'Wet' care homes for older people with refractory alcohol problems: a qualitative study

Background This study describes a registered care home in England and a registered nursing home in Norway which provide permanent care for alcohol-dependent older people who are unable or unwilling to stop drinking and cannot maintain an adequate standard of self-care and/or live independently. Prior to admission, most residents have been living unsafely in their own home or were homeless. They have high levels of contact with health, social and criminal justice services and complex needs as a result of mental illness, poor physical health and physical disabilities. Most have lost contact with their families. The aim is to stabilise drinking, physical and mental health and improve quality of life. The homes are based on a harm reduction philosophy, that is, they focus on strategies to reduce harm from high-risk alcohol use, rather than insisting on abstinence. Residents can drink as much alcohol as they want on the premises but staff encourage them to drink less and in a less harmful way (e.g. spreading drinking throughout the day and having ‘dry’ days). Method We carried out interviews and focus groups with staff and residents, observed verbal exchanges, experiences and routines in communal areas, took field notes during staff rounds and analysed documents such as care plans for individual residents. Key findings • Most residents’ drinking, physical and mental health stabilises and their use of health, social and criminal justice services reduces following admission. • This is achieved by encouraging less harmful drinking, providing on-site health care, assistance with medication and self-care and provision of nutritious meals and social activities. • Wet care homes are viewed by some residents as a safe refuge which has improved their quality of life. • Other residents are frustrated by a lack of personal autonomy. • Suitable outcomes include improved hygiene and nutrition, increased self-esteem, better compliance with healthcare, healthier living which is not entirely alcohol focused and more hope for the future. • Homes should have processes in place to collect quantitative measures which provide clear evidence of impact.        

Working with older drinkers

Findings presented in this report demonstrate that older drinkers have different stressors, precipitating factors and risk factors for relapse than younger drinkers. They also face a number of unique barriers to treatment and are more likely to remain ‘hidden’ from services. Despite these challenges, age-specific practices required to meet the needs of older people and draw them into treatment are poorly understood. The purpose of this project was to develop guidelines on what strategies and treatment approaches are likely to work best with older drinkers based on synthesis of relevant literature, insight from alcohol practitioners who specialise in working with older people and the perspectives of older people receiving alcohol treatment. A set of concise guidance documents will be prepared for health and social care workers and alcohol service providers in due course

Identification of the Cellular Proteins Which Interact With the Essential HSV-1 Protein IE63

Herpesviruses are involved in a range of prominent medical or veterinary diseases making this one of the most significant virus families. The HSV-1 protein IE63 (ICP27) is essential for viral replication, and is the only HSV-1 IE protein which has homologues in every herpesvirus sequenced so far which infect mammals and birds, indicative of its key regulatory role and making it an excellent antiviral target. The aim of this study was to screen a library of cellular proteins to identify those which interacted with HSV-1 IE63. This information was likely to shed light on the mode of action of this protein. The yeast two-hybrid system was used to identify interacting proteins. This system exploits the ability of a 'bait' protein fused to the binding domain of a yeast transcription factor to interact with a target protein fused to the activation domain of the same yeast transcription factor, bringing the two domains into close enough proximity to reconstitute activity of the transcription factor and subsequent transcription of reporter genes in yeast cells. Proteins that do not interact do not permit activation of reporter gene expression. In this study, a truncated IE63 protein was used to screen proteins expressed from an uninfected HeLa cell cDNA library. The protein was truncated because it was found that that the N-terminal ten amino acids of IE63 caused transcription of reporter genes in the absence of an interacting protein. The screen identified eight cellular proteins which interacted with IE63, four of which were of initial interest. These were heterogeneous nuclear ribonucleoprotein K (hnRNP K), casein kinase II (CKII) p subunit, and the splicing factors Spliceosome Associated Protein 145 (SAP 145) and p32:- these interactions were all subsequently confirmed in virus infected cells by others in our laboratory. Truncation mutants of IE63 were constructed and using these in the two-hybrid assay, the regions of IE63 required for these various interactions were mapped as well as the IE63 region required for dimersation. Similarly, using hnRNP K truncations, regions required for interaction with IE63 were identified A region containing the zinc finger domain of IE63, located towards the C-terminus, was required for interaction with the CKIip subunit, with SAP 145 and for IE63 dimerisation. Dimerisation would permit IE63 to form interactions with multiple partners in a complex of proteins with RNA, allowing cross-talk between these molecules. An IE63 region involved in the interaction with hnRNP K contained a five amino acid sequence (SADET) which is well conserved throughout the alphaherpesviruses, and which is present in a region of hnRNP K required for interaction with IE63 and is necessary for the nuclear export of hnRNP K. This region of IE63 could have a role in nuclear export, perhaps recognising a nucleoporin also recognised by hnRNP K. A further IE63 region with runs of prolines was identified as involved in interactions with hnRNP K and CKIip, and was the only region necessary for the interaction with p32. It is highly probable that IE63 inhibits splicing by interacting with SAP 145 and/or p32, and it appears that CKII is recruited by IE63 to phosphorylate itself, hnRNP K and probably other proteins. The function of hnRNP K in uninfected cells is not completely understood but it is thought that the protein has a role in transcription, pre- mRNA processing, RNA transport and translation. It is proposed that IE63 may alter transcription, mRNA processing and transport in the HSV-1 infected cell via its interaction with hnRNP K. The study also demonstrated that IE63 can form interactions with a transcriptional activator ALY, a glutamine-rich protein, the protein human JTV-1 of unknown function and the nucleoporin RIPl. Furthermore, the nucleoporin CRMl which interacts with HIV-1 Rev and facilitates its export to the cytoplasm did not interact with IE63 in the two-hybrid assay, suggesting that IE63 and Rev may use different pathways to cross the nuclear pore. Finally, the HHV-8 (Kaposi's sarcoma herpesvirus) ORF57 homologue of IE63, which also acts post-transcriptionally, did not interact with the hnRNP K, CKIip, SAP 145 and p32 clones identified in the library screen suggesting that these distantly related homologues, which belong to different herpesvirus subgroups, are likely to possess certain different activities. (Abstract shortened by ProQuest.)

