Alcohol and Aging Clinical and Public Health Perspectives

Alexis Kuerbis
Alison A. Moore
Paul Sacco
Faika Zanjani Editors
Alcohol and Aging
Clinical and Public

Health Perspectives
123
Alcohol and Aging
Alexis Kuerbis • Alison A. Moore
Paul Sacco • Faika Zanjani
Editors
Alcohol and Aging

Clinical and Public Health Perspectives
Editors
Alexis Kuerbis Alison A. Moore
Silberman School of Social Work Division of Geriatrics
Hunter College at the City University of California, San Diego
University of New York San Diego, CA, USA
New York, NY, USA
Faika Zanjani
Paul Sacco Department of Behavioral & Community
School of Social Work Health
University of Maryland School of Public Health,
Baltimore, MD, USA University of Maryland
College Park, MD, USA
ISBN 978-3-319-47231-7 ISBN 978-3-319-47233-1 (eBook)

DOI 10.1007/978-3-319-47233-1
Library of Congress Control Number: 2016959504
© Springer International Publishing AG 2016

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The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For Nancy Jack and Stan Kuerbis
—A.K.
For Arthur Brody
—A.A.M.
For Carol and Humbert Sacco
—P.S.
For Farah, Asad, Noah, and Anaya Zanjani,
and Joe Remias
—F.Z.
Acknowledgements
We would like to acknowledge all the adults that have aged and educated us—our
friends, family, clients, patients, and the participants in our studies. We would also
like to express our gratitude to our mentors and the researchers willing to take on
what feels like a sometimes thankless and endless mission for healthy aging. This
book would not have been possible without the enormous efforts of our contributing
authors—we are in your debt—and we are grateful for your work on this book. We
would also like to thank our editor Portia Levasseur for keeping us organized and
moving forward. Finally, both Drs. Moore and Zanjani would like to thank their
Program Officers at both the National Institute for Alcohol Abuse and Alcoholism
(Rosalind Breslow, PhD) and the National Institute on Drug Abuse at the National
Institutes of Health.
vii
Contents
Part I Introduction
1 Thinking Behind Alcohol Consumption in Old Age:
Psychological and Sociological Reasons for Drinking
in Old Age................................................................................................. 3
Catherine Haighton
Part II Epidemiological Perspectives of Alcohol and Aging

2 Understanding Alcohol Consumption Patterns
among Older Adults: Continuity and Change...................................... 19
Paul Sacco
3 Alcohol Use and Comorbid Psychiatric and Subsyndromal
Disorders among Older Adults............................................................... 35
Alexis Kuerbis, Rachel Chernick, and Daniel S. Gardner
Part III Alcohol Effects on Healthy Aging

4 Alcohol Consumption and Cardiovascular Disease
in Aging Populations................................................................................ 57
Edmond K. Kabagambe and Kenneth J. Mukamal
5 Cancer, Alcohol, and Aging.................................................................... 65
Christine L. Savage, Deborah S. Finnell, and Amanda Choflet
6 Alcohol and Cognition............................................................................. 79
Brian Downer and Julie B. Boron
7 Alcohol, Injury, and Aging...................................................................... 97
Namkee G. Choi, Diana M. DiNitto, C. Nathan Marti,
and Bryan Y. Choi
8 Medications, Alcohol, and Aging............................................................ 117
Patricia W. Slattum and Omar E. Hassan
9 The Intersection of Elder Abuse and Alcohol Misuse.......................... 131
Pamela B. Teaster and Nancy Brossoie
ix
x Contents
10 Social and Familial Contexts for Drinking among Older Adults........ 149

Rachel Chernick and Alexis Kuerbis
Part IV Clinical Issues of Alcohol and Aging

11 Screening and Assessment of Unhealthy Alcohol Use
in Older Adults......................................................................................... 169
Alison A. Moore, Alexis Kuerbis, Paul Sacco, Grace I. Chen,
and Maristela B. Garcia
12 Treatment of Unhealthy Alcohol Use in Older Adults......................... 181
David W. Oslin and Faika Zanjani
13 Self-Medication with Alcohol: Aging Issues.......................................... 201
Sarah L. Canham and Pia M. Mauro
14 Adapting SBIRT for Older Adults......................................................... 215
Lawrence Schonfeld
15 Long-Term Care and Alcohol Use.......................................................... 233
Nicholas Castle, Mary Lindsey Smith, and David G. Wolf
16 Drinking, Aging, and Global Public Policy........................................... 247
Marjana Martinic and Anna Sheveland
Part V Future Directions

17 Future Directions for Aging and Alcohol.............................................. 261
Alexis Kuerbis, Alison A. Moore, Paul Sacco, and Faika Zanjani
Index.................................................................................................................. 275
Contributors
Julie B. Boron, Ph.D. Department of Gerontology, University of Nebraska,

Omaha, NE, USA
Nancy Brossoie, Ph.D. Center for Gerontology, Virginia Tech, Blacksburg, VA, USA
Sarah L. Canham, Ph.D. Gerontology Research Centre, Simon Fraser University,
Vancouver, BC, Canada
Nicholas Castle, Ph.D. Department of Health Policy & Management, University
of Pittsburgh, Pittsburgh, PA, USA
Grace I. Chen, M.D. Division of Geriatrics, University of California, Los Angeles,
Los Angeles, CA, USA
Rachel Chernick, L.C.S.W. Department of Social Welfare, The Graduate Center,
CUNY, New York, NY, USA
Amanda Choflet, M.S., R.N., O.C.N. Department of Radiation Oncology &
Molecular Radiation Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
Bryan Y. Choi, M.D., M.P.H. Department of Emergency Medicine, Brown
University Warren Alpert Medical School, Providence, RI, USA
Namkee G. Choi, Ph.D. School of Social Work, The University of Texas at Austin,
Austin, TX, USA
Diana M. DiNitto, Ph.D. School of Social Work, The University of Texas at
Austin, Austin, TX, USA
Brian Downer, Ph.D. Division of Rehabilitation Sciences, University of Texas
Medical Branch, Galveston, TX, USA
Deborah S. Finnell, D.N.S. Department of Community-Public Health, Johns
Hopkins University School of Nursing, The Johns Hopkins University, Baltimore,
MD, USA
Maristela B. Garcia, M.D. Division of Geriatrics, University of California, Los
Angeles, Los Angeles, CA, USA
xi
xii Contributors
Daniel S. Gardner, Ph.D., L.C.S.W. Silberman School of Social Work, Hunter

College at the City University of New York, New York, NY, USA
Catherine Haighton, Ph.D., M.A., B.Sc. Department of Social Work, Education
and Community Health, Faculty of Health and Life Sciences, Northumbria
University, Coach Lane Campus West Newcastle upon Tyne, UK
Omar E. Hassan, B.S. Department of Pharmacotherapy and Outcomes Science,
Virginia Commonwealth University, Richmond, VA, USA
Edmond K. Kabagambe, D.V.M., M.S., Ph.D. Division of Epidemiology,
Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
Alexis Kuerbis, L.C.S.W., Ph.D. Silberman School of Social Work, Hunter
College at the City University of New York, New York, NY, USA
C. Nathan Marti, Ph.D. School of Social Work, The University of Texas at Austin,
Austin, TX, USA
Marjana Martinic, Ph.D. International Alliance for Responsible Drinking,
Washington, DC, USA
Pia M. Mauro, Ph.D. Department of Epidemiology, Columbia University Mailman
School of Public Health, New York, NY, USA
Alison A. Moore, M.D., M.P.H. Division of Geriatrics, University of California,
San Diego, San Diego, CA, USA
Kenneth J. Mukamal, M.D., M.P.H. Department of Medicine, Beth Israel
Deaconess Medical Center, Massachusetts, Brookline, MA, USA
David W. Oslin, M.D. VISN 4 MIRECC, Michael J. Crescenz VA Medical Center,
Philadelphia, PA, USA
Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA
Paul Sacco, Ph.D., M.S.W. School of Social Work, University of Maryland,
Baltimore, MD, USA
Christine L. Savage, Ph.D., R.N., C.A.R.N., F.A.A.N. Department of Community-
Public Health, Johns Hopkins University School of Nursing, Baltimore, MD, USA
Lawrence Schonfeld, Ph.D. Department of Mental Health Law and Policy, Florida
Mental Health Institute, University of South Florida, Tampa, FL, USA
Anna Sheveland, Ph.D. International Alliance for Responsible Drinking,
Washington, DC, USA
Contributors xiii
Patricia W. Slattum, Pharm.D., Ph.D. Department of Pharmacotherapy and

Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
Mary Lindsey Smith, Ph.D., M.S.W. Cutler Institute for Health and Social Policy,
Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
Pamela B. Teaster, B.S., M.A., Ph.D. Center for Gerontology, Virginia Tech,
Blacksburg, VA, USA
David G. Wolf, Ph.D., M.S.O.L. School of Professional & Career Education,
Barry University, Pembroke Pines, FL, USA
Faika Zanjani, Ph.D. Department of Behavioral and Community Health, School
of Public Health, University of Maryland, College Park, MD, USA
Part I
Introduction
Thinking Behind Alcohol Consumption
in Old Age: Psychological 1
and Sociological Reasons for Drinking
in Old Age
Catherine Haighton
1.1 Introduction
Population ageing is taking place in nearly all the countries of the world and this is
expected to continue over the coming years [1]. Alcohol problems often occur in later
life and are associated with notable social, psychological, physical and economic con-
sequences; however, in later life alcohol problems are often less obvious, misdiag-
nosed or go under-detected and under-reported [2]. Alcohol consumption and
alcohol-related deaths or problems have recently increased among older age groups in
many developed countries, including the USA, Australia and several countries of the
European Union [3–7]. This increase in consumption, in combination with the ageing
of populations worldwide, means that the absolute number of older people with alco-
hol problems is on the increase and a real danger exists that a “silent epidemic” may
be evolving [2]. Although there is growing recognition of this public health problem,
clinicians consistently under-detect alcohol problems and under-deliver behaviour
change interventions to older people [8, 9] while nurses report that they do not engage
with older people as they worry about depriving them of the social benefits of drink-
ing [10, 11]. In order for health professionals to successfully intervene with older
people who are experiencing alcohol problems, it is important to understand the
underlying factors that may increase exposure to, or consumption of, alcohol. An
understanding of the different trajectories among older drinkers may also help health
professional in directing treatment towards those affected more severely [12].
This chapter will draw on data from a UK-based qualitative study aimed at
understanding older people’s reasoning about drinking in later life in order to inform
future, targeted, prevention in this group [13]. In 2010, a diverse sample of older
C. Haighton, Ph.D., M.A., B.Sc. (*)

Associate Professor in Public Health and Wellbeing, Department of Social Work, Education
and Community Health, Faculty of Health and Life Sciences, Northumbria University,
Room B125, Coach Lane Campus West, Newcastle upon Tyne NE7 7XA, UK
e-mail: [email protected]
© Springer International Publishing AG 2016 3

A. Kuerbis et al. (eds.), Alcohol and Aging, DOI 10.1007/978-3-319-47233-1_1
4 C. Haighton
adults in the North East of England (aged 50–95) participated in interviews (n = 24,
12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female).
Data were analysed using principles from grounded theory and discursive psychol-
ogy. Participants aged 50 and above were sought in order to consider views both
leading up to and following the transition to retirement, and to consider how prob-
lems after the age of 65 may arise in late working life (see Table 1.1). Detailed
methods have been reported previously [14].
Table 1.1 Interviewee characteristics

Interviewee From interview: self-reported drinking From interview:
number Age Gender status /behaviour lives with
1 61 m Recovering dependent drinker Other residents
Abstinent for 2.5 years
2a 59 f Recovering dependent drinker Adult child
Sensible drinker for 12 years Adult child’s
partner
Grandchild
3a 56 f Dependent drinker Husband
Adult child
4a 61 m Dependent drinker Alone
5 52 m Recovering dependent drinker Alone
Abstinent for 2 months
6 59 m Recovering dependent drinker Wife
Abstinent for 4 weeks
7 57 m Recovering dependent drinker Wife
Abstinent for 2 years
8a 74 m 3 L whisky per week Alone
9 62 m Previously 3–4 pints on 3–4 nights per Alone
week
Abstinent for 6 months
10 60 m Recovering dependent drinker Alone
Abstinent for 1 year
11 55 f Recovering dependent drinker Alone
Abstinent for 9 weeks
12 51 f Previously 3 L cider + 2 cans per day Husband
Abstinent for 1 year Teenage children
13 68 m Recovering dependent drinker Unknown
Abstinent for 5 years
14a 58 f Previously 2 bottles spirits per weekend Alone
Reduced to occasional glass of wine for
past 2 years
15a 65 m Previously 13 pints beer per night Alone
Reduced to 2–3 pints per night for
1.5 years
(continued)
1 Thinking Behind Alcohol Consumption in Old Age… 5
Table 1.1 (continued)
Interviewee From interview: self-reported drinking From interview:
number Age Gender status /behaviour lives with
16a 52 f Reducing dependent drinker Husband
From bottles of spirits to 4 pints, 5 days a Adult children
week
17a 70 f Bottle of wine a day Other residents
Abstinent while hospitalised only
18a 78 f Occasional minimal drinker Other residents
21a 56 m 4–5 pints/night, 2 nights/week Partner and sons
Reduced from previous levels
22a 59 f Previously a bottle a night for a period Partner
Reduced to glass or two of wine a night,
not every night.
23a 58 f 4 vodka and tonics a night, twice a week Partner
24a 72 m 4 pints beer every night, sometimes two Wife
gin and tonics
Source: From Wilson GB, Kaner EFS, Crosland A, Ling J, McCabe K, Haighton CA (2013) A
Qualitative Study of Alcohol, Health and Identities among UK Adults in Later Life. PLoS One
8(8): e71792
a
Currently consuming alcohol
Each motivation for drinking in old age will be accompanied by a verbatim excerpt
from our qualitative data in order to directly illustrate, in the words of older people, their
reasons for consuming alcohol. General findings from our data will be compared with
the academic literature in order to summarise current thinking on each of these causes.
1.2 Reasons for Drinking
1.2.1 Early Onset
I had been drinking all my life, since I was 18. I worked 33 years, so actually it was a
drink culture; you finish work and straight to the pub. I think I was … you get to the stage
where it’s the norm, 5 nights a week. You don’t pay any attention to it when you’re
younger, you think it’s the norm; you’re having a great time. That went on for many years.
(Interview 10, Age 60, Male)
Our data revealed that many participants felt that their drinking had started in
their twenties or thirties, and described this as a response to patterns of heavy use in
youth or within local or work cultures. Individuals who have had alcohol-related
problems over several decades and have survived into old age tend to be referred to
as early onset drinkers. It is estimated that two-thirds of older drinkers fall into this
6 C. Haighton
category [2]. Early onset drinkers tend to have a higher prevalence of antisocial
behaviour than late-onset drinkers and a family history of alcohol dependence [15].
Family estrangements are also frequently seen in this group [15].
Late-onset drinking accounts for the remaining one-third of older people who
use alcohol excessively [2]. Late-onset drinkers usually begin drinking in their 50s
or 60s and tend to be of a higher socio-economic status than early onset drinkers
with higher levels of education and income [2]. Stressful life events, such as
bereavement or retirement, may trigger late-onset drinking in some, but not all,
persons [16]. One study demonstrated that 70 % of late-onset drinkers had experi-
enced stressful life events, compared with 25 % of early onset drinkers [17]. Those
whose alcohol problems are of late onset tend to have fewer health problems and
are more receptive to treatment than those with early onset problems; they are also
more likely to recover spontaneously [18].
A motivational model of alcohol use has been developed which could help our
understanding of the reasons for alcohol consumption in older people [19, 20].
Although the model was originally developed with adolescents and young adults, it
proposes that reasons for consuming alcohol can be categorised as either positive or
negative reinforcement, for example drinking for social (positive) reasons or drink-
ing for coping (negative) reasons [19, 20]. While much of the literature around
drinking in older age proposes an association with coping with significant negative
life events our work [13, 14], and that of others [21–24], also suggests some positive
associations. Therefore, both positive and negative explanations for alcohol con-
sumption will be presented later.
1.2.2 Enjoyment/Socialising
I love a drink … I associate drinking with banter, friends, where I can sit and talk and chat
away to somebody and talk about this and that.
Our focus group participants emphasised strongly that they enjoyed their use of
alcohol, no matter how careful they described themselves as being in their choice of
drinks. Going out for a drink was associated with a change in surroundings, the
opportunity to socialise with old acquaintances and other activities such as bingo.
Younger participants in one group tended to stress how much they enjoyed having a
glass of wine or two in the house. Those who consumed alcohol outside the home
talked positively about needing or liking to meet the ‘gang’, which for them meant
going to a pub or somewhere else they could drink. In one woman’s case, going out
for a drink with friends was described as an occasional relief from the boredom of
staying in as carer for her husband; while another usually went drinking with her
daughter. Many interviewees enjoyed drinking and saw it in some cases as having a
key role in their lifestyle. Drinking could be associated with laughter, good times
and particular ‘ambience’. Some men in the sample described their drinking as
being very strongly enmeshed with their cultural and occupational backgrounds.
Drinking patterns arose from those determined by shift working, relationships with
drinking acquaintances had developed over a long time and favourite haunts were
associated with those people and routines.
Research has revealed that people aged 75 and over who drink are more likely to
be people who still have a fairly active and sociable lifestyle [25]. These findings are
consistent with a study which examined drinking behaviour among US adults living
in a continuing care retirement community. They concluded that alcohol use among
this sample of older adults was largely motivated by a desire for socialisation.
However, the participants in this study were not necessarily representative of the
general population and were not experiencing alcohol-related problems [23]. A
similar study of men and women (65–74 years old) living in private residences or
retirement villages in Australia also found alcohol use was linked with social
engagement in activities and that moderate alcohol use appeared to serve an impor-
tant function as a “social lubricant” [24]. Community-dwelling older people in New
Zealand also reported consuming alcohol for social reasons, before and with meals
and because alcohol helped them to relax [21]. In addition, they also cited encour-
agement from friends and enjoyment of drinking alcohol as reasons for increasing
alcohol use [21] a finding that was replicated in the Whitehall II Cohort Study of
6011 participants aged 61–85 years who cited more social occasions as a reason for
increases in alcohol consumption [22].
1.3 Self-Medication
1.3.1 Mental Health Problems
… then depression, the thing was I turned to drink to sort of shave the edges if you like …
to put on not so much rose-coloured spectacles, but to shade reality and to get a bit out of
reality to … I suppose … not facing things as they are. And depression, you know you
have a drink and then have another one or whatever.
(Interview 12, Age 51, Female)
In many of our interviews talk turned to the use of alcohol as a strategy for cop-
ing with panic attacks or anxiety or to achieve oblivion, ‘blot’ things out or ‘wipe
your mind’. The participant quoted earlier spoke, for instance, of drinking to ‘shut
down’ emotions or ‘shave the edges off reality’, another of drinking to put himself
in his ‘domain’ or ‘safe zone’. We observed that many of our interviewees suffered
from mental health problems and in this context the capacity of drink to provide
relief from stress was also presented as self-medication in their accounts. As a relax-
ant, drink could be seen as a means of alleviating panic attacks. Others spoke of
using alcohol to moderate their moods or ease depression. Some precise descrip-
tions were given of how much alcohol, how often, would achieve the effect of ‘lift-
ing’ mood. At other times participants spoke of using alcohol to get ‘blotto’ and
obliterate feelings they associated with depression, for instance guilt at losing a job,
or memories of abuse, or to forget troubles from their past or present, rather than
cope with them.
8 C. Haighton
Depression, anxiety and other mental health problems are commonly seen in
older individuals with alcohol dependence [26] with many older adults who develop
depressive symptoms having a higher likelihood for day drinking [27]. A study
using daily drink diaries, over a 60-day period, within a community of 154 heavy
drinking residents revealed patterns and thoughts surrounding alcohol consumption.
People commonly drank alcohol to enhance positive daily experiences and also to
mask negative experiences; consequently, the diary entries showed that the indi-
viduals increased their desire to drink following negative work or non-work events.
Also revealed was that women had a tendency to drink more alcohol when stressed
compared to men [28]. Another study reported that the use of alcohol and drugs, to
relieve affective symptoms, was common among individuals with mood disorders in
the general population. Almost one-quarter of individuals with mood disorders
(24.1 %) used alcohol or drugs to relieve symptoms. The highest prevalence of self-
medication was seen in bipolar I disorder (41.0 %). Men were more than twice as
likely as women to engage in self-medication and self-medication was associated
with higher odds of co-morbid anxiety and personality disorders when compared to
individuals who did not self-medicate [29]. Similarly an interview-based study with
community-based older people reported that 23 % cited using alcohol to deal with
mental health problems [30]. It has also been suggested that late-onset alcohol mis-
use is associated with ‘neurotic’ and ‘depressive’ personality traits [31].
However, the relationship between substance use disorders and mental health
problems such as depression and anxiety is complex and the direction of causality is
often in doubt. For example, does increased alcohol intake result from ‘self-
medication’ in depression, or is the depression secondary to high levels of consump-
tion? Davidson reported that depression and alcohol dependence are frequently found
to co-exist but the relationship between these disorders required further elucidation.
Therefore, his study tested several hypotheses related to the relevance of whether a
diagnosis of depression was made before admission or after detoxification in an epi-
sode for those with alcohol dependence. For the episode of drinking which led to
admission, a diagnosis of major depression was found in the majority of patients
(67 %). Once detoxification from alcohol took place, only the minority (13 %) met
criteria for major depression. It is suggested therefore that depression is largely asso-
ciated with the episode of drinking which led to admission in patients who are depen-
dent on alcohol and may be due to the effect of chronic alcohol intoxication [32].
In stark contrast, a recently published study examining the socio-economic
determinants of risk of harmful alcohol drinking and of the transitions between risk
categories over time among respondents to the English Longitudinal Survey of
Ageing (aged 50 or over) found no association between depression and high-risk
alcohol consumption [33].
1.3.2 Physical Health Problems/Insomnia
The pain, even some of my bones with my osteoporosis, my ankles, my everything … the
pain and all that. As soon as I start having a few pints it goes away.
Despite their concerns regarding the impact of alcohol on health in later life, our
participants did discuss and endorse some uses of alcohol for self-medication.
Among the group of younger participants, alcohol was repeatedly endorsed as a
means of relaxation to cope with stress, while it was frequently described as a useful
aid to sleeping or nightcap for older people. Being able to relax or forget about
problems was commonly given as a reason for enjoying drinking. Interviewees
associated drinking with an enjoyable sense that they had no worries, with a sense
of happiness (albeit temporary) or ‘freedom’. Drinking was also often regarded as a
means of relieving physical pain, for instance from broken ribs, torn muscles or
osteoporosis; However habitual, use of alcohol to self-medicate was usually
acknowledged as a temporary solution; pain or anxiety relieved with alcohol would
return more severely in the night.
Alcohol consumption has been linked to pain in the literature, with the majority
of older adults who report drinking problems also reporting severe pain [27]. The
“self-medication” hypothesis states that alcohol consumption is increased to com-
bat rising levels of pain and has been positively identified in younger adults. An
example is a study in Florida looking specifically at jaw and face pain, which
revealed that a quarter of the participants used alcohol to self-medicate [34]. Older
problem drinkers in one study reported more severe pain, more disruption of daily
activities due to pain and more frequent use of alcohol to manage pain than older
non-problem drinkers. More pain was associated with more use of alcohol to man-
age pain; this relationship was stronger among older adults with drinking problems
than among those without drinking problems [35]. However, in a later study exam-
ining the relationship between pain and drinking behaviour in late-middle-aged
adults, results revealed a positive association between pain and drinking problems/
diagnosed alcohol use disorders but no association between the extent of the pain
reported and increased levels of consumption [36]. Other literature has reported
that 40 % of older people used alcohol for medicinal purposes. This was equally
common in females and males and the most common reasons for use were reported
to be heart and vascular disorders (38 %) and sleep disorders (26 %) [30]. The use
of alcohol in aiding sleep was also seen in a study by Sproule et al., revealing that
6 % of older people chose alcohol as a non-prescriptive medication to help them
sleep [37].
1.4 Bereavement
The day she was buried I spent the day at a guest house on the seafront … absolutely
pissed out of my mind. I was so ashamed to meet my children in that condition that I
didn’t go to the funeral, for which they’ll never forgive me.
Our data highlighted that losing a parent or partner was often pinpointed as an
event that had prompted an escalation in alcohol use, with funerals recalled by some
men as involving a severe binge. In the aftermath of one or more bereavements,
participants recalled drinking increased amounts, and in some cases moving on to
10 C. Haighton
stronger drink. The relationship between bereavement and alcohol use is, however,
complex. One study comparing recently widowed men aged 65 years and over with
married men of the same age found similar proportions of widowers and married
men drinking alcohol. However, recently widowed older men reported significantly
greater frequency and quantity of alcohol consumption than married men [38]. This
finding is at odds with another study which reported no significant difference
between the rates of drinking among married men and men who had been widowed
3 years earlier [39]. One possible explanation for this might be that the excessive
alcohol consumption seen in recently widowed older men diminishes after the first
year following bereavement. A longitudinal study examining the impact of bereave-
ment on alcohol consumption among both men and women aged 65 and over found
that, in men who were married at baseline, death of a spouse did not independently
predict a change in alcohol consumption. However, there was a significant interac-
tion effect between death of a spouse and baseline alcohol consumption, with men
who consumed greater amounts of alcohol at baseline being more likely to increase
their alcohol consumption following bereavement [40]. Perhaps bereavement in
men also increases the risk of alcohol use in already established drinkers. A recent
systematic review which examined the relationship between late-life spousal
bereavement and changes in routine health behaviour over 32 different studies
found only moderate evidence for increased alcohol consumption [41].
1.4.1 Retirement/Loss of Work
When it all started going wrong was when I lost my job. Because when I had my job I
hadn’t time to drink to extremes. So it’s all down to … no job, no work.
The loss of work through retirement, redundancy or ill health was also seen in our
data as having caused drinking to become more problematic. For instance, one man
told us that after he retired he had begun drinking through the day to the point where
he was consuming 80 pints of Guinness a week. This trigger had not always occurred
in later life—two women, for instance, spoke of starting to drink during the day as
they found themselves at a loss when they had children and became homemakers—
but its effects had lasted for some. Some men saw their dependent drinking as a
response to their loss of role, for instance feeling guilty at being unable to provide
following redundancy, or no longer feeling important and able to ‘put things right’
once a business had folded. Drinking was not always described as an active response
to the loss of routine and activity in their lives, in that work was often perceived as a
damper on drinking that otherwise had free rein to become problematic.
According to one study however, retirement does not predict substantial changes
in alcohol use for most persons [42]. Retirement is however an important landmark
during a lifetime. In a longitudinal study of older heavy-drinking men, who had
already completed a behaviour change intervention for alcohol problems when they
were over 60 years of age, it was found that 71 % of those who had not yet retired
when successfully treated for late-onset use began drinking heavily again when they
did retire [43]. While other studies have also found an association between retire-
ment and increased alcohol consumption [16] there is evidence showing that men
with existing alcohol problems are more likely to retire than men without such
problems [44]. Therefore, the effect of reverse causality on the relationship between
alcohol use and retirement cannot be overlooked. According to a report on the
English Longitudinal Survey of Ageing retirement was positively associated with
high-risk alcohol consumption for women but not for men [32].
In a more recent poll of 857 UK adults over the age of 60, 13 % reported increas-
ing their drinking following retirement, 19 % due to depression and 13 % to cope
with bereavement [45]. In a larger scale analysis (n = 4674) of data from the US
Health and Retirement Study, retirement was similarly found to be positively asso-
ciated with subsequent weekly alcohol consumption however this observation was
found in men only [46]. A recent narrative review of the literature concluded that
some studies did indeed report an increase in alcohol consumption after retirement,
whereas others found a decrease or no change at all. Those who retired involuntarily
tended to increase their alcohol consumption, whereas retirees who quit voluntarily
did not change their alcohol consumption [47].
1.4.2 Isolation
No, my mother was here but she didn’t bother … do you get what I mean? As the time
went on I became more isolated in here with her, and I was drinking a couple of cans each
night. To me that was just to take the stress away. Dealing with it. But I wasn’t dealing
with it in a sense.
The older people we interviewed described being stuck indoors for various rea-
sons such as illness, anxiety about going out or having no reason to do so. Many
were living on their own and at a distance from family or relations. Spending con-
siderable time without conversation and with little to do could leave older people
inclined to drink alcohol. One interviewee living in a care home felt isolated from
others who lived there, and increasingly stayed in her room drinking.
Some interviewees with spouses or partners told us that their relationships had suf-
fered or ended as a result of excessive or dependent drinking. They described argu-
ments and attempts to hide their drinking from their partner, and perceived a gulf
growing between themselves and partners who did not drink, or whose drinking was
not problematic. Some participants hoped that they could repair the damage that had
been caused, while others told us that their partners had left, or asked them to do so,
when they could no longer cope with the drinking problem. One man viewed the end
of a marriage as potentially a choice of alcohol over the relationship. The loss of rela-
tionships with siblings or children could be seen either as a result of excessive alcohol
use or as part of wider family problems that the alcohol use was also related to: for
instance, previous abuse or the strain of multiple bereavements. Nevertheless, their
relationship diminution was associated with alcohol use becoming problematic.
12 C. Haighton
Interviewees acknowledging alcohol problems recalled falling out or gradually

not wanting to see family members or be seen drinking by them. Family members
without alcohol problems were in turn described as having reached a point where
they did not believe that the interviewee would ever give up drinking after repeated
relapses, and becoming distant. Friction with adult children around alcohol had led
them to issue ultimatums to the interviewee, or become reluctant to bring grandchil-
dren to visit if the interviewee was likely to have been drinking. Some worries were
expressed about the risk of losing relationships with grandchildren. One woman
living in a care home and drinking hazardously, however, told us that her brother
had stopped suggesting that she reduce her alcohol intake when he concluded one
day that she had little else to take her mind off the situation she found herself in. In
general, those whose drinking had been problematic since mid-life described the
breakdown of intimate and family relationships to a greater extent than those who
began drinking heavily in later life.
Isolation is a measure of the size and diversity of a person’s social network and
frequency of social interaction [48]. A study which evaluated a complex interven-
tion for addressing social isolation in older people reported a reduction in alcohol
consumption among participants. The Upstream Healthy Living Centre was a men-
tored intervention for older socially isolated people, designed to provide individu-
ally stimulating creative activity and active (participatory and self-determined)
social contact. The intervention encouraged a number of participants to take better
care of themselves, and improvements in a range of health behaviours were reported
including reduced alcohol consumption [49].
1.4.3 Boredom/Loneliness
You’re going to kill some time, and you’re going in [to the pub] not to get drunk but to
kill some time and just have a couple of drinks, and wander away.
In our sample, drinking was also frequently described as a response to finding

oneself either bored or alone. Sometimes the objective of drinking was reported as
‘filling in the day’ rather than experiencing the effects of alcohol. Loneliness is
prevalent in later life [50] and can be defined as an individual’s subjective evaluation
of feeling without companionship, isolated or not belonging [51]. Although associ-
ated, loneliness is distinct from social isolation, as people with small social net-
works may not feel lonely. Whereas lonely people may have extensive and diverse
social networks [51].
Loneliness has been linked to poor health behaviours including alcohol use [52],
with individuals who are dependent on alcohol reporting being lonelier than mem-
bers of most other groups [53]. While loneliness does not seem to be associated with
increased alcohol consumption in students [52], in a survey, 63 % of middle-aged
adults, who had been diagnosed with drug or alcohol problems, reported being
lonely [54]. In addition, older adults in alcohol day-treatment programmes reported
that loneliness (along with depression and sadness) preceded the first drink on a
typical dinking day [55]. Community-dwelling older adults in New Zealand also
cited loneliness as a reason for increasing alcohol use [21]. In contrast, in partici-
pants aged 50 years and over, from the 2008 wave of the Health and Retirement
study, loneliness was associated with reduced alcohol use frequency but not with
at-risk or binge drinking [56]. There was no association between loneliness and
high-risk alcohol consumption among respondents (aged 50 or over) to the English
Longitudinal Survey of Ageing [32].
1.4.4 Homelessness
Then spent a year … in a tent, where I was blissfully peaceful because I could just lie in
this tent drinking wine from the bottle, or martini from the bottle, depending on if I felt
rich or poor that particular day.
None of the participants in our qualitative study were currently homeless

although some of our participants had experienced periods of homelessness through-
out their drinking histories. In the UK, 40 % of older homeless men are known to be
heavy drinkers or to have alcohol-related problems. The problems are most pro-
nounced among men in their fifties. The majority of these men are White British or
Irish, with only a small proportion from minority ethnic groups [57, 58].
1.5 Conclusion
A third of older excessive drinkers start drinking, or increase their alcohol consump-
tion, later in life. The reasons for this change in behaviour have been associated with
both positive and negative reinforcement. There are many motivating factors which
have been highlighted in academic research over the years including enjoyment,
socialisation, self-medication (for mental health problems, physical health prob-
lems and insomnia), bereavement, retirement, loss of work, loneliness, boredom,
isolation and homelessness. However, the relationship between alcohol use and
many of these factors is complex and future research should focus on the direction
of causality. An understanding of the different reasons why older people increase
their alcohol consumption will however help health professionals identify the most
appropriate behaviour change interventions.
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Part II
Epidemiological Perspectives
of Alcohol and Aging
Understanding Alcohol Consumption
Patterns among Older Adults: Continuity 2
and Change
Paul Sacco
Older adults drink in ways that are reflective of earlier life stages, but alcohol
consumption also changes as people move from middle age to older adulthood.
Habits like alcohol use may continue in later life as people maintain a sense of con-
tinuity [1] from earlier life stages. At the same time, the aging process itself may alter
drinking behavior, as older adults develop health-related conditions or experience
life changes that exert upward or downward pressures on drinking or change the
context and pattern of drinking. Understanding alcohol use among older adults
requires a life course perspective [2], one that sees biological, social, and psychologi-
cal factors as an unfolding process over one’s life. Broadly speaking, to understand
alcohol consumption patterns and associated risks among older adults, one must con-
sider both biopsychosocial processes that emerge earlier in life and aging-specific
processes, such as multimorbidity and retirement. The following chapter will explore
factors that influence how drinking patterns evolve or remain constant and will define
different levels of risk as they are currently framed within public health.
The life course perspective is valuable in understanding the ways in which older
adulthood as a life stage fits within an overall developmental framework. One chal-
lenge is that the definition of older adulthood itself can vary greatly. For both theo-
retical and practical reasons, researchers have chosen either age-specific cutoffs
(e.g., age 65) or event thresholds (e.g., retirement) for defining older adulthood. One
noted developmental theorist defined middle adulthood from ages 40 to 65, with
late adulthood beginning with a transition to beginning at age 60 [3]. After age 65,
older adulthood has been divided into its own stages: the young-old (aged 65–74),
the old-old (aged 75–84), and the oldest-old (aged 85 and older) [4, 5]. Whenever
P. Sacco, Ph.D., M.S.W. (*)

University of Maryland School of Social Work, 525 West
Redwood Street, Baltimore, MD 21201, USA

20 P. Sacco
possible, the age ranges of studies will be included in discussion of research on

alcohol use patterns and older adults with the idea that later middle age samples
(aged 50+) may be very different than samples of the oldest-old.
2.1 Older Adult Drinking Seen Within the Life Course
In the population overall, older adulthood is a life stage in which overall alcohol
consumption decreases, binge drinking becomes less common, and individuals give
up drinking. Brennan and colleagues [6], in a 20-year study of alcohol use among
community dwelling primarily white older adults in early older adulthood (ages
55–65), identified overall declines in consumption levels and number of problems
associated with drinking. In an analysis of the Health and Retirement Study [7],
researchers also identified a decline in alcohol consumption into older adulthood.
Older adults in the Rancho Bernardo study, a longitudinal investigation of older
adults aged 50–89, also reported declines in daily consumption over a period of 24
years [8]. Other longitudinal research suggests that the process of decline also occurs
in late middle age into older adulthood [9]. In addition, data collected internationally
supports the assertion that older adulthood is a period of declining drinking. Analysis
by Gee and colleagues [10] identified decreases in drinking among Japanese older
adults beginning during the sixth decade of life. Similarly, researchers analyzing the
English Longitudinal Study on Aging [11] identified decreased quantity and fre-
quency of alcohol consumption over three waves of data collection.
Two forces specific to later life may be at work in decreasing levels of alcohol
consumption in late life. First, the “sick-quitter” hypothesis [12, 13] suggests that
changes in health during the aging process limit alcohol consumption. With declines
in health, older adults decrease the quantity and frequency of their drinking leading
to lower average consumption in the overall older adult population [11, 14].
Similarly, differential mortality of heavy drinkers may lead to decreases in alcohol
use among cohorts of older adults; these changes in average drinking may be a func-
tion of early mortality of heavy drinkers [15].
Although alcohol use generally declines throughout the course of older adult-
hood, the population of older adults exhibits a great deal of variability in drinking
patterns. Within the general population of older adults, some individuals maintain
stable drinking habits, and some may increase their drinking and develop problems
in older adulthood. Having a history of drinking problems has been found to predict
later increases in drinking among older adults [7, 9, 16, 17]. Although the idea that
history predicts future behavior is intuitive, it provides a simple foundation for
assessing drinking in this population. Measures like the Alcohol Use Disorders
Identification Test (AUDIT) include items on lifetime problems [18] as screening
questions for assessing current alcohol-related risk. In addition to drinking history,
longitudinal research studies have found that older men tend to consume alcohol at
higher levels than women, and their consumption levels decline more slowly than
women’s [6]. Additionally, factors that may be associated with heavier drinking in
late-middle age, such as coping motives/tension reduction related drinking, may be
2 Understanding Alcohol Consumption Patterns among Older Adults… 21
lead a greater decline in drinking with age [19]. Advanced age itself may also
contribute to declines in drinking among older adults. As older adults move from
so-called young-old age (i.e., 65–74) to becoming the “oldest-old” (i.e. 85+), the
process of decreasing alcohol consumption may accelerate [6, 8].
2.2 Understanding Alcohol Abstinence in Older Adulthood
Life course research on alcohol use among older adults points to an overall decline
in consumption due to decreasing quantity and frequency of use as well as transi-
tions to abstinent use. Nonetheless, late-life nondrinking is only part of the absti-
nence picture. Lifetime nondrinkers are a distinct group with characteristics that
may be markedly different from those who stop drinking in late life. This is particu-
larly important when considering health and social correlates of drinking. Numerous
studies suggest that lifetime nondrinkers are more likely to be female, display
greater religiosity (e.g., attend religious services), and have lower levels of educa-
tion than their moderate drinking peers [20, 21]. Recent research by Choi and col-
leagues [22] identified significantly lower risk of anxiety and depressive disorders
among lifetime abstainers than nonbinge drinkers, while former drinkers displayed
a greater likelihood of past-year suicidal ideation. Research on lifetime abstainers
and former drinkers has implications for our understanding of drinking patterns in
late life. Older adult nondrinkers are a heterogeneous population, and as such, life-
time nondrinkers and former drinkers should be studied separately. This is espe-
cially important when considering the issue of health and drinking because the
context for abstinence may be different in these two groups [23, 24]. For instance,
there is a body of research focused on the so-called, j-curve hypothesis [25, 26], the
idea that morbidity and mortality are lower among individuals who drink at low-risk
levels compared to those who abstain completely. Lifetime abstainers and former
drinkers are likely different in relation to their perceived health status, health condi-
tions, and services utilization [22, 27].
2.3 ate-Onset Drinking Problems: Reevaluating

L
the Evidence
The literature on alcohol use across the life course has delved extensively into the
idea that a subgroup of older problem drinkers develops problems only as they reach
older adulthood. Late-onset older adult problem drinkers have been identified using
treatment samples [28–30]. Definitions of what constitutes late vary between 40 and
60 years of age [31], and numbers of individuals who fall into the categories of late
versus early onset also vary from approximately 15 % late alcohol problems [32] to
nearly a 50/50 ratio [29]. People with late-onset alcohol problems have been identi-
fied as having less severe problems than early onset (<40 years old) drinkers and are
seen as responding to age-related life stresses [31].
22 P. Sacco
Data from epidemiologic studies offer a slightly different picture. Longitudinal

research on age of onset across adulthood suggests that new onset of alcohol use
disorders is rare after age 40, and that the aging process itself leads to lower vulner-
ability to new onset disorder and recurrence [33, 34]. One longitudinal study [35] of
older adult late-onset alcohol problems did identify a subpopulation of individuals
who developed mild to moderate levels of alcohol problems which tended to remit
over the course of the study. Moreover, the authors did not find evidence of stress-
related drinking in their sample. Earlier studies of so-called late-onset alcohol prob-
lems have typically utilized samples of older adults in treatment, relying on self-report
of individuals who may have only just recognized that they have a problem with
alcohol but who may have previously met criteria for an alcohol use disorder.
Alternatively, individuals who enter treatment in older adulthood may be more likely
to come from the rare group of individuals who develop an alcohol use disorder late
in life. Based on this evidence, it is likely that late-onset alcohol-related problems in
older adulthood may represent instances of either recall bias or are the result of a low
threshold for problem use (i.e., endorsing a single alcohol-related problem) rather
than a specific subtype of alcohol use. Late-onset problem drinkers may be low
severity problem users, rather than a separate class based on time of onset.
2.4 rinking Patterns in Older Adulthood: Common

D
Definitions
From the previous discussion, two general concepts are important to understanding
alcohol consumption in the older adulthood. In the general population, alcohol con-
sumption decreases and levels of abstention increase as older adults reach late life and
continue to age in older adulthood. National survey data estimate that approximately
40–45 % of older adults (65+) drank alcohol in the past year depending on the survey
and question wording [36, 37]. Nonetheless, alcohol consumption among older adults
is heterogeneous, and different patterns of alcohol use in late life carry different risks
to health and well-being. Among older adults, different drinking patterns may also
have distinct sociodemographic risk factors leading to different threats to health and
well-being. Among older adults, like in younger groups, risks associated with alcohol
use come from either endorsement of alcohol diagnostic criteria (e.g., drinking and
driving) or by exceeding consumption levels (drinking more than two drinks on a
single occasion). The life course perspective informs how risk thresholds are devel-
oped and interpreted, and it has informed research about the validity and utility of
these risk limits when applied specifically to older adults [38, 39].
2.5 Low-Risk Drinking
A majority of older adults who consume alcohol are low-risk drinkers; they con-
sume within guidelines developed by the National Institutes of Health [40]. For
individuals younger than 65, low-risk drinking means consuming no more than 4
drinks on any day and no more than 14 drinks in a given week for men, or consuming
no more than 3 drinks on any day and no more than 7 drinks in a given week for
women. In the case of both men and women 65 and older, drinking guidelines are
the same as they are for younger women, not more than 3 drinks on any day and no
more than seven drinks per week.
Low-risk thresholds for adults 65 and older are different because older adults
have a decreased ability to metabolize alcohol due to changes in lean body mass
associated with aging [41]. Specifically, with older age, body fat increases and total
water decreases. This leads to higher levels of blood alcohol at the same level of
consumption among older adults compared with younger adults [42]. Also, the abil-
ity of the liver to metabolize alcohol decreases as one ages. Both of these aging-
related processes may lead to greater risk of alcohol consumption among older
adults, which in turn provides a rationale for a lower threshold for at-risk drinking
among older adults.
The use of a separate older adult “at-risk” guideline has been the subject of some
debate among researchers. For instance, Lang and colleagues [38] analyzed data
from two national surveys conducted in the United States and England of a subset
of older adults who drank over the specific older adult guidelines but within the
guidelines for younger adults at a baseline time point. There were no significant
differences between individuals who drank within current older adult guidelines
and those who drank over older adult guidelines; however, measures of activities of
daily living, instrumental activities of daily living, and cognition were worse 3 years
later among those who exceeded young adult thresholds of drinking. Similarly,
using mixture modeling, a form of exploratory data analysis which identifies sub-
populations based on indicator variables, Sacco et al. [43] identified a “moderate
risk” class that displayed low likelihood of endorsing alcohol-related problems but
a high probability (>.80) of exceeding weekly drinking limits. Individuals in this
class had levels of self-rated health and mental health that were not different from
individuals who drank at a low-risk level. Together, these studies cast some doubt
on the validity of using a lower consumption threshold for older adults. Further
research may shed light on whether exceeding this more conservative threshold
actually leads to negative health consequences.
2.6 At-Risk Drinking
Although there is ongoing debate and research about what constitutes

consumption-based risk, a proportion of older adults are at-risk drinkers. These
consumption thresholds are based on exceeding either the day threshold (over
65: >3 drinks any given day) or week threshold (over 65: >7 drinks any given
week) [40]. Although terminology may vary by study or clinician, the term
“heavy drinking” refers to individuals who drink over the week guideline and
so-called binge drinking or “heavy episodic use” is synonymous with exceeding
the guideline for within day alcohol use, although the term heavy drinking can
also be used to describe people who exceed both thresholds. It is possible that
24 P. Sacco
these different thresholds are important, as they may be associated with specific
risks for older adults’ health and well-being. For instance, a study by Holahan
and colleagues [44] explored longitudinal outcomes for individuals who were
moderate drinkers (below the weekly at-risk threshold) but who engaged in
heavy episodic drinking (exceeded day threshold). Individuals were first sur-
veyed between the ages of 55 and 65 and followed for 20 years. Episodic heavy
drinkers were twice as likely to have died in the 20-year follow-up period com-
pared with those who were not episodic heavy drinkers.
Figure 2.1 displays data on the prevalence of binge drinking and heavy alcohol
use from the 2014 National Survey on Drug use and Health (NSDUH) [45], using
general population thresholds for these terms. In keeping with life course-related
population declines in alcohol use and consumption levels, rates of past-year use,
binge alcohol use and heavy alcohol use generally follow a stair step pattern from
age 50–55 to age 60 and older. Among those ages 50–54, rates of past 30-day binge
drinking were 23.2 %, and among those aged 65 and older, 8.9 % consumed 5 drinks
or more on a single occasion. These rates were low compared to younger adults;
rates of at-risk and binge drinking using the older adult specific guidelines would
likely be higher. Similarly, prevalence rates for heavy alcohol use in the NSDUH
survey are based on a higher threshold of five drinks on five separate occasions in
the past 30 days (see Fig. 2.1). Therefore, the rates shown are more conservative
than the older adult threshold of seven or more drinks in the past week. Among
100
90
80
70
60
Percent
50
40
30
20
10
0
Lifetime Alcohol Use Past-Year Alcohol Binge Alcohol Use Heavy Alcohol Use Alcohol Abuse or
Use Dependence
50-54 55-59 60-64 65 and Older
Fig. 2.1 Prevalence of lifetime and past-year alcohol use, at-risk drinking, binge use, and DSM-IV
Diagnosis (Data from the 2014 NSDUH [44])
adults over age 50, prevalence of heavy use was 6.7 % for adults aged 50–54, 5.2 %
for those aged 55–59, 4 % for adults aged 60–64, and 2.2 % among adults aged 65
and older [45]. Using data from the 2005 and 2006 NSDUH surveys, Blazer and Wu
[46] estimated that 17 % of men and 11 % of women aged 50 and older were at-risk
drinkers. In this study, these high rates of at-risk drinking are likely accounted for
by using the lower threshold of two of more drinks on a given day.
2.7 roblem Drinking, Alcohol Abuse, Alcohol Dependence,

P
and Alcohol Use Disorder
At-risk drinking has largely been defined by level and pattern of consumption.
Problem alcohol use and disordered drinking (or having an alcohol use disorder)
represent a more severe measure of alcohol-related risk among older adults [47]. A
subset of older adults who are at-risk drinkers develop or have preexisting alcohol-
related problems from earlier life. This level of alcohol-related harm is usually mea-
sured using criteria for alcohol use disorders from the Diagnostic and Statistical
Manual of Mental Disorders (DSM) published by the American Psychiatric
Association [48, 49]. In recent years, the DSM has undergone a major revision.
Previously there were two main diagnoses that represented alcohol problems, alco-
hol abuse and alcohol dependence. In the case of alcohol abuse, an individual
needed to endorse one or more of the diagnostic criteria in Table 2.1 in the past 12
months. For alcohol dependence, individuals who endorsed 3 or more of the criteria
listed in Table 2.1 would meet criteria for a diagnosis.
These two diagnoses were considered hierarchical in that alcohol dependence
was considered a more severe diagnosis than alcohol abuse. Moreover, this hierar-
chical structure was based on the idea that individuals progress from alcohol abuse
to alcohol dependence. Research on both of these assumptions about separate diag-
noses has little empirical support [50, 51]. Based on this evidence, version 5 of the
DSM manual abandoned separate alcohol abuse and alcohol dependence diagnoses,
and combined them into a single diagnosis: alcohol use disorder (AUD).
The diagnostic criteria for AUD are the same as they were for alcohol depen-
dence and alcohol abuse with two changes. For AUD, the criterion specific to
alcohol-related criminal or illegal behavior was removed, and a new criteria focused
specifically on alcohol craving was added (see Table 2.1). In addition, criteria have
been combined under a unitary AUD (see Table 2.1). An individual has to endorse
two or more diagnostic criteria to receive this diagnosis. Additionally, levels of
severity can be denoted based on the number of criteria endorsed over the two
required (2–3 = Mild; 4–5 = Moderate; 6 or more = Severe) [49].
Because diagnostic measures represent the highest level of severity, rates of
DSM-based disorder are lower than rates of binge drinking and heavy drinking. The
NSDUH survey estimated a past-year prevalence rate of alcohol abuse or depen-
dence of 6.1 % among those aged 50–54 and 2.2 % among those ages 65 and older.
Similar to alcohol consumption measures, a stair step pattern of prevalence was
found in the NSDUH, with lower prevalence of disordered drinking with each older
Table 2.1 Alcohol-related disorders: changes from DSM-IV to DSM-5
26
DSM-IV [47] DSM-5 [48]

Alcohol abuse Alcohol dependence Alcohol use disorder
1. Recurrent alcohol use 1. Tolerance as defined by either of the following: 1. Alcohol is often taken in larger amounts over a longer period
resulting in a failure to (a) A need for markedly increased amounts of alcohol to than was intended
fulfill major role achieve intoxication or desired effect 2. There is a persistent desire or unsuccessful efforts to cut
obligations at work, (b) Markedly diminished effect with continued use of the down or control alcohol use
school, or home same amount of alcohol 3. A great deal of time is spent in activities necessary to obtain
2. Recurrent alcohol use 2. Withdrawal, as manifested by either of the following: alcohol, use alcohol, or recover from its effects
in situations in which (a) The characteristic withdrawal syndrome for alcohol 4. Craving or a strong desire or urge to use alcoholb
it is physically (b) Alcohol or a closely related substance is taken to 5. Recurrent alcohol use resulting in a failure to fulfill major
hazardous relieve or avoid withdrawal symptoms role obligations at work, school, or home
3. Recurrent substance- 3. Alcohol is often taken in larger amounts over a longer 6. Continued alcohol use despite having persistent or recurrent
related legal problemsa period than was intended social or interpersonal problems caused or exacerbated by
4. Continued alcohol use 4. There is a persistent desire or unsuccessful efforts to cut the effects of alcohol
despite having down or control alcohol use 7. Important social, occupational, or recreational activities are
persistent or recurrent 5. A great deal of time is spent in activities necessary to given up or reduced because of substance use
social or interpersonal obtain alcohol, use alcohol, or recover from its effects 8. Recurrent alcohol use in situations in which it is physically
problems caused or 6. Important social, occupational, or recreational activities hazardous
exacerbated by the are given up or reduced because of substance use 9. Alcohol use is continued despite knowledge of having a
effects of alcohol 7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem
persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
that is likely to have been caused or exacerbated by 10. Tolerance as defined by either of the following:
alcohol (a) A need for markedly increased amounts of alcohol to
achieve intoxication or desired effect
(b) Markedly diminished effect with continued use of the
same amount of alcohol
11. Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for alcohol
(b) Alcohol or a closely related substance is taken to
relieve or avoid withdrawal symptoms
a
P. Sacco
Criterion Removed DSM-5

b
Criterion Added in DSM-5
age group in older adulthood. In the National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC) Survey [52], the prevalence of past-year AUD was
similar, but slightly lower, with 1.5 % of older adults (65+) endorsing diagnostic
criteria.
Although DSM diagnostic criteria are widely used in clinical settings to measure
and document alcohol-related problems, some diagnostic criteria may be less valid
for older adults than they are for younger groups [53, 54]. For instance, older adults
are less likely to develop tolerance to the effects of alcohol due to age-related physi-
ological changes that inhibit alcohol metabolism. Because of these differences, the
tolerance criterion for AUD (Table 2.1; DSM-5 criterion #6) may be less informative
in identifying individuals at risk. Using Item Response Theory modeling Kuerbis
et al. [47] found the tolerance criterion displayed lower reliability than other criteria
in adults aged 50 and older. Conversely, they found that the social and interpersonal
problems criterion (Table 2.1; DSM-5 criterion #10) discriminated well between
those with alcohol abuse or dependence and those who were not diagnosed. They
surmised that given the fact that heavy use is less normative and that social networks
of older adults are smaller and more cohesive, they may therefore be more respon-
sive to problematic alcohol use than networks of younger adults or youth.
2.8 lternative Measures of Risk: Comorbidity in Older

A
Adults
AUD is the most severe manifestation of alcohol-related pathology among older

adults, but most alcohol-related harm is not a function of disordered drinking [55].
A number of factors may create risks that are unique to older adults. Moore et al.
[56] enlisted an expert panel to develop broader conceptualization of alcohol risk in
older adults. Knowledge gained from this study was used to develop a screening
measure to assess risk in addition to DSM classification and alcohol consumption
[39]. In addition to alcohol consumption, other forms of alcohol related risk were
identified: taking medications that may negatively interact with alcohol, alcohol use
with medical and psychiatric comorbidity (e.g., high blood pressure or major
depressive disorder) where alcohol use may exacerbate the underlying condition,
and alcohol use in the presence of somatic symptoms (falls, insomnia, etc.) that may
be worsened or caused by alcohol (see Table 2.2).
This approach to alcohol use patterns is the most broadly conceived and consis-
tent with a holistic life course-based approach. It extends the use of older adult
consumption limits to a range of aging-specific risk factors. For instance, older
adults commonly take medications that interact with alcohol. A recent study of
community-dwelling older adults (aged 57+) found that 41 % consumed alcohol
regularly and among regular alcohol consumers, 51 % used at least one alcohol
interacting medication [57]. An analysis of the Irish Longitudinal Study on Ageing
identified a high prevalence of alcohol use (60 %) among individuals taking alcohol
interacting medications [58]. Falls are also a common health concern for older
adults, and there is evidence of increased risk of falls among older adults who drink
more than 14 drinks per week [59].
28
Table 2.2 Measures of alcohol risk

Alcohol consumption [39] Alcohol problems [47, 48] Comorbidity risk [59]
At-risk drinking Alcohol use disorder At-risk
Men • DSM-IV Diagnostic Criteria Alcohol use with the following comorbidities in the last
• Greater than 4 standard drinks per met for Alcohol Abuse or 12 months:
occasion and/or Alcohol Dependence or • Liver disease
• Greater than 14 standard drinks per week • DSM-5 Diagnostic Criteria • Pancreatitis
Women and aged +65 met for an Alcohol Use • Gout
• Less than 3 standard drinks per occasion Disorder • Depression
and/or Problem drinking • High blood pressure
• No more than 7 standard drinks per week • One or more DSM-IV/ • Diabetes
DSM-5 criteria endorsed • Sometimes have problems with sleeping, falling, memory,
heartburn, stomach pain, nausea, vomiting, and/or feel
General population low risk No alcohol problems
sad/blue
Men • No DSM-IV/DSM-5 criteria
• Often have problems with sleeping, falling, memory,
• No more than 4 standard drinks per endorsed
heartburn, stomach pain, nausea, vomiting, or feel sad/blue
occasion and
Alcohol use and medications taken at least 3-4 times per week
• No more than 14 standard drinks per week
currently
Women and aged +65
• Medications that may cause bleeding, dizziness, sedation
• Less than 3 standard drinks per occasion
• Medications used for gastroesophageal reflux, ulcer
and
disease, depression
• Medications for hypertension
Older adults (65+) low risk
Low risk
• No more than 3 standard drinks per
• No alcohol interacting medications or comorbidities
occasion and
• Consumption within low-risk drinking guidelines for
older adults
Nondrinking/Abstention
• Has not consumed alcohol in the past year or
• Has not consumed alcohol in lifetime
P. Sacco
Because this measure of alcohol risk focuses more broadly on unhealthy

drinking among older adults, prevalence rates of at-risk consumption using these
benchmarks are higher. In a medical clinic intervention study targeted at older
adults (60+), Moore et al. [60] identified a rate of at-risk drinking of 34.7 %. This
prevalence rate was not based on at-risk consumption only (22.3 %), but also
drinking with concurrent medication use (21.2 %) and/or alcohol use with medi-
cal or psychiatric comorbidities (21.5 %). In a study of alcohol consumption at a
continuing care retirement community [61], rates of at-risk drinking that were
also higher, 46.5 % for consumption-based risk, 39.4 % for disease comorbidity,
62 % for potential medication interaction, and 40.8 % for symptom comorbidity.
Having a broader measure of unhealthy drinking among older adults has both
advantages and challenges from the standpoint of understanding patterns of drink-
ing. Clinically, this approach offers the potential to screen and provide education to
individuals who may experience alcohol-related consequences as a result of comor-
bidity and medication use. Like the use of lower thresholds for consumption among
older adults, it is unclear the extent to which drinking at low levels with medication
that interaction potential or drinking with comorbidities leads to negative health
outcomes among older drinkers. From the standpoint of public health, it is valuable
to screen and provide education about these risks as a means of helping older adults
make educated decisions about drinking and their health. At the same time, research
should attempt to quantify the extent to which low-risk consumption among older
adults (<4 drinks at an occasion and no more than seven drinks in a week) combined
with comorbidity (e.g., depressive symptoms) or medication interactions (e.g., pro-
pranolol) leads to later consequences for older drinkers. It is possible that actual
negative outcomes are rare.
2.9 orrelates of At-Risk and Disordered Drinking

C
Among Older Adults
Alcohol use follows a continuum of risk from abstinence to severe alcohol use dis-
order. Even though overall risk in the older adult population is lower than in younger
age groups, subpopulations of older adults are at-risk drinkers or have an
AUD. Research findings suggest that a number of sociodemographic factors are
associated with different drinking patterns and may be useful in screening and tar-
geting interventions.
At-risk drinking and AUD are more common among the so-called young-old,
and as noted earlier in this chapter, risk declines with advancing age. For example,
Blazer and Wu [46], in their study of NSDUH data, found that both at-risk drinking
and binge drinking were more common among those adults 50–64 years old com-
pared with those 65 and older. Sacco et al. [62] identified that rates of at-risk drink-
ing among women 60 and older (20.5 %) were lower than rates of at-risk drinking
among men (29 %), using gender-specific general population thresholds (i.e., 14
drinks week or <5 drinks on one occasion for men and 7 drinks per week and <4
drinks on one occasion for women). This study also found that older age was
30 P. Sacco
associated with decreased odds of both at-risk drinking and AUD among both men
and women 60 and older. These differences may be a function of age and gender
differences in overall past-year consumption (i.e., risk drinking rates are lower
because past-year drinking rates are lower). NESARC survey findings suggest that
overall rates of past-year alcohol use are lower in older age groups and among
women [36]. In the NESARC survey, men were 83 % more likely to be past-year
alcohol consumers than women. Analyzing Medicare data, Merrick and colleagues
[63] found that adults aged 65–70 were more likely to consume at unhealthy levels
and more likely to binge drink compared to peers in older age groups.
Race and ethnic differences are also important in understanding different alcohol
use patterns, but complexities are important in understanding these relationships.
Blazer and Wu [46] found that African American racial identification was associ-
ated with higher odds of past-month binge drinking, compared with White respon-
dents, in female past-year alcohol consumers only, but this relationship was not
present when considering all women over age 50. This relationship is likely a func-
tion of differences in nondrinking status by race. Older African American women
are less likely to be current drinkers [64], but among women who drink, they are
more likely to binge drink. Other research is consistent with the idea that African
American older adults have higher rates of both nondrinking status [36, 65] and
Alcohol Use disorders [66] and consequences. Sacco et al. [43] analyzed classes of
consumption and problem-based risk among older adults, and found that older
African Americans were less likely to be in a moderate risk class (based primarily
on consumption), but marginally more likely to be in a high-risk class (based on
endorsement of alcohol problems). Data from the Medicare Current Beneficiary
Survey support the idea that at-risk drinking is less common in the total population
of older African Americans, but more common among older African American cur-
rent drinkers [62]. Differences in alcohol consumption between African Americans
and Whites may be explained by greater participation in religious denominations
that proscribe alcohol use among older African Americans [64].
Education and income are also associated with alcohol consumption patterns that
may reflect class differences in attitudes about drinking. Older adults with higher
levels of income and education are more likely to display at-risk drinking patterns
[63]. Some research studies have identified gender differences in these patterns with
less educated women being more likely to take part in binge drinking, while more
highly educated men were binge drinkers [46]. Findings regarding income are
equivocal. Overall rates of at-risk drinking are higher with greater education and
income, but when only current alcohol consumers are considered, findings are
reversed or differences are not seen [63]. Older adults with lower levels of education
display higher likelihood of being in a high-risk drinking class [43]. Data from the
NSDUH survey found that 36.9 % of adults over 50 who did not finish high school
used alcohol in the past year, compared with 55.4 % of those with a high school
education and 71.5 % of those who attended college [37]. It is likely that educated
older adults are more likely to be at-risk drinkers because they are more likely to
drink; however, but if individuals are past-year drinkers, those with less education
are more likely to be at-risk drinkers [46]. Among older adults with higher levels of
education and income, alcohol use may be more normative, leading to greater risk
in the population of older adults. Among alcohol users, this risk is reversed.
One unequivocal finding regarding drinking patterns and associated risks among
older adults relates to marital status among older adults. Those who are divorced,
widowed, or separated may be at higher risk for at-risk drinking and AUD. In a
national survey, adults over 50 who were formerly married (widowed, divorced, or
separated) were 50 % more likely to be at-risk drinkers and 60 % more likely to be
binge drinkers than currently married persons [67]. Again, it should be noted that
some of the risk associated with divorce in particular may arise from the idea that
older adults who are divorced are 24 % more likely to current drinkers than currently
married persons [36]. Essentially, at-risk drinking can only happen if an individual
is currently consuming alcohol, so differential rates of at-risk drinking may be
explained in part by differential rates of current use. Nonetheless, risk associated
with being divorced, separated, or widowed is present even in samples of current
drinkers only, but findings regarding gender differences in this relationship are
mixed. Some studies have found that being formerly married or divorced increases
likelihood of at-risk and binge drinking among men only [46], but other studies
have identified greater odds of at-risk drinking in both men and women [62].
2.10 Conclusions and Implications
To understand the ways in which older adults consume alcohol in late life, both aging-
related processes and lifelong factors should be considered. Although older adulthood
as a life stage is a period of declining risk related to consumption, age-related changes
in health mean that even low levels of consumption can be considered risky. Moreover,
older adults display heterogeneity in drinking patterns from nondrinking, to at-risk
and binge drinking and even AUD. To understand patterns of drinking among older
adults, one must first consider whether older adults currently drink at all and whether
this is a change that has occurred as they reach older adulthood.
Alcohol use in the aging population has been defined through various thresholds
of risk. Each approach brings certain advantages and problems. Using alcohol-
related disorders as a benchmark misses many older adults who may experience
alcohol-related consequences to their health and well-being even though they do not
meet criteria for disordered drinking. More conservative measures of alcohol risk
may identify at-risk drinking in those for whom alcohol use may never compromise
their health. In the future, research should continue to explore more precise and
individualized ways of quantifying risk based on alcohol consumption and other
health factors. Even so, clinical practitioners in geriatrics and gerontology will have
the task of educating individual older adults about their alcohol risk while recogniz-
ing that, among light to moderate drinkers, the level of risk is uncertain.
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Alcohol Use and Comorbid Psychiatric
and Subsyndromal Disorders Among 3
Older Adults
Alexis Kuerbis, Rachel Chernick, and Daniel S. Gardner
The Baby Boom generation, comprising 30 % of the US population, began to turn
65 in 2011 [1]. Due to longer life expectancies [2], the number of older adults is
projected to increase from 40.3 million in 2010 to 72.1 million in 2030 [3]. While
older adults historically demonstrate much lower rates of alcohol use compared
with younger adults [4, 5] and present to substance abuse treatment programs less
frequently than their younger counterparts [6], substantial evidence suggests that
at-risk alcohol use and alcohol use disorder (AUD) among older adults has been
under-identified for decades [7, 8]. Causes of this under-identification include but
are not limited to: the commonly held myth that older adults do not drink alcohol
excessively, the belief that consequences of alcohol use are simply side effects of
normal aging, underreporting of heavy drinking [7] and difficulties with differential
diagnoses of AUD in older adults [9].
In addition to the difficulties identifying AUD among older adults, comorbid
disorders, including other substance use disorders (SUD) or compulsive behaviors
(such as gambling), mood disorders (major depressive disorder, dysthymia, etc.),
anxiety disorders (generalized anxiety disorder, social phobia, posttraumatic stress
disorder, etc.), and severe and persistent mental illness (schizophrenia, bipolar dis-
order, etc.) can further complicate assessment, diagnosis, and subsequent treatment
[10]. Given the impending “silver tsunami” of individuals with substance use and
mental health disorders [3, 11], there is widespread recognition [3, 11, 12] of the
need for more information about identification and assessment of and interventions
related to comorbid disorders among older adults.
A. Kuerbis, Ph.D., L.C.S.W. (*) • D.S. Gardner, Ph.D., L.C.S.W.

