![](./ima/aalogo_1.gif)
National Institute on Alcohol Abuse and Alcoholism No.40 April 1998
Alcohol and Aging
Persons age 65 and older constitute the fastest growing segment of the
American population. Although the extent of alcoholism among the elderly is
debated, the diagnosis and treatment of alcohol problems are likely to become
increasingly important as the elderly population grows. This Alcohol
Alert reviews recent research on the extent of alcohol consumption and
associated problems among the elderly, updating an earlier Alcohol Alert
on this subject (1).
Drinking Prevalence and Patterns Among the Elderly
Surveys of different age groups in the community suggest that the elderly,
generally defined as persons older than 65, consume less alcohol and have fewer
alcohol-related problems than younger persons. However, some surveys that track
individuals over time suggest that a person's drinking pattern remains
relatively stable with age, perhaps reflecting societal norms that prevailed
when the person began drinking (1). For example, persons born after World War II
may show a higher prevalence of alcohol problems than persons born in the
1920's, when alcohol use was stigmatized (2). In addition, some people increase
their alcohol consumption later in life, often leading to late-onset alcoholism
(1).
In contrast to most studies of the general population, surveys conducted in
health care settings have found increasing prevalence of alcoholism among the
older population (3). Surveys indicate that 6 to 11 percent of elderly patients
admitted to hospitals exhibit symptoms of alcoholism, as do 20 percent of
elderly patients in psychiatric wards and 14 percent of elderly patients in
emergency rooms (4). In acute-care hospitals, rates of alcohol-related
admissions for the elderly are similar to those for heart attacks (i.e.,
myocardial infarction) (5). Yet hospital staff are significantly less likely to
recognize alcoholism in an older patient than in a younger patient (6).
The prevalence of problem drinking in nursing homes is as high as 49 percent
in some studies, depending in part on survey methods (7). The high prevalence of
problem drinking in this setting may reflect a trend toward using nursing homes
for short-term alcoholism rehabilitation stays (8). Late-onset alcohol problems
also occur in some retirement communities, where drinking at social gatherings
is often the norm (9).
Comparison among studies is complicated by the diversity of the subject
population: The "elderly" span more than four decades in age and range from the
actively employed to the disabled and institutionalized. Consequently, different
studies employ different definitions of the term (8). In addition, surveys of
alcohol consumption among the elderly are subject to potential sources of error
for some of the following reasons:
- Questionnaires customarily used to screen for alcoholism may be
inappropriate for the elderly, who may not exhibit the social, legal, and
occupational consequences of alcohol misuse generally used to diagnose problem
drinkers (10,11).
- Alcohol-related consequences of heavy drinking can be mistaken for medical
or psychiatric conditions common among the elderly. Such consequences may
include depression, insomnia, poor nutrition, congestive heart failure, and
frequent falls (1).
- Because alcohol-related illnesses are a major cause of premature death,
excess mortality among heavy drinkers may leave a surviving older population
who consume less alcohol (1).
Combined Effects of Alcohol and Aging
Although many medical and other problems are associated with both aging and
alcohol misuse, the extent to which these two factors may interact to contribute
to disease is unclear. Some examples of potential alcohol-aging interactions
include the following:
- The incidence of hip fractures in the elderly increases with alcohol
consumption (12,13). This increase can be explained by falls while intoxicated
combined with a more pronounced decrease in bone density in elderly persons
with alcoholism compared with elderly nonalcoholics (4).
- Studies of the general population suggest that moderate alcohol
consumption (up to two drinks per day for men and one drink per day for women)
may confer some protection from heart disease (14,15).1 Although
research on this issue is limited, evidence shows that moderate drinking also
has a protective effect among those older than 65 (16). Because of age-related
body changes in both men and women, NIAAA recommends that persons older than
65 consume no more than one drink per day (17).
