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July/August 2024
July/August 2024 Issue Alcohol, Health, and Older Adults Talking with older adult patients about alcohol use and their health starts with understanding the guidelines and the latest research on alcohol. Alcohol is one of the most used substances in the United States for adults of all ages, including those older than 65. In fact, the National Poll on Healthy Aging found that “Two in three adults aged 50 to 80 (67%) reported drinking alcohol at least occasionally in the past year. Among those who drank, 42% drank monthly or less often, 19% two to four times per month, 18% two to three times per week, and 20% four or more times per week.”1 Thus, how much an older individual is drinking and how alcohol may interact with their health, particularly in relation to certain diagnoses and medications, is an important conversation for providers to be having. However, it does not always happen. Kathy P. of Bucks County, Pennsylvania, says she has only discussed alcohol with her oncologist—no other doctors—and even then, she was the one who prompted the discussion. “I was the one who had to ask my doctor if I could have a drink, and that was the oncologist.” He told her she could drink in moderation, but no one else ever discussed it with her. Similarly, Donna D., also of Bucks County, has only been asked about her alcohol use on forms. She has arthritis, which she takes medication for, and recently received back injections to address ongoing back pain. She reported that the paperwork she completes for her specialists and primary care physician include questions about alcohol, but that’s the extent. “Lots of forms mention it, but no one ever specifically asks.” Both Kathy and Donna are older than 65. These anecdotal examples may not be the standard throughout the country and with all providers, but they are also not unusual. Conversations about alcohol are often limited to forms and only expanded upon when the answers raise a red flag. “Nowadays, the EMR typically pushes out an annual screen for unhealthy alcohol and other substance use. That has helped increase screening rates tremendously,” explains Alison A. Moore, MD, MPH, FACP, AGSF, Larry L. Hillblom Chair in Geriatric Medicine; a professor of medicine; chief of the division of geriatrics, gerontology, and palliative care; and director of the Sam and Rose Stein Institute for Research on Aging and the Center for Healthy Aging. If the patient indicates that they consume more than the lower limits of alcohol, a more comprehensive screening may be completed. However, Moore says, “My only critique of using this approach is that some older adults may drink at the low-risk limits but still be at risk or actually experiencing problems with alcohol. This occurs most often in combination with certain medications that may interact with alcohol or worsen a medication side effect or reduce the efficacy of that medication.” She notes that alcohol can worsen, for example, gastroesophageal reflux disease (GERD), and so drinking alcohol while taking medication for it can heighten the symptoms. “The same is true for particular conditions that may be caused or worsened by even small amounts of alcohol, depending on the person. An example of this again is GERD, or for those who are unsteady on their feet, alcohol may impair coordination and increase risk for falls,” she says. There are many reasons why conversations about alcohol use may not occur, but one challenge providers face is understanding the data around alcohol use and health, as well as the guidelines released by national and international health organizations. Such a task is harder than it may seem, as some studies have shown benefits while others pinpoint risk. Similarly, some organizations recommend no alcohol while others are more lenient. Having a full picture of the data available and its limitations can help providers make better recommendations and start those conversations. Research Limitations Rachel Visontay, PhD, a postdoctoral research fellow at the Matilda Centre for Research in Mental Health and Substance Use at the University of Sydney, agrees, noting that even factors like health care access can play a part in how drinking levels and health outcomes correlate. “Teasing apart whether it is these other factors causing apparent benefits (confounding), or the alcohol itself, is not easy to do with the kinds of analysis methods traditionally used,” she says. Visontay explains that much of the long-term research on alcohol use and health has been observational, which can lead to biases. Additionally, relying on surveyed individuals to self-report their alcohol use can lead to flawed data, as different individuals may have different views on the same level of alcohol use. “Alcohol itself is complicated,” Moore says. “People may have different personal definitions of what a drink is, and what is one drink to one person might be two for another.” There are alternatives to observational studies, such as a randomized controlled trial in which, for example, participants are assigned different levels of alcohol consumption. This type of study has been completed in short-term projects but does not shed light on long-term impacts. Long-term randomized control trials pose ethical concerns given that alcohol is a known carcinogen. Given these challenges, it is no surprise that research throughout the years has shown both health benefits and risks from alcohol consumption—a fact that can make it difficult to determine what to do in terms of alcohol consumption. And it is the studies showing positive effects that are more likely to generate headlines. “The benefits of moderate drinking for conditions like heart disease and diabetes are frequently reported in the news, and survey research tells us that they are often taken for granted by the public. On top of that, these protective effects are considered when policymakers develop natural, low-risk drinking guidelines, which individuals often turn to for making decisions about their own drinking,” Visontay says. However, more recent research is highlighting the potential harm of alcohol use, showing that the benefits that have been reported either do not exist or are far outweighed by the risks. Recent Studies Visontay’s review explains that “There are three G-methods—the simplest and most popular is the marginal structural model, which generates sequential weights at each time point based on the inverse probability of exposure (ie, the