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Substance Abuse by Older Adults:  Estimates of Future Impact on the Treatment System

Table Of Contents

Chapter 8. Analysis of the National Health and Nutrition Examination Survey (NHANES): Longitudinal Analysis of Drinking Over the Life Span

Frederic C. Blow,* Ph.D.
Kristen L. Barry, Ph.D.
Bret E. Fuller, Ph.D.
Brenda M. Booth, Ph.D.

Abstract: Recent research suggests that older adults currently have unique drinking patterns and alcohol-related consequences. The projected population expansion of the older adult population has serious implications both for the number of alcohol-related problems likely to occur among the elderly and the subsequent costs involved in responding to them. This study examined the changes in drinking patterns of a large sample of adults aged 25 years or older studied over a 20-year period from 1972 to 1992. Data from the National Health and Nutrition Examination Survey I (NHANES I) were analyzed over four waves of data collection. Mean weekly drinking levels for the four waves were calculated based on 5- and 10-year age categories. Only alcohol consumers were included in the mean weekly drinking analysis. Although consumption decreases with age, there are mean consumption changes for the baby boom generation, but these are less dramatic than for the current older adult cohort. Mean consumption appears to remain higher over time for the midlife group than for other age groups. These results suggest that the baby boom generation, as it continues to age, could maintain a higher level of alcohol consumption than in previous older adult cohorts.

 

Introduction

 

Overview of Extent of Problem Drinking in Current Elderly Cohort

Alcohol use disorders are important public health problems among older adults aged 60 years old or older. There is emerging evidence that problem drinking affects a larger proportion of the current cohort of older adults than previously thought (Adams, Barry, & Fleming, 1996; Williams & DeBakey, 1992). In the United States, an estimated 2.5 million older adults have problems related to alcohol, and 21 percent of hospitalized people over age 40 have a diagnosis of alcoholism. Related hospital costs are as high as $60 billion per year (Schonfeld & Dupree, 1995). In 1990, those over the age of 65 comprised 13 percent of the U.S. population; by the year 2030, older adults will account for 22 percent of the population (U.S. Bureau of the Census, 1996). Current projections remain high.

The projected population expansion has serious implications both for the number of alcohol-related problems likely to occur among the elderly and the subsequent costs involved in responding to these problems. In fact, the health costs of untreated alcoholism have been well described, but may be even greater among the elderly. Older adults are already at increased risk for many health problems (Adams et al., 1996), including greater risk for harmful drug interactions, injury, depression, memory problems, liver disease, cardiovascular disease, cognitive changes, and sleep problems (Blow et al., 1992). Treatment for alcohol abuse and dependence is important for economic and humane reasons (Graham, 1986); under-recognition and under-treatment may result in ineffective and costly use of health care resources while the underlying causes of the problem are not addressed. Less intense and brief alcohol interventions have demonstrated positive results with older adults (Fleming, Barry, Manwell, Johnson, & London, 1997) and can play an important role in helping older adults who are at-risk or problem drinkers.

 

Prevalence of Alcohol Use in the Current Older Adult Populations

Prevalence estimates for older at-risk and problem drinking using community surveys have ranged from 1 to 15 percent (Adams et al., 1996; Gurland & Cross, 1982; Robins & Regier, 1991; Schuckit & Pastor, 1978). Among adults over 60 in a large primary care study, 15 percent of the men and 12 percent of the women regularly drank in excess of the limits recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (Adams et al., 1996), which, at the time of the study, were "no more than 7 drinks/week for women and no more than 14 drinks/week for men." Rates of at-risk drinking have varied widely across studies depending on the definition of at-risk and problem drinking and the methodology used to obtain samples.

