Moore, Alison A

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Alcohol Use, At-Risk Drinking and Abuse in Older Adults Alison A. Moore, MD, MPHDavid Geffen School of Medicine at UCLA Division of Geriatric MedicineIntegrated Substance Abuse ProgramOutline1. Epidemiology2. Associations/Predictors3. Treatment Outcomes4. Alcohol risks in Older Adults5. Benefits of Moderate Alcohol Use6. Risks of Immoderate Alcohol Use7. Medical Comorbidity8. Healthy Drinking as You Age StudyDrinking in Older Adults (65+): Results of Three Nationally-Representative Surveys NHIS-2000, BRFSS-2001, NHSDA-2000Alcohol use     Men      Women None 49-60 % 63-72 % < 1 drink/day 27-39 % 22-32 % > 1 drink/day 9-10 % 2-3 %   Breslow et al. J Stud Alcohol 2003Low-Risk Drinking • Under age 65–Men: no more than 2 drinks per day–Women: no more than 1 drink per day• 65 and over: –Men and Women: no more than 1 drink per day USDHHS, PHS, NIH, NIAAAAt-risk drinking• The use of alcohol that causes or increases one’s risk for adverse health outcomes. Drinking Patterns in Older PersonsAt-risk drinkers12%Low-risk drinkers25%Abstainers 60%Abusing or Dependent3%Drinking Patterns in Older DrinkersAbusing or Dependent7%At-risk Drinkers30%Low-risk Drinkers63%Associations with drinking in older adults• Younger age• Male gender• Better socioeconomic status (education, income)• Better health• SmokingPredicted Longitudinal Alcohol Consumption in Three Birth Cohorts of Men and Women From the U.S. Population0.51.52.53.54.55.56.57.520 30 40 50 60 70 80 90Age in YearsNumber of Drinks per Week1905 M1925 M1945 M1905 F1925 F1945 FMoore et al. J Am Public Health 2006 Predictors of Late-Life Drinking Problems• Male gender• Prior and current alcohol use• Smoking• Negative life events*• Insomnia**• Depression/Anxiety**• Pain*• Avoidance coping• Friends’ approval of drinking• No help seeking• Use of psychoactive meds (women)Moos et al. Addiction 2004Treatment for Older Heavier Drinkers Project GOAL• Tested efficacy of brief physician advice in reducing alcohol use among heavier drinkers aged 65+ in primary care• As compared to control group, at 12 months, intervention group subjects had: – 34% reduction in 7-day alcohol use– 74% reduction in # binge drinking episodes– 62% reduction in % drinking > 21 drinks/week.Fleming et al.  J Fam Pract 1999At-Risk Drinkers in PRISM-E• Tested efficacy of integrated care with enhanced special referral for older heavier drinkers in primary care• At six months, both groups had reduced:– average weekly drinking (17.9 to 11.0)– episodes of binge drinking in prior 3 months (21.1 to 11.4)Oslin et al. Psych Serv 2006Treatment for Older Adults with Abuse/Dependence• Generally older adults do as well or better than younger adults in treatment. • Predictors of better outcomes – Longer treatment– Greater involvement in after-care programs– Female gender– Social network that does not encourage alcohol useOslin et al. Addictive Behaviors 2005Satre et al. Addiction 2004Lemke et al. J Subst Abuse Treatment 2003Blow et al. J Subst Abuse Treatment 2000Age-Related Factors that Increase Risks from Alcohol Use in Older Persons• Physiological factors⇑ ratio body fat to lean muscle mass⇑ blood alcohol levels⇑ susceptibility to psychomotor effects (e.g. sedation, confusion, falls)• Other concomitants of aging⇑ morbidity ⇑ medication use Alcohol-Medication Interactions•Increased or decreased drug metabolismsedatives, warfarin, phenytoin, narcotics•Interference with effectiveness of drugsdrugs for HTN, gout, ulcer