Older Adults and Alcohol, © 2004, Information Sheet #3
Best Practice 3...
Using harm reduction
What is Harm Reduction?
Is the only way to help an older person who has an alcohol problem simply to tell them "Stop drinking, and then we’ll help you"? No. That is not always wanted or possible. Sometimes it is not safe, particularly if it means the older person must abruptly stop drinking.
In Canada, most special treatment programs geared to older adults use a "harm reduction" approach to effectively reach and work with older adults.
The term "harm reduction" refers to strategies to help a person avoid harms associated with his or her alcohol use. The goal is to work towards less problematic alcohol use or abstinence. It is a non-confrontational and non-judgmental approach. It helps the person deal with the problems that he or she finds most troublesome in his or her life.
Harm reduction is recognized as an effective approach to alcohol and other drug problems by the World Health Organization (WHO) and Canada's Drug Strategy, as it addresses the underlying factors of alcohol misuse in later life.
Some service providers use harm reduction as a tool to improve the person’s situation by addressing immediate problems. Others consider it more as a specific goal where the aim is to reduce the amount of alcohol that the person is drinking. Both are positive achievements, and useful.
Why Use Harm Reduction?
There are several reasons. Not every older person can stop drinking or wants to stop at the initial point of contact with a service provider. The person may not be in a physical or psychological position to understand or consider that alcohol is causing a problem and that change is possible. Harm reduction accepts these realities.
Harm reduction offers hope to both the older adult and those working with the person. It also provides practical and immediate actions that people can use to help improve the older adult’s life rather than waiting for the individual to stop drinking at some unidentifiable future point. It often helps to stabilize or prevent situations from deteriorating further.
Where to Begin
Harm reduction focuses on immediate harms in the person’s life and works for realistic goals. It begins with whatever problem the older person feels is important to address (for example, more secure housing, improved heath).
It gives service providers a way to begin establishing and maintaining a relationship with an older adult who has an alcohol problem. It gives them strategies on how to offer assistance, even where the older adult feels "it's impossible to stop right now". Harm reduction is helpful whether alcohol has been a long standing problem, or is a more recent one for the older adult.
How to Begin
The harm reduction approach stresses the need to provide support and give the support in a way that the person is in a better position to make decisions and choices. People can help an older adult who has an alcohol problem by helping to
• improve the older adult’s mental or physical health,
• modify the older adult’s attitudes and behaviours, and
• improve the older adult’s living environment.
What Are Some Common Harms?
Older adults who have alcohol problems can face several different types of harms. The specific types will depend on their health, age, sex, marital status, economic status, cultural background, the environment in which they live, and extent of the alcohol problem. Below are some of the more common harms.
Depression affects about one in four older adults who are experiencing alcohol use problems.
To reduce the harms associated with depression (such as self isolation, self neglect, suicide risk), it is important to recognize the depression is occurring. It is also important for mental health services, addiction services, and other allied service providers to work together to help the older adult, without trying to separate out whether the alcohol use is the cause or the effect of the depression.
Older adults should not be denied mental health services because they are drinking. Nor should they be denied addiction treatment services when they have a concurrent mental health problem.
2. Safety Concerns
Several safety concerns arise when an older adult is intoxicated or drinks at unsafe levels, including falls and fire risk (leaving the stove on, falling asleep while smoking). One harm reduction strategy used often in rural and urban settings is to make arrangements through family, friends, volunteers, or neighbours to check on the older adult on a daily basis. Some communities provide a telephone reassurance service for frail older adults, through community or police services.
Older adults who misuse alcohol often have very few connections to their community, health services, or other social services. Effective harm reduction strategies for reducing older adults’ isolation may include
• outreach (going to the person’s home),
• support groups,
• therapies to rebuild social support networks (for example, re-connecting the older adults with willing family members, use of peer groups and self help organizations).
