Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Alcohol Screening and Brief interventions
It is recognised that ‘Interventions aimed at individuals can help make people aware of the potential risks they are taking, or harm they may be doing, at an early stage.
This is important, as they are most likely to change their behaviour if it is tackled early.
In addition, an early intervention could prevent extensive damage’
(NICE Guideline 24, 2011).
There are seven criteria for alcohol dependence used by Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Revised.
- Tolerance: need to drink more to get same effect
- Withdrawal or morning drinking
- Impaired control: drink more or longer than intended
- Unable to cut down
- Large amount of time spent drinking or recovering from drinking
- Neglect other responsibilities or activities
- Continued use despite acknowledgement of problems caused by drinking
Treatment for alcohol problems has traditionally focused on individuals with moderate to severe alcohol dependence.
It is now recognised that this exclusive focus needs to be broadened to include the large group of drinkers whose problems are less severe.
Brief Interventions are effective for many. They should be carried out in general community settings and delivered by non-specialist, trained personnel and are associated with good outcomes and cost effectiveness’ (DoH ROI, 2012).
The terms Screening and Brief Intervention are likely to provoke anguish in some GPs as they imply a time commitment, which simply cannot be met.
This may be reinforced by the fact that the term Brief Intervention is used in the literature to describe both a series of short 15min-type of sessions, and also a once-off 2-4 minute structured discussion.
It is the latter that is suggested here, though it is acknowledged that in certain cases this short discussion will throw up issues that result in a significantly longer time commitment.
It is worth remembering in these instances that scheduling return appointments or referral to the practice nurse for support or follow-up might be a useful and appropriate option.
It is the structured element of the short session of structured brief advice that can allow a GP to gather and impart information in a short period of time.
Recommended target groups include those who may be at an increased risk of alcohol-related conditions which could include patients who :
- have had an accident or a minor injury
- regularly attend the genito-urinary clinics or repeatedly seek emergency contraception
- are involved in crime or other antisocial behaviour
- are truant or miss work on a regular basis
The most common components of brief interventions/counselling that have been shown to decrease drinking are :
Expressed concern from the provider, regarding unhealthy alcohol use
Feedback linking the client's drinking to his/her health issues
Education about recommended drinking limits
Offer of explicit advice to cut down drinking or abstain
Follow-up 2 - 4 weeks later to assess the client's response
Referral to specialty addictions treatment if indicate
The most effective interventions are explicitly client centered and non-confrontational.
Asking the clients' permission to discuss, eliciting their thoughts and using reflection are effective methods recommended for engaging clients in behaviour change.
Longer counselling sessions are not necessarily better. Five minutes of advice has been shown to be as effective as 20 minutes.
There is a growing body of evidence to show that Brief Interventions are effective for hazardous and harmful drinking while more specialist interventions are effective in people with co dependence.
There is good evidence to suggest that brief interventions for excessive alcohol use, aimed at reducing consumption, subsequent alcohol related harm and dependence are both clinically and cost effective and the primary care setting is seen as the most promising location to offer brief interventions (ICGP, 2013).
The 4-As Approach for a structured Screening or Brief Intervention comprises the following – Ask, Assess, Assist, and Arrange.
Step 1 - ASK
Ask patients about their alcohol consumption, using the CAGE or CAGE-AID tools
Read more about CAGE and CAGE-AID tools
Ask about amounts, frequency and patterns, using the AUDIT C tool, and Inform the patient of the results.
Encourage those who are at "low risk" to remain in that category, but if the result is 4 or more for a woman or 5 or more for a man, then move to step two
Read more about AUDIT C
Step 2 – ASSESS
The true amount of alcohol consumed may be assessed using the Consumption Diary.
The level of risk, be it hazardous, harmful or dependent, should be assessed using the full AUDIT tool if possible.
Read more about AUDIT
The patient’s readiness to change should also be assessed, as this will impact on advice given or action taken.
The Wheel of Change ia a useful tools to this end.
Read more about Understanding the Stages of Change
and the Wheel of Change
Steps 3&4 – ASSIST & ARRANGE
At a minimum, advice on safe drinking levels and alcohol reduction should be provided,
When clients are unable to cut down their alcohol consumption or abstain, offer referral to an addictions treatment program, or referral to a support group or mental health professional as required
Alcohol Use Disorders
(NICE guideline 115, 2011)
Focus on Alcohol Misuse in Older People
Elderly and Substance Abuse
This is one of several topics presented in the Thorny Issues sector of this toolkit
Back To : Thorny Issues