Three themes explained the findings: disregarding impersonal information about effects of drinking on health; personally relevant risks of harm — expecting symptoms from excessive drinking; and perceived gains from restricted intake.
Disregarding impersonal information about effects of drinking on health
Older people conveyed their awareness of information about positive and negative effects of health-related behaviour, and how much was considered ‘safe’ to drink. The transitory and seemingly contradictory nature of alcohol-related health messages encountered over time meant that they expressed scepticism about the validity of ‘generic’ information as a source of advice. One participant consequently disregarded health messages, instead consuming what they viewed was sensible:
‘I pay a certain amount of attention to the government’s rules, but if they keep changing them. I view the alcohol rules very much like all the other ones about food. We’ve been told not to eat butter, not to eat eggs. “Eat eggs. Eat butter. It’s good for you.” You’re just told a load of rubbish, basically. You don’t believe a word of it. You reach the point where you look at what you think is sensible rather than believing the letter of the law, because it keeps changing.’
(Older person [OP], Stanley, aged 69 years, male [M])
‘Sensible’ drinking was viewed to be low risk, and encompassed not drinking ‘too much’ or ‘to get drunk’. This finding cut across sex and socioeconomic groups. Views about levels of drinking considered ‘sensible’ differed, resulting in tendencies for heavier drinking among males and those self-identifying as working class. Health risks were assumed relevant only to groups that they perceived were ‘problematic’ drinkers, such as ‘alcoholics’ and younger ‘binge’ drinkers. ‘Moderation’ in drinking was recognised by older adults as a consistent message, which many ascribed to. This did not reflect a defined level of alcohol use and many consumed at hazardous levels.
Practitioners reflected that older people were only responsive to alcohol-related health messages when they were tailored to the individual’s circumstances and drinking practices. Personalising risk communications required a critical understanding of current health messages. This was not normally possible for most practitioners (except pharmacists and nurses, with established roles in alcohol intervention), who had limited alcohol-related training, understanding of age-specific risks, or time for tailoring:
‘We’ve had very little training in the advice we need to provide. Your knowledge is limited. You think, “Oh, cut down, yeah.” But that’s all we’ve got to go on really.’
(Dentist)
Personally relevant risks of harm — expecting symptoms from excessive drinking
Older adults expected they would experience symptoms if their alcohol use was excessive. Any reductions in intake motivated by health risks were prompted by perceived consequences of their drinking, rather than proactive changes to prevent harm. A female participant recognised effects of alcohol on her weight and energy levels, and made the decision to limit drinking:
Nancy (OP, aged 66 years, female [F]):‘I’ve lost quite a lot of weight over the last couple of years. And that’s part of that. I eat more, if I’m drinking. And in itself, it’s quite … ’
Bethany Kate Bareham:‘ calorific.’
Nancy:‘ Yes, so, I was drinking more. I thought, I’m falling asleep in front of the telly. Which I don’t do if I don’t drink. And I just thought, time has come. I think I can do it, and I did do it.’
Others recognised negative effects on mood or when combined with medications, and restricted their intake. Many experienced decreased tolerance for alcohol with age, and restricted their intake accordingly to avoid symptoms from excess. Some reporting high tolerance to alcohol across their lives had not experienced any symptoms attributed to alcohol. Concerns regarding effects on health did not factor into their decisions for drinking.
Practitioners highlighted that not all harms experienced through non-dependent drinking were symptomatic. Those involved in interventions to address alcohol conveyed that it could be difficult to motivate restricted use where older people had not experienced symptoms of harm from drinking. Their older care recipients commonly cited reaching old age to indicate that their drinking was not harmful. Alcohol-related discussions were unlikely to prompt these individuals to contemplate making changes to their drinking, as social care practitioners explained:
Social care practitioner (SCP):‘You’ve got people who’ve been doing this for 50 years and you’re trying to break that habit and nothing bad has happened to them. So then for you to come and say, “Actually, this isn’t good.”’
SCP:‘ There is that sort of dismissive attitude, “Well, I’ve done it all my life and I’ve never come to any harm.”’
This perspective was echoed by some older adults, particularly the oldest individuals.
Alcohol screening test outcomes could provide a concrete indicator of the (potential) effects of older adults’ drinking on their bodies. Screening tests, such as alcohol-related risk scores (conveying increased chance of harm associated with use) or blood tests, were integrated within practice in many care settings. Risk scores helped convey individual risks to older care recipients in a tangible format. A dentist explained how the products of screenings supported patients to link behaviour with effects on their body:
‘The DEPPAs [Denplan PreViser Patient Assessment; oral health risk screening tool, including alcohol-related risks] with them having a written piece of paper in their hand describing their risks, that’s something visual they go away with. I think it helps them to make that link between, “What I’m doing to my body or what I’m putting in mouth affects … ” It’s easier to talk about it because it’s there and it’s in colour.’
