Alcohol problems in older people and the tragic death of Granny Smith

Kieran J Moriarty CBE, MA, MD, FRCP, FRCPI
Non-Alcoholic Trustee for Alcoholics Anonymous 2022 – Current
Consultant Gastroenterologist and Liver Specialist Royal Bolton Hospital 1990-2018
Alcohol Lead, British Society of Gastroenterology 2009-2020
Government Alcohol Adviser 2000-2020

E-mail: trustee.nat6@gsogb.org.uk

‘Granny Smith’ and her tragic death

‘Granny Annie Smith’ (not her real name) was 86 years old, widowed, living alone, neglected, malnourished and taking large doses of strong painkillers for severe arthritis. Family and friends used to bring her alcohol from the Off-licence and supermarket. One bitterly cold Monday in the middle of winter, Annie had spent most of the day in bed so as to save on heating bills. She had been drinking brandy alone to ‘warm her up.’ Alcohol actually causes a fall in body temperature and can induce hypothermia. Older people are especially vulnerable to alcohol, due to this misapprehension, particularly in winter.

As she came downstairs in the afternoon, Annie tripped and fell all the way down, breaking her hip. She lay at the bottom of the stairs, unable to move. Annie became hypothermic and dehydrated, vomited, aspirated the vomit into her lungs and developed pneumonia. Annie’s cries for help went unheard and she was not discovered until the following day, when she was eventually brought into hospital. Tragically, it was too late and she died.

Alcohol-related hospital admissions in older people – Primary Reasons
Surprisingly, perhaps, among both men and women, older people drink more frequently than younger people. However, alcohol misuse in older people is underestimated and often goes undetected, since it presents in a large number of non-specific ways, many of which are linked to the ageing process.

In 2006, at the Royal Bolton Hospital, Milan Mehta, a medical student, David Proctor, our Alcohol Liaison Nurse (ALN), Mary Bird, statistician, Wendy Darling, Consultant Psychiatrist and I published a paper in which we assessed 193 inpatients aged >60 years, who had been referred to the ALN from all hospital wards between 1998 and 2003. We recorded gender, alcohol intake and primary and secondary reasons for admission. We were astonished by the results.

90% of men drank >21 units weekly and 93% of women drank >14 units weekly. These were the so-called UK government ‘sensible level limits’ in 2006. Median weekly alcohol intake was 78.5 units for men and 47 units for women. Acute intoxication, falls, circulatory problems and alcoholic liver disease were the main primary reasons for admission (See Figure 1). Neglect or malnutrition, alcoholic liver disease and hypertension were the main secondary reasons and concurrent health problems. 30% of patients died between 1998 and 2003. Five of these, women and men, had a virtually identical presentation to ‘Granny Smith’. Such stories are extremely distressing for the individual, family, friends and society.

Alcohol misuse in older people: heavy consumption and protean presentations.
Milan M Mehta, Kieran J Moriarty, David Proctor, Mary Bird and Wendy Darling
Journal of Epidemiology and Community Health 2006;60;1048-1052 doi:10.1136/jech.2005.043653

Alcohol causes around 200 health harms, but few people know that the most significant harm is that due to the effect of alcohol on blood pressure and the complications. There is a close relationship between alcohol consumption and hypertension. Excessive consumption predisposes to hypertension-related diseases, including haemorrhagic and ischaemic strokes. Consumption of >42 units/week of alcohol virtually doubles the incidence of hypertension. Encouragingly, blood pressure falls rapidly with abstinence.

Although alcohol contains calories, it provides energy but has little nutritional value. Hence, people dependent on alcohol become malnourished. Their diet lacks essential nutrients, including thiamine and protein. Thiamine deficiency, due to reduced intake and absorption, causes Wernicke–Korsakoff syndrome (Alcohol-Related Brain Damage), whereas protein deficiency produces muscle wasting, immunosuppression and blood clotting disorders. People dependent on alcohol eat inadequately because they spend money on alcohol rather than on food, because alcohol causes satiety, or because mobility problems preclude shopping.

