Summary:
- Older individuals are more likely to experience some of the health benefits of moderate alcohol consumption than their younger counterparts.
- At the same time, physiological and social changes that accompany ageing may increase the likelihood that harm will occur.
- Alcohol consumption generally decreases in the elderly. However, less intensive screening and diagnosis may result in the underdetection of problems.
- Special attention is needed to prevention and screening for alcohol abuse and related problem among older adults, using specially designed instruments.
- For Examples of Targeted Interventions, see the Blue Book index page of www.icap.org.
As the world’s population ages, the elderly are becoming an increasingly important group that merits special attention with regard to health and social issues. These include alcohol consumption, changes in drinking patterns related to age, and the outcomes of drinking that are different for the elderly than they are for younger populations.
As a group, the elderly are more likely than others to experience the benefits of moderate alcohol consumption. At the same time, older adults are also at increased risk for harm from alcohol consumption (see MODULE 8: “At-risk” Populations). The dichotomous outcomes of drinking for the elderly—along with various age-related social, economic, physiological, and psychological factors—require that special attention be paid to this often neglected group in areas of prevention, treatment, and policy.
Moderate drinking and potential benefits
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There is evidence that moderate alcohol consumption has a beneficial effect on all-cause mortality in the elderly (Paganini Hill, Kawas, & Corrada, 2007). Considerable evidence exists for the beneficial effects of moderate drinking on the prevention of certain diseases common among older adults. For example, it is a protective factor against coronary heart disease, heart failure, and myocardial infarction, particularly in older men (Djousse & Gaziano, 2007; Fuchs et al., 2004; Gronbaek, 2006; Mukamal et al., 2003; Rehm, Sempos, & Trevisan, 2003; Trevisan et al., 2004). For postmenopausal women, moderate drinking has been linked to a reduction in the risk for osteoporosis and an improvement in bone density (see MODULE 9: Women and Alcohol; Rapuri, Gallagher, Balhorn, & Ryschon, 2000). Light to moderate drinking among elderly men and women is associated with a reduced incidence of type 2 diebetes mellitus (Djousse, Biggs, Mukamal, & Siscovick, 2007).
Furthermore, moderate elderly drinkers experience benefits for cognitive functioning as compared to those who abstain or report heavy drinking (Bond et al., 2005; Cervilla, Prince, Joels, Lovestone, & Mann, 2000; Deng et al., 2006; Galanis et al., 2000; Ganguli, Vander Bilt, Saxton, Shen, & Dodge, 2005; Ruitenberg et al., 2002; Simons, Simons, McCallum, & Friedlander, 2006; Stampfer, Kang, Chen, Cherry, & Grodstein, 2005; Xu et al., 2009; on delay in cognitive decline among older women, see Stott et al., 2008). Psychological benefits—possibly through reduced stress and improved mood and sociability—may have useful implications in the treatment of some geriatric problems (Baum-Baicker, 1985; Bond et al., 2005; Cassidy et al., 2004; McPhee, Johnson, & Dietrich, 2004; Turner, Bennett, & Hernandez, 1981). However, the consumption of alcohol among the elderly requires careful monitoring along with a range of other lifestyle factors. Despite beneficial effects, older individuals should not be encouraged to increase their drinking for reasons of health.
Alcohol consumption and potential harm
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In general, alcohol consumption decreases with increasing age. While abstainers and light drinkers remain relatively stable in old age, heavier drinkers tend to reduce their consumption over time (Liberto, Oslin, & Ruskin, 1992). According to the research literature, alcohol abuse also appears to be less common among the elderly as compared to younger populations, although the onset of drinking problems late in life has been described (Adams, Garry, Rhyne, Hunt, & Goodwin, 1990; Johnson, Gruenewald, Treno, & Taff, 1998; Liberto et al., 1992; Moore, Endo, & Carter, 2003; Moos, Brennan, Schutte, & Moos, 2005). One explanation could be high mortality of those with lifetime histories of alcohol abuse. However, there is evidence that lower incidence of alcohol abuse in advanced years may actually reflect less intensive screening and diagnosis among the elderly resulting in the underdetection of problems (Culberson, 2006a; Gilhooly, 2005; Lynskey, Day, & Hall, 2003; MODULE 17: Alcohol Dependence and Treatment). As the general population grows older in many countries, studies report an increase in heavy drinkers among the elderly (Bjork, Vinther Larsen, Thygesen, Johansen, & Gronbaek, 2006; Kim, De La Rosa, Rice, & Delva, 2007; Meier & Seitz, 2008).
Risk factors
Older adults are more sensitive to the negative health effects of alcohol than their younger counterparts. This is due to their generally poorer health status and increased likelihood that they use medications that may interact with alcohol (Fink et al., 2002). In addition, the normal ageing process is accompanied by certain physiological changes that can exacerbate the potential for harm. For example, a decrease in total body water and an increase in body fat in the elderly affect the body’s ability to absorb and metabolize alcohol, resulting in higher blood alcohol concentrations than in younger people for the same amount of alcohol consumed (Adams & Cox, 1995; Meier & Seitz, 2008; Onder et al., 2002; Seitz & Simanowski, 1994; Weathermon & Crabb, 1999; see also ANNEX 1: The Basics about Alcohol). For older people, therefore, alcohol consumption, in some circumstances, may be associated with greater risk for injury (Resnick & Junlapeeya, 2004; Yuan et al., 2001), and sustained heavy drinking is associated with a number of negative health outcomes (e.g., elevated risk for gastric cancer in elderly women: Song et al., 2008; liver disease: Meier & Seitz, 2008; diabetes: Riserus & Ingelsson, 2007; depressive/anxiety symptoms: Kirchner et al., 2007). Drinking may be a particular issue for older women. Hormonal changes accompanying menopause may contribute to elevated risk of breast cancer with increased alcohol consumption levels (Onland-Moret, Peeters, van der Schouw, Grobbee, & van Gils, 2005).
