Chapter 2 - Alcohol

Comorbidities

Although alcohol can negatively affect a person of any age, the interaction of age-related physiological changes and the consumption of alcohol can trigger or exacerbate additional serious problems among older adults, including

• Increased risk of hypertension, cardiac arrhythmia, myocardial infarction, and cardiomyopathy
• Increased risk of hemorrhagic stroke
• Impaired immune system and capability to combat infection and cancer
• Cirrhosis and other liver diseases
• Decreased bone density
• Gastrointestinal bleeding
• Depression, anxiety, and other mental health problems
• Malnutrition.

Other biomedical changes of aging are cognitive impairments, which are both confused with and exacerbated by alcohol use. Chronic alcoholism can cause serious, irreversible changes in brain function, although this is more likely to be seen in older adults who have a long history of alcoholism. Alcohol use may have direct neurotoxic effects leading to a characteristic syndrome called alcohol-related dementia (ARD) or may be associated with the development of other dementing illnesses such as Alzheimer's disease or Wernicke-Korsakoff syndrome, an illness characterized by anterograde memory deficits, gait ataxia, and nystagmus. Indeed several researchers have cast doubt on the existence of ARD as a neuropathological disease and suggest that the majority of cases of ARD are in fact Wernicke-Korsakoff syndrome (Victor et al., 1989).

Sleep patterns typically change as people age (Haponik, 1992). Increased episodes of sleep with rapid eye movement (REM), decreased REM length, decreased stage III and IV sleep, and increased awakenings are common patterns, all of which can be worsened by alcohol use. Moeller and colleagues demonstrated in younger subjects that alcohol and depression had additive effects on sleep disturbances when occurring together (Moeller et al., 1993). One study concluded that sleep disturbances, especially insomnia, may be a potential etiologic factor in the development of late-life alcohol problems or in precipitating relapse (Oslin and Liberto, 1995). This hypothesis is supported by a study demonstrating that abstinent alcoholics experienced insomnia, frequent awakenings, and REM fragmentation (Wagman et al., 1977). However, when these subjects ingested alcohol, sleep periodicity normalized and REM sleep was temporarily suppressed, suggesting that alcohol can be used to self-medicate sleep disturbances.

Positive Effects of Alcohol Consumption

Small amounts of alcohol have been shown to provide some health benefits, although abstinence is still recommended for anyone who has a history of alcoholism or drug abuse, who is taking certain medications (see Chapter 3), or who is diagnosed with certain chronic diseases such as diabetes and congestive heart failure. Some studies, largely conducted on male samples, show that low levels of alcohol consumption (one standard drink per day or less) reduce the risks of coronary heart disease (Shaper et al., 1988). However, this cardiovascular benefit may not apply to adults already diagnosed with heart disease. Older adults in this category should not drink unless their physician says otherwise.

"An intriguing epidemiologic finding is the association of regular, but moderate, alcohol use (up to two drinks per day) with lower morbidity and mortality from coronary artery disease," especially in men, when compared with heavy alcohol users and abstainers (Atkinson and Ganzini, 1994, p. 302). "This 'U' or 'J' shaped relationship appears to be quite robust," occurring in diverse cultural and national cohorts (Atkinson and Ganzini, 1994, p. 302). That heavy drinkers have more coronary disease is to be expected, but why should abstainers have higher morbidity and mortality than moderate drinkers? One explanation may be that the abstainer group was heterogeneous in composition and may have included former alcoholics as well as others predisposed to cardiac disease (Atkinson et al., 1992). A number of other studies, including the only one reported to date that consisted of exclusively older adult subjects, likewise failed to account for this possibility in their study designs (Scherr et al., 1992).

Other analyses of abstainer groups report conflicting findings (Shaper et al., 1988; Klatsky et al., 1990). Further study is needed to determine the contributions of alcohol-induced rise in high-density lipoproteins (HDLs) (Srivastava et al., 1994; Davidson, 1989) and antioxidant effects of beverage alcohol (Artaud-Wild et al., 1993) to the association between abstinence and coronary artery disease.

Although moderate alcohol consumption has been shown to improve HDL levels in women (Fuchs et al., 1995), it also has been linked to breast cancer in postmenopausal women (Bucholz et al., 1995). More studies on the risks and benefits of alcohol consumption for older women are needed to clarify this issue.

