Speaker 1: This video demonstrates how nurses and other health professionals can use The Short Michigan Alcoholism Screening Test-Geriatric Version to screen older adults and identify those who drink at levels that put them at risk for negative mental and physical health outcomes.
Janet M. Standard: So, we're here to talk Miss Tipton. She's a 70-year-old West Indian woman who presented here with a fracture of her right foot, ankle actually, after having a couple of drinks and going out to work in her garden. She's divorced. She has two living sons with whom she doesn't have very much of a relationship.
She lost a daughter. Her daughter was age five. She recently in the past two years she has lost her mother and her great aunt. And in the past three years she's also retired and moved to New Jersey. So, there's been a lot of transition. She is currently being treated for hypertension with hydrochlorothiazide, 12 milligrams, Norvasc, five, and insomnia, Ambien 2.5 milligrams. I did the Short MAST on to kind of explore her drinking after the fall.
Hi, Miss Tipton. I'm Janet Standard. I'm a psychiatric nurse practitioner and this is Miss Mancini. She is a student that I'm teaching. I'm wondering if it's okay if she sits in with us during this interview.
Miss Tipton: Yes, I guess.
Janet M. Standard: Okay. Thank you. Miss Salvador suggested I see you to ask you a few questions. She mentioned to me that you had a fall.
Miss Tipton: Yes.
Janet M. Standard: A couple of weeks ago.
Miss Tipton: Right.
Janet M. Standard: And sustained a fracture on your right ankle. How is that ankle, by the way?
Miss Tipton: It's a little sore. But it's coming along.
Janet M. Standard: I bet. Now, she mentioned to me that it happened after you'd had a glass of wine, I guess, at lunch time, or?
Miss Tipton: Yeah, yes. Yes.
Janet M. Standard: Okay. That's fine. But I feel like, or we feel like, we'd like to ask you a few questions about that, if that's okay with you.
Miss Tipton: Okay. I guess so.
Janet M. Standard: Okay. It's kind of routine in this setting. And this is a screening tool that we use many, many times with people. And I'd just like to ask you a few questions, okay?
Miss Tipton: Okay.
Janet M. Standard: Here, let me show it to you, okay?
Miss Tipton: Mm-hmm (affirmative).
Janet M. Standard: This is it. It's called the Short Michigan Alcoholism Screening Test. Okay? So, let's get started. Is that all right?
Miss Tipton: Okay.
Janet M. Standard: When talking with others, do you ever underestimate how much you drink?
Miss Tipton: No.
Janet M. Standard: Okay. Good. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?
Miss Tipton: No.
Janet M. Standard: Okay. Does having a few drinks help decrease your shakiness or tremors?
Miss Tipton: No.
Janet M. Standard: Okay. Does alcohol sometimes make it hard for you to remember parts of the day or night?
Miss Tipton: No.
Janet M. Standard: No, okay. Do you usually take a drink to relax or calm your nerves?
Miss Tipton: Well, yeah. Everybody does sometimes.
Janet M. Standard: Okay. Do you drink to take your mind off your problems?
Miss Tipton: Yeah. Mm-hmm (affirmative). Sometimes.
Janet M. Standard: Okay. Have you ever increased your drinking after experiencing a loss in your life?
Miss Tipton: Yes. Yes.
Janet M. Standard: Okay. Has a doctor or a nurse ever said they were worried or concerned about your drinking?
Miss Tipton: No.
Janet M. Standard: Okay. Have you ever made rules to manage your drinking?
Miss Tipton: Yes. Yes. That I would only drink one drink after dinner with my meals.
Janet M. Standard: Okay. And this is the last question. When you feel lonely, does having a drink help?
Miss Tipton: Yeah. Well, everybody. Yes. Yes. Yes.
Janet M. Standard: Okay. All right.
Miss Tipton: Yes.
Janet M. Standard: So, I'm going to count up, I'm going to score this and then we're going to talk about it a little bit, okay?
Miss Tipton: Okay.
Janet M. Standard: But it looks like you have, you've answered yes to five of these questions. And so, it kind of setting up a little bit of a flag for me that we need to talk a little more, if you're open to it, about some of your drinking.
Miss Tipton: I don't see that it's a problem. I don't think I have a problem.
Janet M. Standard: I'm not saying you have a problem. I think though that we need to explore it a little bit. That would be my recommendation.
Miss Tipton: Well, okay. I'm here to answer your questions.
Janet M. Standard: Okay. Have you noticed any difference in your drinking as you've gotten older?
