low blood pressure among other effects.
Elder adults with AUD do not simply suffer from purely medical issues. There are other social and practical issues that arise with an elder adult with AUD.
One of the most common problems facing families of an elder adult with AUD is the fact that he or she is often still driving. While alcohol-related accidents span all age ranges, an elder impaired adult may also suffer from slower reflexes, diminished eyesight and hearing. In addition, as cognitive function can decline with age, the elder adult may not have the insight to determine whether he or she is safe to drive. Given these factors, an elder adult who continues to drive while suffering from AUD is a danger both to himself or herself, as well as to others.
Unfortunately, elder adults with AUD often suffer significant financial problems. Many elder adults with AUD live on a fixed income. Often their sole source of income consists of social security benefits. An addiction to alcohol can be expensive and consumes limited resources. An elder individual with AUD, who has underlying dementia or has cognitive issues related to AUD is likely to also have problems keeping current with monthly expenses. A significant concern is an individual who has fallen into arrears on a mortgage or property taxes, putting the elder's home at risk for foreclosure. Finding late bills and utility cut off notices is not unusual. Unfortunately, elder adults with AUD are also vulnerable to financial exploitation and credit card debt.
An elder adult who lives independently is often able to conceal the extent of his or her drinking from family members and friends. However, an elder adult is often unable to hide other deficits. An elder adult with AUD may neglect his or her nutrition, having little to no food in the house. Commonly, personal hygiene declines, presenting as unkempt and odorous. An elder adult on a fixed income may not have discretionary income to spend on alcohol and the individual may begin to fail to make mortgage payments or utility bills. An individual who is alcohol dependent may be physically and/or verbally abusive to a spouse or family member. A finalan elder adult who becomes confused with alcohol and wonders out of the house or leaves a stove lit. All of these factors combine to threaten the elder adult's ability to continue to safely live independently.
Alcohol dependence in an elder adult is often complicated by the fact that he or she may be suffering from age-related dementia or another underlying cognitive disorder. For example, an elder adult may have been diagnosed with Alzheimer's, vascular dementia or lewy body syndrome. These cognitive disorders have symptoms that can also mimic those of AUD, such as memory loss, confusion, delirium, agitation and personality changes. The diminished cognitive function associated with dementia means that the elder adult may not be able to appreciate the extent of his or her alcohol dependence or the need for treatment.
One of the difficulties a family member may have is in having the elder adult diagnosed with AUD. An elder adult may feel shame at his or her alcohol dependence and refrain from discussing the issue with a primary care physician or other treater. As with any person battling alcohol abuse, denial by an elder adult is a significant deterrent to diagnosing AUD. Often, an elder adult will hide the evidence of the extent of his or her alcohol problem from family members, or otherwise minimize the amount of consumption. Fear of losing independence is a strong motivator to hiding an alcohol problem. A spouse of an elder adult suffering from AUD may wish to conceal the problem from family members, or may have diminished capacity themselves and simply be unable to identify the problem.
Often, the first time an elder adult might be assessed for alcohol abuse or AUD is at a hospital emergency department. In fact, in the U.S., emergency room doctors treat more patients with alcohol disorders than primary care physicians. An elder adult may come to the emergency department following a fall or collapse due to alcohol-related dehydration. He or she may have been injured in a car accident while alcohol impaired. A family member may bring in an elder adult for confusion or delirium related to a vitamin deficiency caused by chronic drinking. It is these acute medical issues that often provide the first opportunity for the alcohol dependence of an elder adult to come to light.
The emergency room treaters will initially be concerned with the acute medical emergency for which the elder adult was brought in for care. In that case, the objective may not be the underlying chronic problem. However, if alcohol is thought to be a cause of the physical symptoms, or if a family member raises the issue, an assessment may be undertaken in the ED itself. Alternatively, if the elder adult is admitted, an AUD assessment may be performed by psychiatry. If the elder adult is admitted to a psychiatric unit, an AUD assessment may be of benefit to rule out other underlying psychiatric conditions. Lastly, an elder adult who follows up with a primary care physician after hospital discharge may be referred for an AUD assessment.