Low levels of alcohol consumption also appear to promote and facilitate socialization among older adults, suggesting that alcohol plays an important role in community life for older adults (Gomberg, 1990). However, the health of some older adults (e.g., those with chronic conditions, those using certain medications) may be compromised by any alcohol consumption. Again, recommendations for use of alcohol should always be individualized.

DSM-IV

Most clinicians rely on the conventional medical model defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994)for classifying the signs and symptoms of alcohol-related problems. The DSM-IV uses specific criteria to distinguish between those drinkers who abuse alcohol and those who are dependent on alcohol. Figures 2-1 and 2-2 present the DSM-IV criteria, which subsume alcohol abuse indicators within the general categories of substance abuse and dependence.

Although widely used, the DSM-IV criteria may not apply to many older adults who experience neither the legal, social, nor psychological consequences specified. For example, "a failure to fulfill major role obligations at work, school, or home" is less applicable to a retired person with minimal familial responsibilities. Nor does the criterion "continued use of the substance(s) despite persistent or recurrent problems" always apply. Many older alcoholics do not realize that their persistent or recurrent problems are in fact related to their drinking, a view likely to be reinforced by health care clinicians who may attribute these problems, in whole or in part, to the aging process or age-related comorbidities.

Although tolerance is one of the DSM-IV criteria for a diagnosis of substance dependence - and one weighted heavily by clinicians performing an assessment for substance dependence - the thresholds of consumption often considered by clinicians as indicative of tolerance may be set too high for older adults because of their altered sensitivity to and body distribution of alcohol (Atkinson, 1990). The lack of tolerance to alcohol does not necessarily mean that an older adult does not have a drinking problem or is not experiencing serious negative effects as a result of his or her drinking. Furthermore, many late onset alcoholics have not developed physiological dependence, and they do not exhibit signs of withdrawal. Figure 2-3 presents the DSM-IV criteria for substance dependence as they apply to older adults with alcohol problems.

The drinking practices of many older adults who do not meet the diagnostic criteria for abuse or dependence place them at risk of complicating an existing medical or psychiatric disorder. Consuming one or two drinks per day, for example, may lead to increased cognitive impairment in patients who already have Alzheimer's disease, may lead to worsening of sleep problems in patients with sleep apnea, or may interact with medications rendering them less effective or causing adverse side effects. A barrier to good clinical management in these cases may be the lack of understanding of the risks of so-called "moderate drinking." Limiting access to treatment because symptoms do not meet the rigorous diagnostic criteria of the DSM-IV may preclude an older patient from making significant improvements in his or her life.

At-Risk, Heavy, and Problem Drinking

Some experts use the model of at-risk, heavy, and problem-drinking in place of the DSM-IV model of alcohol abuse and dependence because it allows for more flexibility in characterizing drinking patterns. In this classification scheme, an at-risk drinker is one whose patterns of alcohol use, although not yet causing problems, may bring about adverse consequences, either to the drinker or to others. Occasional moderate drinking at social gatherings and then driving home is an example of at-risk drinking. Although an accident may not have occurred, all the elements for disaster are present.

As their names imply, the terms heavy and problem drinking signify more hazardous levels of consumption than at-risk drinking. Although the distinction between the terms heavy and problem is meaningful to alcohol treatment specialists interested in differentiating severity of problems among younger alcohol abusers, it may have less relevance for older adults (Atkinson and Ganzini, 1994), who may experience pervasive consequences with less consumption due to their heightened sensitivity to alcohol or the presence of such coexisting diseases as diabetes mellitus, hypertension, cirrhosis, or dementia.

In general, the threshold for at-risk alcohol use decreases with advancing age. Although an individual's health and functional status determine the degree of impact, the pharmacokinetic and pharmacodynamic effects of alcohol on aging organ systems result in higher peak blood alcohol levels (BALs) and increased responsiveness to doses that caused little impairment at a younger age. For example, body sway increases and the capacity to think clearly decreases with age after a standard alcohol load, even when controlling for BALs (Beresford and Lucey, 1995; Vogel-Sprott and Barret, 1984; Vestal et al., 1977).