Silberman School of Social Work, Hunter College of the City University of New York,
New York, NY, USA
e-mail: [email protected]; [email protected]
R. Chernick, L.C.S.W.
Department of Social Welfare, The Graduate Center of the City University of New York,
New York, NY, USA

36 A. Kuerbis et al.
At present, very little research exists on alcohol use and comorbid disorders
among older adults, and as a result, there is a paucity of information related to
prevalence, differential diagnosis, and treatment of such disorders for this popula-
tion. Furthermore, results of epidemiological studies tend to be delayed in publica-
tion sometimes by 10 years or more. Thus, the most current information on older
adults, AUD, and comorbid disorders has yet to be published.
This chapter will review: (1) age-related complications of substance use and
mental health disorders; and (2) prevalence rates of alcohol use and AUD and
comorbidity with other drug use and related disorders, gambling, and mental health
disorders. Integrated throughout the chapter, the authors will review the scant exist-
ing literature on comorbid disorders among older adults. Given the manner in which
epidemiological studies are often implemented, prevalence rates of comorbid disor-
ders are often reported in the context of another disorder, rather than as rates in the
general population. Prevalence rates of comorbid disorders, where known, will
therefore be reported in the section on the primary disorder. Where available, preva-
lence rates of subsyndromal disorders, defined as symptoms that older adults expe-
rience that are clinically significant but do not full meet criteria for a particular
disorder, will also be reported.
3.1 omplications of Aging Related to Health and Mental

C
Health
Comorbidity of substance use and mental health disorders among older adults is
particularly complex. Given biological changes that occur as a natural part of aging,
many criteria used for identification of substance use or mental health disorders
manifest differently in older adults compared to their younger counterparts. For
example, older adults endorse AUD criteria differently than younger adults [9], sug-
gesting an age-related bias. Criteria such as tolerance to alcohol or not fulfilling a
role obligation may not apply to an older adult whose tolerance naturally reduces
with age and whose number of roles may be reduced due to events such as retire-
ment. Depressive symptoms also manifest differently among older adults, as they
do not demonstrate sadness or depressed mood at the same rates or intensity as their
younger counterparts [3]. Similarly, bipolar disorder is often difficult to diagnose
among older adults given that they are much less likely to manifest manic or hypo-
manic symptoms than younger adults.
Comorbidity in older adults manifests primarily via two distinct pathways. The
first pathway is an adult who had one or more psychiatric disorders in early adult-
hood or middle age and has carried those through to older age. The second pathway
is late onset, where the older adult experiences psychiatric symptoms, including an
AUD, for the first time in later life. Historically, it has been assumed that those with
early onset generally present with greater severity of psychiatric problems and more
entrenched histories of addiction, which may be considered treatment resistant. For
the older adult, however, biological vulnerabilities resulting from natural aging, in
addition to chronic disease or maladies that tend to be more common in later years,
create a complex picture of health for either pathway.
3 Alcohol Use and Comorbid Psychiatric and Subsyndromal Disorders… 37
The Institute of Medicine [3] identified four age-related factors that may pose
unique risk for older adults with substance use and/or mental health disorders. First,
age-related changes in rates of metabolism of all substances, including prescription
medications, can increase risk for development of a SUD or overdose. As one ages,
percentages of lean body mass and total body water decrease, and the ability of the
liver to process alcohol, medications, and other substances is diminished [10]. In
the brain, blood–brain barrier permeability and neuronal receptor sensitivity to
alcohol, medications, and other substances increase. Because of these changes,
older adults experience higher blood concentrations of alcohol or other substances
and may experience increased impairment compared to younger adults [13] at
equivalent consumption levels and with less awareness of their impairment [14–16].
For example, benzodiazepines with long half-lives are contraindicated for older
adults [17]. Benzodiazepines are fat-soluble drugs, and due to increased body fat
common in aging, these drugs have longer duration of action, causing excessive
sedation. In addition, even healthy drinking levels established in early to middle age
and then sustained through older age may be a risk factor for health problems
among older adults [18]. Second, due to their particular life stage, older adults often
experience a greater number of and more significant losses, such as death of a
spouse, partner, or close friends [19]. Such losses can exacerbate existing depres-
sion, substance use, or lead to complicated grief, which is often difficult to distin-
guish from major depression [3].
Third, both acute or chronic medical conditions common among older adults and
the medications used to treat them may cause or exacerbate existing mental health
disorders [3]. For example, physical health problems can worsen depressive symp-
toms and conversely, depressive symptoms can exacerbate physical functioning and
cognition [20, 21]. In addition, the risk for harmful drug interactions, misuse, and
abuse is elevated for older adults, as they take more prescribed and over-the-counter
medications than younger adults [10, 22]. Overall, the number of prescription medi-
cations tends to increase as one ages [23]. Among over 3000 community-based
older adults aged 57 to 85 who were surveyed, 37.1 % of men and 36 % of women
used at least five prescription medications concurrently [23]. The same study found
that about 1 in 25 of participants was at risk for a major drug interaction, often
involving nonprescription medications.
Dangerous medication interactions in older adults also may occur due to a lack
of knowledge about potential interactions or because they see multiple doctors,
each of whom may unknowingly prescribe medications that interact with each other
and/or with alcohol or other substances. For example, drugs such as barbiturates,
benzodiazepines, and opiates [24], which may be legitimately prescribed for a med-
ical condition, may interact with alcohol or marijuana, causing excessive or danger-
ous sedation. Medications for chronic and terminal illnesses, such as antiretroviral
medication for HIV, may not reach therapeutic thresholds in the presence of even
moderate amounts of alcohol. Older adults may also unintentionally misuse a medi-
cation by borrowing a prescribed medication from another person (e.g., taking a
dose of another person’s lorazepam or zolpidem for sleep), taking more than
intended, or confusing pills.
Fourth and finally, functional, sensory, and cognitive impairments that commonly
occur as a natural part of aging may interfere with diagnosis of a mental health or
substance use disorder [3]. Differential diagnosis can be extremely difficult as many
of the symptoms of mental health and substance use disorders mimic symptoms of
medical diseases, such as reduced physical functioning and loss of motor coordination.
For example, dementia shares many of the same symptoms of intoxication, such as
disinhibition, described further below. This can complicate not only diagnosis but also
determining points of treatment initiation [3]. These functional, sensory, and cognitive
impairments may also interfere with an older adult’s ability to comply with treatment
recommendations or medication adherence. The intersection between difficulty with
identification and treatment of these disorders causes what is often referred to as a
descent or “spiral” of deterioration in physical, cognitive, and psychological health
that affects many older adults with co-occurring disorders [3, 20, 25].
3.2 Alcohol Use
Overall, adults reduce their alcohol use as they age [26–29], yet alcohol remains the
most commonly used substance among older adults [6, 30]. According to the 2005–
2006 National Survey on Drug Use and Health (NSDUH), about 56 % of adults
50–64 years old and 43 % of those 65 years old and older reported drinking alcohol
in the past year [31]. For these two age groups overall, past year prevalence rates of
the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) alcohol
dependence, abuse, and subthreshold dependence symptoms were also estimated
for the years 2005–2006, with 50–64 year-olds yielding 1.9 %, 2.3 %, and 7.0 %,
respectively, and those 65 years old and older yielding 0.6 %, 0.9 %, and 5.2 %,
respectively; however, these proportions increase substantially among those older
adults who report past year alcohol use. Among those who reported past year alco-
hol use, 7.4 % of those 50–64 years old and 3.4 % of those 65 years old and older
met criteria for AUD. In 2013, 2.1 % of NSDUH respondents aged 65 and older
qualified for alcohol abuse and/or dependence [32]. Within clinical settings, older
adult rates of AUD range up to 22 % [33–35]. Subthreshold dependence symptoms
have been demonstrated to be quite high among older adults who report past year
alcohol use, among both 50–64 year-olds (12.5 %) and individuals 65 years old and
older (12.1 %) [31].
At-risk drinking is more prevalent among older adults than AUD and is likely
responsible for the preponderance of harm caused by alcohol to the health and well-
being of older adults. Drinking safety guidelines provided by the American
Geriatrics Society and the National Institute for Alcohol Abuse and Alcoholism
recommend that older adults drink no more than seven standard drinks (12 oz. beer,
4–5 oz. glass of wine, 1.5 oz. of 80 proof liquor) per week, and no more than three
standard drinks on any one occasion [28, 30]. Prevalence rates for older adult at-risk
drinking (defined as exceeding the safe drinking guidelines) are estimated to be
16 % for men and 10.9 % for women [36, 37]. This may be in part due to a continu-
ation of drinking habits from middle age.
Binge drinking, generally defined as five or more standard drinks on one occa-
sion, also occurs among older adults [38]. Rates of older adult binge drinking are
19.6 % for men and 6.3 % for women according to the 2005–2006 NSDUH data [34,
39]. In a study of community-based older adults who were seen in internal medicine
offices and reported drinking one or more drinks in the previous 3 months, 67 %
reported binge drinking in the last year [38]. Those in the 2005–2006 NSDUH sur-
vey who endorse subthreshold alcohol dependence were more likely to report binge
drinking than those who endorsed no criteria for AUD [31].
Comorbidity. Very few studies have explored comorbidity among older adults
who drink. Moore and colleagues [30] used 2001–2002 National Epidemiological
Survey on Alcohol and Related Conditions (NESARC) data to estimate lifetime
comorbid use of alcohol, tobacco, and nonprescription drugs among individuals 65
years old and older. They found that 43.5 % used alcohol and tobacco, and less than
3 % used a combination of alcohol, tobacco, and nonprescription drugs. For use in
the past 12 months, these rates were 7.3 % and less than 1 %, respectively. Older
adults 65 years old and older with lifetime AUD were over three times as likely to
have a tobacco use disorder in the past 12 months [40].
Sacco and colleagues [41] used a latent class analysis with data from individuals
who were 60 years old and older who participated in the 2001–2002 NESARC sur-
vey to identify low-, moderate-, and high-risk drinkers. Low-risk drinkers, 89 % of
the sample, were characterized primarily by not exceeding recommended guide-
lines of drinking and no endorsement of AUD symptoms. Moderate drinkers, 9.7 %
of the sample, were characterized primarily by their report of exceeding the recom-
mended drinking guidelines and endorsement of some symptoms of AUD but
remained subthreshold. Finally, high-risk drinkers, 1.2 % of the sample, had much
higher probabilities of endorsing symptoms of AUD than the other two groups. Just
under 82 % of the high-risk group met criteria for an AUD. Predictors of belonging
to the high-risk group were male gender, younger age, less than high school educa-
tion, having current major depression, having antisocial personality disorder, being
the child of an alcoholic, and being a current smoker.
Using 2005–2007 NSDUH data, Blazer and Wu [31] identified factors among
past year alcohol users 50 years old and older that increased the odds of having an
AUD. These factors included being 50–64 years old, male, Black, separated,
divorced, or widowed; having low income, major depression, current nicotine
dependence; using illicit drugs or nonmedical prescription drug use in the past year;
and early onset of alcohol use (<18 years old). Thus, a majority of these risk factors
were comorbid disorders, particularly other SUD.
3.3 Tobacco
Tobacco use is quite prevalent among older adults. Among adults 65 years old and
older in 2000–2001, just under 49.6 % reported lifetime use and 14 % reported use
in the last 12 months [30]. Within the same sample, just over 6 % used tobacco and
alcohol together in the last 12 months; however, tobacco use may be decreasing
among older adults. Data collected by the Centers for Disease Control in 2008
revealed that only 9 % of individuals aged 65 and older reported being current
smokers [42]. Using data from the National Health Interview Survey between the
years of 1987 and 2000, Nelson and colleagues [43] demonstrated a decline in
smokeless tobacco use among adults 65 years old and older from 6.9 % to 2.8 %. A
smaller but still statistically significant decline occurred among 45–64-year-olds
from 5 % to 3.1 %. This decline is likely due to the rise in smoking and other tobacco
use cessation programs and more rigid policies controlling tobacco marketing. Still,
prevalence rates of tobacco use disorder are high among older adults. Using data
from the 2001 to 2002 NESARC survey, the prevalence rate of tobacco use disorder
for individuals 65 years old and older is 8.7 % and 4 % for lifetime and past 12
months, respectively [40].
Comorbidity. Tobacco use among older adults is associated with greater mortality,
risks of coronary events and cardiac deaths, smoking-related cancers, chronic
obstructive pulmonary disease, decline in pulmonary function, development of osteo-
porosis, risk of hip fractures, loss of mobility, and poorer physical functioning [44,
45]. Incidentally, smoking also impairs or inhibits effective treatments for these con-
ditions [46]. Older women are particularly vulnerable to tobacco’s effects, as research
reveals that older women who smoke have double the mortality rate of those who do
not [47]. Tobacco use is also strongly associated, across ages, with mortality rates
among those with schizophrenia, depression, and bipolar disorder [48] in that it is
associated with almost half of the deaths within these subpopulations. Finally, data
from the 2001–2002 NESARC reveal a strong relationship between AUDs and
tobacco use disorders, such that older adults with a lifetime tobacco use disorder are
more than 2.5 times as likely to have an AUD in the past 12 months [40].
3.4 Illicit Substance Use
Compared to their younger counterparts, illicit substance use rates among older
adults remain relatively low. Still, illicit drug use is more prevalent among American
older adults than among older adults in almost any other country in the world [49],
and rates of illicit and prescription drug misuse among adults over 65 are increasing
[5, 6, 30]. Results from the 2013 NSDUH revealed that rates of past month use of
illicit substances doubled on average between 2002 and 2013 (from 1.9–3.4 % to
3.9–7.9 %) among 50–65-year-olds [5]—a statistically significant increase driven
by the Baby Boom generation [5, 50]. Generally, individuals aged 50–64 report
more psychoactive drug use than older groups [37, 51, 52]. For example, in 2012,
19.3 % of adults 65 and older reported having ever used illicit drugs in their lifetime,
whereas 47.6 % of adults between the ages 60 and 64 reported lifetime drug use.
Among older adults who reported illicit substance use in 2012, 11.7 % met criteria
for past year SUD [51]. Despite increasing rates of past month use, the 2013
NSDUH data [32] revealed that only 0.4 % of adults 65 years old and older qualified
for an illicit drug use disorder in the past year, whereas among individuals aged
45–64 that rate is 1.1 %. It is important to note, that even with low rates of illicit
drug use and drug use disorder, older adult drug users may use substances quite
regularly. For example, using the 2005–2006 NSDUH data, Blazer and Wu [37]
found that among cocaine using adults 50 years and older, 57 % reported using
cocaine on more than 30 days in the past year.
Comorbidity with illicit drugs other than cannabis. Due to methodological limi-
tations of recruiting ample amounts of older adults in epidemiological surveys,
there is very little data on comorbidity among older adult drug users. Generally, it is
known, however, that history of past substance abuse and/or mental health disorders
are known risk factors for drug abuse in late life [17].
Cannabis. Cannabis use by older adults is considerably more prevalent than other
illicit drug use. In the 2005–2006 NSDUH, 2.6 % of adults 50 years old and older
reported past year marijuana use, as compared to less than 0.5 % for all other drugs
(e.g., cocaine, methamphetamine, inhalants, and heroin) [37]. When broken down by
age group, 3.9 % of adults aged 50–64, the bulk of the Baby Boomers at that time,
reported past year marijuana use, compared to only 0.7 % of those 65 years old and
older [53]. Among those aged 50 and older reporting marijuana use, 49 % reported
using marijuana more than 30 days in the past year, with a mean of 81 days.
Relatively little is known about medical use of cannabis among older adults—both
licit and illicit. An international survey of just under 1000 older adults across 31 coun-
tries reported that 20.8 % and 6.4 % of users of cannabis-based medicines were aged
51–60 years and 61–76 years, respectively [54, 55]. With the passage of medical
marijuana legislation and relaxed enforcement of drug possession related to mari-
juana, the prevalence rate of use (not necessarily abuse) among older adults may
increase, either to cope with illness-related side effects [34] or for recreational use.
Comorbidity and risks related to cannabis. The increasingly widespread, legal
availability and acceptance of cannabis, for both medicinal and recreational use,
may pose unique risks in an aging population. Across age groups, cannabis is known
to impair short-term memory, increase one’s heart and respiratory rate, and elevate
blood pressure [56]. There is also a fourfold increase in risk for heart attack after the
first hour of smoking marijuana. For older adults, these risks may be particularly
pronounced, especially for those whose cognitive or cardiovascular systems may
already be compromised. It is yet unknown which of the earlier described disease
correlates to smoking tobacco also appear for cannabis.
3.5 rescription, Nonprescription, and Over-the-Counter

P
Medication Use
There is a continuum of prescription medication use—from using it as prescribed,

misuse by the patient, or prescribing practitioner, to endorsing SUD [57]. Older adults
may not use prescription or over-the-counter medications to feel intoxicated, and in
many cases, older adult prescription drug use does not mirror use among younger
counterparts. They may use medications in unsafe amounts, be at greater risk for drug
interactions, and they also may obtain medications from multiple physicians, family
members, and friends. Stock piling is also a possibility for older adults.
In 2012, 2.9 million (0.9 % of the US population) adults 50 years old and older
reported nonmedical use of psychotherapeutic medications in the past year and, like
other substances, they used them less than younger adults [58]. Prescription drugs
of abuse may include benzodiazepines, barbiturates or nonbarbiturate sedative-
hypnotics, and opioid pain relievers. Women are thought to be more likely to abuse
prescription drugs [57], and one estimate of prescription medication misuse among
older women is 11 % [17]. Blazer and Wu [52] reported that in 2005–2006, 1.4 % of
adults 50 years old and older used prescription opioids nonmedically in the last
year, which was higher than sedatives, tranquilizers, and stimulants (all less than
1 %). Actual prescription opioid use disorder among this sample was 0.13 %, yet
dependence was more common than abuse [51]. The most common use of pain
relievers was combinations of acetaminophen and hydrocodone or propoxyphene,
and use of these combinations was much higher for 50–64-year-olds than for those
65 years old and older [52].
Benzodiazepines are the most commonly prescribed psychiatric medication
among all adults. While there are contraindications for use of benzodiazepines with
older adults, they are not only widely prescribed [59] but disproportionately pre-
scribed to older adults [60]. Rates of benzodiazepine use among older adults have
ranged from 15.2 to 32 % [61]. These rates may be impacted by overprescription,
misdiagnosis, or polypharmacy rather than intentional misuse or abuse.
Comorbidity. According to 2005–2006 NSDUH data, nonmedical use of pre-
scription medication among those aged 50 and older was associated with marijuana
use, alcohol use, and past year major depression [51]. Furthermore, while older
adults may use nonprescription opioid pain relievers less than younger adults, there
is evidence that mortality rates resulting from such use among older adults are
increasing. Between 2006 and 2013, rates of older adult mortality due to opioid use
increased and surpassed younger adults in recent years [62]. Data from poison
control centers in the US also revealed an increasing trend among older adult pre-
scription opioid misuse and suicidal intent. With the growing elderly population,
these numbers are likely to continue to increase.
Using Waves 1 (2001–2002) and 2 (2004–2005) of NESARC survey data of
adults 40 years and older, MacKenzie and colleagues [63] estimated the prevalence
of psychiatric disorders at Wave 1 and then the persistence of that disorder at Wave
2. More than any other disorder class, SUD (including alcohol, nicotine, and drug
use disorders) demonstrated the highest rate of persistence at Wave 2 (60.2 %). This
persistence has important implications for comorbidity, and it may be a marker of
chronic, severe vulnerability.
3.6 Gambling
Gambling disorder, as described in the fifth edition of the Diagnostic and Statistical
Manual (DSM-5), is defined as “persistent and recurrent problematic gambling
behavior leading to clinically significant impairment or distress,” as indicated by a
number of symptoms similar to SUDs [64]. It encompasses both problem gambling
and pathological gambling—two terms that are utilized frequently in the

epidemiological literature [65]. Generally, problem gambling is thought of as a sub-
threshold disorder and prodromal to pathological gambling.
Prevalence rates for older adult lifetime gambling disorders range widely from
about 0.3 % to as high as 10.6 % [65], across both population studies and community-
based samples. Within a systematic review of the older adult gambling literature [65],
only one study was found to report a rate of current problem gambling among a com-
munity sample of adults 65 and older: 1.3 % [66]. Current rate of pathological gam-
bling in this same study was 2.7 %. In the systematic review, rate of current pathological
gambling among older adults ranged from 0 to 3.2 % [65]. Differences in rates of
gambling disorders appear to be largely due to differences in measures used—a gen-
eral diagnostic interview revealed lower rates of gambling disorder whereas a special-
ized screening tool, such as the Revised version of South Oaks Gambling Screen
(SOGS), yielded the highest rates of disordered gambling behavior.
While pathological gambling is more prevalent among older men [65], gambling
has been noted to be an emerging problem among older women [67, 68]. Using
NESARC 2001–2002 data, a study found that men and women 65 years old and older
endorsed criteria for problem gambling (12.3 % and 16 %, respectively) and patho-
logical gambling (10.1 % and 4.8 %, respectively) at high rates [69]. Interestingly,
despite the higher rates of more severe gambling disorder in men, older women may
be more likely to attend treatment. One study found that treatment seeking pathologi-
cal gamblers aged 55 and older were more likely to be female, and that older female
gamblers were more likely to start gambling at the age of 55 or older [67], compared
to their male counterparts who reported an early onset of gambling.
Similar to the general population, racial and ethnic differences in gambling
disorder are observed among adults 65 years and older. NESARC (Wave 1:2001–
2002) data revealed that lifetime gambling disorder (either problem or pathological
gambling) among adults 60 years old and older appeared most prominent among
Black respondents (11.3 %), compared to White (9.8 %) or Hispanic respondents
(4.7 %) [70], though differences between groups were not statistically significant,
likely due to small sample sizes compared to the other age groups.
Older adult gambling may manifest differently than younger gamblers. Among
those individuals calling a gambling helpline, older gamblers were more likely to
report lower incomes, longer duration of gambling, and more problems with slot
machines than younger gamblers [71]. Gambling also may be uniquely damaging to
older adults due to a number of life stage factors, including not having enough work-
ing years left or income to make up for losses, and older adults may experience cog-
nitive decline that impairs their judgment. A 2004 study [72] of about 800 seniors
recruited from primary care found that 11 % made large bets or bet more than they
can afford and were identified as at-risk gamblers. In addition, The National Gambling
Impact Study Commission found that gambling among senior citizens increased
from 20 % in 1974 to 50 % in 1998 [67, 73]. Increased accessibility to slot machines
and lotteries overall and in retirement communities, as well as increased online
gambling [74], and increased marketing efforts targeting older adults are likely
responsible for the increase. This in turn increases the risk for gambling disorder.
Comorbidity. Comorbidity of mental and physical health disorders is prevalent

across types of older gamblers [75]. Recreational gamblers surveyed in the 2001–
2002 NESARC had significantly higher rates of alcohol, nicotine, mood, anxiety,
and personality disorders compared to nongamblers. This same group was less
likely to suffer from arteriosclerosis and cirrhosis but more likely to be obese.
Among 800 seniors recruited from primary care [72], predictors of at-risk gambling
included binge drinking, current symptoms of posttraumatic stress disorder, minor-
ity race/ethnicity, and being a patient of the VA. Unlike studies of the general popu-
lation, at-risk gambling in this sample was not associated with cigarette smoking,
gender, or depressive symptoms. In a study of individuals calling a gambling
helpline [71], older gamblers were less likely to report a history of illicit behaviors,
drug problems, indebtedness, and family problems, which may indicate that those
that are treatment seeking may present with less comorbidity.
Within the 2001–2002 NESARC data [75], those respondents aged 60 and older
with a gambling disorder were significantly more likely than nongamblers to have an
alcohol, nicotine, drug, mood, anxiety, and personality disorders. Disordered gamblers
were also significantly more likely to suffer from arthritis and angina. Being an older
adult gambler can be a significant marker of mental and physical health comorbidity.
3.7 Mood Disorders
Mood disorders include, among others, major depressive disorder and dysthymia.
Due to the relative lack of manic and hypomanic symptoms among older adults [3],
even among those who experience bipolar disorder, mania and hypomania will be
reviewed with bipolar disorder under severe and persistent mental illness. According
to the 2001–2003 CPES data, estimates in the US of lifetime depressive disorders,
excluding bipolar disorder, among adults 55 and older who are Non-Hispanic
Whites, African Americans, Caribbean Blacks, Latino Americans, and Asian
Americans 65 and older are 13.8 %, 5.4 %, 11.2 %, 13.9 %, and 6.4 %, respectively
[76]. Prevalence rates of current major depressive disorder among individuals 65
years old and older in community-based samples ranges from 1 to 5 % [77]; with an
average of 3.3 % with current major depressive disorder across Western countries
[78]. Among older adults across western countries lifetime major depression
(16.5 %) is the most common, followed by lifetime AUDs (11.7 %) [78]. About half
of cases of major depressive disorder among American older adults are late onset
[77]. The prevalence rate for past year dysthymic disorder among adults 65 and
older living in the community ranges from 0.6 to 1.6 % [3].
Using Waves 1 (2001–2002) and 2 (2004–2005) of NESARC survey data,
MacKenzie and colleagues [63] estimated the prevalence of psychiatric disorders
among adults 55 and older at Wave 1 and then the persistence of that disorder at
Wave 2. Prevalence rates of past year major depression and dysthymia were 3.7 %
and 1.2 %, respectively, at Wave 1. Persistence at Wave 2 of major depressive disor-
der and dysthymia for those who endorsed criteria for those disorders at Wave 1
were 25.0 % and 16.5 %, respectively. Data from the 2001 to 2002 NESARC survey
demonstrated that among adults 65 and older with major depression, the mean age
of onset was 50 [79]. Only about half of these individuals had ever received
treatment, even though a quarter had reported contemplating suicide.
Subsyndromal mood disorders are also prevalent among older adults [77].
Subthreshold depressive symptoms have been found in 15–20 % of a community-
based older adult population [77, 78]. Due to age biases in the criteria and screening
measures themselves [80], it may be that these diagnostic orphans might otherwise
qualify for mood disorder.
Comorbidity. Data from the 2001 to 2002 NESARC survey demonstrates that
older adults who reported having a lifetime mood disorder were more likely to have
a lifetime AUD, and having any mood disorder also demonstrated increased odds of
past 12 months AUD [40]. In an alternative analysis of the same NESARC data,
Laborde-Lahoz and colleagues [81] examined lifetime comorbidity among adults
aged 55 years and older with either subsyndromal depression or major depression.
They found that those with lifetime major depression were almost three times more
likely to have a SUD or AUD than those without lifetime major depression, after
adjusting for age, income, gender, education, marital status, and race and ethnicity.
Depression and anxiety are highly correlated in the general population, and in
older adults, there are estimates of anxiety disorders occurring among over 50 % of
those with major depression [77, 82]. Depression with comorbid anxiety is usually
a marker of greater severity and duration of depression, and among older adults, the
two together are associated with higher rates of somatic symptoms, disability, and
suicide compared to those who have depression alone.
Major depression is a salient risk factor for suicide, and some studies suggest that
about 85 % of older adults who die by suicide had major depressive disorder [77].
Alcohol abuse is also a known risk factor for suicide. Alcohol and depression are
found to be closely related in the general population [83], though the causal order of
each remains unclear. Individuals with histories of both disorders may be at height-
ened risk for suicide, especially in older age.
3.8 Anxiety Disorders
Anxiety disorders often include panic disorder, specific phobia, social phobia,
generalized anxiety disorder, obsessive compulsive disorder, and posttraumatic
stress disorder (PTSD). While in DSM-5, PTSD now belongs to its own category of
disorders, research on prevalence of PTSD often occurred in the past with other
anxiety disorders, which is why it is reviewed here. According to a review of epide-
miological studies of community samples ranging in age from 55 to over 90 years
old, prevalence in the US of anxiety ranged from 1.2 to 10.2 % [25]. Subsyndromal
presence of anxiety symptoms among these samples ranged from 13.3 to 15 %.
Using Collaborative Psychiatric Epidemiology Surveys (CPES) data from 2001 to
2003, estimates in the US of lifetime anxiety disorders, excluding obsessive com-
pulsive disorder, among Non-Hispanic Whites, African Americans, Caribbean
Blacks, Latino Americans, and Asian Americans 55 and older is 16.8 %, 11 %,
11.5 %, 15.2 %, and 7.9 %, respectively [76].
Prevalence rates of specific anxiety disorders also range widely, primarily due to
differences in measurement methods of symptoms of the disorder [25]. Generalized
anxiety disorder (GAD) appears to be consistently the most prevalent anxiety disor-
der among older adults, though it has often been excluded in epidemiological stud-
ies. Prevalence rates for GAD in the past year reported by the NESARC and CPES
between 2001 and 2003 ranged from 1.1 to 2.1 % for adults 65 years old and older
[3]. Phobic disorder for adults between the ages of 60 and 65 ranges in prevalence
from 3.1 to 8.9 % among community samples [25]. NESARC and CPES estimates
of past year agoraphobia without panic and social phobia were 0.3 % and 0.9–2.6 %,
respectively [3]. Panic disorder across studies of community samples of older adults
60 and older ranges from 0 to 10.5 % [25]. NESARC and CPES data show a range
of past year prevalence rates for panic disorder for those 65 and older to range from
0.8 to 1.1 % [3]. Obsessive compulsive disorder, as estimated by community sam-
ples of adults 60 and older, ranges in prevalence from 0–1.6 % among males to
0.9–2 % among females [25]. Epidemiological surveys from the early 2000s esti-
mate the prevalence of past year obsessive compulsive disorder among adults 65
and older to be 0.8 % [3].
Posttraumatic stress disorder (PTSD) generally has the widest range of preva-
lence among older adults, due to the wide range of measures and samples utilized,
ranging from 0.6 to 2.6 % among those 65 and older according to data from Wave 1
NESARC and CPES 2001–2003 [3]. PTSD is especially complicated for older
adults, who may present with the full disorder PTSD or subsyndromal symptoms,
whose symptoms may lessen or worsen with age [84]. Lifetime prevalence for
PTSD in Wave 2 of NESARC [84] among adults 60 years old and older is 4.5 % for
the full disorder and 5.5 % for subsyndromal PTSD (having just one symptom in
criterion D (symptoms of increased arousal), as opposed to two). Rates were higher
for women than men, with 5.7 % of women reporting symptoms of the full disorder
compared to only 3.1 % of men. Similarly, for those who had lifetime subsyndromal
PTSD, women had a prevalence rate of 6.5 % compared to only 4.3 % of men. PTSD
may occur in special populations, such as veterans who experienced combat, but
also may occur through other experiences such as, unexpected death of someone
close, serious illness, or serious illness of someone close.
Comorbidity. Lifetime anxiety disorder is associated with increased odds of life-
time alcohol and tobacco use disorders among older adults [40]. NESARC (Wave 2:
2004–2005) data revealed PTSD to be associated with increased odds of lifetime
mood disorder, anxiety disorder, drug use disorder, and borderline or narcissistic
personality disorders [84], in addition to decreased psychosocial functioning.
Symptoms of PTSD can also be complicated by the onset of dementia, causing the
initiation of or exacerbating existing aggressive behaviors [85]. Interestingly, while
PTSD appears to be a marker of vulnerability among older adults, it appears to be
significantly associated with alcohol use or AUD in only some samples [3, 84].
MacKenzie and colleagues [63] estimated the persistence of anxiety disorders from
Wave 1 (2001–2002) to Wave 2 (2004–2005) of NESARC survey data for adults 40
years and older and found that anxiety disorders persisted at Wave 2 for 29.5 % of
those endorsing anxiety disorders at Wave 1.
3.9 Severe and Persistent Mental Illness
Severe and persistent mental illness among older adults can include, among other
disorders: schizophrenia, schizophreniform disorder, schizoaffective disorder,
delusional disorder, other psychosis, bipolar disorders types I and II, mania, and
hypomania. The exact prevalence of these disorders is difficult to determine often
because other conditions common in older age, such as dementia, may mimic such
disorders. Looking across national surveys and literature on severe mental illness
among older adults, the Institute of Medicine estimates that 1.4 million to 1.9 mil-
lion older adults (3–4.8 %) had severe mental illness in 2010 [3].
Schizophrenia in the past 12 months has an estimated prevalence of 0.2–0.8 % [3],
according to epidemiological surveys between 2000 and 2003. A recent review of the
literature exploring prevalence rates of psychiatric disorders among older adults across
western countries found that lifetime rates of mania, hypomania, and bipolar disorder,
types I and II, were collectively 1 % of the older adult population [78]. The prevalence
rate for adults 50 and older who currently had these disorders was under 0.5 %. Using
Wave 1 (2001–2002) and 2 (2004–2005) of NESARC survey data, MacKenzie and
colleagues [63] estimated manic episode/hypomania were about 1 % among adults 55
and older. Persistence of these disorders across the Waves was 20.3 %.
A meta-analysis of studies of mental health disorders among adults 50 and older
from North America and Europe [78] identified that the rate for lifetime psychosis
was 4.7 %, and for current psychosis was 1.7 %. One estimate of prevalence of non-
affective psychoses in community-living, older adults was 78,000 people in 2001–
2003 [86]. Studies of psychosis in older age are limited, and it is therefore unclear
as to whether the prevalence of psychosis: increases with age, age-related symptom
presentation differs significantly across the lifespan, or if its increase is more a
marker of increased rates of dementia. One study of individuals 71 and older found
that, among older adults with dementia, 18.2 % experienced delusions and 14.2 %
experienced hallucinations [3]. Participants with dementia also demonstrated high
rates of one or more of the following: disinhibition, irritability or lability of emo-
tion, symptoms of anxiety and depression, and agitation or aggression. As dementia
takes its course, these symptoms generally increase and worsen.
3.10 Other Psychiatric Disorders
Prevalence rates of many psychiatric disorders remain relatively unknown, such as

personality disorders, hoarding, and adjustment disorder. A recently published
study of Wave 2 NESARC data reports that among adults 55 and older, 14.5 % had
one or more personality disorders [87]. While often present in clinical settings, few
population-based estimates of prevalence exist for hoarding and adjustment disor-
der. Some smaller, community-based studies have attempted to estimate these prev-
alences. For example, the Massachusetts public health department reported 471
formal complaints of hoarding between 1992 and 1997 [3]. These cases are of
course only the ones severe enough to be noticed and reported.
3.11 T
wo or More Mental Health or Substance Use
Conditions
Based on data from Waves 1 and 2 of NESARC and the CPES, it is estimated that
between 2 and 2.4 % of adults 65 and older endorse criteria for a diagnosis of two or
more mental health and substance use disorders [3]. The rate of having three or
more of these conditions is between 0.5 and 0.8 %. Unfortunately, rates are not dis-
aggregated in such a way that we may understand the prevalence rate of general
comorbidity among those with AUD alone. Furthermore, as with younger adults,
these rates exclude subsyndromal disorders, thus rates are an underestimation of the
prevalence of older adults with AUD with comorbid symptoms.
3.12 I dentification and Treatment Utilization of Comorbid

Disorders Among Older Adults
Identification of comorbid disorders among any population requires thorough

assessment across time. Due to the fact that a majority of older adults with comorbid
AUD, medical, and other psychiatric disorders present most often in medical set-
tings, such as primary care, emergency departments, and psychiatric hospitals [3],
opportunities for specialized assessment are limited. Healthcare workers working in
either institutions or residential settings, such as in the home of the older adult, must
be aware of and trained in assessing a wide array of symptoms and identifying pos-
sible comorbid disorders. Assumptions that older adults do not drink or use illicit
substances should not be made. Training must be provided for both medical and
psychiatric specialists so that comorbidity is more likely to be identified.
Despite a clear need for services for older adults with comorbid disorders, there
is empirical evidence to suggest that older adults access services at rates far lower
than their younger counterparts [3, 88, 89]. The 2001 NSDUH data revealed that
only about 10 % of older adults with mental health disorders reported receiving any
type of treatment [90], compared to 25 % of younger adults [3]. In the 1996 Midlife
Development in the United States study, adults aged 65 to 74 with mental health
conditions were found 40 to 140 % less like to receive treatment than their younger
counterparts [88]. In addition to finding that older adults were less likely to receive
specialty care, another study, the 1997–1998 Health Care for Communities house-
hold study, found that older adults reported that primary care providers were much
less likely to ask about mental health symptoms or treatment [91].
Part of the reason for underutilization, as referred to earlier, is a lack of identifi-
cation of the disorders or subsyndromal symptoms among older adults. Another
reason may be that older adults often do not identify their mental health or sub-
stance use disorder as needing treatment [3, 92], sometimes confusing symptoms
for a normal part of aging. Additionally, older adults tend to avoid specialized treat-
ment due to stigma [3, 92] related to both the disorders and treatment itself; how-
ever, many older adults report positive attitudes toward treatment, and thus, stigma
is not the primary cause of underutilization of services. One study of 600
community-dwelling adults 60 years and older [93] revealed that there are a number
of additional barriers preventing older adults from obtaining any kind of specialized
care: cost, information about accessing services, lack of age or ethnically appropri-
ate services (including languages available), and lack of transportation. A majority
(80 %) of participants in the study reported that treatment was more than they could
afford. The issue of accessibility is currently a primary barrier to older adults with
comorbid disorders.
3.13 Conclusion
Prevalence rates of comorbid substance use and other psychiatric symptoms and
disorders among older adults who use alcohol or endorse AUD are generally
unknown. Like younger adults, older adults appear to have a high correlation
between substance use and mental health disorders, with each being a risk factor for
the other. Existing studies also point to evidence that older adults with comorbid
disorders, including both physical and mental health conditions, are hard to identify
due to both the complexity and overlapping nature of symptom presentation. For
these same reasons, they also may be difficult to treat, particularly in situation when
accepted treatments for individual disorders have the potential to interact poorly.
Future research must expand upon existing knowledge of the prevalence of men-
tal health and substance use disorders, helping to identify reliable and valid screen-
ing measures in order to increase the accuracy with which we identify both substance
abuse and psychiatric disorders and their subsyndromal counterparts. For greater
understanding of prevalence in the community, research must innovate in its meth-
ods for epidemiological studies, which tend to have difficulty identifying and enroll-
ing older adults who will respond [3]. Most researchers generally consider existing
estimations of mental health and substance use disorders to be underestimations
among older adults.
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Part III
Alcohol Effects on Healthy Aging
Alcohol Consumption
and Cardiovascular Disease in Aging 4
Populations
Edmond K. Kabagambe and Kenneth J. Mukamal
4.1 Introduction
Cardiovascular diseases (CVD), including heart disease, stroke, heart failure, and
hypertension, remain prevalent and are the most common causes of death in the
United States [1, 2] and around the world [3, 4]. Highest CVD incidence and mor-
tality rates are seen among men, the elderly and minority populations (e.g., African
Americans). While mortality due to CVD has decreased overall, many people across
the globe are living with nonfatal forms of CVD [5].
In this chapter, we review effects of alcohol on major CVDs and associated risk
factors overall and with a focus on potential benefits and risks of alcohol in aging
populations. We highlight age-related reduction in alcohol tolerance and the
increased risk for adverse alcohol–drug interactions in the elderly. We also point out
that data on cardiovascular effects of alcohol in the elderly are scant, especially in
those who are 75 years or older. Further, we highlight the need for more studies on
the interaction between alcohol use and medications in old age.
4.2 CVD Incidence and Mortality
According to the American Heart Association and the Centers of Disease Control
and Prevention, CVD is the leading cause of death in the United States [1, 2]. For
instance, in 2013, heart diseases alone accounted for 23.5 % (611,105 deaths) of all
E.K. Kabagambe, D.V.M., M.S., Ph.D. (*)

Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center,
2525 West End Ave., Suite 800, Nashville, TN 37203, USA
K.J. Mukamal, M.D., M.P.H.
Department of Medicine, Beth Israel Deaconess Medical Center,
1309 Beacon Street, 2nd Floor, Brookline, MA 02446, USA

58 E.K. Kabagambe and K.J. Mukamal
deaths in the United States [14]. In the same year, cerebrovascular conditions and
hypertensive disorders accounted for 5 and 1.2 % of all deaths, respectively [14].
The CVD burden is higher in older age groups and CVD mortality increases with
increase in age. For instance, among US men and women with CVD in 2009, the
mortality rates (95 % CIs) per 100,000 population due to CVD were 52.2 (51.5–
52.9) for those aged 45–54 years, 132.3 (131.1–133.5) for those 55–64 years, and
299.8 (297.4–302.2) among those 65–74 years old [15]. Also, compared to Hispanic
or Asian populations, CVD mortality rates (95 % CIs) are highest among non-His-
panic blacks (MR = 141.3; 95 % CI: 139.9–142.8) and non-Hispanic whites
(MR = 117.7; 95 % CI: 117.3–118.1) compared to other populations.
4.3 Alcohol and CVD
Although several studies in the United States and elsewhere have shown that moder-
ate alcohol consumption is associated with reduced risk for heart disease [16–20]
and that heavy intake is associated with increased risk of CVD incidence [6, 21] and
all-cause mortality in various populations (e.g., in Russia [22], China [23], and the
United States [24]), data specific to effects of alcohol in elderly populations remain
scant. The few studies available, e.g., the Cardiovascular Health Study, suggest that
moderate alcohol use is beneficial and may be associated with reduced Medicare
costs among individuals with CVD [25]. The benefits and risks of alcohol consump-
tion are dose dependent with a consistent cut-point for cardiovascular benefits being
1 drink per day for women and about 2 drinks per day for men [21]. These cut-
points have also been observed for associations between alcohol consumption and
all-cause mortality [21, 26].
Although there are many similarities in the effects of alcohol on CVD across
many populations, the magnitude and significance of the association between amount
of alcohol consumed and CVD risk remain inconsistent, especially within countries,
regions, age, sex, race, and other population strata [24, 27, 28]. For instance, in a
large prospective study (n = 34,304) among men and women (45–69 years at base-
line) in Eastern Europe [29], heavy drinking (≥60 g/day) was associated with
increased risk of CHD among men (HR = 1.64; 95 % CIs: 1.02–2.64) but not among
women (HR for women consuming >20 g/day = 1.39; 95 % CI: 0.34–5.76). In another
large prospective study among 220,000 Chinese men, heavy alcohol consumption
was strongly associated with increased risk of stroke and ischemic heart disease but
the association for moderate alcohol intake, though protective, was not as strong as
those observed in western populations [23]. Reasons for the inconsistencies in these
associations remain unknown but may be related to age and the distribution of other
confounding factors that may interact with alcohol consumption to modify effects of
alcohol on CVD. As pointed out in the synthesis of studies from the MIDSPAN
cohort in Scotland with 27,000 participants studied over an ~50-year period, vari-
ables such as occupation, obesity, and smoking, modified the associations between
alcohol consumption and CVD mortality [30]. Genetic differences in alcohol metab-
olizing enzyme genes may also play a role in modifying the associations between
4 Alcohol Consumption and Cardiovascular Disease in Aging Populations 59
alcohol and CVD and could in part account for observed differences in effect sizes
across populations [31]. Alcohol drinking patterns, e.g., weekend vs. weekday or
all-week drinking could also explain some known differences in CVD risk [18, 32].
As shown in a recent review [33], a drinking pattern characterized by moderate
drinking without episodes of heavy drinking may be more beneficial for CVD pro-
tection when compared to patterns that include heavy drinking episodes.
4.4 Alcohol Drinking Patterns and CVD
In additional to amount of alcohol consumed per se, the pattern of alcohol con-
sumption, commonly defined as the number of drinking days per week is also asso-
ciated with CVD outcomes independent of the amount of alcohol consumed [18, 24,
34–37]. In general, a drinking pattern characterized by alcohol consumption on 4 or
more days of the week is inversely associated with MI, stroke, and CVD risk factors
(e.g., type 2 diabetes and insulin resistance-related measures) [38, 39]. When mod-
erate amounts of alcohol are consumed on most days of the week, it is possible that
the body will have prolonged exposure to moderate alcohol and therefore a sus-
tained effect on nutrient status and metabolic processes leading to better CVD ben-
efits. This consistent exposure to moderate amounts of alcohol in the body is also
the proposed biologic mechanism behind the high HDL-C and lower coronary heart
disease events observed among slow alcohol metabolizers (who have an ADH1C
polymorphism) [31] though this hypothesis has been variably confirmed in other
studies [40, 41].
4.5 lcohol, Nutrients, and Intermediate CVD Markers

A
in Aging
The relation between moderate alcohol consumption and intermediate CVD mark-
ers was summarized in two recent reviews [6, 42]. Overall, moderate alcohol con-
sumption is associated with improved concentrations of CVD risk markers,
particularly HDL-C concentrations [18, 31, 43, 44]. Whether HDL-C resulting from
moderate alcohol intake is functional and beneficial for cardioprotection remains
unknown although it does appear to increase cholesterol efflux capacity [45], which
itself has been associated with protection beyond HDL-C concentration alone [46].
While moderate alcohol consumption shows no appreciable benefit on LDL-C, it is
associated with significant improvement in insulin sensitivity [47], C-reactive pro-
tein (CRP) [20, 48], fibrinogen [20, 44], platelet activity [49, 50], blood viscosity
[51], and mechanisms that may protect against CVD.
Alcohol intake may also influence CVD markers through its effects on absorp-
tion and metabolism of nutrients in the body. This is critical especially in the elderly
who may have deficiencies or insufficiencies of nutrients such as folate, vitamin
B12, vitamin D, magnesium, and iron. Indeed, moderate alcohol consumption has
been shown to improve status of nutrients associated with cardiovascular effects.
For example, it improves iron absorption in humans [52, 53] and is associated with
higher vitamin D levels in men [54]. Moderate alcohol consumption also interferes
with absorption and metabolism of lead, fatty acids, and B-vitamins, factors also
known to affect CVD risk. While moderate alcohol use may confer a benefit on
nutrients known to have cardiovascular benefits, heavy alcohol use could lead to
adverse consequences. For instance, heavy alcohol consumption leads to deficien-
cies of magnesium [55], zinc, folate [56], and other nutrients and damages the intes-
tinal lining and the liver impairing nutrient absorption and metabolism [57]. These
effects of alcohol are likely to be worse in the elderly. Except for folate, little is
known about the impact of alcohol-induced alterations in nutrient metabolism on
the cardiovascular system, especially in the older populations where use of dietary
supplements is common. For instance, chronic heavy drinking lowers magnesium
[55], a nutrient needed for proper metabolism of vitamin D [58], implying that
supplementation with vitamin D in heavy drinkers may not be as effective as
intended. These effects of alcohol could also extend to prescription medications that
are in common use among the elderly.
Age also modifies the effects of alcohol consumption on CVD, with no benefit
reported among individuals ≥75 years old in the Honolulu Heart Study [65]. On the
contrary, data from the Cardiovascular Health Study showed that alcohol may have
similar effects in younger (<75 years) and older people [66]. In the same study, sex
did not modify the effects of alcohol on coronary heart disease in participants above
age 65 years. Taken together, moderate alcohol seems to protect against cardiovas-
cular disease across the whole life span but the data on older age groups are scanty.
Theoretical considerations as well as emerging data on intermediate outcomes such
as lipids, suggest that moderate alcohol could beneficially interact with medications
such as statins to improve cardiovascular health but heavy alcohol could worsen
CVD risk, especially in the elderly. Rigorous studies assessing interactions between
alcohol, diet, and medications with regard to CVD in elderly populations are needed.
4.6 Future Studies
While much has been learned about the cardiovascular effects of alcohol in the gen-
eral population, little is known about effects of alcohol in aging populations exposed
to multiple medications. The few available studies (e.g., from the CHS), while very
informative, are limited in that they included few minority populations. The latter
have a large CVD burden and may be more susceptible to problem drinking. New
studies that include diverse populations and focus on how alcohol affects the cardio-
vascular system in old age, medication adherence, access to CVD healthcare ser-
vices and the ability to live successfully in institutionalized facilities for the elderly
are needed.
Studies that focus on how alcohol interacts with CVD prevention or management
practices such as medication use and incidence of adverse events or synergy in ben-
efits are also needed. Most elderly people have never discussed alcohol use with
their healthcare providers [67]. Studies on the need for alcohol use assessments,
especially before prescribing CVD medications may be useful.
Lastly, most of our knowledge on effects of alcohol in the general population or

population subgroups have been based on self-reported alcohol consumption and
are susceptible to biases such as confounding bias. While controlled alcohol feeding
studies in humans are starting to emerge, they are still very few, short-term, and
limited to previous drinkers. Rigorously designed alcohol feeding studies that are
large enough to study medium to long-term effects of moderate alcohol are needed.
Such studies will help to determine whether modulation of alcohol consumption is
important for CVD prevention, especially in the elderly populations who also have
a large CVD burden and exposure to multiple medications.
Acknowledgment We acknowledge the support from the American Heart Association to EKK
that supported literature reviews as part of an earlier project (NSDG # 0635323N).
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Cancer, Alcohol, and Aging
5
Christine L. Savage, Deborah S. Finnell,
and Amanda Choflet
5.1 Epidemiology of Cancer Associated with Alcohol Use
According to the World Health Organization (WHO), cancer accounts for almost
seven million deaths per year [1]. Alcohol is one of the main risk factors for cancer,
with alcohol use attributed to up to 44 % of some cancers [2, 3] and between 3.2 and
3.7 % of all cancer deaths [4, 5]. Since 1988, alcohol has been classified as a car-
cinogen [6]. Types of cancers linked to alcohol use include cancers of the liver,
pancreas, esophagus, breast, pharynx, and larynx with most convincing evidence for
alcohol-related cancers of the upper aeordigestive tract, stomach, colorectum, liver,
and the lungs [2, 7]. All of these cancers have a much higher incidence and mortal-
ity rate in older adults (65 years of age or older). For example, the morality rate in
older adults for esophageal cancer is 21.7 per 100,000 deaths, and in those under 65,
the mortality rate is 1.5 and 2.1 for persons between 50 and 64 years of age, respec-
tively [8]. For alcohol-associated cancers, 66–95 % of new cases appear in those 55
years of age or older [8, 9]. For alcohol-associated cancers, other than breast cancer,
75–95 % of new cases occur in those 55 years of age or older [8, 10, 11]. In invasive
breast cancer, two in every three cases occur in those aged 55 years of age or older
[10]. Thus, alcohol-related cancer in the older adult is a serious public health issue.
C.L. Savage, Ph.D., R.N., C.A.R.N., F.A.A.N. (*) • D.S. Finnell, D.N.S.
Department of Community-Public Health, Johns Hopkins University School of Nursing,
Baltimore, MD, USA
A. Choflet, M.S., R.N., O.C.N.
Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins
Hospital, Baltimore, MD, USA

66 C.L. Savage et al.
Four countries with a decline in alcohol use (France, the UK, Sweden, and US)
have also demonstrated a stabilization or decline in the incidence and mortality rates
for types of cancers closely associated with alcohol use [12]. Based on data from the
National Cancer Institute (NCI), these cancers account for almost a quarter of all
new cancer cases in the US [13].
The increased risk for cancer related to alcohol use is based on a combination of
both quantity/frequency and duration of use, with those consuming alcohol for 20 or
more years at increased risk [14]. This is based on the recommended limits from the
National Institute on Alcohol Abuse and Alcoholism that focuses on quantity—how
much is consumed, frequency, how often it is consumed and pattern of use, and how
often a person consumes alcohol above the recommended limits. The recommended
limits are no more than 4 drinks for healthy adult men under the age of 65 on a single
occasion and no more than 14 drinks in a week. For women and those 65 years of age
and older, the recommended limits are no more than 3 drinks on a single occasion and
no more than 7 drinks in a week [15]. Duration refers to lifetime use of alcohol. Those
who consume alcohol above the recommended limits over their lifetime are at greater
risk for developing alcohol-related cancers [16, 17]. The amount of alcohol consumed
over a lifetime is related to the relative risk of being diagnosed with an alcohol-
associated cancer, and as evidenced by the National Cancer Institute surveillance
data [8], diagnosis is most likely to occur in those over 65. In addition, consumption
of alcohol at lower levels may also increase the risk for alcohol-related cancers.
Nelson et al. reported that daily consumption of 1.5 drinks or greater accounted for
26–35 % of alcohol-attributable deaths [5]. Thus, the evidence is growing that daily
drinking, even at lower levels, increases the risk for developing cancer in later life
with the conclusion that there may be no safe threshold level for alcohol consumption
below which there is no risk for cancer [6, 16, 17].
Another consideration is the possible impact of combined alcohol and tobacco
use on increasing the risk of alcohol-associated cancers. Though many older adults
may have stopped smoking, it is important to determine their lifetime history of
smoking when considering their risk for alcohol-related cancers. The risk for devel-
oping alcohol-related cancer is increased among those who have a history of con-
current tobacco use and at-risk alcohol use [11, 18]. Cao et al. [18] analyzed data
from two cohort studies involving 88,084 women and 47,881 men and found that
light to moderate alcohol use was minimally associated with the risk of developing
cancer and was similar between those currently smoking and those who never
smoked. Among those with a history of at-risk alcohol use, there was an elevated
risk of developing cancer for those who also used tobacco compared with those who
never used tobacco. Talamini et al. [19] also reported a possible synergistic relation-
ship between alcohol and tobacco use. They found a multiplicative risk increase
with heavy consumption of alcohol and tobacco use. Thus, patients who have a his-
tory of both tobacco and at-risk alcohol use should receive early screening for
alcohol-related cancers.
The effects of alcohol and tobacco use are potentiated because smoking increases
the capacity of oral yeasts and bacteria to produce acetaldehyde from ethanol, and
cigarette smoke contains considerable amounts of acetaldehyde that dissolves in
5 Cancer, Alcohol, and Aging 67
saliva. Immediately after alcohol consumption, the level of acetaldehyde in saliva

can exceed 10–100 times the blood level. If a person has poor dental health, often
an issue for older adults, they are apt to have higher levels of bacteria in the mouth;
this, combined with the higher level of acetaldehyde in saliva, adds to the risk for
upper digestive tract cancer [20]. Holding the amount of alcohol consumption con-
stant, persons who smoke have twice as much acetaldehyde in their saliva as those
who do not smoke [21].
Among individuals who have a history of smoking two or more packs of ciga-
rettes and consuming more than four alcoholic drinks per day, the risk of head and
neck cancer is increased greater than 35-fold [22]. Leon and colleagues [23] offer
several reasons for this synergistic effect: (1) the increased permeability of tobacco-
smoke carcinogens through the oral mucosa in the presence of alcohol; (2) the
increased solubility of tobacco-smoke carcinogens in ethanol; (3) increased acetal-
dehyde production from alcohol oxidation by oral bacteria; (4) alcohol-derived
increased induction of CYP2E1 in the liver, which can elevate the amount of toxic
metabolites during the metabolism of carcinogens present in tobacco smoke (e.g.
benzene); (5) alcohol induced increased generation of other cytochrome P450 oxi-
dase system (CYP3A4 and CYP1A2), which can activate tobacco carcinogens; and
(6) alcohol-induced inhibition of the family of CYP enzymes, which could result
in locally increased accumulation of toxic agents by reduced metabolic activation.
The metabolic processes for breakdown of alcohol to acetate, the genetics and
genetic variants for alcohol, and the interaction between alcohol and tobacco smok-
ing aid in understanding the carcinogenic action of alcohol alone and in combina-
tion with smoking. Given the high co-occurrence between alcohol and tobacco
smoking, the problem of poor dental health, and longer duration of both alcohol and
tobacco use, intensive efforts are needed to reduce the harms associated with these
carcinogenic substances in older adults.
5.1.1 Head and Neck Cancers
At least 75 % of head and neck cancer is associated with alcohol and tobacco use
[9]. Even in the absence of tobacco use, the odds of developing head and neck can-
cers in those who drink three of more drinks a day is twice that of the general popu-
lation [24]. The types of head and neck cancers with the highest risk associated with
alcohol use include esophagus, larynx, and pharynx cancer [8]. Using the NCI 2012
data, the incidence and the mortality rate for brain and nervous system cancers are
higher in older adults compared to those 64 or younger. The mortality rate is
17.9/100,000 compared to 2.5/100,000 and the incidence rate is 18.9/100,000 com-
pared to 4.2 [8].
5.1.1.1 Esophageal
Esophageal cancer accounts for approximately 1 % of all new cancer cases, yet
accounts for 2.6 % of all cancer deaths. Only 17.9 % survive 5 years or more. Both
alcohol use and older age are risk factors for developing esophageal cancer.
Eighty-six percent of all patients diagnosed with esophageal cancer are aged 55 or
older at the time of diagnosis with a median age at diagnosis of 67 and a median age
of 69 at death [8, 11, 24]. Using the NCI 2012 data, the incidence and the mortality
rate for esophageal cancers are higher in older adults compared to those 64 or
younger. The mortality rate is 21.7/100,000 compared to 1.5/100,000 and the inci-
dence rate is 21.4/100,000 compared to 1.5/100,000 [8].
5.1.1.2 Larynx
Larynx cancer accounts for approximately 0.8 % of all new cancer cases and
accounts for 0.6 % of all cancer deaths. Just over 60 % survive 5 years or more. Both
alcohol use and older age are risk factors for developing larynx cancer, with 82 % of
all new cases of larynx cancer occurring in those aged 55 or older. The median age
at diagnosis is 65 and 68 at death [8, 19]. Using the NCI 2012 data, the incidence
and the mortality rate for cancers of the larynx are higher in older adults compared
to those 64 or younger. The mortality rate is 5.3/100,000 compared to 0.4/100,000
and the incidence rate is 12.5/100,000 compared to 1.45/100,000 [8].
5.1.1.3 Oral Cavity and Pharynx

Pharynx cancer accounts for approximately 2.8 % of all new cancer cases and
accounts for 1.5 % of all cancer deaths. About 63 % survive 5 years or more. Both
alcohol use and older age are risk factors for developing pharynx cancer. Among all
new cases, 83 % are aged 55 or older. The median age at diagnosis is 62 and 67 at
death [8]. Using the NCI 2012 data, the incidence and the mortality rate for cancers
of the oral cavity and pharynx are higher in older adults compared to those 64 or
younger. The mortality rate is 11.9/100,000 compared to 1.1/100,000 and the inci-
dence rate is 39.7/100,000 compared to 6.3/100,000 [8].
5.1.2 Breast
There are gender differences in alcohol attributable cancer deaths with over half
(56–66 %) of all alcohol-attributable cancer deaths in females resulting from breast
cancer [5]. Breast cancer accounts for 14 % of all new cancer cases and 6.8 % of all
cancer deaths. Among new cases of breast cancer, 42 % are aged 65 years old and
older, with a median age of 61 at diagnosis [8]. Those individuals who are diag-
nosed over the age of 55 are more apt to die from breast cancer, with this age group
accounting for approximately 80 % of all breast cancer deaths. For women, even
low-risk alcohol use (5–14.9 g/day or one standard drink of alcohol or less) increases
the risk of cancer, mainly breast cancer [18]. Using the NCI 2012 data, the inci-
dence and the mortality rate for breast cancers are higher in older adults compared
to those 64 or younger. The mortality rate is 96.3/100,000 compared to 10.4/100,000
and the incidence rate is 431.1/100,000 compared to 81.7/100,000 [8].
5.1.3 Hepatic: Liver and Intrahepatic Duct
Hepatic cancers account for approximately 2.2 % of all new cancer cases, yet
account for 4.2 % of all cancer deaths. Only about 17 % with hepatic cancer survive
5 years or more. Both alcohol use and older age are risk factors for developing
hepatic cancer. Among new cases of hepatic cancers, 80 % are aged 55 years old or
older. The median age at diagnosis is 63 and 67 at death [8]. Using the NCI 2012
data, the incidence and the mortality rate for hepatic cancers are higher in older
adults compared to those 64 or younger. The mortality rate is 30/100,000 compared
to 2.9/100,000 and the incidence rate is 37/100,000 compared to 4.9/100,000 [8].
Persons with a history of at-risk alcohol use are at higher risk for liver cancer with
a confirmed positive association between alcohol use and liver cancer [25]. Alcohol
has been classified by the International Agency for Research on Cancer (IARC) as
a liver carcinogen since 1988 [6]. Even one alcohol drink per day may be associated
with increased risk of liver cancer [20].
5.1.4 Pancreas
Pancreatic cancer accounts for approximately 3 % of all new cancer cases and
accounts for 6.9 % of all cancer deaths. Among those diagnosed with pancreatic
cancer, only 7.2 % survive 5 years or more. Older age is a risk factor for developing
pancreatic cancer, with almost 90 % of all new cases aged 55 or older. The median
age at diagnosis is 71 and 73 at death [8]. The relationship between pancreatic can-
cer and alcohol is less clear; however, those who consumed ≥21 drinks per week
and used tobacco were approximately four times more likely to develop pancreatic
cancer compared to those who did not [26]. Using the NCI 2012 data, the incidence
and the mortality rate for pancreatic cancers are higher in older adults compared to
those 64 or younger. The mortality rate is 65/100,000 compared to 3.2/100,000 and
the incidence rate is 70/100,000 compared to 4/100,000 [8].
5.1.5 Colorectal Cancer
Colorectal cancer accounts for approximately 8 % of all new cancer cases and
accounts for 8.4 % of all cancer deaths. Only 64.9 % with a colorectal cancer diag-
nosis survive 5 years or more. Older age is a risk factor for developing colorectal
cancer, with almost 80 % of all new cases aged 55 or older. The median age at diag-
nosis is 68 and 73 at death [8]. Alcohol use is associated with a moderate increased
risk for development of colorectal cancer [8]. Fredeirko and colleagues [27] reported
that relative risk for colorectal cancer among persons at any age who consumed
alcohol at moderate levels (≥1 drink per day) was 1.2. For those with a history of
heavy alcohol use (≥4 drinks per day), the relative risk was 1.5, thus supporting an
association between even moderate alcohol use and increased risk for cancer. Using
the NCI 2012 data, the incidence and the mortality rate for colorectal cancers are
higher in older adults compared to those 64 or younger. The mortality rate is
82.9/100,000 compared to 4.8/100,000 and the incidence rate is 184.5/100,000
compared to 16.8/100,000 [8].
5.2 ossible Mechanisms Accounting for Alcohol’s

