Effectiveness of Nurse-led Brief Intervention to Reduce the Risky Use of Alcohol and Tobacco Use Among Older Adults: Results of a Pilot Randomized Controlled Trial from India

Abstract

Background:

India has witnessed a gradual increase in substance use among the elderly, driven by the country’s aging population and evolving demographic trends. There remains a lack of scientific foundation regarding the efficacy of brief intervention among older adults in the context of low- and middle-income countries. The current study explored the effectiveness of nurse-led brief intervention to reduce risky substance use patterns among the elderly in the Indian context.

Methods:

The present study is a pilot randomized trial with assessments conducted before and after the intervention at 4-week intervals. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to detect changes in risky substance use, and the intervention was based on the ASSIST Brief Intervention Protocol. The study setting was a government-funded elderly citizen club, which was conveniently selected.

Results:

Out of the 80 contacted participants, 60 subjects were enrolled, evenly divided between intervention and control groups. The mean age of the sample was 69.80 years (SD = 4.2). Although there was some difference in post-follow-up scores, we did not observe a significant benefit for the brief intervention in reducing risky substance use among the elderly in this setting (P > .05).

Conclusion:

The study demonstrated a reduction in risky substance use patterns among the elderly population in both the intervention and control groups. Future trials should adopt rigorous methodological approaches to provide robust clinical evidence for implementing similar interventions aimed at enhancing the well-being of elderly individuals in this setting.

Keywords

Brief intervention nurse risky use alcohol use tobacco use elderly India

Key Messages

This study represents pioneering research on brief interventions aimed at reducing risky substance use among older adults in the Indian context.

Future trials should use rigorous methods to strengthen evidence for similar interventions to decrease substance use patterns among the elderly in this setting.

Normal aging is linked to various changes that result in increased sensitivity to substance use and decreased tolerance. Substance use among older adults is emerging as a major concern for public health. However, the available estimates do not fully reflect the magnitude of the problem due to issues such as underreporting, under-identification, and undertreatment.¹ Data from a national dataset in the US indicates that between 2008 and 2018, the percentage of admissions to substance use treatment facilities for adults aged 55 and older rose from 9.04% to 15.64%, compared to younger adults.² The empirical data suggest that alcohol is the most commonly used substance by older adults. Further, prescription medications such as opioids and benzodiazepines are being overprescribed in older adults. The use of drugs such as cocaine and heroin is increasing in older adults and can be associated with dangerous consequences. Recent trends indicate that older individuals are using illicit drugs more frequently than previous generations.^3,4 Although cross-national comparisons on the epidemiology of substance use disorders exist, there is limited information on the absolute number of older individuals with these disorders, particularly in low and middle-income countries.⁵

Risk factors for substance abuse among the elderly can differ due to a variety of factors, such as economic and cultural disparities between countries and pre-existing medical conditions.⁶ Moreover, the literature indicates that the availability of friends, financial resources, and ongoing stress could be potential predictors of high-risk alcohol consumption among older adults.⁷ Older adults are more prone to experiencing age-related stressors, which are shaped by personal circumstances, social relationships, and family dynamics. Substance abuse among the elderly presents numerous complications due to age-related physiological changes and the prevalence of comorbid conditions. Older adults face numerous medical and psychiatric issues related to substance abuse, including falls, poor nutrition, disorientation, memory loss, sleep disturbances, and severe mood swings. These challenges underscore the clinical complexity unique to this age group.⁸ Due to their lower body mass, older adults are more affected by smaller amounts of substances, experiencing significant psychological and physical effects. Reduced blood flow to the gastrointestinal system, slower liver metabolism, and reduced kidney function lead to slower drug elimination, causing increased and prolonged drug levels in the body and increasing sensitivity to these substances. These factors suggest that older adults are more vulnerable to the impacts of substance abuse, with symptoms of tolerance and withdrawal potentially manifesting differently due to biological changes.⁹

