Home care and alcohol use: a systematic review and thematic synthesis of domiciliary carers' perspectives on alcohol use for older adults in their care

Background
People are living longer with multiple and complex conditions and generally prefer to age in place, relying on formal and informal care. On average, people aged over 50 consume four medications a day. Biological changes due to ageing and medication interactions may increase physical and mental health risks associated with alcohol use. Gradual increases in alcohol consumption in older age groups have been observed. This and the preference for home care, means domiciliary carers (formal and informal) are likely to encounter adults in their care using alcohol.

Aims of the study
To develop understanding about domiciliary carers’ perspectives on older adults’ (aged 50 and over) alcohol use in their care.

Methodology
A systematic review and thematic synthesis of qualitative studies regarding challenges faced by domiciliary carers providing care to older adults using alcohol was conducted (Prospero registration number: CRD42024516660). Eight databases were searched focusing on adults over 50 of any gender, alcohol consumption and domiciliary carers (formal or informal) on 22 February 2024. Searches were restricted to English language with any year of publication. Duplicates were removed and titles and abstracts were independently screened by two reviewers against inclusion criteria. The Critical Skills Appraisal Programme (qualitative studies) was used to assess quality as low, medium or high. A standardised data extraction form was used, and direct quotations were extracted if available. Free coding was applied for description and then developed into analytical themes.

Analysis
Twenty articles reporting 14 individual studies (mainly of medium to low quality) were reviewed. Three main themes (identification, management and training) were developed. Identification revealed alcohol screening was not routinely undertaken. Carers did informally assess clients for alcohol use signs and alcohol issues were commonplace. Management concentrated on the appropriateness, or not, of buying alcohol for clients. Not permitting alcohol risked infringing client autonomy, permitting consumption potentially facilitating harmful use. Consensus emerged however that carers monitor and report excessive alcohol consumption. Not all service providers had guidance on client alcohol use for domiciliary carers. Over a third of carers identified inadequate training. One study reported that alcohol use can mask or complicate dementia care. Another highlighted the necessity to develop confidence to work with clients with cognitive impairment.

Project outcomes
Alcohol use was common. Ascertaining problematic alcohol use was difficult with no screening, and domiciliary carers did not intervene for alcohol problems. Informally assessing clients in their home was risky and placed domiciliary carers in a vulnerable position. Studies reviewed were English language only, mainly of medium to low quality, predominantly situated in the UK and USA where alcohol use in older people is increasing. Findings may not apply to other countries.

Conclusions and recommendations
Domiciliary carers are well placed to assess alcohol use. Resources to assess alcohol use, clear guidelines to balance rights and risks and training to manage alcohol use, particularly with clients with cognitive decline would be advantageous. Staff shortages and unmet care needs could make this problematic. Further research with leadership, management and domiciliary carers to develop clear guidance is required.