Since his wife died six months ago, John, age 83, has begun to drink more and more. Lately, he even forgets to shower and change his clothes. He seems angry all of the time and cries a lot.

Between 1.1 and 2.3 million senior citizens use alcohol to deal with grief and loneliness. What has been called the "hidden population" is now being discovered and measured. Most people tend to reduce their alcohol intake as they get older, perhaps as a response to poor health or a change in social activities. However, society has begun to recognize that the incidence of alcoholism among older persons is on the rise. And while it is difficult to find hard statistics on today's elderly alcoholics, as much as 10% to 15% of health problems in this population may be linked to alcoholism.

One fact is clear: alcohol-related problems among the elderly are much larger than perceived even a decade ago. It also is clear that the response remains devoted to treating their symptoms briefly and directly, rather than getting to the core of the drinking behavior and treating the alcoholism.

John, the 83-year-old widower referred to at the beginning of this article, clearly has a drinking problem. However, his family has been unaware of his increasing alcohol consumption. On visits to their father, John's children observe that he is confused, forgetful and depressed. Like many adult children of aging parents, they view these behaviors as normal signs of aging. This is not uncommon. After all, the effects of alcoholism may mimic those of aging, making diagnosis of alcoholism difficult in the elderly (see Table One). Many symptoms - including aches and pains, insomnia, loss of sex drive, depression, anxiety, loss of memory and other mental problems - may be confused with normal signs of aging or side effects of medications.

The identification of John's drinking problem is further hampered by a reluctance on his family's part to acknowledge that their father could be an alcoholic. It is not uncommon for families to be hesitant to "interfere" with an elderly relative's life, even when multiple car accidents or bouts of confusion suggest that there is a problem.

Even when families or professionals try to get help for their loved one, identification of a drinking problem may be difficult. For example, use of the DSM-IV criteria may present difficulties. Many of the criteria necessary to make the diagnosis of alcoholism are more appropriate for younger persons. These may not apply to elderly individuals who may be more isolated or solitary, less likely to drive and very likely to be retired. In fact, an article in the Journal of Geriatrics suggests that the diagnosis of alcoholism be focused on biomedical, psychological or social consequences.

Stereotypes and Attitudes

Unfortunately, we often don't value our elderly citizens in this country. As a result, some people tend to ignore or shun older people with drinking problems. "After all," they will say, "they're not hurting anyone. Let them enjoy the time they have left. Who cares?" At the same time, therapists may be reluctant to work with older alcoholics because of unrecognizable counter-transference issues, i.e., the elderly client triggers the counselor's own fears about aging. Older clients often are perceived as rigid and/or unwilling or unable to change; and counselors may feel that they are wasting their time on such individuals. However, those who study the science of aging understand that these myths, assumptions and stereotypes are unfounded and often harm elderly individuals who can benefit from treatment.

Aging doesn't have to be a time of loneliness and desperation. Many people find happiness and even adventure in their later years. Those who age successfully tend to have a strong sense of life satisfaction, high self-esteem and positive morals. Older persons who achieve a sense of ego integrity are able to look back on their lives with a sense of satisfaction. Older persons who look back with regret and believe that it is too late to make significant changes may experience a sense of despair and depression. To age successfully is to be able to adjust to the loss of a spouse and other significant individuals, adjust to retirement and reduced income, accept and deal with declining health and establish satisfactory living arrangements.

Unfortunately, not everyone ages successfully. Some cannot accept the physical changes that come with age. Others can't handle the loss of a spouse or friends, or they can't adjust to retirement. And, often, these individuals turn to alcohol.

