Alcohol Misuse and Abuse Reported by Nurse Aides in Assisted Living

Abstract

Alcohol misuse and abuse in Assisted Living (AL) as reported by nurse aides is examined. Data came from a secondary analysis of nurse aides included in the Pennsylvania nurse aide registry. A total of 832 nurse aides had a prior place of employment in AL. Information reported from these nurse aides include the percent of residents identified as drinking alcohol, opinions of alcohol misuse and abuse, and the prevalence of alcohol misuse and abuse. Nurse aides believe a majority (69%) of AL residents drink alcohol. Of these residents, 34% are thought to drink alcohol daily. Estimated prevalence rates show that in 19% of cases nurse aides believe alcohol consumption has influenced residents’ health and 28% are suspected to make poor choices for alcohol consumption. The findings present preliminary evidence that alcohol misuse and abuse may be a problem of importance in AL. Given the potential impact of this on the health, safety, and quality of life for elders, more attention should be focused on alcohol misuse and abuse by residents living in AL.

Keywords

nurse aides assisted living

Alcohol misuse and abuse among the elderly has been called the “invisible epidemic” (Levin & Kruger, 2000) and has long been advocated as a priority area for attention and action. This is based on the notion that alcohol misuse and abuse can have a profound negative impact on health and safety, quality of life, and health care costs. Despite the importance of alcohol misuse and abuse in elders, very little empirical research exists among institutional settings—and none exists in Assisted Living (AL). In the research presented here, alcohol misuse and abuse in AL reported by nurse aides is presented.

Understanding alcohol misuse and abuse by elders living in AL is important. There are many detrimental side effects for elders consuming excessive amounts of alcohol. Potentially negative health outcomes include illness, self-neglect, disability, nutritional deficiencies, and falls. Elders abusing alcohol may also have a higher mortality rate (Joseph, Ganzini, & Atkinson, 1997), have greater psychiatric comorbidity, and require additional mental health and social services (Brennan, 2005). Moreover, threats to the facility and other residents exist from alcohol-related fires.

Background

Assisted Living (AL)

AL is a long-term care setting that typically provides care for residents that require support for one or more activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs). In 1997, there were an estimated 11,459 AL settings nationwide, rising to a more recent estimate of 36,000 in 2009 (Assisted Living Federation of America [ALFA], 2006). The AL industry is regulated by the individual states, and state regulations vary in standards (Administration on Aging, 2005; Carlson, 2007; Hawes & Phillips, 2007). To our knowledge, no state stipulates regulations for alcohol use or consumption in AL.

Unlike the nursing home industry, AL care is generally not reimbursed with federal Medicare or Medicaid funds. Primarily the AL industry directly charges for services. The costs average about $21,000 annually and can be over $50,000 (ALFA, 2006). Thus, the costs are high and residents of AL are generally of higher income, which may be of importance to alcohol consumption. The percentage of elders drinking alcohol is thought to increase with higher income (Liberto, Oslin, & Ruskin, 1992).

The quality of AL is variable. The industry has a reputation for providing high-quality care. Nevertheless, some accounts of poor quality care and inadequate care processes exist. A General Accounting Office (GAO) report notes frequent care problems with “inadequate or insufficient care,” “insufficient, unqualified, and untrained staff,” and “not providing residents appropriate medications” (General Accounting Office, 1999, p. 3). Care problems, for example, could also include inadequate prevention, screening, and diagnosis of alcohol misuse and abuse.

There are several characteristics of the AL context that could potentially lead to situations of elders abusing and misusing alcohol. Such influences include stress, isolation, losses, loneliness, cognitive impairment, and onset of acute and chronic illness (Patterson & Jeste, 1999). For example, 64% of residents have moderate to severe cognitive impairment (Hawes et al., 2003). Gender may also play a role; residents of AL include a high proportion of males (approx. 36%), unlike other long-term care settings which overwhelmingly consist of females. Males drink more frequently and in higher quantities than females (Breslow, Faden, & Smothers, 2003). Placement in AL may also be precipitated by problems associated with prior alcohol abuse or misuse (Klein & Jess, 2002).

Alcohol Use Among Elders in AL

In the United States, varying estimates of alcohol use by elders exist. Estimates of concurrent alcohol use among community-dwelling older adults range from 19% to 38%, with estimates being highest in retirement communities (Pringle, Ahern, Heller, Gold, & Brown, 2005). However, other estimates report that more than half of those age 65 or older report drinking alcohol (The Merck Manual of Geriatrics, 2009).

