Practice Panel: An older person with a drink problem

Substance misuse staff and a service user offer advice on a case involving a man on a downward spiral of alcohol abuse

SITUATION

Chris* is a 69-year-old alcoholic. One year ago he fell badly while climbing the stairs to his first-floor flat. His social worker arranged for him to move to a residential home. Things improved initially and Chris gave up alcohol.

But he struggled with communal living and started drinking heavily again after six months. When intoxicated, he would break the rules of the residential home, such as smoking in his bedroom and being abusive to staff and residents.

He received a number of verbal and written warnings. He would appear full of remorse when sober, but would soon flout the rules on his next drinking binge. The home advised that his eviction was imminent, and, anticipating this, his social worker secured Chris a ground-floor housing association flat and arranged for home carers to provide daily support.

PROBLEM

Chris has been in the flat for just two months and there are already concerns. His drinking has got worse and he is not eating properly.

The home care staff complain about Chris’s inability to use the toilet. He urinates on the floor and defecates in his bed, even though there is a commode in his bedroom.

The social worker recently made an application to the only other local suitable residential home. But when their assessor went to meet him, Chris was intoxicated, naked and covered in faeces. Understandably, the provider declined to assess him. What can halt Chris’s downward spiral?

*Name has been changed

Radomir Lazarevich, area manger, Foundation 66, a drug and alcohol service

Substance misuse services are designed to deliver interventions that should support clients through a period of change in their relationship with alcohol. Older people’s services are designed to provide ongoing care. They need to be able to work together when working with people such as Chris.

Substance misuse practitioners should be a resource for older people’s and housing services, providing training to those teams on treatment pathways, goals, expectations and relapse prevention, so that care and housing services are not denied to a client while he is engaged with the treatment.

For instance, if home care services are supplying him with alcohol (because he physiologically requires alcohol in order to function at all) would they be able to have a discussion with Chris about the brands he is consuming and look into him switching to the weaker brands? It is likely that his drinking may be triggered by isolation but he seems to have been rejected by services with a duty of care.

Overall, older people respond better to substance misuse treatment interventions than other groups, but it is a relapsing condition and it is likely that after a period of improvement his condition will deteriorate for a period of time. Relapse prevention is the key component of the treatment and all service providers should be following the same philosophy.

Putting a meaningful aftercare plan in place supporting Chris to deal with the isolation and lack of social contact is the key to his long-term success. Psychological issues that may be behind his behaviour will need to be addressed alongside other issues. From Chris’s point of view, his crisis may appear a permanent state of affairs. This means that the package that is put in place should not be there to support him only in the moment of crisis, but to manage the factors that are contributing to the development of the crisis.

Glenda Lee, service manager for Turning Point’s Hertsreach substance misuse service

It appears that Chris’s fall was alcohol-related, which represents an identifying factor for additional support.

Because the social worker has established a relationship with Chris, I would suggest they are best placed to take the lead in the initial risk assessment, care co-ordination and referring into specialist alcohol services. This will ensure that Chris has the very best chance of recovery and reintegration into the community.

Chris should be assessed for his alcohol misuse by specialist services who would draw up a care plan highlighting any goals that he would like to achieve. An outreach worker from the specialist alcohol service should also visit Chris in his accommodation on a weekly basis in order to offer any necessary support.

By participating in his own treatment plan, Chris would feel very much a part of the process and be more motivated to make positive changes. As part of the care plan, a behavioural contract could also be drawn up to make boundaries clear.

As a result of the assessment and care planning process, appropriate services for Chris should be discussed and a referral made.

It is essential that any care plan reflects the holistic needs of the client. In this case, it should address how to maintain sobriety with a goal of abstinence, housing issues supported by an outreach worker and how to integrate and form relationships within a communal setting. In addition, I would suggest addressing Chris’s psychological health with the aim of improving overall mental well-being, making lifestyle changes including possible volunteering, as well as ensuring appropriate check-ups with his GP.

By addressing these issues on a weekly basis within motivational interviewing, Chris will have a much greater chance of maintaining sobriety.

Paul Hines, service user, Foundation 66

The acute priority here is Chris’s health. Because he is not eating properly, he might well be malnourished, and that would mean a significant risk of Wernicke-Korsakoff syndrome, which causes a loss of brain function due to deficiency of vitamin B1. He needs to be checked for that immediately, because it can be irreversible. He also needs to be checked for any further physical damage done by his drinking.

If NHS Direct is contacted (while it still exists) it should send a GP to Chris’s residence within an hour or two. The GP will assess his immediate health needs. The home care staff or Chris’s social worker need to call NHS Direct and set the process in motion.

The fact that Chris is in a downward spiral means that the treatment he has received for his alcoholism so far simply hasn’t worked. We need to find what will work. The social worker or GP should refer him to the community alcohol team (or equivalent), who need to make sure that he doesn’t fall through holes in service provision at this crucial time. Simultaneously, the social worker needs to sort out Chris’s perilous housing situation.

What is key now is that his community alcohol team assesses Chris and his needs correctly. They should be skilled assessors who see the process as the big first step in recovery rather than just a box-ticking exercise. Let’s hope that his real long-term needs can be met by the care that’s available. They haven’t been so far, and that’s why he’s in a downward spiral.

What do you think? Join the debate on CareSpace

Keep up to date with the latest developments in social care Sign up to our daily and weekly emails

This article is published in the 9 September 2010 edition of Community Care under the headline “How can we stop him drinking?”