Providing older adults who have experienced alcohol problems with regular opportunities to socialize, such as monthly luncheons are among the strategies that often work to prevent and reduce isolation. Harm reduction also includes offering the older adult encouragement to attend activities (as many older adults can feel apprehensive in new settings at first). It is also important to help them get to the function, as many older adults, particularly older women, do not drive.
4. Poor Health
Most older adults, including those with alcohol use problems, want to maintain their health and retain as much of their physical ability and independence as possible, for as long as possible.
However, older adults with alcohol use problems are at much greater risk of having their health and independence jeopardized by the direct and indirect effects of the alcohol use. They often feel as if they are facing an inevitable decline.
Sometimes, an older adult will have lost contact with a regular physician. Or, he or she may avoid physicians out of fear and anxiety about an existing or potential illness. In some communities there are not enough physicians to meet the community’s needs.
There are several effective harm reduction strategies to help assure that older adult’s health concerns are properly addressed in a timely manner. These may include
• advocating for appropriate health and community services,
• helping the older adult connect with appropriate medical help, keep appointments with specialists, and
• providing transportation, when necessary, to get the older adult to those appointments.
Further harm reduction strategies focus on health education, in particular helping the older adult recognize and understand the connection between his or her pattern of drinking and specific health problems that he or she is experiencing (such as stomach problems, diabetes control problems, peripheral neuropathy). It also includes helping the person see the link between the level of alcohol use, and his or her health and independence. This education process is not a "one shot deal", but involves providing the information at appropriate learning points.
5. Medication Problems
Over 150 medications commonly prescribed for older adults negatively interact with alcohol.
Harm reduction strategies for potential medication harms centre on educating the older adult about negative interactions of alcohol and the specific medications he or she uses (including over the counter drugs, and herbal medicines). Use both verbal and written methods to communicate the information. Other useful strategies include:
• working with the physician to have different, less harmful medications prescribed in light of the older adult’s alcohol consumption, and
• assuring that the physician has an accurate picture of the older adult’s level of alcohol use.
6. Poor Nutrition
Older adults who eat well tend to experience less adverse effects from alcohol than those who do not, even at moderately high levels of alcohol consumption. Older adults misusing alcohol are at a greater risk of malnutrition, and consequently illness.
Alcohol use can affect an older adult’s desire to eat and can affect the ability of the body to absorb vitamins. If an older adult is drinking heavily, she or he may not have enough money left for food. Sometimes, when drinking heavily over a period, the person’s stomach will not handle food well. It is also helpful to recognize that eating alone is seldom relished by older adults in any circumstances.
Strategies to deal with harms associated with poor nutrition may include
• encouraging the person to eat something throughout the day when drinking,
• working with the older adult to arrange to buy his or her groceries before purchasing alcohol,
• helping the person use meal programs, particularly those that give them the opportunity to leave the house (for example, "wheels to meals" programs),
• helping with practical matters that can affect access to proper food (for example, arranging to have a broken refrigerator fixed),
• facilitating socialization and learning opportunities such as having "Flying Solo" cooking classes for people who live and eat alone,
• helping the person find an easily accessible alternative such as a café where he or she can eat inexpensively, without the availability of alcohol.
7. Pain Management
Chronic physical pain from arthritis and lower back injury is common among many older adults. Chronic pain can also lead to emotional isolation from being disabled or functionally impaired. Some older adults deal with their chronic pain by self medicating with alcohol or other drugs.
Some service providers may have misconceptions about older adults. They may erroneously believe that people feel less pain as they age or that older adults should "just learn to live with the pain". Some service providers may have misconceptions about pain medications and are concerned that the older adult will become addicted to the pain relievers.
Harm reduction strategies for pain centre on
• having the older adult’s pain management needs recognized and addressed by the older adult’s physician,
• facilitating proper level and proper use of prescription drugs for pain,
• exploring non-drug alternatives with the person (such as magnesium supplements, heat pads, relaxation therapies, massage, swimming, Tai Chi etc.).