Miss Tipton: Well, I drink a little more now than I did when I was 20.
Janet M. Standard: Okay. How much do you drink? How many drinks a day do you have?
Miss Tipton: Maybe three or four glasses of wine sometimes. Sometimes a little more.
Janet M. Standard: Okay. And I guess what I'd like to talk a little bit about with you is the way in which as we age alcohol affects us differently. I don't know if you're aware of any of those changes that happen.
Miss Tipton: Well, I do take medication.
Janet M. Standard: You do?
Miss Tipton: Yeah.
Janet M. Standard: Okay.
Miss Tipton: But I have had a lot of stressful things happen in my life. And but life goes on. When life throws you many curves, and you just go on. But sometimes having a drink helps to sort of takes the stress away from your body.
Janet M. Standard: What are some of the stressful things that have happened to you?
Miss Tipton: Well, like many people in life, I've lost loved ones along the way. And I've had a divorce. And now in my senior years, I'm more or less alone. My son comes to see me now and again, but not as often as I'd like. And so, I do feel lonely sometimes.
But that's just life. And you just go on. You just don't let it get to you. You just go on with your life. Having a glass of wine sometimes helps to just take the stress away from my thinking and helps me to sleep at night. Yeah.
Janet M. Standard: Yeah.
Miss Tipton: Yeah.
Janet M. Standard: You've mentioned that you've… Who, what kinds of losses have you?
Miss Tipton: I lost my daughter when she was five years old. She was killed in an automobile accident.
Janet M. Standard: How did you deal with that, Miss Tipton? What?
Miss Tipton: I just kept working and just kept on with my life. And I have other children. So, I saw to my other children.
Janet M. Standard: So, you were very strong.
Miss Tipton: I had to be strong.
Janet M. Standard: Yeah.
Miss Tipton: You have to be.
Janet M. Standard: Okay. I understand from your chart, Miss Tipton, that you're on Norvasc for your blood pressure, and hydrochlorothiazide and also, some Ambien for your sleep. Is that right?
Miss Tipton: Yes. Yes, that's right.
Janet M. Standard: After what we've been talking about and considering your fall, would you be willing to change some of your drinking pattern, do you think? You think it's something you'd be interested in doing?
Miss Tipton: I suppose I would think about it.
Janet M. Standard: Good, because I think it's important as we age to it's very important to look at alcohol consumption and how it affects our health. I'd like to take some of the information that I've got, or the information that we've gathered in this interview and through the screening tool and talk to the team about any recommendations they may have.
Miss Tipton: Oh. Okay.
Janet M. Standard: Good. Well, it was a pleasure to get to know you and speak with you today. Thank you very much.
Miss Tipton: Thank you.
Janet M. Standard: Okay. Well, welcome to the team meeting. Thanks for coming everyone. I don't think everyone knows Sharon. So, maybe if everybody could go around and introduce themselves, that would be helpful.
Madeline Naegle: Hi, Sharon. I'm Madeline Naegle.
Sharon Mancini: Hi.
Madeline Naegle: Dr. Naegle.
Sharon Mancini: Nice to meet you, Dr. Naegle.
Lala Strausser: I'm Lala Strausser. I'm the chief social worker at this unit team.
Chee Chan: I am Chee Chen, the psychology chair.
Sharon Mancini: Nice to meet you both.
Janet M. Standard: Okay. Good. I did the Short MAST on to kind of explore her drinking after the fall. And she did score a five on that. Is that right, Sharon?
Sharon Mancini: Yes. That's correct, five.
Janet M. Standard: And I have to say I'm concerned about her drinking. But I really kind of wanted to hear from you Madeline.
Madeline Naegle: Well, I'm glad you chose the Short MAST-G. I think that's a good instrument to get some sense of a problem. That's a high score since the maximum score on that is usually a 10. So, that does raise some concerns I think for all of us about the extent of here problem.
Now, is she somebody who's just drinking too much? Or, is she actually abusing alcohol? And I'd be interested in hearing a little bit more about her patterns of drinking and maybe some other ideas from the team. How long has she been drinking Janet?
Janet M. Standard: I think she told us since she was a teenager. Is that right, Sharon?
Sharon Mancini: Correct. Yes.
Janet M. Standard: Yeah. Yeah. So, and it was a cultural thing for her. She kept saying, "I never thought there was a problem with drinking wine." Apparently, she must have, they drank wine with their meals pretty much every day it sounded to me.
