Addressing the needs of older adults receiving alcohol treatment during the COVID-19 pandemic: a qualitative study

Abstract

Objectives

The COVID-19 global pandemic resulted in major changes to the provision of alcohol treatment in the UK, these changes coincided with increases in the use of alcohol. This study sought to understand the impact of the pandemic on older adults in alcohol treatment, and to explore how changes in the provision of alcohol treatment were experienced.

Method

Semi-structured interviews were completed with older adults (aged 55+) in alcohol treatment, as well as alcohol practitioners providing support to older adults. Data were analysed using thematic analysis. Alcohol use was assessed using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C).

Results

Thirty older adults in alcohol treatment and fifteen alcohol practitioners were recruited. The COVID-19 pandemic was found to result in both increases and decreases in alcohol use; changes in alcohol use depended on a number of factors, such as living arrangements, family support, physical and mental health. Many alcohol treatment services moved to a model of remote support during the pandemic. However, face-to-face service provision was considered to be essential by both older adults in alcohol treatment and alcohol practitioners. Engagement with online support was low, with older adults facing barriers in using online technology.

Conclusion

The study highlights the importance of face-to-face treatment and intervention for older adults in alcohol treatment. Addiction services may see increased demand for treatment as a result of the pandemic; it is important that services consider the needs of older adults, many of whom may be marginalised by a remote model of service provision.

Keywords:

• Older adults
• alcohol
• COVID-19
• alcohol treatment

Introduction

In March 2020 the World Health Organisation declared COVID-19 a global pandemic. Countries around the world responded with stay-at-home orders and social distancing measures in an effort to try and slow the spread of the disease. In the UK, a national lockdown was introduced (i.e. stay-at-home restrictions); this also brought the potential for adverse effects such as boredom, isolation, loneliness, anxiety and stress. These factors are known triggers for increased drinking among older adults (Emiliussen, Andersen, & Nielsen, 2017; van Gils, Franck, Dierckx, van Alphen, & Dom, 2021).

Researchers speculated that the adverse effects to mental health caused by COVID-19 would likely result in increased use of alcohol (Clay & Parker, 2020; Columb, Hussain, & O’Gara, 2020; Holmes et al., 2020; Ramalho, 2020). It is well documented that alcohol use may increase following disasters and pandemics (Cerda, Vlahov, Tracy, & Galea, 2008; DiMaggio, Galea, & Li, 2009; Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004; Wu et al., 2008), and that levels of alcohol use can take time to recover to pre-disaster levels (Vlahov et al., 2004; Wu et al., 2008). A recent article in The Lancet suggests that alcohol use during the COVID-19 pandemic is a major public health concern (Clay & Parker, 2020), the effects of which may be felt for a generation (Finlay & Gilmore, 2020).

Emerging evidence from the UK suggests that there was a significant increase in psychological distress during the early stages of the lockdown (Niedzwiedz et al., 2020) with surveys from other countries indicating higher rates of anxiety, depression and lower mental health well-being (Ahmed et al., 2020; Moccia et al., 2020). Older adults in particular may be at greater risk of adverse effects from lockdown measures, as they are already more vulnerable to experiencing isolation (Satre, Hirschtritt, Silverberg, & Sterling, 2020). The stress and psychological distress associated with COVID-19 has been found to result in increased use of alcohol (Rodriguez, Litt, & Stewart, 2020).

In the UK, the rate of risky drinking is reported to have increased from 25% in February 2020, to 38% in April 2020 (Jackson, Garnett, Shahab, Oldham, & Brown, 2020). Other surveys have reported that between a fifth and a third of people drank more during lockdown (Institute of Alcohol Studies, 2020), with those already drinking heavily showing the greatest increases in consumption (Alcohol Change UK, 2020; Chodkiewicz, Talarowska, Miniszewska, Nawrocka, & Bilinski, 2020; Neill et al., 2020). Among older adults in the UK, research has found that 32% of people aged 50-70 years increased their drinking as a result of the pandemic (Centre for Ageing Better, 2020), with almost one in four adults aged 50+ now classed as high-risk or dependent drinkers (We Are With You, 2020). The impact of COVID-19 on the use of alcohol among people who were already drinking at dependent levels is unknown (Finlay & Gilmore, 2020; Institute of Alcohol Studies, 2020), and we know little about how COVID-19 has affected those in alcohol treatment.

