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Journal of Nursing

Making a Difference: Recognizing the Risk of Alcohol and Benzodiazepine Use by Older Women 

by Connie Caneen, Student Nurse Carol Eliadi EdD, JD, APRN Assistant Dean and Associate Professor, School of Nursing Massachusetts College of Pharmacy and Health Sciences [email protected]


Introduction

Many people in the United States, when thinking about substance abuse, tend to associate the issue with the younger generation. Most of us do not associate substance abuse with the elderly. Substance abuse in the elderly, specifically abuse of alcohol and benzodiazepines, is much higher than most people may think. According to a recent article published by CNN, of the 25.6 million women over the age of 59, seven percent abuse alcohol and eleven percent abuse psychoactive drugs such as benzodiazepines (CNN, 1998). These numbers suggest that a problem exists and that patient education and staff education/ awareness in this area are of high importance.


There are many problems associated with elderly women abusing alcohol and benzodiazepines in terms of both effects and recognition of the problem. These include (1) the obvious physiological and psychological effects of combining both alcohol and benzodiazepines (2) the normal changes of aging that contribute to differences in the metabolism and absorption of medications in the elderly as opposed to younger people and (3) most importantly, how this problem is generally compounded by the lack of awareness by health care professionals to the incidence alcohol and drug abuse by elderly women in this society. Nurses are often the first people within the health care team to assess the patient during a medical appointment or as part of their admission to the emergency department or hospital floor. A clinical presentation of what may be presumed to be a routine or normal process of aging may actually be related to the unanticipated effects of substance use and/or abuse. As the population ages in the United States, the problem of alcohol and benzodiazepine abuse may increase dramatically. Between 2000 and 2005, the resident population aged 55 years and older has increased 13% to 67.1 million. This rate of growth is more than four times the rate for residents under the age of 55 (U.S. Census Bureau, 2007).


Health care professionals often fail to ask questions about alcohol abuse unless a problem is evident, even though it is well known that alcohol can interact negatively with most medications and that the elderly are routinely prescribed medications for a variety of chronic and acute conditions. Health care professionals must be alert to the early signs of hazardous alcohol and drug use and abuse. Nurses should ask general questions about recreational alcohol use. If the person reports that they do consume alcohol, the nurse should move to more specific questions about the amount and frequency of alcohol use. Questions to ask may include: “When was your last drink? How much did you drink that time? Out of the last 30 days, about how many days would you say that you drank alcohol? Have you ever had a drinking problem?” (Jarvis, 2008). As the misuse of prescription medications such as benzodiazepines is also a problem with the elderly, questions regarding current medication usage is also of high importance. Patients should be queried as to the reason for taking each medication, the dose, any presenting side effects and if they understand that alcohol may enhance or have adverse effects if combined with medication (Jarvis, 2008). Health care professionals should also be aware of the tools that are available to assess for alcohol and prescription drug use and dependence/withdrawal such as the CAGE questionnaire and the CIWA scale which are described in detail at the end of this article.


Elderly women are thought to be at greater risk for abusing substances such as alcohol and benzodiazepines as opposed to their younger peers because of a related inability to cope with the many losses in their lives associated with normal aging, such as loss of a spouse, entering into retirement, financial stressors and/or the loss of the family home. According to Erikson, in order for older adults to age successfully they must be in a state of positive integrity vs. negative despair. Negative indicators can include an overwhelming sense of loss and an inability to cope which have been proven to increase the risk for abusing substances by older adults. Positive indicators of integrity include acceptance of the worth and uniqueness of one’s own life and feeling content and satisfied with choices that have been made (Berman, 2008).


It is important for nurses to recognize the signs and symptoms of ineffective coping and to solicit specific information related to the use of alcohol and benzodiazepines by older adult women who are identified to be at risk. Many nurses may be uncomfortable or feel that it is inappropriate or disrespectful to ask questions related to the use of alcohol and benzodiazepines based on their own socialization toward the older adult, but in this case, it is an important and necessary component of the health history and nurses need to be able to overcome self-imposed barriers.