Many of these people, like John, never had a drinking problem prior to this time in their lives. This is called late onset alcoholism. The bad news is that this type of alcoholism may go unrecognized. The good news is that late onset clients have a better chance of recovery because they have a history of handling problems successfully. Some characteristics of late onset alcoholism include:

• presence of significant life events that trigger excessive alcohol use

• minimal, if any, work-related consequences

• fewer marital/family consequences

• absence of consequences with the criminal system

• difficulty with confrontations due to cognitive impairment

• shame as a significant issue

• health or financial restrictions that limit amount or frequency of use

• loss of social network (may be "secret drinkers")

While John began drinking late in life, his friend Henry - whose drinking habits are the same as John's - began drinking much earlier. Early onset alcoholics, such as Henry, are those drinkers who have been drinking excessively for may years. As a result, they may have more difficulty in recovery because of health complications from years of drinking. Some signs and symptoms of early onset alcoholism include:

• experience with or prior history of treatment

• survival into late life despite physical, emotional or psychological consequences of drinking

• "treatment wise" attitude and demonstration of impenetrable prognosis

• lack of acceptance and/or surrender

These are individuals who have sought help in the past, but - for whatever reason - have not been able to maintain sobriety. Table Two shows evidence of greater current psychological damage in the early onset group, while late onset alcoholics studied were more psychologically stable and more compliant with treatment. At the same time, early onset alcoholics also have more health problems from years of abuse. These health issues very often complicate treatment.

Treatment for Elderly Alcoholics

John and Henry were referred to treatment by their families. John's family solicited the aid of an interventionist who helped John enter treatment. Henry has a long-time friend through AA who helped him get into treatment. Both of these men now are in a treatment modality that is best suited for a much younger client. Why is this a problem?

First of all, the idea of rubbing elbows with drug abusers does not fit in with how most seniors view themselves or their problems. They are more likely to drop out of treatment or be noncompliant when they are thrown in with drug abusers. They are likely to say, "I'm not like them. I don't belong here."

At the same time, these people grew up at a time when one was expected to be stoic, to deal with his or her problems privately and not show his or her feelings. The older client needs more gentle confrontation. It often is more helpful to address issues such as isolation, loneliness, grief and shame, as many of these clients are resistant to the disease concept.

Other modifications need to be made to treatment for older alcoholics. For example, programs need to be slower paced. There needs to be more quiet time and more time for clients to complete paperwork. Perhaps the physical environment will need to be modified, i.e., ramps or aids for hearing impaired clients may need to be installed. Physical factors that can complicate senior treatment include actual physical problems, detox complications, physical disabilities, hearing and/or vision impairments and decreased stamina and mental deterioration. Emotional factors that could complicate recovery include lack of motivation, alienation, identification and expression of emotions, limited leisure needs and identification with peers.

The counselor working with these clients needs to be more flexible and more empathetic. Professionals need to speak slower, thoroughly and patiently, explaining every aspect of the treatment program. But, most important, counselors must realize that elderly clients need to be met where they are, not where the counselor wants them to be.

If anyone has any doubt that treatment works for elderly alcoholics, he or she just need look at John. He no longer forgets to shower or change his clothes. He now smiles a lot and has adjusted to a new way of life. He is attending a 12-step program with other recovering seniors and making new friends.

Counselors can help add quality of life to the years our elderly have left. And that is well worth the effort.

Virginia Arnold, CADC, NAADAC, has been a counselor at the Betty Ford Center in Rancho Mirage, CA, for 10 years. She currently is assisting in developing a track for treatment of seniors that will be implemented on an inpatient unit.

Reprinted with permission of the publisher: National Association of Alcoholism and Drug Abuse Counselors, 800/548-097.

References

American Geriatrics Society. (1992). Screening for Drinking Disorders in the Elderly Using the CAGE Questionaire, San Francisco, CA; AGS.

Atkinson, R., MD; Kofoed, L., MD; Turner, J., PhD; Tolson, R., MSW. (1985.) Early Versus Late Onset in Older Persons. Alcoholism: Clinical and Experimental Research, 9;6.

Gupta, Krisham, L., MD (1993). Alcoholism in the Elderly. Alcoholism, 93;2.

For professional, confidential help for alcoholism, aging, or any other personal problem, call the Missouri Lawyers' Assistance Program (MOLAP) 1-800-688-7859.