Exploring associations between perceived HCV status and injecting risk behaviors among recent initiates to injecting drug use in Glasgow

The aim of this study was to explore the influence of testing for hepatitis C virus (HCV) and perceived HCV status on injecting risk behavior. A cross-sectional, community-wide survey was undertaken at multiple sites throughout Greater Glasgow during 2001-2002. Four hundred ninety-seven injecting drug users (IDUs) consented to participate and were interviewed using a structured questionnaire to ascertain HCV test history and injecting risk behavior. The average age of participants was 27 years and the majority of the sample were male (70.4%). Participants had been injecting for an average duration of 2.5 years. Logistic regression analysis revealed no significant associations between having been tested and injecting risk behavior. After adjustment for potential confounding variables, HCV-negatives were significantly less likely to borrow needles/syringes and spoons or filters as compared with unawares and were significantly less likely to borrow spoons or filters as compared with HCV-positives. Due to the cross-sectional design of the study, it is uncertain whether this reduction in risk behavior could be attributed to perception of HCV status. Further research is recommended to consolidate the evidence for this relationship

The characteristics and treatment outcomes of people with very late onset of problem drinking

Background. The characteristics and outcomes of people who begin to experience problems with alcohol later in life are not well understood. This study examines whether people with a very late-onset of problem drinking, defined as occurring after the age of 60, differ in their use of alcohol, mental health functioning, and alcohol treatment outcomes from people with an earlier onset of problem drinking. Method. Seven hundred eighty participants aged 50+ were categorized as either early onset (<25 years, n = 119, 15%), mid-onset (25–39 years, n = 200, 26%), late-onset (40–59 years, n = 376, 48%) or very late-onset problem drinkers (≥60 years, n = 85, 11%). Participants completed measures on alcohol use, mental health, and cognitive functioning. Results. Eleven percent of participants had very late onset of problem drinking. After controlling for age as a covariate, age of onset of problem drinking was not associated with level of alcohol intake or cognitive functioning, but individuals with very late onset of problem drinking had significantly lower levels of depression and significantly better mental health well-being. Age of onset was not associated with treatment outcomes (i.e., change in alcohol use following treatment or treatment completion). Conclusion. People who first experience problems with alcohol after the age of 60 may have better mental health functioning than people with an earlier age of problem drinking. The results suggest that the age of onset of problem drinking may be a poor predictor of alcohol use severity and treatment outcomes and older adults can benefit from alcohol treatment irrespective of the age problem drinking began

