Alcohol in the older population, Part 2: MAST you speak the truth in an AUDIT or are you too CAGE-y?

Do screening tests really work? 

Screening tests can be useful and provide the basis for further discussion. However, as those who regularly deal in substance abuse assessments know, clients are aware of the tests and do know how to answer the questions that will put the “best face” on the outcome. This desire to present the ideal scenario holds true not just for alcohol but for all forms of socially sanctioned behavior and derives from basic psychological defense mechanisms. A case manager may want to consider, “How would I answer these questions if a stranger asked me?” and “If I were drinking, would I want to answer these questions? Would I be truthful?”

What screening tests might be useful? 

MAST 

Another test that has been used for many years is the Michigan Alcohol Screening Test (MAST). The questions are more specific and have the usual caveats that a client may not answer truthfully. However, the MAST itself is geared to a younger population, so the University of Michigan additionally developed a test specific to the older population: the Michigan Alcohol Screening Test–Geriatric Version (MAST-G). Shown in Table 1, this screen takes into account some of the changes of social and physiological behavior associated with older populations. The differences in the questions between the MAST and the MAST-G are obvious, as is the descriptive language used to ask them. The questionnaire can be found in the Substance Abuse and Mental Health Services Administration and the Center for Substance Abuse Treatment's Treatment Improvement Protocols (TIP), TIP 26: Substance Abuse Among Older Adults. This is an excellent resource, dealing with broad-spectrum substance abuse.

Table 1. Michigan Alcoholism Screening Test—Geriatric Version (MAST-G)

	1. After drinking, have you ever noticed an increase in your heart rate or beating in your chest?	YES	NO
	2. When talking with others, do you ever underestimate how much you actually drink?	YES	NO
	3. Does alcohol make you sleepy so that you often fall asleep in your chair?	YES	NO
	4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?	YES	NO
	5. Does having a few drinks help decrease your shakiness or tremors?	YES	NO
	6. Does alcohol sometimes make it hard for you to remember parts of the day or night?	YES	NO
	7. Do you have rules for yourself that you won't drink before a certain time of the day?	YES	NO
	8. Have you lost interest in hobbies or activities you used to enjoy?	YES	NO
	9. When you wake up in the morning, do you ever have trouble remembering part of the night before?	YES	NO
	10. Does having a drink help you sleep?	YES	NO
	11. Do you hide your alcohol bottles from family members?	YES	NO
	12. After a social gathering, have you ever felt embarrassed because you drank too much?	YES	NO
	13. Have you ever been concerned that drinking might be harmful to your health?	YES	NO
	14. Do you like to end an evening with a nightcap?	YES	NO
	15. Did you find your drinking increased after someone close to you died?	YES	NO
	16. In general, would you prefer to have a few drinks at home rather than go out to social events?	YES	NO
	17. Are you drinking more now than in the past?	YES	NO
	18. Do you usually take a drink to relax or calm your nerves?	YES	NO
	19. Do you drink to take your mind off your problems?	YES	NO
	20. Have you ever increased your drinking after experiencing a loss in your life?	YES	NO
	21. Do you sometimes drive when you have had too much to drink?	YES	NO
	22. Has a doctor or nurse ever said they were worried or concerned about your drinking?	YES	NO
	23. Have you ever made rules to manage your drinking?	YES	NO
	24. When you feel lonely, does having a drink help?	YES	NO

Scoring: Five or more “yes” responses are indicative of an alcohol problem. For further information, contact Frederic C. Blow, PhD, at University of Michigan Alcohol Research Center, 400 E. Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952. Source: Blow FC, Brower KJ, Schulenberg JE, Demo-Dananberg LM, Young JP, Beresford TP. The Michigan Alcoholism Screening Test–Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research 1992;16:372. (c) The Regents of the University of Michigan, 1991.

AUDIT 

Another useful tool is the Alcohol Use Disorders Identification Test, referred to as the AUDIT (Table 2). The World Health Organization publishes a manual on its use and how to introduce the test, along with the measure and concerns that stem from the measures.

