Prevalence and patterns of alcohol use in older adults

The study of the prevalence of alcohol use in older adults is complicated by several factors. First, the study population is important as there are large differences in alcohol intake between age cohorts, and even within older adults themselves. Those who are the ‘young-old’ (65–74 years) use alcohol more frequently than the ‘oldest-old’ (85+ years). Second, there are large differences regionally and culturally in alcohol intake. Third, older adults who take up drinking in late life may differ from those who start early in life, and the risk factors may differ in these groups.Reference Wetterling, Veltrup, John and Driessen^12, Reference Liberto and Oslin¹³ Furthermore, those who started drinking earlier in life may be more likely to develop alcohol problems.Reference Moos, Schutte, Brennan and Moos¹⁴

Prevalence rates also vary according to the study setting. For example, studies conducted in care settings, such as nursing homes,Reference Adams^15, Reference Adams¹⁶ emergency departments,Reference Adams, Magruder-Habib, Trued and Broome¹⁷ and hospitals,Reference Ganry, Joly, Stan-Quintin, Queval, Beaudot and Dubreuil¹⁸ have found higher rates of alcohol misuse than studies conducted in general community samples.Reference Moore, Hays, Greendale, Damesyn and Reuben¹⁹ A further problem is that older adults with severe alcohol misuse may choose not to participate in epidemiological studies, resulting in an under-estimate of the importance of alcohol misuse. Those who do participate may under-report their alcohol use.

Alcohol use also varies markedly by country in both levels of alcohol consumption and patterns of drinking. Globally, total consumption was found to be highest in Europe and North America, where alcohol is also often consumed in a detrimental, heavy episodic pattern.Reference Rehm, Rehn, Room, Monteiro, Gmel and Jernigan²⁰ Recent evidence suggests that North Americans are consuming less alcohol relative to 50 years ago.Reference Zhang, Guo, Saitz, Levy, Sartini and Niu²¹ Differences in cohort demographics appear to influence some of this changing consumption.Reference Kerr, Greenfield, Bond, Ye and Rehm²² Across Europe, there are large differences in consumption patterns and beverage choiceReference Sieri, Agudo, Kesse, Klipstein-Grobusch, San-Jose and Welch²³ and consumption patterns are changing.Reference Klipstein-Grobusch, Slimani, Krogh, Keil, Boeing and Overvad²⁴ Evidence may not be generalizable to other cohorts at other periods and in other places.

Another important consideration in evaluating the effects of alcohol is drinking pattern. High volume irregular consumption (‘binge’ or heavy episodic drinking) may be more harmful than high regular intake. Although there has been increasing interest in the consequences of drinking pattern,Reference Murray, Tyas, Snow, Ekuma, Bond and Barnes^25, Reference Rehm, Greenfield and Rogers²⁶ it is not typically assessed in studies of alcohol use. Most studies focus on using standard volume/frequency questions to determine usual levels of alcohol consumption (e.g. 1 drink × 7 days/week and 7 drinks × 1 day/week are both summarized as 7 drinks/week). In younger adults, heavy episodic drinking appears more harmful than large-dose, regular intake of alcohol. In older adults, there are fewer studies that have documented heavy episodic drinking. Recently, Blazer et al.Reference Blazer and Wu²⁷ reported high rates of heavy episodic drinking in older Americans: 14% of men and 3% of women reported heavy episodic drinking (five or more drinks on one occasion, on at least one day in the past month). As younger cohorts – who do drink in binges – age, this phenomenon may become more widespread and problematic.

In summary, the use of alcohol, as well as beverage choice, varies widely between cultures, and has changed over time. In spite of this, some general trends are apparent. First, the level of alcohol use tends to decrease with age,Reference Adams, Garry, Rhyne, Hunt and Goodwin²⁸ but those who consume alcohol continue to drink in older age.Reference Moore, Hays, Greendale, Damesyn and Reuben¹⁹ Moreover, the declines in alcohol use with age seem to be decreasing in younger cohorts.Reference Moore, Gould, Reuben, Greendale, Carter and Zhou²⁹ Second, there seem to be cohort effects with alcohol use in the older population becoming more prevalent. Third, alcohol use is fairly common in older adults. Fourth, heavy episodic drinking is not uncommon among older men, the health effects of which have not been fully elucidated.

