CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

The Alcohol Use Disorders Identification Test (AUDIT)

The following guidelines, questions, and scoring instructions are excerpted from Babor, T.F.; de la Fuente, J.R.; Saunders, J.; et al. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva, Switzerland: World Health Organization, 1992.

How To Use AUDIT

Screening with AUDIT can be conducted in a variety of primary care settings by persons who have different kinds of training and professional backgrounds. The core AUDIT is designed to be used as a brief structured interview or self-report survey. It can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. When the questions are presented in this context by a concerned and interested interviewer, few patients will be offended.

The experience of the WHO collaborating investigators¹ indicated that AUDIT questions were answered accurately regardless of cultural background, age, or gender. In fact, many patients who drank heavily were pleased to find that a health worker was interested in their use of alcohol and the problems associated with it.

With some patients, the AUDIT questions may not be answered accurately because they refer specifically to alcohol use and problems. Some patients may be reluctant to confront their alcohol use or to admit that it is causing them harm. Individuals who feel threatened by revealing this information to a health worker, who are intoxicated at the time of the interview, or who have certain kinds of mental impairment may give inaccurate responses. Patients tend to answer most accurately when:

• The interviewer is friendly and nonthreatening
• The purpose of the questions is clearly related to a diagnosis of their health status
• The patient is alcohol- and drug-free at the time of the screening
• The information is considered confidential
• The questions are easy to understand

Health workers should try to establish these conditions before AUDIT is given. When these conditions are not present, the Clinical Screening Instrument following the AUDIT questionnaire may be more useful. If interviewing the patient is a problem, health workers may use AUDIT to guide an interview with a concerned friend, spouse, or family member. In some settings (such as waiting rooms), AUDIT may be administered as a self-report questionnaire, with instructions for the patient to discuss the results with the primary care worker.

In addition to these general considerations, the following interviewing techniques should be used:

• Try to interview patients under the best possible circumstances. For patients needing emergency treatment or who are severely impaired, wait until their condition has stabilized. In addition, allow them to get used to the health setting where the interview is to take place.
• Look for signs of alcohol or drug intoxication. Patients who have alcohol on their breath or who appear intoxicated may give inaccurate responses. Consider conducting the interview at a later time. If this is not possible, note these findings on the patient’s record.
• If AUDIT is embedded, as recommended, in a longer health interview, use a transitional statement to introduce the AUDIT questions. The best way is to give the patient a general idea of the content of the questions, the purpose for asking them, and the need for accurate answers.
  
  For example: "Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Because alcohol use can affect many areas of health and may interfere with certain medications, we need to know how much you usually drink and whether you have experienced any problems with your drinking. Please try to be as honest and as accurate as you can."
  
  This statement should be followed by a description of the types of alcoholic beverages typically consumed in the population to which the patient belongs (e.g., "By alcoholic beverages we mean your use of wine, beer, vodka, sherry, and so on."). If necessary, include a description of beverages that may not be considered alcoholic (e.g., cider, low-alcohol beer).
• It is important to read the questions as written and in the order indicated. By following the exact wording, you will obtain results more comparable to those obtained by other interviewers.
• Most of the questions in AUDIT are phrased in terms of "how often" symptoms occur. It is useful to offer the patient several examples of the response categories (for example, "never," "several times a month," "daily") to suggest how he or she might answer. When he or she has responded, it is useful to probe during the initial questions to be sure that the patient has selected the most accurate response (for example, "You say you drink several times a week. Is this just on weekends or do you drink more or less everyday?").
  
  If responses are ambiguous or evasive, continue asking for clarification by repeating the question and the response options, asking the patient to choose the best one. At times, answers are difficult to record because the patient may not drink on a regular basis. For example, if the patient was drinking intensively for the month prior to an accident, but not before or since, then it will be difficult to characterize the "typical" drinking sought by the question. In these cases it is best to record the amount of drinking and related symptoms for the heaviest drinking period of the past year, noting that this may be atypical or transitory for that individual.

Record answers carefully, including comments to explain any special circumstances, additional information, or clinical inferences. Often patients will provide the interviewer with useful comments about their drinking that can be valuable in the interpretation of the total AUDIT score.

