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Risky Behaviors in Older Adults

  • Authors: Barbara Resnick, PhD, CRNP, FAAN, FAANP
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Target Audience and Goal Statement

This activity is intended for nurse practitioners, clinical nurse specialists, registered nurses, and any other clinicians with interest in geriatric care.

The goal of this activity is to offer clinicians a review of key topics in geriatric care, focusing on screening and clinical management. Topics include primary care, NP reimbursement, complementary medicine, and palliative care for the elderly.

Upon completion of this activity, participants will be able to:

  1. Describe 3 risky behaviors common in older adults, identify why older adults are at increased risk for these behaviors, and describe how to screen for these behaviors.
  2. List important components of documentation needed to ensure compliance with Medicare policies for reimbursement of NP services in long-term care.
  3. Summarize the current research supporting the effectiveness of complementary therapies commonly used in long-term care settings.
  4. Define palliative care and summarize the role of the geriatric nurse practitioner in providing this care.


  • Barbara Resnick, PhD, CRNP, FAAN, FAANP

    Professor, University of Maryland School of Nursing, Baltimore, Maryland; Nurse Practitioner, Roland Park Place, Continuing Care Retirement Community, Baltimore, Maryland


    Disclosure: Dr. Resnick has no significant financial interests to disclose and she reports no discussion of any investigational or unlabeled uses of commercial products in this activity.

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    This activity, for 3.3 contact hours, has been approved by the Arizona Nurses Association Continuing Education Approver Unit, which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation. AzNA-CE Approval Number: 190-03

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Risky Behaviors in Older Adults

Authors: Barbara Resnick, PhD, CRNP, FAAN, FAANPFaculty and Disclosures


People aged 65 years and older represented 12.4% of the population in the year 2000 but are expected to grow to be 20% of the population by 2030.[1] Those individuals aged 90 years and older are anticipated to have the largest increase in numbers. Along with the increase in number of older individuals, especially the old-old, there is an increase in evidence of "risky behaviors" among these individuals. The most commonly recognized risky behaviors include alcohol use, hazardous driving behavior, and unprotected sexual activity.

Alcohol Use: The Benefit and the Risk

Cindy A. Wojtecki, RN, MS,[2] Facility Education Manager, Veterans Administration Hospital, Syracuse, New York, in a presentation on alcohol withdrawal syndrome in the elderly, defined the at-risk drinker as someone who drinks more than 14 alcoholic drinks per week. At-risk drinkers would also include men who drink 4 drinks in a day, women who drink 7 drinks per week, or those who have 3 drinks per day in a risky situation, such as drinking and driving, or drinking when taking medication that interacts with alcohol.

The extent of risky alcohol use among older adults is not clear. Generally, it has been reported that women drink less than men at all ages, and there is a decline in alcohol use with age.[3] The prevalence of risky alcohol use in community-dwelling older adults varies from 1.5% to 8.2 %.[3,4]

Regular alcohol use has been associated with a variety of adverse health-related complications, particularly in older adults. The negative impact of alcohol on older adults is due to normal age-related changes and the high rate of underlying chronic disease, as well as the likelihood of drug-drug interactions. Table 1 reviews the age-related physiologic changes that affect alcohol use in older adults.

Table 1. Age-Related Physiologic Changes That Influence Alcohol Effects in Older Adults

Decreased blood flow to the liver
Slower renal clearance
Decreased lean body mass
Decreased total body water
Decrease in gastric alcohol dehydrogenase
Reprinted with permission. Resnick B. Alcohol use in a continuing care retirement community. J Gerontol Nurs. 2003;29:22-30.

Specifically, tolerance decreases with age because of changes in body composition and alcohol absorption. With age, there is a decrease in lean body mass and total body water and an increase in percentage of body fat. There is a decrease in blood flow to the liver and reduced efficiency of the detoxifying enzymes in the liver, along with slowed renal clearance of the drug. In addition, there is an age-related decrease in gastric alcohol dehydrogenase, which is responsible for the first step in alcohol metabolism. This means that for each unit of alcohol consumed by older adults, there is a greater amount of alcohol that actually enters the bloodstream compared with younger individuals.

