A 70-year-old man suffers a heart attack and is brought into the Emergency Department. On aspirin therapy for a year, he had stopped it three weeks earlier on his physician's advice after reporting more cardiac discomfort and using more nitroglycerin just to get through the day.
He needs bypass surgery, a fairly common and relatively quick procedure. Once surgery begins, though, so does uncontrolled bleeding. Thirteen hours later, the patient's life has been saved, but he faces a complicated recovery.
Blame a potentially deadly and all-too-common cocktail, says Christine L. Savage, PhD, RN, CARN, professor and chair of the Department of Community-Public Health at the Johns Hopkins School of Nursing (JHSON). Alcohol is an anticoagulant. The patient, a lifelong drinker, was still drinking daily. The doctor didn't know about it because he didn't ask. In addition, the patient had heard only "aspirin," not "children's aspirin," so he had been taking a higher-than-prescribed dosage of that blood thinner. (Nitroglycerin also opens blood vessels to improve flow.)
Simple Questions, Hard Answers
By 2015, all baby boomers will be 50 or older. In an editorial for the Journal of Addictions Nursing, Savage writes that, unlike members of previous generations, many of these individuals have been using alcohol (and other drugs) for their entire adult lives. There are consequences.
"Alcohol is a dirty drug, and it causes all kinds of long-term problems," Savage says. Quoting a 2013 National Institute on Alcohol Abuse and Alcoholism report, she says alcohol contributes to increased risk for more than 65 diseases and conditions, including pancreatic, breast, and ear, nose, and throat cancers, liver disease, injuries, and cognitive impairment.
"It's an equal opportunity problem that cuts across socioeconomic and gender lines," adds Deborah Finnell, DNS, PMHNP-BC, CARN-AP, associate professor in the Department of Acute and Chronic Care at JHSON. "When people come in ... the best practice is to ask questions related to alcohol, tobacco, and other drug use. There are reliable and valid measures -- very simple measures -- that can be used" to screen for these issues. Unfortunately, she says, "those are not being widely implemented."
Savage says, "We tend not to think about the older patient in front of us as somebody whose alcohol use may be putting them at risk, and we're uncomfortable asking the cute grandmother or the stately older man about their alcohol use."
Nancy Hodgson, PhD, RN, assistant professor in the JHSON Department of Acute and Chronic Care, emphasizes the importance of making the effort. That older patient could be experiencing "bereavement, isolation, loneliness, an underlying depression or pain, so they're self-medicating as a numbing agent, using alcohol."
The system incentivizes an acute-care approach when what is needed takes more time, says Laura N. Gitlin, PhD, professor and director of the Center for Innovative Care in Aging at JHSON. "Insurers, what are they paying for? They're paying for a six-minute visit. They're paying for tests. These aren't tests. They are ways of talking to people and coming up with strategies that don't require a chest X-ray or an MRI."
One useful approach to screening and intervention is SBIRT (for Screening, Brief Intervention, and Referral to Treatment), which identifies patients with risky substance use, engages them in a brief conversation about that behavior, and refers those who need it to further treatment.
Finnell says this kind of screening should be standard practice, just like taking a patient's blood pressure, pulse, and weight. She describes the brief intervention as a five- to 10-minute conversation that starts with "asking for permission to talk about it. Because of how society views alcohol and other drug use, it's important to put people at ease."
Hodgson says the nurse is the perfect person to start this conversation. "They have the rapport with the patients, they have the key assessment skills necessary to pick up the subtle changes -- things like fall history, or unexplained lethargy or confusion -- and dig deeper."
"Older adults are probably more likely to talk to the nurse about more sensitive issues than they would perhaps the physician," Hodgson adds.
Leading the Way
Ultimately, Finnell says, the goal is for nurses to be able to identify every patient with risky substance use and to raise awareness. Patients "may say, 'I'm going to continue to drink at the same level I've been drinking.' But if I can get them, at least, to begin to think about that, then I see that as a real success." And if they agree they should decrease their alcohol use, she says, "then that's a greater success."
Savage and Finnell are part of a team working on a Substance Abuse and Mental Health Services Administration-funded training grant to integrate more content about alcohol and drugs into the graduate curricula to prepare nurses to meet this challenge. (For a current study, Finnell has developed a 20-minute video illustrating how alcohol affects the brain. She hopes to use it with patients in primary care who are identified with at-risk alcohol use.)
"We want for nurses who graduate from the Johns Hopkins School of Nursing to be leaders in the nation for moving this set of clinical strategies … across all healthcare settings, all populations, all settings," Finnell says, adding that working nurses also need this education.
"We have over 3 million nurses in the nation," Finnell says. "If those 3 million nurses had all been appropriately educated, then we could make a huge impact in terms of the global harm associated with alcohol use."
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