Several factors influence the characterization of our understanding of alcohol misuse and abuse by elders. Such factors include the biological response of elders to alcohol, diagnosis of alcohol-related problems, and environmental considerations.

Elders respond differently than nonelders to many drugs, including alcohol. Elders tend to have a slower metabolism and blood flow that can cause adverse reactions (McLean & Le Couteur, 2004; Shah & Mooradian, 1997). Decreases in liver mass, liver blood flow, and the kidney glomerular filtration rate reduces the ability to easily eliminate drugs. While the blood-brain barrier function appears to remain intact in elders, it may be more susceptible to disruption by external factors such as drugs and alcohol. So a “paradoxical” situation can exist whereby elders consume less alcohol but suffer increasing adverse consequences from consumption (Klein & Jess, 2002). Given the already impaired health status of many institutionalized elders, these adverse reactions may be particularly prominent in elders living in these settings.

Diagnosing alcohol abuse, misuse, and alcoholism in elders can be a challenge for providers because it often presents itself with the same signs and symptoms as some aging effects (i.e., forgetfulness, loss of balance, and speech problems). Also, a majority of elders are using daily prescriptions, which creates further problems if they mix these prescriptions with use of alcohol. On average, seniors are prescribed between two and seven medications (Carlson, 2007; Culberson & Ziska, 2008), and these rates are even higher in institutional settings such as AL where residents average nine prescription medications (Hawes, Phillips, Rose, Holan, & Sherman, 2003).

Information on alcohol misuse and abuse by elders in other long-term care settings indicates that examining residents in settings such as AL may be important. For example, Sheehan (1997) found wide variation in alcohol misuse among elderly residents of public senior housing. She also identified very little staff training in assessment or policy development in this sector of long-term care.

Reports show that up to one half of nursing home residents suffer from alcohol problems (Klein & Jess, 2002). There is also a high number (36%) of elders in veterans’ nursing homes who suffer from alcohol use disorders (Joseph et al., 1995). Nursing home residents with alcohol-use disorders also present more challenges for staff (Brennan & Greenbaum, 2005). Nursing home residents with alcohol abuse problems are more likely to suffer from depression and anxiety and behavioral problems such as wandering, leading to falls and fractures. Collectively, these additional psychological and medical conditions result in significantly greater use of health services such as emergency department visits as well as mental health and social services care (Hajat, Haines, Bulpitt, & Fletcher, 2004).

Different facility practices with respect to alcohol use by residents exist. Some ALs attempt to keep elders’ lives as normal as possible, for example by offering social activities which may include alcohol. For example, some facilities offer a cocktail hour or allow alcohol in residents’ rooms, which can contribute to alcohol-related problems (Klein & Jess, 2002). In order to help with alcohol-related problems, some facilities have policies and procedures in place that require staff to retain possession of a resident’s alcohol, to monitor use, and some require a physician’s permission for a resident to consume alcohol (Klein & Jess, 2002).

Examining Opinions of Nurse Aides

Nurse aides (also often called Certified Nursing Assistants [CNAs]) provide at least 80% of direct care services to elders in long-term care settings (Institute of Medicine, 2001) and thus are a valuable source of information. In many cases, they become “friends” with residents, and at the very least spend a considerable amount of time interacting with residents. As such, they are positioned advantageously to report on care and issues with these elders (such as alcohol misuse and abuse).

Method

Source of Data

Data came from nurse aides included in the 2009 Pennsylvania nurse aide registry. As part of a research project examining nursing home abuse, a survey was sent to the home address of a random sample of approximately 20% (N = 7,000) of nurse aides in this registry. A total of 4,518 nurse aides returned the questionnaire. However, 832 nurse aides indicated that their prior place of employment was in AL, and they completed the questionnaire items.

The Pennsylvania nurse aide registry was a data source of convenience. It was used for this research because the authors had access to this resource. All states are required by the Centers for Medicare & Medicaid Services (CMS) to maintain a nurse aide registry (Elvidge & Buechlein, 1992).

Questionnaire Development and Response Format

Information from nurse aides working in AL came from a nursing home abuse survey developed by the authors. This survey primarily addressed staff abuse and was developed using a review of the literature, interviews with Directors of Nursing (N = 14), interviews with nurse aides (N = 10), four focus groups with nurse aides (N = 37 participants), and cognitive testing with nurse aides (N = 15). This development process is reported elsewhere (blinded 2011).

All questions were written to be relevant to nurse aides (i.e., face validity), to be relevant to the nursing home context (i.e., content validity), and to be easily understood by nurse aide respondents. Flesch-Kincaid scores of the items ranged from 8.0 to 12.9, which correspond to equivalent U.S. school grade levels (Kincaid, Fishburne, Rogers, & Chissom, 1975).