Lala Strausser: And is there a family history of the alcohol abuse, or dependence?
Sharon Mancini: Yes, there was. In her father, although she didn't really know her father. But she knew, I guess she had heard through family members because he was still in the West Indies, that he did have significant drinking problem.
Lala Strausser: Does she live with someone? Is there someone at home where she's going to be going?
Janet M. Standard: No, she's living alone.
Sharon Mancini: She does volunteer, some volunteer work and she works with children, I believe, in a children's hospital. And she gets a lot of satisfaction from that.
Madeline Naegle: Does she talk about being lonely? Or, does she, even though she's in a social setting?
Janet M. Standard: She actually did talk about being lonely, Madeline. I think even on the SMAST she mentioned that was one of the triggers for drinking was that it helps when, or she feels like it helps when she gets lonely. So, yeah.
Chee Chan: How was she when you were asking her about questions regarding her alcohol drinking?
Janet M. Standard: She was slightly defensive. But I also got the sense that she actually didn't know very much. She didn't have a lot of information about how harmful it could be to her. So, I felt like she was somewhat receptive to the idea that she maybe needed to cut back. But she certainly kept saying, "I'm not an alcoholic. I'm not an alcoholic." Yeah.
Lala Strausser: I would also be concerned about possible depression given her losses and currently her physical condition. So, I just wonder if you talked about it? Did you have a chance to do any depression kind of assessment?
Janet M. Standard: I did feel that she was a little depressed. And I don't know if you agree Sharon, but there was a sense that she felt that she really had to just keep going no matter what had happened to her life. And with these two recent losses of her mother and great aunt, I got the sense that she was kind of the family leader at this point. And there was no room for any weakness on her part, which I think she would have interpreted as being sad, or taking time out to grieve. So, yeah. I do think that she has not adequately grieved her losses, including her daughter.
Lala Strausser: So, it'd be important for her to have someone she could talk to after she leaves the hospital.
Janet M. Standard: That sounds like a good idea.
Sharon Mancini: I would think so. One of the other strengths I think that we should mention is her spirituality. She does find a lot of comfort. And she does have a very strong sense of spirituality and her connection with God. I think is she's a wonderful mix, I think, of risk factors, but strengths at the same time that could definitely use some follow-up care.
Madeline Naegle: There seem to be contradictions in her history as you presented it, Janet. And I'm wondering if we have any objective data and do we have any lab values?
Sharon Mancini: I did check that, Dr. Naegle. She was assessed by the nurse practitioner. And I was able to review her chart. And actually, all of her lab values are within normal range. So, at this point, there hasn't been any impact of her drinking on her physical status.
Lala Strausser: Well, at least we know she's not an alcoholic or alcohol dependent. But still there is a question whether she's abuse… It sounds like she's abusing alcohol. And given her age and her… She does need support, and as I mentioned before, she certainly should have someone to follow up with in addition I guess, to some physical nurse practitioner or visiting nurse or somebody to check her physical condition.
Chee Chan: Well, from your description, it seems like a comprehensive assessment might be prescribed just to get a fuller picture to identify specific triggers. And sometimes, people use alcohol as an escape. Or, some people don't have the language to express their feelings. And it seems like when you were telling me she doesn't fully have an ability to encapsulate her experience, especially in the mourning process.
So, having another person to support her in that way, give her that support she just doesn't seem to have. You said her family doesn't visit much. And she has one friend. So, this alcohol might be a way of expressing her inability to mourn.
Janet M. Standard: Yeah. That's a good point.
Lala Strausser: I would also be concerned about her sleeping pattern, and her insomnia, and use of medication. The possibility of use of medication combined with alcohol is really potentially dangerous.
Janet M. Standard: Yeah. I'm very concerned about the Ambien and the alcohol. Yeah.
Lala Strausser: Yeah.
Madeline Naegle: Janet, did she mention any indication at all to you after you talked with her that she sees a need for changing her habits about alcohol use?
Janet M. Standard: I did ask her if she would be willing to look at changing patterns. And she did, yes. She did say she would be. Are there other recommendations that you think? I mean…
Sharon Mancini: We just want to make sure that she gets the follow-up on her foot.
Janet M. Standard: Oh, okay. So, probably a BNS referral would be good for that. Yeah.
Sharon Mancini: Since she will be going home with a fractured ankle.
Janet M. Standard: Yes.