The elderly seen in medical settings—inpatient, primary care, and other health care settings—have consistently higher rates of at-risk drinking and alcohol-related problems (Adams, Yuan, Barboriak, & Rimm, 1993; Dufour & Fuller, 1995) than those in the general population. Among clinical populations, however, estimates of alcohol abuse/dependence are substantially higher because problem drinkers of all ages are more likely to seek health care than are other individuals (Beresford, 1979; Institute of Medicine, 1990). Among elderly patients seeking treatment in hospitals, primary care clinics, and nursing homes for medical or psychiatric problems, rates of concurrent alcoholism have been reported in the range of 15 to 58 percent (Adams et al., 1996; Beresford, Blow, Hill, Singer, & Lucey, 1990; Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 1991; Gomberg, 1980; Schuckit, 1982). Rates for alcohol-related hospitalizations among older patients are similar to those for heart attacks (Adams et al., 1993).

The lifetime prevalence of alcohol dependence among randomly selected hospitalized medical patients was 20.4 percent for those aged 60 to 69, declining to 13.7 percent among patients aged 70 to 79 and to 0 percent for those 80 or older (Gambert & Katsoyannis, 1995; Liberto, Oslin, & Ruskin, 1992). The prevalence of alcohol dependence, defined as those patients currently drinking and meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence, was somewhat lower for all patients, with 10.4 percent for those aged 60 to 69, 6.8 percent for those aged 70 to 79, and 0 percent for those 80 or older. Although the rates of alcohol dependence have generally been shown to decline with age, in one study using hospital discharge data, the 65 or older group consistently had the highest proportion (approximately 60 percent) of alcohol-related diagnoses that were not primary diagnoses (Stinson, Dufour, & Bertolucci, 1989). Prevalence rates often underestimate the problem because of their tendency to underestimate alcohol problems among older adults (Center for Substance Abuse Treatment [CSAT], 1998).

 

Drinking Guidelines

NIAAA's and CSAT's Treatment Improvement Protocol (TIP) on older adults recommended that older adults consume no more than one standard drink per day or seven standard drinks per week (CSAT, 1998; Dufour & Fuller, 1995; U.S. Department of Health and Human Services [DHHS], 2000). In addition, older adults should consume no more than two standard drinks on any drinking day. It is recommended that the limit for women should be slightly less than one standard drink per day. These guidelines are consistent with empirical evidence for health functioning and risk-free drinking among older adults (Chermack, Blow, Hill, & Mudd, 1996). Studies have addressed the benefits of alcohol use, and their recommendations are consistent with the current evidence on the positive health effects of drinking weighed with negative consequences (Doll, Peto, Hall, Wheatley, & Gray, 1994; Klatsky, Armstrong, & Friedman, 1997; Poikolainen, 1991). It is important to note that, because of concomitant medical conditions (e.g. diabetes, hypertension) or potential adverse interactions with medications, some older adults should be advised to abstain. What might be considered light or moderate drinking for individuals in their 30s may have multiple negative health effects in an older person. Therefore, clinicians who treat older patients need to assess alcohol use levels and be aware of health implications associated with that use.

 

Future Older Adult Cohorts

The primary purpose of this chapter is to provide a better understanding of longitudinal changes in drinking among individuals across the adult life span, with a particular focus on the baby boom generation (i.e., those individuals born between 1946 and 1964). Numerous possible datasets were examined for the longitudinal analyses of change in drinking over time across age groups. After exploration of many datasets suggested by a Federal workgroup, the possibilities were narrowed to a large, nationally representative dataset—the long-term NHANES dataset.

NHANES I was an effort by the DHHS's National Center for Health Statistics (NCHS) to conduct a comprehensive examination of the health of Americans across the life span. (For access to more complete information on NHANES, see http://www.cdc.gov/nchs/nhanes.htm). The NHANES (Cycle I) surveys were designed to measure the nutritional status and health of the U.S. population aged 1 to 74 years and to obtain more detailed information on the health status and medical care needs of adults aged 25 to 74 years in the general U.S. population of noninstitutionalized persons in 1972-1974. Information was obtained by means of a household interview, along with extensive medical examinations. The National Health Epidemiological Follow-up Study (NHEFS), a longitudinal study, uses as its baseline the persons aged 25 to 74 who completed the full medical examination in the 1972-1974 NHANES I study (N = 14,407). This study was a joint venture by the NCHS and the National Institute on Aging (NIA), with collaboration from the National Institutes of Health (NIH) and other Public Health Service (PHS) agencies. Four waves of data were collected on this subset, with follow-ups in 1982, 1987, and 1992.

