Mohammed T. Abou-Saleh

610 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYwas associated with male gender, poorer cognitive function andincome dissatisfaction. The groups did not overlap much,suggesting some positive aspects of alcohol use, and that selfreportedconsumption (they used the top 10% of quantity) maynot necessarily be associated with alcoholism 46 .Mangion et al. found that men aged 65+ classified as alcoholabusers were more independently mobile than those not abusingalcohol, suggesting greater physical fitness 19 . Bristow and Clare,however, found that in an elderly inpatient sample, drinking inexcess was associated with impairment in mobility 34 .Mirand and Welte studied the relationship between healthorientatedlifestyle and heavy drinking among the elderly in ErieCounty, New York, and reported that the prevalence of heavydrinking was 6%. Heavy drinking was positively associated withbeing male, having suburban residency and currently smoking,and negatively associated with SES, rural residency and degree ofhealth orientation. Age and level of active lifestyle were notrelated to drinking 32 .Molgaard et al. found racial differences among 65+ subjects indrinking level, both before and after age 40. Among Whites,73.8% reported drinking after age 40, compared to 48.6% ofBlacks and 44.3% of Mexican-Americans. A higher proportion ofWhites than Blacks or Mexican-Americans reported moreminimal drinking before and after age 40. However, there wereno statistically significant differences for severe drinking amongthe groups 47 .ONSET OF PROBLEM DRINKING IN THE ELDERLYRecent research has focused on the age-of-onset among elderlyproblem drinkers. Specifically, in several studies two groups haveemerged. First, there are elderly who have had problems withalcohol most of their adult life and have survived to old age,generally referred to as ‘‘early-onset problem drinkers’’. There arealso elderly who may or may not have consumed alcohol earlier intheir lives, but who do not become problem drinkers until later intheir adult life. This group is generally referred to as late-onsetproblem drinkers and the incidence of problem drinking has beenhypothesized to be a result of a stressor.Atkinson et al. studied the age of onset among 132 60+ menadmitted into an outpatient treatment program and found onsetafter age 60 in 15% of the sample and in 29% of the sample aged65+. Later-onset alcohol problems were milder and associatedwith greater psychological stability. Treatment variables werebetter predictors of treatment outcome than age of onset 48 .Brennen and Moos reported that late middle-aged problemdrinkers reported more negative life events, chronic stressors, andsocial resource deficits than did non-problem drinkers 49 . However,in their same population, Brennen and Moos 50 studied men andwomen aged 55–65 and compared age-related loss events, overallnegative life events and chronic stressors reported by late-onset,early-onset and non-problem drinkers. Late-onset problemdrinkers consumed less alcohol than early-onset ones, reportedfewer alcohol-related problems, functioned better, and had fewerstressors than early-onset drinkers. They did not find evidence foran association between age-related loss events and the onset oflate-life drinking patterns. Similarly, Barnes found that neitherwidowhood nor retirement was related to heavy drinking. Heavydrinking was twice as prevalent among those subjects aged 60+who were employed compared to unemployed 14 .Brennen et al. 51 found gender differences among late-middleagedand older problem drinkers. Specifically, women withdrinking problems consumed less alcohol, had fewer drinkingproblems, and reported more recent onset of drinking problemsthan did male problem drinkers. The female problem drinkersalso used more psychoactive medications, were more depressedand were less likely to seek treatment. Osterling and Berglundstudied gender differences in first-time admitted alcoholics aged60+ to a treatment center in Sweden and found that age of onsetof problem drinking occurred significantly later in femalescompared to males. During the period 1988–1992, sex ratiosindicated a significant convergence of female patients comparedwith a decade earlier. The authors make it clear that it is notknown whether this represents an increase in problem drinking inelderly females, or whether females feel more free to seektreatment than a decade earlier 52 . Hurt et al. 53 studied 216patients aged 65+ admitted to an alcoholism treatment program.Early-onset alcoholism was present in 59% of the men and 51%of the women, while late-onset alcoholism was present in 39% ofthe men and 46% of the women (time of onset was not availablefor 2%). Few differences were noted between the two groups 53 .Moos et al. 54 followed their cohort of problem drinkers aged55–65 for 1 year. Remitted problem drinkers were those who didnot experience any problems in the 1 year follow-up period. Atbaseline, the to-be-remitted problem drinkers consumed lessalcohol, reported fewer drinking problems, had friends whoapproved less of their drinking, and were likely to seek help frommental health practitioners. In addition, late-onset problemdrinkers were more likely to remit over the 1 year period.OUTCOMES ASSOCIATED WITH PROBLEMDRINKING IN THE ELDERLYSome medical disorders have been found to be more prevalent inelderly with a history of alcohol use or current use. Hurt et al. 53described 216 elderly patients aged 65+ treated for alcoholism inan inpatient treatment program. The frequency of serious medicaldisorders among this group was higher than what would beexpected for the overall population aged 65+. Hypertension wasless frequent among these patients, while alcoholic liver disease,chronic obstructive pulmonary disease, peptic ulcer disease andpsoriasis were more prevalent among the alcoholic group. Thefrequencies of ischemic heart disease, cerebrovascular disease anddiabetes mellitus were about the same as would be found in thegeneral elderly population 53 . Bristow and Clare found, in theirinpatient sample, that excess drinking was associated with morenon-malignant respiratory disease and less ischemic heartdisease 34 .Increased hospitalizations have also been linked with alcoholuse in the elderly. Callahan and Tierney reported from theirsample of patients aged 60+ that patients with alcoholism weremore likely to be hospitalized (21.5% vs. 16.9%) (p=0.02) withinthe year following the interview, compared to those withoutalcoholism 31 . Using 1989 hospital claims data, the prevalence ofalcohol-related hospitalizations among people aged 65+ in theUSA was 54.7 per 10 000 population for men and 14.8 per 10 000for women, a proportion of hospitalizations among the elderlysimilar to that seen for myocardial infarction 55 .Alcoholism has also been linked with mortality in the elderly.Callahan and Tierney found in their sample of elderly patientsthat those with alcoholism were more likely to die within 2 yearsthan those without evidence of alcoholism, 10.6% compared to6.3% (p=0.001), controlling for age, gender, race, education andsmoking history 31 . In their study of inpatients treated foralcoholism, Hurt et al. followed 60 of their patients for anaverage of 5.2 years (range 2–11 years). A total of 32% of thealcoholic patients had died by follow-up. Of those who died, 47%of the deaths could be attributed to the patient’s alcoholism 53 .Colsher and Wallace, using data from the Iowa 65+ Rural HealthStudy, found that 10.4% of the men had self-reported histories ofhaving been previously heavier drinkers. Three-year mortality washigher among this group, compared to those men without a