Certain medical conditions, for example, hypertension and diabetes mellitus, can be made worse by regular drinking of relatively small amounts of alcohol. In addition, the tendency "to take the edge off" with alcohol during times of stress, and its subsequent impact on cognition and problem-solving skills, may provoke inadequate or destructive responses, even in those older adults whose overall consumption over 6 months is lower than that for some younger, problem-free, social drinkers. Furthermore, older drinkers who do not meet the substance abuse criteria for "recurrent use" behavior or consequences may, nonetheless, pose potential risk to themselves or others.

For many adults, the phenomenon of aging, with its accompanying physical vulnerabilities and distinctive psychosocial demands, may be the key risk factor for alcohol problems. To differentiate older drinkers, the Consensus Panel recommends using the terms at-risk and problem drinkers only. As discussed above, not only do the concepts of quantity/frequency implicit in the term heavy drinking have less application to older populations, but the "distinction between heavy and problem drinking narrows with age" (Atkinson and Ganzini, 1994, p. 300). In the two-stage conceptualization recommended by the Panel, the problem drinker category includes those who would otherwise fall into the heavy and problem classifications in the more traditional model as well as those who meet the DSM-IV criteria for abuse and dependence.

Age-Appropriate Levels of Consumption

In its Physician's Guide to Helping Patients With Alcohol Problems, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) offers recommendations for low-risk drinking. For individuals over the age of 65, NIAAA recommends "no more than one drink per day" (National Institute on Alcohol Abuse and Alcoholism, 1995). The Consensus Panel endorses that recommendation and the accompanying refinements presented below (Dufour et al., 1992):

• No more than one drink per day
• Maximum of two drinks on any drinking occasion (New Year's Eve, weddings)
• Somewhat lower limits for women.

A standard drink is one can (12 oz.) of beer or ale; a single shot (1.5 oz.) of hard liquor; a glass (5 oz.) of wine; or a small glass (4 oz.) of sherry, liqueur, or aperitif. The Panel's purpose in promoting these limits is to establish a "safety zone" for healthy older adults who drink. Older men and women who do not have serious or unstable medical problems and are not taking psychoactive medications are unlikely to incur problems with alcohol if they adhere to these guidelines. The goal is to foster sensible drinking that avoids health risks, while allowing older adults to obtain the beneficial effects that may accrue from alcohol. Older adults' alcohol use should be considered as spanning a spectrum from abstinence to dependence rather than falling into rigid categories.

Early Onset Versus Late Onset Problem Drinking

One of the most striking and potentially useful findings in contemporary geriatric research is the new understanding about the age at which individuals begin experiencing alcohol-related problems. Although it appears that alcohol use declines with increasing age for most adults (Temple and Leino, 1989; Fillmore, 1987), some begin to experience alcohol-related problems at or after age 55 or 60.

Early onset drinkers tend to have longstanding alcohol-related problems that generally begin before age 40, most often in the 20s and 30s. In contrast, late onset drinkers generally experience their first alcohol-related problems after age 40 or 50 (Atkinson, 1984,1994; Liberto and Oslin, 1995; Atkinson et al., 1990).

Continuous Versus Intermittent Drinking

Another way of understanding the patterns of drinking over a life span is to look at the time frames in which people drink and the frequency of their drinking. In contrast to ongoing, continuous drinking, intermittent drinking refers to regular, perhaps daily, heavy drinking that has resumed after a stable period of abstinence of 3 to 5 years or more (National Institute on Alcohol Abuse and Alcoholism, 1995).

Intermittent drinking problems are easy to overlook, but crucial to identify. Even those problem drinkers who have been sober for many years are at risk for relapse as they age. For this reason, during routine health screenings, it is important for clinicians to take a history that includes both current and lifetime use of alcohol in order to identify prior episodes of alcoholism. When armed with this information, caregivers can help their older patients anticipate situations that tend to provoke relapse and plan strategies for addressing them when they occur.

Binge Drinking

Binge drinking is generally defined as short periods of loss of control over drinking alternating with periods of abstinence or much lighter alcohol use. A binge itself is usually defined as any drinking occasion in which an individual consumes five or more standard drinks. For older adults, the Consensus Panel defines a binge as four or more drinks per occasion. People who are alcohol-free throughout the work week and celebrate with Friday night or holiday "benders" would be considered binge drinkers.