This chapter describes longitudinal trends in drinking across 20 years of assessments for individuals enrolled in NHANES I in 1972.

 

Methods

 

Survey Specifics

A multistage stratified probability sample of clusters of persons was used in NHANES I to obtain a total of 32,331 subjects, of whom 31,973 were interviewed and 23,808 had medical examinations. The study included adults aged 18 to 74. The NHEFS subset of the sample consisted of 14,407 of the original 20,729 persons. The first follow-up occurred 10 years after the initial data collection in 1982 and consisted of 13,383 people, 93 percent of the target sample. In 1987, all available nondeceased members of the original baseline study were assessed, comprising a sample of 11,750. The fourth and final data collection occurred in 1992 and was conducted on the 11,195 members of the cohort who were successfully traced and assessed again.

However, of the 1992 sample, a total of 8,710 had relatively complete alcohol data for all data collection waves and were included in the current analysis.

 

Data Sources

All data and documentation were obtained from the Inter-University Consortium for Political and Social Research (ICPSR), located within the Institute for Social Research at the University of Michigan. Most data were retrieved from publicly accessible databases located on-line at http://www.icpsr.umich.edu. Access to the 1992 NHEFS data was restricted to faculty and staff at select universities and was ordered specially for this project.

 

Longitudinal Dataset

Data from the 1972 initial NHANES study and the 1982, 1987 and 1992 follow-up surveys were used for this analysis. Once obtained, the datasets were linked by subject identification number so that subject files contained data from four longitudinal time periods. Although the data were collected with a complex stratified sample design, no weights were used in the computation of means and standard deviations.

 

Variables

Weekly Drinking Levels. At all four time periods, data were collected on each participant's number of drinking occasions and number of drinks containing alcohol. Somewhat different questions were asked across the waves of data collection, but weekly number of drinks could be estimated for each wave. The following explicates the process that was used for each wave in order to estimate the weekly number of alcoholic drinks.

Only two questions assessed the number of drinks in this survey: (1) How often do you drink beer, wine, or liquor? (8 point scale); and (2) When you drink, how much do you usually drink over 24 hours? For the latter, the actual number was coded.

The total number of drinks was obtained by calculating the number of drinking occasions scaled in weeks multiplied by the number of drinks typically consumed in a 24-hour period. When estimating the number of drinking days in 1 month, the following transformations were used: everyday = 30.45; just about everyday = 25; 2 to 3 times a week = 10; 1 to 4 times a month = 2; more than 3, but fewer than 12 = .5; and no more than 2 to 3 = .1.

If the subject did not drink, the variable was set to missing to include only drinkers in later estimates. Thus, with this transformation, weekly drinking levels were calculated with the following formula:

Although specific drinking questions were asked about the quantity and frequency of alcohol consumption, other items nested in the food intake section of the survey assessed the amount of beer, wine, and liquor consumed on various occasions. These items were used to calculate measures of the weekly number of drinks for this first follow-up study. One item was used to determine alcohol consumption: On average, how many (cans, bottles, glasses, shots, etc.) of (beer, wine, or liquor) do you drink every day, week, month, or year? Number of drinks was recorded, as well as the time frame for which the subject chose to respond. Three items assessed beer, wine, and liquor consumption separately. The following conversions were used for the time multiplier: day = 365.4, week = 52, month = 12, and year = 1. This conversion was then used in the following equation to assess weekly alcohol consumption:

The questions changed again for the last two data collection points. Three items were evaluated to determine the amount of alcohol consumed: (1) On average, how often do you drink beer?; (2) time period response (week, month, etc.); and (3) On days you drank beer, how many cans, bottles, or glasses did you drink? Thus, appropriate recoding was done to item 1 so that the number of drinks was reflected accurately and 3 to 12 times a year was coded as 6 and no more than 3 times a year was coded as 2. In item number 2, week = 52 and month = 12.

The following formula was used to calculate the weekly number of drinks consumed:

These different strategies were necessary because of inconsistent items across the 20 years that data were collected for the NHANES I follow-up assessments. The estimates were coded to make them as similar as possible, so as not to bias results based on the data alone.