Madeline Naegle: And I would also ask the nurse to speak with her over time to see how extensive her involvement is with other people. If she mentions volunteer, if she mentions church, but does she really mostly invest in those connections? And could she broaden her circle of friends somewhat so that she has a better support system?
Chee Chan: Maybe group therapy might be a possibility, a peer support network. Other people who are going through the same issues she is. She might feel more comfortable speaking with more people she can identify with. It sounds like she has many strengths and she's gone through a personal history of many obstacles. So, if we could frame this in a way this is another thing she can overcome, it would help her to get further treatment.
Janet M. Standard: Yeah. Okay. So, are you recommending then that she have a psycho therapist, or some… Is that what you're thinking?
Chee Chan: Well, given the stigma associated with psychotherapy, possibly frame it in a way where having someone just to support her.
Janet M. Standard: Okay.
Madeline Naegle: If we can provide a way for her to stay in touch with you or yet let you know who she's seeing, maybe we could have some continuity of care. I would get permission from her to follow-up with someone she sees in the community because I do think she would benefit from a comprehensive assessment.
Janet M. Standard: Oh, okay.
Madeline Naegle: Right. Her score on the Short MAST-G is high. And the question of whether or not she's misusing alcohol to manage uncomfortable feelings, or she's actually abusing alcohol, it's not clear. And certainly, speaks to the need for follow-up given a long drinking history and the fact that she is somewhat isolated. And as she gets older, there will be more stressors that she needs to negotiate.
(silence).
There are not very many things written about older adults and problems which they develop around alcohol use. But as a number of older people grow, and we're moving now toward the baby boomers moving into older age, we're going to see more individuals who continue their drinking habits as they've had from younger age and get into difficulty. We're on that edge of misuse or abuse. So, it's essential that all care providers working in general care facilities understand something about alcohol and older adults.
The prevalence of alcohol use, abuse, and dependence in older people is a question that we haven't really understood so well until recently. If we look at alcohol use in the general population, we can say with some security that anywhere between 48% and 51% of the population from age 12 up consumes alcohol at least once a year. Of that particular number, maybe seven to eight percent would have what we would call an abuse problem or a dependence problem.
When we look at older people over the age of 55 who are drinking in excess of the National Institute of Alcohol and Alcohol Abuse limits for older people, then we begin to see co-existing medical conditions, some cognitive impairment, some issues with safety and security. So, we would say in that group we're looking then at heavy drinkers or heavy consumers.
And probably the predominance of those individuals who will make about 15% of all drinkers in this country are men. Men generally consume more than women. So, of all drinkers in this country, about 15% of them who drink heavily would be men over the age of 55. Of women over the age of 55 who drink heavily or who might develop a problem with abuse or dependence, perhaps 12% of that population of drinkers.
So, we always have to qualify it in terms of who is drinking over 55, rather than looking at the general population. People have a lot of questions about what is moderate, healthy drinking. And this tends to change as people age because older people's bodies don't metabolize alcohol as well as they do when they're younger. The National Institutes of Alcohol and Alcohol Abuse has set limits for consumption.
And those limits really speak to the amount that an individual, a man or a woman, could drink every day or every week over a period of say 20 to 30 years and not expect to have adverse consequences for health. And that would include mental health. So, not have depression, not develop cardiovascular problems, not have loss of muscle mass. Any number of medical conditions that might occur. And that amount for women over the age of 65 is one drink a day, or seven drinks per week.
That is also true for men 65 and over, one drink a day. Women do not tolerate alcohol as well at any age. They have limited amounts of alcohol dehydrogenase in their gastric systems. They have less water in their bodies. They generally weigh less, have less muscle mass. So, they begin to show negative effects on their bodies and mentally as well, if they drink heavily over a long period of time.
Years ago, we used to talk about early onset alcoholism and late onset alcoholism. That isn't done so much, but some alcohol experts still speak about it in that way. And in those phenomenon we would see that someone maybe didn't drink at all, or drank very lightly early in life and then as an older person had a number of losses. The losses we associate with late life, death of a spouse, maybe death of a child, retirement, a sudden change in economic status, the onset of an illness, some type of depression, all of these factors.
And we would see that, that individual maybe would start drinking more than he or she ever had before and get into difficulty with a pattern of abuse or dependence on alcohol. The pattern we more often see are people who are social drinkers in their adult lives, and as they get older because they are tolerant to alcohol, they don't modify their intake. So, they go on drinking the same number of drinks, two drinks a day like clockwork. We know lots of people like that at the end of the day.
