CARE OF THE OLDER PERSON

The role of community nursing

in providing integrated care for
older people with alcohol misuse
Tony Rao
Tony Rao is Consultant Old Age Psychiatrist and Visiting Researciter, Soutii London and Maudsley NHS Foundation Trust and
Institute of Psychiatry
Email: tony. rao(^lam. nhs. iik

lcohol misuse is accompanied by considerable

disability. In Europe, the disease burden attributable to alcohol (as measured by disabilityadjusted life years) represents the third commonest risk
factor, second only to high blood pressure and smoking
(Rehm et al, 2012).
About two thirds of men and one third of women aged
65 and over in the UK drink alcohol at least once a week.
Approximately 19% of men and 5% of women in the
same age group drink more than 4 and 3 units, respectively, on any one day (Office for National Statistics, 2013a).
There has been an increase in the percentage of older
people exceeding recommended daily drinking limits by
about 40%) in men and by 100%) in women between 1990
and 2006 (Health and Social Care Information Centre,
2009). Given that the UK population of over 65s is set
to rise by a further 15%> over the next 10 years, to over
10 million people, the public health and clinical implications of alcohol misuse in older people will continue to
grow. This may be especially important for populations
that are at particular risk, such as certain black and ethnic

ABSTRACT
Alcohol misuse in older people is a growing problem for health and social
care providers, but remains largely hidden from public view and therefore
largely overlooked by commissioners. Many older people with alcohol
misuse have a 'dual diagnosis' (alcohol misuse accompanying other mental
disorders) rather than alcohol misuse alone, which requires specialist
nursing expertise. Over the past 10 years, assessment of and interventions
for the detection of alcohol misuse in older people have been developed
within one London borough. This article details the background, strategy
and outcomes of this service, which provides integrated care in a multidisciplinary community mental health team covering an inner-city area with a
high prevalence of alcohol misuse and dual diagnosis in older people.

KEYWORDS
Older people Alcohol misuse Integrated care
Nursing interventions

80

minority groups (e.g. older Irish people), particularly in

areas of high socio-economic deprivation (Rao, 2006).
Alcohol-related deaths and admissions to hospital have
risen considerably over the past 15 years in the UK. From
1991 to 2011, alcohol-related mortality rose by nearly
90% in men in the 5574 age group and 40% in the
75+ age group (Office for National Statistics, 2013b).
Although the north-west of England has the highest prevalence of such mortality m younger age groups, London
has the highest prevalence in the over-75 age group. This
is magnified in boroughs with high levels of deprivation
(e.g. Southwark).
The number of people between the ages of 60 and 74
admitted to hospitals in England with mental and behavioural disorders associated with alcohol use has risen by
150% over the past 10 years. Those aged 75 and over
experience longer periods of hospitalisation than their
younger counterparts. In addition, the number of people
aged 60 and over admitted to hospitals in England with
WernickeKorsakoff syndrome (alcohol-related brain
injury leading to irreversible memory impairment) has
risen by over 140%) over the past 10 years, compared
with an almost static rise in the 15-59 age group
(Alcohol Concern, 2013). These overall findings cannot
be explained purely by rising numbers of older people in
the general population given that the population of people aged 65 and above in England and Wales increased by
11% between 2001 and 2011.
Among people aged 65 and above, London has one of
the highest rates of alcohol-related hospital admissions in
England. Southwark (particularly in the north of the borough, which is covered by the service described below)
has one of the highest rates of such admissions in London.
It also has a rate of alcohol-related mortality in men aged
75 and over that is two and a half times the London average. Older people in Southwark therefore represent a
population at high risk of alcohol misuse.
Ethnicity has the greatest influence over alcohol misuse
in north Southwark, which has one of the largest populations of older Irish men in London. This population

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CARE OFTHE OLDER PERSON

is known to have high rates of mental and behavioural
disorder associated with alcohol misuse of alcohol misuse (Southwark Council, 2013). Older Irish people in
Southwark have a higher prevalence of binge drinking
and drinking above sensible limits compared with older
people in Ireland (Rao et al, 2008), which may have
been influenced by social adversity and marginalisation.
Southwark is also the third most deprived borough in
London. Other influences include a high level of deprivation (Bardsley and Morgan, 1996), as well as more general
factors known to be associated with alcohol misuse in
older people. These include bereavement, depression,
social isolation, retirement and immobility (Crome et al,
2011).

An integrated Community Mental

Health team
North Southwark Community Team for Older People
is a multi-disciplinary community mental health team
(CMHT) responsible for a catchment area of approximately 13 000 people aged 65 and over. Within the
CMHT, there are four community psychiatric nurses, one
of whom has developed specific expertise in alcohol misuse and works alongside a consultant old-age psychiatrist
in the assessment, treatment and provision of aftercare for
older people with alcohol misuse and dual diagnosis. The
process below highlights the new expertise brought to
the team by incorporating innovative and unique nursing expertise in alcohol misuse and applying this to older
people.

