There exists a wealth of evidence regarding the detrimental impact of hazardous alcohol consumption, consuming more than the weekly recommended number of standard alcohol units in any week (21 for males, 14 for females) or half of the recommended number of standard alcohol units in any one day (10 for males, 7 for females), on the physical and mental health of the population. It is estimated that hazardous alcohol consumption accounts for 150000 hospital admissions and between 15000 and 22000 deaths per annum in the United Kingdom . In the older population, those aged 55 years or more, hazardous alcohol consumption is associated with a wide range of physical, psychological and social problems. There is evidence of an association between increased alcohol consumption and increased risk of coronary heart disease, hypertension, haemorrhagic and ischemic stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers . Alcohol consumption is identified as one of the three main risk factors for falls , a major cause of morbidity and mortality in this population. The Royal College of Physicians estimates that 60% of older people admitted to hospital because of repeated falls, confusion, chest infections and heart failure have undiagnosed alcohol problems . Increased alcohol consumption in older age can also contribute to the onset of dementia and other age related cognitive deficits, Parkinson's disease and a range of psychological problems including depression and anxiety . Alcohol use is implicated in one third of all suicides in the older population . It is estimated that 80% of those aged 65 and over regularly take prescribed medication and polypharmacy is common with a third taking at least four prescribed medications per day . Alcohol is a major contraindication for many of the drugs prescribed for older people and alcohol and medication interactions are a common phenomenon. Increased alcohol consumption in older age is also associated with a range of social problems including self-neglect, poor nutrition, social isolation and hypothermia .
The prevalence of hazardous alcohol consumption, this is inclusive of harmful consumption, in those aged 55 years and over is generally lower than the general population. The most recent estimate derived from the Alcohol Needs Assessment research Project  indicates a prevalence of between 15% and 25% and concurs with other estimates derived from the General Household Survey. There is also evidence that the prevalence rate in primary care attendees is higher than the general population . There is evidence that these prevalence rates are under-estimates of the true prevalence rate. Older people are less likely to seek treatment for alcohol use disorders  and alcohol related presentations are often atypical or masked by comorbid physical or psychiatric illness that makes alcohol related diagnosis more difficult . In 2000 16% of the UK population was over the age of 65 and this is expected to increase to 21% by 2026 . As the average age of the population increases the absolute number of older people consuming alcohol at hazardous levels will increase even if the prevalence rate remains stable. Recent research using data derived from the General Practice Research Database indicates that only 5% of people aged 55 years or older with an alcohol use disorder are identified in primary care settings . Opportunistic screening is a proactive screening technique that has been used with some success in a variety of healthcare areas including type II diabetes and Chlamydia  and is particularly useful in identifying conditions in populations who would not usually seek treatment.
A number of paper based screening methods have been developed to identify hazardous alcohol consumption; these include instruments such as the Michigan Alcohol Screening Test , Paddington Alcohol Test , Fast Alcohol Screening Test  and the Alcohol Use Disorders Identification Test . All have acceptable levels of sensitivity and specificity. The Alcohol Use Disorders Identification Test (AUDIT) was specifically developed for use in a primary care population and has 92% sensitivity and 92% specificity for identifying hazardous alcohol use in a UK primary care setting ; more specifically in older populations AUDIT has been demonstrated to have higher sensitivity, 75%, and higher specificity, 97.2% than other screening tests when used in older populations . AUDIT is a short 10-item questionnaire that addresses frequency of alcohol consumption, alcohol related problems and alcohol dependence symptoms. Because of the evidence of under detection and misdiagnosis of hazardous alcohol use in older populations [11, 12] the proactive application of a short universal screening method is likely to be more appropriate. There is evidence that patients are more compliant with screening protocols for alcohol use in healthcare settings and that the environment provides an opportunity for a 'teachable moment' increasing the patient's likelihood to engage in an intervention .
There is a substantial evidence base for the efficacy of brief motivational interventions, aimed at reducing alcohol consumption in primary care. Studies have demonstrated the effectiveness of brief interventions in reducing alcohol consumption in primary care populations in the United Kingdom . Further, there are six systematic reviews focusing specifically upon the effectiveness of brief interventions in primary care populations [22–27] all conclude that brief interventions in primary care populations are effective in reducing alcohol consumption. But many of the studies included in these reviews exclude older patients. There are no systematic reviews or subgroup analyses specifically focussing on older patient groups. There is some evidence from primary research of the efficacy of brief interventions specifically for older hazardous alcohol consumers. In a trial of brief interventions for older alcohol users in primary care in the United States, Fleming et al  reported a 34% reduction in alcohol consumption and 64% reduction in those drinking at hazardous levels at 12 months, significantly better than those who received no intervention. Blow and Barry  also report significantly greater reduction in alcohol use in older populations treated with brief interventions in primary care than controls. There is also evidence from subgroup analyses of existing studies that older patients are at least as likely to benefit from brief interventions as younger patients  and older adults are more likely to adhere and comply with brief intervention treatment regimes . While a number of brief intervention studies have addressed the issue of cost-effectiveness, few have addressed the issue from a pragmatic NHS perspective. The evidence of brief interventions has been criticised for failing to address a wider range of alcohol use disorders including harmful alcohol consumption  and for failing to address more entrenched drinking behaviours.
Screening for alcohol use disorders identifies a range of needs that are likely to require a range of types and intensities of intervention. One of the primary reasons why many general practitioners are reluctant to implement screening into routine care is because they lack the skills of how to deal with the more severe cases identified. Motivational Enhancement Therapy is a relatively short, usually three 40 minute sessions delivered by a trained therapist, but more intensive intervention than a brief motivational intervention. Primary research has shown it to be as effective as other more intensive interventions such as cognitive behavioural therapy, twelve steps facilitation therapy and social behavioural network therapy [33, 34].
Older alcohol consumers are often typified as either 'early onset' drinkers, whose consumption pattern is a continuation of lifetime hazardous consumption or 'late onset' drinkers whose alcohol consumption is a reaction to life events occurring in later life. 'Late onset' drinkers' are more likely to benefit from brief interventions than 'early onset' drinkers who often require a more intensive intervention approach . Physiological changes that occur as part of the ageing process mean that older people are more vulnerable to alcohol and experience alcohol related problems at lower consumption levels than younger people. Stepped care interventions offer a potentially resource efficient means of meeting the needs of this population. Stepped care interventions provide a means of delivering more intensive interventions only to those who fail to respond to less intensive interventions and are more in keeping with rational clinical decision making than the blanket use of any one intervention strategy.
Aims of the study
1. To evaluate the effectiveness of stepped care interventions for older hazardous alcohol users in primary care.
2. To evaluate the cost-effectiveness of stepped care interventions for older hazardous alcohol users in primary care.
3. To screen 4170 primary care attendees aged 55 years or more for hazardous alcohol use using the AUDIT questionnaire.
4. To evaluate the acceptability and validity of opportunistically screening for hazardous alcohol use in older primary care attendees.
5. To estimate the prevalence of alcohol use disorders in an older primary care population.
6. To train 15 practice nurses in the delivery of behavioural change counselling.
7. To conduct a pragmatic randomised controlled trial comparing stepped care interventions with a minimal intervention for older hazardous alcohol users in primary care.
8. To randomise 500 hazardous alcohol users, with equal probability, to either a minimal intervention or stepped care.
9. To conduct 6 and 12 month follow ups on at least 70% of those randomised to assess alcohol consumption, alcohol related problems, quality of life and service utilisation.
10. To study the process of therapy as delivered by both practice nurses and trained therapists.