A major issue with alcohol use in older adults is the potential interaction with at least half of the 100 most commonly prescribed drugs for these individuals. In a study of 311 residents from 3 different Continuing Care Retirement Communities,[5] 38% of the residents reported use of alcohol and high-risk medications (antihypertensives, aspirin, nonsteroidal anti-inflammatory drugs, sedatives, antacids and H2 blockers, narcotics, and warfarin). Common interactive effects between alcohol and prescription medications include: (1) additive sedation when alcohol is combined with hypnotics, sedatives, analgesics, antidepressants, antihistamines, and antianxiety medications; (2) decreased metabolism causing a rise in plasma levels of certain drugs such as diazepam, amitriptyline, and barbiturates; (3) difficulty stabilizing anticoagulants; and (4) increased metabolism of certain drugs such as meprobamate and barbiturates.

At-Risk Drinking in the Elderly

Wojtecki[2] emphasized that healthcare providers need to anticipate regular use of alcohol among older adults. Alcohol use should be considered as part of the differential diagnosis, and older individuals in all settings should be evaluated for alcohol abuse. The American Society of Aging has a helpful Web-based training program for providers, available at[6] Screening tools such as the CAGE (Cut down; Annoyed; Guilt; and Eye Opener)[7] or the Short Michigan Alcohol Screening Test for older adults (MAST-G)[8] are among the 2 screening tools most commonly used with older adults.

An expert panel at University of California at Los Angeles (UCLA) developed another tool, the Alcohol-Related Problems Survey (ARPS), to help practitioners identify nonhazardous, hazardous, or harmful alcohol use in older adults.[3] Nonhazardous drinking by this group of investigators was defined as the consumption of alcohol without clear risk of physical and psychological harm. Hazardous drinking occurred when the drinking placed the individual at risk for medical problems, complicated his or her diagnosis and treatment, or precipitated adverse drug events. Hazardous drinking was associated with the presence of medical problems that may be caused or worsened by alcohol such as liver disease or peptic ulcer disease.

Prior research has shown that the ARPS has a sensitivity and specificity of 82%.[9] The ARPS can serve as an excellent starting point to help practitioners work with older adults to identify their risks related to alcohol use and help them move toward a nonhazardous use of this drug. This type of approach to alcohol use can greatly improve the quality of life of older adults living in any setting.

Resnick[4] has recommended an individualized approach to alcohol use in older adults. Specifically, consideration needs to be given to the individual's age, gender, family history, current medical history, function, and psychosocial status. If, for example, an older woman has a significant history of osteoporosis with fracture, altered gait and balance, mild dementia, and takes warfarin for stroke prophylaxis, it is not likely that the benefits of alcohol use will outweigh the increased risks of falls, potential fracture, worsening of cognitive status, difficulty regulating warfarin, and risk of hemorrhagic stroke. This individual may be best counseled to decrease alcohol use by following the suggestions in Table 2.

Table 2. ETOH Intervention: Counseling to Decrease Alcohol Use

Activity Description
E: Encourage Encourage the older adult to decrease or abstain from alcohol use.
Let them know they are capable of adhering to this behavior change.
T: Teach Teach the older adult about the normal age changes that influence alcohol metabolism.
Teach about the impact of alcohol on body systems, interactions with medications, and benefits of alcohol.
Review the benefits vs risks individually.
O: Obliterate Obliterate the unpleasant sensations that may be causing regular or abusive alcohol use.
Anticipate and obliterate the unpleasant sensations associated with decreasing alcohol use.
H: Help Help to identify goals and support through the process of decreasing and/or eliminating alcohol use.
Reprinted with permission. Resnick B. Alcohol use in a continuing care retirement community. J Gerontol Nurs. 2003;29:22-30.

An individualized approach to managing alcohol use with older adults will help individuals achieve their highest level of health and well-being. In addition, it is likely that this approach will engender a trusting relationship between the older patient and the care provider such that the patient will feel comfortable reporting future alcohol-related problems, should they arise.

