Geriatric Emergency Medicine Fellowship Journal Club: Screening for High-Risk Alcohol Use Among Older Adults in the Emergency Department

Volume 4 | Issue 2 | Article 3 - Journal Club

Kira Gossack-Keenan MD, FRCPC, Ranjeev Kumar MBBS, Don Melady MD, MSc(Ed) MD, CCFP(EM) (COE), FCFP
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Introduction

Alcohol use is the seventh leading cause of death worldwide and is associated with increased risk of various diseases including head, neck, and breast cancers, heart disease, hypertension, osteoporosis, and diabetes, as well as traumatic injuries. In the United States, alcohol use disorder (AUD) remains a prevalent diagnosis: according to the 2021 National Survey on Drug Use and Health (NSDUH), 28.6 million adults ages 18 and older (11.3%) had AUD in the past year.1

Older adults are at higher risk of alcohol-related complications due to underlying comorbidities, frailty, and polypharmacy. Normal aging physiology, notably decreased hepatic metabolism, results in higher blood alcohol concentrations for any given alcohol intake.2 Previous studies have demonstrated an increased risk of dementia and 18-month mortality amongst older patients with high-risk alcohol use. In addition, older adults who drink alcohol have higher healthcare utilization and present more frequently to the Emergency Department (ED).3

Older adults, as all other age groups, continue to drink despite these risks. Data from the NSDUH indicates that approximately 20% of adults aged 60-64 and around 11% over age 65 report current binge drinking.1 The prevalence of alcohol misuse among older adults is 14% for all comers to the ED.4 Sociodemographic factors associated with increased alcohol use amongst older community-dwelling individuals include male gender, single marital status, social isolation, and higher levels of education.5,6

High-risk alcohol use and AUD are often missed among older patients. One barrier to implementing brief interventions to reduce alcohol use is the need for rapid and sensitive screening tools to identify highrisk alcohol use. Optimal screening methods vary with age and demographic group. Traditional screening tools such as the Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) and Alcohol Use Disorders Identification Test (AUDIT) are less sensitive in older patients.7,8 Even if tools are available, they require implementation. A recent survey of 368 emergency physicians conducted by the American College of Emergency Physicians found that 14% reported ‘never’ screening adult patients for excessive alcohol use, with reported barriers including limited time (66%) and perceived lack of treatment options (43%).9 However, screening is important in that it allows for brief interventions, which have been shown to reduce harmful drinking and increase days of abstinence.9-11 Brief interventions have been validated in Emergency Department (ED) settings.12 Screening also allows for the initiation of treatments to decrease alcohol use, including anticraving medications.

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