India has a diverse cultural landscape with varying attitudes toward alcohol and drug use across different regions, religions, and communities. For example, in many tribal communities, alcohol has been traditionally used in rituals and social gatherings. Homemade brews, such as rice beer and palm wine, play a significant role in cultural and religious ceremonies, symbolizing hospitality and social bonding.¹⁰ The use of alcohol in religious and cultural ceremonies can normalize its consumption, potentially ignoring its harmful effects, especially older population.¹¹ Recent evidence suggests an increasing prevalence of tobacco and alcohol use in the older population in India.^12,13 Various psychosocial interventions are available to treat substance use disorders, and the choice of intervention often depends on the treatment stage, setting, and availability of trained professionals.¹⁴ Brief psychological interventions typically involve one to four short counseling sessions with trained professionals, such as physicians, nurses, psychologists, or social workers, utilizing techniques like FRAMES (feedback, responsibility, advice, menu, empathy, self-efficacy). These are structured, short-term strategies aimed at encouraging individuals to reduce or stop their alcohol consumption.¹⁵ The key to a successful brief intervention is guiding behavioral change, and the benefits of screening and brief intervention for risky alcohol and drug use have been well documented.¹⁶ For older adults, the reasons for change may include maintaining independence, optimal health, and mental capacity. By systematically implementing these components, brief psychological interventions offer a comprehensive approach to addressing alcohol use disorders in a manner that is both effective and feasible across various settings.¹⁷

Although research supports that brief interventions are effective in reducing risky substance use in general populations, studies specifically addressing older adults are limited. The elderly population in low and middle-income countries is growing due to decreasing death rates and increased longevity. Therefore, there is a significant research gap, particularly in low and middle-income countries, regarding comprehensive screening and targeted interventions for substance use disorders among the older population. While certain studies have identified the impact of brief interventions in elderly populations,^18–20 there remains a lack of a scientific foundation regarding its efficacy in contexts of low- and middle-income countries. The current study aims to provide clinical-based evidence for nurses to conduct similar intervention programs in de-addiction settings. To date, no study in India has explored the nurse-led brief intervention model to reduce risky substance use patterns among the elderly, prompting the investigator to address this unresolved issue.

Methods

The present study employed a quantitative approach and was structured as a pilot randomized controlled trial, with assessments conducted before and after the intervention at 4-week intervals. The study was conducted in a selected elderly organization in xxxxx, xxx, xxx. The period of data collection was from Apr 1, 2021 to May 15, 2021, and the study was prospectively registered in the clinical trial registry of India (CTRI/xxxx/0x/xxxxxx). The target population consists of elderly clients who use psychoactive substances, while the accessible population includes elderly clients using psychoactive substances within the selected elderly organization in xxx. The sampling criteria are as follows: Elderly members of the selected organization who use psychoactive substances, are available during the study period, and are willing to participate were included. Elderly members who have attended an alcohol or substance use treatment program or who have reported cognitive impairments that hinder their ability to undergo counseling intervention were excluded.

A pre-determined questionnaire was used to assess the socio-demographic data and included age, gender, education, marital status, occupation, and monthly income for the family. Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST-Hindi version) was used to detect the changes in the risky use of substances. The World Health Organization’s ASSIST is a comprehensive tool designed to screen individuals for problematic substance use. Developed by an international group of substance abuse researchers, the ASSIST helps to identify the level of risk associated with alcohol, tobacco, and drug use. The test comprises a series of questions that assess the frequency, type, and impact of substance use on an individual’s health and daily functioning. It covers various substances, including alcohol, tobacco, cannabis, cocaine, amphetamines, sedatives, hallucinogens, inhalants, opioids, and others. The ASSIST provides scores that categorize individuals into low, moderate, or high risk, guiding healthcare providers in making informed decisions about the need for intervention. It is widely used in both clinical and community settings. It is valued for its ability to facilitate early detection and prompt response to substance use issues, thereby promoting better health outcomes.^21,22

The current study followed the standard ASSIST Brief Intervention Protocol developed by the World Health Organization.²³ The key components of the intervention are described below. The process begins with a thorough assessment of the individual’s substance use patterns and related behaviors. This evaluation helps to understand the extent of substance use and its impact on the individual’s life. Following the assessment, feedback is provided. This feedback highlights the risks and potential consequences of continued alcohol use, helping individuals understand the impact of their drinking on their health and well-being. Realistic and achievable goals for reducing or ceasing alcohol consumption are collaboratively set. This step is crucial as it provides a clear and attainable target for individuals to work toward. Individuals are taught coping skills and strategies to manage triggers and cravings. This includes techniques for handling stress, avoiding high-risk situations, and dealing with peer pressure. A follow-up session is scheduled to monitor progress and ensure that individuals remain on track and receive the necessary assistance to achieve their goals. The intervention was provided by a postgraduate student in psychiatric nursing who had undergone online certification training from the American Psychiatric Nurses Association. The control group received minimal advice from the same therapist who was involved in the intervention and was provided with information regarding the harmful effects of substance abuse. This basic feedback involved providing basic information about the risks associated with substance use, including its potential impact on health. The advice was concise and focused on raising awareness rather than offering detailed strategies for change, serving as a baseline for comparison with the more comprehensive intervention provided to the intervention group.