Identification of the potential problem of substance use/abuse in the older adult woman is a crucial component of effective health care treatment. Many health care professionals are more willing to prescribe benzodiazepines to elderly women because statistically women, young or old, are not typically viewed as likely substance abusers. The vast majority of elderly women who abuse drugs and alcohol do not abuse illegal street drugs, but rather they abuse drugs that have been prescribed to them by their physicians.  Older women who abuse alcohol and benzodiazepines are also at higher risk of becoming more quickly addicted to these medications as compared to other cohorts of patients. A recent article in CNN reports that physicians may be exacerbating this problem when treating the older adult female patient. Many physicians will diagnosis elderly women with depression and prescribe treatment with anti-depressants or anxiety medications (benzodiazepines) when the real problem may actually be alcohol abuse that is masked. This then serves to further complicate the clinical situation for the alcohol abusing client as now the patient has the legally prescribed benzodiazepine to combine with alcohol that can lead to a lethal combination (CNN, 1998). Recent studies about the cost of alcoholism to society do not address the elderly specifically and this forgotten population is often times referred to as the, “hidden population.” In 1998, the NIH estimated that alcoholism costs 184.6 billion dollars in lost productivity, medical care, legal services and the cost of traffic accidents; however, this data does not address the cost or impact that results from the dependence on alcohol by the older adults in our society (Smith, 2006).


Alcohol and benzodiazepine abuse in older women is significant to nursing because nurses are strategically situated within the healthcare delivery system to recognize the actual and potential risks of substance abuse in the older adult female patient and to provide appropriate interventions and education. In order to do this effectively, nurses must have the knowledge related to the risk issues and/or the signs and symptoms of the actual abuse of alcohol and benzodiazepines and make a concerted effort to incorporate questions related to the use of these substances into the health history. When elderly women present with complaints such as falls, decreased appetite, weight loss, irritability, chronic heartburn and other subtle signs and symptoms such as difficulty sleeping and/or psychological and somatic complaints, it is important for nurses to consider the possibility of substance abuse and to proceed with a focused health history and physical examination (Finfgeld- Connett, 2004). In considering substance abuse, many nurses may have a classic image of a substance abuser as an individual who is late for work, absent from important functions, having driving violations and/or having marital problems (Finfgeld- Connett, 2004). Because elderly women often have fewer obligations to society, family and friends may not witness these more typical events and as a result, may fail to recognize the need for help or intervention. It is important for nurses to have the knowledge necessary to at least consider the risk factors of substance abuse in older women and to have the comfort level to ask often awkward and uncomfortable questions related to the use of alcohol and benzodiazepines.


Assessing the individual nurse and his/her awareness of benzodiazepine and alcohol abuse in elderly women is an area that has not received much attention in the literature. Most of the literature that does exist focuses on the overall problem of substance abuse in the elderly and the signs and symptoms that may be present in elderly women as opposed to the assessment practices of the nurse when dealing with this actual or potential diagnosis. The literature is also weak in reporting how aware practicing nurses are of the substance abuse problem in the older adult and specifically in the older adult woman.


Review of the Literature


The topic of alcohol and benzodiazepines abuse in the older woman is a topic that has received some research attention, but very little research has focused on nurse awareness in this area. Research reports that there are no age limits to substance abuse and that ages may range from as young as ten years to women in their seventies and eighties.  Susan Foster, director of policy research for the National Center on Addiction and Substance Abuse at Columbia University reports that because nurses are not looking for the problem of substance abuse in older women, it often goes unrecognized even when it stares right at them. The same finding has been reported for physicians as well. A study referenced in this same article reports that a two year survey of four hundred primary care physicians found that less than one percent of them considered a diagnosis of substance abuse in their older female patients even when typical signs and symptoms were described to them. Physicians were more likely to diagnose them with depression or anxiety and prescribe medications that could worsen any existing substance abuse problem. In older women, the most commonly abused substance is not alcohol but prescription drugs such as pain relievers or sedatives (National Women’s Health Report, 2006). In the 1990s the National Center on Addiction and Substance Abuse found that as many as 2.8 million mature women may be abusing sedatives which represent 44% of all women who have been prescribed these medications. Many of these women are also reported to be abusing alcohol as well (National Women’s Health Report, 2006).