P
Carcinogenicity
Ethanol is the principal type of alcohol found in alcoholic drinks. The effects of
alcohol, including both its level of concentration and the concentration of its byprod-
ucts within bodily tissues and blood, are determined mainly by the rate that ethanol
is metabolized [28]. Most of the susceptible regions to damage are those which are
in direct contact with alcohol during what is named the “first passage” of digestion,
when alcohol is initially consumed. The absorption of an alcoholic drink starts in
the upper digestive mucosa and the stomach; however, the bulk of an alcoholic bev-
erage is absorbed by diffusion in the small intestine into the bloodstream and the
body’s water content. The distribution phase of alcohol into the bloodstream
depends on whether or not food is present in the stomach and whether or not the
person is dehydrated; fasting and dehydration raise the rate of absorption and
increases the peak alcohol concentration [29]. There are some reports that after
alcohol absorption, the concentration of alcohol in the colon is higher than in the
blood [30], explaining why alcohol is a risk factor for colon cancer. The majority
(90 %) of alcohol consumed is oxidized in the liver, reducing the amount of ethanol
that reaches the tissues and organs of the body. Oxidation occurring in the liver
explains why alcohol is an important risk factor for hepatic cancer [9]. Elimination
occurs via excretion of body fluids, specifically urine and sweat, and in very small
amounts, via exhalation.
Ethanol is oxidized to acetaldehyde and then to non-toxic acetate through vari-
ous metabolic pathways (Fig. 5.1). Acetaldehyde is a cytotoxic, genotoxic, muta-
genic, and clastogenic compound [7, 29]. When acetaldehyde binds to DNA, the
DNA becomes damaged and proper and complete replication of the cell cannot
occur. In molecular genetics, these DNA adducts can be the start of a cancerous cell,
or carcinogenesis. As people age, chronic inflammation is an important contributing
factor in aging and aging-related diseases. The immune system has an important
role in promoting the clearance of damaged cells [30]. As such, the DNA adduct
formation as a result of alcohol consumption combined with the inflammation pro-
cess may place older adults with alcohol-use history and current alcohol use at great
risk for cancer and aging-related disease. This carcinogenetic and oxidative process
putting older adults at high risk underscores the advice offered by the European
Code Against Cancer (ECAC), “If you drink alcohol of any type, limit your intake.
Not drinking alcohol is better for cancer prevention.” ([31], p. S71)
ROS
Cytochrome
DNA-Adducts
P450 2E1
ADH1B*2 ALDH2*1 /2
ADH1B*1
Ethanol Acetaldehyde Acetate
ADH1C*2
ALDH2*1 /1
ADH1C*1 ALDH2*2 /2
Microbes
Fig. 5.1 Pathways of ethanol metabolism (From Seitz HK, Becker P. Alcohol metabolism and
cancer risk. Alc Res Health. 2007;30(1):38-47 [10].)
5.3 Implications for Older Adults
5.3.1 Counseling Older Adults with Cancer about Alcohol Use
Screening for alcohol use is the first step (see Chap. 13). For those who are 55 years
of age or older, it is important to include duration as a measure of possible risk for
cancer [32]. Once the initial screening for alcohol use is complete, it is important to
establish how long patients have consumed alcohol in both those who are currently
drinking and those who are no longer drinking. The longer the use over the life span,
the greater the risk for development of an alcohol-related cancer [11].
Recommendations have been made by several organizations regarding screening
and management of substance use, but these recommendations are not specific to
the older adult or to cancer patients. Oncology-specific organizations, like the
National Cancer Institute (NCI) and the Oncology Nursing Society (ONS), discuss
substance use primarily in the context of pain management and recommend screen-
ing and risk stratification to avoid opioid misuse during pain management treatment
[32, 33]. A simple screening tool, such as the AUDIT-C, could be easily incorpo-
rated into a standard office visit [34] (Fig. 5.2).
5.3.2 Cancer Therapies and Alcohol Consumption
Alcohol use during cancer treatment can complicate the treatment regimen and lead
to poor long-term outcomes. Older adults are more likely than their younger coun-
terparts to rely on prescription medications [35] and are vulnerable to negative
Fig. 5.2 Secondary prevention: screening for alcohol-related cancer risk
effects from the combination of alcohol and alcohol-interacting drugs [36]. Most
cancer patients are prescribed new medications as part of their treatment regimen,
so this vulnerability has negative implications for both immediate patient safety as
well as efficacy of the medication itself in treating cancer. In one study of lung can-
cer patients receiving treatment, those currently drinking alcohol had a significantly
less favorable response to chemotherapy than those in a control group [37].
Alcohol use appears to impact cancer surgery as well. Alcohol use before sur-
gery in cancer patients has been associated with major post-operative complications
including more frequent re-intubation, myocardial infarction, pulmonary failure,
sepsis, pneumonia, renal failure, and early death [38–41]. Patients with alcohol
withdrawal are significantly more likely to suffer post-operative complications, sys-
temic complications such as tachycardia, hyperthermia, and hypertension, and be
hospitalized longer than their counterparts [42, 43].
5.3.3 Pain Management
Pain management is a significant issue for cancer patients and is complicated by

advanced age and the continued use of alcohol. It has been estimated by the
American Pain Society and the National Comprehensive Cancer Network that 33 %
of patients actively undergoing cancer treatment experience pain, and up to 75 % of
patients with advanced staged disease suffer from cancer pain [44]. The experience
of pain is associated with numerous detrimental physical and emotional conse-
quences such as increased physical symptoms of cancer, increased depression and
anxiety, increased spiritual distress, and stressful intimate relationships [45]. There
is evidence that substance use and pain frequently co-occur, and some researchers
have suggested that patients suffering from a substance use disorder have a higher
risk of poor pain tolerance [46]. In addition, the fear of developing a substance use
disorder may keep patients from reporting pain or requesting pain medications,
leading to higher pain scores and unrelieved pain [44, 47]. These attitudes and
beliefs can also apply to those with a prior diagnosis of an alcohol use disorder who
are now in recovery. Another issue in pain management is the association between
current alcohol use and higher pain medication use over a longer period of time [48,
49]. Thus, effective pain management may require concurrent efforts to assist the
patient in addressing their at-risk alcohol use.
5.3.4 Alcohol and Prognosis
Alcohol use is correlated with poor survival outcomes in oncology patients. In a

large, prospective correlational study of alcohol use and cancer risk, Breslow et al.
found that increased alcohol consumption was associated with higher cancer mor-
tality overall [50]. Jin et al. [51] reported that cancer mortality risk decreased with
decreased alcohol consumption. Other researchers have found that alcohol use is
negatively associated with overall survival in head and neck cancer patients and
non-small cell lung cancer patients [52–54]. In another study, researchers found that
pre-cancer alcohol consumption was correlated with disease-specific but not overall
mortality in breast cancer patients [55]. Alarmingly, the relationship between the
development of cancer and alcohol use does not end with a single cancer diagnosis.
Continued alcohol use has also been correlated with the development of second
primary cancers, with a dose-dependent relationship demonstrated [56]. (Table 5.1)
Table 5.1 Alcohol-associated cancer risk by quantity of alcohol use per day
Relative risk
Organ 7 std drinks (100 g) 4 std drinks (50 g) 2 std drinks (25 g)
Oral cavity and pharynx 6.01 2.85 1.75
Esophagus 4.23 2.21 1.51
Larynx 3.95 1.94 1.38
Breast 2.71 1.67 1.31
Liver 1.86 1.36 1.17
Colon and rectum 1.38 1.18 1.08
Stomach 1.32 1.15 1.07
Pancreas 1.18 1.05 0.98
Source: Data from Bagnardi et al. [17]
5.3.5 Quality of Life
A paradigm shift in cancer care from cure to chronic disease management is cur-
rently underway [49]. Because of the grave prognoses historically associated with
many cancers, there has been a trend within oncology to prioritize cancer treatment
over all other clinical concerns, sometimes at the expense of active management of
comorbid conditions [57]. Today, there is a growing recognition of the importance
of managing comorbid conditions concurrently with cancer treatment. Thus, it is
important to recognize the risks associated with continued alcohol use during che-
motherapy, radiation, and in the peri-operative period.
Another issue for patients during cancer treatment is quality of life. Alcohol con-
sumption at higher levels (defined as drinking over 1800 g/m of pure alcohol a month)
or patients who screened positive for a possible AUD during cancer treatment experi-
enced worse quality of life outcomes, including problems with pain, sleep, dyspnea,
total distress, anxiety, coping, shortness of breath, diarrhea, poor emotional function-
ing, fatigue, and poor appetite [58, 59]. Current alcohol use has also been associated
with higher pain scores and long-term use of opioids [48, 49]. In a prospective quality
of life study, head and neck cancer patients with an identified alcohol problem were far
more likely to be limited to a soft or liquid diet than counterparts with reported low-risk
alcohol use and suffered the worst quality of life outcomes [60].
5.4 Summary
In summary, alcohol-associated cancers are more apt to diagnosed older adults. The
mechanism that contributes to the development of alcohol-associated cancers is
related to lifetime use of alcohol at higher levels. For patients 65 years of age and
older with a history of at-risk alcohol use, there is an increased risk for the develop-
ment of cancer, poorer outcomes during the perioperative period, and over the long
term, increased morbidity, mortality, decreased pain control, and poorer quality of
life. Thus, it is imperative for health care providers to screen for alcohol use in older
adults and to include an assessment of lifetime alcohol use. This can help to identify
older adults at risk for developing alcohol-associated cancers as well as those at risk
for poorer outcomes once diagnosed.
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Alcohol and Cognition
6
Brian Downer and Julie B. Boron
6.1 Introduction
Cognition is a multidimensional construct that represents the mental functions that

are required for a person to be able to store and recall memories, process and inter-
pret information, make decisions, understand commands, and effectively communi-
cate ideas. With advancing age, it is expected for people to experience subtle
declines in cognitive domains related to fluid intelligence such as memory, decision-
making, and processing speed [1]. Conversely, cognitive abilities such as wisdom,
knowledge, language, and other domains reflecting crystallized intelligence do not
typically begin to decline until late in life and can even improve with age [1].
Negative cognitive changes can impair a person’s ability to complete complex tasks,
but these declines do not prevent successfully accomplishing activities that are nec-
essary for day-to-day living such as cooking a meal or managing medications;
hence, individuals experiencing these normative declines are still able to function
and live independently in the community. The severity of cognitive decline that
occurs with advancing age varies substantially from person to person, is dependent
upon genetic, physiological, health, behavioral, social, and cultural factors, and may
lead to cognitive diseases such as dementia, specifically Alzheimer’s disease.
Prior research has demonstrated that more years of educational attainment,
increased physical activity, and greater access to medical care are some factors that
have contributed to a decline in the prevalence of Alzheimer’s disease [2–4].
However, because advancing age is a major risk factor for Alzheimer’s disease, the
B. Downer, Ph.D. (*)

Division of Rehabilitation Sciences, University of Texas Medical Branch,
301 University Blvd, Galveston, TX 77555, USA
J.B. Boron, Ph.D.
Department of Gerontology, University of Nebraska Omaha,
210N CPACS, 6001 Dodge St., Omaha, NE 68182, USA

80 B. Downer and J.B. Boron
growing number of adults living to old age will ultimately lead to an increase in the
number of Alzheimer’s disease cases, with many studies estimating that the number
of older adults living with Alzheimer’s disease will approach or exceed ten million
people by the year 2050 [5–7]. In addition, there are concerns that the continued rise
in obesity, diabetes, and hypertension will contribute to an increase in the preva-
lence of dementia [8], as individuals with these conditions are at an increased risk
for dementia and cognitive decline.
The dramatic increase in the number of older adults living in the United States,
and the expected increase in Alzheimer’s disease and other dementias, has moti-
vated research on identifying health behaviors that may be beneficial for cognition
and protect against or delay the onset of dementia. Alcohol consumption is one such
behavior that has received considerable attention among the scientific community
and in the general public. Despite the common understanding that acute effects of
alcohol distort cognitive abilities, there are also headlines in popular press touting
the potential benefits of consuming alcohol for maintaining cognitive functioning
into old age. While there is evidence that consuming light to moderate amounts of
alcohol is beneficial for maintaining high cognitive functioning, it is important to
also communicate to the general public the negative effects that alcohol can have on
the brain and cognition.
Because older adults routinely consume alcohol [9], it is important for research-
ers and clinicians to have a clear understanding of the impact alcohol consumption
has on cognitive health so that older adults can receive appropriate recommenda-
tions of what constitutes safe alcohol consumption. This chapter provides a general
overview of evidence from research in a variety of disciplines on the positive and
negative long-term effects that alcohol consumption has on the brain and cognitive
functioning. This synopsis will include the effects that prolonged alcohol consump-
tion has on the anatomical characteristics of brain, the modifying effects of alcohol
consumption on cognitive functioning and dementia risk, and plausible explana-
tions for the apparent benefits of light to moderate alcohol consumption on cogni-
tion. The chapter will conclude with recommendations for future research on
alcohol consumption and cognition and the implications that this area of research
has for public health.
6.2 Alcohol and the Brain
It is widely accepted that consuming heavy amounts of alcohol and binge drinking
are detrimental to the brain. Animal studies that have examined the anatomical
changes that occur to the brain as a consequence of consuming alcohol indicate that
heavy alcohol consumption and binge drinking leads to the death of existing neu-
rons [10, 11] and prevents production of new neurons [12, 13]. Even moderate
amounts of alcohol consumed over a short period of time may be detrimental to the
brain. In a study by Anderson and colleagues [14], male and female adult rats were
given a 4 % ethanol liquid mixture for a 2-week period to examine the effect of
alcohol consumption on the production of new neurons in the hippocampus and
6 Alcohol and Cognition 81
performance on motor and learning tasks. The average blood alcohol content of the
rats, given the ethanol mixture, was 0.08 %. There were no significant differences in
performance of these rats on the motor or learning measures, but 40 % fewer new
neurons were produced in the hippocampus compared to rats in the control group.
However, other studies have observed that smaller amounts of alcohol may have no
detrimental effect on neurogenesis in the hippocampus [15].
While animal studies indicate that consuming even moderate amounts of alcohol
is detrimental to the brain, the evidence from epidemiological studies is less clear.
In a study of 589 older adults, subjects who reported consuming light to moderate
amounts of alcohol, in particular wine, had larger total brain volume compared to
older adults who reported that they did not consume alcohol [16]. These findings are
consistent with other epidemiological studies that have observed light to moderate
alcohol consumption to be associated with larger hippocampal volume [17], fewer
brain lesions [18], and less total brain atrophy [19] compared to abstainers.
Conversely, multiple studies have also observed that older adults who reported con-
suming alcohol had smaller total brain volume [20], greater ventricular volumes
[21], and decreased grey matter volume [22]. These discrepant findings may be due,
in part, to the unique characteristics of the sample populations (e.g., multiethnic
cohort [16] versus only non-Hispanic Whites [20]), the period in which alcohol was
measured (e.g., lifetime alcohol consumption [22] versus late life alcohol consump-
tion [17]), and differences in the questions used to measure alcohol consumption
(e.g., not differentiating between types of alcohol consumed [18] versus using separate
questions for beer, wine, and liquor consumption [21]).
The relationship between alcohol consumption and brain health becomes even
more complicated when considering the modifying effects of gender. Multiple stud-
ies have observed differences between older men and women when examining the
relationship between alcohol consumption and brain health [23–25]. In one such
study [26], older men who were moderate alcohol consumers had lower total brain
volume compared to light to moderate consumers, whereas no differences in total
brain volume according to alcohol consumption status among women were detected
[26]. This gender effect may be due to physiological differences between men and
women that effect how the body metabolizes alcohol [27, 28].
There are several factors that may account for the inconsistent, and in some
cases, conflicting findings among epidemiological studies. First, the relationship
between alcohol consumption and brain volume may differ when examined cross-
sectionally versus longitudinally. For example, Duriez et al. [29] conducted a cross-
sectional analysis on 1451 participants and longitudinal analysis on 1111 participants
who were observed 4 years later to examine the relationship between alcohol con-
sumption, total brain volume, and white and grey matter volume among older men
and women. In the cross-sectional analysis, a negative association between alcohol
consumption, total brain volume, and white matter volume was detected for men,
whereas no significant relationship was detected in women. Conversely, the findings
from the longitudinal analysis revealed a positive relationship between alcohol con-
sumption and white matter volume for men and grey matter volume for women.
These findings may reflect differences according to study design, but may also be
due to differences in the characteristics of the cross-sectional and longitudinal samples,

as not all participants from the initial sample returned for the 4-year follow-up.
In addition, the cross-sectional results only relay information on age and/or gender
differences, while longitudinal studies reveal changes over time as a function of age/
gender.
Second, it is important to consider the health characteristics of older adults who
consume light to moderate amounts of alcohol compared to older adults who are
abstainers. Older adults who report consuming light to moderate amounts of alcohol
are often times in good overall health, whereas older adults who report abstaining
from alcohol often have to do so because of the risk for adverse reactions due to any
current health conditions or medications that may interact with alcohol [30].
Therefore, the positive findings for light to moderate alcohol on brain health reported
by certain studies may be due to the overall better health of older adults who con-
sume alcohol.
Third, there is considerable heterogeneity between epidemiological studies in
how alcohol consumption categories are defined, what type of alcohol is being con-
sumed, and the types of questions used to ascertain self-reported alcohol consump-
tion [31]. For example, some studies have used different criteria for men and women
to define alcohol consumption categories [16], whereas other studies do not use
gender-specific categories [18, 21]. This lack of consistency can make it difficult to
directly compare findings and these factors need to be considered when interpreting
the results from epidemiological studies on the relationship between alcohol con-
sumption and brain health.
6.3 Alcohol, Dementia, and Cognitive Impairment
Consuming even moderate amounts of alcohol can be detrimental to the health of

the brain, but there is growing evidence that consuming light to moderate amounts
of alcohol may decrease a person’s risk for developing dementia during old age
and preserve functioning in multiple cognitive domains. The majority of research
on the relationship between alcohol consumption and cognitive functioning has
focused on the amount of alcohol consumed later in life. However, the growing
number of ongoing longitudinal studies that have followed middle-aged partici-
pants into old age has allowed for more research to be conducted on the relation-
ship between alcohol consumption during middle age and cognitive outcomes
later in life.
6.3.1 Late Life Alcohol Consumption
Epidemiological studies that have examined the relationship between late life alco-
hol consumption and cognition have frequently reported that older adults who con-
sume light to moderate amounts of alcohol are less likely to develop dementia and
have higher cognitive functioning compared to older adults who do not consume
alcohol [32]. However, there is some inconsistency in prior research regarding

whether consuming alcohol is protective against specific types of dementia and less
severe types of cognitive impairment. In a meta-analysis of 15 prospective cohort
studies, consuming light to moderate amounts of alcohol was associated with sig-
nificantly lower relative risk (RR) for Alzheimer’s disease (RR = 0.72, 95 %
CI = 0.61–0.86), vascular dementia (RR = 0.75, 95 % CI = 0.57–0.98), and any type
of dementia (RR = 0.74, 95 % CI = 0.61–0.91), but not cognitive decline (RR = 0.28,
95 % CI = 0.03–2.83) [31]. These findings are consistent with a previous meta-
analysis by Peters et al. [33] in which light to moderate alcohol consumption was
associated with a decreased risk for dementia (RR = 0.63, 95 % CI = 0.53–0.75) and
Alzheimer’s disease (RR = 0.57, 95 % CI = 0.44–0.74), but not vascular dementia
(RR = 0.82, 95 % CI = 0.50–1.35) or cognitive decline RR = 0.89, 95 % CI = 0.67–
1.17). Vascular dementia, also known as vascular cognitive impairment, is the sec-
ond most common type of dementia [34] and is caused primarily by the accumulation
of strokes that damage the brain [35]. The inconsistent findings for vascular demen-
tia are somewhat surprising given that light to moderate alcohol consumption is
associated with a reduced risk for stroke [36] and other vascular events [37].
Alzheimer’s disease includes a prodromal period where a patient begins to expe-
rience mild impairments in cognitive functioning. Mild cognitive impairment (MCI)
has been used to describe the prodromal stage of Alzheimer’s disease and is charac-
terized by impairment in multiple cognitive domains, but these impairments are not
severe enough to interfere with a person’s ability to perform day-to-day activities
[38]. There is no strong evidence to suggest that consuming alcohol is protective
against MCI [39, 40] and several studies have reported non-significant findings
[41–43]. In an analysis of 1445 non-impaired and 121 MCI patients aged 65–84
years, consuming less than one drink per day was not found to decrease the risk for
MCI among non-impaired subjects, but MCI patients who reported consuming less
than one drink per day exhibited a slower progression to dementia compared to MCI
patients who were abstainers [44]. However, older adults with MCI should not be
encouraged to start consuming alcohol since heavy alcohol consumption (defined as
consuming >300 kg lifetime alcohol consumption) among MCI patients has been
associated with increased risk for dementia [45]. Genetic, health, and other charac-
teristics of older adults who develop MCI may contribute to the increased risk for
dementia, rather than the alcohol consumption.
Current evidence suggests that the protective effects of light to moderate alcohol
consumption may vary according to whether the primary consumption includes beer,
wine, or liquor [46–48], although non-significant differences have also been reported
[49–51]. Wine has been observed to have the greatest protective effect against
dementia compared to other beverage types, whereas older adults who primarily
consume beer have not consistently been found to have lower risk for dementia [46–
48, 52, 53]. The added benefit of wine has been attributed to several factors including
the antioxidant properties found in wine [54] and the sociodemographic, health, and
dietary characteristics of wine consumers. Older adults who primarily consume wine
tend to be more educated, non-smokers, and in overall better health compared to
those who consume beer or liquor [55, 56]. Moderate wine consumption is consistent
with a Mediterranean diet, which has been observed to have health benefits [57].
These characteristics are all predictors of cognitive functioning during old age and
may explain the differential effects of alcoholic beverage type on cognition.
6.3.2 Midlife Alcohol Consumption
The majority of research on the relationship between alcohol consumption and cog-
nitive outcomes has focused on the amount of alcohol consumed during old age, but
there is a growing body of research that has examined the relationship between
alcohol consumption during middle age and cognitive outcomes several years or
decades later. The evidence from this area of research is mixed with some studies
not detecting a significant relationship [17, 58, 59], while others have reported that
light to moderate alcohol consumption is associated with preserved cognition [60]
and decreased risk for cognitive impairment [31, 61, 62]. Middle-aged adults who
consume heavy amounts of alcohol for prolonged periods of time or engage in fre-
quent binge drinking are more likely to develop wernicke-korsakoff syndrome [63].
Wernicke-korsakoff syndrome is commonly caused by low levels of thiamine and is
characterized by retrograde and anterograde amnesia, difficulties with language,
decreased sensory abilities, and impairment in executive functions [64].
The relationship between midlife alcohol consumption and cognitive outcomes
later in life is complex and may differ according to gender. An analysis of approxi-
mately 3000 French middle-aged (35–60 years of age) adults revealed that women
who abstained from consuming alcohol had lower cognitive functioning 13 years
later compared to women who reported consuming 1–2 drinks per day; for men,
abstainers did not have significantly lower cognition, but those who consumed more
than 3 drinks per day had higher cognitive functioning compared to men who con-
sumed 1–3 drinks per day [60]. However, men who drank eight or more drinks per
day had significantly lower cognitive functioning during old age compared to men
who consumed 1–3 drinks per day [60]. Further, the protective effect of light to
moderate alcohol consumption for dementia appears to be slightly stronger for men
compared to women [31].
There is also evidence that the relationship between the amount of alcohol con-
sumed during middle age and cognitive functioning later in life differs among adults
who have a genetic predisposition for dementia. In a study of 1018 of middle-aged
adults (mean age 48.3 years), the likelihood of being diagnosed with dementia was
significantly higher among infrequent (defined as less than once a month) and fre-
quent (defined as several times per month) alcohol consumers [61], but only among
older adults who were APOE e4+, which is an established genetic risk factor for
dementia [65]. These findings are consistent with another study that reported
middle-aged adults who consumed 1–6 drinks per week were less likely to develop
dementia, but that middle-aged adults who consumed 14 or more drinks per week
and were APOE e4+ were over three times as likely to develop dementia compared
to APOE e4+ abstainers [62]. The APOE e4 allele also increases the risk for MCI
[66] and the risk for MCI among heavy alcohol consumers may be increased for
individuals who carry an APOE e4 allele.
6.4 echanisms to Explain the Relationship

M
Between Alcohol Consumption and Cognition
Several hypotheses have been proposed to explain the potential benefits of light to
moderate alcohol consumption on cognitive functioning. These mechanisms range
from the direct effects that alcohol has on the anatomy and physiology of the brain to
the overall better health of older adults who consume alcohol. This section summarizes
the evidence from research that has sought to identify plausible causal mechanisms to
explain the relationship between alcohol consumption and cognitive functioning
among older adults.
6.4.1 Increased Cell Proliferation in the Brain
Heavy alcohol consumption and binge drinking is detrimental to the health of the
brain and can result in severe brain atrophy, behavioral changes, and dementia.
However, animal studies have produced some evidence to suggest that consuming
smaller amounts of alcohol may promote the production of new neurons in specific
regions of the brain. Aberg et al. [67] observed that female adult mice that had free
access to a 10 % ethanol/water mixture and water during a 9-week period exhibited
a greater increase of cells in the dentate gyrus compared to mice in the water only
control group. In addition, cell proliferation in the dentate gyrus of mice that had
free access to the ethanol mixture for 57 days ceased and returned to pre-consumption
levels, similar to those observed in the control mice, when this group withdrew from
alcohol consumption for the duration of the investigation. This suggests the
increased cell production was a direct result of ethanol exposure [67]. It should be
noted that these findings contradict those described previously by Anderson et al.
[14] in which rats who were exposed to ethanol exhibited decreased neurogenesis in
the hippocampus. These contrasting results may be due to differences in how mice
and rats metabolize and respond to alcohol [68]. Further, the presence of these dif-
ferences highlights how important it is to conduct thorough research on human sub-
jects before recommendations on alcohol consumption can be made.
The dentate gyrus is a specific region of the hippocampus that is involved in
learning and memory [69]. Greater proliferation of neurons in the dentate gyrus
may translate to better cognitive performance, in particular learning and memory
among older adults. This hypothesis is supported by evidence from a study in which
significantly higher performance on measures of memory was observed in older
adults who reported consuming 1–6 drinks per week; this effect was reduced and no
longer statistically significant after controlling for hippocampal volume [17].
6.4.2 Antioxidative Properties of Alcohol
Diet plays an important role in health and epidemiological studies have observed
that consuming a diet that is rich in plant-based foods, whole grains, legumes,
nuts, and low in saturated fat (commonly referred to as a Mediterranean diet) is
associated with a decreased risk for dementia [70]. Many of the foods that make up
a Mediterranean diet have moderate to high concentrations of antioxidants [71],
which may decrease the risk for several health conditions including cancer [72] and
atherosclerosis [73]. Reactive oxygen species (ROS) and free radicals play an
important role in many diseases, including dementia, by damaging DNA, proteins,
and molecules of cells which ultimately leads to cell death [74]. Antioxidants pre-
vent the damaging effects of ROS and free radicals by halting the oxidative process
[75]. Moderate wine consumption is frequently included as part of the Mediterranean
diet, and wine, in particular red wine, contains low concentrations of an antioxidant
called resveratrol [71]. Animal studies that have examined the effects of resveratrol
on the brain have observed that it prevents oxidative stress [76] and reduces the
presence of dementia pathology [77, 78].
A limitation of animal models is that oftentimes animals receive concentrations
of resveratrol and other antioxidants that are far greater than what can be consumed
as part of a normal human diet. This means that the findings from animal studies
may not translate to humans and it is unlikely that the amount of resveratrol and
other antioxidants consumed as part of a normal human diet are sufficient to have an
effect on cognitive health. Some epidemiological studies have identified a benefit of
dietary consumption of antioxidants on cognitive functioning [79, 80], but non-
significant findings have also been reported [81, 82]. A limited number of clinical
trials have studied the effects of resveratrol on the brain and dementia risk (clinical-
trials.gov identifier NCT01219244; NCT00678431; NCT01504854). Early results
from these studies indicate that resveratrol is safe and has minimal side effects when
taken by older adults diagnosed with dementia [83], but it remains to be seen if
resveratrol is beneficial for cognition. Based on all available evidence, it is unlikely
that any potential benefits of wine on cognition are due to resveratrol alone, but
through additional antioxidants and other properties of wine and other foods con-
sumed along with wine.
6.4.3 Health Characteristics of Alcohol Consumers
Several epidemiological studies have reported that light to moderate alcohol con-
sumption is associated with a decreased risk for stroke, diabetes, and heart disease
[36, 84, 85]. Similar to the U-shaped relationship between alcohol consumption and
dementia, heavy alcohol consumption has been associated with poor health [86, 87].
The decreased risk for several metabolic and vascular health conditions for alcohol
consumers has been attributed to antioxidants [54], greater concentrations of high-
density lipoprotein cholesterol in the bloodstream [88], and reduced blood clot for-
mation [89]. Stroke, diabetes, heart disease, and related conditions have all been
associated with lower cognitive functioning during old age [90, 91]. The reduced
prevalence of metabolic and vascular health conditions among light to moderate
alcohol consumers may contribute to the decreased risk for dementia and cognitive
decline for older adults who consume alcohol.
A limitation of the hypothesis that the reduced risk for dementia among light and
moderate alcohol consumers is conferred through the reduced prevalence of adverse
health conditions associated with dementia is the possibility that this relationship is
confounded by reverse causality. Alcohol consumption decreases with advancing
age and adults may reduce their alcohol consumption in response to the onset of
adverse health conditions [92, 93]. Therefore, the higher prevalence of dementia
and lower cognitive functioning among abstainers may be due in part to their worse
health rather than their alcohol consumption.
6.5 Future Research Directions
Significant progress has been made toward understanding the relationship between
alcohol consumption and cognitive functioning during old age, but continued
research is needed before definitive statements about this relationship can be made.
Three general areas of research that can help advance the field include: (1) address-
ing biases and limitations in study design and analysis; (2) differentiating former
drinkers from non-drinkers; and (3) the modifying effects that genetic, behavioral,
health, and social factors have on the relationship between alcohol consumption and
cognitive functioning. Continued research is needed so that appropriate recommen-
dations can be made to older adults as to what constitutes safe alcohol consumption.
Further, it is essential that longitudinal research be used in these future investiga-
tions so that the field can better understand the relationship between alcohol and
cognition, as well as potential mechanisms affecting this relationship.
6.5.1 A
ddressing Biases and Limitations in Study Design
and Analysis
A limitation of large cohort studies is that subjects who choose not to participate or
are unable to participate are often less healthy than those who do participate. Non-
response bias becomes more pronounced with age because only subjects who have
survived to old age and are healthy enough to participate are observed. Studies on
alcohol consumption and cognition are sensitive to non-response bias because light
and moderate drinkers who are not healthy enough to participate in the study will
not be observed. Adults who survive to old age despite consuming very high
amounts of alcohol represent an even more select segment of the general population
because they may have genetic, behavioral, health, social, or other factors that pro-
tect them against the negative effects of heavy alcohol consumption. As a result, the
analytic sample of epidemiological studies is more likely to be comprised of
“healthy” drinkers, which biases results in favor of finding a positive effect of light
to moderate alcohol consumption for cognition and health in general. More empha-
sis needs to be placed on investigators describing the characteristics of participants
who are excluded from the final sample due to missing data or incomplete follow-up
when reporting findings and how these differences may influence results. In addition,
the effect non-response bias may have on the relationship between alcohol con-
sumption and cognition needs to be communicated to the public since it is unclear
if the findings from research are generalizable to the total population.
The incidence of Alzheimer’s disease doubles every 5 years after 65 years of age
[94] and nearly 40 % of older adults aged 85 and over are diagnosed with Alzheimer’s
disease [7]. The relatively old age of onset for most dementia cases means the
observed protective effect of light to moderate alcohol consumption for dementia
may be due to alcohol consumers being more likely to die or drop out of a study as
a result of their alcohol consumption before they develop dementia. This bias may
be especially strong for heavy alcohol consumers. Not properly accounting for
death as a competing outcome has been observed to artificially increase the risk of
dementia among older adults with diabetes [95] and the effect that death and other
competing outcomes may have on the relationship between alcohol consumption
and dementia risk is unclear.
6.5.2 D
ifferentiating Former Alcohol Consumers from Life-Long
Abstainers
The majority of epidemiological studies that have studied the relationship between
alcohol consumption and cognition treat abstainers as the reference category. This
can be problematic because often times the abstainer or non-drinking category
includes older adults who stopped consuming alcohol because of poor health or other
reasons that may also be associated with poor cognitive functioning. Not differentiat-
ing former alcohol consumers from lifelong abstainers has been found to explain
some but not all of the benefit of alcohol consumption for preventing mortality from
cardiovascular causes [96]. The poor health of former drinkers may also explain
some of the benefits of alcohol consumption for cognition and decreased risk for
dementia [97].
Former alcohol consumers are a segment of the aging population that warrants
considerable attention in research. Data limitations can make it difficult to differen-
tiate between former drinkers and abstainers, but ongoing cohort studies such as the
Framingham Heart Study [98] and the Seattle Longitudinal Study [99] are valuable
data sources to study this population. These studies and others have assessed alco-
hol consumption behavior for decades, and in some cases, have followed partici-
pants from middle age through old age. This data can be used to characterize the
drinking patterns of adults who become former drinkers, approximate the age in
which a person stopped drinking, calculate how many years they have been a former
drinker, potential reasons for the reduction in alcohol consumption, and identify the
biological, behavioral, health, and social characteristics of former drinkers. Future
research should focus on these topics and how they may be related to cognitive
functioning during old age.
6.5.3 M
odifying Effects of Genetic, Behavioral, and Social
Factors
6.5.3.1 Genetic Factors

Advances in genome sequencing techniques have enabled large epidemiological
studies to collect genetic data from participants. This data can be used to conduct
gene–environment interaction research to determine if the benefits of alcohol con-
sumption for cognitive functioning differ among older adults with a genetic predis-
position for dementia. The e4 variant of the gene APOE is the strongest genetic risk
factor for late onset Alzheimer’s disease and up to 65 % of patients carry one or two
copies of the APOE e4 allele [100]. A limited number of studies have reported that
the relationship between alcohol consumption and cognitive functioning [58] and
regional brain volumes [17, 18] is modified by APOE e4 allele status, but additional
research is needed to replicate these findings and identify mechanisms to explain
this relationship.
The cognitive outcome of older adults with genetic risk factors or family history
of alcohol abuse is an underrepresented area of research. Forty to 60 % of the risk for
alcohol dependence is explained by genetic factors [101, 102] with the remaining
risk being attributed to environmental factors. ADH1B and ALDH2 are two genes
involved in alcohol metabolisms, and mutations in these genes are associated with
reduced likelihood for alcohol dependence [103]. Specific mutations in these genes
cause a person to metabolize alcohol very rapidly, which leads to unpleasant side
effects (flushing of the skin, nausea, and/or headache) and often limits alcohol
consumption. Research on variations in genes involved in alcohol metabolism and
alcohol dependence may provide insight into why alcohol consumption is associated
with cognitive health in some older adults and not others.
6.5.3.2 Health and Social Behaviors

It is common for people to engage in other behaviors while consuming alcohol. This
complicates the relationship between alcohol consumption and cognition because many
of the behaviors associated with alcohol consumption are positively and negatively
associated with cognitive functioning. For example, alcohol consumers are more likely
to smoke than non-drinkers [104] and smoking has been associated with an increased
risk for dementia and cognitive decline [105]. Therefore, the detrimental effects of
smoking may nullify or reduce the benefits of consuming alcohol for cognition.
The relationship between alcohol consumption and cognition may also differ
between people with or without a history of mental illness. Depression reduces the
volume of the hippocampus [106] and there is growing evidence that depression
plays an important role in dementia. Depression during middle age is recognized as
a risk factor for dementia [107], and high depressive symptoms during old age may
be an early symptom of dementia [108]. Middle aged adults with depression or
other mental illness who self-medicate with alcohol may be at especially high risk
for dementia later in life because of synergistic effects that alcohol and depression
has on the brain.
Older adults who participate in social activities and are socially engaged have
been observed to have lower rates of dementia compared to isolated older adults
[109]. Many adults describe themselves as social drinkers, but the risk for demen-
tia among people who primarily drink socially has not been thoroughly examined
[110, 111]. Epidemiological surveys often include questions that assess a person’s
level of social engagement and these variables can be included in regression mod-
els to control for the effects of social engagement on cognitive functioning.
However, more detailed questionnaires need to be used in research settings to
assess the social context in which people consume alcohol. This data can be used
to study the extent to which the benefits of social drinking for cognition are attrib-
uted to social interactions.
6.6 Summary
Extensive biological and epidemiological research on the relationship between

alcohol consumption, brain health, cognitive functioning, and dementia risk has
been conducted. The evidence from animal models indicates that even moderate
alcohol consumption can have detrimental effects on the brain, but heavy alcohol
consumption and binge drinking have severe consequences to the health of the
brain. Consuming small amounts of alcohol may not have any negative effects on
the brain and may even promote the generation of new neurons in the hippocampus
and limit the severity of neuronal loss that occurs with age. This is supported by
some epidemiological studies that have observed light to moderate alcohol con-
sumption to be associated with larger total brain volume and regional brain volumes
and fewer white matter lesions. However, the findings from epidemiological studies
cannot be interpreted as indicating that there is a causal relationship between alco-
hol consumption and cognition, but there is evidence from animal models that alco-
hol may have a causal effect on cognition. Plausible mechanisms include increased
cell proliferation in the hippocampus and the antioxidative properties of alcohol that
limit the negative effects of oxidative stress on the brain.
Epidemiological studies have consistently observed that light to moderate alco-
hol consumption, in particular during old age, is associated with decreased risk for
dementia and preserved cognitive functioning. Heavy alcohol consumption is
associated with poor cognitive outcomes and, in some cases, wernicke-korsakoff
syndrome. The relationship between alcohol consumption and cognition is highly
complex and may differ according to dementia type, gender, and genetic factors.
While current evidence from epidemiological studies indicates that consuming
light to moderate amounts of alcohol, in particular wine, does not negatively affect
cognition and in many cases is associated with cognitive health, adults who do not
consume alcohol should not be encouraged to increase their alcohol consumption
until further research clarifies these relationships. Inconsistencies between studies
on how alcohol consumption categories are defined make it difficult to determine
the “optimal” amount of alcohol consumption to prevent dementia. It is likely that
the optimal amount of alcohol varies according to a person’s gender, as well as

genetic, physiological, behavioral, and health characteristics, making the issue
extremely complex.
Additional research is needed to better determine what constitutes safe alcohol
consumption for older adults. Future research that emphasizes addressing biases
and limitations in study design and analysis can substantially advance our under-
standing of the relationship between alcohol consumption and cognitive function-
ing. Also, it is important to describe how selection of the analytic sample may
influence results and acknowledge these biases when communicating findings,
especially to the general public. Increasing research efforts on former drinkers and
differentiating between former drinkers and non-drinkers can help address bias in
previous epidemiological studies. Studying the drinking patterns, the age in which
a person stopped drinking, reasons for no longer drinking, and other characteristics
of former drinkers can provide insight into why light to moderate alcohol con-
sumption appears to be beneficial for cognitive functioning among older adults.
Finally, it is necessary to conduct research on the modifying effects that genetic,
behavioral, and social factors may have on the relationship between alcohol con-
sumption and cognition.
In summary, consuming light to moderate amounts of alcohol does not nega-
tively affect cognitive functioning and may protect against dementia and preserve
cognition. Older adults who are in good health can continue to consume alcohol, but
there is no sufficient evidence to suggest that older adults who are non-drinkers
should start consuming alcohol. Furthermore, it is necessary to emphasize that con-
suming any amount of alcohol can have negative consequences, especially for older
adults with chronic health conditions such as diabetes or hypertension or who are
taking certain medications. Continued research on the relationship between alcohol
consumption and cognitive functioning is necessary to make appropriate recom-
mendations for what constitutes safe alcohol consumption.
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Alcohol, Injury, and Aging
7
Namkee G. Choi, Diana M. DiNitto, C. Nathan Marti,
and Bryan Y. Choi
7.1 Introduction
Unintentional injury was the eighth leading cause of death among older adults (aged
65+ years) in the United States in 2013, claiming 45,942 lives [1]. Unintentional
falls (n = 25,464 deaths) and unintentional motor vehicle crashes (MVC; n = 6333
deaths) among older adults are especially serious problems and were the top 2 of 10
leading causes of injury deaths, followed by suicide by firearm (n = 5113) [1].
However, suicides by firearm, poisoning (n = 905), and suffocation (n = 770) claimed
more lives than MVC in the 65+ age group in 2013 [1]. The data also show that
unintentional falls and unintentional MVC ranked first and fourth among the causes
of nonfatal injuries treated in hospital emergency departments (ED) for the 65+ age
group (and the 55–64 age group) in 2013 [1].
As in younger adults, alcohol use in older adults is significantly associated with
injury-related (and noninjury-related) mortality. For example, a case–control study
based on two nationally representative samples of individuals aged 55+ years found
that drinking at least 12 drinks in the last year of life was associated with a 70 %
increase in the risk of death from a fall or MVC and a 60 % increased risk of suicide
[2]. A 4-year follow-up study of 3.9 million veterans also found that controlling for
age, gender, and race/ethnicity, those aged 65+ with alcohol use disorders (AUDs)
had a 2.05 (95 % confidence interval [CI] = 1.77–2.44) times greater hazard of dying
by injury (and a 1.56 [95 % CI = 1.51–1.60] times greater hazard of noninjury death)
N.G. Choi, Ph.D. (*) • D.M. DiNitto, Ph.D. • C.N. Marti, Ph.D.
School of Social Work, The University of Texas at Austin,
Austin, Texas, USA
e-mail: [email protected]; [email protected]; [email protected]
B.Y. Choi, M.D., M.P.H.
Department of Emergency Medicine, Brown University Warren Alpert Medical School,
Providence, RI, USA

98 N.G. Choi et al.
than their age peers without an AUD [3]. The study also found that veterans with
AUDs, regardless of age, died 15 years earlier, on average, than those without
AUDs. A study of 5.3 million ED visits by individuals aged 65+ years in the 2012
National Emergency Data Sample also found that AUDs increased the odds of falls
(compared to no falls) as an ED presenting problem by 2.93 (95 % CI = 2.86–3.00)
and suicide by 6.58 (95 % CI = 5.74–7.54), after adjusting for age, gender, number
of diagnosed chronic physical illnesses, and mental disorders [4]. AUDs also had a
small effect (relative risk ratios ranging from 1.20 to 2.35) on the risk of death,
hospitalization, transfer to another facility, and leaving against medical advice,
compared to discharge after routine care at ED [4].
In this chapter, we summarize previous research on alcohol-related injury and
death in older adults, focusing on falls, MVCs while driving under the influence
(DUI), and suicide and suicide attempts. We then discuss clinical implications of the
research findings including prevention strategies for both unintentional and inten-
tional injuries among the growing numbers of older adults.
7.2 lcohol’s Effects on Injury and Death: Biological

A
and Psychosocial Mechanisms
According to the 2013 National Survey on Drug Use and Health (NSDUH), 42 % of
individuals aged 65+ years were current alcohol users (they consumed at least one
drink in the past 30 days), 9 % were binge users (5+ drinks on the same occasion
[i.e., at the same time or within a couple of hours of each other] on at least 1 day in
the past 30 days) and 2 % were heavy users (5+ drinks on the same occasion on each
of 5 or more days in the past 30 days) [5]. NSDUH data also show that 54 % of the
60–64 age group were current users, 14 % were binge users, and almost 5 % were
heavy users [5]. Although these rates were lower than those in younger age cohorts,
older adults are more susceptible to alcohol’s harmful effects and are at a higher risk
of alcohol-related falls, motor vehicle crashes, and other injuries given age-related
physiological changes.
Older adults often have multiple chronic medical conditions, and they use more
prescription drugs than younger adults [6, 7]. Alcohol use can be especially harmful
because it can exacerbate these physical and mental health conditions, lead to addi-
tional diseases, and cause potentially dangerous interactions with prescription and
over-the-counter medications [8, 9]. Substantial numbers of older adults drink alco-
hol regardless of their physical and mental health conditions. A sample of
community-dwelling, fee-for-service Medicare beneficiaries aged 65+ years in
2005 found that 31 % (95 % CI = 28.0–34.1 %) of those with at least one of seven
chronic conditions (Alzheimer’s disease and other senile dementia, chronic obstruc-
tive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke)
reported alcohol consumption in a typical month in the past year, and 7 % (CI
6.0–7.8 %) reported drinking in excess of National Institute on Alcohol Abuse and
Alcoholism (NIAAA) guidelines [10]. According to these guidelines, older adults
(aged 65+) should not exceed 7 drinks per week and no more than 2 per day.
7 Alcohol, Injury, and Aging 99
A study based on data from the 2005 to 2008 National Health and Nutrition
Examination Survey also found that 14.5 % of drinkers aged 65+ consumed alcohol
above NIAAA recommended limits [11]. When health status was considered,
37.4 % had engaged in harmful consumption (i.e., exacerbating or complicating
existing alcohol-related problems) and 15.9 % had engaged in hazardous consumption
(i.e., drinking which posed risks of future harm) [11].
Drinking quantity does tend to decline with age, but aging- and disease-related
physiological changes (e.g., smaller body mass, lower total body water content, and
decreased gastric alcohol dehydrogenase) lead to higher and longer-lasting blood
alcohol concentrations (BACs) in older adults compared to younger adults [12].
As a result, older adults have decreased tolerance and increased central nervous
system sensitivity to alcohol, with more pronounced effect in women than men
[13, 14]. Alcohol-induced neurotoxicity in late life—affecting judgment, attention,
problem solving, visuospatial and perceptual motor functioning/coordination, infor-
mation processing, reaction time, and balance—can contribute to falls and other
traumatic mechanisms of injury resulting in fractures, delirium, gastrointestinal
problems, and mood disorders [15, 16]. Older adults who take multiple prescription
and over-the-counter medications are also at higher risk for dangerous interaction
effects of these medications with alcohol, which can exacerbate underlying diseases
and cause serious physical and mental health complications. Those who concur-
rently use opioid pain killers or benzodiazepines with alcohol are at especially high
risk for fatal/nonfatal overdose, altered mentation, and traumatic injury which leads
to more ED visits [17–20]. Older women who drink have significantly increased
risk because they generally have less muscle mass than older men; this risk was
linked to women’s heightened sensitivity to over-the-counter and prescription drugs
including tranquilizers or anxiolytics [21].
In addition to impaired coordination and balance, reduced bone mineral density
(BMD) in older adults may pose a risk for fall and fractures. However, the relation-
ship between alcohol consumption and BMD is not clear. Most previous cross-
sectional and longitudinal studies have found that BMD is higher among recent
drinkers and light/moderate drinkers than among long-time abstainers [22–25]. A
population-based cohort study of older adults in the Cardiovascular Health Study
also found that alcohol intake was associated with BMD of the total hip and femoral
neck in a stepwise manner, with approximately 5 % (95 % CI = 1–9 %) higher BMD
among consumers of 14+ drinks per week than long-term abstainers in both genders
and regardless of beverage types [25]. However, this long-term prospective study
(median follow-up lengths for those with and without hip fracture were 7 and 12
years, respectively) also found that 14+ drinks per week, compared to long-term
abstention, was linked to a 25 % higher risk of self-reported falls but a nonsignifi-
cant 1.18 (95 % CI = 0.77–1.81) hazard ratio of hip fracture [25]. The study’s authors
concluded that “the fact that heavier drinking did not lower risk of hip fracture,
despite being most strongly associated with higher BMD, presumably reflects
effects of alcohol outside of bone mineralization, such as on cerebella or peripheral
nerve function” (p. 600). A review of clinical and experimental studies also found
that moderate alcohol consumption may have a protective effect on bone health in
100 N.G. Choi et al.
older adults, whereas excessive consumption is an important risk factor [26].

A study of Australian older men found an inverse relationship between alcohol
consumption and bone quality (determined by quantitative heel ultrasound) and
BMD at the mid forearm site, but it did not find any difference for BMD at other
skeletal sites [27].
Coulson et al. [27] also found that higher alcohol intake was associated with
greater total and central adiposity in older adults, and those consuming 5 drinks or
more a day were more likely to be obese than nondrinkers. Obesity may reduce
injuries from falls, but given the significant association between obesity and falls in
older adults, especially among frail older adults [28–30], older adults who are obese
and heavy drinkers appear to be at higher fall risk. A study of community-dwelling
older adults in the United States also found that obesity and high alcohol consump-
tion (>3 drinks a day) synergistically raised serum alanine and aspartate amino-
transferase levels in older adults, increasing the risk of liver injury [31].
Motor vehicle crashes while driving under the influence (DUI) are likely to result
from the direct biological effects of BAC that impair ability to concentrate, coordi-
nate, track moving objects, process information, and perceive and respond quickly
to a hazardous situation such as an approaching vehicle. Even when there is no
measurable alcohol in the blood, a hangover or other chronic effects of alcohol use/
misuse (e.g., poor sleep, impaired working memory, attention lapses, malnutrition,
anemia, alcoholic neuropathy, liver disease, and other chronic diseases) may
increase driving-injury risk, especially in older adults [32, 33]. DUI-related motor
vehicle crashes and other unintentional injuries may also stem from alcohol-fueled
neurocognitive pathways that can lead to poor decision-making tendencies and high
risk-taking behaviors such as speeding and ignoring traffic signs and exposure to
more hazardous circumstances [34, 35]. Studies show that poor decision-making
tendencies, as indicated by other legal transgressions and other forms of irresponsi-
bility rooted in impulsivity and lack of self-control, are often personality traits
among DUI offenders and recidivists [36, 37].
Alcohol expectancy theory may explain continued alcohol consumption among
many older adults despite alcohol’s association with injury and death. Expectancy
theory posits that people engage in certain behaviors because they are motivated by
the expectation of particular outcomes (reinforcing effects) as a result of engaging
in the behavior [38, 39]. Those with more positive alcohol outcome expectations
(e.g., social and physical pleasure, relaxation, coping, and assertiveness) are there-
fore likely to drink more [40–42]. Studies have found that older adults drink for the
same reasons as younger adults—to enhance positive mood or well-being, obtain
social rewards (e.g., celebrate special occasions with family and friends), to manage
pain and other stressors, for general medicinal purposes, and to cope with and atten-
uate negative emotions (e.g., to forget worries and alleviate depressed or anxious
mood and feelings of loneliness) [43–45]. A 3-year follow-up study of community-
dwelling older adults (n = 401) found that more pain was associated with more use
of alcohol to manage pain, which in turn resulted in more health and drinking prob-
lems [44]. Specifically, among men, more baseline drinking problems interacted
with alcohol use to manage pain predicted more health problems and serious injury.
Among women, more baseline drinking problems interacted with alcohol use to
manage pain predicted more drinking problems.
Gilson et al. [43] found that enhancement motives (but not social and coping
motives) were associated with drinking quantity and that coping motives had
strong direct associations with drinking problems. Significant associations between
late-life depression, anxiety, and alcohol and/or drug use [46–48] and between
psychological distress and binge/heavy drinking have been found [49, 50].
Psychosocial stressors and vulnerabilities and substance use/abuse may be recipro-
cally related, with psychosocial stressors leading to substance use/abuse and drink-
ing too much feeding into higher degrees of psychosocial vulnerabilities including
depression and anxiety [51, 52]. In a study of suicide attempters, substance-induced
depression was found to confer greater risk for suicide attempts than independent
depression [53].
Alcohol use/misuse is also more prevalent among suicidal than nonsuicidal older
adults, and problem drinking or AUDs can elevate suicide risk by interacting with
or exacerbating co-occurring psychiatric illnesses such as major depression and
other age-related suicide risk factors including chronic medical conditions and lack
of social support [54]. Problem drinking and AUDs can also be an independent risk
factor for suicide and suicide attempts in older adults, contributing to a sense of
hopelessness, suicidal ideation, and poor impulse control due to intoxication [54].
7.3 Falls and Fall Consequences Among Older Adults
The Center for Disease Control and Prevention [55] provides the following data on
falls among older adults:
• Falls are the leading cause of both fatal and nonfatal injuries among older adults,
with one in three older adults falling each year, and 20–30 % of people who fall
suffer moderate to severe injuries such as lacerations, hip fractures, and head
traumas. In fact, falls are the foremost cause of both fractures and traumatic brain
injury (TBI) among older adults (and TBI is the cause of about half of fatal falls
in older adults).
• Other consequences of falls in older adults include decline in functional abilities,
loss of independence, reductions in social and physical activities, associated
mental health problems, and reduced quality of life.
• Even if older adults do not sustain injury from falls, the resulting fear of falling
also contribute to limiting their mobility and physical activities, which in turn
increases their risk of falling.
• In 2013, 2.5 million nonfatal falls among older adults were treated in ED and
more than 734,000 of these patients were hospitalized. The direct medical costs
of falls were $34 billion in the same year.
• Individuals aged 75+ years who fall are also four to five times more likely than
those 65–74 years to be admitted to a long-term care facility for a year or
longer.
• Death rates from falls have been increasing sharply over the past decade, and
about 25,500 older adults died from unintentional fall injuries in 2013, and men
are more likely than women to die from a fall. After taking age into account, the
fall death rate is approximately 40 % higher for men than for women, although
rates of fall-related fractures among older women are more than twice those for
men. Older whites are also 2.7 times more likely to die from falls than their black
counterparts.
Risk factors for falls in older adults are multifactorial: poor health, poor neuro-
muscular function (i.e., gait speed and balance) that may be related to arthritis or
stroke, osteoporosis, diabetes, chronic pain, depression, cognitive impairment,
frailty, obesity, assistive device use, poor vision, eye disorder, poor nutrition, poor
sleep, multiple medication intake, especially sedatives/hypnotics, minimal outdoor
activities, male gender, and older age [56–61]. With respect to alcohol consumption,
the 2008 Behavioral Risk Factor Surveillance System showed that consumption of
at least one alcoholic beverage in the past 30 days increased the odds of falls
(OR = 1.19, 95 % CI = 1.00–1.41) and fall-related injuries (OR = 1.30, 95 %
CI = 1.02–1.67) among those 85 years and older [62]. The 2008–2009 Canadian
Community Health Survey-Healthy Aging also showed that consumption of at least
one alcoholic drink per week increased the odds of falling by 40 % among those 65+
years [57]. Furthermore, heavy alcohol use predicts fractures. For example, among
those 55+ years old in a health survey in England, men who consumed more than 8
units of alcohol and women who consumed more than 6 units on their heaviest
drinking day in the past week had significantly increased odds of fractures
(OR = 1.65, 95 % CI = 1.37–1.98 for men and OR = 2.07, 95 % CI = 1.28–3.35 for
women) [63].
As described, unintentional fall injuries are the top leading cause of injury-
related death and of nonfatal injuries treated in EDs [1]. Our analysis of the 2012
Nationwide Emergency Department Sample (NEDS) data set show that fall-related
injury was a presenting problem among 12 % of all ED visits by those aged 65+,
with significant differences among age groups: 9 % among the 65–74 age group,
12 % among the 75–84 age group, and 18 % among the 85+ age group [4]. After
adjusting for age, gender, and the number of diagnosed physical and mental ill-
nesses, AUD increased the odds of falls as an ED presenting problem by almost
three times (OR = 2.93, 95 % CI = 2.86–3.00) among older adults’ ED visits.
Fall injuries have significant long-term physical, mental, and cognitive health
consequences. A 6-year prospective study of older adults (aged 60–93 years) in
Sweden found that those with a history of falls scored significantly lower in health-
related quality of life and life satisfaction at baseline and after 6 years, compared to
non-fallers, especially in the SF-12 physical component [64]. A study based on data
from the Hispanic Established Population for the Epidemiological Study of the
Elderly found that having two or more falls was associated with greater decline in
Mini-Mental Status Exam scores compared to having no fall over a 6-year period,
after adjusting for age, sex, marital status, and education. The magnitude of the
association decreased when adjustment was made for high depressive symptoms,
suggesting a possible mediating effect of depression on the association between

falls and cognition [65]. Furthermore, a study of community-dwelling Swedish
older adults aged 75+ years with a history of at least one self-reported injurious fall
severe enough to cause an ED visit within a 12-month period found they had a
significantly higher risk for sustaining subsequent injurious falls compared to those
with no falls (hazard ratio 2.78; 95 % CI, 1.40–5.50) during a follow-up period of
approximately 5 years [66].
Fall injuries also result in higher and recurrent healthcare costs (hospitalization,
rehabilitation, and/or long-term care facility-based care). Our analysis of the 2012
NEDS data found that fall injuries, compared to no fall injuries, increased the risk of
transfer to another facility (relative risk ratio = 1.69, 95 % CI = 1.66–1.71), after
adjusting for age, gender, diagnosed physical illnesses, and mental health and sub-
stance use disorders [4]. A study of older-adult ED visitors (70+ years) with fall
injuries in Australia found that fall-related ED presentation led directly to hospital
admission in 42.7 % of the cases; 78 % of the admitted patients received acute care
only (length of stay 14.4 days for men and 13.7 days for women) and 12 % under-
went further inpatient rehabilitation (length of stay 35.6 days for men and 30.1 days
for women). After hospitalization, 9.5 % of patients became first-time residents of
long-term care facilities [67]. Even among those older adults who are discharged into
the community, fall injuries often require substantial recurrent healthcare use.
However, drinking problems can interfere with continuing treatment and recovery.
In general, older adults with drinking problems have been found to use primary and
preventive care less often than their age peers without drinking problems [68, 69].
7.4 otor-Vehicle Crashes due to Driving