The study setting was a government-funded elderly citizen club, which was conveniently selected. The potential participants were members of the organization. The investigator introduced and explained the purpose of the study and obtained informed consent. The study was conducted in two phases. In Phase I, the subjects were screened for moderate and high risk of substance use to obtain the requisite sample for the next Phase. Screening was conducted among the available 80 participants, revealing 60 ASSIST screen-positive subjects for alcohol and tobacco. In Phase II, simple randomization was used to assign the 60 screened-positive subjects to either the ASSIST-linked BI (intervention group) or non-specific general advice (control group). Subjects with odd numbers in the sampling frame were assigned to the intervention group, while those with even numbers were allocated to the control group. Based on their intervention status, the study subjects were invited to participate in the brief intervention, during which the WHO ASSIST-linked BI package was administered. The randomization and allocation process were carried out by an individual who was not directly involved in the brief intervention or data collection for the study. The intervention consisted of a single session conducted for a group of 15 members, lasting approximately 15–30 minutes. It was delivered using a didactic approach combined with group discussion. Those in the control group were invited to join on a specific day, and general advice was provided. Out of the 80 contacted participants, 60 subjects were available at the end of the observation period (4^th week follow-up). The recruitment process is described in Figure 1.

Figure 1.

CONSORT Diagram Showing the Study Recruitment Process.

The study was approved by the Biomedical Research Ethics Committee, xxxxx, xxxxx, xxx (Ref No. BREC/xx/xx dated xx/xx/xxxx). Data collection took place in mid-2021, during the second wave of the COVID-19 pandemic in Haryana. Approximately 80% of the total positive cases in this region were reported to be asymptomatic.²⁴ This might explain why no major problems were encountered during the study period. However, all precautions were taken in accordance with the guidelines issued by the Government of India. Participation was entirely voluntary. Comprehensive information about the study was provided to eligible subjects via a patient information sheet, and informed consent was obtained. Participants were informed that they could withdraw from the study at any stage and that confidentiality would be maintained throughout the study. The researcher’s contact details were provided to the participants, who were free to reach out for any treatment-related assistance during the study period.

Statistical Analysis

Analysis was conducted using SPSS version 15, with variables categorized according to levels of measurement. Appropriate descriptive and inferential statistics were then employed for analysis. Descriptive statistics such as mean and standard deviation were utilized for continuous variables. Categorical variables were analyzed using frequency and percentage calculations. To examine associations between categorical variables, the Chi-square test was utilized (or Fisher’s exact test, where the expected frequency in a cell is less than 5). Independent sample t-test was applied to compare ASSIST scores between baseline and follow-up.

Results

The age distribution shows that the majority of participants are between 60 and 70 years old (58.3%) with a mean age of 69.80 years (SD = 4.2) with no significant difference based on the study group (χ² = 1.74, P = .41). Regarding education, most participants completed high school (41.7%), and nearly 13% underwent primary education. Educational levels are similar across both groups, with the highest representation in high school education and no significant difference (χ² = 0.937, P = .817). Marital status, however, differs significantly, with all participants in the intervention group being married, compared to 21 in the control group (χ² = 10.588, P = .001). In terms of occupation, most participants are retired (70.0%), followed by those in self-business (21.7%) and private employment (8.3%). Occupational status shows most participants in both groups being retired, with no significant difference (χ² = 2.258, P = .323). Monthly family income varies, but not significantly, with more participants in the intervention group earning over Rs. 25,000 (χ² = 4.123, P = .127). Co-morbidities, including diabetes, hypertension, and other conditions (such as joint problems, pulmonary diseases, cardiovascular diseases, and multiple physical illnesses), are similarly distributed between the groups, with no significant difference (χ² = 0.627, P = .890). Table 1 compares various demographic and health-related variables between the intervention group (N = 30) and the control group (N = 30). Taken together, both the intervention group and control group were comparable at baseline except for marital status.

Table 1.

Characteristics of the Participants.