The consequences of prescription misuse and abuse of benzodiazepines among the elderly women are also reported in the literature. Older women are more susceptible to the cognitive impairments and overall sedation effects associated with most of these medications. These side effects are reported to increase the elderly woman’s risk for falls, other injuries, unintentional suicide and risk of dangerous interactions with alcohol (National Women’s Health Report, 2006). Dr. Simono-Wastila reported that older women often do not discuss the notion they may have a substance abuse problem because of the significant stigma attached to substance abuse and mental health issues. Providers also may not recognize signs and symptoms of prescription abuse in older women because they attribute them to such things as mental illness, dementia or to the side effects of medications they are taking for other health problems (National Women’s Health Report, 2006).


Deborah Finfgeld-Connett (2004) reports that substance abuse in older women is predicted to become a more prevalent problem as the baby boomer generation ages and that benzodiazepines and alcohol appear to be the two most problematic drugs. As women age the same amount of alcohol that had little to no effect when they were younger can now cause the older woman to become inebriated. This is the result of many physiological factors such as reduced liver and kidney function which delays alcohol metabolism and elimination. As women age, lean body mass and total water content decreases while fat stores increase. Older women respond to benzodiazepines in the same ways as they do to alcohol in that lower amounts of the drug are required to achieve and effect and the effects last longer. If the use of benzodiazepines and alcohol is discontinued abruptly, withdrawal symptoms can develop even if the woman is taking the recommended dose of benzodiazepine medication. Alcohol and benzodiazepines are both depressants causing severe adverse effects when used in combination (Finfgeld-Connett, 2004).


Alcohol and benzodiazepine abuse is so troublesome because in many situations it goes undetected until the consequences become fatal. Health care professionals often overlook the straight forward signs and symptoms of drug and alcohol abuse and attribute them to common complaints of the aging client. Family and friends may over look the abuse because it usually does not result in the socially disruptive behavior as often seen with the younger generation. The older women with substance abuse problems rarely recognize the abuse because they are taking the medications as prescribed by a trusted healthcare provider and perhaps drinking a limited amount of alcohol. Many are unaware of the serious consequences of combining alcohol and benzodiazepines or that the long term use of benzodiazepines can result in a physiological addiction. The brief intervention model by Deborah Finfgeld- Connett, 2004, recommends that patients take responsibility for their choices and initiate manageable steps towards making necessary and healthy changes. The seven elements of the model include assessment, feedback, responsibility, advice, menu, empathy and self-efficacy. Each of these elements can translate to strategies that can be implemented by the nurses to help the client recognize substance abuse problems and help them modify or change their behaviors through a series of brief interventions. Findings from a randomized controlled clinical trial of brief interventions demonstrated the effectiveness of these interventions to reduce alcohol consumption; however, similar findings on benzodiazepine abuse among older women are still lacking (Finfgeld-Connett, 2004).