 

Age Categories

Although subject ages ranged from 18 to 105, due to small numbers on both ends of the distribution, age categories were constructed from the age of the subject at the time of the first NHANES assessment (1972-1974), adjusted, and included ages 25 to 75. The 10-year age category construction included subjects aged 25 to 34, 35 to 44, 55 to 64, and 65 to 75. The cohorts within the baby boom generation were approximately 50 percent of the youngest age category.

 

Drinking Status

Mean weekly drinking levels for the four waves of data were calculated based on 5- and 10-year age categories. Only drinkers were included to reflect the average drinking levels and variation among that group. Drinking categories were also constructed for a cross-tabulation analysis of changes in drinking status across the life span. For men, "lifetime abstinence" was defined as not taking a drink of alcohol in the time period assessed. The time period for each assessment included 1 year prior to each survey, as well as lifetime use. "Abstinence" was defined as having a score of zero for total weekly drinks; however, questions were asked to determine whether the subject drank at some point in his or her life or answered "2 to 3 drinks per year" on the number-of-drinks item, which would produce a total drinking score of less than .001. "Moderate drinking" was defined as having fewer than 15 drinks per week, and "heavy drinking" was defined as having more than 15 drinks per week. For women, these estimates were calculated separately so that moderate drinking was defined as having fewer than 12 drinks per week and heavy drinking as having more than 12 drinks per week.

 

Data Analysis Strategy

Unweighted mean estimates for drinking were calculated for each 10- and 5-year age category and for each gender. Cross-tabulations were specified indicating differences by gender and by age. Further cross-tabulations were specified for calculating a 20-year change in drinking status from 1972 to 1992.

In addition, the four longitudinal values (lifetime abstinence; current 1-year abstinence; moderate use, heavy use) of total drinks from 1972, 1982, 1987, and 1992 were analyzed in a repeated measures analysis of variance (ANOVA), taking into account the unequal spacing between the years. Within effects were tested by running a polynomial analysis on the pattern of the four means to determine shape and linearity. Between-subjects effects were run for gender and age category to determine whether any effects differed by these variables. Interactions were also tested.

 

Results

 

Demographics

Table  1 includes demographic information for the subjects aged 25 to 75 who entered the study between 1972 and 1974. Because of the consistency in demographic data across age groups and for ease of reading, the data were divided into 10-year increments to depict demographics by age categories. The sample was 64 percent female and primarily Caucasian.

 

Alcohol Consumption

Table  2 shows the mean alcohol consumption levels by age group over the four waves of data collection. Consistent with previous reports (CSAT, 1998), alcohol use decreased with increasing age. This can be seen within age groups across time, demonstrating the aging of the individual cohorts over the 20-year course of the study. In addition, there were mean consumption changes for the baby boom generation, but these were less dramatic than for the current older adult cohort. Mean consumption appeared to remain higher over time for the baby boom group than for other age groups.

 

Changes in Drinking Categories

Analyses were performed to assess changes in drinking for all of the age cohorts in the study. Table  3 shows changes in drinking categories for the 1972 age 25 to 29 cohort from the first assessment in 1972 to the last assessment in 1992. The data in this table are presented for that group in particular because this cohort is now at midlife and encompasses a significant proportion of the baby boom group in this study. Higher consumers of alcohol generally decreased consumption over time across all cohorts. However, the youngest cohort, including the baby boom group, was less likely to become abstinent and more likely to remain in the higher drinking categories over time.