Variable	Intervention Group (N = 30)	Control Group (N = 30)	χ²	P
Age A. 60–70 years B. 70–80 years C. 80–90 years Mean age - 69.80 (SD-6.7) years	15 11 04	20 07 03	1.74^a	.41
Education A. Primary education B. High school C. Higher secondary/diploma D. Graduate and above	03 14 07 06	05 11 07 07	0.937^a	.817
Marital status A. Married B. Widow/Widower	30 00	21 09	10.588^a	.001^b
Occupation A. Self-business B. Private employee C. Retired	07 04 19	06 01 23	2.258^a	.323
Monthly family income A. ₹5000–15000 B. ₹16000–25000 C. > ₹26000	04 02 24	09 00 21	4.123^a	.127
Co-morbidities A. Diabetes B. Hypertension C. Others	03 04 23	02 04 24	0.627^a	.890

^aFisher’s exact test.

^bP < .05.

Table 2 presents the changes in alcohol and tobacco consumption based on ASSIST scores for both the intervention group (N = 30) and the control group (N = 30), including specific aspects such as patterns of use and strong desire or urge to use. For alcohol consumption, the baseline ASSIST total scores were 6.10 (SD = 5.33) in the intervention group and 7.00 (SD = 7.04) in the control group, with a t value of −0.58 and a P value of .57, indicating no significant difference. At follow-up, the scores were 5.90 (SD = 5.06) and 6.90 (SD = 6.90), respectively, with a t value of -0.64 and a P value of .52, again showing no significant difference. Patterns of use scores were 1.10 (SD = 1.15) for the intervention group and 1.67 (SD = 2.41) for the control group (t value = −1.06, P value = .29), while the strong desire or urge to use scores were 0.13 (SD = 0.73) and 0.63 (SD = 1.71), respectively (t value = −1.47, P value = .14), neither showing significant differences. For tobacco consumption, the baseline ASSIST total scores were 7.63 (SD = 6.84) in the intervention group and 9.63 (SD = 7.10) in the control group (t value = −1.11, P value = .27). At follow-up, the scores were 7.47 (SD = 6.64) and 9.43 (SD = 6.88), respectively (t value = −1.13, P value = .26), indicating no significant difference. Patterns of use scores were 2.47 (SD = 2.16) for the intervention group and 2.93 (SD = 2.33) for the control group (t value = −0.80, P value = .42), while the strong desire or urge to use scores were 0.80 (SD = 2.07) and 1.10 (SD = 2.29) respectively (t value = −0.53, P value = .59), neither showing significant differences. Overall, the study found no statistically significant differences in alcohol and tobacco consumption, patterns of use, or strong desire or urge to use between the intervention and control groups, both at baseline and follow-up.

Table 2.

Changes in Alcohol and Tobacco Consumption Based on ASSIST Scores.

Variables	Intervention Group (N = 30) Mean/SD	Control Group (N = 30) Mean/SD	t Value	P Value
Alcohol ASSIST^a total scores
Baseline	6.10 ± 5.33	7.00 ± 7.04	−0.58	.57
Follow-up	5.90 ± 5.06	6.90 ± 6.90	−0.640	.52
Patterns of use	1.10 ± 1.15	1.67 ± 2.41	−1.06	.29
Strong desire or urge to use	0.13 ± 0.73	0.63 ± 1.71	−1.47	.14
Tobacco ASSIST^a total scores
Baseline	7.63 ± 6.84	9.63 ± 7.10	−1.110	.27
Follow-up	7.47 ± 6.64	9.43 ± 6.88	−1.129	.26
Patterns of use	2.47 ± 2.16	2.93 ± 2.33	−0.80	.42
Strong desire or urge to use	0.80 ± 2.07	1.10 ± 2.29	−0.53	.59

^aASSIST- Alcohol, Smoking and Substance Involvement Screening Test.

Discussion

This study examined the impact of brief interventions on reducing risky substance use behaviors among members of an elderly group in India. A total of 60 subjects were enrolled, evenly divided between intervention and control groups, with changes in ASSIST scores assessed at a 1-month follow-up. Although there was some difference in post-follow-up scores, we did not observe a significant benefit for the brief intervention in reducing risky substance use among the elderly in this setting (P > .05). The absence of a superior benefit from the intervention may be due to several factors, such as the single-session format, age-related resistance to change, and potential sample contamination, as all participants were from the same organization, increasing the likelihood of contact between groups.