(Dentist)
Where screening results did not indicate harm, older adults drew on this as evidence that their drinking was not a risk, justifying continuation. Despite drinking at hazardous levels, a participant felt their normal blood results demonstrated that their drinking was not problematic:
‘When I get my bloods checked every 6 months, the practice nurse will say, “Your bloods are spot on. There’s nothing in your internal organs ringing bells.” So I don’t think [alcohol is] having a detrimental effect.’
(OP, Malcolm, aged 67 years, M)
Older adults receiving care for long-term conditions, whose health was closely monitored, felt that any personally relevant risks attached to their drinking would be communicated by practitioners. They otherwise assumed their drinking was safe.
Health practitioners recognised that guiding older patients’ understanding of screening results was important to avoid misconceptions that may lead to them maintaining drinking at hazardous levels. However, they explained that they did not systematically screen blood samples for indicators of alcohol-related harm, or convey findings indicating potentially harmful drinking.
Perceived gains from restricted intake
Disease and death were an expected part of late life. Older people were motivated to restrict their intake when they viewed that drinking might affect the state of their health and perceived control over their health and longevity. This view was prominent among participants self-identifying as middle class, who felt being health conscious was important, and perceived agency over their health. For example, men in focus group 2 discussed how they felt it was important to ensure their quality of life was not impeded by ill health caused by their behaviour:
Billy (OP, aged 77 years, M):‘You’re more conscious of it [health, in later life] !’
Jack (OP, aged 73 years, M):‘One knows that one’s quality of life is going to be severely diminished if one suffers from ill health.’
Billy:‘ You are conscious of the fact that your life is coming to an end. You end up being more conscious therefore of I better not do this, because of that stage.’
Older adults often had particular health concerns that they looked to manage by any means. They were more open to adjusting their drinking when they perceived doing so would enhance their quality of life through alleviating health complaints. One participant’s arthritis condition was affecting their mobility. They restricted their alcohol intake to control their weight, and its effect on their condition:
‘I’ve got arthritis in some of my joints, I’m having difficulty getting about. I can’t walk as much as I would like to, so it’s inactivity I’m concerned about. So I’m trying to eat less and drink not necessarily every day. [It’s about] making my life easier and more acceptable.’
(OP, John, aged 66 years, M)
Health practitioners reported that they often conveyed the relevance of alcohol to common health concerns they were managing, including diabetes, high blood pressure, falls risk, and obesity. They reflected that framing reductions in use in terms of potential benefits, given individual concerns, represented an effective way of motivating healthier decisions:
‘If they say, “I’m tired”, or, “My mood is low”. I’ll often reflect back to them, if they’ve drank a lot, “Do you know alcohol lowers your mood? ” Or, “It doesn’t help you sleep. Maybe that would help, if you cut it back.” It’s finding a hook that can make sense to them.’
(GP)
Older adults were clear that they were prepared to limit or stop drinking if this was recommended by health practitioners because of individual health risks. As one participant emphasised:
‘You should follow the doctor’s advice. You just assume the doctor knows what they’re talking about. If I was advised by a doctor, “Don’t drink at all for health reasons.” Then I could stop.’
(OP, Charlie, aged 76 years, M)
Older adults broadly viewed acute illness to be incompatible with drinking. When experiencing ill health, a number of participants described having curtailed their alcohol use. In these circumstances, older adults perceived their health as vulnerable to the hazards of drinking. They were more open to recommendations to reduce intake following such health events, as described by practitioners involved in aftercare and older people who had received advice in such circumstances:
‘ [Nurse] said, “I can see you enjoy a drink and I don’t want to stop you from drinking, but, for the first fortnight or so after you leave the hospital, could you dilute it? ” So I did that with soda water I may tell you, which made quite a nice drink. But she advised me, what I thought was very sensibly due to my age and one thing and another, that I could have a drink but as long as I didn’t have too much immediatelyafter my heart thing.’
(OP, Valerie, aged 88 years, F)
Older adults had also followed practitioners’ advice for restricting intake when prescribed medications contraindicated for use with alcohol.
Some of the oldest participants struggled to manage their declining health, and did not feel they had control over their health state. They were not motivated to attempt to improve health outcomes through restricted drinking. The same participant conveyed that restricting their intake to avoid low energy would be pointless, as they experienced fatigue regardless of drinking:
‘I just have what I enjoy, you see, sometimes, if I don’t have [alcohol] at all, one day death is imminent and the next you can leap a five-barred gate. You don’t know what your day is going to be.’
(OP, Valerie, aged 88 years, F)
Many practitioners experienced in intervention for alcohol remarked on their oldest care recipients’ apathy towards reducing their intake. These individuals were resigned to their limited remaining years, feeling drinking contributed to enjoying these. Practitioners explained this was difficult to address:
‘I think older patients sometimes go, “Well, I’m 89. I haven’t got long left. I enjoy it.” It’s hard to say anything really to that person.’
(GP)