Signs and symptoms of problem drinking in older people
These are shown in Figure 2.
Reasons for alcohol misuse in older people include pain, anxiety, depression, insomnia, social isolation, loneliness, bereavement, divorce, ill health, unemployment, boredom, financial stress and habitual drinking. Since we are all living longer, problem drinking in older people is on the rise and a ‘silent epidemic’ has been developing.

Early vs Late – Onset Alcoholism
The characteristics of Early versus Late – Onset Alcoholism are shown in Figure 3.
Liberto, J. G., & Oslin, D. W. (1995). Early versus late onset of alcoholism in the elderly. International Journal of the Addictions, 30 (13-14), 1799-1818. https://doi.org/10.3109/10826089509071056

Alcohol Consumption Underestimates and Vulnerability to Alcohol
Older people tend to underestimate alcohol consumption, while family members and carers often collude out of a sense of embarrassment and a feeling of ‘this is all that’s left for the drinker’. Healthcare workers also have a lower degree of suspicion when assessing older people and are less likely to refer them for treatment.

Physiological changes in older people increase susceptibility to alcohol. Body water content decreases, resulting in less water to dilute ingested alcohol and higher blood concentrations. Compared with men, women have less body water and lower levels of the stomach enzyme alcohol dehydrogenase, the main enzyme that metabolises alcohol. Moreover, the brain is more susceptible to alcohol. Oestrogens stimulate intestinal absorption of harmful endotoxins, leading to immunologically-mediated liver damage. Hence, women are more susceptible to the physical effects of alcohol, especially liver damage, a rare biological advantage for men.

A further consideration in older people is the interaction of alcohol with prescribed drugs. 80% of people, aged over 65 years, regularly take prescribed drugs and polypharmacy is common. Alcohol especially enhances the sedative effect of drugs, particularly hypnotics, which are often inappropriately prescribed long-term, thus increasing the risk of falling. Alcoholics may also have malabsorption of calcium and are more likely to fall and fracture their hip, requiring operative fixation, with significant morbidity and mortality.

People with alcohol-related problems often give inaccurate histories, due to denial or dementia. Moreover, people may omit to report alcohol for ‘medicinal’ purposes (e.g. spirits in beverages). Drinking at home is particularly likely to be underestimated because the quantities consumed are not measured and are likely to be larger than those dispensed in licensed premises. Therefore, alcohol intakes may be inaccurate or underestimated.

Older Persons concerns about Treatment
• It’s embarrassing to tell people
• Treatment is just for alcoholics and addicts
• Treatment is just for younger people
• Treatment takes too long
• Treatment involves being away from home
• Treatment is too expensive

Prevalence of Alcohol Problems in Older People
The prevalence of alcohol problems in older people in a variety of settings is shown in Figure 4. This highlights the major problem in nursing home patients, one that is often undetected.

How members of Alcoholics Anonymous support and help our older people
Members of the fellowship regularly take or drive older members to AA meetings, especially accessible ones with wheelchair access or where there are Sign Language Interpreters. Assistance for members with mobility issues, particularly in the winter months, by accessing online platforms and staying with an older person in their home to give support and help with any IT problems is also a wonderful act of service.

The Cochrane Evidence Review and the National Health and Care Excellence 2023 Guidance ‘Alcohol – use disorders: diagnosis and management’ have highlighted the superiority of Alcoholics Anonymous/12-Step Programmes over other conventional treatments in achieving long-term abstinence and remission. Alcoholics Anonymous members are finding that more health and social care practitioners are aware of this evidence and guidance and this is leading to increased knowledge about and engagement with AA.

Hopefully, we all care for our older neighbours, family and friends, especially during the winter. We should look closely for alcohol consumption in older people. Thankfully, more people have personal alarms than when we conducted our study in 2006.

‘Granny Smith’s’ desperate cries for help were never heard in life. We can only guess how many ‘Granny or Grandad Smiths’ will die this winter, particularly if it is a cold one and with concern about heating bills. Alcoholics Anonymous, with our self-defining historical traditions of compassion and service, will always take the lead in caring for all members of society, especially our older and most vulnerable ones with alcohol-related problems.