Risk factors for alcohol misuse

Several risk factors for alcohol misuse have been identified. Men are more likely to both use and misuse alcohol. This effect is fairly prominent in most population and clinical samples as well as in most countries.Reference Blay, Fillenbaum, Andreoli and Gastal^30–Reference St John, Montgomery and Tyas³³ It is not clear if this gender effect will persist in younger cohorts as they age. Some studies of adults of various ages report that these gender differences in alcohol use have declined.Reference Grucza, Bucholz, Rice and Bierut³⁴ As women from these younger cohorts grow older, they may be more prone to the adverse effects of alcohol.

Another risk factor is age, with young adults consuming higher levels of alcohol than older adults. Even within older age groups, the young-old appear to consume more alcohol than the oldest-old.Reference Moore, Hays, Greendale, Damesyn and Reuben¹⁹ It is not clear if this is an age effect or a cohort effect. This is important from a public policy perspective: as the current generation of middle-aged adults grows older, there will probably be an increase in alcohol consumption, alcohol misuse, and alcohol-related health problems.

Depression has been identified as a risk factor for alcohol misuse.Reference St John, Montgomery and Tyas^33, Reference Conner, Pinquart and Gamble^35–Reference Swendsen, Merikangas, Canino, Kessler, Rubio-Stipec and Angst⁴¹ The causal nature of this association is less clear. In younger cohorts, the effect seems bidirectional: alcohol misuse causes depression, which, in turn, causes worsening alcohol use. Risk factors for both alcohol misuse and depression operate over long time periods. Drinking patterns are often developed in early life, but may change over time. Thus to clearly establish the temporal association between alcohol misuse and depression and to determine causal pathways will require large longitudinal studies conducted over many decades. Still, addressing and treating depression is important. In a recent meta-analysis of trials in younger adults,Reference Nunes and Levin⁴² treating depression was associated with a modest benefit for depressive symptoms and alcohol use. Antidepressants, as part of an overall intervention in which alcohol was also addressed, were beneficial. In older adults, Oslin et al.Reference Oslin, Katz, Edell and Ten Have⁴³ have also reported that treating depression in those with alcohol misuse was effective in reducing alcohol intake.

Individuals with a higher level of education seem to consume more alcohol, but it is not clear if they are concomitantly more likely to suffer from alcohol-related problems. There are also reports suggestive of the impact of other factors influencing alcohol use, such as education,Reference Karlamangla, Zhou, Reuben, Greendale and Moore⁴⁴ marital statusReference Bristow and Clare⁴⁵ and changes in marital status,Reference Perreira and Sloan⁴⁶ voluntary and involuntary retirement,Reference Perreira and Sloan^46, Reference Henkens, van and Gallo⁴⁷ grief and inadequate support,Reference Grimby and Johansson⁴⁸ and family history of alcoholism.Reference Grant⁴⁹

Limitations to evidence

Studying the epidemiology of alcohol use is problematic. Alcohol use varies considerably between societies and has varied substantially over time. Drinking behaviour is highly dependent upon cultural and social factors, including gender, age cohort, and legal and regulatory issues. To further complicate matters, alcohol use patterns can change over time. Period effects, age effects, and cohort effects may all be present.Reference Zhang, Guo, Saitz, Levy, Sartini and Niu^21–Reference Klipstein-Grobusch, Slimani, Krogh, Keil, Boeing and Overvad^24, Reference Kerr, Greenfield and Tujague⁵⁰ For instance, in the United States, prohibition clearly changed alcohol use patterns fairly dramatically.Reference Blocker⁵¹ The era of prohibition created a period effect, where alcohol use declined. It may also have created a cohort effect, where generations living through the time of prohibition continued patterns of low alcohol use throughout their lives. In contrast, the ‘baby boom’ cohort grew up in a period of high substance use, and this milieu may have created a cohort with chronically high use. Studies have not yet successfully disentangled age, period and cohort effects.

A further difficulty in the study of alcohol use relates to issues with self-reporting, since some people may not accurately report their alcohol intake, both intentionally and unintentionally. Moreover, the reporting may be different in different social groups, cultural groups, and age groups, introducing possible bias and differential misclassification.