Several basic screening tools can be used by medical staff in the emergency department itself, or in an inpatient or outpatient setting, to determine if alcohol abuse is a factor.
The CAGE screening test is a simple 4 question assessment which asks the following questions:
1. C - Have you ever felt that you should cut down on your drinking?
2. A - Have people annoyed you by criticizing your drinking?
3. G - Have you ever felt bad or guilty about your drinking?
4. E - Eye Opener. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
A positive response to 2 or more of these questions is considered to be clinically significant.
The Alcohol Use Disorders Identification Test (AUDIT) is another basic screening tool that can be used in Emergency Departments to assess alcohol problems in an elder adult. The AUDIT consists of 10 multiple choice questions about alcohol use in the previous year. A score of 8+ generally indicates harmful or hazardous drinking.
The Michigan Alcohol Screening Test (MAST) is one of the oldest alcoholism screening tests and is used for identifying dependent drinkers in the general population. The brief MAST is a series of 10 questions. The Short MAST is similar to the brief MAST and has 13 questions. The extended MAST consists of a more in-depth screening consisting of 25 questions. The MAST-G screening tool is specifically directed towards screening elder adults.
The MAST-G may be used more in an outpatient setting such as a primary care physician since the extended questioning of the MAST-G allows the treater to achieve better communication and rapport with the client.
It may be that providers will use one or a combination of the above screening tests, as well as questions derived from DSM-V to determine if a diagnosis of AUD is appropriate. If hospital staff make an initial assessment of AUD, the elder adult may be subject to a more in-depth assessment by a psychiatrist or geriatrician.
By becoming familiar with these screening tools, a child, spouse or other family member may be able to determine the extent to which the elder adult has been assessed for AUD.
Once diagnosed with AUD, an elder adult will likely need a multidisciplinary approach. The individual will likely need a inter-professional team, including physicians, nurse practitioner, social workers and therapists. A large community will often have a dedicated geriatric clinic. Such a clinic may offer psychiatric treatment consisting of medications, therapies and social supports. In addition, this type of clinic may have support groups and social work outreach. If the elder adult does not live in a community with such a clinic, the primary care physician is the first stop in a network of referrals for addiction assistance. The physician may also refer the elder adult to specialists to diagnose and address medical problems associated with, or exacerbated by, the AUD.
The most positive outcome for an elder adult with AUD is to voluntarily agree to treatment and other supports. Optimally, a spouse, family member or physician, or combination of people, will persuade the elder adult to seek assistance. A family intervention may be necessary to impress the seriousness of the situation on the individual who may be in denial.
The elder adult may be persuaded to surrender his or her keys to stop driving. Access to public transportation, dedicated transport for elderly adults or friends and family who can drive the elder adult
With family encouragement, the elder adult may agree to assistance with daily activities such as bill paying and grocery shopping.
If the elder individual with AUD has capacity and consents, a durable power of attorney is a valuable legal document to enable a family member, friend, or third party to provide financial and legal help. The durable power of attorney appoints another person as the agent for the elder individual. The agent can open and close bank accounts, pay bills, negotiate debt reduction and payment, cancel credit cards and resolve mortgage and tax arrearages. If family members can persuade the elder adult to grant power of attorney, it can be extremely helpful to assist the individual with financial and legal issues.
However, a power of attorney is only feasible if the elder adult has the requisite mental capacity. If the elder adult has preexisting dementia or other cognitive impairment linked to the AUD, the elder adult may not have the requisite capacity to execute the document. In addition, the power of attorney is no longer effective if the elder individual with AUD revokes the document. Accordingly, the legal authority granted under this document is only as good as the wishes of the elder adult.