Other harm reduction strategies focus on providing accurate information for older adults and service providers about pain management, including information on the important differences between "drug tolerance", and "drug addiction" as it relates to pain relief.
8. Housing Difficulties
Safe, affordable and secure housing is often the key to an older person being able to handle his or her alcohol use problem. In some cases, if the person’s housing situation stabilizes, the amount of alcohol that he or she is drinking may decrease. On the other hand, if the person’s housing situation deteriorates, his or her physical and emotional health also tends to worsen. Drinking also tends to increase.
Older people who have alcohol problems may risk losing their home as a result of non-payment of taxes or other bills. Those living in apartments risk eviction for nonpayment of rent, behaviour problems, incontinence, or potential harm to others (for example. fire risk).
Harm reduction strategies may also include
• working with the older person to have rent and other bills paid first,
• negotiating and consulting with the building manager to identify the risks and concerns and find ways of reducing these without the older adult being forced to leave,
• providing outreach and support in older adults’ apartment housing,
• working with housing staff to enable special services such as home detoxification to happen on site.
Some older adults with alcohol use problems may have a tendency to develop financial problems, even if their income is adequate. For example, buying alcohol for other people ("drinking buddies") can often leave an older adult without adequate money for necessities such as food, shelter, and utilities.
The problem can be compounded by the older adults’ use of expensive services such as bottle delivery and by some people willing to exploit the older adult. For example, some taxi drivers and bottle delivery services, or even some family members will deliver alcohol and ask for payment by using the older adult’s bank card and PIN, or ask for payment by signed blank cheques, which they can then use to their own advantage.
When actively drinking, the older adult may not be able to gauge his or her own risk of harm. Loss of money for an older adult can lead to a downward spiral of poorer housing, less physical security, and more exploitation.
Some harm reduction approaches work to help the older adult receive all his or her benefits and entitlements in order to find better housing, afford any needed medications, and have adequate food.
For those older adults with severe money problems or memory problems, other harm reduction strategies can be useful. In some low income communities, people can use a daily money management service operated by a community service (where an older adult voluntarily goes on a daily budget for buying alcohol).
It is also possible to have some government benefits (Veterans benefits, Old Age Security) paid to an interested third party such as a reliable family member. The person acts as trustee of the money and only uses the money for the benefit of the older adult.
10. Violence or Abuse from Others
An older adult who has an alcohol use problem is sometimes unable to judge his or her own risk. The person can become vulnerable to muggings or robbery by strangers, or exploitation from family or others. Strategies to reduce this alcohol related harm include helping the older adult plan how to avoid the risky situations (for example, taking out less money when drinking, taking precautions so that others do not see the money).
Strategies in "elder abuse" situations include building trust with the older adult, monitoring the potential abuser, as well as helping the older adult put other safeguards in place (e.g. direct deposit; automatic rent payment) and informing the bank of the potential problem. See the Best Practices sheet on "Elder Abuse".
11. Risky Sex
For some older adults, drinking and socializing in bars go hand in hand. This behaviour can leave them at risk of sexually transmitted diseases (STDs), including HIV and AIDS. Part of the "harm" for older adults may be service providers’ failure to recognize that many older adults are still sexual persons.
Harm reduction strategies can include
• acknowledging that older adults continue to have sexual feelings and can be sexually active,
• providing age appropriate and nonjudgmental information specifically geared to older adults on the sex risks and methods of sexual protection,
• making condoms easily available in washrooms of health centres, seniors’ centres, and bars or other places that older adults may visit.
This is the third in a series of Best Practices Information Sheets
developed by the Seeking Solutions Project, © 2004,
funded by Health Canada and the National Population Health Fund.
You are welcome to copy this material but it cannot be used for commercial purposes. For more information, visit: www.agingincanada.ca .
Page last updated Sunday October 31, 2004
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