Marie Caroselli-Karinia (1985) reports there are much higher rates of prescription drug use by the older adult. Karinia reports that although people over the age of 65 represent 11% of the population, they are taking 25% of all prescribed medications. (Karinia, 1985). These numbers alone should call attention to the increased risk of misuse by this population. As the elderly patient ages there are major alterations in the environment and in relationships which make the individual more vulnerable to using drugs as a means of coping. Karinia reported three patterns of abuse and misuse to include: (1) overuse resulting in over dosage or an excessive level of medication in the bloodstream, (2) underuse as a result of the elderly forgetting to take their prescription medications and (3) the erratic use of medication which incorporates both underuse and overuse such as forgetting to take one dose and the next day taking a double dose. The most commonly abused drugs are those classified as the psychotherapeutics, such as sedatives and hypnotics. The literature also reports that physicians who care for aging clients may feel obligated to offer a cure to those who have frequent office visits for those problems which do not seem clearly defined or to have a definitive cure. Providing medications to these patients may appear to satisfy them in the short term, but little attention is paid to the fact that the prescribed medication, particularly a benzodiazepine, could possibly be harmful to them in the long term. The potential for drug abuse may be further increased in those elderly patients who may be otherwise compromised by marginal levels of mental compensation (Caroselli-Karinia, 1985).


Many health care professionals have failed to recognize actual or potential substance abuse concerns in the older adult female. This could be the result of a lack of education related to the incidence and/or clinical manifestations, a lack of training and even biases related to the presentation of the problem in the older adult woman. It should be standard practice in acute care settings to evaluate an elderly client’s condition for the possibility that the clinical presentation could be drug induced or drug influenced. Health care professionals should teach the patient the risks associated with the long term use of benzodiazepines, the effects of combining alcohol with any prescription or over the counter medications and the possibility of dependence or reliance on certain medications when used for coping or for stress relief. The elderly should be educated that medication should only be used when absolutely necessary and they should be encouraged to periodically review all prescription medications and over the counter medications with their primary health care providers (Caroselli-Karinia, 1985).


Kathleen Ondus (1999) reports that health care professionals often do not address or recognize the abuse of alcohol and drugs in the elderly. The factors contributing to the clinicians’ lack of identification of substance abuse in the elderly can include an overall lack of awareness, a failure to obtain or record accurate drug histories, a failure to periodically reconcile medications profiles with the patient and a reluctance to ask questions they may perceive as embarrassing to the patient. One out of every four hospitalized older adults may have alcohol related problems but most are not admitted to the hospital with a primary diagnosis of alcoholism. Data on prescription drug dependence is scarce, but it is believed to be under reported and under diagnosed. There are many contributing factors that may contribute to the older adult female’s use of benzodiazepines and the subsequent effect from these agents when combined with alcohol. The presence of anxiety, depression and feelings of overwhelming stress can trigger the use of both benzodiazepines and alcohol. Rates of benzodiazepine abuse are actually reported to be the highest in elderly women, which is partly attributed to the fact that elderly women visit their physicians more often than elderly males do. The result of the visit is often a prescription medication and that medication is often a benzodiazepine. Patients who are prescribed benzodiazepines tend to take smaller doses of the drug, but for longer periods of time and as a result, have increased difficulties with subsequent withdrawal (Ondus, 1999).


Summary and Recommendations


The clinical manifestations of alcohol and benzodiazepine use and abuse in older adult women presents a challenge to health care providers as the associated signs and symptoms of alcohol dependence commonly seen in the younger people are typically not the same as those presenting in the elderly. In the absence of these typical signs and symptoms, the health care professional may fail to recognize substance abuse due to a lack of suspicion in the first place, the unwillingness of the patient or family to disclose the problem and/or by  a misdiagnosis whereby the presenting symptoms are attributed to the normal aging process. It is crucial for the health care provider to focus on the symptoms for which the elderly seek treatment as they may represent clues to actual or potential drug or alcohol abuse. Focused questions should be asked during the interview related to substance abuse risks such as experiencing feelings of loneliness or difficulty in managing activities of daily living (ADL’s). Health care professionals caring for the elderly should be familiar with the CAGE questionnaire, (see figure 1) which is designed to identify those at risk for alcohol abuse. (Critical Care Nurse, 2005) Nurses should pay particular attention to teaching the elderly client about the reasons for taking specific medications, the correct dosages, the potential side effects and possible interactions with other medications and/or alcohol. Another important and useful tool for healthcare providers is the Clinical Institute Withdrawal Assessment of Alcohol Scale otherwise called the CIWA scale (Critical Care Nurse, 2005). This scale assesses patients for possible alcohol withdrawal signs and symptoms and recommends corresponding medication treatment regimes based on the results of ascertained scores reflecting various clinical presentations (see figure 2). These types of clinical evaluation tools were developed to assist healthcare providers to quantitatively assess patients for the potential complications that may result from prolonged abuse of prescription medications and alcohol. Utilizing standardized tools allows the healthcare provider to assess the patient using a scientific approach and to advocate for evidenced based interventions and treatment.