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

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

Accessibility and suitability of residential alcohol treatment for older adults: a mixed method study

Background Whilst alcohol misuse is decreasing amongst younger adults in many countries, it is increasing in older adults. Residential rehabilitation (rehab) is a vital component of the alcohol treatment system, particularly for those with relatively complex needs and entrenched alcohol problems. In this study, we sought to find out to what extent rehabs in England have upper age limits that exclude older adults, whether rehabs are responsive to older adults’ age-related needs and how older adults experience these services. Method This is a mixed method study. A search was carried out of Public Health England’s online directory of rehabs to identify upper age thresholds. Semi-structured qualitative interviews were carried out with 16 individuals who had attended one of five residential rehabs in England and Wales since their 50th birthday. A researcher with experience of a later life alcohol problem conducted the interviews. Results Of the 118 services listed on Public Health England’s online directory of rehabs, 75% stated that they had an upper age limit that would exclude older adults. Perceived differences in values, attitudes and behaviour between younger and older residents had an impact on older residents’ experience of rehab. Activities organised by the rehabs were often based on physical activity that some older adults found it difficult to take part in and this could create a sense of isolation. Some older adults felt unsafe in rehab and were bullied, intimidated and subjected to ageist language and attitudes. Conclusion This study identified direct and indirect age discrimination in rehabs contrary to the law. Further research is required to find out if age discrimination exists in rehabs in other countries. Rehabs should remove arbitrary age limits and ensure that they are responsive to the needs of older adults

Improving patient experience for people prescribed medicines with a risk of dependence or withdrawal : co-designed solutions using experience based co-design

Background. Significant concerns have been raised regarding how medications with a risk of dependence or withdrawal are managed and how care is experienced by patients. This study sought to co-design solutions to improve the experience of care for patients prescribed benzodiazepines, z-drugs, opioids for chronic non-cancer pain, gabapentinoids and antidepressants. Method. Twenty patients and fifteen healthcare professionals from five different GP practices were recruited to take part. The study used Experience Based Co-Design. Patients and healthcare professionals completed semi-structured interviews and took part in feedback groups and co-design workshops to collaboratively identify priorities for improvement and to co-design solutions to improve the experience of care. Results. Poor patient experience was common among people prescribed medications with a risk of dependence or withdrawal. Patients and healthcare professionals identified three main priority areas to improve the experience of care: (i) ensuring patients are provided with detailed information in relation to their medication, (ii) ensuring continuity of care for patients, and (iii) providing alternative treatment options to medication. Solutions to improve care were co-designed by patients and healthcare staff and implemented within participating GP practices to improve the experience of care. Conclusion. Good patient experience is a key element of quality care. This study highlights that the provision of in-depth medication related information, continuity of care and alternative treatment to medication are important to patients prescribed medicines with a risk of dependence or withdrawal. Improving these aspects of care should be a priority for future improvement and delivery plans

Factors influencing routine cognitive impairment screening in older at‐risk drinkers: Findings from a qualitative study in the United Kingdom

Cognitive Impairment (CI) screening is recommended for those engaged in harmful levels of alcohol use. However, there is a lack of evidence on implementation. This paper explores the barriers and facilitators to CI screening experienced across a service specifically for older drinkers. The findings draw on data gathered as part of an evaluation of a multilevel programme to reduce alcohol‐related harm in adults aged 50 and over in five demonstration areas across the United Kingdom. It is based on qualitative interviews and focus groups with 14 service providers and 22 service users. Findings are presented thematically under the section headings: acceptability of screening, interpretation and making sense of screening and treatment options. It is suggested that engagement with CI screening is most likely when its fit with agency culture and its purpose is clear; where service providers have the technical skills to administer and discuss the results of screening with service users; and where those undertaking screening have had the opportunity to reflect on their own experience of being screened. Engagement with CI screening is also most likely where specific intervention pathways and engagement practices can be accessed to respond to assessed need

Drinking behaviour and alcohol-related harm amongst older adults: analysis of existing UK datasets.

Older adults experience age-related physiological changes that increase sensitivity and decrease tolerance to alcohol and there are a number of age-related harms such as falls, social isolation and elder abuse, which are compounded by alcohol misuse. Despite this unique vulnerability and the fact that the number of older adults is increasing, the literature on drinking behaviour and alcohol-related harm in older adults is sparse. This article describes a secondary analysis of UK data to address this knowledge gap