Benefits of alcohol use

Reduced mortality from cardiovascular disease has been consistently shown in moderate drinkers compared with non-drinkers.Reference Rimm, Williams, Fosher, Criqui and Stampfer^52, Reference Room, Babor and Rehm⁵³ Physiological mechanisms that may explain this cardioprotective effect include beneficial alterations to lipids,Reference Suh, Shaten, Cutler and Kuller⁵⁴ aggregation of plateletsReference Rimm, Giovannucci, Willett, Colditz, Ascherio and Rosner⁵⁵ and inflammatory pathways.Reference Imhof, Froehlich, Brenner, Boeing, Pepys and Koenig^56–Reference Imhof, Woodward, Doering, Helbecque, Loewel and Amouyel⁵⁸ Moderate alcohol consumers may also have less arterial stiffness.Reference Mattace-Raso, Van Der Cammen, Van Den Elzen, Schalekamp, Asmar and Reneman⁵⁹ The reported benefits of alcohol use may vary by age and gender, and it is not clear if such a cardioprotective effect persists later in life. Some studies demonstrate a protective effect but the effect varies with consumption pattern.Reference Snow, Murray, Ekuma, Tyas and Barnes⁶⁰ Furthermore, moderate alcohol use is strongly confounded by health behaviours and preventive service use.Reference Bryson, Au, Sun, Williams, Kivlahan and Bradley^61, Reference Merrick, Hodgkin, Garnick, Horgan, Panas and Ryan⁶² In addition, safe levels of alcohol use in older adults are influenced by physiological changes, with ageing affecting metabolism of alcoholReference Moreno, Pares, Ortiz, Enriquez and Pares⁶³ as well as by contraindications with co-morbidities that increase with age, such as hypertension.Reference Klatsky⁶⁴ Because of these unresolved issues, encouraging alcohol intake in an older population is not recommended.

The health benefits and consequences of alcohol use may also differ by drinking pattern. Although less studied, heavy episodic drinking appears to be hazardous and not to share the cardioprotective benefits of usual alcohol consumption. The well-known J-shaped association of alcohol use with morbidity and mortality can be explained by the increased risk of heavy episodic drinking overwhelming any cardioprotective effects of usual consumption at higher levels of alcohol use.Reference Murray, Connett, Tyas, Bond, Ekuma and Silversides⁶⁵ Any beneficial effects of alcohol use on reducing the risk of cardiovascular disease appears to be lost when the alcohol is consumed in a heavy episodic pattern, especially in middle-aged and older men. In addition, the cardiovascular consequences of heavy episodic drinking become more harmful in older age, particularly in men.Reference Snow, Murray, Ekuma, Tyas and Barnes⁶⁰ At a population level, heavy episodic drinking may result in very large changes in mortality. Indeed, there is some evidence that the dramatic increase in mortality following the collapse of the Soviet Union was partly due to the increase in heavy episodic drinking.Reference Zaridze, Brennan, Boreham, Boroda, Karpov and Lazarev^66, Reference Zaridze, Maximovitch, Lazarev, Igitov, Boroda and Boreham⁶⁷

Risks of alcohol use

Excess alcohol use is associated with numerous medical and social problems. The association between alcohol use and mortality is difficult to study for all of the reasons noted above. Several studies document a mortality risk from high alcohol use.Reference Callahan and Tierney^68–Reference Batty, Hunt, Emslie, Lewars and Gale⁷³ However, Lang et al.Reference Lang, Guralnik, Wallace and Melzer⁷⁴ found that use above the recommendations for older adults was not associated with higher mortality or functional loss. Lee et al.Reference Lee, Sudore, Williams, Lindquist, Chen and Covinsky⁷⁵ also found that the association between moderate alcohol intake and death was confounded by other important social and lifestyle factors. However, even accounting for this, they found that moderate alcohol intake lowered the risk of death. Overall, it seems that high alcohol use is associated with higher mortality, and moderate alcohol use may be associated with lower all-cause mortality. However, the dose at which these effects become apparent is not clear. It is therefore difficult to make solid recommendations about safe doses of alcohol.

Alcohol misuse is strongly associated with numerous health problems. Cirrhosis,Reference Grant, Dufour and Harford⁷⁶ acute hepatitis,Reference Seitz and Stickel⁷⁷ fatty liver,Reference Seitz and Stickel⁷⁷ pancreatitis,Reference Irving, Samokhvalov and Rehm⁷⁸ peptic ulcer disease, oesophagitis and oesophageal cancer,Reference Franke, Teyssen and Singer⁷⁹ peripheral neuropathy,Reference Schuckit³ cerebellar disease,Reference Schuckit³ tuberculosis,Reference Rehm, Samokhvalov, Neuman, Room, Parry and Lonnroth⁸⁰ medication non-adherence,Reference Bryson, Au, Sun, Williams, Kivlahan and Bradley⁸¹ medication adverse effectsReference Moore, Whiteman and Ward⁸² and accidentsReference Sorock, Chen, Gonzalgo and Baker^83, Reference Vingilis and Wilk⁸⁴ are all strongly associated with heavy alcohol use in all age groups. In addition, falls and fractures,Reference Ryg, Rejnmark, Overgaard, Brixen and Vestergaard^85, Reference Harris, Bryson, Sun, Blough and Bradley⁸⁶ urinary incontinence,Reference Kincade, Dougherty, Carlson, Wells, Hunter and Busby-Whitehead⁸⁷ and sleep disordersReference Chueh, Yang, Chen and Chiou⁸⁸ are associated with alcohol. Suicide risk is markedly increased in older adults who misuse alcohol.Reference Flensborg-Madsen, Knop, Mortensen, Becker, Sher and Gronbaek⁸⁹

