Alcohol misuse is a common but under-recognized problem in older adults. It includes a spectrum of conditions from hazardous use, defined as >7 drinks per week or >3 drinks in one day for older adults, to harmful use, abuse, and dependence. Older adults (age 65 and over) are at particular risk for health problems from alcohol misuse because of chronic illnesses, the use of multiple medications, and age-related changes. Among younger adults, screening, brief intervention, and referral for treatment have been effective to decrease the average quantity of alcohol consumed, and in some studies to reduce injuries, hospitalizations, and ED visits. A small number of studies have looked at interventions for older adults in primary care settings and found that brief interventions can decrease alcohol use. However, the effect of such interventions for older adults in the emergency department (ED) is not known. The goal of this project is to perform a pilot, randomized, controlled trial of a brief intervention and referral for treatment among older adults in the ED with alcohol misuse. The intervention for this trial will consist of a Brief Negotiation Interview (BNI) with a referral for further treatment that is tailored to the patient's needs. The NI is a standardized, well-described intervention that has been implemented in a broad range of clinical settings but has not been specifically tested in older adults in the ED. We will first tes the acceptability of the BNI in older adults in the ED, and then proceed with the pilot, randomized trial. Patients will either receive usual care or the BNI and a referral for further treatment that is stratified by severity of alcohol misuse. Patients with hazardous or harmful alcohol use will follow-up with a primary care physician; patients with alcohol abuse or dependence will follow-up with an outpatient alcohol and substance abuse program; those at risk for serious withdrawal symptoms will be recommended for inpatient treatment. In all cases we will contact the referral physician to help transition the patient's care, and ensure the patien receives a consistent message regarding their alcohol use across the different care settings. There are several reasons why the ED is an important setting in which to screen and intervene for alcohol misuse in older adults. Patients with alcohol misuse have more frequent ED visits. Fewer than half of older adults with alcohol misuse are recognized by their primary care physicians. ED-based interventions allow access to these unrecognized patients as well as patients who lack primary care. Patients may also be more receptive to an intervention in the ED than during a routine office visit, making their time in the ED a teachable moment. As the number of ED visits by older adults continues to grow, it provides a greater opportunity to identify those with alcohol problems and intervene to help improve their health and reduce alcohol-related injuries and hospitalizations. If effective, the intervention used in this project could be broadly disseminated with a substantial impact on public health and health care costs.
This project will assess the ability of a brief intervention with a stratified referral for treatment to reduce hazardous and harmful alcohol use among older adults in the emergency department (ED). This is a pilot study to determine the feasibility of enrollment, randomization, intervention, and follow-up on the primary outcome, which is prevalence of alcohol misuse at 12 months and secondary outcomes that include falls, motor vehicle collisions, and health care services utilization. The results of this work will provide direction for a larger study designed and powered to measure reduction in these patient-centered outcomes following brief intervention and referral for alcohol misuse in older adults to help determine the value and cost-benefit of ED screening and intervention. If shown to be effective, the screening and intervention methods could be widely disseminated to reduce alcohol misuse in older adults, reduce health care costs, and improve health outcomes.