M
Under the Influence (DUI)
There were almost 36 million licensed drivers aged 65+ years in the United States
in 2012, and almost 24 million licensed drivers aged 70+ years in 2013 [70, 71]. The
number of older drivers is expected to double by 2030 as the baby boomers join the
ranks of the 65+ age group and as older adults keep their licenses longer [71, 72].
Older drivers tend to have the lowest accident rate (4 per 100 drivers) of all age
groups; however, per mile traveled, fatal crash rates increase noticeably starting at
ages 70–74 and are the highest among drivers aged 85+ years [73–75]. Older adults
also tend to have more serious injuries requiring more healthcare resources (e.g., more
hospitalization, longer rehabilitation, and more nursing home placement) than
younger drivers [74]. In 2012, more than 5,560 older adults were killed and more
than 214,000 were injured in motor vehicle crashes, which translated into 15 deaths
and 586 injuries on average every day and constituted 17 % of all traffic fatalities
and 9 % of all people injured in traffic crashes during the year [70]. Furthermore,
from 2011 to 2012, traffic fatalities and injuries among older adults increased 3 %
and 16 %, respectively [70].
Alcohol and/or other drug involvement in crashes is less prevalent among older
than younger adults [76], which may explain why previous studies of driving safety
among older adults have focused primarily on age-related declines in cognitive,

functional, and visual capacities [77, 78]. In 2012, drivers aged 65+ were 7 % of all
drivers involved in fatal crashes who had a BAC ≥ 0.08 g/dL [70]. Older adults tend
to restrict or stop driving when physical, cognitive, and/or vision impairments begin
to impact their driving abilities [79–81]. However, older adults tend to overrate their
driving abilities [82–84]. Alcohol use prior to driving may contribute to older driv-
ers’ overrating tendency because these substances affect cognitive functioning,
especially reasoning and decision-making abilities.
Our own analysis based on the 2008–2012 NSDUH found that a little over 50 %
of respondents in the 65+ age group used alcohol and/or illicit drugs, and of these
substance users, 6 % reported driving under the influence of alcohol and 1 % driving
under the influence of illicit drugs. In comparison, about 70 % of the respondents in
the 50–64 age group (mostly baby boomers) used alcohol and/or illicit drugs and of
these substance users, 14 % reported driving under the influence of alcohol and 1 %
driving under the influence of illicit drugs [85]. These numbers signal that the
proportion of older adults who drive under the influence, especially of alcohol, is
likely to increase in the future as the boomers join the ranks of older adults. Our
analysis of the 65+ age group in the NSDUH also found that those who reported
DUI, compared to those who did not, used alcohol more frequently and in larger
quantities. Of DUI reporters, 35 % reported consuming alcohol on 300+ days in the
preceding 12 months, nearly 20 % reported heavy drinking in the preceding 30 days,
and 28 % reported binge, although not heavy, drinking in the preceding 30 days.
More than 21 % of DUI reporters, compared to 2 % of non-reporters, met DSM-IV
diagnostic criteria for AUD (alcohol dependence or abuse) [85]. Multivariate binary
logistic regression analysis confirmed that frequency of alcohol use (OR = 4.72,
95 % CI = 2.98–7.50 for drinking 300+ days as opposed to drinking 0–49 days) and
binge/heavy alcohol use (OR = 3.22, 95 % CI = 2.27–4.58) were significant predic-
tors of DUI. In addition, marijuana use (OR = 4.94, 95 % CI = 2.12–11.52), major
depressive episode (OR = 4.20, 95 % CI = 1.83–9.63), and being male and a college
graduate also increased the odds of DUI. The study also found that of the DUI
reporters, 22 % perceived the need for treatment for their substance abuse problems
but did not receive it.
Using 2008–2012 NSDUH data, we also conducted a latent class analysis (LCA)
to identify subgroups of individuals aged 50+ years who may be at risk of DUI
using alcohol and illicit drug use, self-reported DUI incidents, and other criminal
history as LCA indicators [86]. We focused on those (n = 11,188; 67 % 50–64 years
and 33 % 65+ years) who (1) used alcohol on 50+ days in the past year (i.e., at least
once a week on average); (2) engaged in binge drinking in the past 30 days; or (3)
used any illicit drug in the past year. The LCA identified four classes in ascending
order of DUI risk, with Class 1 (63 %) and Class 2 (19 %) posing no/minimal DUI
risk, and Class 3 (9 %) and Class 4 (9 %) posing greater risk. The rate of alcohol
abuse or dependence was highest among Class 3 (27 %) and Class 4 (20 %) members.
In addition, 14 % of Class 4 members, compared to <0.5 % of the other class
members, had illicit drug abuse or dependence. Relative to Classes 1 and 2
(no/minimal DUI risk), Class 3 (greater risk) endorsed higher levels of heavy
drinking, self-reported incidents of driving under the influence of alcohol, and life-
time arrest history but a lower level of other illicit drug use than Class 2. Relative to
Class 1, Class 4 endorsed higher levels of binge and heavy drinking, marijuana and
other illicit drug use, self-reported DUI, and lifetime arrest history. Class 4 also had
higher levels of marijuana, other illicit drug, and tobacco use, self-reported DUI,
and lifetime arrest history than Classes 2 and 3. The findings also showed that 92 %
of Class 4 members were 50–64 years old and 70 % were men. Class 4 also included
the highest proportion of Blacks, divorced or never married individuals, those with
less than a high-school education, unemployed persons, and those with income
below 100 % of the federal poverty line of all four classes. Although the four classes
did not differ in the number of chronic illnesses, Class 4 had the poorest self-rated
health and the highest rates of MDE (14 %), anxiety disorder (10 %), serious psy-
chological distress (16 %), and serious suicidal thoughts (8 %) of all four classes.
These findings underscore the fact that along with substance use disorders, the high-
est DUI risk groups have significantly lower SES and higher levels of mental disor-
ders. Temporal order between substance abuse and mental health problems could
not be examined because the data were cross-sectional; however, the findings call
for treatment of co-occurring substance abuse and mental disorders in older adults
with high DUI risk.
For older adults, driving is not just a means of transportation, but an essential tool
for staying mobile, socially integrated, and independent [87, 88]. Motor vehicle
crash injuries can result in especially serious physical, functional, and emotional
problems in older adults. Pereira et al. [89] found that higher proportions of older-
than younger-adult (18–64 years) ED patients who had MVC injuries had antici-
pated times to physical recovery and emotional recovery that were 30 days or longer
(41 %, 95 % CI = 28–55 % vs. 11%, 95 % = CI 9–13 % and 45 %, 95 % CI = 35–55 %
vs. 17 %, 95 % CI = 15–20 %, respectively), although both age groups experienced
similar pain severities. Motor vehicle crashes due to DUI are preventable; however,
despite a projected upward trajectory in the number and proportion of older-adult
substance users and the rapidly growing numbers of older adult drivers, DUI among
older adults has received little attention from researchers or policymakers compared
to DUI among adolescents and young and middle-aged adults.
7.5 Suicide and Suicide Attempts
In the United States, there is one completed suicide for every 25 attempts on average;
but the rate among older adults is one completed suicide in every four attempts
[90, 91]. Older adults have higher rates of completed suicide than younger adults
because they are more likely to have serious intent to end their life and to formulate
a lethal suicide plan, have compromised health status making them more suscepti-
ble to injury or other harm from suicide attempts, and own a gun or have prescrip-
tion or over-the-counter medications that can be used to end their life [92, 93].
White men aged 85+ years have the highest completed suicide rate of all age and
gender groups (50.8 per 100,000 residents in 2010), a rate more than four times that
of the general population [7]. A study of those aged 60+ years in the 2007–2009
National Violent Death Reporting System (NVDRS) found that men were 82 % of
all older-adult suicide decedents and that older male suicide rates are nearly six
times that of females (28.3 and 4.9 per 100,000 population) [94]. In addition, males
aged 85 years and older had the highest suicide rates (44.8 per 100,000). Male rates
generally increased with age, while female rates remained fairly consistent [94].
Our analysis of the 2008–2012 NSDUH data found that 1.7 % of the 65+ age
group reported serious suicidal thoughts in the past year; 23 % of these ideators
made suicide plans; and 10 % of the ideators carried out nonfatal suicide attempts
[95]. (Since suicide decedents were not included in the data set, accurate population-
based rates of ideation, planning, and the number of attempts could not be esti-
mated.) In addition, of ideators aged 50+ (we included those aged 50–64 due to the
small number of ideators aged 65+), alcohol/drug abuse or dependence did not sig-
nificantly increase the odds of suicide planning, but it was associated with twice the
odds of a suicide attempt (OR = 2.09, 95 % CI = 1.11–3.91) after adjusting for
income, employment status, marital status, importance of religion, mental disor-
ders, and mental health treatment use. Less than 30 % of the planners and attempters
aged 50+ years received any mental health treatment, and only 8 % of the planners
and 13 % of the attempters received any substance abuse treatment either before or
after their plan/attempt [95].
Although those making both nonfatal and fatal suicide attempts often end up in
the ED, few studies have focused on older-adult suicide attempters in EDs. Using
2006 NEDS data, Carter and Reymann [96] estimated a population rate of 63
suicide-related ED patient visits per 100,000 adults aged 65+ years. Approximately
46 % of all older adult patient visits to the ED for suicide-related injuries were made
by those aged 75+ years, with 12 % made by adults aged 85 years or older. Nearly
43 % of all older adult suicide-related patient visits involved DUDs; 13.5 % of
patient visits involved AUDs.
Carter and Reyman [96] also found that roughly 1.2 % of older adult suicide-
related ED patient visits ended in death, whereas 59 % of patient visits resulted in
hospital admission; more than 26 % resulted in discharge after routine care (with
or without home healthcare), and an additional 29 % in discharge from the hospi-
tal to another facility. Compared to discharge after routine care, once adjustments
were made for age, sex, and hospital characteristics, AUDs decreased the odds of
death (OR = 0.30, 95 % CI = 0.14–0.64). AUDs were also not associated with the
odds of hospital admission, but DUDs increased the odds of death and hospital-
ization by more than three times among suicide-related visits by older adult ED
patients. Using more recent (2012) NEDS data, after adjusting for age, gender,
and diagnoses of physical illnesses and mental disorders, we also found that as
opposed to discharge after routine care, suicide attempts increased the relative
risk of death (either in the ED or at hospital after hospital admission) by 1.67
(95 % CI = 1.21–2.33), hospital admission by 5.96 (95 % CI = 5.54–6.40), transfer
to another facility by 18.31 (95 % CI = 16.80–19.95), discharge with home care
initiation by 2.08 (95 % CI = 1.36–3.18), and other/unknown destination by 5.65
(95 % CI = 3.69–8.65) [4].
Carter and Reyman [96] also found that the most frequent mechanism of suicide-
related injury (when such information was available) among older adult patient vis-
its was poisonings (62.6 %), followed by cutting/piercing (12.1 %), unspecified
mechanism (7.1 %), firearms (5.1 %), and hanging/strangulation (1.7 %). Karch [94]
found that males are most likely to commit suicide using firearms (78 %), followed
by hanging, strangulation, or suffocation (10 %), while females most often utilized
poisoning (41 %), followed by firearms (38 %). Poisoning deaths accounted for only
7 % of male suicides; in addition, the type of poisons most often used differed by
gender. Males most often died from prescription drug overdose (43 %) followed by
inhaling carbon monoxide or other gases (32 %) while females most often died of
prescription drug overdose (64 %) and over-the-counter drug overdose (11 %). Of
those with toxicology testing, females were more likely than males to be positive
for antidepressants and for opiates (45 % vs. 19 % and 37 % vs. 18 %, respectively);
however, the percent of positive tests for alcohol, amphetamines, cocaine and mari-
juana were nearly equal in both sexes. In terms of BAC, 20 % of male decedents and
19 % of female decedents were positive (p = 0.755), while 59 % of male decedents
and 50 % of female decedents had a BAC > 0.08 g/dL.
A study based on data from the 2005–2010 NVDRS found that 16 % of older-adult
suicide decedents, compared to 37 % of the 18–24 year olds, 41 % of the 25–44 year
olds, and 35 % of the 45–64 year olds, had a positive (i.e., any) BAC [97]. Those older
adults who were drinking were more likely to commit suicide by self-poisoning than
by using a firearm or hanging. The BAC level in older-adult decedents with a positive
BAC was also lower than among their younger counterparts (0.12 vs. 0.13 in the 18–24
age group and 0.15 in the 25–44 and 45–64 age groups). Regardless of age group, BAC
among suicide decedents using alcohol was generally highest among firearm suicides
and lowest among poisoning suicides until late life (aged 75+ years), when BAC was
higher among poisoning and suffocating/hanging suicides. The higher rates of positive
BAC and higher BAC levels among older decedents of poisoning suggest increased
lethality of interactions between alcohol and medications among older adults [97].
A study focusing on those aged 60+ years in the 2007–2009 NVDRS found that about
5 % of older adults died of alcohol-only or alcohol and prescription drug poisoning
[94]. Another study, based on the 2003–2009 NVDRS, also found that older men had
higher BAC levels (≥0.08 g/dL) than older women [98].
Our analysis of the 2012 NEDS data showed that suicide attempts were seen in
0.2 % (unweighted n = 9,086; weighted n = 39,266) of all visits by patients 65+ years
[4]. Suicide-related visits compared to nonsuicide-related visits were more likely to
include AUDs (14.7 % vs. 1.4 %), DUDs (6.9 % vs. 0.6 %), and co-occurring mental
and substance use disorders (16.4 % vs. 0.6 %), with significant gender differences
in AUDs in suicide-related visits (19.9 % of visits by males vs. 9.7 % by females),
but no significant gender differences in DUDs in any presenting problem—suicide
attempts, unintentional falls, and other unintentional injuries (overall 7.1 % for male
and 6.7 % for female, p = 0.405). Binary logistic regression results show medium
effect sizes of AUDs (OR = 6.58, 95 % CI = 5.74–7.54) and DUDs (OR = 4.04, 95 %
CI = 3.52–4.63) in suicide-related visits versus nonsuicide-related visits, after
adjusting for age, gender, diagnosis of physical illnesses, and mental disorders.
7.6 Implications for Clinical Practice, Policy, and Research
Unintentional and intentional injuries have serious deleterious effects on older

adults’ physical, functional, cognitive, and mental health and independent living
capacities. Our review confirms the significant effects of alcohol on such inju-
ries, including falls, unsafe driving for self and others, and suicide and suicide
attempts, in addition to alcohol consumption’s overall detrimental effects on
other aspects of physical and mental health (e.g., cancers; infectious diseases;
cardiovascular, hepatic, endocrine, and gastrointestinal diseases; and neuropsy-
chiatric diseases, including AUDs and DUDs) [99–102]. Alcohol’s effects, even
in low or moderate doses, can be especially harmful for older adults given their
decreased ethanol tolerance. Below, we provide recommendations for policy and
clinical practice to reduce injuries, especially alcohol-related injuries, among
older adults.
7.6.1 Fall Prevention
There are many evidence-based fall prevention programs for older adults. A meta-
analysis of 17 randomized clinical trials of exercise programs designed to reduce
falls in older adults found that exercise programs can also reduce severe fall-related
injuries including fractures [103]. Another review of 19 studies of the effect of
“exergaming” also found that it can improve balance control and balance confidence
[104]. Fall prevention programs are also cost-effective [105]. However, we found no
specific prevention programs focusing on alcohol-influenced falls among older
adults. In addition to using the usual fall prevention programs with older adults, we
offer several recommendations for reducing falls. (1) Older adults and their infor-
mal caregivers should be educated about the link between alcohol use and falls,
which can be accomplished through a variety of older adult service programs such
as senior centers and home-delivered meal programs as well as healthcare provid-
ers. (2) Primary care and ED physicians and other aging service providers should
routinely assess for substance abuse problems, provide psychoeducation, brief
interventions, and/or make referrals to substance abuse treatment programs when
indicated for their older patients. Services which help older adults cease or reduce
harmful drinking can result in many mental and physical health benefits, including
reduced risk of falling and fall-related consequences. (3) Clinicians should also
carefully assess the risks of alcohol use among older adults who take such medica-
tions as benzodiazepines since mixing such drugs with even small amounts of alco-
hol is likely to contribute to fall risks. The usual labels and leaflets dispensed with
prescription drugs that warn about the contraindications of consuming alcohol may
be insufficient to dissuade some older individuals from doing so given what may be
lifelong habits of consuming alcohol with meals, at social occasions, or for relax-
ation. (4) Drug-induced neurotoxicity levels and potential adverse drug effects spe-
cific to older age groups also need to be assessed, particularly for those with DUDs,
as they can also lead to falls. (5) Fall prevention programs that include attention to
substance use and substance use problems among older-adults and substance abuse
prevention and treatment programs that include fall prevention components should
be implemented and evaluated.
7.6.2 DUI Prevention
To prevent and reduce DUI among the growing number of older drivers and pro-
mote their driving safety, we also make several recommend recommendations. (1)
Health and social service providers should educate older, substance-using drivers
about age-related changes that impact substance use effects in general and driving
safety in particular and motivate those with substance use problems to seek treat-
ment. (2) Access to evidence-based substance abuse treatment should be facilitated
for older adults with substance use problems in general, and older adult DUI report-
ers in particular, given that NSDUH data show that a substantial proportion of older
DUI reporters perceived the need for treatment but did not receive it. Mental health
and substance abuse treatment is just as effective for older as for younger adults [106,
107]. Community-based substance abuse treatment programs specifically designed
for older adults are needed to increase acceptability of these programs to the older
adult population. (3) Given DUI reporters’ low SES, treatment should be made
affordable and readily available and accessible. New Medicare mental health parity
provisions should enable more older adults to afford mental health and substance
abuse treatment. (4) This review also underscores the need for research to improve
identification of older drivers at high risk of DUI so that effective intervention
approaches, taking into account their characteristics, behaviors, and expectations,
may be developed to prevent crash and injury and prolong their personal mobility.
This includes developing improved protocols for screening for substance abuse and
comorbid mental health conditions in addition to assessments of motor, visuo-
perceptual, and cognitive issue and use of smart technology to prevent driving when
it is not safe, for example, by providing a tool that older adults can easily use to self-
screen their alcohol-impaired driving limitations.
7.6.3 Suicide Prevention
Suicide attempts and fatalities in late life are tragedies that can be prevented.
Screening and treatment for risk factors as well as strengthening protective factors
(e.g., social support) remain significant late-life suicide prevention approaches
[108]. Our review also indicates that other steps should be taken. (1) Providers in
primary care and specialty care settings should carefully conduct suicide risk assess-
ments with older adults, especially those who have mental health and/or substance
abuse problems. (2) Since ideators have high rates of MDE, AUD, and DUD, mental
health and substance abuse treatment programs should reach out to older adults
identified as having suicidal ideation. Information from the NSDUH that nearly
one-quarter of those with serious suicidal thoughts made suicide plans and 10 % of
them made nonfatal suicide attempts also underscores the importance of assessing
suicidal thoughts and providing the services necessary to prevent suicide, especially
among those with mental health substance abuse problems. (3) Findings that less
than 30 % of suicide planners and attempters received any mental health treatment
and less than 10 % of them received any substance abuse treatment either before
or after planning or attempting also underscores the importance of mental health
and substance abuse treatment access for those at-risk, especially racial/ethnic
minorities and those of lower SES. With rapidly increasing numbers of people in the
50+ years age group, treatment programs for this age group should be readily avail-
able, easily accessible, and affordable. Formal and informal care systems need to be
prepared to prompt older adults to get treatment. (4) Community-based suicide-
prevention education and outreach efforts are also needed to alert informal and formal
caregivers of older adults who are at risk of suicide, to help them notice warning signs,
and to aid older adults in seeking help. These important steps must be taken in tandem
with accessible and affordable mental health and SUD treatment services.
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Medications, Alcohol, and Aging
8
Patricia W. Slattum and Omar E. Hassan
8.1 Introduction
The older population in the U.S. is growing as the baby boomers (individuals born
between 1946 and 1964) begin to pass the 65-year-old age milestone. The popula-
tion in the US of adults aged 65 years and older (44.7 million people) was about
14 % of the total population in 2013 but is expected to increase to 22 % of the popu-
lation (82.3 million people) by 2040 [1]. The oldest old (those 85 years and older)
are predicted to triple from 6 million people in 2013 to 14.6 million by 2040. The
older adult population is a disproportionate consumer of prescription and over-the-
counter medications. In a nationally representative sample of community-dwelling
adults aged 57–84 years from the National Social Life, Health, and Aging Project
(NSHAP) in 2005–2006, 81 % regularly used at least one prescription medication
on a regular basis and 29 % used at least five prescription medications. Forty-two
percent used at least one nonprescription medication and concurrent use with a
prescription medication was common, with 46 % of prescription medication users
also using OTC medications [2]. Prescription drug use by older adults in the U.S. is
also growing. The percentage of older adults taking at least one prescription drug in
the last 30 days increased from 73.6 % in 1988–1994 to 89.7 % in 2007–2010 and
the percentage taking five or more prescription drugs in the last 30 days increased
from 13.8 % in 1988–1994 to 39.7 % in 2007–2010 [3]. As the population ages and
the use of prescription drugs increases, the risk of developing a medication-related
problem also increases.
Patterns of alcohol use among older adults are also changing. Most older adults
in the U.S. are light or moderate drinkers and do not exceed the National Institutes
of Alcohol Abuse and Alcoholism (NIAAA) daily or weekly drinking limit for older
P.W. Slattum, Pharm.D., Ph.D. (*) • O.E. Hassan, B.S.

Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University,
410 N. 12th Street, Smith Room 656A, Box 980533, Richmond, VA 23298-0533, USA

118 P.W. Slattum and O.E. Hassan
adults. The prevalence of current (defined as at least one drink in the past 30 days),
binge (defined as 5 or more drinks on the same occasion in the past 30 days), and
heavy alcohol use (defined as 5 or more drinks on the same occasion on each of 5 or
more days in the past 30 days) in 2013 was lower among adults aged 65 or older
(41.7, 9.1, and 2.1 %, respectively) than among all other adult age groups [4].
However, when health status is taken into account, 28 % of light to moderate drinkers
aged 65 and older consumed what would be considered either harmful or hazardous
alcohol consumption [5]. Emerging evidence suggests that the current cohort of
older adults uses alcohol and psychoactive medications at higher rates than previous
generations [6]. Older adults living in retirement communities may be a group at
particular risk. A study of older adults residing in a continuing care retirement com-
munity (average age greater than 80 years; n = 71) found that the average days of
drinking among study participants was about 4 days per week and the average num-
ber of drinks per drinking day was 1.28 drinks [7]. Hazardous drinking, as measured
by the 3-item Alcohol Use Disorders Identification Test (AUDIT-C), was observed
in 15 % of respondents to a survey conducted in a large retirement community in
central Florida, which is higher than reported in the general older adult population
(around 10 %) [8]. As the older population grows and prescription and nonprescrip-
tion medication use increases, alcohol use is also increasing in this population.
Concurrent use of alcohol and medications is a growing health concern.
8.2 hysiologic Changes with Aging Altering Response

P
to Medications and Alcohol
The clinical response to a medication is the net result of a complex series of physi-
ological processes. Medications are absorbed into the body, distributed within the
body, and metabolized and eliminated from the body. These processes that deter-
mine the relationship between the dose of the medication and concentrations of the
medication in the systemic circulation are termed pharmacokinetics. While medica-
tions are in the body, they interact with receptors, enzymes, transporters, or ion
channels to elicit a response. Complex systems act to keep the body in homeostasis.
The relationship between the concentrations of the drug in the systemic circulation
and the response to the medication is termed pharmacodynamics. There are many
sources of variability affecting the response to a medication, including patient and
drug product-related factors. Some sources of variability include age, sex, genetics,
body weight, health conditions, interactions with other medications and foods, route
of administration, dosage form, dosing regimen, and adherence to instructions for
use. Alcohol can be considered as a psychotropic medication in this paradigm.
The aging process can affect the response to a medication by altering its pharma-
cokinetics and pharmacodynamics [9, 10]. Reduced gastrointestinal motility and
gastric acidity can alter the rate or extent of drug absorption. Changes in body com-
position, including decreased total body water and increased body fat can alter drug
distribution. For alcohol, changes in body composition result in higher blood alco-
hol levels in older adults compared to younger adults after the same dose or quantity
8 Medications, Alcohol, and Aging 119
of alcohol consumed. Decreased size of the liver, hepatic blood flow, and function
of Phase I (oxidation, reduction, and hydrolysis) metabolic pathways result in
reduced drug metabolism and increased drug exposure for drugs that undergo Phase
I metabolism. Phase II hepatic metabolic pathways are generally preserved with
aging. Decreased size of the kidney, renal blood flow, and glomerular filtration
result in slower elimination of medications and metabolites by the kidney and
increased drug exposure for medications that undergo renal elimination. Age-
related impairment of homeostatic mechanisms and changes in receptor number
and function can result in changes in pharmacodynamics as well. Older adults are
generally more sensitive to the effects of medications and alcohol which act on the
central nervous system for example. The consequences of these physiologic
changes with aging are that older adults often experience increased drug exposure
for the same dose (higher drug concentrations over time) and increased sensitivity
to medications (greater response at a given drug concentration) than their younger
counterparts.
Aging-related changes in physiology are not the only sources of variability in
pharmacokinetics and pharmacodynamics that must be considered for an individual
person. Older adults experience more chronic diseases that may decrease drug
metabolism and renal elimination than younger cohorts. Frailty may result in fur-
ther decline in drug metabolism, including Phase II metabolic pathways in the liver
[11]. Drug interactions must also be considered as an important source of variability
affecting response to medications in older adults, considering the epidemiology of
medication use in the older population.
8.3 Drug Interactions in Older Adults
A drug interaction is defined as a clinically meaningful change in the effect of one

drug when coadministered with another drug [12]. Many drugs, including alcohol,
have the potential for a drug interaction when administered concurrently, but
whether a clinically meaningful change in effect occurs for a specific person depends
on patient-specific factors including age. Drug interactions are generally classified
as pharmacokinetic interactions, where one drug alters the absorption, distribution,
metabolism, or elimination of another drug resulting in increased or decreased drug
exposure, or pharmacodynamic interactions, where one drug alters the response to
another medication through additive or antagonistic pharmacologic effects [13]. An
adverse drug event occurs when a pharmacokinetic or pharmacodynamic interac-
tion or combination of both results in changes in drug exposure or response that lead
to negative clinical outcomes. The adverse drug event could be a therapeutic failure
if drug exposure is decreased or the pharmacologic response is antagonistic. The
adverse drug event could be drug toxicity if the drug exposure is increased or the
pharmacologic response is additive or synergistic. The threshold for experiencing
an adverse event is often lower in older adults due to physiologic changes with
aging and medical comorbidities, increasing their risk of experiencing an adverse
drug event when medications are taken concurrently.
Drug interactions are generally studied clinically during drug development by

comparing experimentally the pharmacokinetics of two medications that are
expected to be coadministered in practice and hypothesized to have a potential
interaction, given alone, with the pharmacokinetics of the medications taken con-
currently in healthy young adults. Additional data emerges over time as medications
are used concurrently in clinical practice in different patient populations and clini-
cal outcomes are observed by conducting pharmacoepidemiologic studies and mon-
itoring adverse drug event reporting systems [14]. When considering coadministration
of more than two medications, predicting the clinical outcome becomes even more
complex. The clinical outcomes of drug–alcohol interactions may also depend on
the pattern of alcohol consumption. For example, acute ingestion of large quantities
of alcohol may inhibit metabolism of some drugs while chronic (daily use over long
periods of time) may enhance metabolism of some drugs by enzyme induction. The
distribution of alcohol metabolism between cytochrome P450 2E1 (CYP 2E1) and
alcohol dehydrogenase is dependent on whether alcohol consumption is occasional
or chronic [15]. Older adults may be more likely to experience adverse drug events
related to drug–drug and drug–alcohol interactions and our understanding of poten-
tial drug interactions in this population continues to emerge.
8.4 linically Important Alcohol–Medication Interactions

C
in Older Adults
A large number of potential medication–alcohol interactions have been reported in the

literature. Mechanisms of these interactions range from pharmacokinetic interactions
affecting either alcohol or medication exposure to pharmacodynamics interactions
resulting in exaggerated response. Alcohol–drug interactions particularly relevant for
older adults are listed in Table 8.1. This list is not comprehensive and additional
resources such as the drug interaction checker on www.drugs.com should be consulted
when evaluating the safety of concurrent use of alcohol and medications. It is impor-
tant to consider age and comorbid health conditions as well when assessing the risk for
a clinically important drug–alcohol interaction for a specific person.
8.5 pidemiology of Alcohol–Medication Interactions

E
in Older Adults
Epidemiologic evidence suggests that concurrent use of alcohol and medications

among older adults is common. A variety of methods have been used to categorize
levels of alcohol consumption and different definitions of alcohol interacting
medications have been employed across different studies. The definition of older
adult is not consistent across studies either, with some studies including middle-
aged adults (50–65 years of age) in the older adult group. Despite these differences
in study methodology, evidence is growing that alcohol–medication interactions
are a growing concern for the older adult population as medication and alcohol
use increases.
Table 8.1 Alcohol interacting medications

Medication or
medication class Mechanism Clinical effects
Analgesics
Acetaminophen Increased metabolism of Increased risk of severe liver
acetaminophen by CYP2E1, damage
increasing blood levels of
hepatotoxic metabolites
Opioids Additive sedative effects Oversedation, increased risk of
fatal overdose due to respiratory
depression
Nonsteroidal Anti- Additive damage to the gastric Increased risk of gastrointestinal
inflammatory Drugs mucosal barrier bleeding
(NSAIDs)
Some extended-release Alcohol coingestion may lead to Potentially fatal dose of opioid
opiates “dose dumping” of the opiate delivered
Methadone Chronic alcohol use increases Chronic alcohol use may
hepatic metabolism of methadone; decrease the effectiveness of
acute alcohol consumption methadone; acute alcohol
decreases hepatic metabolism of consumption may increase the
methadone risk of a fatal overdose of
methadone
Antibiotics
Ketoconazole, Inhibition of hepatic aldehyde “Disulfiram-like” reaction
metronidazole, dehydrogenase reducing resulting in uncomfortable
tinidazole elimination of aldehyde (a flushing, nausea, vomiting, and
metabolite of alcohol) sweating after alcohol
consumption
Doxycycline Increased metabolism with Therapeutic failure
chronic heavy alcohol use
Isoniazid Increased metabolism of isoniazid Therapeutic failure and
and increased production of hepatotoxicity
hepatotoxic metabolite
Anticoagulants
Warfarin Acute alcohol intake may Alcohol use can increase the
decrease metabolism of warfarin. risk of bleeding by increasing
Chronic use may increase or warfarin effects and by
decrease metabolism of warfarin increasing the risk of falling and
injury
Antidepressants
Tricyclic Additive sedative and hypotensive Oversedation, increased risk of
antidepressants effects orthostatic hypotension
Bupropion Increased effects of alcohol; acute Alcohol intoxication, increased
alcohol consumption and alcohol risk of seizures
discontinuation along with
bupropion can reduce the seizure
threshold
(continued)
Medication or
Antidiabetic agents
Some sulfonylureas Inhibition of hepatic aldehyde “Disulfiram-like” reaction
(chlorpropamide, dehydrogenase reducing resulting in uncomfortable
glyburide, tolazamide, elimination of aldehyde (a flushing, nausea, vomiting, and
tolbutamide) metabolite of alcohol) sweating after alcohol
consumption
Sulfonylureas, insulin Alcohol reduces gluconeogenesis May cause severe or
and is also a source of calories unpredictable effects on blood
sugar increasing the risk for
hypoglycemia or worsening
glycemic control
Metformin Concurrent use may lead to May cause lactic acidosis (with
increased blood levels of lactic symptoms of muscle pain,
acid bradycardia, and dizziness)
Anticonvulsants
Phenytoin Acute alcohol consumption Excessive sedation, altered
decreases phenytoin metabolism; seizure control
chronic use may increase
phenytoin metabolism; additive
sedative effects
Perampanel Additive CNS depression Excessive sedation and
psychiatric effects including
anger, confusion, and depression
Antihistamines/OTC motion sickness and sleep aids
First-generation Additive CNS effects Excessive sedation, decreased
(sedating) motor skills, dizziness
antihistamines
Antihypertensives
Alpha-1-adrenergic Additive hypotensive effects soon Increased risk of postural
blockers (also used to after alcohol ingestion hypotension
treat enlarged prostate),
beta-blockers, calcium
channel blockers,
vasodilators
Antipsychotics
Atypical antipsychotics Additive CNS effects and Excessive sedation and postural
antihypertensive effects hypotension
Phenothiazines Additive CNS effects Excessive sedation and
increased risk of extrapyramidal
side effects
Muscle Relaxants
Skeletal muscle Additive CNS depression Excessive sedation and impaired
relaxants psychomotor function
(continued)
Medication or
Sedative-hypnotics
Benzodiazepines Additive CNS depression Excessive sedation and impaired
psychomotor function
Nonbenzodiazepine Additive CNS effects Excessive sedation, impaired
hypnotics psychomotor function, and
increased risk of complex
behaviors (such as sleep driving)
Sexual dysfunction treatments
Flibanserin Additive hypotensive effects Severe hypotension and syncope
PDE5 inhibitors Additive hypotensive effects Increased risk of postural
hypotension and tachycardia
Miscellaneous agents
Statins Additive hepatotoxicity from both Increased risk of liver damage
chronic excessive alcohol use and
statins
Methotrexate Additive hepatotoxicity Increased risk of liver injury
Metoclopramide Additive CNS effects; increased Excessive sedation and impaired
gastric emptying may increase psychomotor function
blood alcohol levels
Varenicline Increased alcohol intoxication Increased risk of unusual or
aggressive behavior
Source: Data from [15, 40, 41]
Results from epidemiological studies in the U.S. older adult population indicate
that the potential for alcohol–medication interactions in this population is substan-
tial. In a study of alcohol use and alcohol-interacting medications among older adults
using a nationally representative U.S. sample in the National Health and Nutrition
Examination Survey (NHANES) 1999–2010, 77.8 % of current drinkers (defined as
consuming more than 12 drinks during their lifetime and at least one drink in the past
year) used an alcohol-interacting medication in the past month [16]. One-third of
those who drank most frequently (5–7 days per week) were concurrently taking alco-
hol-interacting medications. In a nationally representative U.S. sample of commu-
nity-dwelling older adults in the National Social Life, Health and Aging Project
(NSHAP) 2005–2006, 41 % of participants reported consuming alcohol at least once
per week and 20 % were at risk for an alcohol–medication interaction because they
were using both alcohol and alcohol-interacting medications on a regular basis [17].
The most common medication use reported by regular drinkers in this study was
antidepressants and analgesics. The prevalence of potential drug–alcohol interac-
tions was higher in men for all age groups and increased with age for men but not
women. Approximately 8 % of survey respondents reported using more than one
alcohol-interacting medication with regular alcohol use. Among participants in the
Pennsylvania Assistance Contract for the Elderly program (aged 65–106 years) tak-
ing at least one prescription medication, 77 % were taking an alcohol-interacting
medication and 19 % of the alcohol-interacting medication users reported concurrent
use of alcohol [18]. Greater risk of concomitant exposure was associated with being
in the younger end of the older age group, being male and attaining a higher educa-
tion level. The most common alcohol-interacting medication combined with alcohol
in this study was NSAIDs (20.2 %) followed by prescription antihistamines (20.1 %)
and antihypertensive agents (19.8 %). Although these studies do not document
adverse outcomes associated with alcohol–medication interactions, they do docu-
ment that the potential exists for many older adults.
Epidemiological evidence of the potential for alcohol–medication interactions
among older adults in other parts of the world is accumulating as well. High preva-
lence of concurrent use of alcohol and alcohol-interacting medications have also
been reported in Australian men (43 % of sedative or anxiolytic users were daily
drinkers) [19], in older adults in Finland (42 % of at-risk alcohol users were also
taking alcohol-interacting medications) [20], and in older Irish adults (72 % of par-
ticipants were exposed to alcohol-interacting medications and 60 % of these reported
concurrent alcohol use) [21]. Drinking and medication use patterns in older adults
may differ across countries, but alcohol–medication interactions appear to be a
worldwide concern.
Another approach to thinking about the epidemiology of alcohol–medication
interactions in older adults is to consider the role of medications in defining at-risk
drinking behavior among older adults. Tools like the Comorbidity-Alcohol Risk
Evaluation Tool (CARET) and the Alcohol Related Problems Survey (ARPS) define
at-risk drinking considering quantity and pattern of alcohol use as well as comor-
bidities and concurrent alcohol-interacting medication use. In a study using the
ARPS to identify harmful or hazardous drinking among older primary care patients,
11 % were harmful drinkers and 35 % were hazardous drinkers [22]. Most hazard-
ous drinkers were identified as such because of their concurrent use of alcohol and
alcohol-interacting medications. The most common alcohol-interacting medica-
tions identified through the ARPS were medications for arthritis and pain. In a
cross-sectional analysis of survey data from Project SHARE conducted in primary
care practices, 35 % of older adults were identified as at-risk drinkers using the
CARET [23]. Of the at-risk drinkers, 62 % had alcohol use concurrent with high-
risk comorbidities, 61 % had alcohol use concurrent with high-risk medications, and
64 % had high-risk alcohol use behaviors. High-risk drinking was as likely to be due
to concurrent alcohol and medication use as it was to high use alcohol consumption
patterns. In a study evaluating alcohol use patterns in a continuing care retirement
community, more than 60 % of participants were classified as at-risk drinkers by the
CARET based on medication interactions, and this was the most common form of
at-risk drinking observed in this study [7]. When concurrent medication use is con-
sidered in defining at-risk drinking behaviors, medication–alcohol interactions are a
major contributor to the overall risk associated with consuming alcohol in older
adults. More studies are needed to understand the clinical consequences associated
with this “at-risk” classification in older adults.
8.6 linical Consequences of Alcohol–Medication

C
Interactions in Older Adults
Potential clinical outcomes associated with individual alcohol–medication interac-

tions in older adults are detailed in Table 8.1. Few studies to date have evaluated
outcomes specifically in the older adult population. When at-risk drinking is defined
using comorbidity and medication use-specific thresholds of alcohol consumption
using the CARET, there is an association between at-risk drinking and mortality in
older men but not in older women [24]. The specific contribution of individual med-
ication–alcohol interactions to this association is unknown. In a study using the
2009 Medicare Current Beneficiary Survey (MCBS) data (n = 7163), at-risk drink-
ing was defined based on the CARET and the effects of potential concurrent use of
central nervous system-acting medication and alcohol on the risk for falls was
assessed [25]. Almost 6 % of older adults were identified as at-risk drinkers in this
study. Use of at least one CNS-acting medication and drinking excessive alcohol
(more than 30 drinks per month), or binge drinking (more than four drinks in a
single day over the past year), was significantly associated with increased risk of
falling in the past year (OR 1.72; 95 % CI: 113–2.61). There was no association
detected between alcohol consumption alone and the risk of falling. Alcohol adds to
the risk of falling that is associated with the use of psychotropic medications.
Polypharmacy in general, and psychotropic burden specifically, has been associated
with an increased risk of experiencing a geriatric syndrome such as falls or delirium,
in older adults [26, 27]. Based on its pharmacology, alcohol can be considered as a
psychotropic drug, and alcohol use should be assessed as part of the medication
regimen evaluation to support efforts to prevent or manage geriatric syndromes.
More research is needed to elucidate the risks associated with mixing alcohol and
specific medications in older adults, especially when the quantities of alcohol con-
sumed fall within recommended drinking limits for older adults.
8.7 Particular Concerns: Poor Sleep Quality and Pain
Alcohol may be used for medicinal purposes by older adults and may be used along
with prescription and nonprescription medications for the same indication. In one
study, 17 % of older adults reported using alcohol to self-medicate conditions
including cardiovascular disease (34 %), sleep disturbance (22 %), the common cold
(20 %), indigestion (14 %), relaxation (7 %), stimulation (6 %), and pain (3 %) [28].
In another study, 6 % of older adults reported using alcohol to treat pain [29]. Those
with pain who chose to self-medicate with alcohol reported greater pain intensity,
had more comorbidities, were at higher risk for adverse outcomes, and were more
likely to be depressed than those with pain who did not report self-medication with
alcohol. Older adults who reported more severe pain or more pain-related interfer-
ence with their activities of daily living were more likely to experience drinking
problems [30]. Those with chronic pain may report more alcohol use if the alcohol
is used to cope with or manage pain. In a survey of older adults who reported diffi-
culty sleeping in the past month, 13 % reported drinking alcohol to treat their sleep
complaints [31]. About half of those using alcohol or OTC sleep medications for
sleep had not consulted with their health care provider. Participants were not asked
about concurrent use of alcohol and sleep medications in this survey. In another
study evaluating use of sleep medications in older adults living in retirement com-
munities, 4 % reported using alcohol to aid sleep and 2 % reported using alcohol
along with sleep medications for sleep problems [32]. Combining alcohol and CNS-
active medications can be particularly problematic and can shift to a situation of
misuse or abuse in older adults experiencing pain, sleep disturbances, or anxiety [6].
Older adults suffering from sleep problems or pain may be a particular risk for
alcohol–medication interaction-related adverse events.
8.8 Relevance to Public Health and Health Professionals
Medication–alcohol interactions are a significant concern for older adults. The

prevalence of concurrent use of alcohol and alcohol-interacting medications sug-
gests a need for interventions to raise public awareness of the risks associated with
medication–alcohol interactions. Written warnings to patients about alcohol use
accompanying prescription or nonprescription medications are generally not spe-
cific to the older adult population and often recommend that patients “use caution”
or consult with a healthcare provider before using concurrently with alcohol.
According to a report from the Center for Disease Control and Prevention (CDC),
only 9.3 % of adults 65 years of age or older in the U.S. reported ever discussing
alcohol use with a health professional, and only 4.2 % reported discussing alcohol
use with a healthcare provider in the past year [33]. This percentage is lower than
for all other adult age groups. It is unclear whether healthcare providers are ade-
quately prepared to guide patients on the use of alcohol with prescription drugs and
whether they are proactively engaging with patients around concurrent alcohol and
medication use. In a study of older adults and pharmacists in a community phar-
macy setting, older adults reported little knowledge about the risks associated with
concurrent use of alcohol and medications and those who reported drinking alcohol
in the last few months were less willing to advocate safe use of alcohol with pre-
scription drugs than those who had not consumed alcohol recently [34]. Most phar-
macists expressed a willingness to communicate with older adults about alcohol and
medication safety, but the more time consuming the intervention, the less likely
pharmacists were to be willing to engage in the activity [34].
An additional area that should be discussed is alcohol limits. Recommended
alcohol limits for older adults vary depending on the source. Different countries
define a “standard drink” differently, ranging from 8 to 14 g of alcohol, and the
recommended limit on number of drinks per day varies as well [35]. The rate of
drinking is also important. Drinking slowly (i.e., one drink over 2 h) may decrease
the rate of rise in blood alcohol concentration. When health professionals offer
recommendations for alcohol limits for older adults, concurrent medication use and
medical comorbidities should be considered.
Interventions through healthcare providers can make a difference in patients’
knowledge and behavior regarding concurrent use of alcohol and medications.
At-risk drinkers aged 50 years and older, as identified by the CARET, who received
an educational intervention including a personalized feedback report and educa-
tional booklets by mail, were 73 % less likely to be at-risk drinkers than control
group participants postintervention [36]. Findings from another randomized con-
trolled trial of this intervention (Project SHARE study) in middle aged and older
adult primary care clinic patients who were at-risk drinkers found that the educa-
tional intervention reduced at-risk drinking as defined by the CARET, and that the
effect of the intervention persisted for 12 months [37]. Most (61 %) of the partici-
pants in this study were classified as at-risk drinkers due to concurrent use of alco-
hol and medications.
An interactive BINGO game to educate older adults about the risks associated
with alcohol use and medication interactions has also been evaluated [38].
Participants demonstrated knowledge gains about their own risk, and the majority of
a subset of the participants that were surveyed 30 days after the program reported
that they were more aware of the risks of using alcohol and medications concur-
rently. Screening and brief intervention for substance misuse among older adults, as
implemented in the Florida BRITE project, has the potential to improve medication
and alcohol-related misuse [39]. Public health messaging directed toward older con-
sumers about the risks of drinking alcohol while taking medications has also
increased. The National Institutes of Health and the Substance Abuse and Mental
Health Services Administration make available web-based and print materials for
public education efforts. As the population ages and prescription medication use
increases, more research is needed to inform public health efforts directed at reduc-
ing harm associated with alcohol–medication interactions.
8.9 Conclusions
With the aging of our population, the increasing use of prescribed medications to
manage acute and chronic health conditions, the rise in self-care and over-the-
counter medication use, and the increasing use of alcohol and other substances for
recreational use among older adults, the opportunities for adverse outcomes from
alcohol–medication interactions are growing. Serious adverse outcomes such as
falls, accidents, and hospitalization can have a significant impact on quantity and
quality of life. The adverse outcomes from medication–alcohol interactions are in
large part preventable. To prevent adverse outcomes, it is imperative to raise aware-
ness of the risk associated with alcohol–medication interactions; to educate health-
care providers to recognize and address concurrent use of alcohol and medications;
and to develop, implement, and disseminate effective treatment programs directed
at concurrent use of alcohol and medications among older adults.
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The Intersection of Elder Abuse
and Alcohol Misuse 9
Pamela B. Teaster and Nancy Brossoie
9.1 Introduction
For some older adults, the aging process may accompany an increased reliance on
caregivers. A need for assistance can leave older adults vulnerable to abuse, neglect,
or exploitation. Data about the prevalence of elder abuse and its circumstances are
continuing to be created. Similar to the misuse of alcohol during late life, incidents
of elder abuse often remain hidden because of problems with service provision in
healthcare and social service sectors such as limited screenings among healthcare
providers and underresourced and uneven programs/services available to meet the
needs of this nuanced population of older adults. Furthermore, larger societal views
also come into play, including the social stigma associated with being labeled as a
victim; the potential for severing relational ties; and on an even larger scale, perva-
sive ageist views held about older persons.
Older victims may experience abuse, neglect, and/or exploitation as a one-time
or ongoing event, and they may be victimized by a single type or multiple types of
abuse, known as polyvictimization. Also, elder abuse can occur in a variety of com-
munity or facility settings, with the reality that anyone may become a perpetrator
and anyone may become a victim [1]. Especially for community-dwelling elders,
the abuse is most often a form of family violence perpetrated by a trusted other,
typically adult children or an intimate partner.
Acierno et al. estimate that one in nine older adults living in the community
experiences mistreatment at the hands of a trusted other [2]. Characteristics of abus-
ers include a history of mental illness, difficulty in holding a job, problems in main-
taining relationships, and a dependency upon the older adult for whom they are
providing care. In many instances, the adult child or intimate partner is also abusing
substances such as drugs and/or alcohol [3–5].
P.B. Teaster, Ph.D. (*) • N. Brossoie, Ph.D.

Center for Gerontology, Virginia Tech, 230 Grove Lane, Blacksburg, VA 24061, USA

132 P.B. Teaster and N. Brossoie
In a national study of Adult Protective Services (APS), Teaster et al. found that
for APS there were 253,421 reports of abuse of adults age 60 and over, or 8.3 reports
for every 1000 people over the age of 60 [6]. Despite the prevalence of the problem,
as well as the growing numbers of older adults in the population generally, state and
local mechanisms for identifying, reporting, and investigating suspected cases of
elder abuse are inadequate and heavily reliant upon state APS agencies. In many
states, the budgets of APS and other responders are inadequate to address the prob-
lem. This frequent inadequacy of resources affects the numbers of cases that are
reported, investigated, and substantiated. For example, according to a widely cited
figure by Pillemer and Finklehor [7], as few as one in 14 cases is reported due to
reasons such as fear of reprisal or a reticence by the elder or other family members
to report the misdeeds of another family member. A New York study indicated that
for every report of elder abuse to an agency, 23.5 instances go unreported [8].
Similar to elder abuse, alcohol misuse in late life is also a largely hidden public
health problem that affects approximately 30 % of US adults age 65 and older [9].
Studies worldwide report that alcohol consumption tends to be highest among coun-
tries with high incomes but is also prevalent in low-income countries [5]. Though
older adults consume less alcohol and in smaller quantities than their younger coun-
terparts [10], alcohol consumption in late life can have a significant effect on elders
due to age-related physiologic changes, potential interactions with prescription
medications, and dietary changes.
When drinking becomes problematic, it may also contribute to elder abuse. For
example, older adults may consume increasing amounts of alcohol to cope with
abuse that they are currently experiencing. They may also drink to cope with loneli-
ness, loss of purpose, or depression, thus leaving them open to potential abuse by
trusted others, strangers, or to self-abuse or self-neglect. Similarly, individuals who
are misusing alcohol may become perpetrators of abuse when they become depen-
dent on older adults for more alcohol, income, housing, and daily needs. Perpetrators
may abuse alcohol to cope and to deal with ongoing demands at work and home,
increased frustration, and feelings of entitlement to an elder’s resources. Alcohol
misuse can impair caregiver decision making, lead to neglectful behaviors, and
contribute to loss of self-control, all at the expense of an older adult’s health and
quality of life.
Examining the intersection of elder abuse and alcohol misuse is important in that
both issues affect many people. Adults age 65 and older currently represent 13 % of
the total population and are expected to reach 18 % by 2020 [11]. If issues surround-
ing identifying, reporting, and responding to elder abuse and alcohol misuse
continue unabated, the same challenges will likely escalate in the next decade.
The purpose of this chapter is to examine the intersection of elder abuse and
alcohol misuse. We begin first with a discussion of definitions of elder abuse fol-
lowed by a presentation of theoretical constructs and frameworks used to conceptu-
alize both problems. Next, we examine settings of abuse and salient scholarly
literature on victims and perpetrators as well as the contribution of alcohol to the
problem. We then discuss community and societal responses to elder abuse and
alcohol misuse and conclude with future directions for research and practice.
9 The Intersection of Elder Abuse and Alcohol Misuse 133
9.2 Definitions of Elder Abuse
The field of elder abuse scholarship has long been impeded by definitional prob-
lems, such as when it is regarded as a crime, as the definition is derived from state
statutes or regulations. When it is considered a “family problem,” the tendency is to
disregard it, and consequently, elder abuse receives inadequate attention or resources
by entities that might intervene. The definitional conundrum has driven the quality
and type of research conducted on the topic [12–14].
The most influential publication to date, Elder Mistreatment: Abuse, Neglect,
and Exploitation in an Aging America, produced by the National Academy of
Sciences (NAS), has gained prominence worldwide [15]. Elder mistreatment here is
defined as those “(a) intentional actions that cause harm or create a serious risk of
harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other
person who stands in a trust relationship to the elder or (b) failure by a caregiver to
satisfy the elder’s basic needs or to protect the elder from harm” (p. 40) [12].
Importantly, the NAS definition stresses perpetration of abuse by a trusted other.
Another important definition promulgated by the World Health Organization
(WHO) [5] defines elder abuse as “a single, or repeated act, or lack of appropriate
action, occurring within any relationship where there is an expectation of trust
which causes harm or distress to an older person.” The WHO definition contem-
plates that elder mistreatment can take on multiple types and repeated acts, or poly-
victimization [16].
9.3 Types of Elder Abuse
Regardless of living environment, some older adults with vulnerabilities can be at

risk for elder abuse: physical, sexual, verbal/emotional, neglect (both active and
passive), financial abuse/exploitation, and self-neglect; elder abuse can also include
aspects of domestic violence and intimate partner violence. Each type is described
as follows using definitions taken from the National Center on Elder Abuse [17] and
supported by current research findings (Table 9.1).
Table 9.1 A comparison of prevalence studies and typologies of elder abuse

Acierno Laumann Lifespan of Greater Teaster
et al. [2] et al. [32] Rochester Inc. [8] et al. [6]
Physical abuse 1.6 % 0.02 % 22.4 %/1000 10.7 %
Sexual abuse 0.06 % – 0.03 %/1000 1.0 %
Emotional/psychological abuse 4.6 % 9 % 16.4 %/1000 14.8 %
Neglect 5.1 % – 18.3 %/1000 20.4 %
Exploitation 5.2 % 3.5 % 42.1 %/1000 14.7 %
Self-neglect – – – 37.2 %
Physical abuse. Physical abuse involves physical force that may result in bodily
injury, physical pain, or impairment. It can include acts of violence such as striking
(with or without an object), hitting, beating, pushing, shoving, shaking, slapping,
kicking, pinching, and burning. In addition, physical abuse encompasses the inap-
propriate use of drugs and physical restraints, force-feeding, and physical punish-
ment of any kind [17].
Sexual abuse. Sexual abuse, considered the most hidden of the abuse types [18, 19]
refers to nonconsensual sexual contact of any kind. Sexual contact with any
person incapable of giving consent is also considered sexual abuse. This type of
abuse includes, but is not limited to, unwanted touching and all types of sexual
assault or battery, including rape, sodomy, coerced nudity, and sexually explicit
photographing [17].
Emotional/psychological abuse. Emotional or psychological abuse is unseen
and involves inflicting anguish, pain, or distress through verbal or nonverbal acts. It
includes but is not limited to verbal assaults, insults, threats, intimidation, humilia-
tion, and harassment. Also considered emotional/psychological abuse are threaten-
ing looks and gestures; infantilizing an older adult; isolating him or her from family,
friends, or regular activities; and proffering him or her the “silent treatment” [17].
Neglect. Neglectful acts concern the refusal or failure to fulfill any part of some-
one’s obligations or duties to an older adult. Neglect may include the failure of a
person who has fiduciary responsibilities to arrange care (e.g., remuneration for
necessary services) or the failure or refusal of a provider to offer and deliver an
implied or agreed-upon standard of care [17].
Exploitation. Exploitation is defined as the illegal or improper use of funds,
property, or assets. Examples including cashing a person’s checks without authori-
zation or permission; forging an elder’s signature; misusing or stealing money or
possessions; coercing or deceiving an individual into signing a document (e.g., con-
tracts or a will); and the inappropriate use of a conservatorship, guardianship, or
power of attorney [17]. An illustration of the magnitude of the problem, a review of
incidents involving the exploitation of elders covered in the national media revealed
that cases of exploitation reached $2.6 billion in 2009, a figure that increased to $2.9
billion by 2011 [20, 21].
Self-neglect. Self-neglect occurs when the behavior of an individual threatens his
or her own health or safety and manifests itself as a refusal or failure to provide him-
self/herself with adequate food, water, clothing, shelter, personal hygiene, medica-
tion (when indicated), and safety precautions [17]. Self-neglect is one of the most
vexing of the abuse types because its origin is difficult to pinpoint and because, in its
most extreme form, the problem can result in forced removal of the individual from
his or her home and concomitant loss of the individual’s civil rights. An individual is
not self-neglecting if he or she is mentally competent, understands the consequences
of decisions, and makes a conscious and voluntary decision to engage in acts that
threaten her personal health or safety as a matter of personal choice. Individuals with
limited social connections tend to be more susceptible to self-neglectful situations
than those with many social connections [17].
9.4 Characteristics of Victims and Abusers
Victims. A study by Acierno and colleagues [2] included self-reported elder abuse
data collected from 5,777 older adults: the average age of victims was 71.5 years,
with 60.2 % females. Respondents indicated that 56.8 % were married or cohabitat-
ing, 11.8 % (677) were separated or divorced, 25.1 % (1,450) were widowed, and
5.2 % (303) had never married. Similarly, the Lifespan prevalence study [8] utilized
a survey of 4,136 adults aged 60 years of age and older and revealed that 20.3 %
were between 60 and 64 years of age, 38.0 % were between ages 65 and 74, 29.1 %
were ages 75–84, and 12.7 % were aged 85+. Victims were mostly female (64.2 %).
Respondents were 65.5 % Caucasian, 26.3 % African-American, and 7.6 % were
Hispanic/Latino.
Victims’ risk factors. Risk factors for elder abuse include older age, lack of
social support, female gender, minority race, physical and mental impairments, and
substance abuse. Empirical studies concentrating on specific types of abuse (e.g.,
sexual, financial) have identified adults aged 75 and older as being particularly sus-
ceptible to mistreatment [21, 22]. The link between age and risk for abuse maybe
due to the increased longevity of the oldest-old age group of older adults, many of
whom experience a decline in health that results in greater dependence on others for
self-care than that of the general population.
Lack of social support. Acierno [2] and Amstadter et al. [23] stress that low
levels of social support are correlated with the occurrence of all types of elder abuse.
Elders who are lonely or isolated are significantly more vulnerable to elder mistreat-
ment and alcohol misuse than are those with strong, fleshed-out support systems.
Gender. Older women tend to be victimized at higher rates than their male coun-
terparts [24]. Higher rates of victimized older women can be attributed to their
longer life spans, which may heighten their contact with potential abusers [25].
According to Acierno [2], previous exposure to a traumatic life event (e.g., interper-
sonal and domestic violence) increases the risk of late life mistreatment and offer an
explanation of how vulnerabilities related to the intersection of gender and power
amplify the risk for abuse [26]. In general, women consume lower levels of alcohol
than men in old age, but previous exposure to a traumatic life event, such as vio-
lence, increases the risk of alcohol misuse [27].
Race. Lachs and colleagues [28] found that Black elders are at greater risk for
mistreatment than their White counterparts; Tatara [29] found that Black and Hispanic
elders were overrepresented in data on elder abuse victims, with nearly one in three
being from a minority group. Depending on the culture, race may protect or promote
the occurrence of a minority elder’s risk for abuse [30, 31]. Related to abuse and
alcohol misuse, acceptable consumption of alcohol varies by race and culture.
Physical and mental impairments. Poor overall health and disability exacer-
bate an elder’s risk for abuse. According to Laumann et al. [32], older adults who
reported any type of physical vulnerability were 13 % more likely to report verbal
mistreatment than were study participants who reported none. Similarly, Acierno
et al. [2] reported that the likelihood of financial exploitation by both family
members and strangers increased for older adults with severe physical disabilities,
and poor health predicted neglect. According to Sherod et al. [33], cognitive impair-
ment increases with age and is perhaps the most pervasive and salient risk factor for
financial abuse and exploitation. Alcohol misuse can impair decision making, an out-
come exacerbated if an individual already presents with cognitive impairment [34].
Substance abuse. Research connecting the abuse of alcohol and other sub-
stances is emergent at present, with most data collected predicated on a report of
the victim [35]. Victims may turn to alcohol misuse as a coping strategy, thus
lowering their inhibitions and heightening their risk for poor decision-making,
such as when making decisions related to finances [36]. Additionally, victims are
more likely to abuse alcohol and other substances when the perpetrator is also
abusing the same [37].
9.5 Characteristics of Abusers
Although the body of information concerning elder abuse victims is increasing, far
less is known about abusers than victims. According to the National Committee for
the Prevention of Elder Abuse (NCPEA) [37], substance abuse is the most fre-
quently cited risk factor associated with elder abuse and neglect. Either the victim,
the perpetrator, or both may misuse alcohol, drugs, or medications. Substance abuse
is believed to be a factor in many types of elder abuse, including physical mistreat-
ment, emotional abuse, financial exploitation, and a significant factor in self-neglect.
Amstadter et al. [23] found that perpetrators of physical mistreatment (as compared
to emotional and sexual mistreatment) had a greater likelihood of legal problems,
psychological treatment, living with the victim, being related to the victim, and
substance use during the abuse incident. Brownell et al. [38] discovered that the
pathology or impairment of the abuser was a stronger predictor of abuse than risk
factors for the victim. Similar to the Amstadter findings [23], impaired abusers were
younger than unimpaired abusers, usually lived with the victim, were unemployed,
and had previous involvement with the criminal justice system.
9.6 Responding to Elder Abuse
Responding to elder abuse demands an approach that takes into account the context
of both victims and abusers. To address the problem as one for which a black and
white solution exists is to ignore the subtleties surrounding the problem as well as
to potentially trammel on the rights of the older adults to live life as they choose.
Rallying community professionals (e.g., faith leaders, healthcare providers, law
enforcement, social workers, etc.) who normally come in contact with older adults
(and potential victims) in the course of their work to join forces in responding to
potential abuse is an ongoing struggle in many communities. A common perception
held by community members is that if an older person is being abused or mistreated,
he or she will tell a primary healthcare provider or clergy person. However,
individuals in those professions deny hearing about problems. In reality, community

professionals are highly unlikely to screen, recognize, and report suspected problems,
citing a lack of expertise in screening or intervening, that it is not their role or
responsibility, and a fear of embarrassing and then losing the patient/client, and
patient/client confidentiality [39, 40]. When a sensitive issue such as elder abuse
and/or alcohol misuse is addressed, it is more often than not addressed indepen-
dently of other services, with the exception of healthcare emergencies. In a crisis
situation, state laws generally mandate that law enforcement and emergency
healthcare services report suspected problems to Adult Protective Services for
investigation.
Adult protective services. “Adult Protective Services (APS) are those services
provided to older people and people with disabilities who are in danger of being
mistreated or neglected, are unable to protect themselves, and have no one to assist
them” (p. 1) [41]. In most states, APS programs are the first responders to reports of
the abuse, neglect, and exploitation of vulnerable adults. Most APS programs serve
vulnerable adults regardless of age; however, some serve only older persons (based
either on age or incapacity). A few programs serve only adults ages 18–59 with dis-
abilities that keep them from protecting themselves. Interventions provided by APS
include receiving reports of adult abuse, neglect, or exploitation; investigating
reports; assessing risk; developing and implementing case plans; service monitor-
ing; and evaluation. Adult protection may include providing or arranging for an
array of medical, social, economic, legal, housing, law enforcement, or other pro-
tective emergency or supportive services [41]. Over half of APS programs investi-
gate in both community and facility settings; all are authorized to investigate in
domestic settings (100.0 %), with half authorized in facility settings (68.5 %) [41].
The long-term care ombudsman. Area Agencies on Aging (AAAs) are a
nationwide network of local programs that help older people plan and care for their
needs. AAAs typically house the Local Long-Term Care Ombudsman (LTCO) [42, 43].
Depending on the state, LTCO are advocates for residents of nursing homes, board
and care homes, assisted living facilities, and similar adult care facilities. Either
paid or volunteer LTCO attempt to resolve problems of individual residents and
bring about changes at local, state, and national levels to improve residents’ care
and quality of life.
9.7 The Intersection of Alcohol Misuse and Elder Abuse
Although a growing body of work on the effects of alcohol misuse in late life is
emerging, at present, only a handful of studies examine the contribution of alcohol
to the abuse of older adults. Recognizing that alcohol misuse does not cause a per-
son who drinks to take advantage of another person or commit acts of violence,
alcohol misuse, among many negative consequences, tends to lower inhibitions and
contribute to poor decision-making.
Currently, there is no evidence to suggest that the severity of alcohol use or the
blood alcohol level of a perpetrator at the time of an incident translates to harsher
mistreatment. An analysis of fatal incidents of intimate partner violence (IPV) from

1999 to 2007 involving persons aged 50+ indicated that alcohol was found in the
blood of 21 % of perpetrators. Among victims of IPV, 29 % had consumed alcohol,
and among them, 64 % had a blood alcohol content above 0.07. For individuals
perpetrating a homicide–suicide, 22.2 % had been drinking, and nearly half experienced
known mental health difficulties that contributed to the violence [44].
Drinking habits and patterns of both victim and perpetrator remain elusive.
Estimated rates of alcohol misuse among perpetrators vary from 3 % [45] to 46 %
[34]. Methods for identifying use are heavily dependent on victim report. Elders are
more likely to report incidences of abuse when they are injured and need to receive
medical care [35]. In a retrospective study of incidents of elder abuse [46], victims
reported in 20 % of the care records reviewed that alcohol misuse was a greater
problem and needed more attention than the abuse itself.
Drinking alcohol is a strategy used by males and females as a means to cope with
depression, anxiety, pain, or an uncomfortable situation. Despite providing comfort
in coping, drinking is not a protective factor against abuse. It is estimated that 45 %
of women who drink heavily are victims of abuse [27]. Victims with long-standing
alcohol problems are also at risk for poor decision-making, detecting coercion or
fraud, and resisting potential abuse [4]. Use of alcohol as a coping strategy becomes
further problematic when the older drinker is cognitively impaired. The ability to
plan, make sound decisions, and respond appropriately to people and things is
even more impeded by the presence of alcohol in the brain [34].
A study of 23 perpetrators revealed that abusers were twice as likely as nonabus-
ers to drink more frequently and heavily. Compared to child abusers, they were
more than three times as likely to drink daily and twice as likely to have reported
feeling less inhibited when they drink. Pittaway and Gallagher [46] found that bouts
of severe drinking resulted in the harm of an elder in 14.6 % of elder abuse cases.
A victim’s use of alcohol should also be factored into discussions of misuse
and dependence [45], not because a victim is deserving of abuse, but to better
understand the context of the relationship that alcohol plays in the abuse and the
available network of support that surrounds a victim [47]. Couples with estab-
lished drinking partnerships are more likely to experience incidents of IPV [48].
Victims of elder abuse are four times as likely to abuse alcohol or drugs when the
perpetrator abuses substances [35]. In a study of couples aged 50+, researchers
found that as alcohol-related problems increased between partners, there was a
higher likelihood that IPV occurred [47]. Victims are likely to have poor relation-
ships with their families or to be estranged entirely. If they need care, their family
members may be unwilling to help or may harbor resentments that impede their
ability to provide good care [4].
It is easy to speculate that perpetrators of elder abuse are likely to misuse alcohol
as a means to cope with the daily stressors of caregiving [49, 50]. Still, researchers
disagree as to the relationship between alcohol misuse and elder abuse by caregiv-
ers. Compton et al. [51] stated that no relationship exists; Kleinschmidt [52] sug-
gested that alcohol misuse among caregivers is a strong predictor of elder abuse, and
other researchers have suggested that long-standing drinking problems coupled
with histories of mental health issues [53–55] are key to understanding elder abuse.
Differences in findings are connected to how alcohol consumption is defined,
cultural perceptions of use, and the rates at which elder abuse is reported [56].
Still, the strongest predictor of physical abuse is believed to be a history of alco-
hol misuse [57]. Similarly, a strong predictor of self-neglect is alcohol and other
substance abuse [37, 58]. Not only does self-neglect diminish one’s ability to care
for oneself, but alcohol further limits one’s ability to do so [59].
Researchers and practitioners alike have observed that persons with substance
abuse problems tend to regard older family members, acquaintances, or strangers as
prime targets for exploitation [4]. They may financially exploit an older family
member or stranger for a regular stream of income or to obtain extra money to sup-
port their way of life, including substance misuse. They may also move into their
victim’s home to gain a stronger hold on the victim’s resources or even to use it as
a base of operation for drug use or trafficking [37].
9.8 Frameworks for Explaining Elder Abuse
Models for explaining elder abuse are often based on interpersonal or relationship
models. Historically, acts of elder abuse have been assumed to be the result of frus-
tration over demands of caregiving (paid and informal). Although a caregiver stress
model [49, 50] can be useful in explaining some abuse between caregivers and their
highly dependent victims, the model omits the potential for identifying reasons
for abuse beyond caregiver stress [60]. Following, we discuss interpersonal models,
developmental models, and societal models to explain elder mistreatment. Also, as
indicated earlier, it is important to understand how alcohol may be contributing in
the abuse.
The Cycle of Violence Theory [61] is based on a relationship model derived from
domestic violence research on women who survived abusive relationships. It includes
four stages of relationship violence: escalation, violence, reconciliation, and calm.
The cycle begins with tension escalating between the victim and the perpetrator.
Tension builds to a point when abuse occurs. The couple then enters a period of rec-
onciliation, followed by a period of relationship calm. Once tension begins to build
again, the cycle repeats. Although the theory is useful for therapeutic work in identi-
fying antecedents, behaviors, and consequences with victims and perpetrators, it
does not address the culpability of either participant. Regardless, the theory can play
a useful role in advancing our understanding of elder abuse, especially when contrib-
uting factors such as alcohol are present. Once identified, these contributors could be
removed, thus disrupting the cycle of violence. For example, as mentioned earlier,
bouts of severe drinking led to the abuse/harm incident in 14.6 % of elder abuse cases
in a study by Pittaway and Gallagher [46].
Other interpersonal models used to explain elder abuse are also used to elucidate
alcohol misuse. Social Learning Theory [62] contends that actions are learned
through modeling. Individuals adopt the behaviors of others in their social networks
such that abuse can be a learned behavior just as alcohol abuse can be learned [63].
Similarly, Social Exchange Theory [64] suggests that when relationship dynamics
become unbalanced, such as in caregiving relationships, individuals will resort to
certain acts (e.g., elder abuse or alcohol abuse) to restore relationship balance.
National academies of science framework. An important framework for scholar-
ship on elder mistreatment is that proposed by the NAS, mentioned earlier [12].
Unlike other approaches used to explain elder abuse, this framework was developed
specifically for elder mistreatment and is based on relationships that elders maintain
with others. Included in the framework are dynamics of power, exchange, inequal-
ity, and outcomes of mistreatment. The framework considers quality of life but does
not include the problem of self-neglect. The NAS framework has saliency for
alcohol-related elder mistreatment because of its focus on the relationship of the
elder with the perpetrator, who may be abusing alcohol and thus using it to establish
control over the older adult. It may also be applicable to the older adult who is using
alcohol, the overuse of which may affect his or her quality of life.
Complete reliance on relationship models to explain elder abuse is still quite
limiting because elder abuse can take on many forms, and the course of abuse is
often not linear. Factors such as health, finances, family support, and social expecta-
tions/norms directly and indirectly influence the nature and actions of daily life.
However, using theories and models that can account for multiple external influ-
ences and personal choice can be useful in examining abuse and the intersection of
abuse and alcohol misuse.
Socioecological framework. A model gaining attention for both IPV and elder
abuse is the Socioecological (SE) Framework [65]. The SE framework enables
researchers to consider a complex set of explanatory variables that affect elder mis-
treatment. The model suggests that individuals are embedded in a series of ecologi-
cal systems: (a) the microsystem (i.e., victim within his or her environment); (b) the
mesosystem (i.e., the environment in which the relationship between the victim and
perpetrator exists); (c) the exosystem (i.e., public environments and systems, such as
community services or law enforcement, that focus on the greater good of the com-
munity yet, affect individual well-being); and (d) the macrosystem (i.e., ideological
values, norms, and cultural and institutional patterns) [6, 31]. The Centers for Disease
Control and Prevention [66] uses the SE model to explain violence and examine the
efficacy of prevention strategies by considering risk factors for individual, social,
and economic systems that permit conditions for elder abuse to fester [67]. The
model has also been applied to intervention [68], prevention [69, 70], intimate part-
ner violence [14], and elder mistreatment in nursing homes [71]. Applicable to the
intersection of elder abuse and alcohol misuse, various levels of alcohol stimuli
exposure can occur at every level, family, community, neighborhood—even geriatric
policies on alcohol could play a role in elder abuse cases.
Life course perspective. Another construct for thinking about elder abuse is the
Life Course Perspective [72, 73]. The Life Course Perspective involves social and
historical factors woven through personal biography and development within
which examinations of family life and social change occur. An advantage of this
perspective is that it provides a context for action and intervention, inviting multiple
approaches to think about and solve a problem. The Life Course Perspective as
applied to elder abuse includes age, historical period, and cohort effects. Disadvantages
for its application are its potential for misunderstanding mean values, confounding
social change with social forces, confusing concepts of time and change, problema-
tizing choices, and neglecting intercohort variability. Despite these challenges, this
perspective could help researchers understand the role of alcohol in an abusive rela-
tionship as well as how to mollify its detrimental effects. For example, the Life
Course Perspective can help explain how older adults as well as those who abuse
them regard abusive incidents (some may not think them abusive at all) and well as
intervention efforts.
Other conceptual approaches to exploring elder abuse may also shed light on the
issue and its intersection with alcohol. While most are not empirically testable, they
may inform the many dimensions of abuse, neglect, and exploitation: Power and
Control Wheel [74], Cumulative Inequality Theory [75], Techniques of
Neutralization or “Drift” Theory [76], the Public Health Model [77], the Restorative
Justice Model [78], Multidisciplinary and Transdisciplinary Approaches [79],
Communications Theories [80], and an Ethics of Care Approach [81, 82]. The
development of theories, frameworks, and models for elder abuse and the intersec-
tion of alcohol misuse will need to consider the contribution of individuals and
populations, with neither more important than the other. Continued exploration and
application of theoretical models and approaches to the contribution of alcohol to
elder abuse stands to improve both intervention and prevention efforts.
9.9 Settings for Abuse
Elder abuse can occur at home, in the community, in long-term care settings, or a
combination of settings. Community locations include such locations as an elder’s
own home or the home of an individual with whom the elder lives. It is estimated
that 90 % of all elder abuse occurs in community settings, though an accurate num-
ber is difficult to ascertain because of the ease with which elder abuse can be hidden
in community settings [8, 19]. What occurs behind closed doors in the home may go
unnoticed until someone finally speaks up, as the example of Mamie attests.
Mamie is an 80-year-old woman with mild cognitive impairment. She walks with
difficulty, ambulating in a wheelchair more and more often. Living with her, following
his recent and third divorce is her only son, Thomas, a 40-year-old engineer, who
never seemed to be able to hold a job for any length of time. His relationships with
women were intense but fleeting. Over time, Thomas’ bouts with depression have
increased, and his weekend drinking has extended into the work week as well. Mamie
is a generally cheerful woman, but her painful arthritis and back pain mean that she
depends on asking Thomas to help her more and more, and she just forgets sometimes
that she has asked Thomas for help at all. It seems as though Thomas has become less
patient with her. He needs money, for sure, but he now lashes out with his responses to
her requests, and over the past 6 months, he has started destroying vases on the tables
and pictures on the walls. Recently, Mamie suffered a broken nose and heavy blood
loss when Thomas, in a drunken stupor at the time, hit her and the wall behind her.
The police were called by a neighbor who heard Mamie’s pleas for Thomas to stop.
Mentioned earlier, alcohol-related elder abuse can also occur in long-term care
settings (e.g., assisted living facilities, group homes, mental hospitals, and nursing
homes). According to Hawes [83], on an average day, approximately 1.6 million
people live in a about 17,000 licensed nursing homes, and another estimated 900,000
to 1 million live in about 45,000 residential care facilities. Research suggests that
the 2.5 million vulnerable individuals living in facilities may be at a higher risk for
abuse and neglect than older persons who live at home because they are compro-
mised physically and mentally, as illustrated in the following scenario.
Nearly all his life, Don lived and worked as a banker in a small town. Don contin-
ued to live in the family home after his wife Loris died in her late 70s due to a pro-
tracted illness. Don’s only child, a son, lived 5 hours away. The son called and visited
as much as he and his family could, but over time, Don became lonely, particularly in
the winter months, even forgetting to eat at times. Five years after Loris’ death, he
sold the family home and moved into an assisted living facility (ALF). His gait and
balance had deteriorated to the point that he often stumbled and leaned when he
walked. His once sharp memory had begun to flag: he confused the many and increas-
ing medications that his doctor thought he should take (Don had suffered a heart
attack in his late 60s and later had bypass surgery for blockages). Living at the ALF
helped immensely with his eating regular meals, taking medications, and with his
loneliness, as he enjoyed the programs offered there. Prior to having dinner and simi-
lar to when he was living on his own, Don enjoyed a daily glass of wine, which he
bought in boxes when the facility took the residents on weekly shopping outings.
During the first year he resided at the ALF, Don’s gait and leaning problems increased
to the point that he fell in his apartment and had to be taken to the hospital to sew
some stitches in his forehead due to gashes. An emergency room nurse smelled alco-
hol on Don’s breath and asked him about his drinking. Although he admitted only to
having a small glad of wine, the nurse contacted APS to follow up.
9.10 Looking to the Future
Individual misuse of alcohol increases the likelihood that elder abuse will occur.
Both victim and abuser may be involved in alcohol misuse, with the misuse volun-
tary or forced. Misuse of alcohol may involve physical or mental health problems as
well as the voluntary or forced misuse of substances other than alcohol. Older adults
may misuse alcohol due to an addiction acquired in earlier years. They may drink
because they are depressed, because they are encountering physical pain, or because
they are using it as a coping mechanism for the abuse they are currently experienc-
ing. Abusers may be misusing alcohol for many of the same reasons as the elders
they abuse. Alcohol misuse alone does not “cause” elder abuse, rather, it is a con-
tributor to the problem.
Although noteworthy, much of the research related to elder abuse and alcohol
misuse is dated or focused on one type of abuse only (e.g., domestic violence), sug-
gesting that the topic is deserving of renewed attention. Several factors suggest that
the time has come to reexamine this intersection. First, emphasized previously, the
percentage of adults who are living to older ages is increasing as a percentage of the
total population. Coupled with the fact that older adults are living to older ages
generally and that they may live longer with greater physical and mental impair-
ments, their risk for abuse in later life could grow as well as the sheer numbers of
adults of all genders, races, and cultures who experience abuse.
Second, shifts in sectors of the economy may portend uncertainty related to
employability or sustained employability for intimate partners and children.
Different from previous generations, children may be compelled to return home to
live and become dependent on older parents rather than living in domiciles on their
own. While helping to care for an elder may happen just at the right time for both,
for a child experiencing a combination of mental health and substance abuse prob-
lems, a “perfect storm” for abuse may well develop.
Third, inadequacies in mental health treatment are increasingly evident for
many populations, and because of this, persons may turn to alcohol as a coping
mechanism, one that may devolve into alcohol misuse and include the misuse of
other substances as well. For example, upon discharge, many young persons in the
armed services are facing delays in acquiring sorely needed treatment, and many
older veterans are experiencing the same. Our understanding of the effects of
PTSD is better now than in the past, an understanding that its effects are more long
lasting than earlier regarded. Also, many persons are being relocated from institu-
tions and are now living in the community with greater freedoms. However, many
are offered too few services and supports to help them do so successfully, a circum-
stance that may increase the current (and escalating) rate of elder abuse coupled
with alcohol misuse.
In conclusion, alcohol misuse is a long-standing problem that can contribute to
elder abuse. Its deleterious effects amplify when it is combined with a history of
mental health problems and the misuse of other substances. Without a full under-
standing of this complex problem in conjunction with resources that are adequate
and appropriate for intervention and prevention efforts, the prevalence of the abuse
of older adults in circumstances involving the misuse of alcohol stands to increase
in the ensuing years. Current elder abuse literature indicates the significant need to
provide better alcohol treatment early in life in order to prevent the effect of long-
time alcohol misuse patterns contributing to elder abuse.
9.11 Resources Related to Elder Abuse
Administration for Community Living (ACL).