The association between alcohol use and cognitive impairment is less clear. Thiamine intake is often low in people who misuse alcohol and Wernicke-Korsakoff syndrome is seen more frequently in heavy alcohol users than in non-users.Reference Pearce^90, Reference Sechi and Serra⁹¹ Head trauma is more frequent in heavy alcohol users, and is a strong risk factor for dementia. Alcohol is also a neurotoxin in animal models. However, in epidemiological studies, the effect of alcohol on cognition is less clear.Reference Anstey, Mack and Cherbuin^92–Reference Tyas⁹⁴ Some studies show that moderate alcohol consumption is in fact protective against cognitive decline,Reference Lindeman, Wayne, Baumgartner and Garry^95–Reference Ganguli, Vander, Saxton, Shen and Dodge⁹⁷ and reduces the risk of progression from mild cognitive impairment to dementia.Reference Solfrizzi, D'Introno, Colacicco, Capurso, Del and Baldassarre⁹⁸ However, this effect is strongly confounded by other social and lifestyle factors, making interpretation of these studies somewhat difficult. On the other hand, heavy use of alcohol seems to be associated with an increased risk of dementia.Reference Saunders, Copeland, Dewey, Davidson, McWilliam and Sharma⁴⁰ Two recent reviewsReference Anstey, Mack and Cherbuin^92, Reference Peters, Peters, Warner, Beckett and Bulpitt⁹³ of the literature both conclude that moderate alcohol intake in mid- and late-life may be protective for dementia. However, both studies note that there is considerable heterogeneity in the findings of studies, and considerable risk for selection bias. Further longitudinal research with good measures of alcohol use and misuse conducted over long time frames are needed to address this question. Until these are conducted, encouraging alcohol consumption as a preventative measure for dementia is not warranted based on current evidence.

Alcohol use in older adults is also associated with social consequences. Social problems, such as legal problems or problems at work, are less prominent in older adults than in younger adults. Other social problems, however, persist into late life. Family stress and breakdowns in social and familial relationships are not uncommon in older adults with alcohol misuse. Caregiver stress is seen in caregivers with alcohol-related problems.Reference Sattar, Padala, Arthur-Miller, Roccaforte, Wengel and Burke⁹⁹ Functional impairment is also more prominent in older adults with high alcohol consumption,Reference Perreira and Sloan¹⁰⁰ although moderate intake may be associated with lower risks of functional impairment.Reference Cawthon, Fink, Barrett-Connor, Cauley, Dam and Lewis¹⁰¹

Definitions

Two major classification systems are used to define alcohol use disorders. Historically, both of these classification systems recognized only one disorder: alcoholism. The first editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) did not include diagnostic criteria, but rather provided a description of the disorder. Subsequent iterations of the DSM were therefore revised to include stricter diagnostic criteria and enhance rigour in the diagnosis. Currently, there is good reliability and validity for alcohol dependence in the DSM-IV and ICD-10 definitions. However, the reliability and validity are lower for alcohol abuse/harmful use.Reference Hasin¹⁰³

Substance dependence. The DSM-IV definition of substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following symptoms occurring during the same 12-month period: (1) tolerance, (2) withdrawal, (3) the substance is often taken in larger amounts or over a longer period than intended, (4) a persistent desire or unsuccessful efforts to cut down or control substance use, (5) a great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects, (6) important social, occupational, or recreational activities are given up or reduced because of substance use, and (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.¹⁰⁴

Substance abuse. Alcohol abuse requires fewer symptoms, and thus may be less severe than dependence. It is only diagnosed once the absence of dependence has been established. Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g. repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household); (2) recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile or operating a machine when impaired by substance use); (3) recurrent substance-related legal problems (e.g. arrests for substance-related disorderly conduct); and (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with spouse about consequences of intoxication, physical fights).¹⁰⁴

Harmful use and dependence syndrome. The ICD-10 definitions around alcohol use and misuse differ from the DSM-IV, and use the terminology of harmful use and dependence syndrome. Harmful use is a pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Dependence syndrome is a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with non-dependent individuals.¹⁰⁵

Because both the DSM-IV and ICD-10 diagnostic criteria are precise and sometimes difficult to apply in clinical and research settings, some have advocated other definitions: alcohol misuse, alcohol abuse, and alcoholism have all been widely used and variously defined. These definitions are often not standardized, and are not consistent across studies.

