Perceptions about how receptive older people are to alcohol-related intervention
Practitioners involved in alcohol screening and intervention (detailed in Supplementary Box S1) discussed the challenges of older people recognising when their drinking may represent a risk. Older people’s cultural view of ‘normal drinking’, which often involved daily alcohol use, could overlap with clinical views of hazardous use, particularly among the younger-old (‘baby-boomer’ generation):
‘People do have, say, a glass or two of wine with their meal at night, and it seems to be a bit more socially acceptable. Getting people to look at it differently, that’s not very much on a daily basis, but actually, when you add it up and when you’re looking at how many units you’re having over a week, it maybe is a little bit too much. But it is sometimes difficult to get people to think like that.’
(Nurse)
Practitioners who worked with people of different ages expressed views that older drinkers tended to consume little alcohol relative to younger ‘binge’ drinkers. They described instances where they had not considered alcohol as a cause of potentially related health issues with older adults, particularly those perceived to be low-level drinkers, such as the oldest-old and people in care homes:
‘I did a visit to a care home a few weeks ago and did a liver function test on a patient, not looking for an alcohol problem. They were a bit abnormal … [I didn’t ask about her drinking] because she’s in a nursing home. It didn’t occur to me that in a nursing home somebody might be drinking to excess and that this might be a problem; it made me think I need to be more aware of that.’
(GP)
Practitioners perceived drinking practices to be well established by old age. Many had experience of older people’s resistance to advice, and had low expectations for the success of any intervention to address alcohol use:
GP3:‘The thing with the elders they’re [saying] “I’m eighty-five years old, I’ve been drinking a half bottle of whisky every day.” They’re less likely to change.’
GP4:‘It’s hard to motivate them.’
GP5:‘It’s difficult to argue against.’ (General practice focus group [GPFG])
However, older people’s concerns about the vulnerability of their health in old age was recognised as a motivating factor for healthier lifestyle choices:
‘You certainly get people, as they’re getting older, coming in with more general concerns about their general health and what they can do to help themselves.’
(GP)
Practitioners were all wary of discussing alcohol use, and felt that it could be a sensitive topic for older people. Implying that someone’s drinking may be ‘problematic’ raised issues of stigma. This meant that some avoided raising their concerns with older people, owing to apprehensions about how rapport may be affected were offence caused:
‘I don’t usually interfere unless it’s a problem. And even then it will fracture your relationship, of course it will and it’s really difficult to get them engaged.’
(Social care practitioner)
Many practitioners, particularly the youngest, expressed reservations about telling older people how to live healthily:
‘I do naturally have a great respect for older people, because they’ve been through it, they don’t want a younger person trying to tell them how to live their lives, when they’ve done it quite successfully for the last seventy years.’
(Pharmacist)
Interviewees emphasised older people’s right to use alcohol and take risks. This perspective could deter intervention; and was particularly evident among domiciliary carers. Supporting older people to maintain their established lifestyle was at the heart of their role. Practitioners involved in alcohol intervention focused on ensuring older people’s decisions about drinking were informed:
‘Ultimately, they’re adults … it is their responsibility … [we are] making sure that they’ve got that information so they can make their own informed choice.’
(Nurse)
Most practitioners were acutely aware of the potential roles of alcohol in older people’s social lives and stress management, which contributed to their emotional wellbeing. Alcohol was central to many older people’s social activities, and a source of pleasure at a time in later life when social opportunities may have been limited, and stresses such as bereavement, loneliness, and boredom were common. Some practitioners described making allowances for their older care recipients based on such considerations, and acknowledged that they were less motivated to suggest limiting drinking:
‘I often weigh up a risk–benefit and [am] probably guilty of turning a blind eye to the men who are going out drinking with their mates. There’s a balance … If getting pissed on a Friday is the price they pay to avoid total social isolation, I will roll with that.’
(GP)
Drinking to cope with stresses was broadly perceived by practitioners to be a concern warranting intervention.
Practitioners with clear roles in screening and intervention, and appropriate training to equip them in this work (such as practice nurses and pharmacists), often possessed a belief that addressing alcohol use was part of their key care responsibilities. These practitioners were motivated to discuss alcohol use regardless of their reservations. Through experience, practitioners’ preconceptions about older people’s receptivity to alcohol-related discussion were challenged:
‘Sometimes we worry about raising it because we assume patients are going to feel judged but doing it more often it’s much easier.’
(GP)
An established rapport with older individuals, either through longer consultations (for example, medicine use reviews) or long-term practitioner–patient relationships (common in general practice), was felt to increase the acceptability of alcohol-related discussion:
‘I’ve been seeing my [older] patients for thirty-five years. I’ve earned over the years enough credibility to say, “Look, let’s talk like a couple of grown-ups who know each other very well.” I’ll pretty much always get away with it. I find it very easy to raise questions about alcohol. An experienced GP, I would think, is one of the ideal people to raise it, because of that relationship that they have with patients.’