Similar to the Power of Attorney, a Patient Advocate Designation, also known as a Health Care Power of Attorney, allows a substitute decision maker to make medical and placement decisions for the elder adult with AUD, if that individual cannot make those decisions. While this type of legal document is extremely useful, once again, the elder adult must have requisite mental capacity to execute the Patient Advocate Designation. As with the Power of Attorney, the elder adult must also be willing to allow another person make these decisions. If the elder adult is resistant to medical treatment of possible inpatient care or placement, he or she is unlikely to make this grant of authority.
Unfortunately, it is not uncommon that a situation involving an elder adult with AUD results in a crisis where the individual is hospitalized or in an extremely vulnerable situation. If the elder adult with AUD lacks capacity or objects to executing a Patient Advocate Designation, a Guardianship may be a necessary legal step to protect the individual.
A Guardianship is a proceeding in the Probate Court which provides court authority to the Guardian to make medical and placement decisions for the ward. The Guardianship petition should be filed in the Probate Court in the county in which the elder adult with AUD resides or is present. In other words, the Petition can be filed where the elder adult lives or in a county in which the adult is hospitalized or staying with family. Chronic intoxication and chronic use of drugs are each an applicable basis to find incapacity, along with underlying mental illness and physical illness and disability.
The difficulty lies when an elder adult with AUD clearly needs medical care and supports but he or she has not been found to be incapacitated. Since incapacity is a medical diagnosis, the Petitioner should seek a determination of incapacity by a psychiatrist or other physician who has treated the elder adult.
If the elder adult objects to the Guardianship, the Probate Court will appoint an attorney to represent the adult and will schedule an evidentiary hearing. In that case, the Petitioner can ask for an independent medical evaluation to determine capacity. Under certain circumstances, the Probate Court will appoint an emergency temporary Guardian if an emergency exists before the independent medical evaluation and Guardianship hearing are scheduled.
Like Guardianship, Conservatorship is a process through the Probate Court in which a third-party can petition for court authority to make financial and legal decisions for the elder adult with AUD. A Conservatorship proceeding must be filed in the county in which the elder adult resides. As with Guardianship, an evidentiary hearing will be scheduled by the Court if the elder adult objects to the Petition.
Under certain circumstances, the Probate Court can grant limited legal authority to a third party to assist an elder adult with AUD without the need for a Guardianship or Conservatorship. By issuing a protective order, the Probate Court can authorize, direct, or ratify a contract or other transaction relating to the protected individual's property and business affairs if the court determines that the transaction is in the protected individual's best interests.
In plain terms, a protective order allows a family member or interested third party to obtain legal authority from the Probate Court to address specific legal or financial matters for the elder adult with AUD. For example, an adult child could obtain a protective order to remedy mortgage arrears to prevent a foreclosure of the elder adult's property. Likewise, if the elder adult is vulnerable to financial abuse, the protective order could allow a concerned family member to freeze a bank account or cancel checks.
If the elder adult with AUD is resistant to a Guardianship or Conservatorship, a protective order may offer a compromise solution to assist the elder adult with a specific transaction.
If the elder adult with AUD refuses to stop driving, a family member or interested person can request a driver evaluation. Michigan law authorizes the Secretary of State (SOS) to re-examine a driver when there is reason to believe that the driver may be unable to operate a motor vehicle safely. The SOS will mail out an evaluation date to the elder adult. The SOS will also send out a medical statement and/or a vision statement to be completed by a physician or eye specialist.
If the elder adult with AUD is at risk and there are no Power of Attorney documents or Court granted authority, a family member, friend or third party can initiate an Adult Protective Services (APS) investigation. The person who initiates the investigation remains anonymous. APS staff will investigate allegations of abuse, harm or other serious concerns about the elder adult within 24 hours of the contact. APS can also initiate its own Guardianship proceedings or other legal action if it is deemed necessary to protect the elder adult with AUD from harm.
The best case scenario for an elder adult suffering from AUD is having family support to aid in recovery, medical care and to protect the elder adult from harm caused by problems related to AUD. If there is no family support, or the elder adult is in denial or resistant to help, concerned friends and family should consider legal options to assist with financial and medical decisions for the elder adult.