The finding that older adults have increased their use of alcohol (Centre for Ageing Better, 2020) is concerning given that at-risk drinking has been associated with increased risk of pneumonia (Simou, Britton, & Leonardi-Bee, 2018) and older adults are already at increased risk for adverse effects of COVID-19 (Shahid et al., 2020). It is important we understand why the use of alcohol may have changed among older adults in treatment if we are to fully understand the wider public health consequences of the pandemic, and to establish priorities for service provision.

In response to the pandemic, drug and alcohol services in the UK were advised to remain open but needed to adapt to minimise face-to-face contact (Department of Health and Social Care, Public Health England, 2020; Northern Ireland Department of Health, 2020; Scottish Health Action on Alcohol Problems, 2020). Alcohol services responded quickly, delivering support remotely with staff working from home and with many activities being delivered online. However, there are concerns that service users who lack the appropriate technology may ‘fall through the gap’ (Finlay & Gilmore, 2020). This may be especially true of older adults, as the likelihood of not being online increases with age (Richardson, 2018).

This study aimed to understand the impact of the COVID-19 pandemic on older adults in alcohol treatment (aged 55+). In particular, the study aimed to explore the consequences of the COVID-19 pandemic and lockdown on older adults, and to understand if this impacted the use of alcohol. The study also aimed to identify how alcohol services supported older adults during the pandemic, and how changes to service provision were experienced.

Methods

Study design & participant recruitment

Through our professional networks we identified and approached seven drug and alcohol treatment services; all of those contacted agreed to take part in the study. The seven services covered different sites across the UK, in England, Wales, Scotland and Northern Ireland. All services provided a range of psycho-social interventions, with a focus on harm reduction. One service was a specialised older adult’s alcohol treatment service. To be eligible to take part, services needed to have provided support to people aged 55+.

Older adults in alcohol treatment were recruited by service staff from their client lists; participants were selected on the basis of gender, locality (i.e. urban, suburban, rural), and whether they needed to shield during the pandemic. Alcohol practitioners were approached to take part by their service manager; to be eligible to take part, practitioners needed to have provided support to older adults during the pandemic.

Interviews & data analysis

Individual semi-structured interviews were conducted with older adults and alcohol practitioners either by phone or video call. Interviews with older adults in alcohol treatment lasted up to one hour, interviews with alcohol practitioners lasted an average of 30 min. All interviews were audio-recorded with participant consent. Interviews with older adults in alcohol treatment focussed on their physical health, mental health and the social consequences of the pandemic, including any impact on the use of alcohol and their experiences of receiving alcohol support. Interviews with alcohol practitioners focussed on how services had adjusted service provision and responded to the needs of older adults, how they had experienced the changes in working practices and the perceived short and long-term implications of these changes for future service provision. Interviews took place between July and September 2020.

All interviews were transcribed verbatim and were analysed using Nvivo (version 12). Thematic analysis was used to analyse the data following the principals of Braun and Clarke (2006). Interviews with alcohol practitioners and with older adults receiving alcohol treatment were analysed using different coding frames. Thematic analysis was carried out both deductively and inductively. Material was coded deductively using the key themes discussed in interview. Following this, a number of detailed sub-codes were created, some deductively (following interview questions) and others inductively (to include matters spontaneously and repeatedly mentioned by participants).

Measures

Alcohol use was assessed by using the three consumption questions of the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C is a three-item screening tool, scored on a scale of 0-12. A score of ≥3 for women and ≥4 for men indicates hazardous use of alcohol (Bradley et al., 2007; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998; Reinert & Allen, 2007). The measure has been validated for use among older adults (Aalto, Alho, Halme, & Seppä, 2011; Gómez et al., 2006). Questions were framed in the context of drinking behaviour since lockdown began.

Ethical approval

Ethical approval was granted by the University of Bedfordshire’s Research Ethics Committee (REF: IASR 16/19).

Results

Participants

Thirty older adults were interviewed; 67% (n = 20) were male and 33% (n = 10) were female. The mean age of participants was 66 years (SD: 6.14, range: 57 − 80 years). The mean AUDIT-C score was 4.4 (SD: 4.25, range 0–12). Seventeen participants (57%) were drinking at hazardous levels, with AUDIT-C scores ranging between 4 and 12. Thirteen participants (43%) were drinking at non-hazardous levels, including twelve participants with a score of 0.

Fifteen alcohol practitioners were interviewed; 67% (n = 10) were female and 33% (n = 5) were male. Interviewees included recovery workers, outreach workers, therapeutic intervention workers and a service manager (Table 1).

Table 1. Participant characteristics.

