Alcohol use disorder (AUD) is an increasingly common, under-recognized, and under-treated health concern in older adults. Its prevalence is expected to reach unprecedented levels as the Canadian population ages. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of AUD in older adults.A systematic review of English language literature from 2008-2018 regarding AUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method by drawing on current literature. Recommendations were created and assessed using the GRADE method.Twenty-two recommendations were created. Prevention recommendations: Best advice for older adults who choose to drink is to limit intake to well below the national Low-Risk Alcohol Drinking Guidelines. Screening recommendations: Alcohol consumption should be reviewed and discussed on an annual basis by primary care providers. This type of discussion needs to be normalized and approached in a simple, neutral, straight-forward manner. Assessment recommendations: Positive screens for AUD should be followed by a comprehensive assessment. Once more details are obtained an individualized treatment plan can be recommended, negotiated, and implemented. Treatment recommendations: AUD falls on a spectrum of mild, moderate, and severe. It can also be complicated by concurrent mental health, physical, or social issues, especially in older adults. Naltrexone and Acamprosate pharmacotherapies can be used for the treatment of AUD in older adults, as individually indicated. Psychosocial treatment and support should be offered as part of a comprehensive treatment plan.These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of AUD in older adults within the Canadian context.# INTRODUCTION
Despite increasing rates of illicit and prescription drug misuse among adults aged 65 years and older, alcohol remains the most commonly used and misused substance in this age group. (1) Alcohol use disorder (AUD) and risky alcohol consumption are common among older adults, with reported problem drinking rates ranging from 1-22%. (2) Older women may be at particular risk for alcohol-related problems. (3) A recent study found that a greater proportion of older adults (aged 55-70 years) drank heavily in comparison to younger adults, although AUD, as defined by the DSM-5, was less prevalent among older adults. (1) It can be difficult to identify AUD in older adults, as some of the signs and symptoms of problematic use are similar to age-related health conditions such as poor mobility, cognitive problems, and high rates of multiple comorbidities with falls and fractures, which may occur as a result of alcohol use. (4,5,6) The progression of other chronic illnesses in older adults may also mask AUD. Increased rigor with respect to screening is required, along with a broader interpretation of DSM-5 diagnostic criteria, to identify older adults living with AUD. Special attention should be paid to criteria related to failure in social roles and/or reduced or problematic social interactions, as these may not be as apparent in retired or isolated older adults.
Drinking more than 100g per week of alcohol is known to be associated with a higher risk for all-cause mortality, as well as other adverse health events such as stroke, heart failure, coronary artery disease (excluding myocardial infraction), fatal hypertensive disease, and fatal aortic aneurysm. (7) Excessive alcohol consumption among older adults may increase the risk of several health conditions including hypertension, hemorrhagic stroke, diabetes mellitus, infections, alcoholic liver disease, and gastrointestinal conditions including gastritis, gastric ulcers, and gastric bleeding. (8,9,10,11) There is clear evidence of a dose-dependent pattern of alcohol use increasing the risk of cancer in many organs, including the oropharynx, larynx, esophagus, liver, colon and rectum, and breast. (12) Excessive alcohol consumption in older adults may also be associated with an increased risk of cognitive decline and dementia. (13) AUD is a risk factor for suicide in older adults as concomitant AUD may increase the likelihood for isolation, poor health, and depression. (14,15) Older adults are often on multiple medications to manage chronic diseases. Alcohol use introduces the risk for harmful interactions between alcohol and drugs, and may reduce medication efficacy. Furthermore, older adults generally metabolize alcohol at a slower rate than younger adults (13,16,17,18,) leading to a risk of heightened effects from alcohol among older adults even at relatively low levels of consumption.

# METHODS
The CCSMH Alcohol Guideline Development Working Group was created to lead the process. Peter R. Butt and Marilyn White-Campbell were appointed as co-leads of the group. Group membership was based on willingness to commit to the project and either possessing the required professional expertise or having a lived experience perspective. Ensuring diversity in disciplinary background and geographic distribution across Canada of members guided the final composition of the Guideline Development Working Group.
Members volunteered to focus on either the prevention or management of alcohol use disorder. Within these broad areas, they assumed leadership roles in assessing and drafting recommendations to deal with specific topics. This process was guided by systematic searches of databases to identify relevant literature that was then reviewed by Guideline Development Working Group members. Bi-weekly videoconferences were held to maintain progress, discuss emerging issues, refine recommendations, ensure consistency, and identify gaps. A modified version of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was utilized first to assess (and score) the quality of the available evidence for each recommendation (based on consideration of study design and quality of available studies, applicability to the question being addressed, and confidence in the estimate of the effect); and then to assess its overall strength, which took into account additional factors such as the balance between benefit and harm, patient values and preferences, and whether this would be a wise use of the required resources for implementation (see Box 1). (19) A separate category was created for recommendations that were not primarily based on empirical evidence but represented best clinical practice. These were categorized as consensus recommendations.
Members of the Guideline Working Group voted on all recommendations. For adoption, a recommendation had to achieve consensus approval (75%+ affirmative vote). We were actually able to discuss until we reached 100% member consensus on each recommendation. Further details on the methodology used are available at the following-https:// ccsmh.ca/substance-use-addiction/intro/ The funder had no role in the creation or approval of the recommendations made for alcohol use disorder among older adults. Working Group members submitted annual declarations of potential conflicts of interest, all of which are available upon request.