Risky Driving Among Older Adults: Assessment and Treatment Options

Driving is also a behavior that becomes increasingly risky with age for some individuals. Ruth Tappen, EdD, RN, FAAN, Professor, and Margaret Riccardi, MS, ARNP, BC, CRRN,[10] Advanced Practice Nurse and Research Assistant, Christine E. Lynn College of Nursing, Atlantic University, Boca Raton, Florida, pointed out that while most older drivers are safe drivers, physical changes, medications, and general frailty increase the risk of experiencing a motor vehicle accident. They emphasized that by age 80 years, male drivers are 5 times more likely and females 3.1 times more likely to die in a motor vehicle crash than 20 year olds.[11]

Numerous factors put older adults at increased risk of risky driving, including:

  • Common changes associated with aging (decreased vision and joint range of motion)
  • Acute and chronic medical problems
  • Medications
  • Cognitive changes, particularly changes in attention and changes in executive function

Tappen and Riccardi[10] also reviewed the American Medical Association's Physician's Guide to Assessing and Counseling Older Drivers[12] and suggested that healthcare providers:

  • Be alert to and treat functional changes that affect driving
  • Refer patients for in-depth driving exams as appropriate
  • Talk with patients about safe driving
  • Help patients do self-evaluation of driving
  • Provide alternative transportation solutions
  • Monitor for signs and symptoms of depression after cessation of driving

Components of a Driving Evaluation

Generally 3 areas are evaluated during comprehensive screening for safe driving: evaluation of vision, cognitive ability, and motor function. Vision can be tested using the Snellen chart; cognitive screening is done ideally using tests such as the Clock-Drawing task[13] or the Trail-Making test (Part B).[14] Motor function can be evaluated using the Rapid Pace Walk, evaluation of activities of daily living, or other gait and performance measures. Attempts should be made to correct abnormalities in any of these areas. If poor performance on any of these tests cannot be improved or corrected, then it may be appropriate to encourage cessation of driving and/or to make a referral to a driver rehabilitation specialist.

It is possible the older individual will deny difficulties with driving, refuse additional testing or evaluation, and insist on continuing to drive. Documentation of impairments and use of tools such as those developed by the National Highway Safety Administration[15] are useful to document clinical findings and help individuals and/or families understand the risk of continuing to drive. Tappan and Riccardi[10] recommended self-screening and suggested that healthcare providers encourage patients to complete an "Am I a Safe Driver?" questionnaire (Table 3).

Table 3. Self-Evaluation of Driving Safety

Question Response
Yes No
I get lost while driving.  
My friends/family are worried about my driving.  
Other cars seem to appear out of nowhere.  
I have trouble seeing signs in time to respond to them.  
Other drivers drive too fast.  
Other drivers often honk at me.  
Driving stresses me out.  
After driving I feel tired.  
I have had more near misses lately.  
Busy intersections bother me.  
Left hand turns make me nervous.  
The glare from oncoming headlights bothers me.  
My medication makes me dizzy or drowsy.  
I have trouble turning the steering wheel.  
I have trouble pushing down the gas pedal or brakes.  
I have trouble looking over my shoulder when I back up.  
I have been stopped by the police for my driving recently.  
People will no longer accept rides from me.  
I don't like to drive at night.  
I have more trouble parking lately.  
*Results: If you have checked any of the boxes, your safety, and the safety of others, may be at risk when you drive.

Reproduced from Physician's Guide to Assessing and Counseling Older Drivers. American Medical Association/National Highway Traffic Safety Administration/US Department of Transportation, June 2003. Appendix B -- Patient and Caregiver Educational Materials. Available at: Accessed November 5, 2003.

Clinician Responsibility for Safe Driving in the Elderly

There are legal, moral, and ethical responsibilities at stake in determining who should be allowed to drive and who should not. Legally, each state Department of Motor Vehicles or similar agency decides who is appropriate to continue to drive. Clinicians, family, and friends are also often involved in helping individuals make this decision. There are voluntary physician reporting laws in 35 states.[16] In these states, physicians and nurse practitioners should notify the state authorities about persons believed to be unsafe drivers. In Vermont, patient permission is needed to make such a report, although in Ohio, South Dakota, and Virginia, there is no immunity.