- Alcohol-involved traffic crashes are an important cause of trauma and
death in all age groups. The elderly are the fastest growing segment of the
driving population. A person's crash risk per mile increases starting at age
55, exceeding that of a young, beginning driver by age 80. In addition, older
drivers tend to be more seriously injured than younger drivers in crashes of
equivalent magnitude (18). Age may interact with alcoholism to increase
driving risk. For example, an elderly driver with alcoholism is more impaired
than an elderly driver without alcoholism after consuming an equivalent dose
of alcohol, and has a greater risk of a crash (18).
- Long-term alcohol consumption activates enzymes that break down toxic
substances, including alcohol. Upon activation, these enzymes may also break
down some common prescription medications. The average person older than 65
takes two to seven prescription medications daily. Alcohol-medication
interactions are especially common among the elderly, increasing the risk of
negative health effects and potentially influencing the effectiveness of the
medications (19,20).
- Depressive disorders are more common among the elderly than among younger
people and tend to co-occur with alcohol misuse (11,21). Data from the
National Longitudinal Alcohol Epidemiologic Survey demonstrate that, among
persons older than 65, those with alcoholism are approximately three times
more likely to exhibit a major depressive disorder than are those without
alcoholism (22). In one survey, 30 percent of 5,600 elderly patients with
alcoholism were found to have concurrent psychiatric disorders (23). Among
persons older than 65, moderate and heavy drinkers are 16 times more likely
than nondrinkers to die of suicide, which is commonly associated with
depressive disorders (24).
Does Aging Increase Sensitivity to Alcohol?
Limited research suggests that sensitivity to alcohol's health effects may
increase with age. One reason is that the elderly achieve a higher blood alcohol
concentration (BAC) than younger people after consuming an equal amount of
alcohol. The higher BAC results from an age-related decrease in the amount of
body water in which to dilute the alcohol. Therefore, although they can
metabolize and eliminate alcohol as efficiently as younger persons, the elderly
are at increased risk for intoxication and adverse effects (25).
Aging also interferes with the body's ability to adapt to the presence of
alcohol (i.e., tolerance). Through a decreased ability to develop tolerance,
elderly subjects persist in exhibiting certain effects of alcohol (e.g.,
incoordination) at lower doses than younger subjects whose tolerance
increases with increased consumption (26). Thus, an elderly person can
experience the onset of alcohol problems even though his or her drinking pattern
remains unchanged. These conclusions are supported by laboratory experiments
with rats that indicate age-related changes in tolerance to alcohol (27).
Aging, Alcohol, and the Brain
Aging and alcoholism produce similar deficits in intellectual (i.e.,
cognitive) and behavioral functioning. Alcoholism may accelerate normal aging or
cause premature aging of the brain. Using magnetic resonance imaging techniques,
Pfefferbaum and colleagues (28) found more brain tissue loss in subjects with
alcoholism than in those without alcoholism, even after their ages had been
taken into account. In addition, older subjects with alcoholism exhibited more
brain tissue loss than younger subjects with alcoholism, often despite similar
total lifetime alcohol consumption. These results suggest that aging may render
a person more susceptible to alcohol's effects (29).
The frontal lobes of the brain are especially vulnerable to long-term heavy
drinking (28). Research shows that shrinkage of the frontal lobes increases with
alcohol consumption and is associated with intellectual impairment in both older
and younger subjects with alcoholism (30). In addition, older persons with
alcoholism are less likely to recover from cognitive deficits during abstinence
than are younger persons with alcoholism (28).
Age-related changes in volume also occur in the cerebellum, a part of the
brain involved in regulating posture and balance (31). Thus, long-term alcohol
misuse could accelerate the development of age-related postural instability,
increasing the likelihood of falls (32).
Treatment of Alcoholism in the Elderly
Studies indicate that elderly persons with alcohol problems are at least as
likely as younger persons to benefit from alcoholism treatment. The outcomes are
more favorable among persons with shorter histories of problem drinking (i.e.,
late onset). Additionally, although evidence is not entirely consistent, some
studies suggest that treatment outcomes may be improved by treating older
patients in age-segregated settings (33,23).