(GP)
Processes and practicalities of addressing alcohol use
Practitioners described reminders to raise alcohol use with older people in their practice, including alcohol awareness campaigns and on-screen ‘pop-ups’ in general practice. They would raise concerns about alcohol use when faced with clear-cut symptoms. But there were other ways in which harmful drinking might present itself in older people — such as tremors or an unkempt home — that also prompted discussions about alcohol use:
‘People presenting with certain symptoms and likely conditions, you would bring up alcohol. If someone was yellow, or if someone had abdominal symptoms, pain, diarrhoea — I’d probably bring up alcohol.’
(GP)
Integrating alcohol-related discussion could be problematic in primary care, where practitioners were responsible for a range of care needs. Ensuring that older people understood their alcohol intake and associated health risks, and providing any necessary support, was perceived to be time consuming. Time constraints limited opportunity to discuss alcohol use when caring for older people, as multimorbidity was common with this group, and management of health conditions had to be prioritised:
‘If we had enough time with older people, alcohol would be in it but you would be looking at all their conditions. If they’ve got multimorbidity, alcohol, yes, you would talk about, but sorting them out properly would probably be on your priority list as well. So time is a real constraint. You’ve got to be really careful what you do in ten minutes. If alcohol prevention had to be higher up, you definitely would need a longer consultation.’
(GP)
For other practitioners, general health monitoring appointments created space for alcohol-related discussion. Dedicated time in ‘health checks’ for older adults allowed this potentially sensitive topic to be introduced as part of standard care, which tended to be accepted:
GP4:‘They’re [the patient] probably expecting to be asked in those sorts of clinic situations where it’s a health check or something. Whereas I think with us [GPs] , they’re coming in with something that they don’t think is related to alcohol.’
Nurse 2:‘They might think, “Do I look like a drinker? I’ve only come for a sore on my finger.”’
GP4:‘I think it means we don’t [raise alcohol use] as much.’
GP5:‘If it’s normalised it’s good because it seems to be more acceptable if nursing staff are asking than medical staff because we ask it less.’ (GPFG)
Intervention options, or signposting opportunities for hazardous drinking, were considered important in ensuring that any needs for support were met. When these were not available, practitioners were more reluctant to raise alcohol use with older people:
‘If you can intervene and say, “This is really important and I want you to go and see these people, make an appointment, and that phone number. Do you promise to do that?” that will increase the value of what you’re doing hugely. You have to have that pathway for people to follow.’
(GP)
Professional remit and addressing older people’s alcohol use
Alcohol-related health promotion was a specific responsibility for a number of practitioner groups, and was prioritised in their interactions with older care recipients (see Supplementary Box S1). Everyone else cited barriers, such as time constraints and how receptive older people would be, as influences on the likelihood that they would discuss alcohol use.
Although older people’s support needs were often recognised by practitioners, they were wary of their remit and capability relative to other practitioners for identifying and/or intervening to address potentially risky alcohol use. These individuals tended to view elements of addressing older people’s alcohol use as others’ professional responsibility. Some practitioners expressed a lack of confidence about intervention, or understanding of low-risk alcohol use, especially with older people. This limited their ability to provide support:
‘I’m not sure that I know enough about how good or bad alcohol is for you to be able to justify going any further with [intervention] apart from, “Did you know alcohol is linked to mouth cancer?” That’s as far as it goes really. I don’t go into any depth or any detail because I don’t have the knowledge.’
(Dentist)
Professionals with less training in alcohol intervention, such as dentists, felt that there were others who were better equipped to meet older people’s support needs to make healthier decisions about alcohol use. Pharmacists and GPs demonstrated more extensive knowledge that informed their practice.
Practitioners working in social care for older people did not intervene directly and relied on referrals to health care. However, they described little success in prompting intervention this way as their concerns were often not shared:
DC1:‘We don’t really have much luck with GPs. Normally, if you do a referral, you will get a visit, but GPs only really tend to be interested in illnesses.’
DC2:‘Acute illnesses, like an infection or a UTI.’
DC1:‘Where they can prescribe something. When it comes to other things, I think they tend to just pass it on.’ (Domiciliary care team)
Practitioners working in general practice acknowledged their role in managing older care recipients’ alcohol use. Organisation of services meant allied health professionals, such as nurses and healthcare assistants, were more likely to address older patients’ alcohol use through health screening and brief intervention initiatives for older people:
HCA2:‘I think we [healthcare assistants] ask [about alcohol use] because it’s part of our sequence and it’s part of what we have to ask. It’s ingrained — every contact you’re saying, “Can we just ask you about your smoking, your drinking?”’
GP4:‘ It’s not something that flags up though on our [GPs’] systems unless it’s become an official problem. It’s not all that obvious if we’re seeing them for something else unless we actually look for it.’ [GPFG]