Conclusion


Alcohol and benzodiazepine abuse is a significant problem in the older female population. Older adult females are at increased risk for having potentially lethal adverse reactions from combining benzodiazepines and alcohol. The reasons for the increased risk include a variety of physical, psychological and social reasons discussed earlier. The literature is lacking in the area regarding the specific knowledge base of the healthcare provider as it relates to the incidence of benzodiazepine and alcohol use and abuse in the older female population. Given the incidence and seriousness of benzodiazepine and alcohol use by older adult females, healthcare providers need to make certain that accurate and detailed histories are obtained during every patient encounter, that medications are reconciled regularly, and that signs and symptoms of potential substance abuse are not overlooked or assumed to reflect normal aspects of the aging process.


Figure 1: CAGE questionnaire


CAGE questionnaire - screen for alcohol misuse


Alcohol dependence is likely if the patient gives two or more positive answers to the following questions:


· Have you ever felt you should Cut down on your drinking?


· Have people Annoyed you by criticizing your drinking?


· Have you ever felt bad or Guilty about your drinking?


· Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?


If the person answers yes to two or more CAGE questions, you should suspect alcohol abuse and continue with a more complete substance abuse assessment. 


 








Figure 2: CIWA scale
Patient: _____________  Date: (yy/mm/dd) ____/____/____  Time: (24 hr) _________
 
Pulse or heart rate: ___________  Blood Pressure: ______________
 




















Nausea and Vomiting - Ask "Do you feel sick to your stomach?" "Have you vomited?" Observation.

    * 0 - no nausea and no vomiting
    * 1 - mild nausea with no vomiting
    * 2
    * 3
    * 4 - intermittent nausea with dry heaves
    * 5
    * 6
    * 7 - constant nausea, frequent dry heaves and vomiting.




Tactile Disturbances - Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin? Observation.



  • 0 - none

  • 1 - very mild itching, pins and needles, burning or numbness

  • 2 - mild itching, pins and needles, burning or numbness

  • 3 - moderate itching, pins and needles, burning or numbness

  • 4 - moderately sever hallucinations

  • 5 - severe hallucinations

  • 6 - extremely severe hallucinations


7 - continuous hallucinations


Tremor - Arms extended and fingers spread apart. Observation.


    * 0 - no tremor
    * 1 - not visible, but can be felt fingertip to fingertip
    * 2
    * 3
    * 4 - moderate, with patient's arms extended
    * 5
    * 6
    * 7 - severe, even with arms not extended




Auditory Disturbances - Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things that you know aren't there?" Observation.


    * 0 - not present
    * 1 - very mild harshness or ability to frighten
    * 2 - mild harshness or ability to frighten
    * 3 - moderate harshness or ability to frighten
    * 4 - moderately severe hallucinations
    * 5 - severe hallucinations
    * 6 - extremely severe hallucinations
    * 7 - continuous hallucinations




Paroxysmal Sweats - Observation.


    * 0 - no sweat visible
    * 1 - barely perceptible sweating, palms moist
    * 2
    * 3
    * 4 - beads of sweat obvious on forehead
    * 5
    * 6
    * 7 - drenching sweats




Visual Disturbances - Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things that you know aren't there?" Observation.