Website: www.acl.gov
Clearinghouse on Abuse and Neglect of the Elderly (CANE).
Website: http://www.cane.udel.edu/
Elder Justice Coalition.
Website: www.elderjusticecoalition.com
National Adult Protective Services Association (NAPSA).
Website: www.napsa-now.org
National Association of Area Agencies on Aging (N4A).

Website: www.n4a.org
National Association of States Agencies on Aging United for Aging and Disabilities
(NASUAD).
Website: www.nasuad.org
National Center on Elder Abuse (NCEA).
Website: http://www.ncea.aoa.gov/about/index.aspx
National Committee for the Prevention of Elder Abuse (NCPEA).
Website: www.preventelderabuse.org
National Clearinghouse on Abuse in Later Life (NCALL).
Website: http://ncall.us/
National Consumers’ Voice for Quality Long-Term Care (or Consumer Voice).
Website: http://theconsumervoice.org
National Institute of Justice (NIJ).
Website: www.nij.gov
National Long-Term Care Ombudsman Resource Center (NORC).
Website: www.ltcombudsman.org/
Safe Horizon.
Website: http://www.safehorizon.org/
Social Security Administration.
Website: www.ssa.gov
World Health Organization (WHO).
Website: http://www.who.int/ageing/projects/elderabuse/en/
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Social and Familial Contexts for Drinking
Among Older Adults 10
Rachel Chernick and Alexis Kuerbis
10.1 Introduction
America is rapidly aging. In 2014, one in seven Americans, or 46.3 million indi-
viduals, was 65 or older. In 2030, by the time the last baby boomer has turned 65,
this number will be one in five or 74 million individuals [1]. Demographic shifts
such as declining birth rates and longer life spans are combining with the aging of
the baby boomer generation to create a dramatic greying of the population [2]. As a
result, there has been an increased focus among researchers concerned with how
this demographic shift will impact public health at large. One particular area of
interest involves the use of alcohol among older adults.
Alcohol consumption ranges from abstinence at one end of the spectrum to very
heavy use at the other. It is not always clear at what point low-risk use gives way to
high-risk and problematic use, especially for older adults. Some elders develop
problems as a consequence of drinking relatively small amounts; others are able to
drink much more without negative outcomes. In addition, moderate consumption
has been associated with reduced mortality [3], improved cardiovascular health [4],
and lowered risk of dementia [5]. Adams [6] found that drinkers rated their health
as good or excellent more often than abstainers, exercised more frequently, and
were less likely to be taking medications. While it is possible that health problems
lead to a reduction in drinking, it is also possible that moderate drinking brings
health benefits. Clearly, the relationship between alcohol use and health is a
complex one.
R. Chernick, L.C.S.W.
Department of Social Welfare, The Graduate Center, CUNY, 365 Fifth Avenue,
New York, NY, USA
A. Kuerbis, L.C.S.W., Ph.D. (*)
Silberman School of Social Work, Hunter College at the City University of New York,
2180 Third Avenue, New York, NY 10035, USA

150 R. Chernick and A. Kuerbis
Despite this complexity, there are general guidelines for consumption. The National
Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed low-risk
consumption levels specifically for this age group [7]. According to the NIAAA,
adults 65 and older who are healthy and do not take medications should have no
more than three drinks per day with a maximum of seven drinks per week.
Individuals who consume more than this amount are considered to be at-risk or
problem drinkers. An at-risk drinker is one whose pattern of use does not necessar-
ily cause problems but may result in adverse consequences, either to the user or to
others [8]. A problem drinker engages in more hazardous use.
While alcohol use generally declines with age [9], many older adults continue to
drink regularly. The baby boomer cohort has maintained relatively high levels of
alcohol use in older adulthood compared to earlier generations of older adults.
Some postulate that this is because this group came of age when alcohol and drug
use were both more prevalent and more socially acceptable [10, 11]. In addition,
some specific drinking behavior increases among older adults who do drink. The
prevalence of binge drinking is a case in point. Binge drinking is defined as the
consumption of four or more drinks on one occasion for women and five or more
drinks on one occasion for men [12]. Overall, binge-drinking rates among older
adults are significantly lower than for younger individuals. However, older adults
who do binge drink are doing so with greater frequency—5.5 episodes per month, a
higher rate than any other age group [12].
In 2013, the general population rates from the National Survey on Drug Use and
Health (NSDUH) for current alcohol use among older adults, defined as at least one
drink in the past 30 days, was 41.7 %. The rate for binge use, five or more drinks on
the same occasion on at least 1 day in the past 30 days, was 9.1 %. The rate for heavy
use, five or more drinks on the same occasion on each of 5 or more days in the past
30 days, was 2.1 % [13]. In another nationally representative sample, Blazer and Wu
[14] found at-risk drinking behavior in 17 % of men and 11 % of women. A smaller
community-based sample identified 27.1 % of women and 48.6 % of men drinking
above NIAAA guidelines [15].
While epidemiological studies provide an indication of overall numbers of
older adult alcohol users, they do not describe how particular social and familial
influences can serve as either risk or protective factors for this use. It is well docu-
mented that individual risk factors such as gender, genetic predisposition, and
personality traits can influence alcohol use among older adults [16]. The focus of
this chapter, however, is on how environmental factors such as familial and social
influences either facilitate or hinder the use of alcohol in this group. Specific con-
texts to be explored include: retirement, residential context, and familial and
social networks. Research that discusses these factors in relation to older adult
drinking will be reviewed and discussed. In addition, theoretical explanations for
the etiology of older adult alcohol use will be examined and research data will be
considered in terms of how well they support or contradict these theoretical
explanations.
10 Social and Familial Contexts for Drinking Among Older Adults 151
10.2 Retirement
As the population ages, 20 % of the current workforce will be transitioning into
retirement in the coming years [17]. As a result, it is important to understand more
clearly how this transition affects the health of retirees, including its impact on
drinking behavior. Studying the effects of retirement on drinking patterns is compli-
cated by the fact that the concept of retirement is not defined consistently [17, 18].
Many studies use the traditional definition of retirement as a distinct event [10].
According to this conceptualization, an individual is either retired or not—a dichot-
omous condition. Modern experiences of retirement, however, are not so neatly
divided into two distinct categories. Currently, retirement is not necessarily a singu-
lar event but rather an extended period of time where work situations can range from
full-time employment to partial employment to nonemployment [2, 19, 20].
Retirement today often consists of a “retiree” continuing to be employed either full
or part time, even while officially receiving retirement benefits. Since this “bridge”
employment status is not always taken into account in research on the topic, study
findings can be compromised [18].
As the nature of retirement is changing, it is becoming increasingly important to
break down particular aspects of this experience as opposed to assessing the con-
struct as a single entity [17]. Kuerbis and Sacco [17] performed a literature review of
13 studies examining the relationship between retirement and drinking behavior.
This review found that retirement as a whole had little to no direct impact on alcohol
consumption or problems. Specific aspects of retirement, however, such as preretire-
ment job satisfaction, high workplace stress, involuntary retirement, social roles, and
the size of social network did affect drinking behavior. Preretirement job satisfaction
was associated with more frequent drinking and more problems associated with
drinking [21]. High workplace stress preceding retirement was also associated with
increased drinking in retirement [22], as was involuntary retirement [23, 24]. When
social roles decreased in retirement, alcohol use and alcohol-related problems
decreased as well [25]. When social networks increased in breadth in retirement,
they influenced drinking if these networks supported drinking behaviors [25].
A number of studies have examined the issue of voluntary versus involuntary
retirement on drinking. In a 10-year longitudinal project, Bacharach and colleagues
followed 1279 blue-collar union workers from the transportation, manufacturing,
and construction industries [19, 21, 23, 26]. Participants were surveyed 6 months
prior to retirement, and then once a year for 10 years postretirement. Areas of
inquiry included specific drinking behavior and attitudes, behaviors, situations, and
conditions that might be related to alcohol use. Findings revealed those who per-
ceived their retirement as voluntary showed less alcohol use and problematic conse-
quences of drinking, while those who perceived the decision as involuntary
demonstrated more alcohol consumption [21]. Respondents who felt they had been
forced into retirement against their will were more likely to experience the event as
stressful, which led to drinking more often and in larger amounts. Those who expe-
rienced retirement as voluntary had a more positive outlook; drinking behavior for
this group was less frequent and less problematic. These authors also assessed the
relationship between preretirement job satisfaction and drinking, finding that higher
job satisfaction before retirement was associated with greater alcohol consumption
and drinking problems postretirement [21]. People who are happiest in their jobs are
more likely to feel stress related to the loss of employment and to turn to alcohol as
a coping mechanism once they have left this employment.
A study of older individuals in the Netherlands found similar findings related to the
voluntary/involuntary nature of retirement [24]. Henke, Van Solange and Gallo fol-
lowed 1604 participants over a 6-year period. During that time, 55 % of the initial sam-
ple retired. In this study, involuntary retirement was again associated with an increased
risk of drinking more, suggesting that involuntary retirement can lead to alcohol use as
a means to cope with stressors related to this type of employment departure.
Richman and colleagues [22] surveyed 1654 individuals who were employed by
an urban Midwestern university. Individuals were from a variety of occupations
including clerical staff, maintenance workers and faculty members. Six years later,
71 respondents had retired, about 6 % percent of the initial sample. The authors
measured sexual harassment, generalized workplace abuse, psychological work-
load, and drinking levels both during and after employment. Results suggest that
workplace stress during employment continued to impact drinking behavior even
after the worker was no longer employed and the stressor had been eliminated.
Despite the small number of retirees in the study and the short time period of retire-
ment (1–2 years for most), the study does demonstrate the lingering effects of work-
place stress and its effects on drinking.
Neve et al. [25] utilized data from a 9-year longitudinal study to examine the
relationship between changing social roles in retirement and drinking patterns in a
group of Dutch retirees. Here, the authors were specifically interested in exploring
alcohol use in relation to age-related transitions in social roles. These authors found
that when social roles were reduced in retirement, both alcohol consumption and
alcohol-related problems decreased. In this case, the loss of social roles is not cor-
related with increases in either the use of alcohol or drinking problems, as some
have suggested [10].
Bacharach et al. [26] examined whether or not changes in the quality or size and
composition of social support in retirement affected drinking. When social networks
were consolidated, drinking problems dropped in severity. When social networks
expanded, drinking problems increased. A decrease in the quality of social support
was also associated with increased drinking problems although retirement was not
a significant mediator of this relationship.
In conclusion, distinct aspects of retirement pose both risk and protective factors
for increased alcohol use and alcohol-related problems among retirees. Involuntary
retirement, high preretirement job satisfaction and preretirement workplace stress
are all risk factors for later increases in alcohol use and alcohol-related problems.
Protective factors include fewer social roles, a smaller social network, and more
social support. The impact of retirement on individual drinking behavior seems to
be highly context specific. Retirement can have a variety of effects on an individual
depending on the extent to which they are ready for this transition and whether they
view their new life stage in a positive or negative light.
10.3 Residential Context
Older adults live in a variety of living environments due to a broad range of abili-
ties, supports, and needs. The 2010 Census documented 40.3 million adults aged
65 and older in the United States. Among this group, 96 % were community dwell-
ers, older adults living in distinct housing units. Elders living in private homes,
retirement communities, public housing, and assisted living settings are all included
in the community dwellers group. The remaining 4 % of older adults were living in
a group quarters setting, e.g., nursing homes, psychiatric hospitals, prisons, or
homeless shelters [27]. Alcohol use in five particular residential contexts will be
considered here: (1) community-at-large, (2) public housing/low-income senior
housing, (3) continuing care retirement communities, (4) assisted living, and (5)
long-term care.
10.3.1 Community-at-Large
The vast majority of older Americans continue to live in the community-at-large well
into their older years [27]. Here, community-at-large refers to late-life adults living
independently in private, mixed-age, or noninstitutional residential settings. In an
AARP study conducted in 2010, three-quarters of respondents ages 45 and older
expressed the desire to “age in place” for as long as possible [28]. Perhaps the most
comprehensive investigation to date of community-dwelling older adults and drinking
patterns was conducted by Brennan, Moos, and Schutte of Stanford University [15,
29–31]. This project is unique in that it follows the same group of participants over a
20-year period. Unlike other research on alcoholism and older adults based on cross-
sectional data or longitudinal data from shorter time periods, this study allows for an
examination of changes in alcohol use over an extended period of time in relation to
other life history factors. Areas of inquiry include stressors, social resources, coping
responses, drinking patterns, and psychological well-being.
The initial sample, 1884 individuals, was recruited between 1986 and 1988.
Participants had all sought health services at one of two large medical centers in
the Western part of the United States. These adults were between the ages of 55 and
65 at that time (61 on average). The authors focused on older adults who reported
drinking at least once a week or more; those who abstained or drank very lightly
were excluded from the study. Participants were largely White (90 %), married
(75 %), and high school educated (81 %). Average annual family income was
$44,000.
The first study based on this long-term project was a cross-sectional analysis and
compared a group of 501 problem drinkers with 609 drinkers who did not have
alcohol-related problems [29]. Problem drinkers responded positively to two or
more items on the Drinking Problems Index (DPI) [32]. This 17-item measure was
specifically designed to study problem drinking among older adults. Problem drink-
ing items in the DPI focus on areas where difficulties are more likely to manifest in
an older population such as “had falls/accidents,” “confused,” “neglected appear-
ance,” and “felt isolated.” Investigators explored the relationship between life
stressors and late-life problem drinking [29]. Both acute stressors and chronic
stressors were examined. Acute stressors included events such as death of a spouse,
being demoted or laid off from work or having a home or car burglarized. Chronic
stressors included physical health stressors such as having a cancer diagnosis or
high blood pressure, home and neighborhood stressors such as feeling uncomfort-
able or unsafe in the living environment, or financial stressors such as an inability
to pay bills or afford necessities. Results showed that problem drinkers experienced
more life stressors than nonproblem drinkers. These stressors included both ongo-
ing adverse life events and short-term acute life events.
The same study also measured the relationship between life stressors and social
resources, such as total family income, support at work, and the degree of emo-
tional support from a spouse, a child, or extended family and friends. Problem
drinkers had fewer social resources than the nonproblem drinking group. Problem
drinkers with more stress and fewer resources drank more alcohol, had more
drinking-related problems, were more depressed, and had less self-confidence.
The authors suggest that negative life events, chronic stressors, and fewer social
supports all contributed to the maintenance of drinking problems in later life.
Conversely, drinking problems may contribute to stressful circumstances and
diminished social support [29].
In more recent reports based on this longitudinal study, Moos et al. analyzed
baseline, 10-year and 20-year data to determine relationships between social and
financial resources and high-risk alcohol use [33]. Participants, who were more
financially comfortable at baseline and 10 years, were more likely to report
heavy drinking at 10 and 20 years. These findings support other studies that have
found correlations with excessive alcohol consumption among this population
[34, 35]. Older adults with fewer financial resources might limit alcohol pur-
chases in order to economize funds whereas those with more financial resources
have greater opportunities to buy alcohol and engage in social activities that
involve its use.
In another study with community-dwelling older adults, Resnick and colleagues
examined alcohol use and associated factors in a population where the average age
was 82 [36]. In this study, a total of 3305 community dwellers were interviewed.
Roughly one in five participants reported drinking one to three drinks weekly. Only
1 % acknowledged four to seven drinks weekly, and none reported more than that
amount, although 4 % did not answer the question. It is important to note, however,
that participants were being interviewed as part of the admissions process to a con-
tinuing care retirement community. It is possible that some withheld information
out of concern for being penalized and not being granted admission [36]. In addi-
tion, researchers asked direct questions about the quantity of alcohol used, as
opposed to using a screening tool such as the DPI. Such screening tools can help to
identify drinking among those reluctant to answer a direct question about amount of
alcohol consumed [36]. The Resident Profile measure, a combined objective and
subjective evaluation, was used to evaluate physical parameters, functional perfor-
mance, mental health status, cognitive status, and the extent and quality of social
support [36].
Interestingly, in this study, individuals who reported no alcohol use also scored
worse on the mental and physical health measures. In contrast, individuals who used
alcohol in moderation demonstrated better functioning, cognition, and social supports
[6, 37, 38]. Again, however, it is important to note that this is a cross-sectional study
design. It is impossible to know whether moderate alcohol use actually led to
improved health outcomes, or if the reverse is true—those that were healthier drank
more because of fewer health concerns [36].
Another interesting component of the discussion of older adults residing in the
community-at-large involves neighborhood composition. Research generally shows
that socioeconomically disadvantaged neighborhoods tend to have poorer health
outcomes, including increased alcohol consumption [39]. Some have suggested,
however, that neighborhood ecological characteristics, and in particular, the density
of ethnic enclaves, can serve as a protective factors for older adults in these com-
munities [40]. Some ethnic communities may possess advantages related to social
cohesion and social support mechanisms that offset disadvantages related to eco-
nomic hardship [40].
Problem drinking among older adult men (75+) was investigated in a large
population-based cohort of Mexican-Americans [41]. In a sample of 2069 individu-
als residing in five Southwestern states (Arizona, California, Colorado, New
Mexico, and Texas), problem drinking was measured with the CAGE instrument.
The CAGE consists of four brief questions used to assess problematic drinking.
Questions involve querying the participant on (1) efforts to cut down on drinking,
(2) feeling annoyed by criticism of drinking by others, (3) feeling bad or guilty
about drinking, and (4) requiring an eye-opener first thing in the morning [42].
In this study, two or more affirmative responses were identified as problem drink-
ing and one or zero affirmative answers were identified as nonproblem drinking.
Participants who lived in neighborhoods with a smaller proportion of Mexican-
Americans were nearly twice as likely to drink problematically as those who lived
in neighborhoods with a larger proportion of Mexican-Americans [41]. In this case,
it is possible that communities with higher proportions of Mexican-Americans are
protective against the influence of socioeconomic disadvantage that can lead to poor
health outcomes. Elements of Mexican-American communities that might be pro-
tective are interhousehold family and social networks, strong community institu-
tions, intact families, low residential turnover, and home ownership [43]. Stroope
and colleagues suggest that certain community characteristics offer stability and
structure, possibly alleviating alcohol use related to stress and providing social reg-
ulation of overuse of alcohol [41].
Social control theory posits that strong social bonds, particularly bonds associ-
ated with family, friends, or spiritual communities can serve as a regulatory function
that encourages “socially appropriate” behavior. If these bonds are weakened, indi-
viduals will be less likely to adhere to accepted norms and more likely to engage in
nonnormative behavior such as excessive use of alcohol. Religious ties in particular
are correlated with less alcohol use in older adults [44, 45]. Social control theory is
certainly a valid explanation for the protective factors of high-density Mexican-
American neighborhoods in the Stroope study [41].
10.3.2 Public Housing/Low Income Senior Housing
Nearly two million older adults live in public housing in the United States [46].
Cummings et al. [47] examined alcohol misuse among 187 older adults living in
public housing in a southern city. Seventy-four percent of the sample was African-
American. Participants were generally of lower socioeconomic status with about
50 % not graduating from high school. Income levels for the groups were generally
low—85 % reported monthly incomes of $900 or below. In this sample, unemployed
residents and residents with shorter tenure at their current residence had the highest
drinking levels, as did younger, male, African-Americans. Additionally, 47 % of
drinkers and 21 % of all residents acknowledged binge drinking.
In other research on low-income older adults, Clapp and colleagues studied 174
residents (60 and older) of a low-income residential senior center in a large city in
the southwestern United States [48]. Similar to other epidemiological studies of this
population, 10 % of the residents fell into the at-risk drinking category, about 25 %
of the total number of residents who acknowledged drinking. In this study, higher
levels of education were associated with low-risk drinking, as compared with
abstainers. “Younger” older adult men were more likely to drink. By looking at
empty recycled drinking containers in the facility, the researchers were able to
determine variations in drinking throughout the course of the month. There was a
consistent increase in recycled alcohol containers during the times each month
when residents received social security checks [48].
10.3.3 Retirement Communities
Continuing care retirement communities (CCRCs) are facilities that provide a con-
tinuum of living and care services for older adults that correspond to the changing
needs of this population. The goal of CCRCs is to help older adults age in place and
minimize stressful relocation if need for support increases. Typically, CCRCs offer
apartment or small house independent living, assisted living, and nursing care living
[49]. CCRCs also provide opportunities for social engagement and community
involvement. Increasing numbers of individuals are choosing to live in CCRCs in
their older adult years. In 2010, there were 2000 CRCs in the United States with a total
of 640,000 residents, a number that doubled in the preceding decade [49]. CCRCs are
the most expensive of all long-term care options. As a result, most CCRC residents are
from middle or upper-middle income brackets [50]. In addition, 45 % of new residents
of CCRCs have a college education compared with 20 % of the same age cohort in the
general population [50]. The demographic make-up of CCRCs is largely White,
female, middle to upper-middle class and in their late 70s [49].
Alexander and Duff [51] studied drinking behavior among 260 residents of three
suburban CCRCs in California and Oregon. Residents lived in small houses, condo-
miniums or apartments in gated communities. Clubhouses, golf courses, tennis
courts, and swimming pools were all available on the CCRC grounds. Leisure activ-
ities were plentiful and included bridge clubs, crafting groups, and sports programs.
Residents of these communities were largely middle-class, well-educated, and

Caucasian men and women; the average age was 76. The authors here were interested
not only in the general prevalence of drinking in these communities, but were curious
about the particular relationship between social interaction and alcohol. Were older
adults drinking in response to social isolation and personal loss as some have suggested
[52]? Or was drinking a facilitator and a result of an active social life?
Results of the study found that drinking in these communities was widespread.
Light and moderate drinkers (drinking only on special occasions or limiting use to
one drink per day) comprised 59 % of the sample. Heavy drinkers (daily drinking
with at least two or more drinks on each occasion) represented 20 % of the sample.
Authors also measured degree of social interaction for each participant. Questions
on social interaction included items about marital status, close friendships, and par-
ticipation in community activities. Only 2 % of residents who used alcohol heavily
were socially isolated and drank alone. The vast majority of heavy drinkers had high
levels of social interaction and consumed alcohol in the context of social events. A
strong relationship was found between higher levels of social interaction and alco-
hol use in these communities. The authors conclude that social drinking is wide-
spread in CCRCs and that alcohol use is a significant part of the social norms in
these retirement communities [51].
The authors speculate that perhaps the high prevalence of social drinking is a
reflection of the demographic in CCRCs—generally more educated individuals
with higher incomes [53]. However, an alternate explanation is that the social life of
these communities facilitates alcohol use, and that residents drink as a process of
integrating into the community. Interestingly, almost 10 % of the sample increased
their drinking after moving into the CCRC and 29 % of participants felt that they
had to use alcohol in order to be accepted in some social contexts.
In a study conducted in Australia, Dare and colleagues [54] corroborated these
findings. The study consisted of in-depth interviews with 42 men and women living
in both private residences and retirement communities. Participants were between
65 and 74 years, were of higher socioeconomic status, and lived in Perth, Western
Australia. Most participants were very socially engaged and participated in a variety
of social activities, many of which involved drinking. Alcohol was often served as a
social lubricant and hence a facilitator of social engagement. Conversely, social
engagement also facilitated alcohol use. In retirement communities in particular,
regular opportunities for socializing and a built-in social network enhanced resi-
dents’ opportunities for alcohol use. For participants who did not live in CCRCs,
driving was a major constraining factor for drinking. Those who lived in private
homes and drove home after social events curtailed their drinking in anticipation of
driving. For residents of retirement communities, having access to social events
within walking distance increased their likelihood of drinking at these events.
A study conducted by Sacco et al. [55] focused on patterns of alcohol consump-
tion in CCRCs and how drinking motives and affective states influence alcohol use
behavior. The study was conducted at a CCRC in the Washington, D.C. metropoli-
tan area with 71 participants, all of whom resided in independent living. Data on
drinking behavior was collected via telephone calls for eight consecutive days after
an initial face-to-face interview. During these calls, participants were asked to

report on activities, emotions, and alcohol use behaviors for the previous day.
The study [55] found hazardous alcohol use to be rare among the sample although
drinking associated with contraindicated medications or disease comorbidities was
more common. Almost half of the respondents drank over the recommended NIAAA
guidelines [7]—the average percentage of drinking days was about four days per
week while the average number of drinks per drinking day was 1.28. In terms of
motivation, participants drank for social reasons at much higher levels than for
coping reasons, i.e., to manage negative emotional states. This research challenges
the notion that older adults use substances primarily as a coping mechanism related
to late-life stressors such as loss or loneliness [56].
Burruss et al. [57] explored beliefs and attitudes about drinking among a sub-
sample (n = 11) of the older adults from the study described above. These partici-
pants all self-identified as regular drinkers, that is, they drank on at least 6 out of the
8 days prior to the screening. Many reported that drinking was a long-term habit or
routine carried over from earlier life stages. Drinking for these individuals was not
a response to a specific event, but was a routine related to socialization or relaxation.
Participants acknowledged that when drinking took place outside of these routines,
peer norms and the availability of alcohol in the CCRC did influence use. The
authors conclude that drinking behavior for these older adults provides a sense of
continuity from earlier life stages and is a normative part of socialization in these
continuing care communities.
Social learning theory suggests that alcohol use trajectories are strongly influ-
enced by attitudes and behaviors of an individual’s social networks, particularly
family and friends. When individuals engage in social activities with family and
friends who approve of and engage in drinking, alcohol use, and misuse are rein-
forced [58, 59]. Evidence shows that among older adults, participation in social
activities is correlated with higher levels of alcohol consumption [34, 60]. It is clear
from this research that social networks and the desire for socialization have a sig-
nificant impact on alcohol use in older adults [54] and that retirement communities
enhance drinking opportunities and reduce constraints for residents.
10.3.4 Assisted Living
Assisted living (AL) refers to a long-term care setting for older adults who require
assistance with a range of activities, including instrumental activities of daily living
(e.g., shopping, cleaning one’s home, taking medication). Assisted living facilities
can range in intensity of services, and some provide support that is almost equiva-
lent to the services provided by nursing homes. Assisted living facilities charge
patients directly, whereas nursing homes are generally reimbursed through Medicare
or Medicaid. Residents of these facilities are generally from higher income
brackets. Because income and alcohol use are correlated [11], it is a risk factor for
drinking behavior in AL settings.
Very little research has been conducted with older adults in assisted living. One of
the only studies available surveyed 832 nursing aides in Pennsylvania who had
recently worked in assisted living facilities [61]. According to these aides, 69 % of AL
residents drank alcohol and 34 % residents drank alcohol daily. Close to one-third of
aides (28 %) had observed or had evidence of residents making “poor choices for
alcohol consumption” and one-fifth (19 %) had observed or had evidence of alcohol
use influencing residents’ health [61]. These numbers seem high relative to alcohol
use in the general population; however, it is important to note that respondents are
nursing aides, not older adults themselves. These aides are providing secondhand
information about the individuals in their care. In addition, they are not clinicians
trained to provide clinical diagnoses. Despite these limitations, the results do indi-
cate that AL staff regularly observe what they label as problematic alcohol use in
these facilities. The authors suggest that higher estimates of alcohol use in this study
reflect the particular demographics and characteristics of AL environments that are
risk factors for problematic use. These include the fact that AL residents comprise
a higher proportion of men from upper income brackets and that AL settings fre-
quently offer easy access to alcohol.
10.3.5 Long-Term Care
In the United States, about 3 % of older adults live in nursing homes [27]. Despite the
fact that this consists of 1.3 million people, few recent studies have examined alcohol
use in these settings. Data from the 2004 National Nursing Home Survey (NNHS)
showed the prevalence of current DSM alcohol dependence and abuse among older
adults in nursing homes to be only 1 % [62]. Weyerer et al. [63] reported higher rates
in a study of nursing home residents in Manheim, Germany. These researchers found
that 7.4 % of nursing home residents had alcohol use diagnoses. In a 1997 Veterans
Administration study, the prevalence of a lifetime history of alcohol problems was
29 % with 9 % drinking within 1 year of admission [64]. In an older study of VA nurs-
ing homes, Joseph et al. found 29 % of residents reported active symptoms of alcohol-
related problems at admission [65].
Klein and Jess [66] explored the range of institutional policies related to alcohol
use in 111 intermediate care and homes for the elderly in a northeastern state. Here,
the authors were interested in policies, treatment, training, and staff attitudes related
to alcohol use in nursing homes. The authors interviewed facility administrators
about alcohol-related policies in their institutions and their own attitudes towards
residents’ use of alcohol. Most administrators estimated the proportion of residents
in their facilities that had alcohol-related health conditions to be about 10 %. These
results, however, are somewhat subjective, as only 57 % of the institutions had a
formal alcohol screening process upon admission. Given the generally high rates of
alcohol-related problems in other older adult residential facilities, this estimate
reflects a tendency for these problems to go unrecognized by staff at these facilities
[66]. The authors reported that the screening of residents for alcohol use problems,
treatment of problems, and training of staff were all limited. Furthermore, institutions
varied greatly in terms of alcohol-use policies. Almost half of respondents felt it

was inappropriate for residents to consume alcohol, yet three-quarters allowed
alcohol consumption in certain circumstances. The authors identified a generally
conflicted view on the part of these administrators as to whether or not alcohol was
a drug to be controlled or a social beverage to be enjoyed—a conflict shared by the
larger society.
In conclusion, these studies demonstrate how environmental factors can have
both risk and protective influences on older adult alcohol use in the settings described
above. In the community, the empirical evidence shows that chronic stressors and
reduced social supports are all associated with drinking problems in later life.
Conversely, drinking problems can also contribute to stressful circumstances and
diminished social support. Studies on older adults in specific communities or in
higher levels of care demonstrate that being in a higher income bracket is associated
with increased rates of drinking, as is having access to income during certain times
of the month for those in lower income brackets. A significant protective factor for
older adults includes living in high-density ethnic neighborhoods despite the poten-
tial risk factors of socioeconomic disadvantage.
Regardless of setting, social networks were found to facilitate opportunities for
drinking, as did geographic proximity to social activities that involved alcohol. The
relationship between social interactions and alcohol use is a complex one, however.
Increased social interaction is associated with improved health outcomes in older
adults, therefore to the extent that social interaction does not involve at risk drink-
ing, it is likely to be protective. Risk in this case might be related to the degree to
which social interactions facilitate high-risk or problematic levels of drinking.
10.4 Familial and Social Networks
10.4.1 Spousal Factors
In general, alcohol use in younger couples has been found to be highly concordant,
that is, individuals in a relationship tend to engage in similar drinking behaviors [67,
68]. Less is known, however, about alcohol use concordance between older couples.
Graham and Braun [69] examined similarities in drinking behavior between spouses
in a study of 826 community-dwelling older adults in Ontario, Canada. Results
showed high concordance of drinking between spouses—whether they drank at all,
how much they drank, and how frequently. One factor that was associated with
heavier drinking in spouses was higher education, which the authors speculate
might be due to an association between education levels and more liberal attitudes
towards drinking. In addition, higher education is also correlated with higher
income, which in turn is associated with increased alcohol use. Results here clearly
indicate that drinking behavior between older spouses is strongly associated.
Graham and Braun [69] also explored how the loss of a spouse impacts drinking
for the surviving spouse. The authors hypothesized that men increase their drinking
after their wives die due to the loss of the moderating effect on their drinking behavior.
This hypothesis was born out by study results as indicated by higher drinking rates for
groups of divorced/separated men and widowed men than married men. Results for
women participants did not support this hypothesis, indicating that women and men
might respond differently to the loss of a spouse vis-à-vis drinking behavior.
In addition to the concordance of drinking behavior, researchers have also stud-
ied the impact of the quality of the marital relationship on drinking. In the Brennan
and Moos study that compared problem and nonproblem drinking behavior [29], the
authors found that problem drinkers who reported less empathy and support from
their spouses consumed larger amounts of alcohol and reported more drinking-
related problems. Marital stressors were correlated with higher levels of alcohol use
and drinking-related problems. The authors suggest that for problem drinkers, con-
flicts within the marital relationship and less support from a spouse may be particu-
larly likely to result in problematic drinking. At the same time, these close
relationships can be negatively impacted by these alcohol-related problems.
In contrast, when looking at nonproblem drinkers, Brennan and Moos [29] found
that married people consumed more alcohol than unmarried people. The authors
propose that this might be a result of married people using alcohol in social con-
texts, perhaps during a meal or at a social occasion when alcohol is served. Among
nonproblem drinkers, marital stress was not associated with level of alcohol
consumed.
10.4.2 Children
The literature on the relationship between adult children and their older adult parents
who might have problematic alcohol use is minimal. Some suggest that adult children
might be ashamed of the problem and chose to ignore it [8]. While not referring to
children specifically, Moos et al. [33] did find that heavy drinking impacted relation-
ships with extended family members. When older adults in their study reported
high-risk alcohol use at 10 years, the 20-year data showed a decline in the quality
of extended family relationships. The implication here is that excessive alcohol
consumption among older adults can negatively impact family relationships.
10.4.3 Friendships
Brennan and Moos [29] also found that older adults who reported less empathy and
support from friends drank more alcohol, were more depressed, and were less self-
confident. More stressors involving friends were associated with more drinking
problems. Similar to the findings on marital conflict above, conflict in close friend-
ships can prompt alcohol-use problems; conversely, these relationships can suffer as
a result of alcohol-related problems. More support from friends was correlated
with fewer drinking-related problems, reduced rates of depression, and increased
self-confidence. These findings underscore the significance of social support from
friendships in late adulthood.
Moos et al. [31] also found a strong element of social selection among participants’
drinking. More participation in social activities and friends’ with greater approval of
drinking predicted increased probability of high-risk alcohol consumption.
Individuals who engaged in heavier drinking chose both friends and partners who
approved of this type of drinking. As opposed to social network theory discussed
earlier where social networks influence behavior, social selection theory proposes
that alcohol consumption changes an individual’s social context [33]. Studies
among younger adults have shown that heavier drinkers chose partners and friends
who approve of heavier drinking [70] and that excessive drinking can alienate social
networks. The Moos study supports the idea that social selection also has a strong
influence on drinking behavior among older adults.
In conclusion, relationships with spouses, children, and friends all impact alco-
hol use behavior in older adults. In general, there is high concordance of drinking
behavior between elderly couples. Separation, divorce, or death are all risk factors
for increased levels of alcohol use among men, but not necessarily among women.
Less social support from both spouses and friends are also risk factors for increased
alcohol use. On the other hand, heavier drinking can negatively impact these mar-
riages and friendships.
10.5 Conclusion
In sum, as the population ages it is becoming increasingly important to understand

how older adults are impacted by alcohol use. This chapter reviewed how various
social and familial influences serve as either risk or protective factors at all levels of
alcohol use—risk, high-risk, and problematic. Overall, it would appear that like
their younger counterparts, environmental stress (involuntary retirement) and social
factors (marital discord or strong social networks that drink) are highly influential
in the older adult’s drinking patterns. How those factors come about to influence an
older adult’s drinking may be unique, given the life stage. Greater understanding of
these social and familial factors will allow clinicians, policymakers, and researchers
to better serve this group of vulnerable individuals.
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Part IV
Clinical Issues of Alcohol and Aging
Screening and Assessment of Unhealthy
Alcohol Use in Older Adults 11
Alison A. Moore, Alexis Kuerbis, Paul Sacco, Grace I. Chen,
and Maristela B. Garcia
11.1 Introduction
The older adult population is rapidly growing, in large part due to the aging of the
baby boom generation who comprise 30 % of the US population and the first of
whom turned 65 years old in 2011 [1]. Baby boomers engage in higher rates of
alcohol use compared to previous cohorts [2] and also have a higher prevalence of
alcohol and other substance use disorders [3] and treatment admissions for sub-
stance use disorders [4]. Though older adults use alcohol at lower rates than younger
adults [5], the sheer size of the older adult population and the aging of the baby
boom generation are expected to drive up prevalence rates of unhealthy alcohol use
including alcohol use disorders (AUDs) among older adults.
11.2 Older Adults’ Risks Associated with Alcohol Use
Alcohol use has different risks in older adults than in younger adults. For example,
as one ages, the percentage of lean body mass and total body water decrease which
results in a higher blood alcohol concentration per amount of alcohol consumed
A.A. Moore, M.D., M.P.H. (*)

Division of Geriatrics, University of California, San Diego, San Diego, CA, USA
A. Kuerbis, L.C.S.W., Ph.D.
Silberman School of Social Work, Hunter College at the City
University of New York, New York, NY, USA
P. Sacco, Ph.D., M.S.W.
School of Social Work, University of Maryland, Baltimore, MD, USA
G.I. Chen, M.D. • M.B. Garcia, M.D.
Division of Geriatrics, University of California, Los Angeles, Los Angeles, CA, USA

170 A.A. Moore et al.
compared to younger adults [6]. Also, older adults experience increased brain
sensitivity to the effects of alcohol compared to younger adults [7–9] which results
in impaired psychomotor performance [10]. Because older adults may have multi-
ple comorbidities and take multiple medications they are also at risk for negative
consequences from concurrent alcohol use [7, 11, 12]. Alcohol may worsen com-
mon comorbidities like hypertension, depression, insomnia, and gastroesophageal
reflux disease (GERD) and interact with medicines like antihypertensives, pain
medications, and medicines used for GERD. [13, 14] Because of these facts, it is
increasingly understood that health care professionals need to screen and assess for
unhealthy alcohol use among aging adults.
11.3 Definitions
Because of the increased risk of health consequences of drinking in older adults,

low risk drinking limits for adults age 65 years and older have been defined by the
National Institute on Alcohol Abuse and Alcoholism (NIAAA) as drinking no more
than three drinks on any day and no more than seven drinks per week [15]. A stan-
dard drink in the United States is defined as 14 g of absolute ethanol. Drink equiva-
lents are: 12 oz of regular beer, 8–9 oz of malt liquor, 4–5 oz. of table wine, and
1.5 oz of 80-proof spirits (e.g., whiskey, gin, vodka, tequila).
One challenge to alcohol screening and assessment is the variety of terminology
used in the literature on alcohol to refer to various types of alcohol use. Here, we
will define current use as the use of alcohol within the past 12 months. Unhealthy
use has been defined as the use of alcohol that exceeds recommended drinking lim-
its and includes a spectrum of risk [16]. At-risk or heavy use includes use that car-
ries risk but has not resulted in harm. Problem drinking is the use of alcohol that has
resulted in harm but does not meet Diagnostic and Statistical Manual of Mental
Disorders (DSM) criteria for an AUD.
The formal diagnosis of an AUD relies on the criteria outlined by the Diagnostic
and Statistical Manual of Mental Disorders (DSM). The DSM-Fifth Edition (DSM-
5) now merges alcohol abuse and alcohol dependence into AUD [17]. To meet cri-
teria for an AUD, one must have at least 2 of 11 symptoms noted in Table 11.1. The
severity of an AUD is defined as mild (the presence of 2–3 symptoms), moderate
(the presence of 4–5 symptoms, or severe (the presence of six or more symptoms).
Because of the biologic and social factors unique to older adults, some of these
symptoms may be less relevant to them and so presents challenges for an accurate
diagnosis [18]. For example, because of age-associated physiologic changes that
increase the effects of alcohol and other substances, older adults generally experi-
ence a reduction in tolerance to substances. Also, interruption in social and occupa-
tional roles or other consequences of unhealthy alcohol use may be less likely to
occur or less noticeable in older adults [19, 20]. Additionally, clinical symptoms of
AUDs may mimic, overlap, and exacerbate common medical and psychiatric symp-
toms. For example, older adults and their health care providers may not recognize
that problems such as depression or falls are related to drinking [18]. Because of
11 Screening and Assessment of Unhealthy Alcohol Use in Older Adults 171
Table 11.1 Alcohol use disorder criteria: considerations for older adults
DSM-5 criterion for AUD [17] Consideration for older adult
Alcohol is often taken in larger amounts or Cognitive impairment can prevent adequate
over a longer period than was intended self-monitoring. Alcohol may impair cognition
among older adults to a greater extent than
younger adults
There is a persistent desire or unsuccessful Same as a general adult population
efforts to cut down or control alcohol use
A great deal of time is spent in activities Consequences from alcohol use can occur from
necessary to obtain alcohol, use alcohol, or using even small amounts
recover from its effects
Craving or a strong desire or urge to use Same as a general adult population
alcohol
Recurrent alcohol use resulting in a failure Role obligations may be different for older
to fulfill major role obligations at work, adults due to life stage transitions such as
school, or at home retirement. Role obligations more common in
late life are caregiving for a spouse or family
member, such as a grandchild
Continued alcohol use despite having Older adults may not realize the problems they
persistent or recurrent social or interpersonal experience are from alcohol use
problems caused or exacerbated by the
effects of alcohol
Important social, occupational, or Older adults may engage in fewer activities
recreational activities are given up or regardless of their use of alcohol
reduced because of alcohol use
Recurrent alcohol use in situations in which Older adults may not identify or understand that
it is physically hazardous their use is hazardous, especially when using
alcohol in smaller amounts
Alcohol use is continued despite knowledge Older adults may not realize the problems they
of having a persistent or recurrent physical experience are from alcohol use
or psychological problem that is likely to
have been caused or exacerbated by alcohol
Tolerance, as defined by either of the Due to increased sensitivity to alcohol with age,
following: older adults may have lowered tolerance
1. A need for markedly increased amounts
of alcohol to achieve intoxication or the
desired effect.
2. A markedly diminished effect with
continued use of the same amount of
alcohol.
Withdrawal, as manifested by either of the Withdrawal symptoms can manifest in ways
following: that are more subtle and protracted
1. The characteristic withdrawal syndrome
for alcohol
2. Alcohol (or a closely related substance
such as a benzodiazepine) is taken to
relieve or avoid withdrawal symptoms
Source: Data from Barry et al [52] and Kuerbis et al. [53]
these challenges, it is likely that AUDs are under-recognized in older adults. One
study explored whether there were differences in responses to diagnostic criteria for
AUDs using DSM-IV, between middle-aged and older adults [20]. This study found
that older adults were half as likely as middle-aged adults to endorse criteria related
to tolerance, activities to obtain alcohol, social and interpersonal problems, and
physically hazardous situations.
11.4 C
hallenges in Screening for Unhealthy Alcohol Use
in Older Adults
The United States Preventive Services Task Force has recommended that all
adults be screened to identify unhealthy alcohol use [21], but older adults, in
particular, are rarely asked about alcohol use habits or screened for unhealthy
drinking [22, 23]. There are multiple reasons for limited screening in older
adults. These include possible stigma associated with disclosure of unhealthy
drinking, not being aware that an older adult’s drinking habits may be unhealthy,
limited time during clinical encounters especially if there are other conditions to
address, and similarities of symptoms of unhealthy alcohol use with other condi-
tions in older adults [24].
11.5 Screening and Assessment Methods
Screening should start with questions about alcohol consumption. If warranted, then
further assessment should be made. One approach to screening and assessment
advocated by the National Institute on Alcohol Abuse and Alcoholism in the publi-
cation “Helping Patients Who Drink Too Much” [25] includes four steps: Step 1:
Ask about Alcohol Use; Step 2: Assess for Alcohol Use Disorders; Step 3: Advise
and Assist; and Step 4: At Follow-up: Continue Support.
11.5.1 Step 1: Ask About Alcohol Use
In the interest of valid responses from patients, clinicians should ask permission
first before conducting a screening [26]. This approach may help to put the patient
at ease and helps to create a tone of respect for the individual. Among older adults
in particular, respectful interaction may decrease stigma about reporting drinking
behaviors. Second, we recommend that clinicians avoid any term that could be con-
strued by the patient as stigmatizing, such as “alcoholic” or “problem drinker.”
Rather, current practice supports the use of objective quantity and frequency of
alcohol use.
Two recommended screening questions for unhealthy alcohol use are the
following: “Do you sometimes drink beer, wine, or other alcoholic beverages?” If
the response is no, stop. If the response is yes, ask: “How many times in the past
year have you had four or more drinks in a day?” If the response is none, it is
recommended to give advice to stay within recommended drinking limits and/or
to recommend lower limits if the person takes medications that may interact with
alcohol and/or have a health condition that alcohol may worsen. If the response is
one or more times, the person is considered an at-risk drinker and the person’s
weekly average of drinking should be assessed by asking “On average, how many
days a week do you have an alcoholic drink” and “On a typical day, how many
drinks do you have?” To calculate the weekly average, one multiplies these two
numbers. This information on heavy drinking days and weekly average should be
recorded in the person’s record. Next, further assessment for an AUD should
occur (see Step 2).
11.5.2 Step 2: Assess for Alcohol Use Disorders (AUDs)
If an older adult endorses the initial screening questions, a full screening can be
used as a means of gathering more information about risk. If warranted, a complete
assessment of alcohol use in the context of the person’s functional status, comorbid
conditions, medication used, and symptoms should be performed [7].
11.5.3 Screening Instruments Validated in Older Adults
Screening tools can assess the level of risk associated with alcohol use and sev-
eral have been validated in older adults including the CAGE [27], the Michigan
Alcohol Screening Test-Geriatric Version (MAST-G) [28], the Short MAST-G
[29], the Alcohol Use Disorders Identification Test (AUDIT) [30], the AUDIT-C
[31], and the Comorbidity-Alcohol Risk Evaluation Tool (CARET) [13] (see
Table 11.2). Screening instruments for alcohol provide more information about
the level of risk of a specific older adult, but they are not a replacement for a
complete substance use assessment. Because these screening measures are brief
and in many cases can be self-administered, they offer decision support for health
care providers who have to assess older adults and treat medical conditions
efficiently.
Table 11.2 Screening tools for unhealthy alcohol use validated in older adults
Assesses amount Assesses Number of
of alcohol use symptoms of AUD items Sensitivity/specificity
CAGE + 4 86 %/78 %
AUDIT + + 10 86 %/87 %
AUDIT-C + 3 94 %/80 %
MAST-G + 24 95 %/78 %
SMAST-G + 10 75 %/69 %
CARET + + 26 92 %/51 %
11.5.4 The CAGE
The CAGE questionnaire [27] is the most common screening tool for lifetime problem
alcohol use. It includes the following four questions: (1) Have you ever felt that you
should Cut down on your drinking? (2) Have people ever Annoyed you by criticizing
your drinking? (3) Have you ever felt bad or Guilty about your drinking? (4) Have you
ever had a drink first thing in the morning to steady your nerves or get rid of a hang-
over (Eye opener)? In older adults, the CAGE has a sensitivity of 86 % and specificity
of 78 % to detect a lifetime AUD at a cut point of one positive question [32]. One limi-
tation of the CAGE is the inability of the instrument to distinguish between current
and lifetime problems. It also does not take into account the unique vulnerabilities of
older adults. The CAGE questions do a poor job of identifying at-risk drinkers who
may not meet full criteria for an AUD, but are unhealthy drinkers [33].
11.5.5 The MAST-G and SMAST-G
The MAST-G [28, 34] is a modified version of the Michigan Alcohol Screening Test
[35] and was the first tool designed to identify drinking problems for the older adult.
The MAST-G includes stressors and behaviors relevant to alcohol use in older
adults. It contains 24 questions with yes/no responses and five or more “yes”
responses indicate problematic use. It has sensitivity of 95 % and a specificity of
78 % to detect an AUD [34]. The Short MAST-G [29] has ten questions with two
“yes” responses indicating a problem with alcohol. In one study, it had a sensitivity
of 75 % and specificity of 69 % [36]. It can identify lifetime problem use, but it does
not ask information about frequency and quantity of alcohol consumption and does
not distinguish among lifetime and current problems. The lack of questions specific
to quantity and frequency of drinking limits the utility of the MAST-G in that older
adults may experience consumption-related alcohol harm even though they do not
endorse problems.
11.5.6 The Alcohol Use Disorders Identification Test (AUDIT)
Developed by the World Health Organization (WHO), the AUDIT assesses for cur-
rent alcohol problems. [30] It contains ten questions about quantity and frequency
of use, alcohol dependency, and consequences of alcohol abuse. Unlike the CAGE
and the MAST-G, it was developed to better identify the spectrum of unhealthy
alcohol use. Each of the questions is scored on a 4-point continuum, with total
scores ranging from zero to 40. The cutoff threshold of 5 is used to indicate hazard-
ous drinking in older adults [37]. Compared to the Timeline Follow-Back [38] (a
method using a calendar to recall amount of drinking), the sensitivity and specificity
of the AUDIT to identify heavy drinking at this cut point exceeded 85 % in a study
of 517 adults aged 65–74 years [39]. Similarly the AUDIT-C, a three item test that
includes the first three questions of the AUDIT, had a sensitivity of 94 % and a
specificity of 80 % when using a cut point of 4 [39]. We recommend the AUDIT as
a measure for use in clinical practice. Because it was developed by the WHO [30],
it has been used in a variety of settings, such as primary care, emergency depart-
ments [40], and other aging-specific settings like senior centers [41]. Moreover, the
AUDIT has been used internationally [42, 43] and with diverse groups [44].
11.5.7 The Comorbidity Alcohol Risk Evaluation Tool (CARET)
The CARET [45, 46] is a screening instrument that identifies older adults whose use
of alcohol places them at risk for harm. It is derived from two other measures, the
Alcohol-Related Problems Survey (ARPS) and the short ARPS [47, 48]. It asks
questions using a past 12-month time frame and uses algorithms to identify at-risk
drinkers within seven domains of risk: (1) amount of drinking; (2) episodic heavy
drinking (e.g., >4 drinks on one occasion); (3) driving after drinking; (4) others
being concerned about the respondent’s drinking; (5) medical and psychiatric con-
ditions; (6) symptoms that could be caused or worsened by alcohol; and (7) medica-
tions that could interact negatively with or whose efficacy could be diminished by
alcohol. Respondents who have one positive response in any of the seven risk cate-
gories are considered at-risk drinkers. Using this threshold, it has a sensitivity of
92 % and a specificity of 51 % compared to a criterion standard. [13] Because it
includes items on medications and comorbid conditions common in older adults, it
identifies older adults who would not be identified as at-risk on other screening
measures [48]. The CARET has been used in randomized controlled trials [45, 49,
50] and identifies most older adults as unhealthy drinkers due to combination of
alcohol use with medications, symptoms, and medical and psychiatric conditions.
The CARET is distinctive in that it approaches alcohol-related risk broadly from
the perspective of medical risk and aging. The CARET is aging-focused like the
MAST-G, but includes common comorbid conditions, medications, and symptoms
in older adults. The MAST-G focuses on psychosocial aspects of aging and alcohol
use such as drinking to cope with loneliness.
11.5.8 Step 3: Advise and Assist
Following the steps in the NIAAA Guide, when the initial screening and assessment
(Step 1) and screening and assessment (Step 2) of an older individual indicate they
are unhealthy drinkers, it is recommended that clinicians share findings and make
clear recommendations (Step 3). For example, a clinician might say: “Based on
your responses to the screening questions, your current drinking is more than is
medically safe.” It is important to relate the advice about drinking to the patient’s
presenting problem and overall medical findings. This is an opportunity for the
health care provider to educate the older adult about the potential health-related
consequences of their use. When presenting this information, the clinician should
share health information on NIAAA drinking guidelines, as well as identify
possible connections between the presenting health concern of the older adult to
unhealthy drinking. For instance, if an older adult presents for the medical treatment
of high blood pressure, the clinician can discuss data that suggests higher alcohol
consumption is associated with high blood pressure. One crucial aspect of this dis-
cussion is maintaining respect for the autonomy of the older adult. Assuming the
older adult has decisional capacity, they have the choice to drink in an unhealthy
manner. Admonishing the older adult for their drinking will not necessarily change
their behavior and may simply engender resentment.
In the interest of building motivation to change at-risk alcohol use, the clinician
can have what is often termed a “brief negotiated interview” or BNI with the older
adult. Once information is shared with the individual, the provider can use open-
ended questions and reflective listening to understand the role of alcohol in the
person’s life. The discussion can begin by asking the individual about their reaction
to the medical information on alcohol use shared after the screening is completed.
Drawn from the work of Miller and Rollnick [51] in motivational interviewing, the
idea behind the BNI is to help the older adult to identify discrepancies between their
current behaviors and their goals. Two techniques from motivational interviewing
can be used to help facilitate the BNI: decisional balance and the readiness ruler.
Decisional balance involves asking the client about the “Pros and Cons” of their
use. The clinician first asks about the pros or benefits of alcohol use for the person.
The purpose of this question is to foster an understanding of how alcohol use is seen
by the individual is helping him or her in some way. Then, the clinician asks the
person about the cons or problems that they associate with their use. After talking
about what they see is positive about their drinking, the person may be more willing
to consider the problems associated with their use. The clinician then uses reflective
listening and other communication techniques to have the older adult reflect on their
use and problems associated with it.
The readiness ruler uses a scaling question to gauge the older adult’s readiness to
make a change in their alcohol use. The scaling question is simply, “On a scale from
1 to 10, how ready are you to make a change to your use of alcohol right now?” The
patient then provides the clinician with a number, such as “4”. The clinician then asks
the person why they are not a lower number on the scale (e.g., “2”). The purpose of
this approach is twofold. It allows for a measure of ambivalence by the patient, as
opposed to asking them if they are ready or not. Additionally, it fosters what Miller
and Rollnick [51] call “change talk” by the older adult. Instead of lecturing the
patient about reasons to change, the patient is reflecting on and offering the provider
a list of reasons why they are considering change even if they are ambivalent.
The BNI concludes with a discussion of what the patient would like to do in
terms of an action plan. The clinician can help the older adult to identify a goal
and make a plan. In the brief intervention model, the clinician should be flexible
and patient centered in planning. Planning should be tailored to the personal
goals, preferences, and clinical presentation of the person and should be elicited
from the older adult. Clinicians should consider approaches that reduce harm and/
or help to foster increased insight into alcohol risk. For example, a provider could
work with an older adult patient to monitor their use of alcohol to get a sense of
how much they are drinking or assist the person to set limits on their drinking in
ways that will reduce risk. For many older adults, alcohol use is a long-standing
pattern of behavior so a single office visit combined with advice may not be suf-
ficient for many at-risk or unhealthy drinkers. Instead, we would suggest that
providers see the alcohol screening and the brief negotiated interview as a
beginning.
11.5.9 Step 4: At Follow-Up: Continue Support
With that in mind, it is important to ask older adults about their alcohol use at each
visit, especially those identified as at-risk to monitor for change in alcohol con-
sumption. If they are at-risk, then reinforce and support continued adherence to
recommendations. For those who are not dependent, renegotiate alcohol use goals
if needed, encourage the patient to return and rescreen regularly. For those who are
dependent, ideally coordinate care with an addiction specialist, consider initiating
or maintaining medications for alcohol dependence for at least 3 months and address
coexisting disorders as needed.
If the patient has not been able to meet and sustain the alcohol use goal, then it is
important to acknowledge that change is difficult, support any positive change,
relate alcohol use to problems, and consider engaging significant others. For those
without dependence, it is useful to renegotiate goal and plan and reassess diagnosis
if the patient is unable to make change. For those with dependence, consider, if not
done already, referring to an addiction specialist or consulting with one, recommend
a mutual help group, and prescribe a medication used for AUDs.
11.6 Conclusions
Alcohol is the most commonly used substance in older adults and has unique risks
in this population primarily because of (a) changes in physiology with age that
increase blood alcohol levels for a given amount of alcohol and alcohol’s sedating
effects and (b) increases in comorbidity and medication use. Despite these facts,
screening for alcohol use and particularly unhealthy alcohol use is not regularly
conducted among older adults. Barriers to screening and assessment include limited
time in ambulatory settings, discomfort on the part of older adults and their provid-
ers in assessing possible unhealthy use, and similarities of symptoms of unhealthy
use and other morbidities common in later life. There are a number of tools avail-
able to screen for the spectrum of unhealthy alcohol use developed and/or validated
in older adults. One of these tools, the CARET, may also help with assessment as it
obtains information about comorbid conditions, symptoms, and medications that
may increase risk from alcohol use and may be used to provide specific feedback
about risks to the older adult. Assessment using the four step approach advocated in
the publication “Helping Patients Who Drink Too Much” [25] may be used for older
adults as well as for younger adults. Brief advice or referral to specialty care may be
warranted depending on the amount and frequency of alcohol use and the presence
or absence of other indicators unhealthy use.
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Treatment of Unhealthy Alcohol Use
in Older Adults 12
David W. Oslin and Faika Zanjani
12.1 Introduction
Alcohol use disorders are some of the leading causes of disability worldwide; how-
ever, alcohol use management is often not appreciated as relevant to the care of older
adults [1]. With respect to alcohol use disorders, epidemiological census-based work
estimates that approximately 4 % of older community dwelling adults and up to 22 %
of older adults in clinical care meet the diagnostic criteria for an alcohol use disorder
[2–5]. In addition to the growing elderly population, the prevalence of late life addic-
tion has been predicted to increase because of cohort changes. The current cohort of
60-year-old adults represents a group who were raised during the 1960s, and as such,
participated in the increased use of and addiction to heroin, cocaine, tobacco, and
alcohol [6]. Both the continued substance use and a history of substance disorders
will likely have physical and mental health consequences for this cohort as it ages.
The public health impact of alcohol use disorders, as well as other substance use
disorders, among older adults will increase over the next several decades.
Although research in late life addictions has developed too slowly, research has
demonstrated the efficacy of both psychosocial and pharmacological treatment of
alcohol use disorders for older adults. There is also emerging evidence indicating
that reduction in alcohol use among older adults can lead to improvement in health
and related quality of life. Almost as important has been the scientific identification
and better understanding of the effects “at-risk” drinking on the health of older
adults and the ability to beneficially reduce alcohol consumption in this group.
D.W. Oslin, M.D. (*)

VISN 4 MIRECC, Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
Department of Psychiatry, Perelman School of Medicine, University
of Pennsylvania, Philadelphia, PA, USA
F. Zanjani, Ph.D.
Department of Behavioral and Community Health, School of Public Health,
University of Maryland, College Park, MD, USA