Characteristic	N (%)
Gender
Male	20 (67%)
Female	10 (33%)
Age, years
55 − 59	2 (7%)
60 − 64	13 (43%)
65 − 69	7 (23%)
70 − 74	3 (10%)
≥75	5 (17%)
AUDIT-C drinking status
Hazardous drinker	17 (57%)
Non-hazardous drinker	13 (43%)
Living arrangements
Lives alone	17 (57%)
Lives with partner/family	10 (33)
Other: care home/homeless hostel	3 (10%)
Shielding due to COVID-19 pandemic
Yes	11 (37%)
No	19 (63%)

Change in the use of alcohol during the pandemic

The experiences of older adults in alcohol treatment during the pandemic varied greatly and depended on a number of factors, including their living arrangements and family situation, their living environment, their lifestyle and health prior to lockdown, whether they were shielding, whether and to what degree they were receiving informal or formal support, whether they were able to tap into or develop new coping strategies, and their overall mental health and resilience.

The impact of the pandemic on the use of alcohol was mixed. In general, older people who were living alone and drinking heavily prior to the onset of the pandemic continued to do so. Alcohol use increased for some as a way to cope with the difficulties of lockdown, or because the usual strategies to manage drinking, such as engaging in alcohol-free social activities, were not available. In some cases, drinking increased as a result of changes from drinking in social settings (i.e. pubs) to drinking at home, or because people were buying alcohol in bulk to reduce the need to go shopping as often. Alcohol practitioners reported that in some cases this had resulted in alcohol-related accidents and hospitalisations. Alcohol practitioners also noted that some previously discharged clients were returning to the service, and the numbers of new referrals during the pandemic were high.

‘Most of my elderly or older clients, I should say, have struggled with coronavirus, increased drinking and not just volume, increased volume, have moved from maybe a lower strength alcohol to a higher strength alcohol, maybe moved from wine to spirits, purely as a way of dealing with things’. (Alcohol practitioner, England)

‘Every day seems a bit the same and so every day I say to myself, well I’ll just drink half a bottle of wine (…). I can’t really put different things, distractions in to give myself a different routine particularly, or not as easily as I previously could (…). I think there’s a bit of apathy sets in when life is closing down a bit and you think, well what else is there to enjoy? (…) I can’t go out and socialise and meet people. So my comfort is a bit of wine in the evening’. (Older adult in alcohol treatment, female, aged 61)

However, for some older adults lockdown resulted in decreased alcohol use. This was mainly as a result of less opportunity to purchase alcohol for those who were unable to shop for themselves or shopped less often, the closure of pubs and the lack of social situations in which to drink. Notably, around one third of our sample consisted of people in recovery who were not drinking prior to lockdown and had managed to remain abstinent throughout the pandemic. In their case, the support received from services was seen as invaluable for maintaining abstinence.

Support from alcohol services during the pandemic

For most older adults in treatment, contact with their alcohol practitioner during the pandemic was by phone, with only a few clients receiving limited face-to-face contact. In a minority of cases, participants accessed peer support group meetings online.

The nature of phone support was often rather informal and consisted of ‘chats about everything’ rather than structured alcohol interventions. This was important as many older adults complained of loneliness and having no one to talk to on a daily basis. Both alcohol practitioners and older adults felt phone support was highly accessible and offered a greater degree of flexibility, and alcohol practitioners reported more frequent client contact. The anonymity of phone calls was also perceived to be a benefit by some older adults, as was the lack of needing to travel to appointments, particularly for those living in remote rural areas.

Nevertheless, both alcohol practitioners and older adults in treatment had a clear preference for face-to-face contact. Older adults missed the social interaction with their alcohol worker; face-to-face meetings were seen as more genuine, more personable, and easier to follow, especially by people over the age of 65. Moreover, some older adults found it difficult to explain how they were feeling or to ask for help when contact was over the phone. The lack of face-to-face contact was also a significant challenge for alcohol practitioners, as face-to-face contact was considered to be essential in working with older clients. Assessment often relies on non-verbal cues (e.g. client presentation, self-care, home environment etc.) and the absence of face-to-face contact made it difficult to fully assess client need and to ascertain risk. Several alcohol practitioners described cases where they felt alcohol-related falls and hospitalisations could have been avoided or better managed if the client had been seen in person. Contact by phone also meant that completing structured work or formal assessments was difficult.