# RESULTS/RECOMMENDATIONS Recommendation #1
For women 65 years of age or older, no more than 1 standard drink per day, with no more than 5 alcoholic drinks per week, is recommended; for men 65 years of age or older, no more than 1-2 standard drinks per day, with no more than 7 per week in total, is recommended. Non-drinking days are recommended every week.  a. Depending upon health (i.e., dementia; Parkinson's disease; hemorrhagic stroke; epilepsy; cardiac dysrhythmias; hypertension; sleep apnea; COPD; liver disease; pancreatitis; GI and breast cancers; compromised balance or mobility), frailty, and medication use (i.e., benzodiazepines, opioids, Gabapentinoids, sedating antidepressants), some adults should adhere to these recommended lower levels of alcohol consumption before they reach the age of 65.
 b. As the older adult ages, especially those with comorbidities (as above), alcohol should be further reduced to 1 drink or less per day, consumed on fewer occasions, and consideration should be given to abstaining from alcohol.
 c. It is recommended that older adults do not drink when operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or potentially dangerous physical activity; preparing for bed or having to arise at night; making important decisions; while responsible for the care of others; if living with serious physical or mental illness or a substance use disorder. 

# DISCUSSION
There is a plethora of clinical guidance in the management of Alcohol Use Disorder but a paucity of evidence attributable to the unique and highly diverse older adult population. These guidelines represent a systematic approach to the literature, with particular attention to the evidence, context, and expertise. The guideline group provided multidisciplinary insight, critical analysis, clinical acumen, and lived experience. These 22 guideline recommendations for AUD in older adults cover prevention, screening, assessment, and treatment. Although good evidence exists for the treatment of AUD in adults, there is a dearth directly applicable to the older adult population. The literature varied in its definition of older adults and grappled with the diversity of this population with regard to comorbidities, living circumstances and supports, sex and gender, cultural influences, and treatment outcomes in the context of generally declining health.
Studies focused on older adults, inclusive of sub-populations, are needed to create evidence for the effectiveness of psychosocial and pharmacological treatments. The inconsistency around thiamine dosages and routes in detox need to be addressed for all patients. Somewhat related is the determination of the efficacy of oral thiamine supplementation to prevent Wernicke-Korsakoff's syndrome in ongoing chronic, heavy drinkers. Also, in need of further study is the recommendation for managed alcohol tapering in a controlled environment for those transitioning in their level of care. Finally, the use of toxicology screens in the context of falls would greatly assist in identifying the role of substance use in this common, yet highly problematic, occurrence in the older adult population.
In order to facilitate implementation of these recommendations the clinician needs to remain engaged through screening, assessment and treatment, to support both harm reduction and the potential transition into recovery. This is often described as a journey in which the patient is learning how to live without chemical coping, to address their many issues, and reconnect with life. Awareness of these transitions and the provision of appropriate support, without enabling, is an important part of the clinical role and relationship. Appropriate treatment and longitudinal, comprehensive care can be as successful with substance use disorders, as with any other chronic disease.
Care would be greatly assisted by expanded treatment resources, both pharmacologic and non-pharmacologic, for older adults with AUD. Prevention, through beverage alcohol labelling, social marketing of the low-risk drinking guidelines, and education of clinicians, is also important to reduce the human, health, and economic burden of alcohol misuse.

# CONCLUSION
Older adults are more sensitive to the effects of alcohol, and their bodies process alcohol slower than younger bodies do. Many older adults drink alcohol without problems. When problems do develop, they may begin at a young age or later in life. As the population of Canada ages, there is a growing need for resources regarding alcohol use in older adults. The recommendations found in our Clinical Guidelines are intended to provide health-care workers and policy-makers with evidence-informed, clinically relevant direction and advice on the prevention, screening, assessment, and treatment of AUD in older adults. We hope practitioners will find them both a practical and useful clinical aide, and that community members will find them a helpful educational resource. The expanded version of these guidelines can be accessed electronically (www.ccsmh.ca).
-r approval of the recommendations. Authors received an honorarium for their work. A rigorous process was undertaken to ensure that members of the working group did not have any significant conflict of interest.