Efficacy may vary across study settings and various other contexts. Therefore, a conclusive determination regarding the efficacy of brief interventions in older adults presents challenges, especially due to the need for more existing literature. For example, a previous study evaluated the effectiveness of two 10- to 15-minute physician-delivered counseling sessions, which demonstrated a 34% reduction in 7-day alcohol use, a 74% reduction in episodes of binge drinking, and a decrease in the frequency of excessive drinking in the intervention group (P < .005) compared to those in the control group at 3, 6, and 12 months.¹⁸ Additionally, the findings of the Florida Brief Intervention and Treatment for Elders (BRITE) project revealed improvements in alcohol use, medication misuse, and depression measures among those who received the brief intervention.²⁰ The lack of evidence of a superior benefit of brief interventions in elderly populations in this setting warrants cautious interpretation. First, many trials have reported significant effectiveness with more than one session, whereas the current findings are limited to a single session. Second, most of the previous evidence is generated from Western countries.^18–20 At the same time, the current study population is conveniently selected from a senior citizen organization in an urban setting. Culture plays a significant role in shaping attitudes and behaviors related to substance abuse in India.²⁵ Common challenges we faced during data collection and intervention included participants needing to adhere to the pre-determined schedule and resistance to change due to age-related factors. However, these issues were effectively addressed through prior intimation and collaborative support from the organization’s senior representative. By recognizing the perceived stigma on treatment-seeking decisions and integrating cultural sensitivity into interventions, policymakers, and healthcare providers can better support elderly individuals in achieving healthier lifestyles.²⁶ Third, the optimal content, length, and frequency of interventions remain unclear, often characterized as “motivational interviewing” in earlier studies. This has sparked a debate surrounding the efficacy and effectiveness distinction in trials of nurse-led alcohol interventions.^27,28 Establishing standards and implementation protocols tailored to specific settings, whether primary healthcare centers, general hospital wards, or outpatient settings, is imperative. Moreover, ongoing education is necessary to effectively utilize available resources, and manuals for intervention delivery should be adapted to accommodate diverse clinical settings.

Various healthcare professionals have conducted most psycho-educational intervention studies. However, this study emphasizes the effectiveness of a nurse conducting brief psycho-education in the elderly population in the Indian setting. Empirical evidence supports the involvement of nurses in delivering brief psychological interventions to reduce harmful alcohol use in primary healthcare populations.²⁹ However, despite nurses often assessing patients’ alcohol use in primary healthcare settings, they need to utilize validated screening tools. They may need more knowledge, potentially leading to inappropriate interventions or missed intervention opportunities. The present study highlights the necessity for specialized training and education for nurses to effectively deliver such interventions. For example, nurses working in primary care settings, such as health and wellness centers, could be trained, as these types of interventions are aimed at delivering a single brief session rather than extended interventions. Future trials are needed to explore the acceptance, potential effectiveness, and cost-effectiveness of similar interventions in various aspects such as setting, content, and credibility of the therapist.³⁰ Strengthening education to enhance registered nurses’ knowledge and skills related to caring for patients with substance use disorders is crucial for improving patient experience and outcomes.³¹

Limitations

The present study can be regarded as pioneering research on brief interventions to reduce the risky use of substances among older adults in the Indian context. To the best of our knowledge, there are no published studies, even from Western contexts, on the implementation of a similar nurse-led brief intervention in older adults. The study employed standardized tools for outcome assessment, and a validated structured module was utilized in the intervention. The major limitations include the lack of sample size estimation, the assessment of both pre- and post-intervention data by the same researcher, and the potential for data contamination, as all subjects were members of the same organization. Further, the generalizability of the study findings is limited due to methodological constraints, such as the lack of blinding procedures, which increase the risk of biases, including selection bias, detection bias, and performance bias, as well as reliance on self-reported and subjective outcome measures. The long-term effects of the intervention program were not assessed due to time constraints. Additionally, the study is a pilot trial focused solely on subjects attending a single elderly organization in North India, potentially increasing the risk of sampling bias.

Future Directions

Overall, this study emphasizes the pivotal role of nurses in managing alcohol dependence and the potential benefits of empowering them with the skills and knowledge to lead effective intervention programs. The recommendations from this study advocate for policy changes to support nurse-led initiatives, increased funding for related training programs, and further research to explore innovative approaches to enhance adherence and abstinence in elderly populations.

Conclusion

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

The authors are truly grateful to the experts and study subjects who supported the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Declaration Regarding the Use of Generative AI

None Used.

Ethical Approval

The study was approved by the Biomedical Research Ethics Committee, University of Health Sciences, Rohtak (Ref No. BREC/2021/004 dated 18/02/2021).

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Informed Consent

The investigator introduced and explained the purpose of the study and obtained informed consent.

Presentation at a Meeting/Conferences/Seminars

Nil.

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Supplementary Material

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