But as they age, they don't metabolize the alcohol as well. So, a man, for example, might have his two drinks before dinner, but then fall asleep in his chair shortly after dinner. And not want to go out in the evening, not want to be with other people. So, that as older people become either less active physically, or more socially isolated, or are not as engaged in a larger world, they may come to depend on alcohol to lift their spirits.
Maybe close out unhappy memories, block out unfortunate happenings. And then we suspect that they may be somewhere really on a very thin line between alcohol misuse, that is using it as a drug versus using it as a social lubricant, and abusing alcohol by drinking large amounts on a regular basis.
Some of the medical, emotional, psychological problems associated with heavy drinking can be detected in people as they age. And they may be identified in relation to an onset of a medical illness such as, as I've mentioned, cardiovascular disease, which is the most common associate with heavy alcohol consumption. Or, diabetes in people who again, are taking in more alcohol, which is metabolized and turned to sugar.
And association with other factors such as, a family history of diabetes, or a family history of alcoholism. We increase the risk for these individuals that they'll develop medical problems. One that stands out in mind is sort of a decreasing mental acuity. Maybe a withdrawal into one's self, loss of sharpness and accuracy of mental function. This is problematic if someone continues to work and many older people do these days.
A decrease in physical activity, not having that sort of motivation to get up and go. Taking an energetic walk, do the biking they used to do, withdrawing from social situations. Feeling depressed more days than not. And not recognizing that the depression is really a function of a general dampening down of their emotions due to the nature of alcohol as a drug. It's a sedative. It's a depressant.
Many people use alcohol to deal with anxiety and have done it all their lives. As they become older and more comfortable with themselves and the world, they don't feel as anxious. They don't feel that sense of fearfulness and restlessness. But they continue to consume alcohol.
So, alcohol becomes more sedating and more weighing down on one's mood. And also sometimes, really gets in the way of enjoying physical activities like golfing, or tennis, or going to museums, getting out, being in the world.
Doctors and nurses do tend not to ask older people about their alcohol and drug use. It's a pattern that we've observed. And that many of us who work in this field bring up all the time in our teaching sessions and talking with patients as well. And actually, the failure to do that has to do either with ignorance on the part of the care provider in terms of not understanding the changes that take place in the body as a person ages.
And how that changes drug and alcohol use. But I also think it relates to stigma in terms of expectations about what older people do in later life. Now, we joke about the fact that 50 is the new 40. And we all are looking at a longer lifespan than we had anticipated. And that staying healthy and feeling good is really part of a pattern that we can plan for now.
When caregivers, doctors, and nurses, and people, social workers, psychologists, don't ask people about their alcohol and drug use they're ignoring an important area of their lives which could impinge negatively not just on their physical health, but also on their psychological well-being. It's a well-known factor for example that older men who drink too heavily have difficulty performing well sexually.
Both men and women have less interest in sex when they're heavy consumers of alcohol. And certainly, other drugs. But caregivers tend to think that if they ask an older person about heavy drinking or suggest that he or she cut down, it's as if they're taking away one of the few pleasures left in life, without thinking that there are lots of pleasures that we can engage in as we age.
And many of them are intellectual pursuits. Things that people didn't have time to do when they were younger, skills that they can learn, taking on new activities. Learning to write, putting together a novel, engaging in kinds of travel. All of these require energy. And alcohol is a depressant as are other drugs. And we know that for people over the age of 50, at least half of them have at least one prescription, and more often than not more.
In fact, one-third of all prescriptions which are written for older adults in this country are written in a way that they contribute to a whole repertoire of medication. So, it's not unusual to add to that repertoire of medication alcohol or some other recreational drug. And this tends to take away from both psychic and physical energy.
The Short Michigan Alcohol Screening Test-Geriatric Version is a 10 item yes or no questionnaire. A score of two or above indicates that there may be a problem. But with any other screening test, we're just getting a general sort of blank predictability. And in this case, this particular tool has a predictability value around 88% that there's a likelihood that the individual has some kind of problem.
But it does not really define or diagnose the problem. So, a positive response to this screening tool, like any other, means that the individual should have a comprehensive evaluation including a complete drug and alcohol history, a mental status exam, a family history of risk factors that may suggest there's a problem with alcohol use or over reliance on alcohol.
Whenever taking a drug or alcohol history, what we call a collateral history is very helpful, especially with older people because an individual may have memory problems, which have not been detected. And may have a drinking problem, which is a hidden problem. It's the secret. The drinking is done in isolation.