‘You can say anything on the phone though, can’t you? If it was possible, yeah, I’d rather speak face to face’. (Older adult in alcohol treatment, female, aged 79)

‘In terms of, from my perspective, I find it difficult in that I’m not able to have visual on that client, I can’t judge how they’re feeling, are they grey? Are they jaundiced? Are their anxieties getting bigger? What’s their mobility like? The tell-tells signs that I pick up when I go in to a client’s home, what empty bottles are lying about, what is their food in the fridge? Are they looking after themselves? Are they taking the medication? Are blister packs being used? All those kinds of things really, yeah’. (Alcohol practitioner, England)

Moreover, phone support was not suitable for participants with memory, speech or hearing impairments, or serious mental health issues. It could also be difficult for those who had not disclosed their engagement with an alcohol service to family members. In some cases, in-person socially distanced visits continued for particularly vulnerable clients; such visits were seen as essential to ascertaining risk and minimising harm.

Online video calls were not used by anyone in this study for their one-to-one meetings. The ability of older clients to access online resources was limited for a number of reasons, including not having access to technology or the Internet, not knowing how to use technology, health barriers or learning difficulties, or anxiety around online support. Many older adults had not been using modern technology much, or at all, prior to lockdown, and few chose to engage in online support with their alcohol service.

Of the minority who did engage in online support, this was to access peer support groups. Peer support groups were viewed by service users as important for achieving and maintaining recovery. Alcohol practitioners also noted that for some service users who had never been to a support group before, engaging with the group online in the first instance was a positive experience and helped to relieve anxiety about participation.

In general, the support received by alcohol services was very much valued and needed. Those who remained abstinent saw it as integral for sustaining their recovery and emotional well-being during lockdown, although some service users felt they needed a greater level of support than they had received.

‘The support, it was amazing. It was really, really, really good. Because they kept in touch, and it’s been amazing. Without, see if I didn’t have the support group during the lockdown, I wouldn’t have been able to cope, I wouldn’t have. I don’t think I would have been able to cope, I think I might have been back on the drink, to be honest with you. But with having the support, and having somebody that listens to me, you know, it’s amazing, you know’. (Older adult in alcohol treatment, male, aged 62)

‘I’ve already said to them I need more help than I have at the moment, I don’t feel as if I’ve being supported to a level, ideally I’d like to give up altogether drinking. At the moment, I’m just treading water and need some intervention, whatever that is’. (Older adult in alcohol treatment, male, aged 62)

Discussion

This study aimed to understand how the COVID-19 pandemic affected alcohol use among older adults in alcohol treatment. The study found that whilst for many the stress and difficulties experienced as a result of the pandemic led to an increase in drinking, for others the period of national lockdown and the associated closure of pubs and social situations in which to drink led to a reduction in the use of alcohol. A third of the older adults in this study were people in recovery who were abstinent at the time of lockdown; for them, the support offered by alcohol services during the pandemic was essential for maintaining abstinence. The study also found that for those older adults who were drinking heavily prior to the onset of the pandemic, use of alcohol remained relatively unchanged, with continued heavy drinking.

These findings reflect those from wider UK general population surveys of alcohol use, with both increases and decreases in alcohol use (Alcohol Change UK, 2020; Jackson et al., 2020; YouGov, 2020) and help explain why the use of alcohol may have changed for some older adults. Increased use of alcohol among older adults is of particular concern, given the increased risk of adverse effects of COVID-19 among this group (Shahid et al., 2020). It is therefore crucial that older adults have access to appropriate help and support for alcohol use.

One of the key findings of this study was the importance of face-to-face contact for older adults in alcohol treatment. Older adults preferred to engage with their keyworker face-to-face rather than remotely, and face-to-face contact was considered essential by alcohol practitioners in order to fully assess client risk and ascertain client need.

Evidence suggests that one of the most important aspects of working with older adults with alcohol problems is ‘building a relationship with them and giving them time, letting them talk, getting them to reminisce and establishing trust’ (Wadd & Galvani, 2014, p. 662), and establishing a good rapport has been identified as particularly important in working with older drinkers (Wadd, Lapworth, Sullivan, Forrester, & Galvani, 2011). This may be more difficult to achieve when working with older adults remotely.

It is also important to note that some older adults found it difficult to ask for help when contact was by phone. Research suggests that older adults with alcohol problems are often acutely sensitive to the stigma associated with alcohol problems (Wadd & Galvani, 2014), and stigma has been found to be greater among this age group (Health Canada, 2002). Stigma can lead to feelings of shame and guilt and can result in the concealment of alcohol-related problems, and is known to be a barrier in help-seeking for alcohol use (Keyes et al., 2010; Lancaster, Seear, & Ritter, 2017). It is possible that face-to-face contact helps to break down barriers in asking for alcohol-related help and support among older adults. These findings have implications for the mode of service delivery for alcohol use interventions among older adults.