Assessment of alcohol misuse

All referrals are assessed with a standardised generic assessment tool, supplemented by questions covering alcohol
use, particularly estimations of quantity/frequency for
alcohol intake. As part of the generic assessment, a more
specialised assessment covers a substance misuse history
and any associated physical and mental health problems.
This allows a formulation that includes predisposing
(e.g. genetic and early life experiences), precipitating and
maintaining factors to alcohol misuse, followed by a diagnosis and treatment plan.
A more detailed account of alcohol misuse included
the age of the person when they first drank alcohol and
the development of alcohol use/misuse, including any
dependence syndrome. Any other substance use/misuse
is also documented. Wherever possible, an age-specific
screening tool such as the Short MAST-G (Blow et al,
1992) is encouraged. The life history of the patient will
cover any family history of alcohol misuse, occupational
risks (e.g. high-risk occupations such as working in construction industry), domestic violence and relationship
problems, work record, forensic history (e.g. violence),
mental disorders (e.g. personality disorder, depression,
cognitive impairment such as dementia), self-neglect,
financial problems, activities of daily living and concerns
over safeguarding. Physical complications from alcohol
misuse are also covered, in conjunction with further

82

information from the patient's GP.

Nursing observations for signs of alcohol withdrawal
(e.g. tremor, sweating, agitation and sensory disturbance)
are also vital in the assessment of alcohol misuse, with
prompt referral to in-patient services for detoxification.

Short-term interventions for alcohol

misuse
Interventions are tailored according to the severity of
misuse, i.e. low, increasing, high risk or dependence. Brief
interventions for older people with alcohol misuse have a
proven clinical benefit in reducing both quantity and frequency of drinking (Schonfield et al, 2010). A systematic
review of 29 trials in primary care for younger people
found a reduction of 45 UK units of alcohol per week
compared with assessment only, treatment as usual, or
written information (Kaner et al, 2007).
Brief advice is given regarding sensible drinking and the
harms associated with alcohol. This is usually a conversation lasting 25 minutes, during which there is an estimation of drinking patterns, awareness of risks, benefits of
cutting down or stopping and advice on how to achieve
goals. Motivational enhancement treatment can be used to
extend such interventions and is a systematic intervention
approach based on the principles of motivational psychology that use motivational strategies to enhance a person's
own resources for changing the pattern of substance use
(Sellman et al, 2001). By using structured feedback, facilitating plans and assessing motivation to change drinking behaviour, progress is reinforced and reviewed with
a focus on enhancing reduction in high-risk drinking
behaviour.

Long-term community support

Community engagement is central to achieving successful health and social care outcomes. Home visits by the
community nurse as care coordinator offers a wealth of
opportunity in monitoring alcohol misuse, assessing level
of function, monitoring nutrition and compliance with
medication, as well as linking into constructive daytime
activities. The CMHT also has a support and recovery
worker who works alongside the specialist nurse to
accompany patients to local amenities such as day centres
and the GP surgeries. Other advocacy services can also be
accessed for befriending and advice on benefits. The final
outcomes achieved are harm reduction from alcohol and
improved health and social outcomes.

involving the multidisciplinary team

Successfully improving lives through addressing alcohol
misuse requires a coordinated approach from all health
professionals and support staff. There need to be clear
lines of communication with the consultant psychiatrist
if there are concerns over suicide risk, physical health
problems or medico-legal matters. Joint decision-making
at multidisciplinary meetings should involve expertise
from all health and social care professionals, together
with maintaining a care plan around alcohol misuse. This

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CARE OF THE OLDER PERSON

should also include using a Care Plan Approach (CPA),
supplemented by a risk assessment, crisis and contingency
plan, aU of which should be geared towards recovery.

Involving families and carers

Alcohol misuse may remain hidden within families, given
the stigma accompanying it. As such, families often take
several months or even years to identify a problem and to
then seek help.
Families may not be able to assess exactly how much
older people drink or may deny excessive use as a way of
justifying misuse by rationalising it as 'the only pleasure
they have'. However, they play a central part in motivating older people to seek for treatment for alcohol problems and community nurses form a core role in facilitating this process.

Legal and ethical aspects of care

Training in the assessment of capacity is essential for community nurses working with older people with mental
disorders. This is especially relevant given that one of the
core features of dependence syndromes is the persistence
of substance misuse in spite of being aware of the harm
from the substance being taken. Using the core feature
of harm awareness, an assessment of mental capacity
in substance misuse may therefore help to distinguish
unwise decisions from a lack of mental capacity. The latter
may also change over time and there is often a complex
interplay with periods of intoxication, depression and the
development of alcohol-related brain injury.
Elder abuse is not uncommon for older people with
alcohol misuse and community nurses should be aware of
the alerting procedures involved in safeguarding vulnerable adults.

