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Alcohol Use in Long-Term Care Communities: Juggling Choice and Safety

      Alcohol consumption is a part of life for many people, and nearly half (43.9%) of Americans aged 65 and older consume alcohol. It’s not surprising that many want to continue to drink in some capacity after they enter a post-acute and long-term care facility. But this can present a challenge for practitioners and staff in their efforts to balance safety and choice.
      Drinking “is very much a quality-of-life issue,” said Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, professor and Sonya Ziporkin Gershowitz chair in gerontology at the University of Maryland School of Nursing in Baltimore. “In many facilities, we have a weekly happy hour, and some of the residents come out of their rooms for it but won’t for any other activities,” she said, showing that it can be an important social activity for some residents.
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      Alcohol consumption can be a normal and even beneficial part of life for many older adults, but it can also contribute to accidents, behavior issues, and drug interactions. How can facilities balance safety and choice?
      Photo by Pavel Danilyuk on Pexels.

      Perspective, Not Hysteria

      Alcohol consumption by residents needs to be on everyone’s radar because it can contribute to falls or other accidents, behavior issues, and/or complications from drug interactions. However, there is a common notion that all alcohol use is dangerous for older people, despite evidence to the contrary. As Paul Sacco, MSW, PhD, associate professor in the University of Maryland School of Social Work, says, your grandmother’s glass of wine is different than a young person drinking shots. “We need to avoid a hysterical response. We shouldn’t just unilaterally take away alcohol; instead, we should help patients to be informed consumers,” he said.
      Although some practitioners may be discouraging their patients from drinking alcohol, others see its value for some individuals. For example, Karren Ganschinietz, a long-time certified nurse assistant, says, “In private duty, I would fix a client a scotch and water every evening. Then when that individual was admitted to the hospital, the nurse would give them a drink every night. The physician wrote an order for it,” she said. These types of “social prescriptions” are becoming more popular as links between health, well-being, and quality of life have become more apparent.

      Conversations, Culture, and Cocktails

      “Patients often can be reliable reporters of their drinking, so I would go to them first. My experience is that they usually are honest about their drinking habits,” said Dr. Sacco. He noted it also is possible to use screening tools such as the Alcohol Use Disorders Identification Test (AUDIT, http://bit.ly/3EkOmcf) to identify unhealthy drinking habits. Any conversation with residents, he stressed, should involve nonjudgmental questions about the patient’s drinking. This includes being aware of language. For instance, he said, “You don’t want to ask people if they’re alcoholics. Instead, you want to ask questions calmly and clearly in a confidential setting.”
      Asking the right questions can clarify not only how much someone drinks but why they drink, and this can be very enlightening. “In asking about drinking, we can find out about things that are bothering [residents] such as boredom, sleeping problems, depression, or grief and if they are self-medicating with alcohol,” said Dr. Sacco. It may be possible to identify and address motives for unhealthy alcohol use.
      Of course, for some people having a glass of wine with dinner or a cocktail at cocktail hour has just been an important part of their daily routine. Taking the glass of wine or cocktail away from them when they enter a facility can feel like another loss — another thing they no longer have control over — and this can trigger feelings of grief, sadness, and even depression.
      “Maintaining a habit that you had when you were younger may be meaningful to some people, and you don’t want to immediately take that away from them,” Dr. Sacco said.
      Similarly, a margarita can trigger happy memories of a honeymoon in Mexico or a Friday happy hour can remind them of joyful times with friends and family. In these cases, the drink is much more than a drink — it is a link to a time in their life when they were healthy and surrounded by loved ones.
      Of course, when residents are cognitively impaired or otherwise unable to have a conversation about alcohol use, the family can be helpful. However, it is important to realize that not all family members may know or be willing to talk honestly about their loved one’s alcohol use or history of drinking.

      Step by Step

      It is useful to have some sort of alcohol/drug/tobacco assessment as part of every admission. Staff should be trained to have these conversations. Dr. Sacco stressed, “Drinking is deeply engrained in culture and very normative in many. You hear stories about things like a 100-year-old woman who drinks a glass of wine every day.” Dr. Resnick observed, “In my clinical work of 40 years, I always assume someone drinks and take it from there. If they say they don’t drink, that’s fine. If they do, we can talk about any medications that might contraindicate alcohol use or other issues as appropriate.”
      It is important to train staff about how to engage and to be careful about stereotypes, Dr. Sacco suggested. For instance, they shouldn’t make assumptions about someone’s drinking habits based on how they look and should be careful to not be paternalistic.
      At the same time, the staff need to know what signs of inebriation and alcohol abuse to watch for. Dr. Resnick said, “I had a resident go to the hospital once because they were drunk, but the staff thought they were having a stroke.”
      Dr. Resnick noted that while everyone becomes disinhibited when they drink, it is usually only problematic when they become verbally or physically abusive or if they are at risk for falling or doing something to hurt themselves or others. There are some people who drink too much but behave in a way that doesn’t put themselves or others at risk. “Even if it’s unhealthy for them, people have a right to drink. You can work with the family, especially if the person is no longer able to make decisions,” she said.
      While the facility care team can offer information and guidance to residents about drinking, they can’t unilaterally prevent residents from drinking or claim to be an alcohol-free residence. However, they can manage alcohol use to some degree. For instance, as Dr. Resnick said, happy hour can limit residents to two drinks and control the amount by ounce.
      The bigger problem, she said, is when friends and relatives bring in alcohol and do not inform the staff, or they take residents out for dinner and don’t monitor their alcohol intake. Dr. Resnick noted, “If someone comes back after leaving the facility, staff has every right to ask if they had anything to drink and address that appropriately.”
      Branden Fillbrook, a nursing home certified nursing assistant, said, “I’ve had residents ask me to buy or bring them alcohol and then get upset when I refuse. I explain that I can’t do this and that it would put my job and career at risk if I did. This generally ends the discussion.” However, the staff should know that if such situations persist or they feel threatened or even just uncomfortable, they should report it to a supervisor.