And yet, family members recall that, that individual at a recent party, or bar mitzvah, or wedding, drank too much and wasn't in good control. And in fact, at a previous celebration had that same pattern. So, when we have signs that the individual is consuming alcohol at irregular times, is consuming too much, it's helpful to ask permission to talk to a family member.
The Short MAST-G can be administered by a registered nurse. It can be administered by a nurse with advanced practice training. It could be administered by a physician and a general practice or primary care practice, a geriatrician. The most important thing about the screener is being able to identify key concerns about the questions within it and to know when to explore further.
A straightforward score of two or three, really requires more discussion and gathering more information from the client. So, we could want the provider or whoever's administering the tool to have good interviewing skills and to feel a sense of rapport with the client. Since the screening tool is short and can be done in a short time, in a few minutes, five to 10 minutes, it should certainly be part of an annual physical.
But most older people come to see specialist care providers rather frequently because they have many chronic illnesses. In those situations, the provider might suspect that the older patient is having a problem with alcohol or some other drug. And that might be evident in doing a mental status exam, some slight confusion, the change in memory. And then it's helpful to use the Short MAST-G each time the patient returns to the care setting.
One of the very important things about using this screener, or any other mental health screener with the older individual is to be sensitive to the fact that it's highly stigmatic to talk about mental health problems to older individuals still. Within our society, there remains a believe that a mental health problem or especially, a problem with alcohol is not something which is neurologically or psychologically determined to be an illness.
But is a weakness or a failing. And older people are particularly sensitive to that belief. So, the individual who comes to an interview should be treated with respect and sensitivity when broaching these questions. And to lead into the questions not only in a non-judgmental way, but with an emphasis on health.
I want to know the answers to these questions because you and I are trying to make a plan for your healthcare. And if I know what drugs you're using, it's much easier for me to make a decision about which medications you should be on, what kind of dose of a medication you might be on, and maybe some reasons for the changes in your emotions, your mood, or your psychological function from time to time.
In recent years, we've learned a new technique called Motivational Interviewing. And in motivational interviewing we try to help the patient either recognize the resistance or we try to roll with the resistance. In other words, acknowledging that maybe the patient's not ready to hear you right now. But I'd like to say a few things about alcohol use that you might want to keep in mind for the future.
The goal is to try to change the client's ambivalence about the use of alcohol, which may be very mixed. I enjoy the way it makes me feel. I don't like what it does to my golf score. I enjoy the way it makes me fell, but then I don't function so well sexually. Or, I tend to withdraw from other people. So, there's an ambivalence there.
There are good things about alcohol use, not so good things about alcohol use. With motivational interviewing we try to move the person away from ambivalence toward a position of modifying drinking habits and changing the way alcohol is consumed to be in a healthier place. So, to move from heavy drinking for example to moderate drinking. And motivational interviewing helps us tip that decision scale by looking at the pros and cons of alcohol use.
Alcohol use that is more moderate and healthy versus heavy alcohol use. We can also sometimes introduce a notion that increasingly now we have some pharmacologic options that assist with heavy drinking. One of them is the new medication ReVia or naltrexone, which helps to cut down on heavy drinking for the individual whose always been a heavy consumer.
For people who are in recovery, other medications such as acamprosate are something that seem to keep alcohol cravings in check as well used over time. And then we introduce the notion of support groups and support systems, such as 12 step programs, which can help the individual decide whether or not he or she has a drinking problem. Motivational interviewing therefore, can be helpful with the individual in coming to terms with the fact that their behavior might not be healthy in relation to alcohol.
Come to terms with the need for treatment, if they find on their own they can't contain or change their drinking behaviors. And also, to face a lot of the challenges in recovering to a point where they don't use alcohol at all. And they find they've changed their lifestyle to be just fine without drinking. To change in a long term away from the use of alcohol to find other ways of coping, other things that they enjoy, and to achieve a different level of health.
Some excellent resources include the website for the National Institute of Alcohol and Alcohol Abuse. In fact, they have two new curricula, which will soon by online for nursing and social work, which are available by going to their niaaa.gov website. The Hartford website is certainly one which we recommend for people in terms of again, finding to try this instrument. And some other associated instruments such as screening for depression, which might be linked to alcohol use or other drug use.
The American Geriatric Society has published guidelines about screening for alcohol use, alcohol abuse, and identifying possible alcohol dependence. And that as well is on their website and available to all care providers. And finally, I'd like to recommend that you consult the companion article to this video tape, which is available through the American Journal of Nursing online.