The roie of community nursing in

service development
South London and Maudsley NHS Foundation Trust is
the first mental health trust to have developed a dual
diagnosis strategy, and this in the process of being implemented (Rao and Shanks, 2011). Community nurses are
central to delivering this strategy, with a nurse from each
team having undergone specialist training in this area
(Saxton et al, 2011).This has enabled a nurse in each of
the CMHTs for older people to have competencies in the
following areas:
Screening for the presence of concurrent mental
health difficulties and substance misuse
Developing and sustaining collaborative therapeutic
relationships with patients
Systematically assessing the needs of patients and
constructing basic care plans designed to address
these needs
Implementing simple, low-intensity evidence-based
interventions safely and effectively in partnership
with patients
Recognising patients whose needs are sufficiently
complex to require high-intensity interventions and

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referring them to specialist services

Understanding the prevalence, nature and severity of
alcohol misuse within the patient group
Developing awareness of the effects of alcohol misuse
on the mental health, social role performance, and
interpersonal relationships of patients with concurrent mental disorder
Using valid and reliable brief screening techniques
to identify the presence of substance misuse and to
measure its severity
Using a motivational interviewing approach to
explore the advantages and disadvantages of reducing
substance use and enhance readiness for change
Using structured problem-solving to identify personal strategies to facilitate and sustain a reduction in
substance use
Using brief health education techniques to help individuals understand the effects of substance misuse and
encourage reflection on the need for change.
At a more strategic level, the Trust Dual Diagnosis
Steering Group comprises senior nursing staff, some of
whom have a background in addiction psychiatry, which
has been invaluable. The target areas include the following
three main components.

Care pathways
Protocols and guidelines have been developed to promote
effective inter-agency working between services working
with people aged 65 and over with mental health and
substance misuse difficulties. There is a specific emphasis
on ensuring effective communication and information
sharing between directorates and also between agencies
across the statutory, private and other third-party sectors.

In-patient services
There is currently a process of engagement with the
Trust's addictions services to promote clear guidance for
older people's service users requiring in-patient detoxification, and the development of care pathways and
protocols for managing in-patient treatment and care. At
present, there is no formal arrangement within Mental
Health of Older Adults services for community-based
detoxification from alcohol.

Workforce development and training

There is continued development and delivery of the
5-day dual diagnosis training programme to nursing staff
across Mental Health of Older Adults services. There is
also regular feedback on the quality and effectiveness of
the training to the Education and Training Committee. In
addition, there has been the development of supervision
and support systems to support the delivery of dual diagnosis interventions following the 5-day training.

Other outcomes
Although not confined to the interventions offered by
community nurses, these nurses formed an integral part
of the favourable outcomes seen from the first research

83

CARE OF THE OLDER PERSON

paper in the UK to examine assessment and community-

Conclusion

based outcomes of alcohol misuse and dual diagnosis from

Meeting the needs of older people with alcohol misuse

in-patient services for older people. Using a retrospec-

requires core competencies dehvered within truly inte-

tive anonymised case note survey from 2006 to 2011,

grated care. It is a need that will continue to grow and

108 patients aged 65 and over with alcohol misuse were

nurses working in community mental health services for

identified. Fifty patients were taken on by community

older people should be well prepared to meet the future

mental health teams (CMHTs), of whom

rising demand.

19 patients

B|CN

(38%) had achieved abstinence from alcohol or controlled

drinking at the 6-month follow-up stage.

The future of community nursing

for older people with alcohol
misuse
Now that a fi-amework has been established for delivering
safe and effective clinical services for older people with alcohol misuse in our own mental health trust, there is scope for
replicating this good practice elsewhere in the UK. Using
more valid outcome measures may also offer a clearer benefit
in making a difference to the lives of our older people who
experience problems with alcohol misuse. One such tool,
the Outcomes Star, was originally developed for homeless
populations but has been successfully adapted for use in older
people. It has 10 outcome areas, which are staying as well as
you can (physical and mental health), keeping in touch (use
of time and social networks), feeling positive (motivation
and managing change), being treated with dignity (choice
and control), looking after yourself (self-care and mobility),
staying safe (safety) and managing money (economic wellbeing).
There is also still further scope within our own trust for
community nurses to forge closer links with care of the elderly services and with social care and voluntary organisations.

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KEY POINTS
Alcohol misuse in older people is a growing clinical and public health
problem
The provision of integrated care for older people with alcohol misuse
requires expertise in the needs of both older people and in substance
misuse
Assessment and brief intervention should incorporate age-specific
screening tools anda comprehensive history that includes all aspects of
alcohol-related problems across the lifespan
Community nursing interventions can improve both health and social

Mental Health, Toronto, http://tinyurl.coni/pmaniftp (accessed 2 January

2014)
Saxton L, Lancashire S, Kipping C (2011) Meeting the training needs of staff
working with older people with dual diagnosis. Adv Dual Diagnosis 4(1):
36-46
Schonfeld L, King-Kallimanis BL, Duchene DM et al (2010) Screening
and brief intervention for substance misuse among older adults: the
Florida BRITE project. JourBo/ Information 100(1): 108-14. doi: 10.2105/
AJPH.2008.149534
Sellman JD. Sullivan PF, Dore GM, Adamson SJ, MacEwan I (2001) A randomized controlled trial of motivational enhancement therapy (MET) for
mild to moderate alcohol dependence. J Stud Alcohol 62(3): 389-96
Southwark Council (2013) Alcohol related issues for Southwark residents aged
65 and older, http://tinyurl.com/oxh9r6y (accessed 2 January 2014)

outcomes for older people with alcohol misuse

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