Questions were asked using four formats: (1) observed or have evidence that this happened, (2) the resident told you this happened, (3) someone other than the resident told you this happened, and (4) you suspect that this happened. These formats were used because some types of abuse can happen quickly and may not be observed by the nurse aide. A 3-month time period was also used. Three months was chosen as a reference period because in focus groups nurse aides believed they could reliably report abuse using this time frame.

Of significance to the research presented here, we asked nurse aides about abuse in their prior place of employment. All sections of the survey used the item stem wording: “in your prior place of employment.” As we described earlier, this was fortuitous, as several nurse aides indicated their prior place of employment was in AL.

The questionnaire asked for nurse aide personal characteristics (e.g., age), work characteristics (e.g., number of residents cared for), and information about the prior facility of employment (e.g., ownership). More specifically, the abuse questionnaire had items addressing verbal, physical, psychological, material exploitation, medication, and sexual abuse. Because medication abuse and alcohol abuse often co-occur (Blow, 1998), questions were asked regarding both.

We define alcohol misuse as heavy drinking. We operationalized alcohol misuse with two survey items: One of the items addresses nurse aides’ opinions of poor choices in alcohol consumption and a second addresses misuse of alcohol. Alcohol abuse is defined as “the use of alcohol to such an extent that it causes physical or psychosocial harm” (The Merck Manual of Geriatrics, 2009, p. 7). We operationalized alcohol abuse using three survey items: One of the items addresses nurse aides’ opinions of the influence of alcohol on residents’ health, a second addresses untreated alcohol-related problems, and a third item specifically asks if residents have abuse problems. These survey items used a fixed response and asked, for residents under their care, if the nurse aide ever had (i.e., yes, no) observed or have evidence of the alcohol misuse/abuse (using the four formats described earlier). In addition, a fill-in-the-blank approach was used for some survey items to identify the actual number of residents involved.

Analyses

Given that very little information is available on alcohol use in AL and given the sample of convenience hypotheses were not developed, descriptive analyses are presented. First, the percentages and means for the sample of nurse aides and AL are provided. This provides information on the representativeness of the sample. The information was compared with national data from nurse aides and AL.

Second, the percentage of residents identified as drinking alcohol by nurse aides is provided. This provides some basic information on the frequency of alcohol use by residents in AL; although, we note that the quantity and type of alcohol consumed by residents was not examined.

Third, the percentage of nurse aides responding to each questionnaire item on the opinions of alcohol use is provided. This provides information on the nurse aides’ opinion of whether any alcohol misuse/abuse in question had occurred (using each of the formats presented earlier, observation or evidence that this happened, etc.).

Information on the number of individual residents identified as abusing alcohol was collected (for the “observed or have evidence” category of questions). Information on the number of individual residents cared for in 3 months was also collected. Prevalence is a measure of the number of observations of an event that occur in a population during a specified time period (Last, 1995). Thus, in this research an approximate prevalence rate was calculated by using information on the number of individual residents identified in each alcohol misuse/abuse item divided by the number of residents cared for in 3 months. However, we note that the prevalence information is presented as an approximate rate, as it comes from self-reports by nurse aides.

Results

Of the 4,451 surveys returned, 855 were from nurse aides whose previous place of employment was in AL (the overall survey response rate was 64%). Some nurse aides (i.e., 23) indicated that they had not worked at the AL site for 3 months. The responses for these nurse aides were not included in this research, giving an analytic sample of 832.

Table 1 presents descriptive statistics of the nurse aide sample, along with self-reported characteristics of the AL settings in which they worked. Most characteristics of the sample were not significantly different from equivalent characteristics recorded in national samples of AL (ALFA, 2006). Also, most nurse aide characteristics of the sample were not significantly different from equivalent characteristics recorded in the 2004 National Nursing Assistant Survey (NNAS, 2007). The NNAS was conducted as a supplement to the 2004 National Nursing Home Survey (NNHS). Nurse aides were most likely to be an average of 31 years old, be female, and have a high school diploma. However, significantly fewer minority nurse aides were included in our sample compared to the NNAS.

Table 1.

