Kathleen Ondus (1999) reports that health care professionals often do not address or recognize the abuse of alcohol and drugs in the elderly. The factors contributing to the clinicians’ lack of identification of substance abuse in the elderly can include an overall lack of awareness, a failure to obtain or record accurate drug histories, a failure to periodically reconcile medications profiles with the patient and a reluctance to ask questions they may perceive as embarrassing to the patient. One out of every four hospitalized older adults may have alcohol related problems but most are not admitted to the hospital with a primary diagnosis of alcoholism. Data on prescription drug dependence is scarce, but it is believed to be under reported and under diagnosed. There are many contributing factors that may contribute to the older adult female’s use of benzodiazepines and the subsequent effect from these agents when combined with alcohol. The presence of anxiety, depression and feelings of overwhelming stress can trigger the use of both benzodiazepines and alcohol. Rates of benzodiazepine abuse are actually reported to be the highest in elderly women, which is partly attributed to the fact that elderly women visit their physicians more often than elderly males do. The result of the visit is often a prescription medication and that medication is often a benzodiazepine. Patients who are prescribed benzodiazepines tend to take smaller doses of the drug, but for longer periods of time and as a result, have increased difficulties with subsequent withdrawal (Ondus, 1999).

Summary and Recommendations

      The clinical manifestations of alcohol and benzodiazepine use and abuse in older adult women presents a challenge to health care providers as the associated signs and symptoms of alcohol dependence commonly seen in the younger people are typically not the same as those presenting in the elderly. In the absence of these typical signs and symptoms, the health care professional may fail to recognize substance abuse due to a lack of suspicion in the first place, the unwillingness of the patient or family to disclose the problem and/or by  a misdiagnosis whereby the presenting symptoms are attributed to the normal aging process. It is crucial for the health care provider to focus on the symptoms for which the elderly seek treatment as they may represent clues to actual or potential drug or alcohol abuse. Focused questions should be asked during the interview related to substance abuse risks such as experiencing feelings of loneliness or difficulty in managing activities of daily living (ADL’s). Health care professionals caring for the elderly should be familiar with the CAGE questionnaire, (see figure 1) which is designed to identify those at risk for alcohol abuse. (Critical Care Nurse, 2005) Nurses should pay particular attention to teaching the elderly client about the reasons for taking specific medications, the correct dosages, the potential side effects and possible interactions with other medications and/or alcohol. Another important and useful tool for healthcare providers is the Clinical Institute Withdrawal Assessment of Alcohol Scale otherwise called the CIWA scale (Critical Care Nurse, 2005). This scale assesses patients for possible alcohol withdrawal signs and symptoms and recommends corresponding medication treatment regimes based on the results of ascertained scores reflecting various clinical presentations (see figure 2). These types of clinical evaluation tools were developed to assist healthcare providers to quantitatively assess patients for the potential complications that may result from prolonged abuse of prescription medications and alcohol. Utilizing standardized tools allows the healthcare provider to assess the patient using a scientific approach and to advocate for evidenced based interventions and treatment.

Conclusion

      Alcohol and benzodiazepine abuse is a significant problem in the older female population. Older adult females are at increased risk for having potentially lethal adverse reactions from combining benzodiazepines and alcohol. The reasons for the increased risk include a variety of physical, psychological and social reasons discussed earlier. The literature is lacking in the area regarding the specific knowledge base of the healthcare provider as it relates to the incidence of benzodiazepine and alcohol use and abuse in the older female population. Given the incidence and seriousness of benzodiazepine and alcohol use by older adult females, healthcare providers need to make certain that accurate and detailed histories are obtained during every patient encounter, that medications are reconciled regularly, and that signs and symptoms of potential substance abuse are not overlooked or assumed to reflect normal aspects of the aging process.

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