The stereotype of an alcoholic is one of an unkempt, down-and-out street person. But researchers and clinicians are discovering an 'invisible epidemic' of drinking problems among older men and women. Alcohol related disorders are common among the elderly, and a study in the British Journal of Medicine says that the ageing of populations is likely to result in an increase in their numbers.
Although there is a paucity of population-based data on alcoholism specific to Hong Kong, the mainland, and Asia, it appears to be a rapidly expanding problem, says Lam Tai-hing, Sir Robert Kotewall professor and director of the School of Public Health at the University of Hong Kong. 'In China, alcohol is heavily promoted, and drinking white spirits with high alcohol content is very common. In Hong Kong, the beer and wine tax has been reduced to zero since 2008, with rapidly expanding promotion, advertisements, trade and consumption,' says Lam.
Drinking in late life
Alcohol problems among the elderly tend to differ. Some elderly people have been drinking excessively for most of their lives. Others use relatively small amounts of alcohol, but mix it with prescribed medications in harmful ways. Still others develop alcohol problems late in life.
Late life drinking problems - those that begin after the age of 60 - develop for a variety of reasons. Elderly people find that the listings in their address books dwindle as friends and family move or pass away. Health problems begin to interfere with their ability to get out and about. Little by little, almost without realising it, someone can become isolated and lonely, and seek comfort from the bottle.
'Old people who live alone appear to be at greater risk for alcoholism,' says Dr Barnett Meyers, professor of psychiatry and clinical epidemiology at Weill Medical College of Cornell University in White Plains, New York. A glass of wine at lunch and then at dinner, or a few bottles of beer in front of the television, may seem like a 'quick fix'. It helps the drinker to relax, get comfortable, numb the pain of loneliness, get a good night's sleep, and re-create warm memories of times that were once spent with a spouse.
An invisible epidemic
Alcohol problems in the elderly go undetected or misdiagnosed because they occur behind closed doors in private homes or apartments, rather than in the club and bar settings that attract youths.
Seniors generally don't have to arrive at work at a specified time and don't have as large a social network as younger people. So their problems are less obvious to family members, close friends and even their doctors. Older people may visit doctors several times a year but many physicians fail to look for or recognise drinking problems.
Some simply aren't attuned to the symptoms of 'problem drinking' and may erroneously attribute falls, mental confusion, traffic accidents and other problems resulting from alcohol use, to illness or to the ageing process itself.
'Many doctors do not ask for a detailed history of smoking and drinking, unless there are symptoms and signs suggestive of alcohol-induced diseases, such as fatty liver or liver cirrhosis, or other psychosocial problems brought up by patients or relative,' says Lam.
Even when physicians suspect a drinking problem, they may be too embarrassed or too busy to do anything about it. In some cases, they are simply too forgiving.
How to tell when someone is drinking too much
Clearly, the combination of age, alcohol use, health problems and prescribed medications can result in serious trouble. For this reason, the same standards used to assess 'problem drinking' in younger individuals can't be used for individuals over 60. Studies show that alcohol can exacerbate existing hypertension, heart problems, diabetes, and memory lapses.
Heavy drinking can exact an even worse toll. It can permanently damage the brain and central nervous system, as well as the liver, heart, kidneys and stomach. When mixed with prescribed and over-the-counter medications, alcohol use may even prove deadly.
Seniors, like many young people, will often go to great lengths to cover up and hide their alcohol use. Denial makes it difficult for physicians and family members to recognise a problem and convince the affected individual to seek treatment.
To assess whether an elderly person's drinking is really a problem, Meyers suggests that physicians, family members and patients themselves think about whether recent drinking patterns are typical for that individual. If they aren't, it may be symptomatic of attempts to 'self-medicate' an underlying medical or psychiatric condition, as is often the case with people who are depressed.
Relatives can play a vital role in helping their family members, explains Lam.
'They should assess whether that member is drinking excessively and whether there are alcohol-related and other health problems.
'They should advise older family members to stop drinking and, failing that, to reduce their drinking,' he adds.
Meyers describes recent visits from several bright, independent and accomplished older patients who spontaneously recognised that their own alcohol use might be becoming a problem.
One patient, a 70-year-old widower, became depressed and had difficulty falling asleep after his only daughter, who he was very close to, married and moved to another part of the country.
The patient told Meyers, 'When I get lonely, I can't get to sleep without having a glass of wine or two before going to bed.'
A 75-year-old patient reported having trouble falling asleep. She began to drink within months of losing her husband and asked, 'Doctor, is this a problem?'
A third patient, a 70-year-old retiree, admitted that he was having 'a drink or two during the day' for the first time in his life while his younger and more socially active wife was away from home.
This was a new pattern for him, and he volunteered the information with some concern that he might be 'turning into an alcoholic'.
The role doctors can play
'Although this self-confessional attitude may be more common in the office of a psychiatrist,' says Meyers, 'all physicians who treat seniors should communicate an open and inquisitive attitude that allows for a good discussion of drinking behaviour.
'But answers to such questions, are not always clear-cut.' Drinking should not be discouraged on the basis of age alone, he says. 'It isn't appropriate to infantilise older people,' Meyers said. 'When a patient suddenly begins drinking late in life, we need to work together, and view the drinking as a signal.'
'The establishment of an open relationship with a physician - one that allows for monitoring alcohol consumption, providing guidelines and using additional interventions that may be needed - is a critical step in the management of this type of patient.'
Doctors and patients need to keep in mind that regardless of age, when recognised and detected, alcoholism is a treatable illness.
Elderly people who are socially isolated or clinically depressed are particularly vulnerable and in greatest need of such vigilance by their doctors.
If you suspect you or a loved one needs help
Speak to your physician or a member of the clergy.
Find an Alcoholics Anonymous group at www.aa-hk.org/ .
Contact a programme serving seniors in your community. There are limited services available specifically for problems drinkers, such as those provided by Tung Wah Group of Hospitals' alcoholism counselling service (http://atp.tungwahcsd.org ).
Dr Irene S. Levine is a clinical psychologist and professor of psychiatry at the New York University School of Medicine.