 

 

Table 1 NHANES 1972 Sample Demographic Characteristics: 10-Year Age Categories

Variable

Age Category

25 to 34

35 to 44

45 to 54

55 to 64

65 to 75

N

Percent

N

Percent

N

Percent

N

Percent

N

Percent

Gender

                   

    Male

768

32.20

652

30.38

726

43.89

485

43.42

520

36.93

    Female

1,617

67.80

1,494

69.62

928

56.11

632

56.58

888

63.07

Marital Status

                   

    Divorced

108

4.53

119

5.55

79

4.78

36

3.23

40

2.84

    Never married

237

9.95

92

4.29

74

4.47

38

3.41

77

5.48

    Separated

73

3.06

72

3.36

32

1.93

25

2.24

15

1.07

    Widowed

16

0.67

48

2.24

75

4.53

139

12.46

388

27.60

    Married

1,949

81.79

1,813

84.56

1,394

84.28

878

78.67

886

63.02

Race

                   

    Asian

16

0.67

27

1.26

7

0.42

6

0.54

4

0.28

    African American

250

10.49

270

12.59

174

10.53

123

11.02

174

12.36

    Native American

7

0.29

8

0.37

1

0.06

3

0.27

2

0.14

    Caucasian

2,110

88.54

1,839

85.77

1,471

88.99

984

88.17

1,228

87.22

Education

                   

    Grade school

42

1.91

123

6.17

130

8.56

114

11.06

266

20.32

    Some high school

348

15.82

525

26.33

519

34.17

419

40.64

589

45.00

    High school graduate

805

36.59

641

33.65

469

30.88

264

25.61

223

17.04

    Some college

398

18.09

260

13.04

165

10.86

109

10.57

121

9.24

    College graduate

288

13.09

226

11.33

132

8.69

64

6.21

65

4.97

    Graduate school

319

14.50

123

9.48

104

6.85

61

5.92

45

3.44

NHANES = National Health and Nutrition Examination Survey.

 

 

Table 2 Mean Drinks Per Week, by Gender and Age Group (5-Year Increments), for 1972, 1982, 1987, and 1992 Data

Age

Year

Males

 

Females

Mean

Standard Deviation

N

 

Mean

Standard Deviation

N

25 to 29

1972

5.16

8.78

445

 

1.51

3.84

851

 

1982

7.09

12.21

424

 

2.37

5.78

816

 

1987

6.44

12.20

421

 

2.23

6.87

810

 

1992

4.67

8.86

417

 

1.70

3.72

801

30 to 34

1972

6.31

11.91

323

 

2.31

10.29

766

 

1982

7.65

13.22

311

 

2.65

5.87

748

 

1987

6.76

13.82

306

 

2.10

5.11

743

 

1992

5.59

11.26

302

 

1.83

4.39

739

35 to 39

1972

6.48

9.53

327

 

1.99

4.50

753

 

1982

8.81

14.84

321

 

2.90

6.60

738

 

1987

6.92

14.85

315

 

2.30

9.02

722

 

1992

5.03

8.82

305

 

1.52

3.93

713

40 to 44

1972

6.71

11.44

325

 

1.91

4.93

741

 

1982

8.63

13.92

321

 

2.41

5.29

730

 

1987

7.08

14.24

307

 

1.83

4.42

715

 

1992

5.21

9.90

295

 

1.45

3.55

688

45 to 49

1972

8.52

18.07

362

 

2.00

5.10

469

 

1982

7.66

15.46

361

 

1.82

4.18

461

 

1987

7.02

17.89

339

 

1.50

3.94

448

 

1992

4.79

9.55

312

 

1.20

3.30

423

50 to 54

1972

6.43

12.37

364

 

2.04

4.98

459

 

1982

5.93

11.31

361

 

2.27

4.91

457

 

1987

4.28

8.89

319

 

1.87

5.68

439

 

1992

3.12

6.91

279

 

1.69

4.70

398

55 to 59

1972

5.42

11.17

286

 

1.59

4.60

343

 

1982

5.97

10.30

283

 

1.52

4.16

343

 

1987

5.00

10.74

265

 

1.07

3.42

335

 

1992

2.90

5.76

203

 

.82

2.66

292

60 to 64

1972

4.09

7.34

199

 

2.12

8.27

289

 

1982

4.10

7.42

199

 

1.80

5.97

287

 

1987

3.59

7.78

180

 

.96

3.03

276

 

1992

2.44

5.62

123

 

.88

3.03

227

65 to 69

1972

4.98

13.63

350

 

1.13

3.53

554

 

1982

4.73

10.34

350

 