If the healthcare provider cannot report the individual to the local Motor Vehicle Administration without consent, then the provider should at least give the older individual tips for safe driving, and safe driving classes should be recommended. Table 4 provides some examples of these resources. Repeated driving safety and transportation challenges should be addressed with older patients and attempts should be made to maintain the individual in a safe driving status while helping him or her maintain optimal quality of life.

Table 4. Information Regarding Safety Tips for Driving and Classes

AARP 55 ALIVE Driver Safety Program: 1-888-227-7669
National Safety Council Defensive Driving Course: 1-800-621-7619
Driving School Association of the Americas, Inc: 1-800-270-3722

The Hidden Risk of Sexual Activity Among Older Adults

Gail A. Fox, ARNP,[17] Advanced Practice Nurse, Medicine Division West Palm Beach Veterans Medical Center, West Palm Beach, Florida, in a presentation about AIDS, HIV, and sexually transmitted diseases (STDs) in the elderly, reviewed the current incidence of AIDS and STDs among older adults. Fox reported that more than 10% of AIDS patients in the United States are over the age of 50 years, and the AIDS rate is increasing in people in their sixties and seventies. Other reports have indicated that approximately 75,270 people older than age 50 years have been diagnosed with AIDS in the United States and account for 11% of the cases of AIDS.[18]

The mortality among older individuals who contract HIV is, as anticipated, extremely high, with 37% of those over the age of 80 years dying within 1 month of diagnosis.[19] Older individuals particularly at risk for HIV, AIDS, or STDs are those who have had unprotected sex, shared needles when using drugs, received blood transfusions prior to 1986, and men who engage in homosexual activities.

Unfortunately, despite the fact that elders do engage in behavior that puts them at risk for HIV, older adults are less likely to perceive themselves at risk and less likely to adopt safer sexual and needle sharing behaviors. Survey research,[20] for example, has noted that condom use is practiced regularly among young and middle-aged couples but not among older couples. Moreover, aging is associated with physiological changes, which increase risk for any infection including HIV, pneumonia, urinary tract infections, or cellulitis.

Older adults with HIV are also more likely to be diagnosed late in disease, experience progression more quickly, and survive for a shorter period than their younger counterparts. Comorbidities are frequent in older adults with HIV infection and can complicate the disease process and management.

There have been several reasons identified as to why older individuals do not protect themselves against exposure to HIV or other STDs. Specifically, these reasons include:

  • Most women are past menopause, so they don't fear getting pregnant

  • While the safe sex battles of the 1980s were raging, many of today's seniors were settled in marriages, so STDs "were something that happened to somebody else"

  • Older adults grew up at a time when men made many decisions in most relationships, and if the male does not want to use a condom, then it is not used

  • Women outnumber their male counterparts, giving those men many partners from which to choose. The women therefore are willing to remain unprotected based on male preference

Other STDs Among Older Adults

STDs are reported among older persons, although at lower rates than among younger persons.[21] The most common STDs are nongonococcal urethritis in men and genital herpes in women. As compared with younger persons, older individuals more frequently seek care at private clinics and have symptoms at the time of the clinic visit.

Screening, along with early diagnosis, counseling, and treatment, plays an essential role in preventing STDs and HIV infection. Prevention and control of STDs and HIV infections depend on 4 major activities: (1) educating persons who are at risk about means of reducing transmission; (2) detecting untreated cases, both symptomatic and asymptomatic; (3) effectively diagnosing and treating infection and counseling infected individuals; and (4) evaluating, counseling, and treating the sex partners of infected persons.

Older adults, unfortunately, are less likely to be tested for STDs and HIV, and these individuals are also less likely to believe a condom can prevent these infections.[22,23] Healthcare providers, as well as older individuals, need to maintain an increased awareness of the risk of development of STDs and HIV, particularly in sexually active individuals. Older individuals who complain of fatigue, weight loss, and/or failing memory should have HIV considered as a differential diagnosis.

