The drinking generations: alcohol and the over-fifties
Risky drinking – in decline among young people – is a growing problem among those in their fifties, sixties and seventies. The good news is that older people respond well to intervention.
Risky drinking – in decline among young people – is a growing problem among those in their fifties, sixties and seventies. The good news is that older people respond well to intervention
When you think about a problem drinker, the image that comes to mind probably isn’t Tom or Barbara from The Good Life – or indeed their snobbish neighbours Margo and Jerry.
But the Goods and the Leadbetters were constantly reaching for the gin and tonic or heading to the pub for a pint, and who could forget the Christmas 1977 episode where all four got sloshed on home-made peapod burgundy?
Even today, it’s hilarious – but the health impact of the 1970s' relaxed attitude to alcohol, exemplified by The Good Life, is far from funny. Adults who liked a drink in the 1970s and 1980s are still drinking. Figures from NHS Digital show that in 2015-16 there were 1.1 million hospital admissions related to alcohol in England alone, and 45% of the patients were aged between 55 and 74, higher than for any other age group.
Population at risk
Experts have also warned that while risky drinking is declining in the UK and Australia, the over-fifties are bucking that trend and are drinking more.
‘At a public health level we are faced with a population at risk from alcohol misuse, influenced by early life exposure to advertising, the social acceptability of intoxication and ongoing increasing affordability and ready access to alcohol,’ says Tony Rao, co-chair of the substance misuse in older people working group at the Royal College of Psychiatrists.
‘One of the main problems is that alcohol misuse is often not detected, because the assumption is that alcohol misuse is a younger people’s problem. There can also be collusion from family, who make excuses for their relative’s disturbed sleep, for example, rather than admitting it is probably the result of drinking, and ageism from health professionals who don’t see this as something worth tackling at this stage in someone’s life.’
‘Screening and brief intervention is inexpensive and can improve health outcomes’
Dr Rao says this ‘therapeutic nihilism’ is partly to blame for the fact that older people attending A&E are less likely to be screened for alcohol misuse than younger people. This is the case even when alcohol is a likely contributor to their attendance, for example because they have fallen over while impaired by drink and fractured a hip or sustained a brain injury.
These patients are missing out on potentially life-saving or life-enhancing treatment, whether brief advice from a health professional or referral for specialist help.
The good news, says Dr Rao, who is also a consultant in old age psychiatry at South London and Maudsley NHS Foundation Trust (SLAM), is that older people do at least as well as younger age groups in terms of positive outcomes after intervention.
‘Screening and brief intervention is inexpensive and can improve health outcomes,’ he says, adding that SLAM has now introduced mandatory screening with the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT).
Motivated to act
‘Older people are often pleasantly surprised when informed that they can do something about their alcohol use, and are often motivated to take action,’ says Dr Rao.
The penalties of not tackling the problem are serious, he says. Older people, especially women, are more likely to experience harmful effects from alcohol than younger people, and are also more likely to be taking drugs that interact with alcohol, such as benzodiazepines and painkillers.
Older women are also more likely to be victims of domestic violence or other forms of abuse as a result of other people’s drinking.
RCN professional lead for public health nursing Helen Donovan says nurses are in a good clinical position to talk to people about the risks of drinking too much. ‘It’s similar to discussions about wider public health messages – it’s about making every contact count,’ she says.
‘It’s part of the nurse’s role to talk about a healthy lifestyle’
‘Even if someone is coming to see you for an entirely different reason, it’s part of the nurse’s role to talk about a healthy lifestyle, and that’s the case whatever the clinical setting, whether it’s practice nursing, in A&E, or anywhere else.’
Patients expect health professionals to talk about public health issues such as smoking, obesity and alcohol, and most are receptive, she adds. ‘One of the issues is that there are a lot of mixed messages out there. We need to be very clear that people should not be drinking more than 14 units of alcohol per week, and that they should have at least two to three alcohol-free days per week.’
She warns that messages around the so-called protective qualities of alcohol can also be misinterpreted – for example, if a paper is published saying that one glass of wine is good for your heart, some people will jump on that as a positive reason to drink, although the paper has been referring to ‘one glass of wine’ only.
Culture of drinking
Ms Donovan agrees that social acceptability and the availability of alcohol have contributed to a culture of drinking in the over-fifties, and says different public health strategies are required for different age groups. While she backs the implementation of a minimum unit price for alcohol, she says additional action is needed to target older people.
‘The older generation aren’t, in general, consuming the cheap ciders and the strong lagers. It’s the shared bottle of wine every day of the week that’s the problem.’
Raising awareness of the health consequences of long-term drinking is also important, she adds. ‘For example, we know that alcohol can cause some forms of dementia. People are living longer, and with long-term conditions, so this is something that we need to take seriously, and nurses have a real role to play.’
