Mohammed T. Abou-Saleh

EPIDEMIOLOGY OF ALCOHOL PROBLEMS 609ounces of absolute alcohol/day was 8.4% in East Boston, 6.6% inNew Haven, 5.4% in Iowa, and 7.2% in North Carolina 25,26 .The prevalence of heavy drinking in clinical samples is similar.Adams et al. screened 5065 patients aged 60+ seen in primarycare and found 15% of the men and 12% of the women regularlydrank in excess of recommended limits; 9% of the men and 2% ofthe women reported regularly consuming more than 21 drinks perweek 33 . Bridgewater et al. reported that the prevalence of heavydrinking was 27% in men and 9% in women in their sample of101 patients from general practice 27 . In their Liverpool study,Saunders et al. found a total of 6.1% of the men and 2.4% of theyear 3 subjects regularly exceeded safe consumption limits. Thesefigures translate into 19.5% of the men and 19.6% of the womenbeing regular drinkers who were exceeding sensible limits. Theyobserved a decline with age in the proportion of subjects who wereregular drinkers 29 . Bristow and Clare interviewed 650 medical andgeriatric admissions over 65 and found 9% of the men but few(0%) of the females drank in excess of recommended safety limits.Another 10% had cut down, primarily because of medicalreasons. Compared to the non-drinkers and light drinkers, theheavy drinkers were more likely to smoke, not to be married, andto have some impairment of mobility 34 . Iliffe et al. found 3.6% ofthe men in their sample and 3.2% of the women admittedconsuming more than 21 and 14 units of alcohol per week,amounts in excess of recommended safe limits for males andfemales. Neither drinking status nor total weekly alcoholconsumption was associated with age, cognitive impairment,depression, falls or inpatient or outpatient care 28 .Although the overall prevalence is low, heavy drinking amongolder adults is of much concern, with perhaps as much as 20% ofusers drinking in excess of recommended limits.IDENTIFICATION OF PROBLEM DRINKINGIN THE ELDERLYPhysicians may have difficulty recognizing alcoholism in elderlysubjects. First, screening instruments used in younger populationsmay not be reliable for older adults. Adams et al. comparedresponses to a beverage-specific self-administered questionnaireabout the quantity and frequency of alcohol use and episodes ofbinge drinking to the widely used CAGE questionnaire (Cutdown, Annoyed by criticism, Guilty about drinking, Eye-openerdrinks) 35 in 5065 primary care patients aged 60+ and found theCAGE performed poorly in detecting heavy or binge drinkers 33 .Lutrell et al. similarly concluded the sensitivity of standardizedscreening instruments was low in patients aged 65+ admitted asemergencies 36 . In addition, many of these screening instrumentsinquire about frequency and quantity of alcohol use. Many elderlymay drink daily but in smaller amounts. These small quantities,however, may cause problems because of interactions withmedications and chronic illness 4 .Second, criteria for alcoholism often include problems withsocial and/or occupational functioning. However, many olderadults are less likely to be married or employed, and therefore lesslikely to report marital or job problems. Older drinkers may bemore likely to maintain a ‘‘low profile’’ and not cause publicdisturbances resulting in legal problems 5 .Finally, physicians may fail to diagnose alcoholism in theelderly, perhaps because they often fail to obtain alcoholhistories 37 or because they confuse perceived symptoms of agingwith symptoms of alcoholism 5 . Curtis et al. screened all newadmissions to the medical service at the Johns Hopkins Hospitalfor alcoholism using the CAGE 35 and the Short Michigan AlcoholScreening Test (SMAST) 38 . The prevalence of alcoholism was27% in patients under age 60 and 21% in patients 60+. These agedifferences were not significant. However, 60% of screen-positiveyounger patients were identified as having alcoholism by theirhouse officers, compared to only 37% of those aged 60+. Elderlypatients with alcoholism were less likely to be diagnosed if theywere White, female or had completed high school 39 .In a similar study, Adams et al. screened patients aged 65+who came to the emergency department for alcoholism. Usingtheir criteria of either CAGE-positive or self-reported drinkingproblem and alcohol use within the past year, they found thecurrent prevalence of alcohol abuse was 14%, with a highprevalence (22%) among those presenting with gastrointestinalproblems. Physicians, however, detected only 21% of currentalcohol abusers 40 . In a study conducted in The Netherlands,scores on the Dutch version of the Munich Alcoholism Test 41 andmedical records were obtained from 132 patients aged 65+staying at University Hospital Leiden. Two-thirds of the alcoholicpatients were recognized by the attending physician 30 . Finally,medical staff identified only 33 of 99 problem drinkers amonginpatients aged 65+ in three hospitals in New South Wales 42 .These studies consistently show that older problem drinkersmay be more difficult to identify as a result of poor screeninginstruments, failure of clinicians to consider problem drinking as apossible contributing diagnosis, and difficulty in separatingproblems caused by alcohol from those caused by other diseases.FACTORS ASSOCIATED WITH ALCOHOLUSE IN THE ELDERLYAmong the elderly, alcohol use has been shown to be associatedwith male gender 17,22,31–33,43 , higher income 22 , more education 22,33 ,lower socioeconomic status 32 , being married 33 and current orformer smoking 32–34 . Other studies have found alcohol useassociated with less education 31 . Goodwin et al. found nodifferences in social support between elderly drinkers and nondrinkersand no relationship between alcohol intake andemotional status 22 .Two factors often associated with alcoholism in late life aredepression and impairments in cognitive functioning. Saunderset al., using data from their Liverpool study, reported 44% of men65 or older with a history of heavy drinking were given currentpsychiatric diagnoses, compared with 12% of the men without ahistory of heavy drinking. The most common diagnoses weredepression and dementia. The association between drinkinghistory and current psychiatric morbidity was not explained bycurrent drinking habits 44 . Finlayson et al. 45 studied 216 patientsaged 65+ admitted to the hospital for treatment of alcoholism.Patients with late-onset alcoholism (aged 60+) reported a higherfrequency of life events associated with problem drinkingcompared to those with earlier onset. The most common comorbidpsychiatric disorders were tobacco dependence (67%),organic brain syndrome (25%), atypical or mixed organic brainsyndrome (19%) and affective disorder (12%); 14% of thepatients had a drug abuse or dependence problem, all usinglegally prescribed drugs 45 . Similarly, Speckens et al. found thatalcoholics used more psychotropic drugs compared to nonalcoholicsand suffered more often from organic brain disease 30 .Iliffe et al., however, found among patients aged 75+ thatcurrent drinking was not related to age, depression or mentalstatus score 28 . Goodwin et al. found that those elderly whoconsumed alcohol performed better on the cognitive functioningtests, but no relationship was found between past alcoholconsumption and present cognitive performance. The authorsconcluded that alcohol may not impair cognitive functioning inthe elderly 22 . In a study of adults aged 70–75 in Italy, self-reportedalcohol consumption was associated with male gender, bettermood, less cognitive and functional impairment, better health, notliving alone and being married, while CAGE-positive alcoholism