Table 2. The AUDIT Questionnaire

	Circle the number that comes closest to the patient's answer.
	1. How often do you have a drink containing alcohol?
	(0) Never	(1) Monthly or less	(2) Two to four times a month	(3) Two to three times a week	(4) Four or more times a week
	2. How many drinks containing alcohol do you have on a typical day when you are drinking? (Code number of standard drinks)1
	(0) 1 or 2	(1) 3 or 4	(2) 5 or 6	(3) 7 to 9	(4) 10 or more
	3. How often do you have six or more drinks on one occasion?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	4. How often during the past year have you found that you were not able to stop drinking once you had started?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	5. How often during the past year have you failed to do what was normally expected from you because of drinking?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	7. How often during the past year have you had a feeling of guilt or remorse after drinking?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?
	(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
	9. Have you or someone else been injured as a result of your drinking?
	(0) No	(2) Yes, but not in the past year		(4) Yes, during the past year
	10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
	(0) No	(2) Yes, but not in the past year		(4) Yes, during the past year

	Procedure for scoring AUDIT
	Questions 1–8 are scored 0, 1, 2, 3, or 4. Questions 9 and 10 are scored 0, 2, or 4 only. The response is as follows:
		0	1	2	3	4
	Question 1	Never	Monthly or less	Two to four times per month	Two to three times per week	Four or more times per week
	Question 2	1 or 2	3 or 4	5 or 6	7 to 9	10 or
	Questions 3–8	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
	Questions 9 and 10	No		Yes, but not in the last year		Yes, during the last year

Total scores of 8 or more are considered hazardous use.

As with all tests, the case manager should record answers carefully, using a comments section to explain any special circumstances, additional information, or clinical inferences. Often patients make comments or elaborations about their drinking that can help in making a determination of the total AUDIT score.

What do I do with someone who will not answer or is evasive? 

In the substance abuse treatment community, hesitancy or evasiveness is a warning flag, indicating the need for follow-up. Rephrasing the questions sometimes works. For other clients who challenge your need to know, a brief, light, nonjudgmental explanation of the purpose of your inquiry sometimes helps. Reframing may put the client at ease, especially if he or she considers alcohol use to be associated with shame or guilt, and the case manager can place it into a medical history framework.

Working with medical staff and having access to medical test records can be a means of checking the veracity of a person's self-report. For example, the gamma glutamyl transferees in the plasma (GGTP) test looks at a specific enzyme found in the liver and is a measure of function associated with liver injury or disease that may be associated with (but is not limited to) alcohol use. A difference between a person's self-report and the GGTP may warrant further investigation and follow-up. Discussing such tests and their results with the primary care physician is encouraged.

My client drinks just a couple of drinks a day. How can such a small amount be a problem? 

Actually, it can be—and many older people are unaware of the implications of their changing physical state and how it interplays with alcohol use. Not infrequently, body mass changes, weight decreases, and the ability to tolerate the previously “normal” number of drinks in a given situation is diminished. Controlled tests on blood alcohol content (BAC) levels, measured on the basis of numbers of drinks and body weight, have shown older persons to maintain a higher BAC level than those of younger persons, leading to the hypothesis that the older body does not metabolize alcohol as efficiently. Prescription and over-the-counter (OTC) medication effectiveness are influenced by alcohol use; some responses are exaggerated or potentiated in the mix. An example of this is antihistamines and alcohol, the combination of which exaggerates the drowsy effect of each. A more thorough explanation of the interactions of medications can be found in the National Institute of Alcohol Abuse and Alcoholism's publications, including their recent Alcohol Alert. These handy, quick references can help explain the case manager's concern and need for screening. The site is www.niaaa.nih.gov.

Now that I have done the screening, what does it mean? 