182 D.W. Oslin and F. Zanjani
It is projected that by the year 2020, the number of older adults requiring sub-
stance use disorder treatment will increase to 5.7 million [7], a significant departure
from the estimated 1.7 million in need of treatment in 2000 and 2001 [6]. Hence, in
order to meet the special needs of older adults experiencing problems with alcohol,
it is imperative that social services, professionals, and providers within primary and
specialty care settings, particularly specialty mental health care, learn to recognize
signs and symptoms of alcohol misuse and gain a firm understanding of available
treatment options. Doing so will enhance efforts directed toward reducing problem-
atic alcohol use and foster improvements in overall quality of life among older
adults with substance use problems. This chapter will highlight the recent advances
in the understanding of treating late life alcohol use disorders and highlight areas of
critical need for further research.
12.2 Terms
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the
Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment
Improvement Protocol on older adults recommend that persons age 65 and older
consume no more than one standard drink/day or seven standard drinks/week [8, 9].
In addition, older adults should consume no more than three standard drinks on any
drinking day. These drinking limit recommendations are consistent with data
regarding the relationship between heavy consumption and alcohol-related prob-
lems within this age group [10]. These recommendations are also consistent with
the current evidence for a beneficial health effect of low-risk drinking [11, 12].
Drinking guidelines also highlight an important distinction between problem
drinking or at-risk drinking and alcohol use disorders. Understanding patterns of
alcohol use can help inform the treatment and counseling of older adults across set-
tings. Thus, in order to capture alcohol use variability, or “spectrum of use,” a num-
ber of categories have been created to effectively select treatment management
regimens, such as problem drinkers, at-risk drinkers, in addition to the well-
recognized alcohol use disorders. In general, any level of alcohol consumption that
produces negatives outcomes requires treatment; however, the intensity of treatment
can vary on the level of drinking and the identified negative consequences.
At-risk or excessive alcohol users among older adults are those who consume
alcohol above recommended levels yet experience minimal or no substance-related
health, social, or emotional problems. Given the guidelines outlined above, exces-
sive alcohol use can be defined as drinking more than one drink per day. Targeting
and identifying older adults in this category is important; although they currently
may not be experiencing any detectable alcohol use-related problems, these indi-
viduals may have a high risk of developing health problems should their alcohol use
remain consistent or increase over time. Preventive brief interventions for at-risk
users are valuable and effective, and abstinence or reductions in alcohol use have
been shown to improve quality of life for this group. Of particular importance to
older adults are the interactions between alcohol and both prescribed and
12 Treatment of Unhealthy Alcohol Use in Older Adults 183
over-the-counter medications, especially among psychoactive medications such as

benzodiazepines, opioids, and antidepressants. Alcohol use is one of the leading
risk factors for developing adverse drug reactions and is known to interfere with the
metabolism of many medications such as digoxin and warfarin [13–16].
Problem use or misuse describes a pattern in older adults in which alcohol con-
sumption is at a level whereby adverse medical, psychological, or social consequences
have occurred or are significantly likely to occur. Thus, this category of use is not
defined by the quantity or frequency of use but rather the extent to which alcohol use
impairs physical and/or psychosocial functioning. The risks associated with this pat-
tern of alcohol use may be underestimated. Nevertheless, because older adults in this
group are at a greater risk of negative consequences such as falls, cognitive impair-
ment, driving-related problems, cardiovascular disease, sleep problems, liver disease,
pancreatitis, and harmful alcohol–medication interactions [17], they represent a group
that would greatly benefit from screening, identification, and intervention [18–20].
Alcohol use disorder is defined, according to new DSM-5 criteria, as a problem-
atic pattern of alcohol use leading to clinically significant impairment or distress,
occurring with a 12-month period [21]. The degree of severity for the alcohol use
disorder is met with the level of presence for specified symptoms: Mild (2–3 symp-
toms), Moderate (4–5 symptoms), Severe (6+ symptoms). The new criteria replace
the previous stratified abuse and dependence categorization of the disorder. The
current criteria lists 11 specific symptoms used to evaluate the state of individual
alcohol use, pertaining to persistent (1) large amounts of alcohol consumption, (2)
desire/unsuccessful efforts to reduce alcohol consumptions, (3) large amount of
dedicate time for alcohol activities, (4) alcohol cravings, (5) failure to fulfill major
obligation due to alcohol, (6) alcohol use despite contributing social/interpersonal
problems, (7) withdrawal from activities due to alcohol, (8) alcohol use in physi-
cally hazardous situations, (9) alcohol use despite knowledgeable contribution to
physical or psychological problems, (10) tolerance, and (11) withdrawal. Alcohol
use disorders are associated with the same risks of medication interactions, falls,
and cognitive problems as at-risk drinking, but are also associated with significantly
increased morbidity and mortality from disease-specific disorders such as acute
pancreatitis, alcohol-induced cirrhosis, or alcohol-related cardiomyopathy as well
as increasing the risks for such diseases as hypertension and the risk of trauma from
falls or motor vehicle accidents [22].
DSM-5 criteria for alcohol use disorders have yet to have been sufficiently vali-
dated among older populations to ensure that the symptoms and consequences set
forth in DSM adequately capture disordered use in later life [23]. Moreover, deter-
mining whether individuals meet diagnostic criteria relies heavily on self-reported
behavioral symptoms. This is potentially problematic because self-report is suscep-
tible to bias with the presence of memory impairments, lack of insight or knowledge
regarding the adverse effects of alcohol use, or unwillingness to admit symptoms.
For example, alcohol misuse may go unnoticed or unreported because an older adult
does not link the consequences of alcohol use to their health or social problems.
Notwithstanding these limitations in diagnostic criteria, identifying older adults
with alcohol use disorders is essential because they represent a group in need of
specialized treatment and services.
One final group of older adults to consider is those with a past history of an alco-
hol use or substance use disorder. The effect of past heavy alcohol use is highlighted
in the findings from the Liverpool Longitudinal Study demonstrating a fivefold
increase in psychiatric illness among elderly men who had a lifetime history of 5 or
more years of heavy drinking [24]. The association between heavy alcohol con-
sumption in earlier years and psychiatric morbidity in later life was not explained
by current drinking habits. Therefore it is extremely important to continuously mon-
itor and evaluate, and treat if necessary, the psychiatric health of older adults with a
history of alcohol use disorders.
12.3 Diagnosis
The first step in treatment is diagnosis. The simplest and most efficient screen for
identifying the broad risk of alcohol use is the AUDIT-C which is a 3-item self-
report questionnaire [25]. There are other instruments clinicians can use as a follow-
up, such as the SMAST-G [26], AUDIT [27], and the CAGE [28] that have more
in-depth questions about consequences, health risks, and social/family issues, but
are longer and, in the case of the CAGE, has less sensitivity for detecting at-risk
alcohol use. When using a screening tool such as the AUDIT-C, clinicians need to
then assess the patient with questions about alcohol-related problems, a history of
failed attempts to stop or to cut back, or withdrawal symptoms such as tremors.
Clinicians should conduct a diagnostic evaluation and consider specialized alcohol
treatment with an emphasis on treatment targeted to older adults. The use of vali-
dated assessment instruments such as the Structured Clinical Interview for DSM-5
(SCID [29, 30]) can be of great help to clinicians and researchers by providing a
structured approach to the assessment process as well as a checklist of items that
should be administered with each older adult receiving an alcohol assessment.
For future research in aging, lifetime patterns of drinking and drinking problems
are also important to quantify although validated methods for obtaining lifetime
diagnostic information are lacking; however, there is no evidence that in the absence
of dementia, self-report of drinking is less reliable in older adults than in younger
adults [31, 32]. Self-report of alcohol use remains the principal method of ascertain-
ing history. Biomarkers, such as liver function tests and carbohydrate-deficient
transferrin, only have modest specificity and overall low diagnostic sensitivity.
There are, however, some laboratory markers of alcohol abuse (e.g., AST, GGT,
MCV, and CDT) that may be helpful to consider in special cases [33].
12.4 Treatments
Although there are numerous treatment options for alcohol use in later life, little
formal research has been conducted to compare the relative efficacy of these various
approaches among older adults. The general recommendation is to begin with the
least invasive treatment options for older adults suffering from alcohol use
disorders, and gradually increase intensity as needed, starting with brief interven-
tions, going to more formal outpatient, 12-step programs and medication therapy,
then to the most intensive inpatient withdrawal/detoxification treatment programs.
Nevertheless, results from existing studies are promising with older adults who
engage in treatment being extremely successful at obtaining alcohol goals of absti-
nence and reduction [34], and having comparable or significantly better outcomes
than their younger counterparts [35–38]. Older adults also are more likely to com-
plete treatment than are younger patients [39, 40], and experience immediate ben-
efits [41]. Evidence actually also indicates age-specific treatment can be more
beneficial for older adults [42]. Recent evidence from Moore et al. and Ettner et al.
also demonstrates the effectiveness of multilevel treatment delivery among older
adults [43, 44]. Therefore, despite ageist beliefs, older adults are quite receptive and
responsive to treatment, especially in programs that offer age-appropriate care [45,
46] and have providers who are knowledgeable about aging issues [47–49]; how-
ever, issues of adherence and engagement [50] and disease-specific appropriateness
need to be considered [51].
12.4.1 Brief Interventions/Therapies
Low-intensity brief interventions or brief therapies/advice are cost-effective and

practical techniques that can be used in the initial treatment of at-risk and problem
drinkers in a variety of clinical settings [52]. Brief interventions are time-limited
and should have a nonconfrontational approach. Such interventions are based on the
concepts and techniques from the behavioral self-control literature, with one of the
hallmarks being the need to encourage individuals to change their behavior through
motivational interviewing [53].
Randomized clinical trials of brief interventions for alcohol problems among
older populations reveal that older adults can be engaged in brief intervention pro-
tocols and find the protocols acceptable [54–56], even over the telephone [51].
Results also point to a greater reduction in alcohol consumption among at-risk
drinkers receiving brief interventions as compared with control groups [57, 58]. For
example, in one randomized clinical study, older primary care patients randomly
assigned to a brief intervention arm received two 10 to 15-min physician counseling
visits and two follow-up telephone calls from clinic staff that involved advice, edu-
cation, and the creation of contracts [54]. Results from this study demonstrated that
rates of alcohol use at 12-month follow-up were significantly lower for patients
randomized to the brief intervention arm. Likewise, older primary care patients ran-
domized to a single brief intervention session have been shown to have significantly
greater reductions in alcohol consumption compared with usual care 1 year later
[59]. Although these trials were conducted in primary care settings, brief interven-
tions for older adults are very likely to be effective in mental health care settings as
well. Thus, geriatric mental health providers are encouraged to gain familiarity with
brief intervention therapy both as a primary treatment tool and, if needed, as a way
to motivate patients for more formal addiction treatment.
Brief intervention can also just be a starting point for entry into alcohol use dis-
order treatment, as demonstrated by Schonfeld and colleagues in the Florida BRITE
project [60]. The Florida BRITE project implemented the SAMHSA SBIRT
(Screening, Brief Intervention, Referral to Treatment) treatment model to older
adults in Florida over an extensive 3-year study. The treatment model utilized brief
intervention as the first line of treatment, thereafter if needed more intensive brief
outpatient cognitive behavioral therapy was provided over 16 sessions; referrals to
other treatment could be provided at any time throughout the treatment window
when deemed necessary. Study findings indicated a successful reduction in drinking
using the tiered SBIRT treatment model for alcohol misuse.
12.4.2 Psychosocial Interventions
The literature regarding the efficacy of psychological therapies, the next tier of sub-
stance use treatment, specifically for the treatment of alcohol use disorders in older
adulthood is sparse; however, the existing effective psychosocial treatment inter-
vention programs generally cover outpatient care, with most often multiple inter-
vention aspects, including education, brief interventions, motivational interviewing
and enhancement, psychotherapy, individual and group therapy, family therapy,
self-management, life skills/problem-solving therapy, case management, medica-
tion management, and cognitive behavioral therapy. For example, in one study of
older veterans with alcohol problems, Schonfeld et al. [61] showed that individuals
who completed 16 weeks of outpatient group-based treatment intervention for
relapse prevention were more likely to abstain at 6-month follow-up than noncom-
pleters. Using cognitive behavioral and self-management approaches, the group
sessions included modules on coping with factors such as social problems, loneli-
ness, depression, anxiety, and dealing with high-risk situations for relapse. In
another treatment study, three different manual-guided, individually delivered psy-
chosocial treatments (cognitive behavioral therapy, motivational enhancement ther-
apy, and 12-Step facilitation) that spanned 12 weeks were found to be effective in
reducing alcohol consumption among adults (7 % of whom were age 60 or over)
with an alcohol use disorder one year posttreatment [62]. While multiple simultane-
ous psychosocial intervention use appears to be the norm for treating older adults
with alcohol use disorders, there has been some indication that older adults may
best perform with cognitive behavior therapies in an outpatient context [63].
Primary care can also be an effective context to deliver alcohol treatment to older
adults. Moore et al. [43] and Ettner et al. [44] showed the effectiveness of multilevel
treatment delivery within a primary care context. Specifically, during an office visit,
older adult drinkers assigned to the study intervention received education, personal-
ized report, drinking diary, advice from the primary care provider, and telephone
counseling from a health educator. The multifaceted intervention used with older
at-risk drinkers in primary care showed a reduction in the amount of drinking at 12
months.
12.4.3 Twelve-Step Programs
A large proportion of outpatient community-based and residential treatment pro-

grams incorporate the traditional 12-step peer support model of recovery and reha-
bilitation. Originally initiated with the advent of Alcoholics Anonymous (AA) and
later adapted by groups such as Narcotics Anonymous (NA), the 12-step model
involves group support and encouragement to help members achieve and maintain
sobriety. Here participants share their experiences with one another and follow the
12 steps, which include admitting to one’s addiction, recognizing the influence of a
greater power as a source of strength, and acknowledging and atoning for past mis-
takes [64].
Although self-help groups have been associated with positive outcomes for many
individuals, findings regarding rates of group engagement and outcomes among
older adults remain mixed. In their matched comparison of older versus younger
and middle-aged adults who participated in age-integrated inpatient residential
treatment, Lemke and Moos [65] found that older patients engaged in 12-step pro-
grams as frequently as their younger and middle-aged counterparts when assessed
at follow-up. Results also indicated that more involvement in self-help groups post-
treatment was associated with better outcomes across all three age groups.
Similarly, an investigation of patients who had completed an outpatient treatment
program for chemical dependency yielded no age group differences in AA affilia-
tion 5 years posttreatment [38] and found that older adults have favorable long-term
outcomes following treatment relative to younger adults. Upon examination of a
subset of participants in the sample who reported attending 12-step meetings in the
prior year, no age group differences in the actual number of meetings attended
emerged; however, despite the fact that rates of attendance appeared to be compa-
rable across age groups, the depth of involvement differed. Older adults were less
likely than middle-aged adults to self-identify as being a 12-step group member and
were less likely than younger and middle-aged adults to report calling a fellow
group member for help. Comparable results were observed in examining 1-month
postdischarge outcomes among alcohol-dependent patients admitted to a 12-step
residential rehabilitation program [66]. Although rates of postdischarge abstinence
and AA attendance did not differ across middle-aged and older adults, older adults
were significantly less likely to contact a sponsor. Furthermore, older adults were
less likely than middle-aged adults to engage in formal aftercare (31.2 % vs. 56.4 %),
with no significant difference in 1-month outcomes.
Taken together, these findings highlight the importance of more careful examina-
tion of factors that may be related to 12-step program attendance, such as degree of
engagement and identification that lead to undermined treatment outcomes among
older adults. These include but are not limited to perceived stigma, level of comfort
regarding disclosure of personal information in group settings, degree to which age-
relevant issues are addressed during group meetings, and logistical barriers, such as
lack of transportation and health problems that may preclude older adults from
attending group sessions and engaging with sponsors [13, 14]. Understanding of
such factors in 12-step programs can further improve older adult substance use
treatment outcomes.
12.4.4 Pharmacotherapy of Addiction
Pharmacological treatments have not traditionally played a major role in the long-term
treatment of older alcohol-dependent adults. Until recently, disulfiram was the only
medication approved for the treatment of alcohol use disorders, but was seldom used
in older patients because of concerns related to adverse effects. In 1995, the opioid
antagonist naltrexone was approved by the FDA for the treatment of alcohol use disor-
ders. The use of naltrexone was based on studies demonstrating an interaction between
endogenous endorphin activity and alcohol intake. The FDA approval of naltrexone
was based upon studies by Volpicelli et al. [67] and O’Malley et al. [68] demonstrating
the efficacy of naltrexone for the treatment of middle age patients with alcohol use
disorders. In both studies, naltrexone was found to be safe and effective in preventing
relapse and reducing the craving for alcohol.
Oslin and colleagues have extended this line of research by studying a group of
older veterans age 50–70 [69]. The study was designed as a double-blind placebo
controlled randomized trial with naltrexone 50 mg per day. The results were similar
to the other clinical trials with half as many naltrexone-treated subjects relapsing to
significant drinking compared to those treated with placebo. It is important to note
that there was no improvement in total abstinence, but there was improvement in
relapse to heavy drinking. Thus, failure to achieve abstinence should not be seen as
a failure of treatment. Although this study did not include many elderly subjects, it
does raise the hope that opioid antagonists may have clinical efficacy among older
alcoholics. Naltrexone can also be effective for managing alcohol disorders in the
presence of comorbidity, such as PTSD [70].
Recently, acamprosate has been studied as a promising agent in the treatment of
alcohol use disorders. While the exact action of acamprosate is still unknown, it is
thought to reduce glutamate response [71]. The clinical evidence favoring acampro-
sate is impressive. Sass and colleagues studied 272 alcohol-dependent subjects in
Europe for up to 48 weeks using a randomized placebo controlled study of acam-
prosate. Forty-three percent of the acamprosate-treated group was abstinent at the
conclusion of the study compared to 21 % in the placebo group [72]; however, here
there are no studies of the efficacy or safety of acamprosate among older patients.
Topiramate also holds promise in the treatment of alcohol use disorders; however,
again, topiramate has not been studied in older adults and carries with it the poten-
tial for cognitive impairment as a side effect [73].
12.4.5 Detoxification and Withdrawal
Another important treatment issue to consider is that alcohol withdrawal symptoms

commonly occur in patients who stop drinking or markedly cut down their drinking
after regular heavy use. The classical set of symptoms associated with alcohol with-
drawal includes autonomic hyperactivity (e.g., increased pulse rate, increased blood
pressure, and increased temperature), restlessness, disturbed sleep, anxiety, nausea,
and tremor. More severe withdrawal can be manifested by auditory, visual, or tactile
hallucinations; delirium; seizures; and coma. During hospitalizations, patients may

be particularly vulnerable to alcohol withdrawal if the clinical team is unaware of
the use of these substances. Alcohol withdrawal can range from mild and almost
unnoticeable symptoms to severe and life-threatening ones. Other substance use
disorders, such as those related to benzodiazepines, opioids, and cocaine, have dis-
tinct withdrawal symptoms that are also potentially life threatening. Elderly patients
have been shown to have a longer duration of withdrawal symptoms and withdrawal
has the potential for complicating other medical and psychiatric illnesses in older
adults—indicating the possible need for a longer duration of withdrawal treatment;
however, there is no evidence to suggest that older patients are more prone to alco-
hol withdrawal or need longer treatment for withdrawal symptoms [74].
Highlighted by the potential for life-threatening complications, all clinicians car-
ing for older patients who have alcohol use disorders need to have a fundamental
understanding of withdrawal symptoms and the potential complications. All clini-
cians should demonstrate knowledge of the most common withdrawal symptoms
and the anticipated time course of the symptoms. In addition, all clinicians should
be able to complete a standardized assessment of withdrawal such as the revised
Clinical Institute Withdrawal from Alcohol-version A [75]. Those clinicians in set-
tings in which withdrawal management or treatment is available also need to be
competent in providing detoxification management. This includes the use of benzo-
diazepines for the management of alcohol withdrawal. Furthermore, gabapentin has
been shown to be safe and an effective alternative to benzodiazepines for treating
mild alcohol withdrawal [76, 77], but has yet to be examined in older adults.
12.4.6 Treatment Matching
Future studies will need to clarify the point at which patients are unable to be treated
in primary care or mental health clinics but rather need referral for specialty addic-
tion care. To address this point, a contemporary study compared the engagement of
older primary care patients referred to traditional specialty mental health providers
versus those referred to an integrated care model using a brief intervention within
primary care settings [78]. Study results demonstrated that older at-risk drinkers,
both problem and nonproblematic, assigned to integrated care showed a consider-
able decrease in drinking, with slightly greater improvement evidenced in problem
drinkers and higher engagement in treatment for both problem and nonproblematic
drinkers than those in specialty care. While the study results were able to identify an
interaction between treatment context, individual characteristics, and drinking out-
comes, the findings could not explain why there were still some older adults that did
not show improvement in drinking behaviors. Thus in terms of a public health per-
spective, there is no one best treatment option across the board. Rather, it is likely
that patients with less severe disease can and should be treated in primary care set-
tings, and patients with more severe disease should be treated by their principal
clinician in conjunction with specialized mental health care.
12.5 M
oderators and Correlates of Treatment Response
and Adherence
Outside of treatment availability, context, adherence, and outcomes, it is important

to better understand individual variability. The exploration of individual geriatric
treatment variability is very limited, and there are indications that further explora-
tion is needed in certain areas. For example, age-specific treatment, or age match-
ing, has been shown to improve treatment completion, specifically higher rates of
attendance among older adults at group meetings when compared with mixed-age
treatments. In one study of male veterans with alcohol problems who were ran-
domly assigned after detoxification to either age-specific or standard mixed-age
treatment, outcomes at 6 months and 1 year showed that elder-specific program
patients were 2.9 times more likely at 6 months and 2.1 times more likely at 1 year
to report abstinence compared with mixed-age group patients [79]. In this study,
treatment involved a special inpatient unit and emphasized peer support, promotion
of self-esteem, and time-limited goal setting. The treatment approach involved
being respectful of patients’ ages, by calling them “sir/ma’am” and reminiscence
therapy was used to help participants emphasize past successes.
The type of treatment setting also may affect rates of adherence [80]. In the pre-
viously described study comparing engagement outcomes among older primary
care patients referred to specialty mental health providers versus those referred to an
integrated care model using a brief intervention, 60.4 % of at-risk drinkers attended
at least one visit in the integrated care model [78]. In contrast, only 33 % of patients
attended at least one visit to a specialty provider. It is important to note that these
differences emerged in spite of efforts to address barriers to specialty care, such as
co-payments and insurance claims, and to assure appointments within 2 weeks of
patients being identified with at-risk drinking. In addition to type of treatment
affecting treatment adherence, issues of referral management should be further con-
sidered to better engage older adults in referral alcohol treatment when referral care
is deemed necessary [81–83].
Finally, certain patient-level characteristics may differentially predict treatment
outcomes. For example, women may have more favorable treatment outcomes than
men. Satre et al. [84] demonstrated that 6 months after treatment at a private outpa-
tient chemical dependency program, older, alcohol-dependent women were signifi-
cantly more likely to report abstinence from alcohol and drugs during the prior 30
days than men (79.3 % vs. 54.0 %, p = 0.02). Similarly, among patients who were not
abstinent, men reported a mean of four heavy drinking days over the prior 30 days,
and none of the women reported heavy drinking. In addition to gender, variables
associated with older age that may be related to more favorable treatment outcomes
include longer retention in treatment and not having close social network members
(e.g., family and friends) who encourage alcohol or drug use [84]. Research indi-
cates that individual levels of social support can affect treatment outcomes for older
adults. Specifically where low levels of social support can be managed through
standard treatment, and for high supported individuals, brief interventions can suf-
fice [85].
Genetic variability is also an understudied, promising area of exploration that

would allow for better understanding of how genetic makeup can influence treat-
ment outcomes, for example, why some older adults do and other do not respond to
treatment interventions [86]. Genetic lines of research can elucidate effects of poly-
morphism on alcoholism etiology and treatment response [87]. A better understand-
ing of genetic influences could feed into better treatment outcomes through
translation into personalized medicine.
12.5.1 Comorbidity Treatment Issues
Epidemiologic studies have clearly demonstrated that comorbidity between alcohol

use and other psychiatric symptoms is common in younger age groups. Less is
known about comorbidity between alcohol use and psychiatric illness in late life
[88]. A few studies do indicate that concurrent alcohol use disorder increases
chances of suffering from mental health problems [89]. Blow et al. [90] reviewed
the diagnosis of 3,986 VA patients between ages 60 and 69 presenting for alcohol
treatment [90]. The most common comorbid psychiatric disorder was an affective
disorder found in 21 % of the patients. Of these patients, 43 % had major depression.
Blazer et al. [91] studied 997 community dwelling elderly of whom only 4.5 % had
a history of alcohol use problems [91]; however, of these subjects, almost half had
a comorbid diagnosis of depression or dysthymia.
Comorbid depressive symptoms are not only common in late life but are also an
important factor in the course and prognosis of psychiatric disorders. Depressed
alcoholics have been shown to have a more complicated clinical course of depres-
sion with an increased risk of suicide and more social dysfunction than nonde-
pressed alcoholics [92–96]. Moreover, they were shown to seek more treatment.
Results from a randomized placebo controlled trial examining naltrexone as an
adjunct to sertraline and psychosocial support failed to demonstrate an added value
of naltrexone [95]; however, there was a robust association with reduction of relapse
during treatment, less frequent drinking during treatment, and improved depression
response. This trial underscored the need to treat alcohol use disorders concurrently
while treating depression. Alcohol use prior to late life has also been shown to influ-
ence treatment of late life depression. Cook and colleagues [94] found that a prior
history of alcohol use problems predicted a more severe and chronic course for
depression [94].
The relationship between alcohol use and dementing illnesses such as Alzheimer’s
disease is complex. While Wernicke-Korsakoff’s syndrome is well described and
often caused by alcohol use disorders, alcohol-related dementia may be difficult to
differentiate from Alzheimer’s disease. Clinical diagnostic criteria for alcohol-related
dementia (ARD) have been proposed and now validated in at least one trial, suggest-
ing a method for distinguishing ARD, including Wernicke-Korsakoff’s syndrome,
from other types of dementia [97, 98]. The epidemiology of ARD has varied greatly
with each study because of the prior lack of criteria. In one of the few community-
based studies including alcohol survey data, the Epidemiologic Catchment Area
study found the prevalence of a lifetime history of alcohol use disorders was 1.5
times greater among persons with mild and severe cognitive impairment than those
with no cognitive impairment [99]. Similarly, Finlayson et al. [100] found that 49 of
216 (23 %) elderly patients presenting for alcohol treatment had dementia associated
with alcohol use disorders [100]. As might be expected, patients with alcohol-related
dementia who become abstinent do not show a progression in cognitive impairment
compared to those with Alzheimer’s disease [98].
Sleep disorders and sleep disturbances represent another group of comorbid dis-
orders associated with excessive alcohol use. Alcohol use causes well-established
changes in sleep patterns, such as decreased sleep latency, decreased stage IV sleep,
and precipitation or aggravation of sleep apnea [101]. There are also age-associated
changes in sleep patterns including increased REM episodes, a decrease in REM
length, a decrease in stage III and IV sleep, and increased awakenings. Age-
associated changes in sleep can all be worsened by alcohol use and depression.
Moeller and colleagues [102] demonstrated in younger subjects that alcohol and
depression had additive effects upon sleep disturbances when they occurred together
[102]. Wagman and colleagues [101] also have demonstrated that abstinent alcohol-
ics did not sleep well because of insomnia, frequent awakenings, and REM frag-
mentation [101]; however, when these subjects ingested alcohol, sleep periodicity
normalized and REM sleep was temporarily suppressed, suggesting that alcohol use
could be used to self-medicate for sleep disturbances. A common anecdote from
patients is that alcohol is used to help with sleep problems.
12.6 Future Research Directions for Treatment
Alcohol misuse among older adults represents a pressing public health issue, both
now and for years to come. In light of changes in demographic and cohort trends,
recent years have seen an increase in the number of older adults who misuse alco-
hol. Moreover, there is a growing awareness that older adults often engage in at-risk
or problem alcohol use. Nevertheless, individuals in need of treatment or at risk for
future problems often go unidentified and untreated. Thus, research and clinical
efforts aimed at improving screening efforts and identifying system, provider, and
patient-level factors that may interfere with screening and referral processes for
older adults at risk are warranted. In this vein, a better understanding among clini-
cians and patients of recommended drinking levels and the risks associated with
moderate to heavy alcohol consumption is needed, particularly in light of the high
prevalence of co-occurring medical and psychiatric problems in this age group.
Clinicians also should ensure that screening becomes a part of routine practice
when caring for their older patients.
Furthermore, because both provider recommendations and patient engagement are
influenced, in part, by the availability of effective treatment, better dissemination of
information regarding currently available and efficacious treatments for at-risk use
and alcohol use disorders among older adults is needed. It is important to note, how-
ever, that treatment studies in addiction have traditionally excluded older patients.
Thus, research endeavors should continue to focus on developing more effective

treatments for alcohol misuse in later life, taking into consideration and empirically
assessing the various factors (e.g., patient-, treatment-, and system-related) that may
moderate treatment engagement and outcomes. Along these lines, more formal
research that focuses on the relative efficacy of various treatment modalities, specifi-
cally among older adults, is needed. Finally, given that these issues are particularly
relevant to older adults, future work may benefit from examining nutrition, vitamin
supplementation, and comorbid medical and psychiatric illness, both as foci for treat-
ment and as aspects of health that may be complicated by alcohol use.
Traditionally, treatment studies in addiction have excluded patients over the age
of 65. This bias has left a tremendous gap in knowledge regarding treatment out-
comes and an understanding of the neurobiology of addiction in older adults.
Table 12.1 summarizes the existing knowledge base with important priorities listed
for the future. Multiple health behavior change treatment, including alcohol change,
can have a major positive health impact; however, thus far it has not been effectively
demonstrated and requires further pressing inquiry [103]. It is also important to
further understand how older adult choice of treatment effects treatment adherence
and treatment outcomes [104].
Unfortunately, there are only a few studies examining changes in health or
quality of life after the initiation of abstinence. Among veterans, Lemke and
Moos [65] have demonstrated greater improvement in psychological distress and
drinking problems at 1 year compared to middle-aged adults in inpatient treat-
ment [65]. Among community programs, older adults have been shown to have
robust and comparable improvement in quality of life and comparable rates of
Table 12.1 Summary of randomized treatment research on late life alcohol use disorders
Evidence base
from
randomized
trials General effect Future needs
Problem and at-risk drinking
Brief treatments Five randomized Brief intervention/advice Randomized trials in other
trials [43, 51, reduce drinking high-risk settings such as
54–56, 59, 107] behavioral health, home
care, and the emergency
room, using differentiated
at-risk/hazardous and
DSM diagnostic
dimensions.
Alcohol use disorders
Psychosocial Six randomized Outpatient and inpatient Randomized trials
treatments trials [42, 50, psychosocial programming designed to better
63, 79, 84] reduces drinking; greater understand age-dependent
improvement with adherence and treatment
age-appropriate treatment outcomes, using new
DSM criteria.
(continued)
Evidence base
from
randomized
trials General effect Future needs
Naltrexone Two randomized Medication is well tolerated Clinical pharmacology
trials [36, 69] and effective trials need to begin
Antabuse No trials – enrolling older adults
specifically in rather than excluding
older adults them which is the general
practice. Greater advocacy
from the geriatrics field
should be focused on
medication treatment in
the addiction field. There
are specific needs for
safety studies as well as
efficacy studies.
Other –
condition(s)
Comorbidity One There was no evidence for This is a critical area of
Randomized efficacy of naltrexone when need both for patients
trial for added to sertraline and with current alcohol use
depressed psychosocial support disorder or at-risk
alcohol- drinking and for those
dependent with past histories of
patients [95] alcohol use disorder or
at-risk drinking.
abstinence to middle-aged adults [35, 66]. Other researchers have also found that
forced abstinence associated with nursing home or rehabilitation placement leads
to improvements in activities of daily living, alcohol-related cognitive impair-
ment, and the discharge back to a home setting [98, 105, 106]. These reports of
the reversibility of morbidity associated with alcohol use provide perhaps the
greatest argument for initiating treatment in older adults; however, further
research is needed to better understand health benefits and consequences of alco-
hol treatment in older adults.
Furthermore, acamprosate, disulfiram, baclofen, topiramate, and nalmefene have
not been studied in RCTs in the elderly, nor have any subgroup or post hoc analyses
in elderly patients been published. Controlled studies evaluating the efficacy of
medication for the treatment of alcohol withdrawal symptoms in older persons are
also lacking [47]. Having more hybrid or comparative trials to examine effective
alcohol treatments would tremendously advance geriatric addiction science.
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Self-Medication with Alcohol: Aging
Issues 13
Sarah L. Canham and Pia M. Mauro
The use of alcohol and other substances to personally manage one’s physical/mental
health problems has been referred to as self-treatment, and more commonly, self-
medication. Though there is some variation in its measurement, self-medication is
generally conceptualized as the use of alcohol or other substances to relieve discom-
forting physical/mental health symptoms or to cope with negative affect [1]. The
goals of this chapter are to review: the prevalence of self-medication with alcohol
among adults in mid- and late life; reasons for self-medication with alcohol; outcomes
of self-medication with alcohol; mechanisms by which to identify self-medication
with alcohol; and opportunities for treatment and prevention of self-medication with
alcohol. A conceptual model based on the extant research is presented as a way to
integrate the current state of knowledge in this area. As self-medication with alcohol
can contribute to the underlying causal pathway between alcohol use and comorbid
health issues in later life, our goal here is to synthesize the available literature on
issues of self-medication with alcohol and to suggest avenues for future study.
13.1 Prevalence of Self-Medication with Alcohol
Prevalence estimates of self-medication with alcohol in general and older adult

populations range between 5 and 20 %, depending on the population under study
and measurement of self-medication with alcohol. In a sample of healthy, retired
Caucasian adults aged 65–74 years, 12 % reported using alcohol to cope during a
S.L. Canham, Ph.D. (*)

Gerontology Research Centre, Simon Fraser University, Vancouver, BC, Canada
P.M. Mauro, Ph.D.
Department of Epidemiology, Columbia University
Mailman School of Public Health, New York, NY, USA

202 S.L. Canham and P.M. Mauro
stressful encounter [2]. Among community-dwelling adults aged 75 and older in

Finland, 19.7 % reported use of alcohol for medicinal purposes [3]. More recently,
5.1 % of a nationally representative community-based sample of US adults aged
54–99 years reported frequently using alcohol to cope with stress [4]. Since health
may deteriorate with age, and alcohol is contraindicated when using certain medica-
tions, adults with more medical conditions and who use certain prescribed medica-
tions may be less likely to use alcohol in general or to cope with stress in particular
[4]. Moos and colleagues [5] suggest that older adults with more health problems
tend to restrict their alcohol consumption.
Self-medication with alcohol has also been reported in community-based
samples of individuals with comorbid mental health disorders in the National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC), though
data specific to middle-aged and older adult subsamples is limited. The NESARC
assessed self-medication separately for different mood episodes or anxiety disor-
ders, among the general US noninstitutionalized civilian population aged 18
years and older, by asking participants if they ever used substances to relieve
their mood or anxiety symptoms. In one study using data from the NESARC,
15.4 % of adults with major depressive disorder, 22.1 % of people with bipolar I
disorder, and 23.9 % of people with bipolar II disorder reported self-medication
with alcohol [6]. In other studies using NESARC data, self-medication with
alcohol was reported by 23.3 % of adults with a diagnosable substance use disor-
der [7], 18.3 % of persons diagnosed with generalized anxiety disorder, 16.9 % of
people with social phobia, and 15.0 % of people with panic disorder with agora-
phobia; 7.7 % of adults aged 65 and older with any anxiety disorder reported
self-medication with alcohol [8].
13.1.1 Gender and Racial/Ethnic Differences in Self-Medication

with Alcohol
Research with both general population samples [8] and older adults [3] has reported
similar proportions of men and women who self-medicate with alcohol. Mauro and
colleagues [4] reported that 6.1 % of men and 4.3 % of women in a sample of adults
aged 54 years and older frequently used alcohol to cope with stress. Other research,
however, has identified gender differences in the use of self-medication with alco-
hol, with men more likely to self-medicate with alcohol than women [9]. For
instance, men aged 18 years and older who have mood disorders have been found
to be more than twice as likely than women to use substances to relieve distressing
mood symptoms [6], and older men are also more likely to use alcohol to cope with
pain and arthritis than older women [10–12]. Men have been found to have more
reactive drinking behaviors than women in response to social influences and stress-
ors (e.g., to financial/legal problems, death of someone close, and emotional dis-
tress) [13, 14]. While women are more likely to report greater exposure to family
interpersonal problems, the death of someone close, and emotional distress, men
report greater exposure to workplace problems [13]. Future research should extend
13 Self-Medication with Alcohol: Aging Issues 203
these investigations of gender differences by exploring whether older men and

women experience similar or unique health outcomes as a result of self-medication
with alcohol.
There are also racial/ethnic differences in the prevalence of self-medication with
alcohol. Particularly, non-Hispanic/Latino Whites report alcohol self-medication
more frequently than other racial/ethnic groups. In a sample of adults aged 54 years
and older, frequent alcohol use to cope with stress was reported by 5.3 % of White/
Caucasian participants, 2.7 % of Black/African-American participants, 7.3 % of
participants who reported another race, 5.3 % of non-Hispanic/Latino participants,
and 3.5 % of Hispanic/Latino participants [4]. Non-Hispanic White older adults
have also been found to be more likely to use alcohol to self-medicate pain than
older adults identifying as Hispanic or non-Hispanic Black [11]. These differences
may be partially due to discrepancies in attitudes toward drinking alcohol across
racial/ethnic groups [15, 16]. As demographic changes in the US are expected to
lead to corresponding changes in the racial/ethnic composition of middle-aged and
older adults [17], future studies should explore whether cohort changes are associ-
ated with altered patterns of self-medication with alcohol across racial/ethnic
groups.
13.2 N
egative States Associated with Self-Medication
with Alcohol
For purposes of self-medication, alcohol is used as a sedative-hypnotic to enable

feelings of relaxation, affection, closeness, or aggression [1]. For instance, middle-
aged and older adults may use alcohol as a way to cope with distress, anxiety,
depression, sleep problems, and pain.
13.2.1 Self-Medication with Alcohol to Cope with Distress
According to the stress and coping theory, the use of alcohol to cope may be a reac-
tion to problematic life circumstances among individuals who lack more adaptive
coping skills and who try to avoid problems or negative affect [18, 19]; that is, alco-
hol is used as a form of self-medication to manage life stressors. Indeed, stressful life
events are associated with greater odds of alcohol use disorders in both older men
and women, though the temporal relationship may be bidirectional—alcohol use dis-
orders could lead to more stressors, but increased stress could also result in alcohol
use disorders [14]. In addition, having low levels of social support or few social
resources in times of stress can lead to alcohol use as a form of self-medication [20].
For older adults experiencing distress, alcohol may be used to ease tension and
suffering, and the general declining of alcohol consumption with age may be
delayed as a result of stressful events [21]. Increased alcohol consumption to cope
with interpersonal stressors is not uncommon. Older adults who experience marital
separation, the loss of a friend because of move, illness or injury to a relative, or the
death of a loved one may turn to alcohol to cope with these stressors [21, 22]. The
loss of social status may also serve as a means for adults to self-medicate with alco-
hol. For instance, the loss of support and feelings of despair experienced by retirees
can lead to increased alcohol consumption. For persons with drinking problems,
retirement may increase stress and exacerbate existing drinking problems [23].
In comparison to these interpersonal stressors, which are associated with
increased alcohol consumption, health stressors and health events have been associ-
ated with reduced alcohol consumption in later life [5, 24, 25]. Abstinence or less
frequent drinking in later life has been associated with poor self-rated health, medi-
cal conditions, medication use, and acute health events [24, 26, 27]. Future research
should explore the underlying variation across individual decisions to abstain versus
self-medicate in the face of different life stressors. For instance, research suggests
that older adults who find meaning in religion or have an affiliation to a fundamen-
talist church, avoid drinking [28]. Having insight into individual differences on
whether alcohol might be used to self-medicate, can inform methods for improving
management of distress.
13.2.2 Self-Medication with Alcohol to Cope with Anxiety

and Depressive Symptoms
Self-medication is a common behavior among persons who experience symptoms

of anxiety or depression. In a nationally representative sample of adults aged 18–98
years from the US, 20.3 % of persons with an anxiety disorder also reported using
alcohol to manage their symptoms [9]. There was also a significantly greater preva-
lence of having a family history of alcohol problems among adults with an anxiety
disorder who self-medicated compared to adults with an anxiety disorder who did
not report self-medication with alcohol (49.8 % vs. 64.7 %) [9]. Such findings are
consistent with data from a sample of noninstitutionalized adults aged 15–54, show-
ing that having any anxiety disorder is associated with a 21.9 % prevalence of self-
medication with alcohol or drugs; the highest prevalence of self-medication in this
sample was among persons with generalized anxiety disorder [29].
As another form of self-medication, alcohol may be used as a way to reduce
negative feelings and cope with depressive symptoms. In a sample of noninstitu-
tionalized adults aged 15–54 who reported self-medication with alcohol or drugs,
56.8 % also had major depression, compared with 30.7 % of participants who did
not self-medicate [29]. This finding is consistent with data from a sample of US
adults aged 18 years or older: people with depression were significantly more likely
to drink alcohol to cope when compared to community controls [29]. Drinking to
cope was more likely for both depressed patients and community controls who
experienced more negative life events or less family support; depressed patients
were also more at risk for negative life events or poor family support than commu-
nity controls. Life context vulnerabilities (i.e., negative life events and poor family
support) basically explained the risk for depressed patients to rely on alcohol use
coping [30].
13.2.3 Self-Medication with Alcohol to Treat Sleep Problems
Alcohol has also been reported as a way to self-medicate “worries” that cause sleep
disturbances, to induce sleep in the general population [31], and to manage sleep
disturbances among older adults [3, 32]. In a sample of women aged 85 years and
older living in an urban area, all 155 participants reported sleep difficulties and 70 %
reported using alcohol to help with sleep [33]. In a longitudinal sample of adults
aged 18 years and older, individuals with anxiety disorders or dysphoria at baseline
who also reported sleep disturbances because of worry had an increased risk of
developing alcohol-related problems over the follow-up period (median 12.6 years)
[31]. Among patients in treatment for alcohol dependence, those who report insom-
nia have been found to be more likely to report using alcohol to sleep (55 %) when
compared to patients without insomnia (28 %) [34].
Persons who use alcohol as a sleep aid report greater difficulty falling asleep,
lower total sleep time, and greater daytime sleepiness compared to persons who do
not use alcohol as a sleep aid [35]. A review of research on the association between
disturbed sleep and alcohol use reported that low to moderate alcohol use (up to 2–3
standard drinks) before bedtime initially promotes sleep, but these effects diminish
after as few as 3 days of chronic use [36].
Research has found older women to report fewer risks associated with using
alcohol to help with sleep, while highlighting the convenience and effectiveness of
using alcohol to sleep, as reasons to drink before bed [33]. Qualitative research
exploring the reasons why older adults self-medicate with alcohol for sleep distur-
bances, could identify alterative, more adaptive ways of coping with sleep prob-
lems. For instance, if alcohol is considered to be a convenient and effective sleep aid
despite contradictory evidence that alcohol use results in more symptoms of insom-
nia compared to persons who do not use alcohol [35], treatment should include
education of the potential risks of self-medication with alcohol.
13.2.4 Self-Medication with Alcohol to Treat Pain
Pain is associated with drinking problems in both cross-sectional and longitudinal

studies [37, 38], but the relationship between alcohol use and pain varies based on
the amount and frequency of alcohol use and the severity of the pain [38, 39].
Reliance on alcohol to reduce pain has been associated with both more frequent and
heavier alcohol consumption and alcohol use disorders among older adults [24]. In
a community sample of older adults, problem drinking was associated with pain and
the use of alcohol to self-medicate pain [37]. More than a third (37.9 %) of older
adults with drinking problems reported using alcohol to cope with pain; up to about
57 % of men and 59 % of women with drinking problems reporting moderate or
severe pain also reported using alcohol to cope with pain [37]. Furthermore, among
those without drinking problems, 15.1 % of men and 12.5 % of women reported
using alcohol to cope with pain [37]. This study also found gender differences in the
3-year effects associated with alcohol use to cope with pain. Among people who at
baseline reported problem drinking and who self-medicated with alcohol, men were
more likely to have negative health outcomes (e.g., serious injury) 3 years later,
while women were more likely to report heavier drinking at follow-up [37].
In contradiction to the self-medication hypothesis, a longitudinal sample of older
adults who reported numerous painful conditions were found to use alcohol less
frequently compared to older adults with fewer painful conditions [38]. Though not
explored in their study, Brennan and colleagues [38] suggest that these findings may
be the result of participants’ attempts to avoid medication–alcohol interactions or
participants’ reductions in social interaction, thus having fewer opportunities to use
alcohol. These ideas are supported in recent findings indicating feelings of loneli-
ness were associated with less frequent drinking among middle-aged and older
adults [40]. In order to better contextualize these disparate findings, future research
should explore the reasons why older adults do or do not self-medicate their
physical/mental problems with alcohol.
13.3 Outcomes of Self-Medication with Alcohol
The use of alcohol to self-medicate is considered maladaptive [34] and is associated

with a host of negative outcomes. The changing physiology of older adults, along with
higher prevalence of comorbid health issues and more frequent medication use [41,
42], exacerbates the risks of self-medication with alcohol. For adults in mid- and late
life, self-medication with alcohol has been found to result in the development of alco-
hol use disorders as well as the worsening of physical and mental health conditions.
13.3.1 Self-Medication with Alcohol Can Lead to Alcohol Use

Problems
Self-medication with alcohol has been found to predict alcohol use and drinking
problems over a 10-year period in a community sample of adults [43]; to predict risk
for excessive alcohol consumption and drinking problems over both 10- and 20-year
follow-up periods in community samples of late-middle-aged adults [19, 24]; and to
be a risk factor for the development of alcohol use disorders in community samples
of adult drinkers [7, 44].
Significantly more average daily alcohol consumption and risk of alcohol depen-
dence have been reported among persons with anxiety disorders who self-medicate
compared to individuals who do not self-medicate [9]. Crum and colleagues [45]
support this finding with data from the NESARC, indicating that in a population-
based sample of US adults aged 18 years and older, there was a greater risk of
developing alcohol dependence among participants who reported self-medication of
anxiety with alcohol. For these participants, the experience of dependence was more
likely to persist. Likewise, Robinson and colleagues [7] found that among partici-
pants who had a baseline anxiety disorder and who reported self-medication with
alcohol, 12.6 % developed an alcohol use disorder at follow-up.
13.3.2 Self-Medication with Alcohol Can Precipitate or Worsen

Negative Health Outcomes
The use of alcohol to aid with sleep has been found to disrupt sleep architecture and
cause sleep-related problems and daytime sleepiness [35, 36, 46]. Though alcohol
is commonly used to aid with sleep initiation, it can worsen sleep-related breathing
disorders and cause snoring and obstructive sleep apnea [36]. Alcohol also impairs
sleep by increasing movement disorders, periodic leg movements, and sleepwalk-
ing; causing gastritis, esophageal reflux, polyuria, and nocturia; and causing
unsteadiness and falls, particularly among older adults [36].
Similarly, self-medication with alcohol has been found to increase the risk of
being diagnosed with a mood or personality disorder compared to individuals who
did not self-medicate [8]; to predict the development of social phobia in participants
with baseline subclinical anxiety or baseline alcohol or other drug use disorders [7];
and to be significantly associated with suicidal ideation and suicide attempts in a
noninstitutionalized sample of US respondents aged 15–54 years with anxiety [29].
Self-medication with alcohol has also been associated with increased mental health
treatment utilization and decreased mental health-related quality of life in a sample
of US adults with a diagnosed anxiety disorder [47]. Such associations may be
driven by maladaptive coping skills of individuals who self-medicate [29, 47].
13.4 Conceptual Model of Self-Medication with Alcohol
Based on this review of the existing literature, we have developed a conceptual model
of self-medication with alcohol (Fig. 13.1) as a way to integrate the current state of
knowledge and highlight areas for hypothesis development and testing. Of note,
demographic factors (e.g., age, gender, and race/ethnicity) and family history of alco-
hol problems are potential moderators of these multiple different relationships and
should be considered in future evaluations of the pathways leading to or from self-
medication with alcohol, as well as alcohol use problems or poor health outcomes.
Fig. 13.1 Conceptual model of self-medication with alcohol

Pathway “A” indicates that self-medication with alcohol can result from and
result in negative affective states, such as distress, anxiety, depression, sleep
problems, or pain, as well as from interpersonal stressors, low social support, few
social resources, and negative life events. These risk factors for self-medication
with alcohol are moderated by a number of factors in pathway “B,” including
avoidance coping and positive alcohol use expectancies. Among late-life problem
drinkers, being more reliant on avoidance coping strategies to manage stressors
has been found to increase the risk that negative events will lead to more drinking
problems [48]. Thus, individuals who lack more adaptive coping strategies may
be more likely to use alcohol to manage their stress. Moreover, individuals who
have positive alcohol expectancies report heavier alcohol use [49, 50]. Those who
associate alcohol consumption with positive outcomes may be more inclined to
use alcohol to cope.
As noted in pathway “C,”self-medication with alcohol has been found to result
in the development of alcohol use disorders as well as the worsening of physical and
mental health problems. Thus, the level of alcohol consumption becomes an impor-
tant consideration, particularly if older adults are drinking more, drinking for longer
than intended, or prioritizing drinking over the fulfillment of other roles—are all
symptoms of an alcohol use disorder [51]. Future research should explore the varia-
tion in when self-medication leads to alcohol use disorders and other negative health
outcomes by age, gender, ethnic/cultural, or other subgroup to determine potential
moderation of this pathway.
Our conceptual model indicates that self-medication with alcohol does not fully
mediate the relationship between negative affective states and negative health out-
comes. As indicated by the bidirectional pathway “D,” there may be more than one
pathway for individuals to experience alcohol use problems or poor health out-
comes beyond self-medication with alcohol. Indeed, there could be other mediating
pathways between the negative states discussed (i.e., distress, anxiety, depression,
sleep problems, pain, and poor social support and resources) and negative outcomes
(i.e., alcohol use problems and poor health outcomes). Conversely, alcohol use
problems and poor health can lead to distress, anxiety, depression, sleep problems,
and pain as well as exhaust social support and resources. Avoidance coping and
positive alcohol use expectancies can moderate the relationship between risk factors
of self-medication with alcohol and negative health outcomes, as indicated in path-
way “E.” Research suggests that poor coping skills among individuals with alcohol
use problems [20] and positive alcohol use expectancies among drinkers [52] influ-
ence drinking, drinking levels, and negative drinking outcomes. For instance, the
use of avoidance coping strategies has been found to predict problem drinking in
late life; compared with nonproblem drinkers; late-onset problem drinkers reported
responding to stressors or negative affect by drinking alcohol [25]. These bidirec-
tional relationships deserve attention in future research in order to tease apart pre-
cipitating factors for each pathway.
13.5 I dentifying Self-Medication with Alcohol Among Older

Adults
As part of regular practice, clinicians should evaluate the use and misuse of alcohol
(along with drugs and prescription medications) among older adults who have
symptoms of distress, anxiety, depression, poor sleep, and pain. Rather than limit
screening to standardized questions of misuse and disorder, which may not capture
the use of alcohol as a medicine [3], clinicians should directly ask about self-
medication with alcohol among people reporting alcohol use. For instance, as done
in the NESARC, clinicians could ask patients about the use of substances to relieve
their negative mood or anxiety symptoms. Identifying older adults who self-
medicate with alcohol could enable more targeted screenings [53]; in particular
asking older patients their reasons for using alcohol could help identify those who
may require further assistance or intervention. For instance, if patients are self-
medicating with alcohol to cope with their sleep problems, it will be clinically
important to attend simultaneously to both their underlying sleep issues and boost-
ing adaptive coping skills to reduce self-medicating behavior. Similarly, improved
assessments of pain, sleep difficulties, and underlying symptoms of depression and
anxiety, for which older adults are self-medicating with alcohol, are needed [31].
While the development of improved screening measures may help clinicians iden-
tify alcohol problems among older adults [54], knowing an individual’s alcohol
consumption patterns is an important supplement to formal screening tools [53].
Identifying older adults who use alcohol to self-medicate has clinically relevant
implications since older problem drinkers have been found to have positive treatment
outcomes that persist over time [55]. In conjunction with screening, brief interven-
tions should be incorporated into regular clinical practice, as these may be important
first steps in reducing maladaptive self-medication with alcohol and offer important
educational opportunities to maximize more adaptive coping strategies [56, 57].
13.6 T
reatment and Prevention of Self-Medication
with Alcohol
Self-medication with alcohol is one of many ways people may cope with various
negative states. However, as evidenced by the prevalence of self-medication with
alcohol among middle-aged and older samples, as well as general population sam-
ples, the use of alcohol to cope with negative affect is not a universal experience.
Many persons affected by distress, anxiety, depression, sleep disorders, and pain do
not use alcohol to manage their symptoms. For instance, only 20 % of Menary and
colleagues’ [9] sample of adults with anxiety disorders reported using alcohol to
cope. Accordingly, there is a wide range of coping mechanisms beyond alcohol use
to manage negative affect.
Effective strategies for treating negative affect largely include behavioral thera-
pies or pharmacotherapies (e.g., antidepressants, pain or sleep medications). For
instance, insomnia treatments include pharmacotherapy, lifestyle interventions
(e.g., the avoidance of caffeine and alcohol), behavioral therapies (e.g., progressive
relaxation or sleep restriction), and cognitive-behavioral therapy (CBT, which
works to restructure negative or erroneous thoughts, ideas, and attitudes about
sleep) [33, 58]. Educating older adults about the risks and consequences of self-
medication with alcohol as it applies to their own lives [53] could encourage safer
alcohol consumption.
Behavioral therapies can be effective in treating persons with alcohol use disor-
ders [59] and could be adapted to treat self-medication behavior. Such therapies
target harmful alcohol consumption behaviors by working to change individuals’
underlying thoughts that lead to alcohol use (CBT), encouraging coping skills
beyond alcohol consumption (coping skills therapy), identifying and preparing for
situations or triggers which might lead to relapse (relapse prevention therapy), and
rewarding desirable behaviors while removing rewards for undesirable ones (con-
tingency management) [59]. Cooper and colleagues [49] have also suggested
restructuring ideas about and expectations of alcohol use as an appropriate interven-
tion. Indeed, individuals who successfully completed a 12-week CBT treatment
program were found to be less likely to endorse positive outcomes of alcohol use
compared to those who did not complete treatment [60]. Building competencies that
utilize more adaptive ways of coping with negative emotions (e.g., anger manage-
ment and assertion training) is also of value. Furthermore, since men and women
react differently to different stressors, treatments should be adaptable to individual
needs and experiences [13].
Additional methods of minimizing self-medication with alcohol include attempts
to reduce life stressors and strengthen social supports and resources [48].
Nevertheless, many stressful life events are unavoidable and may trigger an indi-
vidual’s coping responses. Thus, it is important to identify which coping resources
older adults utilize to deal with negative affective states, pain, or sleep problems,
and to encourage the use of adaptive coping strategies [30]. For instance, reducing
avoidance coping [48], increasing the use of mindfulness and acceptance-based
coping [61], and problem-solving and approach coping [62] can help older adults
who self-medicate with alcohol by appropriately managing the distress and prevent-
ing future occurrence.
Avoidance coping may be used more frequently by individuals with alcohol-
related problems than adults without alcohol-related problems [62], and better
drinking outcomes have been associated with decreased avoidance coping over an
8-year follow-up, particularly for men [20]. Interventions that focus on developing
approach coping skills may help older adults manage negative affect. Approach
coping is a problem-focused method of coping that makes use of cognitive and
behavioral processes to overcome stressors [37]. Acceptance-based interventions,
as well, could be used to prevent relapse among alcohol-dependent adults and to
improve mood and reduce alcohol craving [61].
13.7 Conclusions and Future Directions
This chapter has outlined the literature on self-medication with alcohol among
middle-aged and older adults. Despite the growing body of evidence, a great deal of
work remains to be done. First, studies often rely on the use of a single item to
assess the use of self-medication with alcohol [9, 30]. However, self-medication
with alcohol is complex. Future research should involve teasing out the frequency
and amount of alcohol used as a form of self-medication to cope with negative affect
and explore how different consumption levels might result in different outcomes.
For instance, greater frequency or levels of self-medication with alcohol increase
the risk for alcohol use disorders [9].
Longitudinal studies are needed to explore the temporal relationships between
negative affect and self-medication with alcohol among older adults. As suggested
by our conceptual model, the pathways and antecedents to self-medication with
alcohol are complicated and multifactorial. In addition, qualitative research is
needed to deepen our understanding of self-medication with alcohol by exploring
the individual-level experiences of older adults.
Lastly, as evidenced throughout this chapter, middle-aged and older samples
have been largely underrepresented in many population-based studies. As a result,
the intricacies of differences in patterns across genders, and racial/ethnic or other
sociodemographic subgroups remain understudied. Future research should concen-
trate on ethnic and cultural variations in self-medication with alcohol in middle to
later life, as older adults continue to make up an increasing proportion of the
population.
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Adapting SBIRT for Older Adults
14
Lawrence Schonfeld
14.1 Introduction
Since the 1990s, screening, brief intervention, and referral to treatment or

“SBIRT” has been a successful model for addressing risky or problematic use
among older adults. In some ways, it is a supplement to services offered by formal
substance abuse treatment services. This is important, as traditional substance
abuse treatment and prevention services more often focus on youth, young adults,
and middle-aged adults.
For more than 40 years, published research has shown that compared to younger
individuals, and compared to their proportion of the general population, older adults
are vastly underserved by substance abuse treatment systems. For example,
treatment admissions in 2011 indicated that people ages 55–64 and people ages
65 and older represent 5.6 and 0.7 % of all admissions, respectively, in the USA [1].
A number of factors may contribute to this underutilization including funding, pri-
oritization of target populations, inability of programs to address elders’ comorbid
health concerns, age-inappropriate assessments, and reliance on indicators that are
less likely to occur in the older population. Given state-level funding priorities and
appropriations of federal block grants for substance abuse treatment, state-level
policymakers are unlikely to earmark funds for elder-specific treatment when ado-
lescents’ and young adults’ problems are more visible to the systems that serve them
and more visible to their families, school systems, and employers. For example,
younger adults may exhibit drinking-related problems, such as increased absenteeism
at work, automobile accidents, domestic violence, and marital discord. In contrast,
many older adults diagnosed with alcohol problems have been shown to drink in
L. Schonfeld, Ph.D. (*)

Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health
Institute, College of Behavioral and Community Sciences, University of South Florida,
13301 Bruce B. Downs Blvd, MHC 2700, Tampa, FL 33612, USA

