National Institute on Alcohol Abuse and Alcoholism No. 2 October 1988
Alcohol and Aging
Problems of alcohol abuse among the elderly (persons aged 65 years and older) are receiving increased attention. Data suggest that untreated alcohol abuse among older persons is a more serious problem than has been previously recognized and that it is likely to become an even greater problem as the "baby boom" portion of the population ages. As with younger patients, alcoholism among the aged is treatable. Greater awareness of the issues involved with alcohol and the older generation can help clinicians and other treatment professionals to identify problems accurately and to provide the best possible care.
Until recently, the problem of alcohol and other drug abuse among the elderly has been overlooked in both the gerontological and alcohol literature (Minnis 1988; Atkinson 1987). Minnis attributed this oversight to several factors: (1) early addiction research tended to focus on narcotics, ignoring other non-opiate substances; (2) an influential theory by Winnick (1962), derived from his study of heroin abuse, suggested that drug abuse "matures out" after age 45; and (3) attention to problems of addiction tended to focus on the young because of their massive use of drugs in the 1960s.
At first glance, evidence in the literature appears to support the proposition that the elderly consume less alcohol and that problems associated with their drinking are less serious than those among younger persons. Indeed, surveys of alcohol consumption among the general population (Clark & Midanik 1982; AEDS 1987; Smart & Adlaf 1988) indicate that the percentage of people reporting abstinence increases with age. These surveys also show that older persons who consume alcohol drink less on the average than younger people. In addition, older persons appear to be at lower risk if we look at survey studies of the prevalence of alcoholism and alcohol abuse using nonclinical samples (community surveys) and definitions articulated in the DSM-III (Glynn et al.1984; Wiiliams et al.1987; Clark & Midanik 1982).
Several theories have attempted to explain why the elderly appear to drink less alcohol (Gomberg 1982): (1) Older persons often have smaller incomes and less discretionary money to spend on alcohol. (2) Even though they can metabolize alcohol as efficiently as younger persons, older persons experience higher levels of peak alcohol concentrations for similar doses because with age a person loses lean body mass in which to distribute water-soluble alcohol (Vestal et al. 1977). Thus older persons can experience effects of alcohol while imbibing less. (3) There is also evidence that, for any given level of blood alcohol, there remains an intensified sensitivity to alcohol in older persons (Vogel-Sprott & Barrett 1984). (4) Serious medical problems are more prevalent in the older population, which may cause older persons to reduce their alcohol consumption. (5) Finally, because alcohol abuse is a major cause of mortality, early mortality among lifelong alcohol abusers may leave a surviving older population who consume less alcohol and have fewer associated problems.
While studies of the general population indicate that the elderly have fewer alcohol related problems, clinical studies paint a darker picture (Douglass 1984; Gomberg 1982); estimates of the percentage of older persons in hospitals or other health care facilities who evidence illness or other serious consequences of alcohol abuse range from 7.5 to 70 percent. Apparently, problems with alcohol do not necessarily decrease with age, and many such problems are not easily identified outside a hospital or other treatment setting.
Is there evidence suggesting that people do not necessarily drink less alcohol as they grow older? Yes, but the data are found in longitudinal and retrospective studies, as opposed to the cross-sectional studies cited above. A cross-sectional study is conducted at a single point in time, and any age-related differences may not reflect effects of aging in any single individual. For example, differences in the drinking patterns between a 70-year-old man and a 50-year-old man may have nothing to do with age per se; rather, the 70-year-old man may drink less because he happened to have lived through Prohibition and the Great Depression, times when certain norms about drinking prevailed. The 50 year-old man lived through a different and unique set of historical and cultural influences that may have allowed him to drink more. These influences are called "cohort effects," and if they do influence lifelong drinking patterns, there will likely be more alcohol problems in future generations of the elderly, as today's middle-aged and younger populations bring their current higher levels of alcohol consumption into old age.
In contrast to cross-sectional studies, longitudinal and retrospective studies track the same individuals at different points in their lifetime and show changes associated with the aging of individuals in the study. Recent longitudinal and other data (Dufour et al. 1988; Reich et al.1988; Glynn et al. 1984) provide evidence of stable drinking patterns as a person ages.
Is it possible that some people in old age increase their alcohol consumption? There is continuing evidence (Hurt et al. 1988) of the phenomenon called late-onset alcoholism. In this clinical study, at least 41 percent of the people age 65 and older who were enrolled in a Mayo Clinic alcoholism treatment program reported symptoms of alcoholism that began after age 60. Data on late-onset alcoholism in other studies reviewed by Gomberg (1982) and Williams (1988) provide further evidence that one's alcohol consumption may not be consistent across time; some people may actually increase their consumption as a response to age-related stresses, such as loss of employment and widowhood or other bereavement.
While there may be less drinking among the elderly overall, there appears to be a hidden alcohol problem for this group. Why do alcohol problems among the elderly elude identification? According to Bienenfeld (1987), most elderly drinkers come to medical attention for treatment of problems apparently not related to alcohol. It has been suggested (Graham 1986) that many criteria used in screening and diagnosis of alcohol abuse and alcoholism are inappropriate for this population, leading to underestimates of the scope of the problem:
* Self-reports of consumption may not be accurate because of memory problems, difficulties in mental averaging, and higher levels of denial of unfavorable characteristics among older persons. In addition, the traditional cutoff points used to define heavier drinking may be inappropriate for older persons because of increased sensitivity to alcohol.