Once a diagnosis or concern has been identified, treatment is a viable option at any age. The consensus is that the shorter the drinking history is, the more successful the treatment will be. Thus, screening can identify a problem before it is of serious clinical concern and may avoid a problem altogether; identifying the problem as soon as possible can increase the chances for a positive treatment outcome.

What are some treatment considerations? 

Regardless of the diagnosis, older persons' needs and abilities must be taken into account. Depending on age and functioning, consideration includes a slower-paced therapy, addressing physical limitations and accessibility (including transportation) and attention to social supports.

For older persons, in the initial stages of alcohol misuse or abuse, a general education is beneficial. In this regard, a medication review with contraindications of alcohol use may be appropriate, as may be a discussion of body changes over time and the increased negative effects of alcohol use from a physiological aspect. Practically speaking, listening to why the client drinks may be helpful in addressing the amount of alcohol consumed. An example is the older drinker who may perceive a benefit in having a nightcap to fall asleep, unaware of alcohol's interference with normal sleep patterns that result in the client falling asleep but not sleeping soundly or restfully. In terms of general physical health and education, the older person may not be aware that there are alcohol-related vitamin and general dietary deficiencies when alcohol curbs appetite or does not permit proper absorption and processing of food. The client may not be aware of how alcohol impairs cognition and recall, and thus the number of “senior moments” may increase as a result of alcohol use. And, in terms of OTC medications, has the client read the label? Not infrequently there is habitual use of a medication without thinking about contraindications or complications resulting from concurrent alcohol use—such as the classic example of antihistamines and alcohol—and the increased drowsiness expressed as a symptom is related to a specific medication that has been taken without consideration of the synergistic effects when mixed with ethanol.

Heavy drinkers who do not see the need to change their lifelong patterns may benefit from the case manager's supplying information on normative drinking behavior. That simple understanding may be sufficient to begin the process of change. The goal in this case is to reduce drinking to a level that decreases the likelihood of negative consequences and increases the client's positive function.

For those who meet the criteria of dependence, abstinence is considered the best end result. For those with physiological dependence, medical intervention is mandatory and is often done on an inpatient basis as a precaution, because withdrawal from alcohol can be life-threatening. There may be additional complications from age-related health concerns as well as other medication issues. The problem with inpatient treatment is what arises after a client leaves the medical setting: Will the client's relationship to alcohol change in the daily social environment? This means not only detoxification but also longer-term rehabilitation. Some clients may need medication specific to alcohol abuse, ones that help to decrease craving or have an aversive effect if alcohol is consumed. Use of these medications must be assessed individually and with full knowledge of the older person's other medical concerns and prescriptions. A physician who is certified by the American Society of Addiction Medicine or is very familiar with medical management of alcoholism would be an asset. For older persons who have serious illness and pain issues, consultation with a pain management specialist who also knows the ramifications of substance and alcohol abuse is imperative.

Some clients may meet the criteria for dependence without physiological dependence; they are not at biological functioning risk. Changing the patterns of a lifetime is not easy and may have to take place over time. Initially a clinician's work may be related to harm reduction, focusing on a general decrease in consumption, slowly changing the client's drinking pattern, which may eventually lead to abstinence. There are several books and pamphlets outlining means for education and basic primary treatment, and a case manager who is familiar with the techniques will facilitate the treatment direction. Generally, attitudes and behaviors can be changed in several ways, most of which emphasize the ability and the personal responsibility of the client for the behavior and include individual and group therapy, brief intervention techniques, and outside support. Again, medication may be beneficial if it is not contraindicated by other ongoing medical conditions.

But I am not a substance abuse specialist! What do I do? 

For case managers, it is vital to remember that alcohol abuse does not take place in a vacuum. Older persons have specific susceptibilities and needs that must be addressed in treatment. Regardless of the diagnosis—abuse or dependence—for older persons to effect a change in behavior, the case manager and client must understand the factors contributing to alcohol use. This means that for those who are facing a major situational life change, such as retirement and an attendant loss of identity, and use alcohol to address such issues, assisting the older person in finding a way to feel productive and contributory is mandatory in changing drinking patterns. If grief and loss are significant, contact with a grief therapist or other support group dealing with bereavement is important. Should isolation be a contributor to drinking, that becomes the focus of clinical intervention.