216 L. Schonfeld
response to depression, loneliness, grief, boredom, and loss of social support.

Recommended limits differ for these two age groups as well.
Research indicates that among the general population of older adults, alcohol
consumption declines with increasing age [2, 3]. For certain groups, such as those
residing in active, planned retirement communities, drinking can exceed recom-
mended limits but is perceived as part of an enjoyable social activity. Older people
who were used to consuming a few drinks a day during their youth and even into
middle age may now find that it takes fewer drinks to become impaired because of
increased sensitivity resulting from changes in metabolism, interactions with medi-
cations, and consequences of medical illnesses. Compounding the problem of older-
age drinking is the fact that many older adults are not screened on a routine basis for
alcohol problems by their physicians, aging services, and other service providers.
Results from national household surveys and treatment admissions data suggest
that substance use among the older population is a growing problem, given the
aging of the US population and the projections of future need for formal substance
abuse treatment. For example, the 2013 National Household Survey on Drug Use
and Health (NSDUH) revealed that among 41.7 % of people ages 65 and older were
current alcohol users, while 9.1 % were binge and 2.1 % heavy alcohol users. Adding
mature adults aged 50–64 to these numbers doubles these percentages for binge and
heavy use [4].
Han and colleagues projected that the number of adults aged 50 or older with
substance use disorders would be more than double from approximately 2.8 million
annually in 2002–2006 to approximately 5.7 million in 2020 [5]. While there have
been a number of studies indicating that specialized programs for older adults with
diagnosed substance use disorders have excellent outcomes [6–9], specialized
programs for people ages 50 and older are on the decline [10].
14.2 SBIRT as a National Initiative
SBIRT is a method proven to be effective in identifying and intervening with a large

proportion of the population: those who demonstrate risky or problematic use of
substances. As a national initiative in the USA, SBIRT has been funded through
grants from the Substance Abuse and Mental Health Services Administration
(SAMHSA). From 2003 to 2015, SAMHSA awarded 17 medical residency training
grants, 32 state cooperative agreements, 12 campus screening and brief intervention
(SBI) grants, and 14 medical professionals training grants [11]. The model has been
applied successfully with various populations. In this chapter, the adaptation of
SBIRT for older adults is discussed.
As noted in a study published in 1996 by World Health Organization (WHO)
[12], the history of the SBIRT model can be traced to efforts in the 1980s to address
harmful use of alcohol (maladaptive pattern of use that leads to physical or mental
harm) or hazardous alcohol use (referring to harmful drinking patterns such as fre-
quent intoxication) in primary care settings quickly and effectively for the general
population. In the majority of published research studies, brief advice and
14 Adapting SBIRT for Older Adults 217
counseling were implemented by healthcare providers in primary care, hospital

units and emergency departments, and health clinics for intervening with individuals
who screen positive.
There is ample evidence supporting the efficacy of screening and brief interven-
tion in these settings. For example, a 1997 meta-analysis involving 12 studies using
random control trials concluded that brief alcohol interventions were effective for
reducing heavy drinking across gender, intensity of intervention, type of clinical
setting, and higher-quality clinical trials [13]. The WHO study group conducted
randomized trials of 1260 men and 299 from healthcare centers in eight countries
[12]. All participants were considered at risk of alcohol-related problems based on
quantity or frequency of use but with no history of alcohol dependence. Subjects
were assigned to one of three conditions, all of which received a health interview.
One group received five minutes of simple advice and an illustrated pamphlet to
promote sensible drinking or abstinence. A second group received 15 min of brief
counseling about drinking, a problem-solving manual that described the benefits of
moderate drinking or abstinence, ways of coping with high-risk drinking situations,
and constructive alternatives to drinking. The control group only received the health
interview. At 9 month follow-ups, the results revealed that while all three groups
reduced alcohol quantity and frequency, both the simple advice group and brief
counseling group had significantly greater reductions than the control group. Other
studies involving similar methodologies for brief advice in primary care practices
and managed care organizations have also demonstrated its efficacy along with use
of educational materials in producing similar outcomes [14–16].
14.3 SBIRT and Older Adults
In the 1980s, the published literature began focusing on the need for developing age-
appropriate screening, assessment, and services for older adults who met diagnostic
criteria for inpatient or outpatient treatment of alcohol abuse [8, 17, 18]. Despite the
development and implementation of effective treatment programs for older adults
diagnosed with substance use disorders, relatively few older adults entered treat-
ment, and they remained a disproportionally underserved population.
14.3.1 SBIRT in Primary Care and Emergency Departments
Fleming and colleagues, who had previously applied brief physician advice with a
general primary care practice population [16], conducted a randomized controlled
trial specifically for primary care patients ages 65 and older [15]. Known as Project
GOAL (Guiding Older Adult Lifestyles), the study involved 158 patients from 24
Wisconsin primary care practices, with 146 completing 12-month follow-ups. In the
brief advice condition, patients received two 10–15-min sessions of brief advice by
their physicians. Each physician utilized a health promotion workbook to provide
the patient with feedback about his or her health and review information about
218 L. Schonfeld
drinking behavior, adverse effects, and cues for drinking. The workbook included a
drinking agreement in the form of a prescription to be signed by the patient and
physician and drinking diary cards for the patient to record alcohol consumption.
Results showed that in comparison to controls, those receiving the brief advice
demonstrated reduced weekly alcohol consumption and fewer binges [15].
Screening older adults for substance misuse in primary care physician offices
and hospital emergency departments seems logical given data from the 2004–2007
National Health Interview Survey (NHIS) [19]. According to the NHIS, doctor vis-
its in the past 12 months increased from 87.8 % for those aged 55–64 to 94.9 % of
people 75–84 years old and then to 96.6 % of those 85 years old and older. Past
12-month hospital emergency department visits also increase dramatically with age
ranging from 18.8 % of those aged 55–64 to 32.5 % of those aged 85 and over. In
one example of screening in a hospital emergency department, Adams and col-
leagues [20] screened 205 older adults finding self-reported drinking problems in
14 %, many of which were not detected by their physicians.
14.3.2 SBIRT in Other Venues
Recognizing that older adults with risky or problematic drinking behavior may not
always be found in healthcare settings, a number of projects have applied SBIRT to
other service provider agencies. In one of the first such applications, the Staying
Healthy Project (SHP) was conducted in California, where service providers other
than physicians or psychologists were trained to conduct the brief intervention [21].
Screenings were conducted in aging services’ settings such as senior housing or
senior centers and brief interventions were guided by the health promotion work-
book as used in the earlier Project GOAL study [15]. Out of 4322 people ages 60
and older who were screened, 77 % were found to be abstinent. There were 164
participants who screened positive, and then randomly assigned to either a control
condition (n = 90) or brief intervention (n = 74) conducted by social workers, resi-
dent or service coordinators, activity directors, or nurses. While both groups dem-
onstrated a decrease in drinking, the brief intervention group had significantly fewer
days drinking liquor and number of beers consumed per day.
14.4 The Florida BRITE Project
The same model was later adapted for the Florida BRITE Project (BRief Intervention
and Treatment for Elders) [22]. BRITE served as a pilot project funded by the state
of Florida Department of Children and Families (DCF) Substance Abuse Program
Office. Florida DCF identified and funded one service provider agency in each in
four counties to implement BRITE. Targeting adults ages 60 and older, staff mem-
bers labeled as health educators were trained to conduct screening in locations
where older adults resided (their individual homes or apartments) or where they
received aging or other social services. In addition to alcohol use, BRITE also
focused on misuse of prescription and over-the-counter medications, as well as use

of illicit drugs. Furthermore, BRITE included brief screens for depression and
suicidal ideation, as previous research has shown that older substance abusers were
likely to use alcohol or other substances as a palliative for depression. Outreach,
identification of people with positive screens, and referral processes were conducted
mostly through aging and behavioral health services and their usual referral net-
works. Only a small percentage of outreach activities were conducted through
healthcare settings, such as hospitals or primary care practices.
Health educators typically assessed older adults in their homes, at senior centers,
in senior apartment complexes, at health fairs for seniors, and other community-
based settings. A total of 3497 individuals were screened. Brief intervention was
offered to any individual screening positive for substance use problems. The inter-
vention was guided by the health promotion workbook used in earlier studies but
modified to include education for individuals misusing medications and to address
any use of illicit substances. All health educators were required to use the workbook
along with motivational interviewing techniques.
Results showed that more than half of the screenings were positive for either
substance use, depression, or both, and 22 % of those screening positive received at
least one brief intervention session using the workbook. Individuals who screened
positive for depression and/or suicide risk but negative for any risk of substance use
were referred to mental health providers for follow-up assessment and services.
Prescription medication misuse was the most prevalent substance use problem, fol-
lowed in decreasing order by alcohol, over-the-counter medications, and illicit sub-
stances (the latter representing only about one percent of the problems identified).
An interesting finding was that only about 10 % (n = 339) of referrals were specifi-
cally for alcohol problems, but when screened for alcohol problems, about 16 %
(n = 556) of participants were found to be risky or problematic drinkers. Similarly,
while referrals for illicit drug use amounted to about 1 % (n = 40) of all screenings,
more than double actually screened positive as using illicit drugs, such as mari-
juana. In contrast, the number of referrals for prescription (n = 925) and over-the-
counter medication misuse (n = 272) were slightly higher than those who screened
positive for those categories. Such findings may be indicative of “hidden substance
abuse” where older adults may be more likely to be overlooked and under-identified
by traditional outreach and screening methods. As expected, depression was more
frequently reported as part of the referral process (n = 2248) and often present
among those who screening positive for substance misuse. Results showed that
about 21 % of all screenings resulted in at least one brief intervention session.
At discharge and 30-day follow-ups, improvement in all areas (alcohol, medication
misuse, and depression measures) was demonstrated.
Florida later applied for and received a $14 million, 5-year, state cooperative
grant from the Substance Abuse and Mental Health Services Administration
(SAMHSA) Center for Substance Abuse Treatment (CSAT) to implement SBIRT
specific to older adults and to expand the Florida BRITE Project beyond the pilot
stage. The Florida effort differed from SBIRT initiatives conducted in other states.
First, given Florida’s priorities to better serve its large older adult population, rather
220 L. Schonfeld
than a general healthcare population of potentially all ages, BRITE concentrated

solely on older adults (under the SAMHSA/CSAT grant the BRITE minimum age
criterion was lowered to 55 years to reach a larger number of people). Second,
whereas SBIRT staff in other states screened almost exclusively in healthcare set-
tings (e.g., hospital emergency departments, primary care physicians’ offices, and
trauma centers), BRITE included many other sites in order to screen older adults,
such as where they lived or where they received aging or social services.
The award of the 5-year federal grant required that certain changes be imple-
mented to accommodate the requirements all state grantees had to meet. Changes
included a target of total screenings, a requirement that screening be conducted in
healthcare settings as well as in other settings, and use of several screening elements
including the Alcohol, Smoking and Substance Involvement Screening Test
(ASSIST) [23]. For Florida, the target of 66,074 screenings of older adults was
determined by SAMHSA/CSAT. The Florida DCF Substance Abuse Program
Office oversaw the award of contracts to various healthcare and non-healthcare
agencies. BRITE contracts were awarded to specialty hospitals, aging services,
behavioral health programs, health clinics, and a veterans’ hospital. Over the 5 years
of SBIRT funding, health educators employed by one of 29 agencies in 18 counties
screened 85,001 people at 75 different sites [24].
One outstanding question when adapting SBIRT to older adults was whether
there would be similar proportions of negative screens, as well as positive screens at
moderate, moderate to high, or high level of risk compared to other states that
implemented SBIRT in a general population. Results from the first cohort of six
states receiving SBIRT grants led to expectations about the proportions of negative
and positive screens [25]. All six states conducted SBIRT in medical settings, such
as hospital emergency departments, community health clinics, federally qualified
health centers, trauma centers, and school-based health clinics. A total of 459,599
patients were screened over the 5-year period across all states in the first cohort of
state grantees, of which 22.7 % were positive for substance misuse, 15.9 % received
a brief intervention, 3.2 % received brief treatment (3.2 %), and 3.7 % were referred
to specialty treatment. Thus, the expectations for all grantees were that three quar-
ters of screenings would reveal either no substance use or lack of any substance
misuse, and among the positive screens, most would receive a brief intervention
immediately after the administration of the screen.
Out of the 85,001 screenings in the Florida BRITE Project, 8165 (9.6 %) adults
ages 55 and older were found to be at moderate or high risk for one or more sub-
stances. A total of 6600 (80.8 %) actually received SBIRT services with most
(83.4 %; n = 5436) receiving at least one brief intervention session for alcohol or
medication misuse, while the remainder received brief treatment (5.9 % of service
recipients, n = 387) or referral to treatment (11.8 %; n = 777). Therefore, in general,
it would appear that SBIRT universal screening for an older population may have a
higher proportion of negative screens. Non-healthcare providers identified a higher
proportion of the positive screens with 10.1 % for mental health, 10.4 % for aging
services, and 11.7 % for substance abuse providers, while healthcare sites identified
only 8.4 %. Thus, the elder-specific Florida BRITE Project observed a smaller
percentage of positive screens compared to SBIRT grantees screening a general-age

but often younger population. It should also be noted that aging services also
completed a much higher percentage (57.4 %) of required 6-month follow-ups,
compared to mental health (42.9 %), substance abuse providers (25.9 %), and lastly
the healthcare providers (13.5 %) [24].
Some important lessons were learned in implementing an SBIRT model in
Florida. In the next section, the components of SBIRT and adaptions for addressing
the need of the older adult population are discussed.
14.5 Adaptation of SBIRT for Older Adults
14.5.1 Developing the Network for SBIRT
The first lesson learned from implementing the Florida BRITE Project was related
to SAMHSA’s requirement that grantees screen in healthcare settings, as SAMHSA
regards SBIRT a healthcare-based model. In contrast, our Florida-based project was
proposed and funded as a more diverse application of SBIRT in which the Florida
Department of Children and Families (DCF) awarded contracts to both healthcare
facilities/providers as well as non-healthcare provider agencies. Some contracts
were awarded to hospitals, a trauma center, primary care practices, and urgent care
clinics. For these sites, hospital or clinic staff conducted screenings and brief inter-
ventions. Non-healthcare providers receiving contracts included aging-services,
mental health services (community mental health centers and behavioral healthcare
agencies), or substance abuse treatment service providers that conducted SBIRT in
numerous settings in the community. This latter group screened in various commu-
nity settings but was also required to screen in healthcare settings. These agencies
were initially met with resistance from hospital administrators who were reluctant
to sign written agreements permitting BRITE health educators to conduct SBIRT
services on site. It often took several months of discussions among providers,
Florida DCF, and the hospitals to address concerns over HIPAA, confidentiality, and
liability. Once written agreements were enacted, hospital administrators’ concerns
were allayed, and they began to view SBIRT specialists as a wonderful addition to
their programs, with the side benefit of keeping patients engaged during otherwise
long and boring waiting periods between tests and examinations by hospital staff.
14.5.2 General Issues Regarding Screening Older Adults
Research suggests the need for adaptation of screening instruments for addressing
older adults’ misuse of alcohol, rather than relying on criteria typically used with
younger people. The first adaptation relates to what constitutes risky or problematic
use of alcohol and the quantity consumed. In general, while alcohol consumption
decreases with age, sensitivity to alcohol increases. For example, Moos and col-
leagues [3] in their longitudinal study of 55–65-year-olds followed for 10 and 20 years
222 L. Schonfeld
found that while health problems increased, alcohol consumption declined with age.
The exception was alcohol increases among patients trying to manage pain [3].
While health problems lead individuals to seek medical help, alcohol is typically
overlooked or of less concern than those presenting problems. Age-related changes
in metabolism and health conditions can lead to higher blood alcohol concentrations
in older adults even when they consume less alcohol than their youth, resulting in
increased risk for health problems, accidents, and falls. For this reason, expert pan-
els in both the USA and the UK have recommended lower drinking limits for older
adults to remain healthy [26, 27]. This in turn indicates the need for modification of
quantity/frequency criteria embedded within alcohol screening instruments.
In the Florida BRITE Project, the NIAAA prescreen was used [28], in which
males are identified as positive for alcohol risk if they drink more than five drinks
on any one occasion and four drinks for females. Yet, expert panels have recom-
mended no more than one drink per day for older men and “somewhat less” for
older women [27]. Lowering the criteria for older adults would result in more cases
being classified as “at risk”; however, a caveat is that a low criterion may not be
applicable to all elders, as is the case in planned retirement communities, where
residents seek an active and social lifestyle. Research suggests that many adults in
these communities drink beyond recommended limits but regard drinking as part of
the social activities, do not report many health concerns, and report a high quality of
life. This was seen in a 2012 survey of The Villages, a large retirement community
of over 90,000 residents in central Florida. Out of 11,102 surveys returned in which
the three-item AUDIT-C alcohol screen was included, hazardous drinking was
reported in 1600 (15.4 %) of respondents. Drinking was negatively correlated with
depression, and most (three-quarters or more) respondents believed they were more
social, more active, and had a higher quality of life than seniors living outside of
The Villages [29].
Similarly, there are concerns about what constitutes risk of prescription medica-
tions, whether concomitant with alcohol use or not. Younger adults may engage in
nonmedical use of prescription medications, such as opioids, for recreational pur-
poses. For many older adults, medication misuse is a problem, but the motivation or
intention to misuse is often different than it is for their younger counterparts.
Furthermore, many older adults have legitimate prescriptions for the medications
and should not be considered as illicit drug users.
In implementing SAMHSA SBIRT grants, several assessments were required.
Following a positive prescreen, SAMHSA required completion of the GPRA
(Government Performance and Results Act) quantity/frequency measures, as well
as administration of the ASSIST [23], which asks participants to respond to ques-
tions about ten different forms of substance use. Out of the 85,001 screenings, 8165
adults ages 55 and older were found to be at moderate or high risk for one or more
substances. Among these, 31.1 % consumed alcohol to the point of intoxication, and
13.1 % were found to be using illicit drugs. Importantly, misuse of medications
could only be categorized using the GPRA classification as “illegal drug use,” even
when many of the older adults identified were misusing or making errors in appro-
priately prescribed medications. This categorization has important implications for
intervention. If we viewed adults’ medication misuse as illicit behavior, the intervention

might be different, focusing on elimination of the medication during the brief
intervention sessions. If we view older adults’ medication misuse of legitimately
prescribed medications as errors rather than intentional efforts to recreate, then
patient education would be the appropriate strategy.
14.5.3 Prescreening
As illustrated in Fig. 14.1, SBIRT begins with universal screening, the key element
to a public health approach. In medical settings, such as emergency departments or
primary care clinics, universal screening is interpreted as everyone who enters those
venues is asked to participate in the screening process. Rather than a lengthy instru-
ment, universal screening is actually best implemented by using a very brief pre-
screen. By this we refer to an instrument with just a few questions (perhaps three or
four) that can easily be committed to memory by the interviewer. The prescreen
must have sufficient sensitivity to identify older people potentially at risk and have
a simple response format (yes/no). The purpose of a prescreen is to determine the
need for a comprehensive assessment that will identify the extent or level of severity
of the drinking problem. It is possible that a person may have a positive prescreen
while assessed as low risk on the comprehensive assessment. In either case, that
person would only receive feedback about the results, and no further intervention
other than praise for maintaining a healthy lifestyle.
Use of a simple prescreen also increases the likelihood that it will be incorpo-
rated into the initial assessment by healthcare, aging, and social service providers.
A very brief instrument is also ideal for an older population, where negative screens
are likely to be revealed due to increased abstinence or declining alcohol consump-
tion in the general population of older adults. Its brevity allows healthcare and
service providers to move quickly on to other issues, such as presenting medical
problems. At the same time, a few simple questions are less likely to be perceived
by the older adult as threatening and also less likely to cause fatigue or resistance to
a lengthy interview.
A number of prescreens are available and have been used to determine need
for SBIRT services. The AUDIT-C [30] is a three-item version of the Alcohol Use
Feedback
Low Risk
Only
Moderate Brief
Positive Risk Intervention
ASSIST
Prescreen? Moderate to Brief
High Risk Treatment
Referral to
High Risk
Treatment
Fig. 14.1 Model for screening and providing SBIRT services

224 L. Schonfeld
Disorders Identification Test [31]. The items ask: How often do you have a drink
containing alcohol? How many drinks containing alcohol do you have on a typical
day when you are drinking? How often do you have six or more drinks on one
occasion? Bush and colleagues validated the three-item version among mostly older
(mean age 67; 91 % were 50 and older) sample of veterans, finding that the AUDIT-C
was superior in identifying heavy drinkers compared to the CAGE (which only
identified 56 %).
The CAGE is often mentioned because of brevity and ease of use. The name is
an acronym derived from key words in its four questions: Have you ever felt you
should cut down on your drinking? Have people annoyed you by criticizing your
drinking? Have you ever felt bad or guilty about your drinking? Have you ever had
a drink first thing in the morning to steady your nerves or to get rid of a hangover
(eye-opener)? [32] Similarly, the CAGE-AID uses the same four questions, but
modified by inclusion of drug use or alcohol use at the end of each item [33]. A yes
to two or more questions indicates further assessment is needed. However, the
CAGE alcohol screen lacks a time frame for determining when the alcohol-related
behaviors occurred. For older adults, universal screening might reveal positive
results due to alcohol problems that occurred in the distant past. Furthermore, the
sensitivity of the CAGE for an older population has been found to be rather low
[34], with implications that lowering the criteria to just one positive answer may be
sufficient to flag the older adult who would benefit from further assessment for
alcohol problems.
Another example of a prescreen is published by the National Institute of Alcohol
Abuse and Alcoholism [28] as was used in the Florida BRITE Project. The first
question is: How many times in the past year have you had five or more drinks in a
day (for men; or four or more drinks in a day (for women)? If a person indicates no
such drinking, they are provided with some educational material about the content
of alcoholic beverages. On the other hand, if the person answers at least once, then
they are asked: On average, how many days a week do you have an alcoholic drink?
And, on a typical drinking day, how many drinks do you have? By multiplying the
answers to both, a weekly average is obtained to determine the need for further
screening. This prescreen was used in the Florida BRITE Project; however, as sug-
gested earlier, use of the NIAAA prescreen may lead to under-detection of an alco-
hol problem in an older adult due to the increased sensitivity for whom fewer drinks
on any one occasion may be problematic.
The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)
is a ten-item screen with a yes/no response format developed from a 28-item instru-
ment specifically for older adults [35]. Each “yes” response is scored as one point
and scores from 2 to 10 are judged as positive screen for possible alcohol problems.
In contrast to the CAGE, Moore and colleagues found that the SMAST-G may result
in a higher number of positive screens even with fewer drinks per week, suggesting
that the SMAST-G may detect older persons at risk of developing alcohol problems
[36]. While recommended by SAMHSA as screen for older adults’ alcohol use,
as a universal prescreen it would require a little more time and less likely to be
committed to memory by screeners.
Lastly, another possible prescreen, although lengthier, is the National Institute of

Drug Abuse’s (NIDA) modified version of the ASSIST. The NIDA Quick Screen
[37] can be self-administered online, or conducted as an interview beginning
with the premise: “In the past year, how often have you used the following?” and
followed by four items: Alcohol (For men, five or more drinks a day. For women,
four or more drinks a day); tobacco products; prescription drugs for nonmedical
reasons; and illegal drugs. For all, the respondent uses the five-point, Likert-type
scale with potential responses: never, once or twice, monthly, weekly, or daily or
almost daily. For alcohol, if the person responds other than “never,” the individual
is considered an at-risk drinker, and the screener is advised to begin brief intervention
or other services.
In summary, the above instruments indicate that all have certain advantages as a
public health approach of universal prescreening of all eligible people. Clinicians
will need to decide whether or not such instruments can be easily incorporated
into routine, initial health interviews, and level of comfort in administering each.
The principle message, however, is to ensure that older adults are asked questions
about their drinking. Physicians, nurses, and other healthcare professionals can
encourage good behavior following a negative screen.
14.5.4 Comprehensive Risk Assessment
A brief prescreen is used to rule out individuals who do not consume alcohol or
illicit drugs, or rule out those who consume alcohol but at low risk levels. For posi-
tive screens, the next step is to assess the severity of the problem. The ASSIST
(Version 3.0) was required of grantees during the time BRITE was implemented.
The ASSIST remains a useful instrument for determining the type of SBIRT inter-
vention appropriate for the level of assessed risk. The ASSIST screens for lifetime
as well as recent use of ten substances: tobacco, alcohol, cannabis, cocaine, amphet-
amines, inhalants, sedatives, hallucinogens, opioids, and other drugs. The first set of
questions address lifetime use with an easy response format of yes or no, exempting
any with no lifetime use from further questions. Should any “yes” response occur,
the sets of questions that follow focus on use in the past 3 months (how often the
person used; how often the person had a strong desire or urge to use; and how often
the use led to health, social, legal, or financial problems?), followed by questions,
again about any use in the past (Has a friend or relative or anyone else ever expressed
concern about your use? Have you ever tried and failed to control, cut down, or stop
using? Have you ever used any drug by injection?). Response sets use different
Likert-type scales on the questions and require use of a response card to help the
person keep track of the possible answers from which to choose.
Following a positive prescreen for alcohol, as illustrated in the next level in Fig. 14.1,
ASSIST total scores for each problem substance are interpreted as low, moderate,
moderate to high risk, and high risk levels. As shown in Table 14.1, there are slight
differences in scoring for alcohol problems in comparison to other substances, such as
illicit drugs, including abuse of prescription medications (Table 14.1).
226 L. Schonfeld
Table 14.1 Range of ASSIST total scores and level of risk for alcohol or other substance
Assessed level of risk
Low Moderate Moderate to high High
Alcohol 0–10 11–19 20–26 27+
Other substance 0–3 4–19 20–26 27+
Each substance identified as problematic will result in a total score to guide the
SBIRT service delivery. These scores dictate what SBIRT services will be offered.
Low risk indicates that the person should receive positive feedback about their
ability to abstain or consume alcohol at acceptable levels. Moderate risk triggers the
decision to provide an immediate brief intervention session that relies on the use of
motivational interviewing to elicit a change in behavior. Moderate to high risk sug-
gests the use of brief treatment, which emphasizes motivational interviewing,
problem-solving, teaching coping strategies, and other skills to reduce risk. Finally,
high risk indicates the need to refer the individual to a substance abuse specialist or
treatment service.
The ASSIST should work well with older adults in their 50s and 60s, but may be
more challenging for the oldest group (mid-70s and older) for several reasons. First,
the initial, large validation study on the instrument was restricted to individuals ages
18–45, and therefore excluded older individuals [38]. Only one study (conducted in
France) appears to have demonstrated the validity for people ages 65 and older [39].
While the ASSIST does not address quantity of substances used, it does not need to
be adjusted to reflect the lower, recommended limits for drinking in older adults;
however, it does rely on frequency of use measures that may not apply the same to
older adults who are at risk compared to younger adults. In the Florida BRITE
Project, many screeners employed by aging services reported that the ASSIST was
not elder-friendly, in that its structure of the assessment was challenging for older
adults with cognitive or memory issues, as well as concerns about fatigue factor
from extensive assessments of health, cognition, nutrition, and other domains.
There is also a concern about how the ASSIST addresses older adults’ use and
misuse of prescription medications, whether concomitant with alcohol use or not.
As discussed earlier in this chapter, the ASSIST’s categorization of medication mis-
use was a major concern in conducting the Florida BRITE Project since any use
other than the prescribed method had to be categorized as illicit drug abuse in order
for the older adult to receive services. Older adults who receive prescriptions often
make unintentional errors in taking medications such as underuse or overuse, in
contrast to younger adults who might engage in recreational use.
Recognizing that the ASSIST may not be elder-friendly, it remains the preferred
instrument for identifying adults’ risk levels. This in turn helps the staff member
to determine the level of SBIRT services needed and standardizes the approach
without relying on individual counselors’ judgments. In the final level of Fig. 14.1,
the recommended SBIRT services are listed and based on the total score for the
substance being evaluated. Individuals at moderate levels would be offered brief
intervention.
14.5.5 Conducting Brief Interventions
Brief interventions with older adults have been shown to be effective in reducing risky
or problematic use of alcohol and as effective as with younger adults [40, 41]. The
intervention utilizes motivational interviewing (MI), the recommended approach for
motivating individuals to make a change in their substance use behavior [42]. MI is
appropriate for individuals who may be ambivalent or unaware of the harm that their
drinking can cause. When implemented properly, the aim is to motivate a person to
change behavior using principles and methods such as reflective listening, expressing
empathy, avoiding arguments and confrontation, rolling with resistance, use of cogni-
tive dissonance to create discrepancies in one’s belief about drinking vs. one’s actual
drinking behavior, and enhancing the client’s self-efficacy. The “readiness ruler” is
also used to assess how ready the person is to make a change in their behavior.
The acronym “FRAMES,” which stands for Feedback, Responsibility, Advice,
Menu of alternatives, Empathy, and Self-efficacy, is used to help providers imple-
ment MI effectively and motivate the person with the substance use problem to
make a change in behavior. This approach has long been recommended for use with
older problem drinkers as well [27].
The first principle, Feedback, occurs immediately after assessment (e.g., the
ASSIST) to provide the person with information about the risks associated with his/
her drinking at current levels, general education about the harmful effects, how
drinking relates to current problems, and how older adults in general respond to
alcohol. The principle of Responsibility refers to emphasis in the conversation that
the person is responsible for his/her own behavior, can make choices about drinking,
and encourages retaining personal control over drinking and its consequences.
Advice refers to the health educator providing information about the harmful conse-
quences of continued drinking, to make the person aware that continued drinking
could cause or exacerbate significant health problems, and education about the ben-
efits of cutting down or quitting drinking. The next principle is providing a Menu of
Options to help individuals choose a strategy for change from a list of alternatives
suggested in the MI session. Examples may include keeping a log of drinking, learn-
ing coping strategies to cope with high-risk situations and alternatives or methods to
avoid them, identifying others who can provide them support, providing written
materials to help them learn to overcome the problem, and providing a list of com-
munity providers of treatment services. The principle of Empathy refers to the MI
counselor or health educator’s approach to use reflection and empathy during the
interaction. Finally, the principle of Self efficacy refers to building the person’s con-
fidence to make a change in behavior and their drinking.
The FRAMES approach provides the trained health educator or brief intervention
counselor with positive strategies for motivating the person to change his or her
drinking behavior. A related strategy is the “5As approach” [43], referring to the five
characteristics used in behavioral and health counseling: assess, advise, agree,
assist, and arrange. Healthcare providers are able to bill Medicare for “annual alcohol
screening, and for those that screen positive, up to four, brief, face-to-face behavioral
counseling interventions per year for Medicare beneficiaries” using code G0443
228 L. Schonfeld
[44], provided that those four counseling interventions are completed “based on the
5As approach adopted by the United States Preventive Services Task Force
(USPSTF).” As listed by Centers for Medicare and Medicaid Services, the 5As are:
1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of
behavior change goals/methods.
2. Advise: Give clear, specific, and personalized behavior change advice, including
information about personal health harms and benefits.
3. Agree: Collaboratively select appropriate treatment goals and methods based on
the patient’s interest in and willingness to change the behavior.
4. Assist: Using behavior change techniques (self-help and/or counseling), aid the
patient in achieving agreed-upon goals by acquiring the skills, confidence, and
social/environmental supports for behavior change, supplemented with adjunc-
tive medical treatments when appropriate.
5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide
ongoing assistance/support and to adjust the treatment plan as needed, including
referral to more intensive or specialized treatment.
14.5.6 Staff Training Issues
Professionals who deliver brief interventions should receive training that addresses
MI and the 5As to ensure that the principles are being followed. Some may seek
formal training or certification in MI, while other may receive in-service training or
participate in short workshops. While MI is applicable to any age group, training on
aging-related issues would be helpful to avoid potential biases and misconceptions
due to ageism, as well as educate providers about aging-related changes in metabo-
lism, cognition, physical health, mental health, and social activity.
Health promotion workbook [41] authored by SAMHSA provides structure for
interviewing the individual. The workbook covers steps that ask the person to identify
future (next 3 months) goals for physical, emotional, social, and financial well-being;
providing the person with a summary of health habits (exercise, nutrition, alcohol,
medications); education components about drinking and medication use in the older
population; alcohol–medication interactions; consequences of at-risk drinking; rea-
sons to cut down or quit; a series of steps to create a plan related to the substance
misuse; deciding a drinking limit, keeping a diary of use; handling risky situations;
medication management; and a summary of the session. In pilot study of BRITE,
it was found that use of the workbook helped the wide array of health educators
maintain the MI principles and goals [22].
14.5.7 Brief Treatment
Individuals considered to be at moderate to high levels of risk can be offered partici-

pation in brief treatment. As part of the BRITE protocol, health educators had the
option of using the SAMHSA manual Substance Abuse Relapse Prevention for
Older Adults [9] for individuals at moderate to high levels of risk. The approach
based on earlier work with older adults in formal substance abuse treatment involved
a 16-session curriculum utilizing cognitive-behavioral and self-management
approaches that could be conducted in group or individual sessions. The manual’s
content provides a curriculum with an elder appropriate assessment for identifying
each person’s high-risk situations for substance use, perceived positive and negative
consequences of use, methods for teaching the person to understand the compo-
nents of his or her substance use behavior chain, and the curricula to teach clients
self-management and CBT skills necessary to deal with high-risk situations and
prevent relapse. The curriculum provided examples of high-risk situations appropri-
ate to older adults, such as drinking at home and alone and drinking in response to
depression. While designed for older adults, the skills training could readily be
adapted for any age group.
During the pilot phase of the BRITE project we found that relatively few provid-
ers utilized this protocol, and instead opted to use the brief intervention approach.
In SBIRT, for individuals with moderate risk, one session may be sufficient to moti-
vate a person to change behavior. For individuals at higher risk, brief treatment
works best if the person can return for several sessions, with each session lasting an
hour. Thus skills training can be implemented, and clients can report to the therapist
about any high-risk situations encountered, urges to use substances, and what skills
the person did or did not employ to avoid a lapse or a relapse.
14.5.8 Referral to Treatment
In SBIRT, referral to treatment is the recommended service for anyone at highest

level of risk on the ASSIST. Referral of older adults to formal substance abuse
treatment is sometimes a challenge. As noted earlier, while there are increases in
older adults requiring treatment, there are fewer elder-specific treatment pro-
grams. As a result, referral to treatment programs may be geared towards the
higher profile cases involving youth and younger adults. If treatment admission
is voluntary, many older adults may find it difficult to identify with younger
adults in treatment.
A concern in sending referrals to substance abuse treatment providers is that
the staff members are unlikely to have expertise in dealing with an aging popula-
tion. In interviews with a national sample (n = 346) of private treatment center
administrators, only 18 % indicated that their center provided special services
(separate tracks, special groups, or lectures/services) for older adults. They also
found that Medicare payment capability predicted availability of special services
[45]. Thus, while there are increasing trends of older adults misusing substances,
older adults still remain a small minority of admissions to treatment. If universal
screening is implemented, SBIRT providers will need to work hard to develop an
appropriate referral network and memoranda of understanding to ensure that older
adults scoring at the highest level of risk will have options for treatment
services.
230 L. Schonfeld
14.6 Conclusions
The SBIRT model is an evidence-based practice that has been used for many years
with various populations. Primarily designed for screening and intervention with
medical patients, the model can be effective in other venues and with older adults.
In this chapter, several areas that clinicians should consider as adaptations of proce-
dures with older adults for states that have been funded by SAMHSA to implement
SBIRT on a large scale were presented. A first consideration is to adapt prescreen-
ing criteria to accommodate older adults’ increased sensitivity to alcohol and other
substances, as well as lifestyle. Providers should consider whether risk for alcohol
should be measured at levels lower than that for younger adults. Secondly, providers
should determine if use of lengthier comprehensive assessments, such as the
ASSIST, will cause fatigue or resistance among the oldest-old. Finally, an issue to
be considered is if and when to use structured or standardized approaches to deliver
brief intervention and brief treatment. This refers to using a health promotion work-
book or substance abuse relapse prevention manual so that healthcare providers and
health educators maintain a consistent style and use of motivational interviewing, as
opposed to allow each person to provide brief interventions as he or she sees fit.
Incentives for providers to offer SBIRT services are that they can intervene at
an early stage of a previously unidentified alcohol or drug problem, and with the
older population, providers can bill Medicare for screening and brief counseling
sessions. As with all treatment and prevention services, the more simple the screen-
ing and intervention, the more likely it will be incorporated into routine practice.
Both healthcare services and aging services should incorporate a universal pre-
screen for alcohol problems in their routine of initial assessments. Building a refer-
ral network of providers through formal agreements and through informal means
such as participating in elder-services’ coalitions or networks will also enhance
coordination of care.
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Long-Term Care and Alcohol Use
15
Nicholas Castle, Mary Lindsey Smith, and David G. Wolf
Alcohol misuse among older adults has been called the “invisible epidemic” [1] and
has long been advocated as a priority area for attention and action. This is based on
the notion that alcohol can have a pronounced negative effect on health, quality of
life, and health care costs. Alcohol misuse or unhealthy alcohol use is a broad term
that includes persons who exceed recommended guidelines (e.g., more than one
drink daily), engage in risky behavior, and meet criteria for alcohol abuse or depen-
dence [2]. Despite the importance of alcohol misuse in older adults, very little empir-
ical research exists examining this (or other alcohol-related issues) in long-term care
(LTC) settings. In this chapter, a review of the literature of alcohol misuse in LTC
settings is presented. In this review, we consider LTC settings for older adults to
include nursing homes, assisted living, and senior high-rise communities.
Measurement of alcohol consumption is multidimensional, and terms used to
represent use and misuse are varied, including alcoholism, alcohol abuse, alcohol
dependence, heavy drinking, and binge drinking. In examining the literature on
alcohol use in LTC settings, we include alcohol misuse, which we define as heavy
drinking: drinking a quantity and frequency above recommended guidelines but not
meeting criteria for alcohol abuse or dependence.
N. Castle, Ph.D. (*)

Department of Health Policy & Management, University of Pittsburgh,
130 DeSoto Street, A610 Crabtree Hall, Pittsburgh, PA 15261, USA
M.L. Smith, Ph.D., M.S.W.
Cutler Institute of Health and Social Policy, Muskie School of Public Service, University of
Southern Maine, 34 Bedford Street, Wishcamper 410, Portland, ME 04104, USA
D.G. Wolf, Ph.D., M.S.O.L.
School of Professional & Career Education, Barry University,
15900 Pines Boulevard, Pembroke Pines, FL 33027, USA

234 N. Castle et al.
Alcohol misuse is not a new phenomenon among older adults; alcohol continues
to be the most commonly abused substance by older adults [3]. More than half of
those aged 65 or older report drinking alcohol [4]; however, as described below,
older adults living in LTC settings (i.e., assisted living facilities, nursing homes,
elderly high-rise communities) may be at higher risk. For example, research by
Klein and Jess suggests that up to one-half of nursing home residents suffer from
alcohol problems [5].
Older adults are especially susceptible to the adverse consequences of alcohol
use because of the physiological changes associated with aging [6]. Aging leads to
an impaired ability to metabolize and clear alcohol from one’s system due to com-
promised hepatic and renal functioning, a decreased effectiveness of the blood–
brain barrier, and an increased use of medications. For example, older adults respond
differently to various drugs because they tend to have a slower metabolism and
blood flow that can cause adverse drug reactions. In addition, liver and kidney func-
tioning may also be affected by alcohol consumption. This can lead to a paradoxical
situation whereby seniors consume less alcohol, but suffer increasing adverse con-
sequences from consumption [5]. Given the often impaired health status of LTC
residents, these adverse reactions may be of particular significance in these
settings.
Alcohol misuse in LTC settings has considerable significance. Alcohol-related
medical problems are associated with hospitalization of older Americans; indeed,
they are associated with hospitalization more often than heart attacks and cost tax-
payers more than $230 million yearly in Medicare paid hospital bills [7]. In addition
to being associated with increased risk of health complications, alcohol misuse in
seniors is also associated with higher health care utilization, which means higher
health care costs [8]. Seniors that abuse alcohol often have longer hospital stays [9]
and the prevalence of hospitalization and cost of health care services may be much
higher than reported because alcohol misuse often goes underidentified and undiag-
nosed in older adults. These numbers can suggest a lack of training and knowledge
of alcohol as a problem by staff and a possible paucity of screening, diagnostic, and
treatment services in LTC settings [10].
Moreover, the majority of older adults are using daily prescription medica-
tions, which creates further problems if seniors mix prescriptions with alcohol
[11]. On average, older adults are prescribed between two and seven medications
[11], and these rates are even higher in LTC settings averaging nine prescription
medications [12].
Furthermore, LTC residents with alcohol-related problems are more likely to
suffer from illness, self-neglect, disability, nutritional deficiencies, depression and
anxiety, and behavioral problems such as wandering leading to falls and fractures
[9, 10]. Older adults in LTC may also have a higher mortality rate [13], greater psy-
chiatric comorbidity, and require additional mental health and social services [14].
Collectively, these additional psychological and medical conditions result in signifi-
cantly greater use of health services such as emergency department visits as well as
mental health and social services care [15]. Threats to the facility and other resi-
dents exist from alcohol-related fires. Thus, alcohol misuse by seniors living in LTC
15 Long-Term Care and Alcohol Use 235
represents an important concern for the health of residents and quality and safety of
the delivery of health care.
Diagnosing alcohol abuse and misuse among seniors can be a challenge for
health care providers because individuals may often present with the signs and
symptoms that may be typical aging effects (i.e., forgetfulness, loss of balance,
and speech problems) [5]. Existing measures of alcohol use, even those developed
specifically for geriatric populations, are based on paradigms of alcohol use that
have conceptualized alcohol-related problems in terms of disorders. These para-
digms are not as useful when applied to older drinkers whose alcohol use, regard-
less of consumption level, can be problematic because of age-related physiological
changes, medication use, and issues related to functional mobility [2]. A lack of
adequate detection and diagnostic techniques for older adults means that substance
abuse often goes undetected in this population, and those needing treatment do not
receive services. Typically, substance-related problems in this population are only
identified when these individuals are hospitalized for physical illnesses.
In the following sections, we present findings from the literature regarding
alcohol use and misuse in specific LTC settings (nursing homes, assisted living, and
senior high-rise communities).
15.1 Nursing Homes
Nursing homes typically act as the permanent residence (home) or as a short-term

rehabilitation facility, mostly for older adults [16]. The majority of nursing homes
are certified by Medicare and/or Medicaid, while others are licensed by individual
states [17]. In the USA, about 16,100 nursing homes exist [18], and approximately
3.5 million people reside in a nursing home in any given year [18].
As noted above, drinking problems are associated with multiple negative health
outcomes. However, the mere use of alcohol may not precipitate LTC placement.
Kaplan and associates [19] analyzing data collected over 14 years identified that
former drinkers and infrequent drinkers were more than twice as likely to be placed
in a LTC setting compared to moderate drinkers. Alcohol misuse, on the other hand,
may precipitate use of LTC settings [9].
Issues in nursing homes often mirror those of the larger society. Disease (such as
HIV) and medical conditions (such as obesity) are common diagnoses among
patients in nursing homes. Therefore, it is not surprising that nursing home residents
may have prior or ongoing alcohol misuse. Nursing home staff report that a signifi-
cant number of nursing home residents have health problems related to alcohol use
[5]. There are also a high number (26 %) of elders in Veterans Administration (VA)
nursing homes that suffer from active alcohol misuse [20]. However, we note that
these studies are dated, and more recent rates of nursing home residents with alco-
hol problems are needed. The authors’ ongoing research would suggest that rates
are high, but not at the levels reported in these prior studies. Research has also
shown that nursing home residents receiving alcohol and drug treatments are some-
what uncharacteristic of typical residents.
Nursing home residents receiving alcohol and drug treatment tend to be younger
(less than 50) and male [21]. Two studies conducted at VA nursing homes designed
to assess the effect of alcohol use disorders among patients were identified showing
higher morbidity rates among younger residents who abused alcohol. Additionally,
the level of care and utilization of health care services among residents who had
alcohol use disorders was much higher [13, 22]. A study from the National Nursing
Home Survey in 2005 also showed older adult nursing home residents with alcohol
misuse used hospital inpatient services more frequently, required more mental
health and social services, and had longer lengths of stay [14].
Nursing home residents with alcohol misuse also present more challenges for
staff [22]. As such, many facilities have alcohol use policies. The National
Association Directors of Nursing Administration in Long Term Care (NADONA/
LTC) completed a survey on nursing home policies in regard to items brought in
from outside of the facility [23]. The survey included items that asked about over-
the-counter medications, alcohol, and cigarettes. Of the 299 surveys that were
mailed, 94 (33 %) of the nursing homes had a written policy on alcoholic beverages,
178 (60 %) facilities required physician orders to allow alcohol consumption, 67
(22 %) required a physician order and the resident was also monitored, and 64
(21 %) had staff education to support their alcohol policy [23].
As we describe below for Assisted Living, alcohol consumption can be seen as
both beneficial and harmful in nursing homes. Harm includes behavior issues and
health issues; whereas, benefits include social and quality of life issues. Past com-
mentaries have examined the pros and cons of these alcohol consumption issues
[24]. However, the resident population of nursing homes has changed in recent
years; residents are older and sicker [16]. So, despite policies that may exist, it may
be that alcohol consumption may not be an option for many.
A recent development in nursing homes is the increased use of resident-cen-
tered care, which entails moving care towards a more home-like environment in
which processes are more resident friendly. Resident-centered care is often
referred to as “culture change” [25]. One definition of resident-centered care is
“an ongoing, interactive process between residents, caregivers and others that
honor the residents’ dignity and choices in directing their daily life” ([26], p. 1).
Another is “resident centered care is an ongoing, interactive process between resi-
dents, caregivers and others that honor the residents’ dignity and choices in direct-
ing their daily life” ([26], p. 1). This transformative approach caring for residents
can lead to facility practices that are different from the past. Facilities attempt to
keep seniors’ lives as normal as possible; this includes offering social activities,
varied meal times, etc.—but, to date little data exists as to whether this includes
alcohol consumption.
A further recent development in nursing homes is an emphasis on acute care
transfers (e.g., ER use and hospitalization). Due to multiple chronic conditions and
frailty, nursing home residents are at high risk for acute care transfers. For example,
20 % of Medicare residents admitted to nursing homes from hospitals are readmit-
ted to the hospital within 30 days [27]. Potential negative resident outcomes from
acute care transfers include mortality, physiological decline, and psychological
decline. Yet, it has been noted that approximately 50–66 % of all acute care transfers
are potentially preventable [27]. In addition, acute care transfers are an emphasis
area for Centers for Medicare & Medicaid Services (CMS), as they contribute to
unnecessary health care costs. Nursing homes are under considerable pressure to
reduce acute care transfers. Given the association of alcohol use with acute care
transfers [14], nursing homes may implement more appropriate alcohol use poli-
cies—or at least be more cognizant of alcohol-related issues.
15.2 Assisted Living
In 1997, there were an estimated 11,459 assisted living settings in the USA, rising to
a more recent estimate of approximately 40,000 in 2014 [28]. As of 2014, there were
about one million Americans living in assisted living/residential care communities
[28]. Assisted living is a LTC setting that typically provides care for residents that
require support for one or more activities of daily living (ADLs) and/or instrumental
activities of daily living (IADLs). The assisted living industry is not regulated by
federal legislation, but by individual states. State regulations vary in standards and
the oversight used for these settings likewise can vary [29]. Not surprisingly, the
quality of assisted living varies. A General Accounting Office (GAO) report noted
frequent care problems with “inadequate or insufficient care,” “insufficient, unquali-
fied, and untrained staff,” and “not providing residents appropriate medications”
([30], p. 3). Care problems could also include inadequate prevention, screening, and
diagnosis of alcohol misuse and abuse. The long-term care ombudsman program has
reported that problems in assisted living settings are commonly reported [31]; how-
ever, alcohol misuse or abuse has not been delineated in these reports.
The cost of assisted living is a factor important to the development of the
industry. Assisted living care is generally not reimbursed with federal dollars
(i.e., Medicare or Medicaid programs). The out-of-pocket costs that seniors and
their families incur for assisted living can be over $60,000 annually [28]. This may
be important for alcohol use. Residents of assisted living settings are generally of
higher income, and the percentage of older adults drinking alcohol is higher among
those with higher income [32].
There are several characteristics of assisted living settings that could potentially
lead to AUDs and alcohol misuse among seniors. Influences that can lead to alcohol
misuse include stress, isolation, losses, loneliness, cognitive impairment, and onset
of illness [33]. For example, 64 % of residents have moderate to severe cognitive
impairment [12]. Residents of assisted living settings include a higher proportion of
males (approximately 36 %), unlike other LTC settings which overwhelmingly consist
of females (approximately 73 %). Males drink more frequently and in higher quantities
than females [34]. Placement in an assisted living setting may also be precipitated
by prior alcohol abuse or misuse [5].
Alcohol can be seen as both beneficial and harmful in assisted living settings
because alcohol is a normal part of an adult’s social life. This can lead to different
facility practices. Some facilities attempt to keep seniors’ lives as normal as
Table 15.1 Alcohol policies in assisted living settings

Question Yes (%)
We permit residents to consume alcohol at the facility 82
We permit residents’ family/guests to bring alcohol into the facility 87
We permit residents’ family/guests to consume alcohol at the facility 89
We provide information to residents on the risks of alcohol use/abuse 61
We are aware of specific residents who abuse alcohol 75
We provide happy hours or various social gatherings where alcohol is served 82
We offer staff training on how to recognize alcohol problems 46
Source: Data from authors’ ongoing research
possible by offering social activities which may include alcohol. For example, some
facilities offer a cocktail hour or allow alcohol in residents’ rooms, which can
contribute to alcohol problems. In order to help with alcohol problems, some facilities
have policies and procedures in place that require staff to retain possession of a
resident’s alcohol to monitor use and some go as far as to require a physician’s per-
mission for a resident to consume alcohol [5].
Recently, Castle and associates [35] examined alcohol misuse and abuse as
reported by nurse aides working in assisted living. A total of 832 nurse aides from
Pennsylvania were included. These nurse aides believed the majority (69 %) of
assisted living residents drank alcohol; these consumption rates are higher than
those reported for community-dwelling older adults. Of these residents, 34 % were
thought to drink alcohol daily. It was also estimated that in 19 % of cases, nurse
aides believed alcohol consumption had influenced residents’ health and 28 % were
suspected to be making poor choices for alcohol consumption.
A follow-up study examined policies reported by assisted living top managers. A
total of 1,800 assisted living settings from most states in the USA were included. As
shown in Table 15.1, a majority (82 %) of assisted living settings permitted residents
to consume alcohol at the facility. However, staff training on how to recognize alco-
hol problems was somewhat lower (i.e., 46 %).
Only 9 % of the facilities provided an alcohol screen upon admission to the facil-
ity and 13 % of facilities screened patients regularly for alcohol problems. These
findings may represent a missed opportunity in LTC to implement (or encourage)
effective policies and procedures for prevention and screening, and effective treat-
ment programs for residents with alcohol misuse or abuse. More information on
facility practices is needed.
The results of this recent study indicate that assisted living facilities are in a par-
ticularly difficult dilemma. On the one hand, they need to attract private-paying
clients (who may expect a facility bar, happy hours, and social events including
alcohol) and on the other hand they are charged with assuring the health and safety
of residents under their care. For example, facility policies around alcohol con-
sumption may benefit some residents by facilitating interaction and reducing social
isolation. However, these same policies may be harmful to residents who are at risk
for alcohol abuse or misuse. The potential benefits or detrimental effects of alcohol
use vary based on each individual’s health situation and need to be weighed against
other common health complications of alcohol in older adulthood. Assisted living
facilities need to ensure that policies and practices around alcohol use ensure the
maximum quality of life and safety of all residents.
15.3 Senior High-Rise Communities
Senior high-rise communities are buildings with 20 or more units offering subsi-
dized housing to elders (they are one specific component of what is generally known
as senior housing). Senior high-rise communities are an important component of
housing for older adults, with an estimated 1.2 million seniors living in these set-
tings in the USA. However, little is known about the services that are provided in
these settings or the services that need to be provided in these settings.
Numerous service problems have been identified in senior high-rise communi-
ties. For example, the General Accountability Office (GAO) identified 6 % of pub-
lic housing units to be in “severe distress” ([36], p. 2), which included lack of
appropriate support services, further reports noted that a majority of seniors were
“disadvantaged” with respect to health services ([37], p. 4), and many HUD programs
were not “designed to provide supportive services for the elderly” ([38], p. 1). Care
problems may include inadequate prevention, screening, and diagnosis of alcohol
misuse and abuse.
Sheehan [39] found wide variation in estimates of alcohol misuse among resi-
dents of 100 public senior housing units. However, in larger units the average per-
cent of seniors considered to be problem drinkers was 9 %. This rate was also
considered to be an underestimate by the authors as it was based on staff rather than
self-report. The author also identified very little staff training in assessment or pol-
icy development in this area and a majority of housing mangers had no policy
regarding alcohol misuse.
Examining alcohol misuse in senior high-rise communities may be especially per-
tinent given the recent development of aging-in-place policies. That is, many older
adults wish to age in familiar areas and remain as independent as possible—which is
often termed aging-in-place [25]. Policy makers have seized upon aging-in-place as
initiatives that may provide cost-effective care. That is, aging-in-place can delay
potentially expensive nursing home care. Providers, such as integrated care compa-
nies, have also realized the same benefits. Thus, aging-in-place initiatives have devel-
oped as potentially important tools for care—they are seen somewhat as a panacea for
controlling costs, and as having few detrimental drawbacks. However, the idea of
aging-in-place may in some cases have surpassed the capacity of seniors to actually
safely do so. The number of older adults in need of substance abuse treatment of any
kind is expected to increase from 1.7 million in 2000/2001 to 4.4 million by 2020 [8].
With seniors, policy makers, and providers all pushing for the same goal, the limits of
“aging-in-place” may be stretched—including services for older adults with alcohol
abuse issues. In fact, substance abuse prevention and treatment services designed to
meet the unique needs of seniors are very limited in the USA. [8].
In 2006, as little as 7 % of substance abuse treatment facilities reported having
treatment specifically for older adults [40]. Research indicates that older adults
respond well to an age-specific support style in nonconfrontational group treatment
settings [41] as well as individualized treatment programs that incorporate group
and family counseling [42]. Age-specific treatment options may be key to success-
fully treating alcohol misuse among seniors.
Findings from a recent study of older adults (conducted in 2012) living in 20
senior high-rise communities in the Pittsburgh region indicate that alcohol use in
these senior high-rise communities is “high” and alcohol misuse may be problem-
atic. Data for this study came from an ongoing evaluation of service provision of the
20 senior high-rise communities and included interviews with 320 residents [43].
The response rate was 92 % and seniors interviewed were 58 % female, 67 % minor-
ities, had an average age of 77.4, and had on average lived in the facility 4.2 years.
The interviews were conducted in private, in the senior’s apartment, and included
questions addressing alcohol use. Interview results are provided in Table 15.2.
These findings are presented with the caveat that they are from a relatively small
sample, and they may not be representative of other regions of the country. Of
potential significance, this shows 26 % of seniors report having six or more drinks
on one occasion.
The first ten items used in the questionnaire in the senior high-rise communities
came from the Alcohol Use Disorders Identification Test (AUDIT; [44]), described
further below. A score of 8 or more on the AUDIT is considered to indicate hazard-
ous or harmful alcohol use. From the 320 residents used in our research, 34 % had a
score of 8 or more.
Based on these findings, a national mail survey was used to examine alcohol
misuse in senior high-rise communities (conducted in 2012). Building managers
were asked to complete a questionnaire, and 450 surveys were returned (response
rate = 78 %). A majority (72 %) of residents were reported as drinking alcohol. Of
those residents who reported consuming alcohol, 34 % were considered to be regu-
lar drinkers who had one or more drinks daily. Moreover, 48 % of respondents sus-
pected that residents made poor choices for alcohol consumption. In communities
with a high minority representation (i.e., 50 % or more minorities), alcohol misuse
and abuse was reported to be high (averaging more than 16 % of residents). These
communities were also significantly less likely to report the availability of health
services or use of screening tools for alcohol misuse. Also, in 13 % of cases respon-
dents believed alcohol consumption had influenced residents’ health.
Protocols in research by Clapp et al. [45] may be advantageous in further exam-
ining alcohol misuse in senior high-rise communities (and other LTC settings).
These researchers examined drinking behavior among low-income older adults, by
using a combination of self-reports and unobtrusive measures such as a bogus recy-
cling program [45].
Table 15.2 Alcohol use items of elders living in elderly high-rise communities
Item Response scale Mean
How often do you have a drink containing Never; monthly or less; two 37 % (four or
alcohol? to four times a month; two to more times a
three times a week; four or (week)
more times a week
How many drinks containing alcohol do 1 or 2; 3 or 4; 5 or 6; 7 to 9; 31 % (7–9)
you have on a typical day when you are 10 or more
drinking?
How often do you have six or more drinks Never; less than monthly; 26 % (weekly)
on one occasion? monthly; weekly; daily or
almost daily
During the past year, how often have you Never; less than monthly; 17 % (weekly)
found that you were not able to stop monthly; weekly; daily or
drinking once you had started? almost daily
failed to do what was normally expected of monthly; weekly; daily or
you because of drinking? almost daily
needed a drink in the morning to get monthly; weekly; daily or
yourself going after a heavy drinking almost daily
session?
had a feeling of guilt or remorse after monthly; weekly; daily or
drinking? almost daily
During the past year, have you been unable Never; less than monthly; 8 % (weekly)
to remember what happened the night monthly; weekly; daily or
before because you had been drinking? almost daily
Have you or someone else been injured as a No; yes, but not in the past 9 % (yes, during
result of your drinking? year; yes, during the past year the past year)
Has a relative or friend, doctor or other No; yes, but not in the past 17 % (yes,
health worker been concerned about your year; yes, during the past year during the past
drinking or suggested you cut down? year)
Are you drinking more now than in the Yes; no 58 % (yes)
past?
Does having a drink help you sleep? Yes; no 33 % (yes)
Source: Data from authors’ ongoing research
15.4 Discussion
The previous sections provide findings from the literature regarding alcohol mis-
use in nursing homes, assisted living, and senior high-rise communities as LTC
settings. Clearly, the research in this area is sparse. However, a few areas are worth
highlighting as potential areas of future discussion and investigation—detection
and caregivers.
15.5 Detection
Because older adults with alcohol misuse have not been thoroughly examined in the
research, the dearth of knowledge on screening, diagnosis, and treatment of older
adults with alcohol misuse makes it difficult to establish best practices for health
care professionals tasked with identifying or treating substance abuse disorders in
older adults [46].
There are several tools/instruments designed to detect alcohol abuse and misuse.
However, these assessment tools are generally not specifically designed for use with
seniors. This can create a detection barrier. As mentioned earlier, the senior popula-
tion is in a different stage in life and in LTC settings tend to be separated from the
rest of society. Many of the assessment tools ask questions that relate workplace
issues, school issues, parenting problems, or driving concerns, all of which do not
pertain to the LTC older adult population [46].
There are currently three primary screening instruments, among others, used to
detect alcohol abuse within the older adult population, the CAGE (Cut-down,
annoyed, guilty, eye-opener) questionnaire, The Michigan Alcoholism Screening
Test-Geriatric Version (MAST-G), and the Alcohol Use Disorders Identification
Test (AUDIT; [44]).
The CAGE questionnaire is meant to be a screening tool for alcohol abuse and
dependence. It can be used in primary care settings and was created as an easy tool
for health care providers to remember and therefore more likely to be used [47]. It
consists of four questions: “Have you ever: (1) felt the need to cut down on 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 can be adminis-
tered orally or as written questionnaire, and can be given at emergency care, sur-
gery, DWI offenders, enlisted Armed Forces, college students, industrial workers,
and workers in employee assistance programs.
The AUDIT tool was developed by the World Health Organization (WHO) to
assist providers in detecting patients with harmful alcohol patterns [48]. The AUDIT
is a ten question screening tool that asks questions on the frequency of one’s drink-
ing, alcohol dependence, and problems caused by alcohol. The AUDIT is not as
easily applicable as the CAGE tool, but it is no longer than a two to four minute
questionnaire that can be administered in a variety of health care settings.
The MAST-G is tailored to seniors. The MAST-G highlights the special employ-
ment and social situations of those who may be retired or facing different aging
process that may lead to alcohol abuse. It is primarily used in outpatient settings to
identify those who are risky alcohol users, abusers, or alcoholism [49].
The screening of older adults can be a challenging task. Many studies have used
the AUDIT, CAGE, and the MAST-G to understand the alcohol abuse concerns in
the USA. However, in order to further understand the severity of alcohol abuse
assistance residents need, the identification and delivery of appropriate interven-
tions are vital. There is an increased need for screening and assessment tools exclu-
sively designed for seniors, along with providers who are more comfortable with
using such screening tools. And to assist resident in need, to increase the awareness
of increased alcohol use, and to create an easy to use tool for medical providers, the
U.S. Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration for Substance Abuse Treatment published, “Alcohol
Use Among Older Adults, a Pocket Screening Instrument for Health Care and
Social Service Providers” [50].
15.6 Health Professionals
Primary care providers play a crucial role in detecting alcohol abuse among older
adults. About 87 % of older adult patients see their primary care physician regularly,
an opportunity for early alcohol abuse detection. There are many other important
people who also play a role in alcohol abuse detection such as family, friends, social
workers, and home health nurses. It is vital that those who regularly interact with the
elderly are aware of alcohol abuse concerns, and are also adequately trained to
respond to the issue.
The attitude of many medical providers and social service providers can affect
the detection of alcohol abuse, as many view this as the patients only pleasure as
they enjoy the last years of life. The lack of training can make the alcohol conversa-
tion uncomfortable and is often times overlooked as a result of stereotypes or biases.
Many clinical providers do not ask the crucial questions, if the senior is having
problems with alcohol consumption. Some providers may feel senior patients do not
benefit from alcohol treatment. Typically also, older adults do not work, have fewer
social obligations, and spend most of their time at home, making it more difficult for
people to recognize changes in behavior. When a change in behavior does occur,
alcohol abuse is routinely overlooked, and the provider relates the occurrence to
other issues associated with aging such as dementia, falls, skin trauma, insomnia,
weight loss, hypertension, or other health issues, which are also the effects of alco-
hol and aging. Provider attribution of alcohol-related problems to age-related health
conditions is further exacerbated by the fact that many older adults feel embarrassed
by their alcohol use or keep their abuse hidden from providers, family, and friends
making it more difficult to identify alcohol abuse or misuse in this population.
Screening and brief intervention specific to nursing homes, assisted living, and
senior housing may be useful for medical providers and social service providers.
Extensive work in this area by Schonfeld et al. may be an opportunity for new ave-
nues in this area [51]. The Florida Brief Intervention and Treatment for Elders
(BRITE) project had significant success in identifying alcohol misuse in older
adults (as well as prescription medication misuse, over-the-counter medication
abuse, and illicit substance abuse [51]).
15.7 Conclusion
Given the potential importance of alcohol misuse on the health and quality of life
for seniors, clearly more research in this area is warranted. Over the past decade,
assisted living has experienced rapid growth in capacity, and nursing homes and
senior communities still represent numerous institutional care setting for older
adults. We should not miss the opportunity to implement appropriate policies and
procedures for prevention and screening, and effective treatment programs for
seniors with alcohol misuse residing in LTC.
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Drinking, Aging, and Global Public Policy
16
Marjana Martinic and Anna Sheveland
As a population, older adults generally drink less heavily and are more likely to
abstain from alcohol altogether than younger age cohorts [1, 2]. However, because
of physiological changes associated with aging, older adults are more susceptible to
the effects of alcohol [3] and, therefore, the negative consequences of drinking can
be more pronounced. The prevalence of alcohol use disorders (AUDs) among the
elderly is also not negligible—in the United States, for example, it is estimated at
three percent [4], while statistics from Germany suggest that some 400,000 elderly
individuals suffer from alcohol-related problems [5]. There is also evidence from
some high-income countries that alcohol-related problems, such as AUDs, are often
under-detected among the elderly [6–8]. At the same time, research points to certain
physiological and psychological benefits associated with low to moderate drinking
among elderly individuals [9–11]. The duality of these outcomes can present a chal-
lenge for the crafting of policies and recommendations to appropriately address
drinking among the elderly.
The number of elderly individuals worldwide is rising. This is due, in part, to the
aging of the “baby boomer” generation in developed countries, but also to increas-
ing longevity in less developed parts of the world. There is also evidence that drink-
ing patterns have been changing among the aging baby boomer cohort; their drinking
is heavier than among previous generations [12], and these individuals also seem to
be decreasing their consumption at a slower rate as they age [2]. As the world’s
largest living cohort transitions into old age, absolute numbers of older people are
increasing, both in developing and in developed countries, and with them the preva-
lence of alcohol-related problems [7, 13, 14].
Thus, drinking among the elderly is an issue in need of attention through public
policy and interventions. To date, public policies have largely ignored the elderly
M. Martinic, Ph.D. (*) • A. Sheveland, Ph.D.

International Alliance for Responsible Drinking,
1225 19th Street NW, Suite 500, Washington, DC 20036, USA

248 M. Martinic and A. Sheveland
and their particular needs and concerns. This chapter examines current policy measures
and intervention approaches specifically targeting older individuals, and discusses
areas where additional efforts are needed.
16.1 A
lcohol Policies: Regulatory Measures and Targeted
Interventions
From a public health perspective, alcohol policies are intended to minimize risk
from harm and to maximize benefits for the individual and for society. Since drink-
ing cultures, attitudes, and patterns vary significantly among countries, strategies
for reducing harmful drinking should be crafted and applied in ways that are effec-
tive and sustainable, but also appropriate for the specific context. Two different yet
complementary approaches make up the body of alcohol policies. Regulatory mea-
sures governing the physical and economic availability of alcohol, as well as its
quality and integrity, provide the policy framework. They rely on legislation and a
central role for government in implementation and enforcement. The second
approach consists of targeted interventions, tailored to specifically address instances
of harm. These do not require legislation and do not rely solely on government
intervention. Rather, responsibility for implementation can be shared by various
stakeholders and sectors of society. These include, for example, healthcare profes-
sionals and researchers, civil society organizations and NGOs, as well as appropri-
ate private sector entities, such as alcohol producers, the insurance industry, and
others. Working in partnership with each other, as well as with government, these
actors can harness resources and provide a potentially more agile response to key
issues than government acting alone. Since policies reflect the state’s level of
engagement with the individual and its perceived role in fostering the well-being of
its citizens, the implementation of regulation versus targeted approaches varies
among countries.
Regulatory measures around alcohol are applied at the whole-of-population level
and, with a few exceptions, do not differentiate among target groups. They are aimed
at the young as much as at the elderly, and at heavy drinkers as much as at those who
drink lightly. Generally, public policies around drinking rely on the assumption that
reducing average consumption across entire populations will also correspond to a
decrease in harmful outcomes. Included in this panoply of measures are restrictions
on where alcohol may be sold, to whom and by whom, and rules around hours during
which sales are permitted. Taxes on alcohol beverages are an integral part of the
regulatory framework for alcohol and in many countries represents a substantial
source of government revenue. Regulatory measures are also implemented around
the advertising and marketing of alcohol and, in most countries, a legally mandated
minimum age for the purchase of alcohol beverages [15] and levels of blood alcohol
(BAC) [16] for operating motorized vehicles complete the array. However, regula-
tory measures, by their very nature, are broad based and suffer from certain limita-
tions. They are insensitive to differences among groups of drinkers, their particular
drinking patterns, susceptibility to alcohol, and other potential risk factors.
16 Drinking, Aging, and Global Public Policy 249
While age has long been recognized as an important consideration that merits
particular attention with regard to policy, in most countries around the world, the
emphasis is generally on reducing the potential for harm in young people. There has
been far less political will to address the particular needs of older adults through
public policies, including that of alcohol. While it has been suggested that those
alcohol policy measures that have an impact on middle-aged populations are equally
applicable to older individuals [17], older people do not often feature on the list of
high priorities for policy makers when it comes to reducing harmful drinking. To
date, there is also a lack of consensus on and consistency in what constitutes “old
age” and the “elderly,” which makes application of measures difficult. Various
thresholds have been suggested, including as low as 55 years of age [18], however
the most common cutoff seems to be 65 years of age [19].
Recognizing the general dearth of information and good practice around address-
ing alcohol problems among the elderly, the EU-funded VINTAGE project Good
Health into Older Age [20] was designed to “build capacity at the European, coun-
try and local levels by providing the evidence base and collecting best practices to
prevent the harmful use of alcohol amongst older people” ([21], p. 221). A scoping
exercise of the number of programs implemented across EU Member States showed
that programs had been implemented in only a handful of countries, notably the
United Kingdom, Finland, the Netherlands, and Italy. The main reason given for the
absence of programs was the lack of public health policies that address prevention
strategies around alcohol consumption and related problems aimed specifically at
the elderly. Other factors identified include generally low awareness of alcohol
problems among, and the special needs of, the elderly, as well as a lack of resources,
and the perception among policymakers that old age is too late to address these
problems [22].
While regulatory measures provide the framework for alcohol policies, tack-
ling harmful outcomes is often best achieved through the complementary use of
targeted interventions that aim to reduce risk and harm in known vulnerable popu-
lations. Such interventions are pragmatic, and responsive, and can be tailored to
specific needs. Targeted interventions offer options for addressing alcohol-related
harm in a flexible, sustainable, and culturally appropriate way [23]. Since they do
not rely solely on regulation and legislation, they can be implemented through the
involvement of different sectors of society, including health professionals, civil
society, the private sector, local and national governments, and intergovernmental
organizations.
Targeted interventions can be adapted to address key areas: at-risk drinkers, risky
behaviors, and high-risk contexts. Included among these interventions is alcohol
education, both formal and informal, covering the range from population-wide cam-
paigns and messaging, to school-based programs, and specific interventions
designed to raise awareness and knowledge that can help equip individuals to make
informed choices about whether or not to drink [23]. They also include approaches
designed to change perceptions around what constitutes “normative” drinking.
These interventions also include efforts aimed at the elderly, as discussed later in
this chapter.
A second targeted intervention approach is the identification of risky drinking

patterns through screening, coupled with measures to change risky behaviors and,
depending on the specific needs and severity of the problem, includes referral to
treatment. Interventions in this category have been applied with considerable success
across different groups and ages, and are reasonably cost effective to implement
[24, 25]. They can be integrated into primary health care, can be standalone efforts,
or can be linked with screening for other health issues, such as antenatal care, work-
place wellness programs, and other similar initiatives.
Another area in which targeted interventions have an important role is alcohol-
impaired driving, where common measures include the setting of age-specific
BAC limits or graduated driver’s licenses. Both of these are aimed at young peo-
ple. Other interventions that reduce the risk of alcohol-related road traffic crashes
include the provision of alternative transportation and designated driver schemes.
A concept related to these interventions is that of responsible hospitality, with the
training of service staff in retail outlets, bars, restaurants, and other venues to help
minimize the likelihood of intoxication among patrons. Related measures include
the modification of the drinking environment to make drinking occasions safer,
particularly in areas where there is a high concentration of nighttime entertainment
venues [23].
While many of these interventions are as applicable to elderly individuals as
they are to other age groups, there are a few areas where specific efforts have been
made to target the unique needs of older individuals. Education and awareness
includes the crafting of drinking guidelines with specific advice and recommenda-
tions for the elderly. Tailored screening, intervention, and treatment for alcohol
problems can be adapted to meet the needs of older individuals. Related to these
measures is also the training and education of service providers for the elderly to
be able to offer advice and intervention. Efforts around road traffic safety can be
adapted to fit the drinking and driving patterns of elderly individuals. Targeted
measures need to take into account not only the chronological age of those for
whom they are intended, but should reflect the reality of changing lifestyles among
the elderly and related risk.
16.1.1 Drinking Guidelines
Appropriate information on drinking and tools to equip those who choose to drink
to understand the relationship with outcomes and to avoid harmful drinking patterns
are provided by government bodies, quasi-governmental organizations, and profes-
sional societies in many countries around the world [26]. Drinking guidelines offer
recommendations around daily or weekly drinking (or both), gender-specific rec-
ommendations, and may include considerations around age, health status, and other
factors that influence the relationship between drinking and outcomes. However,
few official guidelines offer specific recommendations for the elderly (Table 16.1).
Where such advice is given, recommendations for the elderly are generally lower
than for the general adult population.
Table 16.1 Drinking guidelines for the general adult and aging population (based on national
recommendations, unless where noted otherwise)
Guidelines for the general
adult population (in grams
Country pure ethanol) Guidelines specific to older adults
Australia Men: ≤20 g/day; ≤40 g on “Specific population groups can be at increased
[27] any one occasion risk if they drink alcohol; these include: …older
Women: ≤20 g/day; ≤40 g people aged over 60 years.”
on any one occasion
Austria [28] Men: ≤24 g/day “Older people’s bodies may be more sensitive
Women: ≤16 g/day to alcohol, therefore they should decrease their
alcohol consumption.”
Denmark Men: ≤168 g/week “If you are elderly, be especially careful with
[29] Women: ≤84 g/week alcohol.”
Finland [30] Men: ≤2 drinks (20 g)/day Men: ≤1 drink or 10 g/day
Women: ≤1 drink or 10 g/ Women: ≤1 drink or 10 g/day (same as for
day general population)
Hong Kong Men: ≤20 g/day “‘Low risk’ is not ‘no risk.’ Even within these
[31] Women: ≤10 g/day limits, drinkers can still have problems if they
drink too quickly, have health problems or are
older.”
Italy [32] Men: ≤36 g/day Elderly people are also advised to limit the
Women: ≤20 g/day consumption of alcohol to one drink daily. (A
drink is defined as containing 12 g of ethanol.)
New Men: ≤30 g/day, ≤210 g/ Men over 64 years old: ≤30 g/day, or ≤150 g/
Zealand [33, week, ≤60 g on one occasion week, or ≤50 g on one occasion
34] Women: ≤20 g/day, ≤140 g/ Women over 64 years old: ≤20 g/day, or
week, ≤40 g on one occasion ≤100 g/week, or ≤40 g on one occasion
Switzerland Men: ≤26 g/day “Those over 60 years of age should be aware of
[35] Women: ≤24 g/day differences in how alcohol affects them.”
United Men: ≤14 drinks (112 g)/ “Some groups of people are likely to be affected
Kingdom week more by alcohol and should be more careful of
[36] Women: ≤14 drinks (112 g)/ their drinking on any one occasion:
week
(Equivalent to16 g/day for • (…) older people.”
men and women)
United Men: ≤28 g/day, ≤196 g/ Men: <7 drinks/week, or 1 standard drink/dayb
States week Binge drinking defined as >3 standard drinks/
[37–39] drinking occasion
Women: ≤14 g/day, ≤196 g/ Women: <7 drinks/week, or 1 standard drink/
week day
Binge drinking defined as >2 standard drinks/
drinking occasion
“Adults over age 65 who are healthy and do not
take medications should not have more than:
3 drinks on a given day
7 drinks in a week”
Source: Data from [26]
a
A UK unit is defined as 8 g of ethanol
b
A standard drink is defined as 12 g in the recommendations for the elderly, while the regular U.S.
standard unit is 14 g
Some recommendations go further than simply offering advice in terms of

quantity and frequency of drinking. For example, the U.S. government’s Substance
Abuse and Mental Health Services Administration (SAMHSA) and Administration
on Aging (AOA) offer the following guidelines, which state that older individuals
should abstain from alcohol completely if they:
“are taking certain prescription medications, especially psychoactive prescription medications

(e.g., opioid analgesics and benzodiazepines); have medical conditions that can be made worse
by alcohol (e.g., diabetes, heart disease); are planning to drive a car or engage in other activities
requiring alertness and skill; or are recovering from alcohol dependence” ([38], p. 1).
The U.K. Royal College of Psychiatrists has pointed out that recommended limits
for consumption are based on research on younger adults. As a result, the Royal
College points to changes that accompany aging that make, older adults more sus-
ceptible to alcohol-related harm, which means that ‘safe’ levels of drinking for the
elderly may be lower than those offered in guidelines for the general population.1
The recommendations also note the need for local policies regarding older people
with substance use problems to facilitate admission and treatment [7].
In Germany, recently released joint guidelines on prevention, screening, and
treatment, issued by a number of scientific and medical associations, now include,
for the first time, a chapter specifically dedicated to the elderly, addressing the need
for the screening and treatment of alcohol problems [40]. While these guidelines do
not recommend particular levels of consumption for older adults, they do point to
the need for lower levels of drinking, depending on health status and age [41].
16.1.2 Screening and Brief Intervention
A second area for targeted interventions around drinking that has been adapted for
the elderly focuses on the identification of those individuals at heightened risk for
alcohol-related harm through screening and the subsequent provision of interven-
tions and referral to treatment. Screening and brief intervention (SBI) approaches
are effective in reducing harmful drinking [42–44], including among elderly popu-
lations [45, 46], and have an impact on alcohol-related mortality and morbidity [8].
Recent modeling exercises suggest they are also cost effective for governments to
implement as a strategy to reduce alcohol-related harm [25, 47, 48].
However, the effectiveness of SBI can differ depending on both the conditions of
its implementation, and certain characteristics of the patients screened, such as gen-
der, education level, perceived self-efficacy, or drinking level and frequency [43, 46,
49–51]. The need for tailored instruments that are more sensitive to the needs and
life contexts of the elderly than those included in standard screening for adults, has
been highlighted [52–54]. It has also been suggested that elderly adults would
benefit from regular screening for alcohol problems [55].
1
It should be noted that at the time of the writing of this chapter, the UK Department of Health
had just issued revised guidelines for alcohol consumption, but these were not yet reflected in
guidelines issued by the Royal College of Psychiatrists.
In offering advice to elderly people, there are additional factors to be considered.