The use of medications to promote abstinence has not been studied extensively
in elderly subjects. However, one study has suggested that naltrexone (ReVia®)
may help prevent relapse to alcoholism in subjects ages 50 to 70 (34). Results
of research in animals suggest that age-related alterations in specific chemical
messenger systems in the brain may alter the effectiveness of medications used
to treat alcoholism and mental disorders (35).
Alcohol and Aging--A Commentary by NIAAA Director Enoch Gordis, M.D.
Because alcohol problems among older persons often are mistaken for other
conditions associated with the aging process, alcohol abuse and alcoholism in
this population may go undiagnosed and untreated or be treated inappropriately.
Health care providers should discuss alcohol use with their older patients as a
part of routine care. Advice to older patients should include the medical
conditions common to older people, such as high blood pressure and ulcers, that
can be worsened by drinking and over-the-counter and prescription drugs that can
be dangerous, or fatal, when mixed with alcohol. Where there is no medical
condition that would preclude the use of alcohol, older patients should be
advised to limit their alcohol intake to one drink per day. Finally, health care
providers, including emergency room personnel and admitting physicians who
suspect an alcohol problem in their elderly patients, should refer such patients
to treatment. It is a mistaken belief that older persons have little to gain
from alcoholism treatment; each stage of life has its own rewards for sobriety,
and they are all valuable.
Acknowledgments
The National Institute on Alcohol Abuse and Alcoholism wishes to acknowledge
the following individuals who have contributed their time and expertise to the
development of the Alcohol Alert series over the past several years: John
Allen, Ph.D.; Loran D. Archer; Gregory Bloss; Gayle Boyd, Ph.D.; John Doria;
Mary Dufour, M.D., M.P.H.; Michael Eckardt, Ph.D.; Joanne Fertig, Ph.D.; Richard
Fuller, M.D.; David Goldman, M.D.; Bridget Grant, Ph.D., Ph.D; Brenda Hewitt;
Susanne Hiller-Sturmhoefel, Ph.D.; Jan Howard, Ph.D.; Walter Hunt, Ph.D.; Leslie
Isaki, Ph.D.; Robert Karp, Ph.D.; William Lands, Ph.D.; the late Markku
Linnoila, M.D., Ph.D.; Stephen Long; Susan Martin, Ph.D.; Margaret Mattson,
Ph.D.; Diane Miller; Theodore Pinkert, M.D.; Norman Salem, Jr., Ph.D.; Eve
Shapiro; Ernestine Vanderveen, Ph.D.; Kenneth Warren, Ph.D.; Forrest Weight,
Ph.D.; Dianne Welsh; Ellen Witt, Ph.D.; Lori Wolfgang; and Sam Zakhari, Ph.D.
References
(1) National Institute on Alcohol Abuse and Alcoholism. Alcohol
Alert No. 2: Alcohol and Aging. Bethesda, MD: the Institute, 1988. (2)
Beresford, T.P. Alcoholic elderly: Prevalence, screening, diagnosis, and
prognosis. In: Beresford, T., and Gomberg, E. Alcohol and Aging. New
York: Oxford University Press, 1995. pp. 3-18. (3) Adams, W.L.
Interactions between alcohol and other drugs. In: Gurnack, A.M., ed. Older
Adults' Misuse of Alcohol, Medicines, and Other Drugs: Research and Practice
Issues. New York: Springer, 1997. pp. 185-205. (4) Council on Scientific
Affairs, American Medical Association. Alcoholism in the elderly. JAMA
275(10):797-801, 1996. (5) Adams, W.L.; Yuan, Z.; Barboriak, J.J.; et
al. Alcohol-related hospitalizations of elderly people. JAMA
270(10):1222-1225, 1993. (6) Curtis, J.R.; Geller, G.; Stokes,
E.J.; et al. Characteristics, diagnosis, and treatment of alcoholism in elderly
patients. J Am Geriatr Soc 37:310-316, 1989. (7) Joseph, C.L.