The level of alcohol harm is higher in Scotland than in the rest of the UK. There were 1,265 alcohol-related deaths in Scotland last year, the vast majority aged over 45. Again, men in the older middle-age brackets are more likely to drink hazardously or harmfully than younger people – 40% of men aged 55-64 did so, compared with 34% of those aged 16-24.
‘It’s concerning that so many people in their fifties and sixties are classed as hazardous and harmful drinkers’
Alison Douglas, chief executive of Alcohol Focus Scotland, says: ‘It’s concerning that so many people in their fifties and sixties are classed as hazardous and harmful drinkers, increasing their risk of cardiovascular disease, cancer, liver damage and mental health problems.
‘Sadly, we are also seeing high rates of alcohol-related hospital admissions and deaths among the over-fifties.
‘The baby boomers have lived through a time when alcohol has become increasingly affordable, widely available and socially acceptable. Alcohol is 60% more affordable than it was in 1980, particularly in supermarkets, where we now buy most of our alcohol.
‘Health professionals play an important role in identifying and supporting people who are drinking too much. However, we can prevent problems developing in the first place by making it easier for people to drink less. The Scottish government’s upcoming alcohol strategy must focus on reducing the widespread availability and marketing of alcohol.’
The Royal College of Psychiatrists working group on substance misuse in older people is due to publish an updated report on the issue next year – and it is likely to have a strong focus on women. ‘In 2005-06, three in ten of all alcohol-related admissions were women. In 2015-16 this rose to four in 10. So the gender gap is closing,’ says Dr Rao.
‘For alcohol-related deaths, between 2005-06 and 2015-16 there was an increase of 9% in the 45-59 age group versus 29% in the 65-79 age group among women.’
Dr Rao would like to see improved awareness of drinking guidelines among nurses and other health professionals, and better screening, including detection of mental disorders – which can lead to alcohol misuse – and use of other drugs such as painkillers.
He would also like better access to psychological therapies for drinking problems and accompanying mental disorders, and better integration between health and social care professionals.
These are practical steps, but he would also like to see a cultural change among baby boomers and the generation just behind them. ‘It’s important to stop it before it becomes a habit,’ he says.
‘Yes, it’s about availability and about lack of awareness of glass sizes, for example. But it’s also attitudinal – among the baby boomer cohort it’s socially acceptable to drink. But when it comes to people’s health, that’s far from a recipe for The Good Life.’
Intervention in the community
As an alcohol community nurse, Jill Emmerson leads a team that works in GP practices to tackle problem drinking, ideally before it becomes a problem.
The Foundations GP alcohol project works with practices in Middlesbrough to identify patients who might need help with an alcohol problem. Using the AUDIT-C tool, which consists of a few brief questions about people’s alcohol use, project workers can offer immediate help or advice, or direct people to specialist support provided by Ms Emmerson and colleagues.
‘We are seeing more people in the over-fifties age group,’ she says. ‘Life expectancy is increasing, and people’s lifestyle choices are catching up with them.’
Drinking alcohol above the recommended limits has health consequences, she says, including impaired judgement, which can lead to risky behaviours, and problems with balance and co-ordination, which can lead to falls.
The liver takes longer to process alcohol as people grow older, she adds, especially if they are taking prescription or non-prescription drugs.
‘We know that alcohol increases the risk of stroke, heart disease and some cancers,’ she says. ‘People focus on the impact on the liver, but it also has a major impact on the heart, and on mental health problems as well.’
Retirement can be a trigger for drinking more, she believes, which could be one factor in the growth in alcohol misuse in older people. ‘People are retiring earlier and going into holiday mode, which maybe involves having a little tipple through the week. We all go on holiday, but most of us come back to work and behave accordingly. That’s not the case if you are retired.’
Her service sees people from all walks of life and at all stages, from the person who is drinking above the recommended limits to the person who has an alcohol addiction.
One of the major aims is to tackle the stigma associated with addiction services. She sees their role as bringing alcohol services to the GP practice, so people feel they are going to the doctor rather than to an identified addiction service.
Where a problem is identified the service works with individuals for five sessions in the GP practice setting. People are given a thorough health check and questioned about their alcohol use and lifestyle. The service can detox patients and offer medication to prevent a relapse.
It has had a positive impact, with 11 out of the 18 GP practices that are taking part showing a vast improvement in A&E attendances, while engagement with alcohol services has also improved.
Ms Emmerson would like action taken more widely to tackle the UK’s alcohol problem. ‘There’s a need for more publicity – people don’t necessarily understand what a unit is,’ she says. ‘And we also need to tackle pricing – alcohol is so cheap, and that is simply wrong.’
Jennifer Trueland is a freelance journalist