disease, GERD, depression, insomnia•Exacerbation of side effectshypotension (nitrates), sedation (narcotics, sedatives), GI bleeding (NSAIDs, ASA)•Increased blood alcohol levelsH2-blockersWeathermon et al. Alc Res Health 1999CasesDr. Babor is a 80 yo who drinks 2 drinks most daysCasesDr. Barry is an 70 yo who drinks 1 drink dailyCasesDr. Blow is a 65 yo who drinks 3 drinks on most daysConditions that may be prevented by moderate alcohol use• All-cause mortality• Coronary heart disease• Congestive heart failure• Cerebrovascular disease– Ischemic stroke• Diabetes• Cholelithiasis• DementiaAlcohol Use and Risk of Mortality: ACS Cancer Prevention Study II1000150020002500300035004000None <Daily 1 2 3 4+Drinks per Day Low CHD Risk High CHD RiskDeath Rate per 100KThun et al. NEJM 1997N=142,117 subjects aged 60-79Alcohol Use and Risk of CHD: Meta-analysis of 28 cohort studiesCorrao et al. Addiction 2000Alcohol Consumption and Risk of Incident Dementia Cardiovascular Health Study, 1992-199900.20.40.60.811.21.4None < 1 1-6 7-13 ≥ 14 FormerDrinkerQuitterOdds RatioMukamal et al. JAMA 2003*95% CI excludes 1.0** Average Weekly Number of Drinks ConsumedDrinking Pattern and Risk of MI: Health Professionals Follow-Up Study, 1986-199800.20.40.60.81<1 1-2 3-4 5-7Number of Days per Week Alcohol is Consumed<10.0 gm/drinking day10.0-29.9 gm/drinking day30.0+ gm/drinking dayRelative RiskMukamal et al. NEJM 2003Moderate Alcohol Use and CHD• Light to moderate (~1 drink) regular (most days) alcohol consumption linked to favorable CHD outcomes.• Moderate alcohol intake linked to increase in HDL and reduced platelet aggregation and increased fibrinolysis.Alcohol Use and Positive Health Outcomes: Study Limitations• Older drinkers have to be well enough to drink• Heavier or problem drinkers tend to avoid cohort studies• No long-term RCT data (ever?)Cases-further detail• Dr. Babor is an 80 yo who drinks 2 drinks daily and has had a TIA• Dr. Barry is a 70 yo who drinks 1 drink most days and has no CHD• Dr. Blow is a 65 yo who drinks 3 drinks on most days and has no CHDConditions for which alcohol use is causative/detrimental• Lip and oropharyngeal cancer• Esophageal varices and cancer• Laryngeal cancer• Liver cirrhosis and cancer• Gastro-esophageal hemorrhage• Acute and chronic pancreatitis• Female breast cancer• Epilepsy• Hypertension• Cardiac arrhythmias• Hemorrhagic stroke• Psoriasis• Depression• Alcohol use disordersRisks for Disability among Older Drinkers (50+) as Compared to Abstainers NHEFS 1982-1992 (N=3871)Drinking Group Incident Disability   <15 drinks/week 0.80 (0.66, 0.96)  (N=1509)    >15 drinks/week 0.80 (0.54, 1.20) (N=412)      What conditions may be caused or worsened by alcohol use? 1 or more drinks per dayGastritis, ulcers, liver and pancreas problems2 or more drinks per dayDepression, gout, GERD, breast cancer, insomnia, memory problems, falls3 or more drinks per dayHypertension, hemorrhagic stroke, gastrointestinal diseases, cancer of many varietiesWhat is the effect of moderate drinking if you have comorbidities for which alcohol is beneficial?• Evidence that moderate alcohol use is beneficial among those persons having:–CHD–Stroke–Diabetes –HypertensionAlcohol Use and Mortality in Men with Stroke Physicians' Health Study00.20.40.60.811.2Rarely or Never <1 per Week 1-6 per Week >=1 per DayRisk Ratio0.88(0.60-1.28)0.64(0.48-0.85) 0.71(0.54-0.94)1.0(referent)Jackson et al. Arch Intern Med 2003.Cases-further detail• Dr. Babor is an 80 yo who drinks 2 drinks daily and has had a TIA and a stroke• Dr. Barry is a 70 yo who drinks 1 drink most days and is depressed• Dr. Blow is a 65 yo who drinks 3 drinks on most days and has hypertensionWhat about drinking and multiple comorbidity?