Alcohol Consumption for Older People
Objectives: To estimate disability plus mortality risks in older people according to level of alcohol intake.
Design: Two population-based cohort studies.
Setting: The Health and Retirement Study (United States) and the English Longitudinal Study of Aging (England).
Participants: Thirteen thousand three hundred thirty-three individuals aged 65 and older followed for 4 to 5 years.
Measurements: Difficulties with activities of daily living (ADLs), instrumental activities of daily living (IADLs), poor cognitive function, and mortality.
Results: One-tenth (10.8%) of U.S. men, 28.6% of English men, 2.9% of U.S. women, and 10.3% of English women drank more than the U.S. National Institute on Alcohol Abuse and Alcoholism recommended limit for people aged 65 and older. Odds ratios (ORs) of disability, or disability plus mortality, in subjects drinking an average of more than one to two drinks per day were similar to ORs in subjects drinking an average of more than none to one drink per day. For example, those drinking more than one to two drinks per day at baseline had an OR of 1.0 (95% confidence interval (CI)=0.8-1.2) for ADL problems, 0.7 (95% CI=0.6-1.0) for IADL problems, and 0.8 (95% CI=0.6-1.1) for poor cognitive function. Findings were robust across alternative models. The shape of the relationship between alcohol consumption and risk of disability was similar in men and women.
Conclusion: Functioning and mortality outcomes in older people with alcohol intakes above U.S. recommended levels for the old but within recommendations for younger adults are not poor. More empirical evidence of net benefit is needed to support screening and intervention efforts in community-living older people with no specific contraindications who drink more than one to two drinks per day.
Alcohol misuse and abuse is associated with numerous health and social problems and substantial excess mortality. In response, the U.S. Preventive Services Task force recommends identification of hazardous drinking and intervention in primary healthcare settings. However, defining the boundary between moderate and hazardous drinking is problematic, especially in older people.
Aging is associated with a number of physiological changes suggesting increased sensitivity to alcohol; for example, with declining body water content, older people tend to have higher blood alcohol concentration after a standard dose. Evidence from humans and laboratory rats indicates that aging interferes with the body's ability to adapt to the presence of alcohol. Based largely on such findings, the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that those aged 65 and older limit themselves to one alcoholic drink per day, half the limit for adult men younger than 65.
In contrast to in the United States, current U.K. recommendations for older people are the same as for younger adults; men drinking three to four "standard units" of alcohol per day (an average of 1.7-2.25 drinks/d) and women drinking two to three standard units (1.1-1.7 drinks/d) "will not accrue significant health risk," although lower limits for older people have been advocated. Most other countries make no specific recommendations for older people; exceptions are Italy, where guidelines for older people are approximately 25% lower than for younger adults, and New Zealand and Australia, where guideline levels are the same for all adults, but older people are advised to consider drinking less.
Recommendations based on physiological vulnerability in old age face a major challenge from empirical evidence that moderate alcohol intake (at least for >1 to 2 drinks/d) are associated with fairly flat mortality risks. This flat consumption-mortality relationship for moderate consumption is linked mainly to a protective effect with regard to cardiovascular disease, a pattern confirmed in meta-analyses of 116,702 subjects and supported by "genetic randomization" evidence. Mortality risks for moderate consumption may, incidentally, also be lower than for abstinence or excessive consumptions, especially in older people. Although hidden confounders may account for some of the abstinence effect, because older people have high rates of cardiovascular disease, the balance of risk and benefit from strictly moderate alcohol consumption may be positive or neutral. Thus, there is clearly a case for exploring evidence-based definitions of hazardous drinking for older people.
If mortality rates in older people consuming more than one to two drinks per day are not higher than rates for those with lower levels of alcohol consumption, it may nevertheless be that physical or cognitive functioning or disability is adversely affected. Everyday functioning is a sensitive and more meaningful measure of the burden of disease than individual diagnoses, because older people often have several diagnoses, and severity varies greatly. The links between alcohol consumption and disability are poorly understood; a meta-analysis concluded that the risk magnitude posed by alcohol use for a range of outcomes, including cognitive and physical functioning, was uncertain and that prospective studies were needed.
This study examined the association between alcohol consumption and physical disability (alone and with mortality) and between alcohol consumption and cognitive function in two linked nationally representative prospective studies of older people. Specifically, the ORs of negative outcomes were estimated across the range of alcohol consumption, paying special attention to consumption in the disputed range of more than one to two drinks per day, higher than U.S. guidelines but within U.K. recommendations for older people.