1.00

3.21

551

 

1989

2.15

5.00

299

 

.63

2.47

499

 

1992

1.87

4.89

151

 

.29

1.45

325

70 to 75

1972

3.50

8.17

170

 

.89

3.07

354

 

1982

3.57

8.30

170

 

.91

3.06

331

 

1987

2.69

7.62

130

 

.45

2.04

288

 

1992

1.84

6.47

52

 

.20

1.01

147

 

 

Table 3 Drinking Categories, by Gender, for the 1972 Cohort Aged 25 to 29: Longitudinal Changes

Year / Age

Female

 

Male

N

Percent

 

N

Percent

1972 (aged 25 to 29)

         

    Lifetime abstinence

147

11.40

 

40

3.10

    Current (one-year) abstinence

146

11.32

 

34

2.64

    Moderate drinking

535

41.47

 

342

26.51

    Heavy drinking

17

1.32

 

29

2.25

    Total

845

65.50

 

445

34.50

Missing = 7

         

1982 (aged 35 to 39)

         

    Lifetime abstinence

15

1.39

 

6

0.56

    Current (one-year) abstinence

296

27.48

 

78

7.24

    Moderate drinking

389

36.12

 

178

16.53

    Heavy drinking

53

4.92

 

62

5.76

    Total

753

69.92

 

324

30.08

Missing = 3

         

1987 (aged 40 to 44)

         

    Lifetime abstinence

26

2.44

 

18

1.69

    Current (one-year) abstinence

302

28.36

 

74

6.95

    Moderate drinking

387

36.34

 

187

17.56

    Heavy drinking

26

2.44

 

45

4.23

    Total

741

69.58

 

324

30.42

Missing = 1

         

1992 (aged 45 to 49)

         

    Lifetime abstinence

46

5.54

 

50

6.02

    Current (one-year) abstinence

212

23.95

 

107

12.88

    Moderate drinking

199

23.95

 

171

20.58

    Heavy drinking

12

1.44

 

34

4.09

    Total

469

56.44

 

362

43.56

Missing = 0

         

Using a multivariate ANOVA (MANOVA) test, there was a significant change in drinking levels over time (Wilk's lambda = .95; f = 116.07; df = 3; p < .0001). Two interactions in the within- and between-subject factors were also significant: consumption by age (Wilk's lambda = .99; f = 3.47; df = 12; p < .0001) and consumption by gender (Wilk's lambda = .98; f = 40.07; df = 3; p < .0001). These findings imply that the patterns of means over time for total drinks per week are different across age category and gender.

The polynomial analysis also showed significant linear (f = 85.09; df = 1; p < .0001) and quadratic (f = 147.98; df = 1; p < .0001) effects for these means. The cubic trend was not significant. The linear and quadratic slopes were, however, significantly different between variables of the age category and gender. This shows that the trend in the series of four means of total drinks per week was largely quadratic in nature, indicating that early and late age drinking was less, whereas midlife drinking was much heavier. Further, the linear and quadratic trends varied by age category and by gender. This also explains the significant interactions between total drinks and age category, as well as total drinks and gender.

 

Discussion

Results from this study demonstrate that drinking levels are higher for the midlife group, including those in the baby boom generation. These new findings are somewhat suggestive that future cohorts of older adults in the United States, particularly the cohort currently in midlife, could be faced with issues related to their alcohol consumption, and most importantly, at-risk drinking as they age. This will place increasingly large numbers of older persons at increased risk for negative health consequences for which the health care system needs to be prepared.

 

Issues Unique to Older Adults

Record numbers of senior citizens are seeking costly health care for acute and chronic conditions (Schneider & Guralnick, 1990; Waldo, Sonnefeld, McKusick, & Arnett, 1989). At-risk drinking is a prevalent concern (Adams et al., 1996) and can significantly affect a number of health conditions in this age group, including hypertension, stroke, and cardiovascular problems (Fleming & Barry, 1992; Klatsky et al., 1997).