The AUDIT Questionnaire

Circle the number that comes closest to the patient’s answer.

How often do you have a drink containing alcohol?
(0) Never	(1) Monthly or less	(2) Two to four times a month	(3) Two to three times a week	(4) Four or more times a week
How many drinks containing alcohol do you have on a typical day when you are drinking? (Code number of standard drinks.*)
(0) 1 or 2	(1) 3 or 4	(2) 5 or 6	(3) 7 to 9	(4) 10 or more
How often do you have six or more drinks on one occasion?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3) Weekly	(4) Daily or almost daily
Have you or someone else been injured as a result of your drinking?
(0) No	(2) Yes, but not in the last year	(4) Yes, during the last year
Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
(0) No	(2) Yes, but not in the last year	(4) Yes, during the last year

*In determining the response categories it has been assumed that one drink contains 10 g alcohol. In countries where the alcohol content of a standard drink differs by more than 25 percent from 10 g, the response category should be modified accordingly.

Record sum of individual item scores here. ____________________________

Procedure for Scoring AUDIT

Questions 1-8 are scored 0, 1, 2, 3, or 4. Questions 9 and 10 are scored 0, 2, or 4 only. The responses are scored as follows:

		0		1		2		3		4
Question 1		Never		Monthly or less		Two to four times per month		Two to three times per week		Four or more times per week
Question 2		1 or 2		3 or 4		5 or 6		7 to 9		10 or more
Questions 3-8		Never		Less than monthly		Monthly		Weekly		Daily or almost daily
Questions 9-10		No				Yes, but not in the last year				Yes, during the last year

The minimum score (for nondrinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.

AUDIT "Clinical" Questions and Procedure

Trauma History
Have you injured your head since your 18th birthday?	(3) Yes	(0) No
Have you broken any bones since your 18th birthday?	(3) Yes	(0) No

Clinical Examination
Conjunctival infections	(0) Not Present	(1) Mild	(2) Moderate	(3) Severe
Abnormal skin vascularization	(0) Not Present	(1) Mild	(2) Moderate	(3) Severe
Hand tremor	(0) Not Present	(1) Mild	(2) Moderate	(3) Severe
Tongue tremor	(0) Not Present	(1) Mild	(2) Moderate	(3) Severe
Hepatomegaly	(0) Not Present	(1) Mild	(2) Moderate	(3) Severe
GGT Values*	Lower normal	(0-30 IU/L)=(0)
	Upper normal	(30-50 IU/L)=(1)
	Abnormal	(50 IU/L)=(3)

* Gamma glutamyltransferase. The purpose of the GGT test is to provide information about hepatobiliary diseases, to assess liver function, and to detect alcohol ingestion. These values may change with laboratory methods, and standards may vary with sex and age of the drinker.

Record sum of individual item scores here. ____________________________

Scoring and Interpretation of AUDIT

As indicated by the AUDIT questions, each item is scored by checking the response category that comes closest to the patient’s answer.

On the basis of evidence from the validation study,² two cutoff points are suggested. The cutoff depends on the purpose of the screening program or the nature of the research project.

A score of 8 or more produces the highest sensitivity, whereas a score of 10 or more results in higher specificity. In general, high scores on the first three items in the absence of elevated scores on the remaining items suggest hazardous alcohol use. Elevated scores on items 4 through 6 imply the presence or emergence of alcohol dependence. High scores on the remaining items suggest harmful alcohol use.

The Clinical Screening Instrument is considered to be elevated when the total score is 5 or more. Here, too, the examiner should give careful consideration to the different meanings attributed to alcohol-related trauma, physical signs, and elevated liver enzyme levels. False positives can occur in individuals who are accident prone, use drugs (such as barbiturates) that induce GGT action, or have hand tremor because of nervousness, neurological disorder, or nicotine dependence.

References

1. Saunders, J.B., and Aasland, O.G. WHO Collaborative Project on the Identification and Treatment of Persons with Harmful Alcohol Consumption. Report on Phase I: Development of a Screening Instrument. Geneva, Switzerland: World Health Organization, 1987.
2. Saunders, J.B.; Aasland, O.G.; Babor, T.F.; et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction 1993, 88(6):791-804.

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