individual’s level of alcohol consumption given their covariate profile) and uses a product of these weights in estimating the causal effect.”2 Visontay says, “We found that studies using these methods tend not to support the idea that a little bit of alcohol has health benefits. This was particularly notable in the case of heart disease, which to date has been one of the conditions for which benefits frequently appear in the observational literature. Although there was less research, it appears that the benefits of moderate alcohol consumption for type-2 diabetes are also overblown, and at best are limited to a small protective effect in overweight women. Interestingly, the review did not rule out a causal role of low-level drinking in protecting against depression, although more research is needed here.” Similarly, a systematic review and meta-analysis of studies linking daily alcohol consumption and the risk of all-cause mortality aimed to determine whether low-volume alcohol consumption was associated, either positively or negatively, with risk of death by any means. The review, which was published in March 2023, examined more than 100 studies completed between 1980 and July 2021. Altogether, more the 4.8 million individuals were included as participants in the cohort reviewed. The analysis found “(1) no significant protective associations of occasional or low-volume drinking (moderate drinking) with all-cause mortality; and (2) an increased risk of all-cause mortality for drinkers who drank 25 g or more and a significantly increased risk when drinking 45 g or more per day.”3 Additional studies have looked closely at the link between alcohol consumption and conditions such as arthritis, as well as alcohol and aging in general. While not all are conclusive that there’s significant risk, most show that there is, at least, no significant benefit. Guidelines “Moreover, there are no studies that would demonstrate that the potential beneficial effects of light and moderate drinking on cardiovascular diseases and type 2 diabetes outweigh the cancer risk associated with these same levels of alcohol consumption for individual consumers.”4 Also in 2023, guidelines in Canada were updated but with slightly different recommendations. The 2023 Canadian Guidance on Alcohol and Health advises that an adult should consume no more than two drinks per week. It also stresses that an individual should not have more than two drinks per drinking occasion, with the standard drink size being 12 oz of beer or cider, 5 oz of wine, or 1.5 oz of a spirit, such as vodka or rum. Other countries have much more forgiving guidelines. Australia recommends no more than 10 alcoholic beverages per week. The United States advises two or fewer drinks for men per day and one or less for women. The United Kingdom’s guidelines call for no more than 14 drinks per week, with those drinks spread out over at least three days. There are also guidelines that extend beyond how many drinks per day or week an individual should consume and look at how to best prevent and treat alcohol use disorders. For example, also in Canada, a group of multidisciplinary experts worked to create the Canadian Guidelines on Alcohol Use Disorder Among Older Adults, which offers recommendations on how to prevent, screen, assess and treat alcohol use disorders in individuals older than 65. “Available data indicates that 60% to 80% of older adults in Canada consume alcohol. Overall rates of alcohol use in Canada have remained stable over the past decade. While males overall tend to consume more alcohol than females, alcohol use disorders are more often undiagnosed in females,” says Claire Checkland, executive director of the Canadian Coalition for Senior’s Mental Health. To develop the guidelines, “We formed a multidisciplinary panel of experts led by two guideline panel cochairs. Guideline panel members included experts from mental health, geriatric health, and addiction fields, and persons with lived and living experiences. Our process included a systematic review of literature in the field and then the subsequent development of evidence-based best practice recommendations for clinical practice,” she explains. The recommendations include increased awareness for the risk of alcohol use through labeling, screening older adults for alcohol use at least annually, and asking older adults about their alcohol use in all medical settings included but not limited to hospitals, rehabilitation facilities, community services, and specialized programs. From Research to Recommendation “Asking older adults about substance use helps to normalize the conversation and creates a more open, trusting environment,” Checkland says. “This approach also reduces shame older adults who use alcohol often feel, which prevents them from seeking help.” Christopher Kitamura, MD, a geriatric psychiatrist at Baycrest in Toronto, Canada, and an assistant professor at the University of Toronto, adds that “It is also important to educate older adults on the physiologic changes in the body that accompany aging (including greater sensitivity to alcohol and slow metabolism of alcohol), and about the myriad of potential health effects.” Kitamura further emphasizes that providers should also be aware of the reasons for a patient’s alcohol use and dispel false, often ageist assumptions about why people drink. In doing so they will be able to have more thorough and honest conversations with their patients, leading to better assessments. In turn, this will allow older adults to make the best choices they can about their alcohol use and also receive the most effective medical care, as they are able to be more forthcoming and learn more about how said use affects them. — Sue Coyle, MSW, is a freelance writer in the Philadelphia suburbs.
References 2. Visontay R, Mewton L, Sunderland M, Chapman C, Slade T. Is low-level alcohol consumption really health-protective? A critical review of approaches to promote causal inference and recent applications. Alcohol Clin Exp Res (Hoboken). 2024;48(5):771-780. 3. Zhao J, Stockwell T, Naimi T, Churchill S, Clay J, Sherk A. Association between daily alcohol intake and risk of all-cause mortality: a systematic review and meta-analyses. JAMA Netw Open. 2023;6(3):e236185. 4. No level of alcohol consumption is safe for our health. World Health Organization website. https://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health. Published January 4, 2023.
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