Laboratory abnormalities

Laboratory abnormalities are commonly seen in older adults with alcohol misuse. However, no laboratory test or battery of tests is specific or sensitive for alcohol misuse.Reference Aertgeerts, Buntinx, Ansoms and Fevery¹⁰⁶ Gamma Glutamyl Tranferase (GGT) is often elevated, since it is induced by alcohol.Reference Schuckit³ However, other commonly used medications and common medical problems also cause an elevation of GGT. Macrocytosis is also often elevated in those who misuse alcohol. However, many other common conditions cause macrocytosis as well. Low platelet counts are often seen in those with alcohol misuse, but again, there are many other conditions that cause low platelet counts other than alcohol. Overall, these laboratory tests may be helpful in the assessment of alcohol use in older adults.Reference Conigrave, Davies, Haber and Whitfield¹⁰⁷ However, alone, or considered together, they are neither sensitive nor specific for alcoholism.

The CAGE questionnaire

The CAGE questionnaireReference Ewing^120, Reference Ewing¹²¹ was developed for use in care settings in people of all ages. It has been studied in older populations as well. The CAGE is a four-item instrument that is easy to administer, takes little training, is easily remembered, is quick to perform, and has been widely used for a long period of time. The four simple questions are ‘Have you ever: (1) felt the need to cut down your drinking; (2) felt annoyed by criticism of your drinking; (3) had guilty feelings about drinking; and (4) taken a morning eye opener?’ The CAGE was developed in the 1970s, prior to the era of methodological rigour in validating instruments. In spite of this, it has reasonable inter- and intra-rater reliability. In younger groups, a cut-point of two or more has been proposed. Among older adults, the sensitivity and specificity of the tool has been studied, and most recommend a cut-point of one or more to attempt to maximize sensitivity.Reference Buchsbaum, Buchanan, Centor, Schnoll and Lawton^113, Reference Buchsbaum, Buchanan, Welsh, Centor and Schnoll¹¹⁴ Malet et al. report acceptable sensitivity and specificity in hospital settings.Reference Malet, Schwan, Boussiron, Aublet-Cuvelier and Llorca^116, Reference Malet, Llorca and Reynaud¹²² However, they report low sensitivity in older French people in the general population.Reference Malet, Brousse and Llorca¹²³ Others have also reported poor performance of the CAGE in older women, with a low sensitivity even with a revised cut-point.Reference Bradley, Boyd-Wickizer, Powell and Burman¹¹¹

A further problem is that the CAGE measures lifetime alcohol misuse, rather than current misuse. However, lifetime alcohol use is a dimension of alcohol consumption particularly important in older adults, and supplements other instruments that focus on current use. Overall, despite its strengths and widespread use, the CAGE has limitations in detecting alcohol misuse in older adults, particularly in older women.

The Michigan Alcohol Screening Questionnaire

The Michigan Alcohol Screening Questionnaire (MAST) is an extensive questionnaire of alcohol use and misuse. It is longer and more cumbersome to administer than the AUDIT (Alcohol Use Disorders Identification Test) or the CAGE. In addition, it has a low sensitivity for alcohol misuse in older adults. Two recent meta-analyses have been conducted that caution against the use of the MAST and its derivatives in older adults.Reference Berks and McCormick^110, Reference Fiellin, Reid and O'Connor¹¹⁵ The MAST may give different information on alcohol use than the CAGE questionnaire.Reference Moore, Seeman, Morgenstern, Beck and Reuben¹¹⁷

The AUDIT-C (Alcohol Use Disorders Identification Test)

The original AUDIT questionnaire was developed in 1993 and was a ten-item questionnaire. Subsequently, several shortened versions were proposed. The AUDIT-C is a six-item questionnaire for case finding of alcoholism. AUDIT-C at a cut-off of ⩾ 3 showed a sensitivity of 100% and a specificity of 80.7%. The AUDIT-C appears to perform as well as the longer AUDIT in older populations, although there are relatively few studies comparing the two versions in older populations. Fiellen and O'ConnorReference Fiellin, Reid and O'Connor¹¹⁵ conducted a systematic review and concluded that AUDIT was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity 51–97%; specificity 78–96%), while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity 43–94%; specificity 70–97%). Overall, they noted that there was no ideal screening instrument, but that the current instruments were preferable to other methods of identification of alcohol misuse.