Case managers can approach alcohol issues as a collaborative process. Using the local community and treatment providers means having a team approach to the client's alcohol use. Social workers and psychologists will be able to assist in addressing the psychological and mental health needs of the client, including isolation and stress issues. If the clinician knows and understands the issues of substance abuse, then one team member may be sufficient. However, professionals should not overstep or overreach their level of competence. The case manager should ascertain the credential and treatment approach, as well as the expertise in geriatrics, of the provider.

Should the case manager consider a formal treatment program, knowing the program, its population draw, and the philosophy and dynamics of the program is essential. The 70-year-old alcoholic who is retired and has never been in trouble may not relate to a treatment center that specializes in middle-age alcoholics with legal involvement and polydrug users. Treatment should be appropriate and match the needs of the client across many parameters. Case managers are encouraged not to just talk to staff at the treatment center but to visit the center, speaking with staff, seeing the physical plant, and making sure of accessibility and the ability of the center to truly meet the client's needs.

Outside support groups that encourage abstinence are available; the best known of these self-help groups is Alcoholics Anonymous. For many persons, regardless of age, attending such a meeting for the first time is a challenge and is perceived as an admission of alcoholism; the client may be resistant to such admission because of the stigma attached to doing so. Other options for social support include self-management and recovery training (SMART), Secular Organizations for Sobriety, church groups, or the use of social clubs or activities that encourage positive behaviors not associated with alcohol. A case manager should become familiar with organizations in his or her area, attend the meetings to verify the philosophy of the group, and be able to proceed with a suggestion to attend the program(s). The personal touch often is a key to having a client consider attending and in later discussions can serve as a springboard for follow-up questions and encouragement.

That seems like a lot of work. Why should I see these places or talk to outside providers? 

In a word: credibility. A client is more willing to trust the case manager who can explain a program's setting and theory, the way to get there, and the age range and philosophy of the provider. Having this knowledge will assist the case manager in matching the client to the program, and if there are problems down the road, the case manager will have contacts with whom to discuss the case and any alternatives. Yes, it is work, often “extra” work. But knowing the person to whom one is referring or the resources of the community maximizes the chances for a positive treatment outcome.

What about slips or relapse? 

It happens. The first thing to keep in mind is simply that it is not unexpected—not in the younger or older population. The length of relapse and its impact can be lessened, however, by early intervention. Therefore, a case manager benefits from having regular contact with the older person and repeating or reviewing the initial alcohol assessment at intervals to check on functioning and any changes. Maintaining contact with the treatment team and outside providers also is important, as collaborative colleagues may see changes in attitude or behavior that will benefit from quicker intervention—staving off a long-term relapse. A key to addressing a slip or relapse is the openness of communication that permits the evaluation of “triggering issues”—the situations or occurrences that lead to the return to use—this may be indicative of the return of a stressor, such as an ill spouse or the death of a spouse; a change in living, financial, or social status; or change in personal health. A relapse or a return to risky behavior necessitates reassessment of needs and goals.

Any last thoughts? 

Our aging population is but a mirror of ourselves. It reflects what is in all of us: a lifetime of both joy and sadness. The many senior years our clients and we have left should be lived as fruitfully as possible. We need to recognize that no one—not at any age—is immune to alcohol abuse or addiction.

To be effective, case managers must be aware of the potential and actual problems associated with alcohol abuse and must be able to address them. In the process we can secure for our clients the services they need. At the same time, we are providing for ourselves.

This article is, at best, the tip of the proverbial iceberg. It is offered in outreach to fellow clinicians in hopes of encouraging a greater understanding of substance use and the support mechanisms necessary to ensure that the golden years of our clients are fruitful, productive, and filled with moments of joy.