Older people are more likely than their younger counterparts to drink alone and at
home, so harmful patterns may not be readily evident [56]. Also, given that elderly
individuals are likely to have poorer health than their younger counterparts and more
likely to be using prescription drugs for various conditions, SBI should take into
account potential interactions and the effect of comorbidity with other health out-
comes on drinking and appropriate interventions. Although not as common as among
younger age groups, there is evidence of drug abuse among elderly individuals
[57, 58], which also requires consideration in the implementation of screening.
A recent systematic review has pointed to some gaps in the evidence around the
impact of SBI on older populations, suggesting that further research is warranted
[59]. However, some research into the effectiveness of SBI for older age groups sug-
gests that they are most effective when integrated into general primary care settings,
rather than through referral to a psychiatric or mental health care facility [49].
16.1.3 Training for Care Providers
Given the particular needs of elderly individuals, specific training is recommended for
professionals who work with them—notably physicians, nursing staff, other health
workers, and home carers—as there is evidence of a lack of understanding and aware-
ness among many health professionals of drinking problems in elderly patients [14, 60].
Physicians and other health workers often fail to take alcohol consumption and poten-
tial problems into account when diagnosing their older patients [61, 62] and may
mistake alcohol-related problems with those related to aging [63].
It has also been suggested that a network of so-called gatekeepers, who have
regular contact with the elderly and whose help can be enlisted in looking out for
problems and for referrals to health and other professional services may be needed
[64]. These “gatekeepers” would include meter readers, postal workers, delivery
persons, paper carriers, and grocers; in a word, all those with regular contact with
the elderly. While such broad networks may not be a realistic goal to achieve, there
is a more immediate and important role for family members, friends, and neighbors,
who should be aware of the issues facing the elderly with regard to alcohol and able
to recognize when intervention is needed. In particular, community workers and
social workers may also have easier access to the elderly than health workers and
can be enlisted for this purpose. However, it is clear that broader public awareness
and information campaigns to raise the overall level of knowledge around drinking
among the elderly and its potential outcomes are needed.
16.1.4 Road Traffic Safety
The various challenges of aging include the loss of mobility and independence.
For many older adults, particularly in developed countries, the ability to drive an
automobile or other motorized vehicle directly symbolizes the retention of auton-
omy over at least some aspects of daily life. However, given the deterioration of
vision and reaction time that accompany aging, along with research showing that
older drivers display greater impairment after consuming alcohol than younger
drivers [65], greater attention is needed to educating older adults and the general
public about special considerations around drinking and driving among the elderly.
Stopping short of legislating lower BAC levels for older adults, which are likely
untenable for both practical and political reasons, there may be room to craft
particular recommendations around lower consumption levels, or around abstaining
from drinking altogether when operating a motor vehicle. Alternatively, encourag-
ing older adults to use alternative transportation when they have been drinking
offers a pragmatic solution through a targeted intervention. Serving staff in bars,
restaurants, taverns, and other outlets that serve alcohol can also be encouraged to
pay particular attention to older patrons’ drinking, and to offer transportation, as has
been done for younger populations.
16.2 Concluding Remarks
Global demographics are changing rapidly. With the movement of the largest living
generation into old age and increasing life spans in many countries around the
world, the global population is growing older and will continue to for years to come.
This has implications for the importance of public policies that are sufficiently well
crafted to account for the specific needs of the elderly.
By virtue of sheer numbers, the current health burden from older individuals will
be greater than that from previous generations, creating an imperative for preven-
tion in earlier years, but also increased emphasis on addressing harmful outcomes
and reducing risk for harm in older age. Their growing numbers combined with the
adoption and persistence of drinking patterns (e.g., heavier drinking overall, more
drinking among women, and less reduction in consumption with age) that differ
substantially from previous cohorts, mean that the elderly are likely to increasingly
contribute to the burden of harmful drinking.
To date, harmful drinking among aging individuals in both developing and devel-
oped countries has received relatively little attention in terms of public health policy.
This is in part a reflection of a shortage of political awareness and will to tackle the
issues, and in part the result of insufficient resources. In many countries, notably in the
developing world, drinking in old age is not a public health priority and there is a dearth
of information on drinking patterns and alcohol-related harm among older people.
It seems clear, therefore, that governments are ill equipped to tackle the issue
alone. A new model is therefore needed that allows government to retain its role and
mandate but also allows engagement by other stakeholders in contributing to the
reduction of harmful drinking among the elderly. As a point of departure, govern-
ments have a role in providing information to their citizens about health issues,
including about alcohol consumption, in order to encourage informed decisions
about drinking. Drinking guidelines that pay attention to the elderly are needed.
These should point to potential health risks associated with alcohol consumption for
older adults, but also reflect the potential health benefits of moderate drinking that
apply to many older individuals. Governments also have an important role in
collecting information about the health and welfare of their citizens. This includes
information about consumption patterns and outcomes. Such information is essential
in describing the extent of the problem but also in helping to identify possible solutions.
Another basic and essential role of government is the strengthening of health services
so that they are equipped to handle alcohol-related issues among the elderly.
Beyond this, however, the answer to policy and interventions likely lies in mul-
tistakeholder engagement. This approach also reflects current global trends in health
and development, such as those laid out in the U.N. Sustainable Development Goals,
and calls for the engagement of actors outside of government. Among them are
researchers who provide evidence-based advice that will inform interventions and
approaches to prevention. Civil society can offer the engagement of communities
and grassroots movements, and the private sector can bring its knowledge and
much-needed resources to the table.
The insurance industry, for example, which bears a significant portion of the
economic burden of an aging population and their so-called longevity risks, would
be an obvious stakeholder with an interest in the well-being of older adults. Attention
to the risks, but also to some of the benefits for cardiovascular health, type II diabe-
tes, and dementia that are associated with moderate drinking, seems an appropriate
area for insurance providers to address. Investment in wellness programs aimed at
older adults, which also cover drinking and the prevention of alcohol-related harms
are potentially cost-effective ways of improving health and preventing harmful out-
comes. Such programs can be a useful tool in reducing the burden of disease associ-
ated with harmful drinking.
There is also a role for the companies that produce alcohol beverages, and whose
efforts include partnerships with a range of other stakeholders in an effort to reduce
alcohol-related harm. Commitment to corporate social responsibility is high on the
agenda of such companies. While it is generally aimed at preventing underage
drinking and harm to young people, the scope of such interventions and activities
can be broadened to also include older individuals. Included are activities such as
educational programs, support for prevention, and the provision of information on
responsible drinking.
There is an urgent need for comprehensive, integrative policies around drinking
as it relates to older adults that can be put into place at the national and also the
international level. Yet public policies in their strictest interpretation are likely inad-
equate to address the challenges and provide the requisite resources for action.
A whole-of-society approach offers itself as a viable complement to public policies.
In this model, each actor has a well-delineated role to play and each can bring
different expertise and resources to bear in the interest of the public good.
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Part V
Future Directions
Future Directions for Aging and Alcohol
17
Alexis Kuerbis, Alison A. Moore, Paul Sacco,
and Faika Zanjani
This edited book highlights a variety of areas in the study of alcohol and aging with
each chapter considering gaps in research specific to different topic areas. In this
chapter, we take a broad view, and make recommendations for research, policy,
and practice in the field of alcohol and aging. The proposals put forward in the
chapter respond to relatively understudied areas in the field of alcohol and aging but
also delve into areas where research can be enhanced using innovative methods that
have not been applied to older adult populations extensively. In addition to research,
the chapter identifies areas where policy and practice change is crucial to improving
outcomes for older adults. Even though many possible avenues for research and
practice change are discussed, it is clear that opportunities for research, practice,
and policy innovation are abundant and hold the potential to decrease unhealthy
drinking and improve older adult health.
A. Kuerbis, L.C.S.W., Ph.D. (*)

Silberman School of Social Work, Hunter College at the City University of New York,
2180 Third Avenue, Rm 435, New York, NY 10035, USA
A.A. Moore, M.D., M.P.H.
Division of Geriatrics, University of California, San Diego,
9500 Gilman Drive, MC 0665, San Diego, CA 92093, USA
P. Sacco, Ph.D., M.S.W.
School of Social Work, University of Maryland-Baltimore,
525 West Redwood Street, Baltimore, MD 21201, USA
F. Zanjani, Ph.D.
Department of Behavioral and Community Health: School of Public Health,
University of Maryland, 4200 Valley Drive, College Park, MD 20742, USA

17.1 Research
Research on alcohol use among older adults emerged as alcohol researchers began
to explore older adults as a subpopulation. In a monograph published by the National
Institute on Alcohol Abuse and Alcoholism (NIAAA) in 1998 [1], Edith Gomberg
and colleagues wrote a chapter focused on identifying research priorities in alcohol
and aging. They noted that gerontology in alcohol research was an emerging area,
discussed the frustrations of having a dearth of research in on aging and alcohol use,
and recognized challenges going forward.
Now, nearly 20 years later, the depth, breadth, and sophistication of research on
alcohol use among older adults is clear. Looking forward, we identify some impor-
tant areas where the field can build on important findings from the last 20 years.
Since Gomberg et al. [1], some areas of research have progressed extensively, while
some of the gaps they identified remain. Additionally, the passage of time itself
means that aging research faces new challenges and new opportunities. The aging of
the population is no longer part of an imagined future, and findings from research
conducted on earlier generations of older adults may not be as pertinent for or appli-
cable to new cohorts of older adults. New methods utilizing emerging technologies
promise to provide new insights about alcohol use in older adulthood and give
researchers the opportunity to revisit research questions with powerful new tools.
17.1.1 The Aging Tsunami: The Storm Has Come
Population aging has fueled a sense of urgency related to the mental health of older
adults including expansion of research [2]. This makes sense given the seismic
changes in the demographic makeup of the United States and the world. To assess
future need for alcohol and other substance treatment services, Gfroerer and Han [3,
4] conducted two analyses using data from the National Survey on Drug Use and
Health to estimate prevalence of substance use disorder and treatment need in 2020.
They forecasted very large increases in the number of individuals with substance
use disorder (2.8–5.7 million) and needing treatment (1.7–4.4 million).
For the purposes of responding to treatment need and fostering prevention, future
research should delve into the emerging cohort of older adults. Specifically, are the
projected numbers of individuals needing treatment materializing? If numbers are
increasing, is this a function of simple population change or is the prevalence of
older adults with alcohol and other drug-related conditions changing? Research has
suggested that the Baby Boom cohort is distinct from earlier cohorts of older adults
related to their use of alcohol. To respond effectively to treatment needs of this gen-
eration, research should explore how this generation of older adults may be distinct
qualitatively from previous cohorts of older adults. For instance, research suggests
that inpatient treatment admissions for comorbid alcohol and drug use are increasing
as a proportion of total treatment admissions among older adults [5]. Research should
explore risk factors in light of comorbidity including tobacco use, illicit drug use,
and prescription drug misuse.
17 Future Directions for Aging and Alcohol 263
Beyond prevalence of use and co-occurring drug use, researchers should explore
how generational shifts in attitudes toward drinking may be driving changes in use.
For instance, relatively little research has focused on drinking motives [6, 7] and
alcohol expectancies [8, 9] among older adults. It would be useful to understand
how these concepts map on to consumption, at-risk drinking, and alcohol problems
as a means of developing treatment models in this population. More generally, data
should be gathered on perceptions of drinking among older adults, as generational
shifts may be at taking place. Whereas age grading [10, 11] (i.e., the idea that cer-
tain behaviors are appropriate or not appropriate based on age) may have suppressed
alcohol use among older adults in previous generations, current older adults may
not ascribe to the idea that it is appropriate to decrease or quit drinking in older
adulthood.
17.1.2 Diversity in Older Adulthood: Opportunities for Alcohol

Research
The current cohort of older adults and future generations of older adults are more
diverse than earlier cohorts. Relatively little research has focused specifically on
diversity in older adulthood and alcohol use including race/ethnicity [12–15], gen-
der [16, 17], socioeconomic status [18, 19], religion [12, 15], and sexual orientation
and sexual identity [20]. Through research on older adult subpopulations, the field
can adapt a more nuanced understanding of older adults and aging. Scholarship in
this area can identify groups who may be at higher risk and characterize potential
mechanisms that contribute to that risk.
Diversity is also important in life course development. In their work exploring
issues and future directions in alcohol research, Gomberg and colleagues [1] dis-
cussed the challenges of defining the cutoff for older adulthood. Since that time,
the fastest growing segment of the population is the so-called oldest-old [21], yet
there is very little research on alcohol use in this population [22]. On the other end
of the age spectrum, late middle age is becoming an area of increasing concern, as
research has recently identified increases in mortality rates in this group, possibly
attributable in part to alcohol [23]. Broadly speaking, we recommend that research
studies consider development within older adulthood by targeted sampling of
groups at different ages, through recognition of event-based markers of older adult-
hood (e.g., retirement) and by designing studies that bridge earlier life stage devel-
opment (i.e., midlife) and older adulthood through longitudinal designs. National
longitudinal studies such as the Health and Retirement Survey (HRS) and the
Midlife in the United States (MIDUS) Study are examples of existing data that
have supported research on life course development and drinking. Thus, opportuni-
ties for expanding knowledge about developmental transitions already exist and
need to grow further.
17.1.3 Social Context and Drinking: Implications for Older Adult
Research on older adults and drinking has tended to consider older adults as a
monolithic group, largely neglecting contextual factors. Compared with research on
young adults and adolescents, scant research has explored how alcohol use is asso-
ciated with social support and social networks among older adults [24, 25]. (See
Chap. 10 for more on social support, social networks, and drinking.) Social network-
based research has primarily focused on social support for recovery [25] and con-
sumption changes during the retirement process [24]. This research is a solid
foundation for future study that can further examine potential causal links between
social network constructs and alcohol use. We recommend increased utilization of
methods such as social network analysis to research how social networks influence
individual older adult use. For instance, researchers utilized data from the
Framingham Heart Study to analyze social networks and alcohol consumption and
found that changes in one’s social network’s drinking influenced personal alcohol
consumption [26] among a sample of participants who were middle-aged adults at
baseline. Research by Bacharach and colleagues [24] suggests that among those
with a history of problem drinking, changes in social network size may lead to
decreases in alcohol consumption among older adults.
Even less is known about the role of neighborhood context in alcohol use among
older adults. In a study [27] conducted in Baltimore, Maryland, researchers identi-
fied associations between “neighborhood psychosocial hazards” and binge drinking
among late middle aged and older women but not men. Aside from this study, there
is limited research on neighborhoods that includes older adults as a specific popula-
tion of interest. (For a more in-depth review of neighborhood research and aging,
see Chap. 10.) Research on the influence of neighborhood on older adult health is
extensive [28]; perhaps these studies could be extended to include alcohol use.
In the area of behavioral health research, the use of ecological momentary assess-
ment Ecological Momentary Assessment (EMA) [29] or “experience sampling” has
advanced our understanding of within- and between-person variation in alcohol use.
EMA studies are designed to gather data on individual experiences that vary over
time within an individual (e.g., alcohol craving) and are collected using paper dia-
ries or through technological means (e.g., mobile phones). The advantage of these
approaches is the ability to assess between-person (e.g., individuals who are prone
to craving) and within-person (e.g., when a person experiences increased craving)
influences on alcohol-related outcomes. Although this method is becoming more
widely employed in other areas of alcohol research [30–32], its use specific to older
adults and alcohol use is limited [33].
17.1.4 Genetics
Similarly, in alcohol research specific to aging, genetically informed research is

very rare [34, 35] compared with the body of literature on alcohol use. Considering
the importance and growth of genetic research in understanding alcohol use,
research is limited in the context of aging in mid to late life. We recommend

inquiry into the relative genetic and environmental contributions to alcohol-
related problems in the population of older adults using twin methodologies.
Research could also compare how contributions of genes and environment may be
different in older adult populations versus younger groups. In a similar manner,
very little research has considered developmental change in genetic contribution
to alcohol use among older adults. Longitudinal research conducted with younger
groups (i.e., young adults) suggests that developmental processes are an impor-
tant component to the understanding the importance of genes and environment in
alcohol use [36]. Perhaps genetic studies of late life development can add to our
overall knowledge of how genetic risk and environment play out later in the life
course.
17.1.5 Understanding Drinking by Understanding Abstention
Lifetime abstinence is another area where risk can be understood from a life
course perspective. In assessing the role of alcohol on health among older adults,
data suggests that current and past alcohol use may be important and that lifetime
abstainers are different from former drinkers [37, 38]. Research studies should
consider alcohol transitions beyond onset of drinking to explain factors that con-
tribute to the decision to quit drinking in older adulthood. Morbidity and disabil-
ity may be an important component in forecasting use or abstention among future
cohorts of older adults, as illness may exert downward pressure on alcohol use.
Similarly, little research has explored long-term recovery among older adults
with a focus on health and psychosocial correlates of recovery. It is likely that
past problematic alcohol use can create greater health difficulties in older age [39],
but research is limited regarding how older adults with past alcohol problems
fare in old age.
17.1.6 Alcohol and Medications: Quantifying Risk
Although a solid body of research has identified comorbid alcohol and medication
use as potentially problematic [40–42] (see Chap. 8), there is little evidence about
the specific hazards of alcohol and medication co-use [43]. Which medications are
particularly hazardous when combined with alcohol? When alcohol is combined
with medication, what are the specific acute and chronic risks? Little is known about
actual public health impacts of alcohol and medication co-use among older adults.
We would contend that at the current time, most data regarding observable out-
comes (e.g., falls, bleeding, and hospitalization) are speculative when considered
outside the lab, and researchers have suggested that many potential interactions do
not display a clinical effect [44]. Pharmaceutical and medical record data may be a
source of data to quantify serious events associated with alcohol and medication
co-use.
17.1.7 Treatment and Older Adults
In the long term, while older adults seem to have more positive alcohol treatment
recovery [25], mechanisms to aid in understanding the success are mostly unknown.
Research on treatments adapted for older adults must be expanded. Little is known
about the efficacy of specific established evidenced-based practices, such as motiva-
tional interviewing, among older adults, despite the assumption that it works equally
well for clients of all ages. (See Chaps. 12 and 14 for more information.) Like ado-
lescents, older adults may experience differential motivation to change certain
behaviors later in life. In the existing, albeit limited, literature, structured treat-
ments, such as cognitive behavioral therapy, appear to be more successful than other
less structured treatments.
17.1.8 Health Promotion
There is a need for increased research in community-level health awareness cam-

paigns and behavioral change programs for older adults [45]. Relatively few com-
munity health programs are geared toward improving the health of older adults,
and even fewer focused on healthy drinking among older adults [45–47]. Public
health campaigns on alcohol and aging need to be clear about recommended drink-
ing limits for older adults, the age-related hazards of alcohol consumption, and be
able to identify when specialized clinical treatment for alcohol behaviors is needed.
After the development and implementation of such programs, extensive evaluation
needs to be conducted for wider dissemination. For example, research could evalu-
ate how alcohol-warning labels [48] can be enhanced by adding a component on
alcohol and aging indicating drinking limit recommendations and age-related
hazards, and also providing alcohol drink equivalents or serving sizes to improve
personal regulation.
Another important area for health promotion research among older adults is
stigma. Stigma has been consistently identified as a major treatment barrier among
older adults [49–51]. More research is needed to design and identify effective pre-
vention models to combat stigma surrounding alcohol use among older adults.
These efforts hold the promise of decreased unmet treatment need by removing
barriers to treatment based on older adult attitudes about seeking help for an alcohol
problem.
17.2 Health Policy and Clinical Practice
Research has the potential to influence future outcomes for older adults, but policy
and practice must be responsive to population changes that are already taking place.
For the sake of public health, scholars in alcohol and aging should advocate not only
for research but also for concrete changes in policy and clinical practice related to
older adults. Multiple evidence-informed steps can be taken to prevent unhealthy

alcohol use among older adults as well as improve services to those who have
alcohol-related problems. Although the following recommendations are not exhaus-
tive, they provide a starting point for responding to the challenge of older adults,
substance use, and alcohol use in particular.
17.2.1 The Challenge of an Ill-Prepared Workforce
While existing clinical treatments have been shown to be effective for at least the
older adults who self-select into treatment (described in Chap. 12), there is an
urgent need for expansion of treatment services for older adults at all levels of care.
Workforce issues are primary—few professionals, across disciplines, are educated
about the unique needs of older adults, particularly in relation to mental health and
substance use disorders [52–54]. A severe shortage of professionals specializing in
geriatrics and aging, along with shortage of behavioral health specialists is already
upon us.
One way to begin to address such an overwhelming shortage is to educate health
care professionals and existing providers in geriatric care. Most providers will
undoubtedly encounter older adult patients and clients that they may not be cur-
rently trained to treat effectively. In addition, targeted recruitment of new health
care professionals into geriatrics, with training in behavioral health, is also needed.
A reliance on lay persons (e.g., community health workers) who have been given
proper training and oversight to help with the shortage of fully trained providers
may be a reasonable solution [52]. For example, utilizing models tested in low- and
middle-income countries that have poorly resourced health care systems, innovative
interventions can be used to address workforce shortages for addressing population
health among older adults [52, 55].
17.2.2 Improving Access to Care
In addition to workforce issues, access to specialized care for older adults is subop-
timal. In addition to a dearth of available specialized treatment programs with age-
specific services [56], there are additional barriers for older adults to access
specialized mental health and substance abuse treatment—particularly integrated
care that addresses both. In the few studies that have examined such barriers, pro-
hibitive cost and lack of transportation are two primary challenges that older adults
who wish to pursue more specialized services face [57, 58]. These barriers are also
primary barriers for other subpopulations experiencing difficulties with mental
health and substance use disorders [59]. Barriers more specific to older adults include
a concern about services being oriented only to younger people and attitudes that
reflect a perception that they are too old to change [57, 58]. More than other groups,
older adults may be influenced by friends or family who encourage getting help and/
or if a serious disease or health condition warrants change. Addressing these barriers

and facilitators to treatment should become a primary goal of the health care system
preparing to better service these clients.
Existing treatment programs should expand services to include age-specific
components, such as special and adapted groups, in order to tailor treatment to
and reduce isolation of older adult patients. In addition, community outreach by
existing treatment programs to the older adult community will also go a long way
in welcoming potential patients and clients who might otherwise avoid treatment
due to the fear of being the only older person struggling with behavioral health
issues. Most importantly, service providers must take into account that older
adults are an extremely heterogeneous group with vastly different needs as they
age. Tailoring to the individual as much as possible could be considered ideal
treatment at any age.
In primary and specialty care settings, the increase in the utilization of medica-
tions for substance use could be an important way to expand frontline interventions
for older adults and ultimately improve access to care. While many medications
have been demonstrated to be safe, some medications, such as disulfiram, which can
have adverse cardiovascular effects, may be contraindicated for this group [60].
17.2.3 Moving to Integrated Care for Older Adults
Older adults express a desire for integrated mental health and substance abuse ser-
vices, which, with some exceptions, are still rare for all age groups due to a persis-
tently siloed healthcare system. Many programs and policies have attempted to
address this bifurcation of mental health and substance abuse services; however,
these integrated services remain relatively scarce. Expanding access to care through
increased third-party payment, such as through Medicare and increased availability
of age-specific integrated care will be crucial to addressing the low utilization rates
of specialized treatments by older adults.
Studies, such as Healthy Living as You Age [61] and Project SHARE [62, 63],
demonstrate that with a multipronged approach and repeated contact, older adults
can significantly improve their health outcomes in a short time with lasting effects.
Integrated care and case management interventions, such as the services provided
and tested in the PRISM-E [64–66] study, also provide important information about
how supportive services can directly improve outcomes, as well as facilitate suc-
cessful treatment and recovery.
A primary obstacle for these types of services is that payment mechanisms are
still being negotiated among third-party payers. While case management services
are paid for in some states under Medicaid reformation, such as in New York with
the advent of so-called Health Homes, reimbursement rates are generally low, and
hospitals and agencies must cover the gap in costs. For future success of these kinds
of services, payers must recognize the long-term cost benefits of utilizing continu-
ing care and case management services.
17.2.4 Implementation of Screening and Brief Intervention Models
Primary care remains the main access point to healthcare and services for mental
health and substance abuse treatment. Physicians and other health care providers
working in primary care must be educated on how to assess the older adult for men-
tal health and substance use issues. Assessment must include questions similar to
the CARET (as described in Chap. 11) that ask about alcohol use, illicit drug use,
prescription medication, and health and mental health symptoms. Many symptoms
of hazardous alcohol use can mask themselves as conditions or diseases more com-
mon in later life. Providers must be trained effectively to identify and differentiate
these symptoms and potential conditions.
As described in Chap. 12, SAMHSA has supported a specific brief intervention
protocol known as Screening, Brief Intervention and Referral for Treatment
(SBIRT), to identify and engage those in need of mental health and substance abuse
treatment [67]. More information on SBIRT as an intervention and SAMHSA’s
support for this model can be found at the SAMHSA’s online SBIRT portal [68].
In Chap. 14, Schonfeld describes in detail the benefits and challenges of a statewide
SBIRT project targeted specifically to older adults. The Florida BRITE Project is
one of the few programs to be implemented on such a large scale, and it shows
incredible promise in engaging older adults in discussions and services regarding
alcohol, drug, and mental health issues.
One of the most striking components of the success of the BRITE Project is its
engagement with older adults in community settings—sometimes within their own
homes. Education and intervention can be maximized by incorporating dissemina-
tion of information, initial assessment, and brief intervention in nontraditional set-
tings—outside the healthcare system. Senior centers or beauty and barbershops and
other aging-specific settings offer unique opportunities to reach community mem-
bers. Using these venues can significantly reduce stigma and provide a way to nor-
malize issues as common and treatable.
17.2.5 Potential for Online and Mobile Health Interventions
Another avenue for future expansion of intervention is via online or mobile health
interventions, such as short message service (SMS) or text messaging to provide
continued support for positive alcohol change. While still in its infant stages, online
and text messaging interventions have already been piloted [47] and implemented
[69] to address a multitude of health conditions, including hazardous alcohol use
and alcohol use disorder. Despite stereotypes to the contrary, older adults pursue
education about their alcohol use and its consequences online already [70, 71], and
they are generally quite open to engaging with interventions utilizing mobile
technology for other health conditions [72, 73]. For example, alcoholscreening.org,
an online screening and feedback tool that provides preliminary information about
risks for continued drinking, had 18,564 visitors aged 50–64 and another 3485 aged
65–80 in 2013 [71]. Online and mobile interventions offer unique opportunities to
address some of the primary barriers to care among older adults.
17.2.6 Enhancing Community Prevention
Community agencies need to address alcohol and aging as a component of their

prevention strategy. For example as part of the Older Americans Act, a wide array
of service programs have been authorized through a national network of State
Agencies on Aging, area agencies on aging, and service providers [74]. With a goal
of improving older adult heath, substance abuse needs to be implemented regularly
in educational campaigns and behavioral change programming to reduce alcohol risk.
Collaboration between government entities (e.g., Area Agencies on Aging) and
local community partners (e.g., aging services agencies) are crucial to the effective-
ness of these efforts [75].
17.3 Conclusions
Research, policy, and practice initiatives need to be responsive to demographic

changes arising from the aging of the Baby Boom generation. Shifts in substance
abuse risk profiles at different points across the lifespan demand that we reevaluate
our singular focus on youth and young adulthood in alcohol research and practice.
Recent research documenting trends of increased mortality among white middle-
aged individuals nationally pointed specifically to heavy drinking as a contributing
factor [23], while trends for alcohol-related risk behavior among youth show a
declining trend [76]. Researchers, policy makers, and clinicians must direct atten-
tion and resources to the second half of life.
Just as the overall population is changing with respect to risk for alcohol-related
problems, the population of older adults is more diverse than ever before.
Approaches to research and efforts at health promotion should be mindful of this
diversity. Sophisticated research approaches that use design and methodological
elements to understand this diversity will yield a more valid understanding of alco-
hol use problems, causes, and consequences. Similarly, respect for diversity in
clinical practice and alcohol policy will lead to effective prevention and interven-
tion models.
One important component of this diversity relates to physical health and mental
health. In both research and practice, stakeholders should be mindful of the inter-
connectedness of somatic health, mental health, and behavioral health. In research,
this entails thinking holistically when asking research questions and developing
research designs that consider these domains together. For practitioners and policy-
makers, integrated care should become the norm.
Just as integrated care models address horizontal domains, research and practice
must also be vertically integrated. Research should address multiple levels of influ-
ence, individual, family, and larger community systems. Conceptualizing research at
multiple levels can inform prevention and intervention models aimed at alcohol use
among older adults. At the same time, stakeholders in prevention and intervention
should consider the role of social context at multiple levels using a research-informed
understanding of the interplay of individual, family, and larger influences on use.
Although this text has been directed at readers interested in alcohol and aging
specifically, effective research and practice should start by conceptualizing older
adulthood as part of a continuum of life course development. Understanding diver-
sity of outcomes (like alcohol use) in older adulthood requires that we understand
how earlier influences shape the aging process. Our recommendation therefore is to
consider not only the individual and effects of multiple influences on alcohol use,
but finally to remember that these influences unfold over time.
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Index
A pharmaceutical and medical record, 265

AA. See Alcoholics Anonymous (AA) policy and clinical practice, 266–270
Abusers primary care, 269
characteristics, 136 PRISM-E study, 268
Activities of daily living (ADLs), 237 prohibitive cost and lack of
Administration on Ageing (AoA), 252 transportation, 267
Adult Protective Services (APS), 132, 137 resourced health care systems, 267
Aging, 59–60, 65–70, 262–270 risk factors, comorbidity, 262
cancer risk (see Cancer) SAMHSA’s online SBIRT portal, 269
chronic inflammation, 70 siloed healthcare system, 268
and CVD (see Cardiovascular disease social network-based research, 264
(CVD)) specialized care, 267
CVD markers, 59–60 treatment recovery mechanisms, 266
research workforce issues, 267
age grading, 263 AL. See Assisted living (AL)
age-specific components, 268 Alcohol consumption, 20–21
alcoholscreening.org, 269 alcohol-related disorders, 26
Baby Boom cohort, 262 measures, risk, 28
challenges and opportunities, 262 older adults (see Older adulthood)
diversity in older adulthood, 263 Alcohol expectancy theory, 100
drinking motives and alcohol Alcohol Related Problems Survey (ARPS), 124
expectancies, 263 Alcohol tolerance, 57
EMA, 264 Alcohol use
Florida BRITE Project, 269 at-risk drinking, 38
genes and environment, 265 binge drinking, 39
geriatric care, 267 latent class analysis, 39
government entities and local NSDUH survey, 38
community partners, 270 subthreshold alcohol dependence, 39
Health Homes, 268 subthreshold dependence symptoms, 38
health programs, 266 Alcohol use disorder (AUD), 181–194
lifetime abstinence, 265 criteria, 171
medications, 265 diagnostic criteria, 25
mental health, 262 older adults
middle-aged adults, 264 acamprosate, 188
morbidity and disability, 265 age-appropriate care and providers, 185
neighborhood context, 264 at-risk/excessive alcohol users, 182, 183
NIAAA, 262 brief interventions, 185–186
Older Americans Act, 270 comorbidity, 191–192
online/mobile health interventions, 269 degree of severity, symptoms, 183

A. Kuerbis et al. (eds.), Alcohol and Aging, DOI 10.1007/978-3-319-47233-1
276 Index
Alcohol use disorder (AUD) (cont.) current, binge and heavy alcohol use, 118
detoxification management, 189 cytochrome P450 2E1 (CYP 2E1) and
diagnosis, 184 alcohol dehydrogenase, 120
drinking guidelines, 182 epidemiologic evidence, 120
drinking limit recommendations, 182 frailty, 119
DSM-5 criteria, 183 medications, 118, 120–123
group sessions, 186 NHANES and NSHAP, 123
hybrid/comparative trials, 194 NSAIDs, 124
intensive inpatient withdrawal/ older adult population, 117
detoxification treatment pharmacokinetics, 118
programs, 185 polypharmacy, 125
late life addiction, prevalence of, 181 poor sleep quality and pain, 125–126
Liverpool Longitudinal Study, 184 prescription drug use, 117
morbidity, 194 public health and health professionals,
NIAAA and SAMHSA, 182 126–127
opioid antagonist naltrexone, 188 variability sources, 118
primary and specialty care settings, 182 Alcoholics Anonymous (AA), 187
primary care, 186 Alcohol-induced neurotoxicity, late life, 99
problem and nonproblematic at-risk Alcohol-related dementia (ARD), 191
drinkers, 189 Alzheimer’s disease
problem use/misuse, 183 advancing age, 79
psychosocial and pharmacological alcohol consumption, 83
treatment, 181 incidence, 88
psychosocial treatment intervention late onset, 89
programs, 186 American Geriatrics Society, 38
randomized treatment research, 193–194 Antioxidative properties, alcohol, 85–86
research endeavors, 193 Anxiety disorders
risks, 183 comorbidity, 46
topiramate, 188 prevalence rates, 46
treatment response and adherence, PTSD, 45, 46
190–192 AoA. See Administration on Ageing (AoA)
twelve-step programs, 187 APS. See Adult Protective Services (APS)
withdrawal symptoms, 188, 189 ARD. See Alcohol-related dementia (ARD)
tolerance criterion, 27 Area Agencies on Aging (AAAs), 137
young-old, 29 ARPS. See Alcohol Related Problems Survey
Alcohol Use Disorders Identification Test (ARPS)
(AUDIT), 20, 174–175, 240, 242 ASSIST. See Alcohol, Smoking and Substance
Alcohol, Smoking and Substance Involvement Involvement Screening Test (ASSIST)
Screening Test (ASSIST) Assisted living
adults’ risk levels, 226 ADLs and IADLs, 237
challenges, 226 alcohol policies, 238
description, 220 care problems, 237
NIDA, 225 characteristics, 237
total scores and alcohol risk level, 226 cost of, 237
Version 3.0, 225 facility practices, 237
Alcohol–drug interactions GAO report, 237
adverse drug event, 119 long-term care ombudsman program, 237
aging process, 118 nurse aides, 238
CARET and ARPS, 124 private-paying clients and residents, 238
in clinical practice, 120 Assisted living (AL)
comorbidity and medication use-specific long-term care setting, older adults, 158
thresholds, 125 research on, 159
continuing care retirement community, 118 residents, 159
Index 277
At-risk drinking Cardiovascular diseases (CVD)

consumption thresholds, 23 and alcohol, 58–59
episodic heavy drinkers, 24 alcohol consumption and intermediate
NSDUH survey, 24 CVD markers, 59, 60
prevalence rates, older adults, 38 drinking patterns, 59
AUD. See Alcohol use disorder (AUD) HDL-C concentrations, 59
AUDIT. See Alcohol Use Disorders incidence and mortality, 57–58
Identification Test (AUDIT) LDL-C, 59
CARET. See Comorbidity-Alcohol Risk
Evaluation Tool (CARET)
B CCRCs. See Continuing care retirement
Behavioral Risk Factor Surveillance System communities (CCRCs)
2008, 102 Center for Substance Abuse Treatment
Benzodiazepines, 42, 99 (CSAT), 219
Binge drinking, 150 Cognition, 80–87
African American racial identification, 30 alcohol and brain
neurons, 80 animal studies, 80, 81
prevalence, 24 cross-sectional vs. longitudinal
Blood alcohol concentrations (BACs), 99 analysis, 81
Blood viscosity, 59 epidemiological studies, 81, 82
Bogus recycling program, 240 gender effect, 81
Bone mineral density (BMD), 99, 100 neurogenesis, 81
Brief negotiated interview (BNI), 176 and alcohol consumption
antioxidative properties, 85–86
health characteristics, consumers,
C 86–87
CAGE questionnaire, 174 increased cell proliferation, 85
Canadian Community Health Survey-Healthy biases and limitations, study design and
Aging, 2008–2009, 102 analysis, 87–88
Cancer, 71–74 dementia and cognitive impairment
alcohol’s carcinogenicity, 70–71 late life alcohol consumption, 82–84
alcohol-associated cancer risk, 73 midlife alcohol consumption, 84
alcohol-related, 65, 66, 72 educational attainment, 79
breast, 65, 68 former alcohol consumers and life-long
colorectal, 69, 70 abstainers, 88
esophageal, 65, 67–68 genetic factors, 89
head and neck, 67 health and social behaviors,
hepatic, 69 89–90
larynx, 68 negative cognitive changes, 79
morality rate, 65 Comorbid disorders, 42–44
older adults anxiety disorders, 45, 46
alcohol and prognosis, 73–74 gambling
counseling, 71, 72 identification and treatment, older adults,
pain management, 72, 73 48, 49
quality of life, 74 illicit substance use, 40, 41
therapies and alcohol consumption, mental health or substance use
71–72 conditions, 48
oral cavity and pharynx, 68 mood disorders, 44, 45
pancreas, 69 prescription medication use, 41, 42
quantity/frequency and duration, alcohol, 66 severe and persistent mental illness, 47
risk factors, 65 tobacco use, 39, 40
smoking and, 66, 67 Comorbidity-Alcohol Risk Evaluation Tool
Carcinogenicity, 70–71 (CARET), 124, 175
278 Index
Continuing care retirement communities (CCRCs) Elder abuse, 134

continuum of living and care and alcohol misuse, 137–139
services, 156 APS, 137
demographic make-up of, 156 community locations, 141
leisure activities, 156 interpersonal models, 139
light and moderate drinkers, 157 Life Course Perspective, 140, 141
NIAAA guidelines, 158 LTCO, 137
social drinking, prevalence of, 157 mistreatment, 133
social engagement, 157 NAS framework, 140
social engagement and community prevalence studies and typologies, 133
involvement, 156 resources, 143–144
social learning theory, 158 socioecological framework, 140
socialization/relaxation, 158 The Cycle of Violence Theory, 139
Coping types
avoidance, 210 emotional/psychological abuse, 134
life context vulnerabilities, 204 exploitation, 134
mindfulness and acceptance-based, 210 physical abuse, 134
and positive alcohol use self-neglect, 134
expectancies, 208 sexual abuse, 134
self-medicating behavior, 209 EMA. See Ecological momentary assessment
stressful life events, 210 (EMA)
with sleep problems, 205 Ethanol, 66, 67, 70, 71
Coping skills therapy, 210
CSAT. See Center for Substance Abuse
Treatment (CSAT) F
CVD. See Cardiovascular diseases (CVD) Falls
consequences, 101
death rates, 102
D fatal and nonfatal injuries, 101
DCF. See Florida Department of Children and injuries, 102, 103
Families (DCF) older adults, 101
Dementia and cognitive impairment, 83, 84 prevention, 108, 109
late life alcohol consumption risk factors, older adults, 102
Alzheimer’s disease, 83 unintentional fall injuries, 102
mild cognitive impairment (MCI), 83 Familial and social networks
vascular dementia, 83 children, 161
wine consumption, 83 friendships, 161–162
midlife alcohol consumption spousal factors, 160–161
APOE e4 allele, 84 Feedback, Responsibility, Advice, Menu of
infrequent and frequent alcohol alternatives, Empathy and
consumers, 84 Self-efficacy (FRAMES)
Wernicke-Korsakoff syndrome, 84 Centers for Medicare and Medicaid
Depression, 89 Services, 228
DPI. See Drinking Problems Index (DPI) principles, 227
Driving under the influence (DUI) trained health educator/brief intervention
motor vehicle crashes, 100 counselor, 227
prevention, 109 Florida BRITE Project, 186,
DUI. See Driving under the influence (DUI) 243, 269
Florida Department of Children and Families
(DCF), 218, 220, 221
E FRAMES. See Feedback, Responsibility,
Early onset drinking, 5, 6 Advice, Menu of alternatives,
Ecological momentary assessment Empathy and Self-efficacy
(EMA), 264 (FRAMES)
Index 279
G L
Gambling disorder Late-onset drinking
comorbidity, 44 stressful life events, 6
pathological gambling, 43 Late-onset drinking problems, 22
prevalence rates, 43 Lifetime nondrinkers, 21
racial and ethnic differences, 43 Lipids, 60
South Oaks Gambling Screen (SOGS), 43 Liverpool Longitudinal Study, 184
Gastroesophageal reflux disease (GERD), 170 Long-term care (LTC), 237–239
General Accounting Office (GAO) report, age-related health conditions, 243
237, 239 alcohol misuse, 233
Generalized anxiety disorder (GAD), 46 alcohol-related medical problems, 234
Genetics, 67, 70 assessment tools, 242
Government Performance and Results Act assisted living (see Assisted living)
(GPRA), 222 AUDIT tool, 242
GPRA. See Government Performance and BRITE project, 243
Results Act (GPRA) diagnosis, 235
drinking problems, 160
hepatic and renal functioning, 234
H in older adults, 234
Health and Retirement Survey (HRS), 263 institutional policies, 159
Heart failure, 57 long hospital stays and cost, 234
Honolulu Heart Study, 60 medical and social service
Hospitalization, 98, 103, 106 providers, 243
HRS. See Health and Retirement Survey mortality rate, comorbidity and mental and
(HRS) social health, 234
Hypertension, 57 nursing homes, 159
prescription medications, 234
primary care providers, 243
I primary screening instruments, 242
IADLs. See Instrumental activities of daily risks, 160 (see also Senior high-rise
living (IADLs) communities)
Illicit substance use Long-Term Care Ombudsman
cannabis, 41 (LTCO), 137
comorbidity, 41 LTC. See Long-term care (LTC)
psychoactive drug use, 40
Injury, 101
alcohol’s effects, 98–101 M
deaths, 97, 102 Magnesium deficiencies, 60
falls, 102 (see also Falls) MAST-G. See The Michigan Alcoholism
motor-vehicle crashes, 103–105 Screening Test-Geriatric Version
suicide-related, 106, 107 (MAST-G)
unintentional, 97, 102 MCI. See Mild cognitive impairment
Injury and aging (MCI)
alcohol’s effects, 98–101 Medications, 60
falls and, 101–103 and alcohol use, 57
motor-vehicle crashes, 103–105 CVD, 61
and suicide, 105–107 interaction, alcohol, 60
unintentional injury, 97 MI. See Motivational interviewing (MI)
Instrumental activities of daily living Midlife in the United States (MIDUS)
(IADLs), 237 Study, 263
International Agency for Research on Cancer MIDUS. See Midlife in the United States
(IARC), 69 (MIDUS) Study
Irish Longitudinal Study on Ageing, 27 Mild cognitive impairment (MCI), 83
280 Index
Mood disorders factors, 208

comorbidity, 45 late-onset problem drinkers, 208
depression and anxiety, 45 stress and coping theory, 203
major depression, 45 NESARC. See National Epidemiologic Survey
prevalence rates, 44 on Alcohol and Related Conditions
subsyndromal, 45 (NESARC)
Motivational interviewing (MI) NIAAA. See National Institute on Alcohol
aging-related issues, 228 Abuse and Alcoholism (NIAAA)
brief interventions, 227 NIDA. See National Institute of Drug Abuse
FRAMES, 227 (NIDA)
health educators, 228 NIDA Quick Screen, 225
Motor vehicle crashes NSDUH. See National Household Survey on
alcohol/drug involvement, 103 Drug Use and Health (NSDUH)
DUI, 100, 104, 105 Nursing homes
injuries, 105 acute care transfers, 236
older drivers, 103 benefits and harms, 236
disease and medical conditions, 235
former and infrequent drinkers, 235
N higher morbidity rates, 236
NA. See Narcotics Anonymous (NA) NADONA/LTC survey, 236
NADONA/LTC. See National Association permanent residence/short-term
Directors of Nursing Administration rehabilitation, 235
in Long Term Care (NADONA/LTC) research, 235
Narcotics Anonymous (NA), 187 resident-centered care, 236
National Academy of Sciences (NAS), Nutrient metabolism, 60
133, 140
National Association Directors of Nursing
Administration in Long Term Care O
(NADONA/LTC), 236 Old age alcohol consumption, 7–9
National Cancer Institute (NCI), 66, 71 bereavement, 9–13
National Committee for the Prevention of boredom/loneliness, 12–13
Elder Abuse (NCPEA), 136 early onset drinking, 5–6
National Epidemiological Survey on Alcohol enjoyment/socialising, 6–7
and Related Conditions (NESARC), homelessness, 13
27, 39, 202, 206, 209 interviewee characteristics, 4–5
National Health and Nutrition Examination isolation, 11–12
Survey, 99 positive/negative reinforcement, 6
National Household Survey on Drug Use and retirement/loss of work, 10–11
Health (NSDUH), 216 self-medication
National Initiative mental health problems, 7–8
alcohol interventions, 217 physical health problems/insomnia, 8–9
harmful/hazardous alcohol use, 216 Older adulthood, 20, 21, 25–27
primary care practices and managed care alcohol abstinence
organizations, 217 former drinkers, 21
risky/problematic use of substances, 216 lifetime nondrinkers, 21
SAMHSA, 216 alcohol abuse, 25
National Institute of Drug Abuse (NIDA), 225 alcohol craving, 25
National Institute on Alcohol Abuse and alcohol dependence, 25
Alcoholism (NIAAA), 66, 98, 150, at-risk drinking, 23–25
170, 182, 262 AUD (see Alcohol use disorder (AUD))
National Violent Death Reporting System comorbidity, 27–29
(NVDRS), 106 correlates, at-risk and disordered drinking,
Negative affect 29–31
behavioral/pharmacotherapies, 209 drinking patterns, 22
Index 281
drinking, life course baby boomer generation, 247

decline, consumption, 20 care providers, training, 253
English Longitudinal Study on Aging, 20 drinking guidelines, 251
“sick-quitter” hypothesis, 20 drinking patterns, 250
variability, drinking patterns, 20 physiological and psychological
late-onset, 21–22 benefits, 247
low-risk drinking, 22–23 recommendations, 250
social and interpersonal problems regulatory measures, 248
criterion, 27 road traffic safety, 253–254
stages, 19 SAMHSA and AoA guidelines, 252
Older adults, 80 SBI (see Screening and brief intervention
Alzheimer’s disease, 80, 88 (SBI))
cognitive health and alcohol consumption targeted interventions
(see Cognition) alcohol-impaired driving, 250
MCI, 83 alcohol-related harms, 249
socially engaged, 90 areas, 249
wine consumers, 83 education and awareness, 250
Older Americans Act, 270 risky drinking patterns through
Oncology Nursing Society (ONS), 71 screening, 250
taxes on alcohol beverages, 248
P
Perpetrator, 131, 132, 136–140 Q
Pharmacological alcohol treatment Quality of life, 74
acamprosate, 188
opioid antagonist naltrexone, 188
topiramate, 188 R
Polyvictimization, 131, 133 Relapse prevention therapy, 210
Prescreening Resident Profile measure, 154
AUDIT-C, 223 Residential context, 153–156, 158–160
CAGE sensitivity, 224 AL (see Assisted living (AL))
clinicians, 225 CCRCs (see Continuing care retirement
comprehensive assessment, 223 communities (CCRCs))
healthcare, aging and social service community-at-large
providers, 223 CAGE, 155
NIAAA, 224 chronic stressors, 154
NIDA Quick Screen, 225 DPI, 153
screening and services, 223 inquiry areas, 153
SMAST-G, 224 medical centers, 153
Prescription medication Mexican-Americans, 155
benzodiazepines, 42 neighborhood composition, 155
comorbidity, 42 problem drinkers, 154
misuse, 42 Resident Profile measure, 154
older adult, 41 social control theory, 155
Psychosocial alcohol treatment housing units, 153
group sessions, 186 low income senior housing, 156
outpatient care, 186 LTC (see Long-term care (LTC))
primary care, 186 public housing, 156
Psychosocial stressors, 101, 108 Retirement
Public policy, 249, 250, 252–253 Dutch retirees, 152
alcohol consumption and related high workplace stress preceding, 151
problems, 249 individuals occupations, 152
alcohol-related problems, 247 on drinking patterns, 151
attention in young people, 249 preretirement job satisfaction, 151
282 Index
Retirement (cont.) referral to treatment, 229

protective factors, 152 research, 216
“retiree”, 151 SHP, 218
transportation, manufacturing and staff training issues, 228 (see also The
construction industries, 151 Florida BRITE Project)
voluntary/involuntary nature, 152 three-item AUDIT-C alcohol
screen, 222
underutilization factors, 215
S younger adults, 222
SAMHSA. See Substance Abuse and Mental Self-medication, 7–9
Health Services Administration mental health problems
(SAMHSA) bipolar I disorder, 8
SBI. See Screening and brief intervention depression, 7, 8
(SBI) stress relief, 7, 8
SBIRT. See Screening, Brief Intervention and physical health problems
Referral to Treatment (SBIRT) combat pain, 9
SCID. See Structured Clinical Interview for insomnia, 9
DSM-V (SCID) Self-medication with alcohol
Screening and assessment methods abstinence/less frequent drinking, 204
advise and assistance, 175–177 anxiety/depression, 204
AUDIT, 174 clinicians, 209
AUDs, 173 community samples, 206
BNI, 176 community-based samples, individuals, 202
CAGE questionnaire, 174 conceptual model, 207
CARET, 175 educational opportunities, 209
follow-up, 177 gender racial/ethnic differences, 202–203
MAST-G, 174 individual’s alcohol consumption
questions, 172 patterns, 209
SMAST-G, 174 loss of social status, 204
tools, 173 maladaptive, 206
Screening and brief intervention (SBI) maladaptive coping skills, 207
characteristics of patients, 252 mid- and late life, adults, 206
harmful drinking, control of, 252 NESARC, 202
prescription drugs, 253 pain, treatment of, 205, 206
primary care settings, 253 pathways, 208
Screening, Brief Intervention and Referral to physical/mental health problems, 201
Treatment (SBIRT), 186, 216–218, prevalence, 201
227, 269 prevention, 210
age-related changes, 222 sleep problems, 205
brief interventions, 227 social phobia development, 207
FRAMES (see Feedback, stressful life events, 203
Responsibility, Advice, Menu of treatment, 209
alternatives, Empathy and worsen sleep-related breathing
Self-efficacy (FRAMES)) disorders, 207
motivational interviewing (MI), 227 Senior high-rise communities
brief treatment, 228–229 aging-in-place policies, 239
comprehensive risk assessment, 225–226 alcohol use items, 240, 241
formal substance abuse treatment AUDIT, 240
services, 215 GAO and HUD, 239
GPRA classification, 222 housing mangers, 239
national household surveys and treatment national mail survey, 240
admissions data, 216 nonconfrontational group treatment
National Initiative (see National Initiative) settings, 240
network development, 221 self-reports and unobtrusive measures, 240
Index 283
substance abuse prevention and treatment health educators, 219

services, 240 in medical settings, 220
Severe and persistent mental illness non-healthcare providers, 220
dementia, 47 positive screens and referral processes, 219
lifetime psychosis, 47 prescription medication misuse, 219
schizophrenia, 47 SAMHSA/CSAT, 220
Short message service (SMS), 269 The Michigan Alcoholism Screening
SHP. See Staying Healthy Project (SHP) Test-Geriatric Version (MAST-G),
SMS. See Short message service (SMS) 174, 224, 242
Social environment Tobacco use
baby boomer cohort, 150 comorbidity, 40
binge drinking, 150 National Health Interview Survey, 40
demographic shifts, 149 older adults, 39
moderate consumption, 149 Tobacco-smoke carcinogens, 67
NIAAA, 150 Twelve-step programs
NSDUH, 150 (see also Residential AA and NA, 187
context) examination of factors, 187
retirement, 151–152 outpatient treatment program, 187
Socialisation, 6–7 recovery and rehabilitation, 187
Socioecological (SE) framework, 140 self-help groups post-treatment, 187
South Oaks Gambling Screen (SOGS), 43
Staying Healthy Project (SHP), 218
Stroke, 57 U
Structured Clinical Interview for DSM-V Unhealthy alcohol use, 172
(SCID), 184 AUD criteria, 171
Substance abuse, 105, 106, 109 GERD, 170
assessment, 108 problem drinking, 170
community-based substance abuse screening and assessment (see Screening
treatment programs, 109 and assessment methods)
evidence-based treatment, 109 United States Preventive Services Task Force
prevention and treatment programs, 109 (USPSTF), 172, 228
and psychosocial stressors, 101
treatment, 104
Substance Abuse and Mental Health Services V
Administration (SAMHSA), 182 Victims
Suicide and suicide attempts gender, 135
older adults, 105 physical and mental impairments,
poisonings, 107 135, 136
prevention, 109–110 poly-victimization, 131
race, 135
risk factors, 135
T substance abuse, 136
The Cycle of Violence Theory, 139
The Florida BRITE Project
ASSIST, 220 W
DCF, 218 Wernicke-Korsakoff syndrome, 191
depression, 219 Whitehall II Cohort Study, 7

Alcohol and Aging Clinical and Public Health Perspectives

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Alexis Kuerbis

Alcohol and Aging

Clinical and Public

Alcohol and Aging

ISBN 978-3-319-47231-7 ISBN 978-3-319-47233-1 (eBook)

Library of Congress Control Number: 2016959504

© Springer International Publishing AG 2016

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Part II Epidemiological Perspectives of Alcohol and Aging

Part III Alcohol Effects on Healthy Aging

10 Social and Familial Contexts for Drinking among Older Adults........ 149

Part IV Clinical Issues of Alcohol and Aging

Part V Future Directions

Julie B. Boron, Ph.D. Department of Gerontology, University of Nebraska,

Daniel S. Gardner, Ph.D., L.C.S.W. Silberman School of Social Work, Hunter

Patricia W. Slattum, Pharm.D., Ph.D. Department of Pharmacotherapy and

C. Haighton, Ph.D., M.A., B.Sc. (*)

© Springer International Publishing AG 2016 3

Table 1.1 Interviewee characteristics

1.2 Reasons for Drinking

1.2.1 Early Onset

1.3.1 Mental Health Problems

1.3.2 Physical Health Problems/Insomnia

1.4.1 Retirement/Loss of Work

Interviewees acknowledging alcohol problems recalled falling out or gradually

In our sample, drinking was also frequently described as a response to finding

None of the participants in our qualitative study were currently homeless

P. Sacco, Ph.D., M.S.W. (*)

© Springer International Publishing AG 2016 19

possible, the age ranges of studies will be included in discussion of research on

2.1 Older Adult Drinking Seen Within the Life Course

2.2 Understanding Alcohol Abstinence in Older Adulthood

2.3  ate-Onset Drinking Problems: Reevaluating

Data from epidemiologic studies offer a slightly different picture. Longitudinal

2.4  rinking Patterns in Older Adulthood: Common

2.5 Low-Risk Drinking

2.6 At-Risk Drinking

Although there is ongoing debate and research about what constitutes

2.7  roblem Drinking, Alcohol Abuse, Alcohol Dependence,

DSM-IV [47] DSM-5 [48]

Criterion Removed DSM-5

2.8  lternative Measures of Risk: Comorbidity in Older

AUD is the most severe manifestation of alcohol-related pathology among older

Table 2.2 Measures of alcohol risk

Because this measure of alcohol risk focuses more broadly on unhealthy

2.9  orrelates of At-Risk and Disordered Drinking

2.10 Conclusions and Implications

2. Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life course epidemiology. J Epidemiol

Alexis Kuerbis, Rachel Chernick, and Daniel S. Gardner

A. Kuerbis, Ph.D., L.C.S.W. (*) • D.S. Gardner, Ph.D., L.C.S.W.

© Springer International Publishing AG 2016 35

3.1  omplications of Aging Related to Health and Mental

3.2 Alcohol Use

3.4 Illicit Substance Use

3.5  rescription, Nonprescription, and Over-the-Counter

There is a continuum of prescription medication use—from using it as prescribed,

and pathological gambling—two terms that are utilized frequently in the

Comorbidity. Comorbidity of mental and physical health disorders is prevalent

3.7 Mood Disorders

1.2 Reasons for Drinking

1.2.1 Early Onset

1.3.1 Mental Health Problems

1.3.2 Physical Health Problems/Insomnia

1.4.1 Retirement/Loss of Work

2.1 Older Adult Drinking Seen Within the Life Course

2.2 Understanding Alcohol Abstinence in Older Adulthood

2.3 ate-Onset Drinking Problems: Reevaluating

2.4 rinking Patterns in Older Adulthood: Common

2.5 Low-Risk Drinking

2.6 At-Risk Drinking

2.7 roblem Drinking, Alcohol Abuse, Alcohol Dependence,

2.8 lternative Measures of Risk: Comorbidity in Older

2.9 orrelates of At-Risk and Disordered Drinking

2.10 Conclusions and Implications

3.1 omplications of Aging Related to Health and Mental

3.2 Alcohol Use

3.4 Illicit Substance Use

3.5 rescription, Nonprescription, and Over-the-Counter

3.7 Mood Disorders

3.8 Anxiety Disorders

3.9 Severe and Persistent Mental Illness

3.10 Other Psychiatric Disorders

3.12 I dentification and Treatment Utilization of Comorbid

4.2 CVD Incidence and Mortality

4.3 Alcohol and CVD

4.4 Alcohol Drinking Patterns and CVD

4.5 lcohol, Nutrients, and Intermediate CVD Markers

4.6 Future Studies

5.1 Epidemiology of Cancer Associated with Alcohol Use

5.1.1 Head and Neck Cancers

5.1.1.3 Oral Cavity and Pharynx

5.1.3 Hepatic: Liver and Intrahepatic Duct

5.1.5 Colorectal Cancer

5.2 ossible Mechanisms Accounting for Alcohol’s

5.3 Implications for Older Adults

5.3.1 Counseling Older Adults with Cancer about Alcohol Use

5.3.2 Cancer Therapies and Alcohol Consumption

5.3.3 Pain Management

5.3.4 Alcohol and Prognosis

5.3.5 Quality of Life

6.2 Alcohol and the Brain

6.3 Alcohol, Dementia, and Cognitive Impairment

6.3.1 Late Life Alcohol Consumption

6.3.2 Midlife Alcohol Consumption

6.4 echanisms to Explain the Relationship

6.4.1 Increased Cell Proliferation in the Brain

6.4.2 Antioxidative Properties of Alcohol

6.4.3 Health Characteristics of Alcohol Consumers

6.5 Future Research Directions

6.5.3.1 Genetic Factors

6.5.3.2 Health and Social Behaviors

7.2 lcohol’s Effects on Injury and Death: Biological

7.3 Falls and Fall Consequences Among Older Adults

7.4 otor-Vehicle Crashes due to Driving

7.5 Suicide and Suicide Attempts

7.6 Implications for Clinical Practice, Policy, and Research

7.6.1 Fall Prevention

7.6.2 DUI Prevention

7.6.3 Suicide Prevention

8.2 hysiologic Changes with Aging Altering Response

8.3 Drug Interactions in Older Adults