Characteristics of Nurse Aides and Assisted Living Facilities

Characteristic	Percent	M (SD)
Personal characteristics of nurse aides (N = 832)
Gender (female)	94%
Age (years)		31.4 (8.1)
Race (minority)	41%	—
Marital status (single)	32%	—
Highest level of education (high school)	77%	—
Work characteristics of assisted living facilities (N = 832)^a
Number of residents cared for (past 3 months)	—	13 (6)
Permanent resident assignment (yes)	82%	—
Facility characteristics of assisted living facilities (N = 832)^a
Facility size (number of beds)	—	78 (72)
For-profit ownership	72%	—
Chain membership	39%	—
Average occupancy (estimated)	95%	(5)

Information was reported by nurse aides, not from a facility survey.

Table 2 presents descriptive statistics of nurse aides’ opinions of alcohol use by residents. A majority (69%) of residents were reported as drinking alcohol. Of these residents drinking alcohol, 34% were considered by nurse aides to be drinking daily.

Table 2.

Characteristics of Resident Alcohol Use in Assisted Living Reported by Nurse Aides

Characteristic	Percent
How many residents DO NOT drink alcohol?	31%
How many residents drink alcohol?	69%
Of those residents drinking alcohol …
How many residents rarely drink alcohol?	27%
How many residents drink alcohol regularly?	39%
How many residents drink alcohol daily?	34%

Note. N = 832 nurse aides.

Table 3 presents descriptive statistics (percent and n) for the items examining alcohol misuse and abuse. In most cases, the highest values were for nurse aides “suspecting” alcohol misuse and abuse. For example, in the 3-month period, 44% of nurse aides responded that they suspected that some of the residents under their care had made poor choices for alcohol consumption. Nevertheless, some of the values for having observed or having evidence for alcohol misuse and abuse are also high. For example, 40% of nurse aides responded that they had observed or had evidence that for some of the residents under their care alcohol had influenced the residents’ health.

Table 3.

Nurse Aides Opinions of Alcohol Misuse and Abuse in Assisted Living

Alcohol Misuse/Abuse Item (Question Stem: In the Past 3 Months, Have Residents Under Your Care EVER …)	Observed or Have Evidence Percent^a (n)	The Resident Told You Percent^a (n)	Someone Other Than Resident Told You Percent^a (n)	You Suspect Percent^a (n)
Made poor choices for alcohol consumption	32% (262)	26% (214)	16% (133)	44% (370)
Had a tendency for alcohol misuse	16% (129)	25% (205)	21% (178)	31% (261)
Had alcohol abuse problems	14% (120)	13% (111)	19% (157)	39% (322)
Had untreated alcohol related problems	21% (171)	29% (242)	17% (144)	57% (472)
Had alcohol use seem to influence their health	40% (329)	19% (157)	15% (125)	26% (218)

Note. N = 832 nurse aides.

The percentages in the table were calculated using nurse aides responding “yes” to the question. Thus, the percentages represent nurse aide opinions.

Prevalence rates using the “observed or have evidence” category and given as yearly rates are presented in Table 4. This shows that nurse aides believe that approximately 28% of residents in their care have made poor choices for alcohol consumption. Also, in 19% of cases nurse aides believe alcohol consumption has influenced residents’ health.

Table 4.

Estimated Prevalence Rates of Alcohol Misuse and Abuse in Assisted Living Reported by Nurse Aides

Alcohol Misuse/Abuse Item^a
(Question Stem: In the Past 3 Months, How Many Residents Under Your Care Have …)	Prevalence Per 1,000 Residents per Year^b
Made poor choices for alcohol consumption	28%
Had a tendency for alcohol misuse	11%
Had alcohol abuse problems	12%
Had untreated alcohol related problems	8%
Had alcohol use seem to influence their health	19%

Note. N = 832 nurse aides.

Using information from “observed or have evidence” items. The percentages in the table were calculated using figures provided by nurse aides. Thus, the percentages represent residents.

Prevalence rate was calculated by using information on the number of individual residents identified for each alcohol misuse/abuse item divided by the number of residents cared for in 3 months. Figures are given as yearly rates.

Discussion

Alcohol misuse and abuse by institutionalized elders represents an important concern for the quality and safety of health care. Virtually no information exists on alcohol use in AL (Castle, Wagner, Ferguson, Smith, & Handler, in press). The results of this study are higher compared to those elders living in the community, and they indicate that 69% of AL residents drink alcohol (as reported by nurse aides). We speculate that these higher estimates are a reflection of the AL environment, which includes higher income males and ready access to alcohol.

The descriptive results provide some evidence that alcohol use and misuse may indeed be an issue of concern. For example, nurse aides believe that 8% of residents have untreated alcohol-related problems. With an estimated 1.0 million elders living in AL (ALFA, 2006), this equates to about 80,000 elders possibly in need of services. These estimated prevalence rates indicate further research on alcohol misuse and abuse in AL may be useful, as we may need adjuvant services in this area for the protection of elders’ health.

