Q&A: Addressing alcohol intake with older patients

Primary care physicians often face challenges discussing alcohol use with older patients, according to a study published in the British Journal of General Practice.

“Practitioners perceived drinking practices to be well established by old age,” Bethany Kate Bareham, PhD, a research associate at the Institute of Health and Society at Newcastle University in the U.K., and colleagues wrote. “Many had experiences of older people’s resistance to advice and had low expectations for the success of any intervention to address alcohol use.”

For the qualitative study, Bareham and colleagues interviewed 35 practitioners of different medical professions about their experiences addressing alcohol use and their views about alcohol habits among patients aged 50 years or older. Most of the practitioners were younger than 40 years and consumed alcohol; 25 were women. They had been practicing medicine from 3 to 40 years.

The researchers’ interviews revealed particular sensitivities and difficulties tied to discussions about alcohol use with older patients. Practitioners emphasized older patients’ rights to use alcohol, which “could deter intervention,” according to Bareham and colleagues. Also, addressing how alcohol intake correlated with health risks and providing support was “perceived to be time consuming” by the practitioners. Instead, they prioritized age-related health issues and long-term conditions over discussions about alcohol use. In addition, practitioners, particularly younger ones, had reservations about addressing alcohol moderation with patients who were older than them.

However, Bareham and colleagues identified several ways to improve patient-provider discussions about alcohol use, such as dedicating time to address alcohol use, undergoing training to better identify alcohol-related risks and tailoring interventions for older patients.

William Cooke

While the study was conducted in Northern England — where alcohol use is a significant public health threat, according to the researchers — William Cooke, MD, FAAFP, FAFAM, owner and operator of Foundations Family Medicine in Indiana, said the implications are relevant for clinical care and practice management in the U.S.

Healio Primary Care spoke with Cooke about approaching alcohol use and behavioral changes with older patients.

Healio Primary Care: Do American physicians face similar challenges with discussing alcohol intake with older patients?

Cooke: I think so. It is a culturally accepted form of self-medicating, and older adults are set in their ways. The provider is oftentimes younger as well, which makes for a different dynamic. You want to be respectful.

Healio Primary Care: How would you approach behavioral changes in a respectful way?

Cooke: All the evidence points towards a doctor-patient relationship being the most effective when it’s a collaboration. The old school of patriarchal hierarchy doesn’t have good evidence behind it. Building and fostering that collaborative relationship with our patients are what allows us to assist patients in behavior change. I believe strongly in motivational interviewing, so not really so much telling patients what they should and should not do, but assessing where they are, what behaviors they're conducting and their understanding of the harms, risks and benefits of those behaviors, and then the inner resource to provide education. Challenge the areas where there may be conflict between their desires for life and what they’re saying they’re doing. Pointing out those conflicts is an opportunity for them to then work through them. It’s not me conflicting with their behavior; it’s their own views conflicting with what they want from a health standpoint and pointing those out and helping them work through those is what I found to be the most effective. I think the evidence pans out with that as well, looking again at the concepts of motivational interviewing.

Healio Primary Care: The study focused specifically on patients 50 years or older as “older patients,” but that is fairly young, wouldn’t you say? At what patient age should physicians be addressing alcohol moderation?

Cooke: I don’t think there is a lower limit cut off on age. I think alcohol is potentially harmful as soon as people become introduced to it.

Healio Primary Care: Do you think this kind of topic warrants additional sensitivity training among medical students?

Cooke: Having medical students and young physicians trained in motivational interviewing is ideal. People come to doctors because they trust doctors and they want information, but they don’t necessarily want to be told what to do. We are talking about adults 50 years and older — these are well-established adults, oftentimes very productive people, sometimes business owners and executives and such. They don’t necessarily respond well to being told what to do, but they respond really well to an expert with evidence-based information that they can share and assist them in making their own decisions.

There’s a lot of things that can assist with the process that allows patients to feel a little safer approaching these sorts of topics. For example, questionnaires do a really good job of bringing that information to the forefront without a person sitting there probing someone for answers. So, using questionnaires when they’re checking in because they’re used to filling out information. By the time they get back to the provider’s room, we see the information and then we can talk a little bit more about it. And then using motivational interviewing, and those screening tools go into Screening, Brief Intervention and Referral to Treatment (SBIRT). So, the screening are those questionnaires that they fill out, and it could apply to just about any condition. For example, if a patient screened positive on the training tools for alcohol, the brief intervention is having a conversation about alcohol, the risks, benefits, how often, their understanding of the risks and benefits and giving information so that you’re briefly intervening in that visit, and then referral to treatment. If it does come up that they are drinking a little bit more than what is healthy or more than they want or it’s interfering with their relationships or their job performance and they do want help, that is the referral to treatment part. SBIRT is evidence based and can be implemented in a primary care setting very easily.

Healio Primary Care: One of the problems that the study addresses is that practitioners have a limited time with each patient to discuss everything that has to be addressed. Should alcohol use be a priority topic?

Cooke: The whole idea of SBIRT in general is that our time with patients, unfortunately, is often brief and limited. So, if before I even enter the room a problem has already been identified by the patient completing the screening part using iPads and technology, and even been given some information based on what their answers were in the screening tools, I can do that brief intervention when I go into the room. With the referral to treatment part, in my clinic we do a warm handoff. We have found that patients are more likely to follow up for drug and alcohol issues, anxiety, depression and those sorts of issues, if they meet the therapist, if I introduce them immediately. People are fine with that; they don't mind meeting someone. You can get them talking and set up a follow-up appointment. The patient is more likely to keep the appointment because they have met each other and had that conversation.

Alcohol-related deaths harm more Americans than other illicit substances combined, so it is a significant issue and one that we really should be addressing.

Reference:

Bareham BK, et al. Br J Gen Pract. 2021;doi:10.3399/BJGP.2020.1118.