O’Connell and colleagues rightly highlight the ‘silent epidemic’ of
alcohol use disorders in elderly people (1), but the role of mental health
services may have been understated.
Services for older people with alcohol misuse face considerable
challenges. The United Kingdom 2001 General Household Survey found that
15% of men and 6% of women reported drinking above recommended ‘sensible’
limits of 21 and 14 units of alcohol respectively, during the previous
week (2). This may be an underestimate, given that the survey relies on
self report rather than other methods of obtaining information. As
parameters defining ‘sensible’ drinking do not fall with age, it is also
likely that older people may be at greater risk from the hazards from the
same levels of alcohol intake. As pointed out in the review, elderly
people are more sensitive to the harmful effects of alcohol than their
younger counterparts. However, it is inaccurate to state that metabolism
and excretion are ‘largely unchanged’, as it is known that there is a
reduced body water to fat ratio, decreased hepatic blood flow, a decreased
rate of hepatic alcohol metabolism and reduced renal clearance with aging.
Reasons for under-detection and misdiagnosis are explored, but one of
the landmark studies in this area has been left out. This was the striking
finding that a quantitative alcohol history was taken in only 2 out of 56
people aged 65 and over, admitted with an acute medical condition to a
Nottingham hospital(3). It is all the more relevant in light of alcohol
misuse being present in 15 per cent of liaison psychiatry referrals to an
inner city London teaching hospital, with 25 per cent of referrals with
alcohol misuse in the same study showing a depressive disorder (4).
Unfortunately, the review article does not do justice to the
implications of alcohol misuses for mental health services. Alcohol
remains a legal and readily available drug that is taken outside the
auspices of medical care; mental health problems such as harmful drinking
and alcohol dependence do not fall within the remit of the Mental Health
Act, unless accompanied by a comorbid mental disorder, commonly depression
or dementia.
Mental health service planners for older people who misuse alcohol
are left with a dilemma. One of the possible strategies is to incorporate
older people into dual diagnosis services, so that both alcohol misuse and
mental disorders can be treated together. The operational framework for
managing alcohol misuse could run along similar lines to severe mental
illness. A proposed model that is currently widely used in the United
Kingdom is the ‘SIDD’ definition, comprising dimensions of Safety,
Informal/formal care, Diagnosis, Disability and Duration (5). Sadly, such
services for older people are few and far between.
The road to planning, implementing and evaluating mental health
services for older people with alcohol misuse requires a clearer vision.
At present, vulnerable older people who require assessment and treatment
are stranded between parallel medical and mental health services.
At best, there is a limited place for them in whatever dual diagnosis
services exist. At worst, we have done no more than scratch the surface of
a problem that will continue to weigh heavily upon services that remain
ill equipped to meet its needs.
(1) O’Connell H et al. Alcohol use disorders in elderly
people—redefining an age old problem in old age. BMJ 2003;327:664-667
(2) Walker A et al. Living in Britain. Results from the 2001
General Household Survey. 2002; London:Office of National Statistics
(3) Naik PC, Jones RG. Alcohol histories taken from elderly people
on admission BMJ 1994;1308:248
(4) Rao R. ‘Sadly confused’: the detection of depression and dementia
on medical wards. Psychiat. Bull. 2001;25: 177-179
(5) Department of Health. Building Bridges: A Guide to Arrangements
For Inter-agency Working For the Care and Protection of Severely Mentally
Ill People. 1995;London: Department of Health
Rapid Response:
Mental Health Services face tough challenges
Dear Sir
O’Connell and colleagues rightly highlight the ‘silent epidemic’ of
alcohol use disorders in elderly people (1), but the role of mental health
services may have been understated.
Services for older people with alcohol misuse face considerable
challenges. The United Kingdom 2001 General Household Survey found that
15% of men and 6% of women reported drinking above recommended ‘sensible’
limits of 21 and 14 units of alcohol respectively, during the previous
week (2). This may be an underestimate, given that the survey relies on
self report rather than other methods of obtaining information. As
parameters defining ‘sensible’ drinking do not fall with age, it is also
likely that older people may be at greater risk from the hazards from the
same levels of alcohol intake. As pointed out in the review, elderly
people are more sensitive to the harmful effects of alcohol than their
younger counterparts. However, it is inaccurate to state that metabolism
and excretion are ‘largely unchanged’, as it is known that there is a
reduced body water to fat ratio, decreased hepatic blood flow, a decreased
rate of hepatic alcohol metabolism and reduced renal clearance with aging.
Reasons for under-detection and misdiagnosis are explored, but one of
the landmark studies in this area has been left out. This was the striking
finding that a quantitative alcohol history was taken in only 2 out of 56
people aged 65 and over, admitted with an acute medical condition to a
Nottingham hospital(3). It is all the more relevant in light of alcohol
misuse being present in 15 per cent of liaison psychiatry referrals to an
inner city London teaching hospital, with 25 per cent of referrals with
alcohol misuse in the same study showing a depressive disorder (4).
Unfortunately, the review article does not do justice to the
implications of alcohol misuses for mental health services. Alcohol
remains a legal and readily available drug that is taken outside the
auspices of medical care; mental health problems such as harmful drinking
and alcohol dependence do not fall within the remit of the Mental Health
Act, unless accompanied by a comorbid mental disorder, commonly depression
or dementia.
Mental health service planners for older people who misuse alcohol
are left with a dilemma. One of the possible strategies is to incorporate
older people into dual diagnosis services, so that both alcohol misuse and
mental disorders can be treated together. The operational framework for
managing alcohol misuse could run along similar lines to severe mental
illness. A proposed model that is currently widely used in the United
Kingdom is the ‘SIDD’ definition, comprising dimensions of Safety,
Informal/formal care, Diagnosis, Disability and Duration (5). Sadly, such
services for older people are few and far between.
The road to planning, implementing and evaluating mental health
services for older people with alcohol misuse requires a clearer vision.
At present, vulnerable older people who require assessment and treatment
are stranded between parallel medical and mental health services.
At best, there is a limited place for them in whatever dual diagnosis
services exist. At worst, we have done no more than scratch the surface of
a problem that will continue to weigh heavily upon services that remain
ill equipped to meet its needs.
(1) O’Connell H et al. Alcohol use disorders in elderly
people—redefining an age old problem in old age. BMJ 2003;327:664-667
(2) Walker A et al. Living in Britain. Results from the 2001
General Household Survey. 2002; London:Office of National Statistics
(3) Naik PC, Jones RG. Alcohol histories taken from elderly people
on admission BMJ 1994;1308:248
(4) Rao R. ‘Sadly confused’: the detection of depression and dementia
on medical wards. Psychiat. Bull. 2001;25: 177-179
(5) Department of Health. Building Bridges: A Guide to Arrangements
For Inter-agency Working For the Care and Protection of Severely Mentally
Ill People. 1995;London: Department of Health
Competing interests:
None declared
Competing interests: No competing interests