Misuse of alcohol and drugs in the nursing home. In: Gurnack, A.M., ed. Older
Adults' Misuse of Alcohol, Medicines, and Other Drugs: Research and Practice
Issues. New York: Springer, 1997. pp. 228-254. (8) Adams, W.L., and
Cox, N.S. Epidemiology of problem drinking among elderly people. In: Gurnack,
A.M., ed. Older Adults' Misuse of Alcohol, Medicines, and Other Drugs:
Research and Practice Issues. New York: Springer, 1997. pp. 1-23. (9)
Atkinson, R.M.; Tolson, R.L.; and Turner, J.A. Late versus early onset
problem drinking in older men. Alcohol Clin Exp Res 14(4):574-579, 1990.
(10) Lakhani, N. Alcohol use amongst community-dwelling elderly people: A
review of the literature. J Adv Nurs 25(6):1227-1232, 1997.
(11) Adams, W.L. Late life outcomes: Health services use and the clinical
encounter. In: Gomberg, E.S.L.; Hegedus, A.M.; and Zucker, R.A. Alcohol
Problems and Aging. NIAAA Research Monograph No. 33. NIH Pub. No. 98-4163.
Bethesda, MD: NIAAA, 1998. (12) Bikle, D.D.; Stesin, A.; Halloran,
B.; et al. Alcohol-induced bone disease: Relationship to age and parathyroid
hormone levels. Alcohol Clin Exp Res 17(3):690-695, 1993. (13)
Schnitzler, C.M.; Menashe, L.; Sutton, C.G.; et al. Serum biochemical and
haematological markers of alcohol abuse in patients with femoral neck and
intertrochanteric fractures. Alcohol Alcohol 23(2):127-132, 1988. (14)
Klatsky, A.L.; Armstrong, M.A.; and Friedman, G.D. Alcohol and mortality.
Ann Intern Med 117(8):646-654, 1992. (15) Thun, M.J.; Peto, R.;
Lopez, A.D.; et al. Alcohol consumption and mortality among middle-aged
and elderly U.S. adults. New Engl J Med 337(24):1705-1714, 1997. (16)
Fried, L.P.; Kronmal, R.A.; Newman, A.B.; et al. Risk factors for 5-year
mortality in older adults: The cardiovascular health study. JAMA
279(8):585-592, 1998. (17) Dufour, M.C.; Archer, L.; and Gordis, E.
Alcohol and the elderly. Clin Geriatr Med 8(1):127-141, 1992. (18)
Waller, P.F. Alcohol, aging, and driving. In: Gomberg, E.S.L.; Hegedus,
A.M.; and Zucker, R.A. Alcohol Problems and Aging. NIAAA Research
Monograph No. 33. NIH Pub. No. 98-4163. Bethesda, MD: NIAAA, 1998. (19)
Korrapati, M.R., and Vestal, R.E. Alcohol and medications in the elderly:
Complex interactions. In: Beresford, T., and Gomberg, E., eds. Alcohol
and Aging. New York: Oxford University Press, 1995. pp. 42-55. (20)
National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert. No.
27: Alcohol-Medication Interactions. Bethesda, MD: the Institute, 1995.
(21) Welte, J.W. Stress and elderly drinking. In: Gomberg, E.S.L.;
Hegedus, A.M.; and Zucker, R.A. Alcohol Problems and Aging. NIAAA
Research Monograph No. 33. NIH Pub. No. 98-4163. Bethesda, MD: NIAAA, 1998.
(22) Grant, B.F., and Harford, T.C. Comorbidity between DSM-IV
alcohol use disorders and major depression: Results of a national survey.
Drug Alcohol Depend (39):197-206, 1995. (23) Moos, R.; Brennan, P.;
and Schutte, K. Life context factors, treatment, and late-life drinking
behavior. In: Gomberg, E.S.L.; Hegedus, A.M.; and Zucker, R.A. Alcohol
Problems and Aging. NIAAA Research Monograph No. 33. NIH Pub. No. 98-4163.