Other interview components

Asking older adults about the pattern of their alcohol consumption is also important. Clinicians should ascertain how frequently a client drinks, the amount that they drink, and the pattern of drinking. As previously noted, heavy episodic drinking may have different health effects than heavy regular drinking, and efforts should be made when conducting clinical assessments to determine the degree to which clients engage in both types of drinking behaviour.

Finally, obtaining collateral history may be important. In general, obtaining collateral history from families and other sources is important in caring for older adults. Whitford et al.Reference Whitford, Widner, Mellick and Elkins¹²⁴ found that the specificity of collateral report was 82.4% and the sensitivity was 71.9% for alcohol misuse. Asking collateral informants about the social situation, social supports, drinking companions and caregiver stress is also important.

Summary of case-finding instruments

In summary, case-finding for alcohol misuse in older adults is difficult: clinical acumen for detecting misuse is poor, laboratory abnormalities are insensitive and non-specific, and questionnaires have gender biases and mediocre sensitivity and specificity. At the current time, however, it seems reasonable to continue to use these instruments, realizing their limitations. While they have limited sensitivity and specificity, they perform better than clinician judgement and are easy to administer. Developing and validating easily administered alcohol case-finding instruments should be a research priority.

Brief alcohol intervention programmes

Primary-care based brief alcohol interventions have been reviewed numerous times in the past, and all have shown a modest benefit in reducing alcohol intake, at least in men.Reference Bertholet, Daeppen, Wietlisbach, Fleming and Burnand^125–Reference Wilk, Jensen and Havighurst¹²⁷ In most of these reviews, brief alcohol intervention programmes are defined as a therapeutic or preventative consultation of short duration undertaken either by a health care professional, general practitioner, or nurse, with the aim of reducing alcohol consumption. They usually include several stages: assessment, feedback, information, advice, and provision of self-help materials. They are generally not conducted over long time frames. Few of the trials included in these meta-analyses were conducted in older adults, and the effectiveness of brief alcohol intervention programmes is thus less clear in older adults. However, Oslin et al.Reference Oslin, Pettinati and Volpicelli¹²⁸ found that older adults were more adherent with both medical and psychosocial interventions than younger adults.

In contrast to primary-care based programmes, there is less evidence for the effectiveness of hospital-based programmes. McQueen et al.Reference McQueen, Howe, Allan and Mains¹²⁹ reported two trials: they concluded that the evidence for brief interventions delivered to heavy alcohol users admitted to general hospital is still inconclusive.

Motivational interviewing

Motivational interviewing has also been shown to reduce alcohol use in younger adults. Vasilaki et al.Reference Vasilaki, Hosier and Cox¹³⁰ conducted a meta-analysis of 22 randomized clinical trials. The interventions were somewhat longer than a brief alcohol intervention, and were defined as a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. In their review, Vasilaki et al.Reference Vasilaki, Hosier and Cox¹³⁰ determined that motivational interviewing programmes reduced alcohol intake. However, the mean age in many of these studies was 33 years, making generalizations to an older population problematic. Furthermore, the authors found that these interventions, when studied in an older population, may be less effective than in a younger population.

Other interventions

Because alcohol withdrawal carries substantial risks in an older population, some advocate in-patient admission for detoxification.Reference O'Connell, Chin, Cunningham and Lawlor⁷ Benzodiazepines are useful in preventing alcohol withdrawal seizures, but it is unclear what dosage would be appropriate for older adults. Disulfuram can precipitate deliriumReference O'Connell, Chin, Cunningham and Lawlor⁷ and caution is advised in its use in an older population. Recently, naltrexone has been studied in a younger population (mean age of 44 years), and may be beneficial.Reference Anton, O'Malley, Ciraulo, Cisler, Couper and Donovan¹³¹ More research in older populations is needed prior to widespread adoption.

Summary of alcohol use interventions

Overall, there is evidence that interventions to reduce alcohol intake are modestly effective in younger populations, but there is less evidence of their effectiveness in older adults. Research is required to determine if brief interventions are effective in older adults, and, if so, which methods may be most effective. Until such evidence is available, it is reasonable to hope that interventions that seem to be effective in younger adults will also afford some assistance to older adults dealing with alcohol misuse.