There is evidence that particular predictors of harm from drinking may be found among the elderly (Atkinson, Tolson, & Turner, 1990; Boyle & Davis, 2006; Merrick, Horgan, et al., 2008; Schutte, Brennen, & Moos, 1998). Those who develop problems are more likely to rely on alcohol as a means of coping with stressors, and often have a history of doing so during their younger years (Schutte et al., 1998). Stressors related to old age include the loss of spouses and loved ones, diminished social networks, cessation of employment, loss of income, and increased health problems. Among older women—who tend to outlive their spouses—such problems may be particularly common (Blow & Barry, 2002).
Prevention, screening, and treatment
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Screening for problem drinking in the elderly is often underutilized and may not accurately reflect the nature and extent of problems. There is evidence that the tools used for screening younger populations, such as standard questionnaires and other instruments, may not be adequate for use among the elderly (Beullens & Aertgeerts, 2004; Nemes et al., 2004). It may be difficult to discern certain markers of problems—such as decreased productivity, family problems, and decreased social participation—among changes that accompany ageing (Beullens & Aertgeerts, 2004; Graham & Romaniec, 1986; O'Connell, Chin, Cunningham, & Lawlor, 2003; Patterson & Jeste, 1999). In fact, problems related to harmful drinking may be confused with other consequences of ageing (Culberson, 2006a; Letizia & Reinbolz, 2005).
More reliable markers may be the interaction of alcohol with medications, the onset of various diseases, and the decreased ability to function effectively. It is important also to note that problems among the elderly may become apparent at lower levels of drinking than among younger age groups. Screening instruments, such as the Alcohol-Related Problems Survey (ARPS), have been designed for specific use with older adults and tailored to assess drinking problems within the context of other confounding factors (Berks & McCormick, 2008; Fink et al., 2002; Moore et al., 2003). In addition, older individuals can benefit from screening that is applied in combination with health education (Nguyen & Matern, 2001).
Just as screening for problems among the elderly requires careful tailoring to their needs, so does treatment. Few treatment facilities are designed with older adults in mind (Schultz, Arndt, & Liesveld, 2003). They are often ill-equipped to meet the specific needs of the elderly, such as the ability to address the limited mobility and access to transportation among patients. In general, interventions that are integrated into primary care for the elderly are generally more effective, especially where information can be personalized (Bartels et al., 2004; Fink, Elliott, Tsai, & Beck, 2005). There is evidence that, as is the case with other groups, older adults may respond particularly well to brief interventions (Blow & Barry, 2002; Culberson, 2006b).
Particular attention is needed to preparing health providers to be able to adequately address the needs of the elderly. Recognizing and assessing problems may require special skills and tools not used for the general population. However, it is important that these approaches are integrated into the primary healthcare system, and that they are sensitive to the changing needs of an ageing population. In addition, attention is needed to follow-up care for older patients treated for substance abuse. Currently, they are less likely than younger individuals to receive aftercare (Oslin, Slaymaker, Blow, Owen, & Colleran, 2005).
It has been suggested that the elderly are less likely than younger individuals to seek medical assistance; this is particularly true for older adults with harmful drinking patterns, who also tend to be less likely to use preventive medical services recommended for their age group (e.g., mammogram, vaccinations, and glaucoma screening) (Merrick, Hodgkin, et al., 2008). Therefore, other venues may be an appropriate means of delivering targeted interventions to them. These may include pharmacies, senior centers, or other venues where the elderly are likely to gather. Particular attention is needed to those older individuals who are housebound and therefore even less likely to interact with health professionals.
Conclusions
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Although older drinkers may benefit particularly from the positive health outcomes of moderate alcohol consumption, health and social factors associated with ageing also place the elderly at particular risk for harm. Special attention is needed when addressing alcohol problems among the elderly, as their needs are different from those of younger individuals, and problems may manifest themselves in a different way. Policy-makers and healthcare providers need to work together to ensure that older adults receive adequate prevention and, where necessary, treatment that is appropriate and sensitive to their particular needs.
POLICY OPTIONS: Alcohol and the Elderly
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In developing policies and approaches, consideration of a number of key elements is required. While some may be necessary at a minimum and under most conditions, others may not be appropriate in all cases, or may be difficult to implement. The list below offers a menu of areas that need to be addressed, based on effective approaches that have been implemented elsewhere. Specific examples are provided in the Examples of Targeted Interventions section of the ICAP Blue Book.
Information
Drinking guidelines with specific information for the elderly, providing balanced information on risks and benefits.
Recommendations on drinking sensitive to the changing physiology, social context, and psychological needs of older adults. Recommendations may be provided through:
- Physicians and healthcare providers.
- Social workers and assisted living personnel.
Access to prevention and treatment
Training of health workers to recognize problematic drinking patterns among the elderly. Where adequate care is unavailable or populations are hard to reach, others may be of assistance, including social workers.
- Access to screening and treatment appropriate for elderly individuals.
- Screening tools for the general population may not be sensitive enough; specially designed tools may be needed.
- Familiarity with health issues facing the elderly and the ability to distinguish drinking problems from other possible health problems.
- Brief interventions may be particularly effective among this population.
Special considerations
Older individuals may be difficult to reach, and intervention may be needed through other channels (e.g., social workers and others).
Social isolation, loss of networks may contribute to co-morbidity of drinking problems with psychiatric conditions.
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