      Medications and Drinking

      Older adults may be taking medications that can interact with alcohol. Alcohol can disrupt the metabolism of the medication or interact with the medication and cause adverse health events and problems such as dizziness or sedation.
      Medications that can interact with alcohol appear in a number of drug classes, including analgesics (nonsteroidal anti-inflammatory drugs, acetaminophen, opioids), antibiotics (such as erythromycin), anticoagulants (warfarin), anticonvulsants (phenytoin), antidepressants (tricyclics, monoamine oxidase inhibitors), antidiabetic agents (such as insulin), antihistamine (ranitidine and cimetidine), antiprotozoal (metronidazole), antipsoriatic (acitretin), antipsychotics (phenothiazines), gastroprokinetic agents (cisapride and metoclopramide), nitrates (nitroglycerine), and sedatives (barbiturates and benzodiazepines). For a full table, see Edith V. Sullivan and Adolf Pfefferbaum, eds., Alcohol and the Nervous System, volume 125 of The Handbook of Clinical Neurology (Elsevier, 2014:543–559).
      There are many factors to consider regarding alcohol use and medications. “Depending on factors such as the volume or frequency of alcohol intake, the effects can vary. Some interactions can happen quickly — as soon as someone has one drink. Other interactions make take longer to appear,” said Stephen Creasy, PharmD, director of clinical services at PharMerica. In general, however, he suggested, “think of alcohol as a drug — a chemical that has an impact on various systems when it enters the body.”
      Of course, some impact of alcohol will depend on each person’s health. For instance, in people with diabetes, alcohol can affect blood sugar levels, and even occasional drinkers can be negatively impacted. Alcohol consumption also causes increased insulin secretion, leading to low blood sugar, or hypoglycemia.
      Dr. Creasy said, “You can work with the pharmacist to look at a patient’s regimen and potential interactions with alcohol. They can look for possible therapeutic alternatives or other ways to alter medication regimens.” It is important to talk with residents — and family members, as appropriate — about the potential impact of alcohol use. “Ramp this up when the person is being discharged. It is important to address these issues when someone goes home and you can’t control or monitor their alcohol use,” said Dr. Creasy. “The more alcohol the person consumes, the more of an issue it becomes.”

      Prohibition Isn’t the Answer

      It may seem like an easy answer just to say, “No drinking.” However, this interferes with residents’ rights and isn’t likely to stop those who really want to drink. It can also lead to other problematic behaviors, such as bartering with other residents for alcohol or asking staff to do things that make them uncomfortable.
      The authors of “Determinants for the Use of Alcohol in Long-Term Care Settings: A Comparative Analysis of Personal Choice, Public Health Advice, and the Law” (J Am Med Dir Assoc 2021;22:9–14) suggest considering three key frameworks for the risks involved in a resident’s choice to drink alcohol.
      • 1.
        Public health framework: “promotes elimination of risk as this removes the possibility of health-related harm and improves population health, which is perceived to be for the public good.” This perspective considers individual risks and benefits associated with consuming alcoholic beverages.
      • 2.
        Human rights framework: “considers the social and psychological harm experienced by an older person when something important or pleasurable — such as the choice to drink alcohol — is removed, including social isolation, loss of culture and frustration at loss of control over decision-making.”
      • 3.
        Legal framework: involves “legal mechanisms, in the form of legislation, regulations, and common law (judge-made law) govern a resident’s decision to consume alcohol,” including residents’ rights. This framework also addresses decision-making capacity — that is, the resident’s cognitive ability to make informed decisions about alcohol consumption.
      Integrating these frameworks can help facilities develop and implement policies and practices that effectively balance patients’ rights and autonomy with safety. It also helps ensure that residents and family understand the risks of alcohol use. This is significant because they need to understand how their behaviors impact themselves and others.
      Senior contributor Joanne Kaldy is a freelance writer in New Orleans, LA.

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