Forty-four percent of nurse aides report that of the elders under their care some have made poor choices for alcohol consumption. What nurse aides mean by this could vary, but this could include drinking and driving or mixing alcohol with prescription drugs. This could also mean facility practices and policies regarding alcohol are exacerbating use. Information on facility practices is needed. This may represent a particularly difficult dilemma for AL. On the one hand, they need to attract private-paying clients (who may expect a facility bar, happy hours, and social events including alcohol), and on the other hand, they are charged with assuring the health and safety of residents under their care auspices.

Detection and management training for staff may be important. For example, signs of potential alcohol misuse and abuse can be included in training (falls; auto accidents; forgetfulness; ulcers; stomach or pancreas inflammation; liver disease; high blood pressure; mood swings; speech problems; tiredness; isolation & changes in behavior). However, this may also represent facility-specific endeavors, as mandated nurse aide training is minimal. The current national training provisions for nurse aides in nursing homes include completing 75 hours of training and passing a competency examination. Some training requirements exist in some states for AL, but these are almost always less stringent than the already low provisions for nursing homes.

Limitations and Suggestions for Future Research

Several limitations exist with the research presented. Clearly, the most significant limitation is that the information reported comes from nurse aides and not directly from elders living in AL. The information presented represents opinions of these nurse aides. Interviews and screening of elders should be part of a future research agenda in this area.

The alcohol misuse and abuse information came from a survey designed for nurse aides working in nursing homes. This nursing home context may have influenced some of the responses. Moreover, the responses were from nurse aides randomly selected from a registry. We have no information on the facilities in which these nurse aides worked. Thus, the information reported may be biased by including duplicate responses from the same AL.

Nurse aides are not clinicians and cannot provide clinical diagnoses. As described earlier, the nurse aides used in this research represent a sample of convenience. Moreover, nurse aides were from Pennsylvania, potentially limiting the representativeness of the sample. Nurse aides may have different experiences with and cultural understandings of alcohol misuse and abuse. This may influence beliefs with respect to alcohol and influence the responses given. However, given the paucity of information on issues related to alcohol use in AL, we believe the information is relevant and significant.

The literature examining alcohol use is replete with terms and definitions. Very little consensus exists regarding these terms and definitions; thus, our use of alcohol “abuse” and “misuse” could be operationalized in other ways. For example, one often used definition of “misuse” is drinking exceeding 14 standard drinks per week or 4 drinks per day for men and more than 7 standard drinks per week or 3 drinks per day for women (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2005). We did not ask for this detail in our survey. The quantity of alcohol consumed was not examined in this research. Thus, the level of alcohol use may represent very infrequent drinking, and may not be problematic. Future research may benefit from more detailed investigation. That is, the items included on our survey were brief and could be substantially expanded.

In addition, data are especially lacking on screening, incidence, facility policies, treatment approaches, prevention, and use of health services to ameliorate the potential problem of alcohol misuse and abuse. For example, we do not differentiate between late/new onset versus early onset alcohol abuse (Zucker, 1995). Furthermore, the potential benefits of limited alcohol use were not examined. It would be interesting to balance the research with a survey including these potential benefits (increased socialization, etc.).

States use various names for what is commonly called assisted living. Alternative terms include board and care, residential care, personal care, and congregate care (Carlson, 2007). Some of the services provided and regulations governing care also vary by state (Zimmerman & Sloane, 2007). Thus, our findings coming from Pennsylvania may not be representative of these other “assisted living” settings in other states. Also, a survey of assisted living policies regarding alcohol use may help give further perspective in this area. We have little knowledge on how many facilities actually serve alcohol as part of the social activities at their site, for example.

Conclusion

Clearly, this research should be interpreted in light of the many incumbent limitations. Nevertheless, the findings do present preliminary evidence that alcohol misuse and abuse may be a problem recognized by AL staff. One substantial challenge (if these findings are replicated) is how this information can be used to shape clinical practice and policy in AL. Given the potential importance of this on the health and quality of life for elders, we believe we should heed this early warning signal and further examine this issue. Over the past decade, AL has experienced rapid growth in capacity and currently represents the most numerous institutional care setting for elders requiring some assistance in ADLs. We should not miss the opportunity to implement appropriate policies and procedures for prevention and screening, as well as effective treatment programs for residents with alcohol misuse or abuse.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This research was supported, in part, by a grant from the Agency for Healthcare Research and Quality 1 RO3 HS0165347-01A1. Approval for this research was given by the University of Pittsburgh IRB.

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