* Many scales (e.g., the Michigan Alcoholism Screening Test) used to diagnose alcohol abuse measure the prevalence of social, legal, and job-related problems. However, such scales were often validated with younger patients and may be inappropriate for the elderly, who are likely to be more socially isolated, no longer driving, retired and, therefore, not subject to many social. Iegal, and job related consequences of drinking.
* Many symptoms of alcohol abuse, such as musculoskeletal pain, insomnia, loss of libido, depression, anxiety. and loss of memory or other cognitive impairment, may be misunderstood as simply conditions often seen among nonalcoholic older patients (Bienenfeld 1987). In younger persons, such symptoms often signal a diagnosis of alcoholism; in older persons, symptoms such as these may be attributed to dementia or other illnesses.
;Once an alcohol problem is identified in an elderly patient, there are special issues to consider. For example, there is an increased risk for drug interactions, especially adverse drug reactions, in the elderly. Older alcoholics have a high incidence of illness and problems not caused by alcohol (Hurt et al. 1988; Finlayson et al. 1988). Among these are chronic obstructive pulmonary disease, peptic ulcer disease, psoriasis. tobacco dependence. organic brain syndrome, affective disorder. and abuse of or dependence on legal prescription drugs. The potential for drug interactions increases with greater reliance on prescription drugs, multiple prescriptions, difficulty in correct self administration, and age-related changes in physiology and is further aggravated by the use of alcohol (Williams 1988). For example, Abrams & Alexopoulos (1987) emphasize that alcohol abuse among older persons can mimic and/or contribute to major depression. Also, Larsen and colleagues (1987) discovered that some apparent dementia in older patients is actually a form of drug-induced cognitive impairment, reversible in the absence of the drugs. Thus, it is likely that reduction of alcohol consumption could improve treatment outcomes among the elderly.
In absolute and relative numbers, the size of the elderly population will grow in the next decades from an estimated 28.6 million (12 percent of the total population) in 1985 to 58.8 million (20 percent of the total population) in 2025 (U.S. Bureau of the Census 1984). Even under the conservative assumption that current rates of alcoholism will continue, the sheer numbers of people who are maturing into old age means increasing numbers of elderly alcoholics and alcohol abusers (Williams et al. 1987).If future generations of the elderly drink more than today's older generation, the size of the problem will be even greater.
Even though alcohol abuse or alcoholism may be more difficult to diagnose in older patients, it is nevertheless worth the addition aleffort to identify and treat them. Although questions remain concerning the optimal setting for treating older alcoholics, they can achieve the same success rates as younger patients, and older problem drinkers in treatment may be more likely than younger drinkers to complete a course of therapy (Atkinson 1987; Kofoed et al.1987; Williams 1984).
Alcoholism Treatment and Older Americans A Commentary by
NIAAA Director Enoch Gordis, M.D.
Health care personnel, families, and other individuals and institutions that interact with older persons need to recognize that alcoholism treatment is at least as effective for older individuals as it is for anyone in the general population. They also should understand that alcoholism treatment is life-enhancing at any age and that each age brings its own rewards for sobriety, e.g., the younger person keeps his or her job, whereas the older person is reinstated in the affection of family or friends.
Identifying alcohol-related problems among older persons may present more challenges than with other age groups. Because of retirement or other lifestyle changes that limit older persons' interaction with social, legal, and other networks, there are fewer opportunities for their alcohol abuse or alcoholism to be observed. However, older persons are likely to visit a primary health care unit where presenting conditions that may be the consequence of alcohol abuse or dependence can be identified. These include depression, malnutrition, insomnia, cognitive problems, and loss of interest in life.
It is essential that primary care practitioners determine if an underlying alcohol problem might be present. Failure to do so risks unwanted interaction with properly prescribed medication, subjects patients to side effects of unnecessary prescriptions, and may interfere with treatment for medical problems unrelated to alcohol abuse or alcoholism. Patients in whom alcohol abuse or dependence is suspected should be referred for further diagnosis and treatment.
Regarding alcoholism treatment, evidence on the best setting for treating older alcohol abusers and alcoholics is controversial. More research is needed to define which patients will do better in alcoholism treatment programs devoted solely to the older patient and which will do well in programs for mixed ages.
Although the relative effectiveness of various alcoholism treatment settings is unresolved, some aspects of treatment for older persons with alcohol-related problems are clear. In addition to alcohol abuse or dependence, older persons often have general medical problems that may require attention. Consequently, together with counseling and other supportive services, alcoholism treatment programs serving older persons should have easy access to general medical services. Some modification of regimens used in detoxification and long-term management of alcoholism also may be needed for older individuals. For example, in some cases it is safer to accept a modest level of withdrawal tremor than to risk over sedation in a patient with chronic pulmonary disease. Many also believe that disulfiram should not be used in older patients, although I have prescribed it without problems in an occasional patient who is in good physical health and insists on having it.
U. S. Surgeon General C. Everett Koop, M.D., sponsored a Workshop on Health Promotion and Aging in March of this year. The alcohol-related recommendations contained in the workshop proceedings (DHHS 1988) are informative, and I recommend them to you. A copy of the proceedings may be obtained from the National Health Information Center, P.O. Box 1133, Washington, DC 20013-1133, Telephone (800) 336-4797.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service * National Institutes of Health
Updated: October 2000