Bethesda, MD: NIAAA, 1998. (24) Grabbe, L.; Demi, A.; Camann, M.A.; et
al. The health status of elderly persons in the last year of life: A comparison
of deaths by suicide, injury, and natural causes. Am J Public Health
87(3):434-437, 1997. (25) Dufour, M., and Fuller, R.K. Alcohol in the
elderly. Annu Rev Med 46:123-132, 1995. (26) Kalant, H.
Pharmacological interactions of aging and alcohol. In: Gomberg, E.S.L.;
Hegedus, A.M.; and Zucker, R.A. Alcohol Problems and Aging. NIAAA
Research Monograph No. 33. NIH Pub. No. 98-4163. Bethesda, MD: NIAAA, 1998.
(27) Spencer, R.L., and McEwen, B.S. Impaired adaptation of the
hypothalamic-pituitary-adrenal axis to chronic ethanol stress in aged rats.
Neuroendocrinology 65(5):353-359, 1997. (28) Pfefferbaum, A.;
Sullivan, E.V.; Mathalon, D.H.; et al. Frontal lobe volume loss observed
with magnetic resonance imaging in older chronic alcoholics. Alcohol Clin Exp
Res 21(3):521-529, 1997. (29) Oscar-Berman, M.; Shagrin, B.; Evert,
D.L.; et al. Impairments of brain and behavior: The neurological effects of
alcohol. Alcohol Health Res World 21(1):65-75, 1997. (30) Harper, C.;
Kril, J.; Sheedy, D.; et al. Neuropathological studies: The
relationship between alcohol and aging. In: Gomberg, E.S.L.; Hegedus, A.M.; and
Zucker, R.A. Alcohol Problems and Aging. NIAAA Research Monograph No. 33.
NIH Pub. No. 98-4163. Bethesda, MD: NIAAA, 1998. (31) Sullivan, E.V.;
Rosenbloom, M.J.; Deshmukh, A.; et al. Alcohol and the cerebellum. Alcohol
Health Res World 19(2):138-141, 1995. (32) Malmivaara, A.;
Heliovaara, M.; Knekt, P.; et al. Risk factors for injurious falls leading to
hospitalization or death in a cohort of 19,500 adults. Am J Epidemiol
138(6):384-394, 1993. (33) Atkinson, R. Treatment programs for aging
alcoholics. In: Beresford, T., and Gomberg, E., eds. Alcohol and Aging.
New York: Oxford University Press, 1995. pp. 186-210. (34) Oslin, D.W.,
and Mellow, A.M. Neurotransmitter-based therapeutic strategies in late-life
alcoholism and other addictions. In: Gomberg, E.S.L.; Hegedus, A.M.; and Zucker,
R.A. Alcohol Problems and Aging. NIAAA Research Monograph No. 33. NIH
Pub. No. 98-4163. Bethesda, MD: NIAAA, 1998. (35) Druse, M.J.;
Tajuddin, N.F.; and Ricken, J.D. Effects of chronic ethanol consumption and
aging on 5-HT2A receptors and 5-HT reuptake sites. Alcohol Clin Exp Res
21(7):1157-1164, 1997.
1 A standard drink is generally considered to be 12 ounces of beer, 5
ounces of wine, or 1.5 ounces of distilled spirits, each drink containing
approximately 0.5 ounces of alcohol.
All material contained in the Alcohol Alert is in the public domain
and may be used or reproduced without permission from NIAAA. Citation of the
source is appreciated.
Copies of the Alcohol Alert are available
free of charge from the National Institute on Alcohol Abuse and Alcoholism
Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686.
Full text of this publication is available on NIAAA's World Wide Web site at
http://www.niaaa.nih.gov
![](./ima/hhslogo1.gif)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service * National Institutes of Health
![](./ima/publicat.gif)
![](./ima/niaaabar.gif)
|