    * 0 - not present
    * 1 - very mild sensitivity
    * 2 - mild sensitivity
    * 3 - moderate sensitivity
    * 4 - moderately severe hallucinations
    * 5 - severe hallucinations
    * 6 - extremely sever hallucinations
    * 7 - continuous hallucinations







 


















Anxiety - Ask "Do you feel nervous?" Observation.


    * 0 - no anxiety, at ease
    * 1 - mildly anxious
    * 2
    * 3
    * 4 - moderately anxious, or guarded, so anxiety is inferred
    * 5
    * 6
    * 7 - equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions


Headache, Fullness in Head - Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate dizziness or lightheadedness. Otherwise, rate severity.

    * 0 - not present
    * 1 - very mild
    * 2 - mild
    * 3 - moderate
    * 4 - moderately severe
    * 5 - severe
    * 6 - very severe
    * 7 - extremely severe


Agitation - Observation.

    * 0 - normal activity
    * 1 - somewhat more than normal activity
    * 2
    * 3
    * 4 - moderately fidgety and restless
    * 5
    * 6
    * 7 - paces back and forth during most of the interview, or constantly thrashes about.


 Orientation and Clouding of Sensorium - Ask "What day is this? Where are you? Who am I?

    * oriented and can do serial additions
    * cannot do serial additions or is certain about date
    * disoriented for date by no more than two calendar days
    * disoriented for date by more than two calendar days
    * disoriented for place and/or person



 


Patients scoring less than 10 do not usually need additional medication for withdrawal.  



Total CIWA-A Score _____


Rater's Initials _____


Maximum Possible Score - 67



References


Berman, A., Snyder, S., Kozier, B., Erb, G. (2008). Kozier & Erb’s: Fundamentals of nursing 8th


      edition. Upper Saddle River, NJ: Pearson Education Inc.


Burns, N., Grove, S.K. (2005). Understanding Nursing Research: Building an evidence- based


      Practice, 4th edition. St. Louis, Missouri: Saunders.


CNN. (June 4, 1998). Study finds widespread substance abuse among older women.


      Retrieved November 23, 2008, fromhttp://edition.cnn.com/HEALTH/9806/04/women.drugs.study/index.html


Caroselli-Karinia, Marie. (June, 1985). Drug Abuse and the Elderly. Journal of Psychosocial 


      Nursing, 23(6), 25-30.


Critical Care Nurse. (June, 2005). Clinical Institute Withdrawal Assessment of Alcohol Scale.


      Retrieved on March 10, 2009 from www.erowid.org/chemicals/alcohol.


Critical Care Nurse. (June, 2005). Cage questionnaire-screen for alcohol misuse.


      Retrieved on March 10, 2009 from www.erowid.org/chemicals/alcohol


Finfgeld-Connett, Deborah. (August, 2004). Treatment of Substance Misuse in Older


      Women: Using a brief intervention model. Journal of Gerontological Nursing,


      August 2004, 30-37.


Jarvis, C. (2008). Physical examination and health assessment (5th Edition). St. Louis: Saunders.


National Women’s Health Report. (December 2006). Older Women and Substance


      Abuse. National Women’s Health Report, 28(6), 6.


Ondus, K.A., Hujer, M.E., Mann, A.E. and Mion, L.C. (August 1999). Substance Abuse


      And the Hospitalized Elderly. Orthopedic Nursing, July/August 1999, 27-36.


Smith, W. L. (2006, June 23). Alcohol Abuse and the Elderly: The Hidden Population.


      Retrieved November 23, 2008, from http://ezinearticles.com/?Alcohol-Abuse-and-the-Elderly:-The-Hidden-Population&id=227801


U.S Census Bureau. (2007). Older adults in 2005. Retrieved on March 3, 2009 from:


      http://www.census.gov/population/www/pop-profile/profile_list.html.

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