Identifying older binge drinkers can be difficult because many of the usual clues, including disciplinary job actions or arrests for driving while intoxicated, are infrequently seen among aging adults who no longer work or drive. Although research is needed on the natural history of binge drinkers as they age, anecdotal observations indicate that younger binge drinkers who survive to their later years often become continuous or near-daily drinkers.

Gender

Studies indicate that older men are much more likely than older women to have alcohol-related problems (Myers et al., 1984; Atkinson, 1990; Bucholz et al., 1995). Since the issue was first studied, most adults with alcohol problems in old age have been found to have a long history of problem drinking, and most of them have been men (D'Archangelo, 1993; Helzer et al., 1991b). About 10 percent of men report a history of heavy drinking at some point in their lives. Being a member of this group predicts that one will have widespread physical, psychological, and social dysfunction in later life (Colsher and Wallace, 1990) and confers a greater than fivefold risk of late-life psychiatric illness despite cessation of heavy drinking (Saunders et al., 1991). Forty-three percent of veterans (who can be assumed to be mostly male and mostly alcohol - as opposed to drug-abusers) receiving long-term care were found to have a history of substance abuse problems (Joseph et al., 1995; D'Archangelo, 1993). Men who drink have been found to be two to six times more likely to have medical problems than women who drink (Adams et al., 1993), even though women are more vulnerable to the development of cirrhosis.

Older women are less likely to drink and less likely to drink heavily than are older men (Bucholz et al., 1995). The ratio of male-to-female alcohol abusers, however, is an open question. Bucholz and colleagues noted a "substantial excess of men over women," larger than the gap observed in younger age groups (Bucholz et al., 1995, p. 30). Another study, however, found "a higher than expected number of females," (Beresford, 1995b, p. 11), whereas a study of older patients in treatment facilities found a ratio of 2:1 (83 men to 42 women) (Gomberg, 1995).

Both epidemiological research, including the findings of the ECA studies of the National Institute of Mental Health (Holzer et al., 1984), and clinical research consistently report later onset of problem drinking among women (Gomberg, 1995; Hurt et al., 1988; Moos et al., 1991). In one study by Gomberg, for example, women reported a mean age at onset of 46.2 years, whereas men reported 27.0 years. Furthermore, 38 percent of older female patients but only 4 percent of older male patients reported onset within the last 10 years (Gomberg, 1995).

A number of other differences between older male and female alcohol abusers have been reported: In contrast to men, women are more likely to be widowed or divorced, to have had a problem drinking spouse, and to have experienced depression (Gomberg, 1993). Women also report more negative effects of alcohol than men (Gomberg, 1994), greater use of prescribed psychoactive medication (Brennan et al., 1993; Gomberg, 1994; Graham et al., 1995), and more drinking with their spouses.

Although research has not identified any definite risk factors for drinking among older women, Wilsnack and colleagues suggest that increased amounts of free time and lessening of role responsibilities may serve as an etiological factor (Wilsnack et al., 1995). It should also be noted that women generally are more vulnerable than men to social pressure, so their move into retirement communities where drinking is common probably has an impact.

Differences between men and women have implications for treatment. Women of all ages are less likely than men to appear at treatment facilities. Among older women who may be socially isolated or homebound, outreach is particularly important. Families, physicians, senior centers and senior housing staff, and the police play important roles in helping to identify women who abuse alcohol (see Chapter 5 for more on community outreach). To be effective, however, all of these potential outreach agents must be sensitive to women's feelings of stigma, shame, and social censure.

Loss of Spouse

Alcohol abuse is more prevalent among older adults who have been separated or divorced and among men who have been widowed (Bucholz et al., 1995). Some researchers have hypothesized that a significant triad of disorders may be triggered in older men when their wives die - depression, development of alcohol problems, and suicide. The highest rate of completed suicide among all population groups is in older white men who become excessively depressed and drink heavily following the death of their spouses (National Institute on Alcohol Abuse and Alcoholism, 1988; Brennan and Moos, 1996).