• Very little dataAt-risk drinking increases mortality in older men NHANES 1971-NHEFS 1992At-Risk Drinker(322 deaths)Abstainer(2426 deaths)Adjusted Hazard Ratio (95% CI)All (n=3726;2673 deaths)1.12 (0.97-1.30) 1.08 (0.98-1.19)Men (n=1711; 1379 deaths)1.20 (1.01-1.41) No sex interactionWomen (n=2015; 1294 deaths)0.87 (0.61-1.24) No sex interactionMoore et al, JAGS 2006At-Risk Drinkers• Dr.Babor is an 80 yo who drinks 2 drinks daily, has had a TIA, a stroke, takes an H2 blocker for GERD, and has insomnia.• Dr. Barry is a 70 yo who drinks 1 drink most days, is depressed, and has fallen twice in the last month.• Dr. Blow is a 65 yo who drinks 3 drinks on most days, has hypertension, and takes an NSAID.How to assess risk in older drinkers who use alcohol and have comorbidity?Comorbidity and Alcohol Risk Evaluation Tool (CARET)–Screening questionnaire that uses computer-scored clinical decision rules to identify older persons who may be at-risk drinkers– Includes items on medical conditions (7), symptoms (6), medications (11), alcohol use (3), anyone being concerned about person’s drinking (1), driving after drinking (1)Moore et al. Med Care 1999Healthy Drinking as You Age• NIAAA-funded RCT whose aim is to test the efficacy of a screening and intervention method to reduce at- risk drinking in primary care among adults aged 55+• At-risk drinkers identified by CARET and randomized to control or intervention groups at time of baseline visit to primary care provider• Follow-up at 3 and 12 monthsBaseline visit to primary care provider• Control Group– Booklet on  healthy behaviors including but not limited to alcohol use• Intervention Group– Personalized risk report– Booklet on healthy drinking behaviors– Advice from physician– Health educator calls (at 2, 4, 8 weeks)Drinking Patterns in Older DrinkersAbusing or Dependent7%At-risk Drinkers30%Low-risk Drinkers63%Current baseline data : At-risk drinkers (n=588)• Average age is 69 years.• 418 (71%) male, 170 (29%) female• Median # drinks per occasion = 3• Median frequency of drinking = Daily• Average number of risks = 3 (range 1-7)Why are older drinkers at-risk? (n=588)• Alcohol w/ meds: 74%• Alcohol w/ disease: 51%• Alcohol w/ symptoms: 60%• Drinking 4+ drinks at once: 23%• Alcohol amount alone: 48%• Driving after drinking: 24%• Anyone concerned about drinking: 15%Other information from study• Description of at-risk older drinkers• Whether the intervention reduces at-risk drinking/amount of drinking• If so, what is associated with positive changeConclusions• 40-60% of older persons drink alcohol• In cohort studies alcohol has benefits or risks in regard to CHD and CHD-related outcomes depending on amount and frequency of alcohol use• Alcohol is a risk for many other disease outcomes Conclusions (cont)• Most older drinkers are not at-risk because they would meet criteria for alcohol abuse or dependence, but rather because of the amount of alcohol they drink given their comorbidities.• More data needed on the effect of alcohol use and multiple comorbidity on health outcomes• Hope that interventions to reduce at-risk use of alcohol may have positive health effects 

Alcohol use, at-risk drinking and abuse in older adults

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Alcohol use, at-risk drinking and abuse in older adults

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