When I said enough is enough: reducing alcohol related harm in older people

Dr Tony Rao is a Consultant Old Age Psychiatrist who has worked for the NHS for over 30 years. At the start of his career, he did not expect to find alcohol harm and addiction so prevalent among his patients and, in this blog, describes how his observations helped shape his practice.

As a career old age psychiatrist, I had no training in addictions psychiatry, other than a vague recollection of some of the problems needed for me to make a diagnosis of alcohol dependence. In my clinical exam, when asked “please could you assess this patient’s motivation to stop drinking”, I was rooted to the spot. I failed it, floundering around with no clue where to start. But it didn’t really matter. I didn’t need these skills as an old psychiatrist, did I? So, I mopped my brow and continued my training. Although the career that lay ahead of me was unexpected, it became not just fulfilling, but a life less ordinary.

As soon as I walked through my office door 22 years ago, the referrals came in thick and fast. An older man living in squalor and at risk of eviction. An older woman who fell repeatedly after ‘one too many’. A younger man with possible dementia following several years of heavy drinking. Five years later, the moment of truth appeared in my mind like an epiphany. As I sat on the ward at the end of another four hour ward round; I cast my eye across the list of patients. Half of my patients had an alcohol problem accompanying their anxiety, depression or dementia; on an Old Age Psychiatry ward. I said to myself something that I will never forget: “Enough is enough!”  Whether the ex-docker or the older Irish ex-road construction worker, I had to come clean that I had not the faintest idea as to how I could look after them in the way that they deserved.

What followed was a career in harm reduction from the damage done by alcohol; with the foundations being laid from an MSc in Addictions that gave me the knowledge, skills and appropriate non-judgemental and non-confrontational attitudes that I desperately needed. What a steep learning curve it was. Like a CAGE questionnaire, it was an eye opener. Not just that. Through my dissertation, I was able to look in more detail about what it was like to be marginalised and living in poverty and how that affected drinking and the spiral of despair into which lives can slowly dissolve.

It was to be the beginning of a productive journey through unchartered territory, with the odd Scylla and Charybdis making for more turbulent seas along the way.

The first few years after my MSc were spent embedding putting my competencies into practice. What it says on the lecture presentation or in textbook is very different from the patient in front of you. I knew the main problem was going to be overcoming stigma around alcohol use and the mental disorders that accompany drinking. It wasn’t long before I   became aware that under-reporting and denial were the very cornerstones of resistance and the huge ambivalence that accompanies any contemplation of a change in drinking behaviour. But it wasn’t until several years later that I started asking about alcohol use, not as part of medical or past psychiatric history, but in the social history. Alcohol is the glue that binds social interactions, the lubricant for celebrations and the tonic for unwinding. It lies at the very heart of how we live our lives. As a question as “do you ever have a drink now and again?” soon replaced “how often do you have a drink containing alcohol?” It would be the make or break question that would determine the likelihood of a therapeutic relationship; with the hope of a brighter future. A life, rather than just an existence ruled by drink.

The clinical journey, combined with my training in old age psychiatry, addiction and an academic background would also provide the impetus for a contribution the Greater Good. As I sit writing this just over 15 years after completing my MSc, I’d like to think that I’ve covered all angles. Policy development, public education through the media, research, bespoke training the Third Sector and integrated care within the NHS. When I presented at a recent conference for the Faculty of Social and Rehabilitation Psychiatry, I was asked “what is the one thing that you would like to achieve in your work with older people who have alcohol problems?” It was simple. “To see Mr X or Mrs Y be able to get to the shops independently or have contact with friends and family without being weighed down by the harm done by alcohol”. That was it. My clinical work even inspired me to write a book, based on a true clinical encounter. But that’s another story.

Written by Dr Tony Rao

Download the audiobook of ‘Catch Me When I Fall’ by Dr Tony Rao on Amazon.

This blog was published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Alcohol Health Alliance or its members.