Other Losses

As individuals age, they not only lose their spouse but also other family members and friends to death and separation. Retirement may mean loss of income as well as job-related social support systems and the structure and self-esteem that work provides. Other losses include diminished mobility (e.g., greater difficulty using public transportation where available, inability to drive or driving limited to the daylight hours, problems walking); impaired sensory capabilities, which may be isolating even when the elder is in physical proximity to others; and declining health due to chronic illnesses.

Health Care Settings

High rates of alcoholism are consistently reported in medical settings, indicating the need for screening and assessment of patients seen for problems other than substance abuse (Douglass, 1984; Liberto et al., 1992; Adams et al., 1996). Among community-dwelling older adults, investigators have found a prevalence of alcoholism between 2 and 15 percent (Gomberg, 1992b; Adams et al., 1996) and between 18 and 44 percent among general medical and psychiatric inpatients (Colsher and Wallace, 1990; Saunders et al., 1991).

Substance Abuse Earlier in Life

A strong relationship exists between developing a substance use disorder earlier in life and experiencing a recurrence in later life. Some recovering alcoholics with long periods of sobriety undergo a recurrence of alcoholic drinking as a result of major losses or an excess of discretionary time (Atkinson and Ganzini, 1994). Among the 10 percent of older men who reported a history of heavy drinking at some point in their lives, widespread physical and social problems occurred in later life (Colsher and Wallace, 1990). Drinking problems early in life confer a greater than fivefold risk of late-life psychiatric illness despite cessation of heavy drinking. Indeed, some research suggests that a previous drinking problem is the strongest indicator of a problem in later life (Welte and Mirand, 1992) and that "studying older alcoholics today may help to anticipate the demands that these younger alcoholics will eventually place on our resources and society" (Bucholz et al., 1995, p. 19).

Comorbid Psychiatric Disorders

Estimates of primary mood disorder occurring in older alcohol abusers vary from 12 to 30 percent or more (Finlayson et al., 1988; Koenig and Blazer, 1996). Although research does not support the notion that mood disorders precede alcoholism in older adults, there is evidence that they may be either precipitating or maintenance factors in late onset drinking. Depression, for example, appears to precipitate drinking, particularly among women. Some problem drinkers of both sexes who do not meet the clinical criteria for depression often report feeling depressed prior to the first drink on a drinking day (Dupree et al., 1984; Schonfeld and Dupree, 1991).

Patients with severe cognitive impairment generally drink less than nonimpaired alcohol users. Panelists report that, among individuals who are only mildly impaired, however, alcohol use may increase as a reaction to lower self-esteem and perceived loss of memory. Axis II disorders are more likely to be associated with early onset interpersonal and alcohol-related problems and less likely to affect the individual for the first time at age 60 or older. Late onset alcohol abuse is less associated with psychological or psychiatric problems and more likely linked to age-associated losses. The exception might be the intermittent drinker who has been in control and whose alcohol or psychiatric problems surface again later in life. See Chapter 4 for more on psychiatric comorbidity.

Family History of Alcohol Problems

There is substantial cumulative evidence that genetic factors are important in alcohol-related behaviors (Cotton, 1979). Some studies have suggested that there may be a greater genetic etiology of problem drinking in early onset than in late onset male alcohol abusers (Atkinson et al., 1990). Researchers studying the genetic tendency of a group of male alcohol abusers assert that these men often have an early history of drinking that worsens over time (Goodwin and Warnock, 1991; Schuckit, 1989).

Although most human genetic studies of alcohol use have been conducted on relatively young subjects, several studies using a twin registry of U.S. veterans have focused on significantly older individuals (Carmelli et al., 1993; Swan et al., 1990). The results of these studies provide strong evidence that drinking behaviors are greatly influenced by genetics throughout the lifespan (Heller and McClearn, 1995; Atkinson, 1984).

Tobacco

Smoking is the major preventable cause of premature death in the United States, accounting for an estimated five million years of potential life lost (U. S. Preventive Services Task Force, 1996). Every year, tobacco smoking is responsible for one out of every five American deaths (U. S. Preventive Services Task Force, 1996). Despite these compelling statistics, however, 25.5 percent or 48 million adults are current smokers (National Center for Health Statistics, 1996).