Abstract and Introduction
Abstract
Objectives: To estimate disability plus mortality risks in older people according to level of alcohol intake.
Design: Two population-based cohort studies.
Setting: The Health and Retirement Study (United States) and the English Longitudinal Study of Aging (England).
Participants: Thirteen thousand three hundred thirty-three individuals aged 65 and older followed for 4 to 5 years.
Measurements: Difficulties with activities of daily living (ADLs), instrumental activities of daily living (IADLs), poor cognitive function, and mortality.
Results: One-tenth (10.8%) of U.S. men, 28.6% of English men, 2.9% of U.S. women, and 10.3% of English women drank more than the U.S. National Institute on Alcohol Abuse and Alcoholism recommended limit for people aged 65 and older. Odds ratios (ORs) of disability, or disability plus mortality, in subjects drinking an average of more than one to two drinks per day were similar to ORs in subjects drinking an average of more than none to one drink per day. For example, those drinking more than one to two drinks per day at baseline had an OR of 1.0 (95% confidence interval (CI)=0.8-1.2) for ADL problems, 0.7 (95% CI=0.6-1.0) for IADL problems, and 0.8 (95% CI=0.6-1.1) for poor cognitive function. Findings were robust across alternative models. The shape of the relationship between alcohol consumption and risk of disability was similar in men and women.
Conclusion: Functioning and mortality outcomes in older people with alcohol intakes above U.S. recommended levels for the old but within recommendations for younger adults are not poor. More empirical evidence of net benefit is needed to support screening and intervention efforts in community-living older people with no specific contraindications who drink more than one to two drinks per day.
Introduction
Alcohol misuse and abuse is associated with numerous health and social problems and substantial excess mortality. In response, the U.S. Preventive Services Task force recommends identification of hazardous drinking and intervention in primary healthcare settings. However, defining the boundary between moderate and hazardous drinking is problematic, especially in older people.
Aging is associated with a number of physiological changes suggesting increased sensitivity to alcohol; for example, with declining body water content, older people tend to have higher blood alcohol concentration after a standard dose. Evidence from humans and laboratory rats indicates that aging interferes with the body's ability to adapt to the presence of alcohol. Based largely on such findings, the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that those aged 65 and older limit themselves to one alcoholic drink per day, half the limit for adult men younger than 65.
In contrast to in the United States, current U.K. recommendations for older people are the same as for younger adults; men drinking three to four "standard units" of alcohol per day (an average of 1.7-2.25 drinks/d) and women drinking two to three standard units (1.1-1.7 drinks/d) "will not accrue significant health risk," although lower limits for older people have been advocated. Most other countries make no specific recommendations for older people; exceptions are Italy, where guidelines for older people are approximately 25% lower than for younger adults, and New Zealand and Australia, where guideline levels are the same for all adults, but older people are advised to consider drinking less.
Recommendations based on physiological vulnerability in old age face a major challenge from empirical evidence that moderate alcohol intake (at least for >1 to 2 drinks/d) are associated with fairly flat mortality risks. This flat consumption-mortality relationship for moderate consumption is linked mainly to a protective effect with regard to cardiovascular disease, a pattern confirmed in meta-analyses of 116,702 subjects and supported by "genetic randomization" evidence. Mortality risks for moderate consumption may, incidentally, also be lower than for abstinence or excessive consumptions, especially in older people. Although hidden confounders may account for some of the abstinence effect, because older people have high rates of cardiovascular disease, the balance of risk and benefit from strictly moderate alcohol consumption may be positive or neutral. Thus, there is clearly a case for exploring evidence-based definitions of hazardous drinking for older people.
If mortality rates in older people consuming more than one to two drinks per day are not higher than rates for those with lower levels of alcohol consumption, it may nevertheless be that physical or cognitive functioning or disability is adversely affected. Everyday functioning is a sensitive and more meaningful measure of the burden of disease than individual diagnoses, because older people often have several diagnoses, and severity varies greatly. The links between alcohol consumption and disability are poorly understood; a meta-analysis concluded that the risk magnitude posed by alcohol use for a range of outcomes, including cognitive and physical functioning, was uncertain and that prospective studies were needed.
This study examined the association between alcohol consumption and physical disability (alone and with mortality) and between alcohol consumption and cognitive function in two linked nationally representative prospective studies of older people. Specifically, the ORs of negative outcomes were estimated across the range of alcohol consumption, paying special attention to consumption in the disputed range of more than one to two drinks per day, higher than U.S. guidelines but within U.K. recommendations for older people.
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