This study found there to be significant challenges in supporting older adults online, with only a minority of participants engaged in online support groups and no-one engaged in online one-to-one support. This was for a variety of reasons, most notably, not having access to technology, not knowing how to use it, or not feeling comfortable with using video calls. There is a generational ‘digital divide’, which may prevent older adults from accessing online help and support compared to younger people. Older adults are more likely to have never been online compared to other age groups, with those aged 55+ accounting for 78% of those who have never been online (Richardson, 2018). Concerns have been raised that the rapid move to online treatment as a result of the COVID-19 pandemic may mean that some people ‘fall through the gap’ (Finlay & Gilmore, 2020), and may not receive the treatment they need. The current study supports this, and suggests this may be especially true for older adults in alcohol treatment.

There have been calls for addiction services to more widely implement telemedicine (Cantor, Stein, & Saloner, 2020), that is, delivering interventions and supporting people using technology (i.e. phone/video calls, emails and text messages). Telemedicine has been found to result in similar outcomes as in-person therapy for alcohol use (Lin et al., 2019), and there have been calls to improve access to telemedicine for drug and alcohol treatment (Mallet, Dubertret, & Le Strat, 2020). However, the results of this study suggest there may be some barriers in engaging older adults effectively using remote (i.e. non face-to-face) methods. There are also concerns regarding privacy, safety and establishing rapport with telemedicine (Cowan, McKean, Gentry, & Hilty, 2019) and the acceptability of telemedicine needs to be established for alcohol use treatment (Lin et al., 2019). Nevertheless, the results of this study demonstrate that support by phone is feasible among older adults in alcohol treatment, and some older adults were engaged in online peer support groups. If telemedicine within addictions treatment is to develop then consideration needs to be given as to how best to support older adults to engage effectively using technology. A supportive training and learning environment with in-person training may be required to help older adults engage effectively (Kuerbis, Mulliken, Muench, Moore, & Gardner, 2017). Given the importance of face-to-face contact highlighted in this study, it is suggested that telemedicine for older adults in alcohol treatment should be an ancillary or complementary service, delivered in addition to face-to-face treatment and support.

To our knowledge, this is the only study to examine the impact of the COVID-19 pandemic on older adults in alcohol treatment. This study has several strengths, including recruiting participants from services across the UK, and interviewing alcohol practitioners as well as older adults in treatment. However, there were also some limitations. Older adults were invited to take part in the study by service staff, and this may have resulted in an element of selection bias. Recruitment was challenging as many services did not have a large number of adults aged 55+ in treatment; this meant that the approach to sampling was more opportunistic than initially planned. Interviews for the study were conducted remotely, either by phone or video call, and this may have precluded some older adults from taking part. Lastly, AUDIT-C scores in this study were relatively low, meaning the sample may not be representative of older adults in alcohol treatment.

Emerging data indicates increases in alcohol use in both the UK (Institute of Alcohol Studies, 2020) and worldwide (Canadian Centre on Substance Use and Addiction, 2020; Chodkiewicz et al., 2020; Rodriguez et al., 2020; Stanton et al., 2020; Vanderbruggen et al., 2020) in response to the COVID-19 pandemic. In the UK, only one in five harmful or dependent drinkers currently receives the support they need (Public Health England, 2018). It is estimated that 8.4 million people in England are now drinking at higher-risk levels, compared to 4.8 million people pre-pandemic (Royal College of Psychiatrists, 2020). Among older adults, evidence suggests there has been a significant increase in the use of alcohol in response to the pandemic (Centre for Ageing Better, 2020). Taken together, these findings suggest there is likely to be an increase in demand for alcohol treatment.

Older adults in alcohol treatment may be at risk of being further marginalised if they do not receive the support they need; this study suggests that face-to-face contact is an essential part of supporting older adults in alcohol treatment. Tackling alcohol related harm during COVID-19 is a public health priority and needs to be an integral part of the UK’s COVID-19 recovery plan (Finlay & Gilmore, 2020). Older adults in particular may require special consideration, with a flexible approach to treatment that prioritises face-to-face support.

Acknowledgements

We would like to thank all of the services and participants who took part in this study for their time, honesty and valuable insights.

Disclosure statement

The authors report no conflict of interest.

Additional information

Funding

This study was funded as part of the Drink Wise, Age Well programme. The Drink Wise, Age Well programme is funded by the National Lottery Community Fund through its Rethink Good Health programme. The funding body was not involved in the design, conduct or interpretation of the findings or the writing of this manuscript. Their only contribution was providing the funding for the study.