Surveys show that cigarette smoking, although fairly widespread among older adults, declines sharply after age 65. In 1994, approximately 28 percent of men ages 45 to 64 reported current use of cigarettes; among those age 65 and older, however, this figure was only about 13 percent. In the younger age group (ages 45 to 64), women have lower smoking rates than men, but after age 65, the levels are similar. Approximately 23 percent of women ages 45 to 64 reported smoking cigarettes in 1994, whereas about 11 percent of those age 65 and older currently smoked (National Center for Health Statistics, 1996). Although the trend in use declines with age, the problem remains significant with over 4 million older adults smoking regularly (Salive et al., 1992).

Smoking is a "major risk factor for at least 6 of the 14 leading causes of death among individuals 60 years and older (i.e., heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, pneumonia/influenza, lung cancer, colorectal cancer) and a complicating factor of at least three others" (Cox, 1993, p. 424). Current cigarette smoking is also "associated with an increased risk of losing mobility in both men and women" (LaCroix et al., 1993). Not surprisingly, older adult smokers have a "70 percent overall risk of dying prematurely" (Carethers, 1992, p. 2257), and fewer smokers "make it to the ranks of older adults as compared with non-smokers and quitters" (Cox, 1993, p. 423). In addition to increasing the risk of disease, smoking may also affect the performance of prescription drugs. For example, smokers tend to require higher doses of benzodiazepines to achieve efficacy than do nonsmokers (Ciraulo et al., 1995).

Smoking in older problem drinkers is far more prevalent than in the general older adult population, making tobacco use the most common substance use disorder among older adults. Some researchers estimate that 60 to 70 percent of older male alcohol users smoke a pack a day (Finlayson et al., 1988), an assessment consistent with studies indicating that the prevalence of smoking among alcoholics generally is above 80 percent (Jarvik and Schneider, 1992).

Although there have been few studies on interventions that are especially useful to older adults regarding smoking cessation, the advantages of quitting at any age are clear (Fiore et al., 1990; Orleans et al., 1994a; Rimer and Orleans, 1994; Orleans et al., 1994b). Two years after stopping, for example, the risk of stroke begins to decrease. Mortality rates for chronic obstructive pulmonary disease decline; bronchitis, pneumonia, and other infections decrease; and respiratory symptoms such as cough, wheezing, and sputum production lessen (U. S. Preventive Services Task Force, 1996). As another example, a 60-year-old male smoker who quits can expect to reduce his risk of smoking-related illness by about 10 percent over the next 15 years (Cox, 1993).

As with alcohol and drug abuse, studies suggest that many clinicians fail to counsel patients about the health effects of smoking, despite the fact that "older smokers are more likely to quit than younger smokers" (Salive et al., 1992, p. 1268). However, tailoring smoking cessation strategies to older adults so that their unique concerns and barriers to quitting are addressed improves success rates. Brief intervention, for example (see Chapter 5), can more than double 1-year quit rates for older adults (Rimer and Orleans, 1994). In one study of older smokers using transdermal nicotine patches, 29 percent of the subjects quit smoking for 6 months (Orleans et al., 1994). Because there is little evidence that adults in recovery from alcohol problems relapse when they stop smoking, the Panel recommends that efforts to reduce substance abuse among older adults also include tobacco smoking (Hurt et al., 1993).

Psychoactive Drugs

Older adults' use of psychoactive drugs combined with alcohol is a growing concern (see Chapter 3). In a study of inpatients age 65 and older in a chemical dependency program, 12 percent had combined dependence on alcohol and one or more prescription drugs (Finlayson et al., 1988). In addition, an early report by Schuckit and Morrissey found that two-thirds of women in an alcohol treatment center had received prescriptions for abusable drugs, usually hypnotic and antianxiety drugs, and one-third reported abusing them (Schuckit and Morrissey, 1979). The drug-abusing women in this study reported more suicide attempts and early antisocial problems and had received more psychiatric care than the alcoholic women who did not abuse their prescriptions. These findings are of particular concern because anxiolytics, hypnotics, and stimulants may be used to treat alcohol and other drug abusers.

An additional concern is that psychoactive drugs may combine with alcohol to create adverse drug reactions. A recent study found that the combination of alcohol and over-the-counter pain medications was the most common source of adverse drug reactions among older patients (Forster et al., 1993). Such drug interactions result from a lack of understanding among physicians, pharmacists, and older adults themselves about the potential dangers of consuming alcohol when taking certain medications.