Low risk behaviors should be encouraged, such as practicing mutually monogamous relationships and partner reduction and aggressive use of condoms (male and female versions). Moreover, healthcare providers should focus on early diagnosis of STDs and HIV so that appropriate treatment can be initiated. Sexual activity should be assumed instead of doubted, and assessments in older individuals should include a complete sexual history, evaluation of sexual organs, and appropriate screening tests.


  1. Health United States, National Center for Health Statistics, 2002. Available at: Accessed November 4, 2003.
  2. Wojtecki C. Alcohol withdrawal syndrome in the elder population: systematic assessment and treatment. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 22nd Annual Conference; September 17-21, 2003; West Palm Beach, Florida.
  3. Moore A, Hays R, Greendale G, Damesyn M, Reuben D. Drinking habits among older persons. Findings from the NHANES I epidemiologic follow up study (1982-1984). J Am Geriatr Soc. 1999;47:412-416. Abstract
  4. Resnick B, Perry D, Applebaum G, et al. The impact of alcohol use in community-dwelling older adults. J Comm Health Nurs. 2003;20:135-145.
  5. Adams W. Alcohol use in retirement communities. J Am Geriatr Soc. 1996;44:1082-1085. Abstract
  6. Alcohol, Medications, and Other Drugs: Use and Abuse in the Elderly. American Society on Aging, 2003. Available at: Accessed November 4, 2003.
  7. Ewing J. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252:1905-1907. Abstract
  8. Powers J, Spickard A. Michigan Alcoholism Screening Test to diagnose early alcoholism in general practice. South Med J. 1984;77:852-856. Abstract
  9. Moore A, Hays R, Reuben D, Beck J. Using a criterion standard to validate the Alcohol-Related Problems Survey (ARPS): a screening measure to identify harmful and hazardous drinking in older persons. Ageing. 2000;12:221-227.
  10. Tappen R, Riccardi M. Driver assessment of the older adult. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 22nd Annual Conference; September 17-21, 2003; West Palm Beach, Florida.
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  12. Physician's Guide to Assessing and Counseling Older Drivers. American Medical Association/National Highway Traffic Safety Administration/US Department of Transportation, June 2003. Appendix B -- Patient and Caregiver Educational Materials. Available at: Accessed November 5, 2003.
  13. Braunberger P. The Clock-Drawing Test. Available at: Accessed November 4, 2003.
  14. Arbuthnott K, Frank J. Trail Making Test, Part B as a measure of executive control: validation using a set-switching paradigm. J Clin Exp Neuropsychol. 2000;22:518-528. Available at: Accessed October 17, 2003.
  15. Injury Prevention: Older Road Users. NHTSA. Available at: Accessed November 4, 2003.
  16. State licensing requirements and reporting laws. Physician's Guide to Assessing and Counseling Older Adults. American Medical Association. Available at: Accessed October 17, 2003.
  17. Fox G. HIV and STDs in the elderly: a silent epidemic? Program and abstracts of the National Conference of Gerontological Nurse Practitioners 22nd Annual Conference; September 17-21, 2003; West Palm Beach, Florida.
  18. Centers for Disease Control and Prevention. AIDS among persons aged > 50 years; United States, 1991-1996. Atlanta, Ga: Centers for Disease Control and Prevention; 1999. Available at: Accessed November 4, 2003.
  19. HIV/AIDs and Older Adults. National Association on HIV Over Fifty. Available at: Accessed November 4, 2003.
  20. Bruhin E. Power communication and condom use: patterns of HIV relevant sexual risk management in heterosexual relationships. AIDS Care. 2003;15:389-401. Abstract
  21. Xu F, Schillinger JA, Aubin MR, St Louis ME, Markowitz LE. Sexually transmitted diseases of older persons in Washington State. Sex Transm Dis. 2001;28:287-291. Abstract
  22. Goodroad B. HIV and AIDS in people older than 50. J Geront Nurs. 2003;29:18-24.
  23. Mack K, Bland S. HIV testing behaviors and attitudes regarding HIV/AIDS of adults ages 50 to 64. Gerontologist. 1999;39:687-694. Abstract