Recent research has suggested that elderly individuals currently have unique drinking patterns and alcohol-related consequences, social issues, and treatment needs. This is likely to continue with future cohorts of older adults, and in particular for the baby boom generation. Thus, early identification and secondary prevention of alcohol problems in late life are likely to require new elder-specific approaches. Older adults present challenges in applying brief intervention strategies for reducing alcohol consumption. Because drinking guidelines are lower for older adults and because historical and cultural stigma lead to feelings of disgrace, older adult problem drinkers find it particularly difficult to identify their own risky drinking. However, because the midlife baby boom generation grew up with fewer prohibitions toward drinking and other drug use than the current older adult group, less shame and guilt regarding intervention for at-risk drinking may be present. Future research will need to include "age cohort" as a potential predictor variable to determine the most useful strategies for presenting this generation with health information related to at-risk drinking.

In addition, chronic medical conditions may make it more difficult for clinicians to recognize the role of alcohol in decreased functioning and quality of life. These issues present barriers to appropriate identification and targeted interventions for this vulnerable population.

 

Drinking Guidelines for Older Adults

The data from the current analyses should be placed in the context of the beneficial health effects of alcohol. In particular, the findings that drinking levels seem to increase in the baby boom generation over time suggests that this segment of the population may be appropriate targets for preventive interventions focused on moderating use with increasing age. NIAAA recommends that persons aged 65 or older consume no more than seven drinks per week or no more than one drink per day (Dufour & Fuller, 1995; NIAAA, 1995). Four or more drinks on two or more occasions per month is considered binge drinking. In the United States, one standard drink is 12 grams of alcohol; in the United Kingdom and Europe, one standard drink is 8 grams of alcohol. Adjustments in the recommended guidelines should be made by country.

As suggested earlier, older adults pose special concerns when setting drinking criteria. Compared with younger people, older adults have an increased sensitivity to alcohol and over-the-counter and prescription medications. There is an age-related decrease in lean body mass versus total volume of fat, and the resultant decrease in total body volume increases the total distribution of alcohol and other mood-altering chemicals in the body. Liver enzymes that metabolize alcohol and certain other drugs are less efficient with age, and central nervous system sensitivity increases with age. Of particular concern in this age group is the potential interaction of medication and alcohol. For some patients, any alcohol use in combination with the use of specific over-the-counter or prescription medications can be problematic. Because of age-related changes in how alcohol is metabolized and the potential interactions between medications and alcohol, alcohol use recommendations are generally lower than those set for adults younger than 65 and are usually made on an individual basis (CSAT, 1998).

Maintenance of heavy consumption by females in the midlife cohort is of particular concern because, based on metabolism, women across age groups are more sensitive to the effects of alcohol than men. Also, they are more likely than men to have a shorter trajectory from low-risk to high-risk use and serious alcohol-related problems ("telescoping of symptoms") (CSAT, 1998). In the next 25 years, the health care field may see a trend for women to maintain heavier drinking patterns over time, thus leading to a greater need for prevention/intervention strategies (CSAT, 1999).

 

Long-Term Patterns of Use: Future Needs

With 20 years of follow-up data, NHANES is one of the longest longitudinal analyses of drinking data among adults. These results point to the future prevention and treatment needs among the baby boom generation. Future work in this area is needed to appropriately target those most at-risk for the negative health consequences related to alcohol use. Additionally, alcohol and prescription medication interactions are largely unknown and should also be a focus of future research in this area. The health care field is presented with a challenge to provide care to a greater number of older adults who may be experiencing the health-related effects of alcohol consumption. There is also a unique opportunity to continue to develop and test innovative methods to provide quality, cost-effective alcohol screening and brief interventions. This will ensure that the growing population of older adults receives state-of-the-art "best practices" care to promote health and minimize the emotional, physical, and financial costs associated with alcohol-related problems.

 

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* To whom correspondence should be sent at University of Michigan, Department of Psychiatry, 400 E. Eisenhower Parkway, Suite A, Ann Arbor, MI 48108. Telephone: 734-930-5139. E-mail: fredblow@umich.edu. Opinions in this chapter do not reflect the opinions of the Department of Veterans Affairs, The University of Michigan, or The University of Arkansas for Medical Sciences.

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