Health Promotion and Aging
"Alcohol"

Erma Polly Williams, M-R-E.
Continuing Education Faculty, Rutgers Center of Alcohol Studies
Consultant to the New Jersey State Division on Aging
Consultant to the New Jersey State Division on Alcoholism

Alcohol is here to. stay. Older people probably have a better sense of the
meaning of that statement than younger people since anyone over the age of 55
lived part of their life under Prohibition. Anyone over the age of 65 probably
remembers at least fragments of the "roaring twenties", and anyone over seventy
probably recalls Temperance slogans, speeches and rallies. Older people are also
here to stay. With people over 65 representing approximately 12% of the
population, they are the fastest growing segment of the society, and include many
more people of increasingly advanced age. As the quality of life for these older
people is strongly tied to the maintenance of health, it is appropriate that
there should be a consideration of the relationship of age and alcohol from a

health perspective.

Interest and concern about the incidence of alcohol use and abuse by the older
portion of the population have increased dramatically over the last 20 years.
This increase is evident in the core of alcohol literature, as well as in the
publications of many disciplines, reflecting the multidisciplinary dimensions of
the phenomenon. It 1s being addressed in professional journals, giving evidence
that the problem is being encountered by the many systems and agencies that
provide services to older people. Yet despite this tide of attention, the area
of study and the level of response to the need do net seem to gain much headway.
In view of all the needs of older people in our society, problems related to
alcohol are relegated to a low place on the priority list. And in the alcohol
field, the aged do not appear to generate the excitement and involvement of other

population groups.

The society is becoming increasingly sensitive to the presence of elderly people.
By sheer weight of numbers, it is becoming more imperative that issues related to
their health and well-being be addressed. The pervasiveness of the use of
alcohol as a societal practice, and the types of impact that this use can have on
the indjviduals and the resources of the society, require that it be one of the
areas addressed in relation to the older segment of the society-

BASIC DEMOGRAPHIC AND POPULATION DATA

Extent of drinking

In considering the data available that indicates the nature and the extent of the
problem, it should be noted that the designaticns of the older age and the
designations related to alcohol use and abuse are specific to the individual
study, and become relative terms when used to discuss several studies that may

not have the same specific criteria.

Cross sectional. studies of the use of alcohol have provided information that,

when compared to younger age groups, the rates of abstainers increase and the
percentage of drinkers decrease in the older age groups. Cahalan et al. (1969),
using national household survey data, reported the percentage abstainers by age
group: age 40-49, 29%; age 50-59, 40%; and age 60+, 47%. The proportion of heavy
drinkers for the same age groups were 15%, 10% and 6%, respectively. For men,
Cahalan reported that more than half of the men over 65 were not regular drinkers
(54% being either abstinent or infrequent drinkers) and the lowest percentage of
heavy drinkers were found in this age group. In the age group of 60-64, 20% were
classified as heavy drinkers, representing 35% of those that drank. At age 65,
this figure dropped to 7%, cr 11% of those that drank. In the same study, for
women, there was similar decline but evidenced at age 50. Two thirds of women
aged 50 to 64 did not drink at all or infrequently. After age fifty, the
percentage of heavy drinkers among woren became inconsequential.

Similar tendencies were reported by Barnes (1979) from a general population
survey in western New York state, by Christopherson et al. (1984) from a survey
in rural Arizona, and by Meyers et al. (1981) from a household survey in Boston.
Barnes noted that while the regional rates of heavy drinking are significantly
higher than the national rates, the trends holds. Rates ef abstinence increased
from 13% for those age 50-59, to 31% for age 60-96. In addition, Barnes refined
the age group of 60+ and reported that 24% of males age 60-69 were heavy
drinkers; for those age 70-96, 6% were in that category. Among females, heavy
drinkers accounted for none of those age 60-69, but 2% of those age 70-90.

The reasons for the decrease in the proportion of drinkers from the younger to
the older age categories has been considered by several researchers. Items were
included in several studies that inquired about previous drinking patterns or
problems. Responses frequently mentioned concerns for health or health problems
that were experienced as a reason to temper the quantity and/or the frequency of
drinking. Other responses rang-d from economic reasons, changing social
opportunities, and changing response to the substance. Gomberg (1982) has
summarized possible explanations for the decrease in social drinking as economic
(decrease in drinking may result frem lower income), physiology (change in
obtained blood alcohol levels with physical aging), effects of alcohol (resulting
impacts and behaviors are no longer worth the cost), life cycle differences
(decrease a natural occurrence as cohorts ages), unique historical aspects
(drinking habits of current generation influenced by Prohibiticn, Depressicn),
and medical problems (health status, with increased medical problems, cause older
people to limit or eliminate drinking).
2

Two additional items shceuld be kept in mind when considering this data. The
cohorts of older people that are reported in each cf these studies are products
of the social and historical influences of their time, which are then intertwined
with an array of unique individual experiences. Subsequent generations of older
people will, in many respects, be very different from the clder people of these
studies. Specifically, it should be remembered that cross sectional studies
present data that evidence a lower percentage cf abstainers and an increase in
the level of drinking in the younger age groups.

There is also evidence in surveys that drinking practices remain consistent
overtime with some people. Christopherson (1984) has presented data that there
is a tendency for people to carry drinking patterns into old age as long as
circumstances and health permit. Data from the Normative Drinking Study confirms
this (Glynn et al. 1984). Men, originally surveyed in their 40's and 50's, ten
years later reported consistent drinking habits. It would appear that future
would present a larger proportion of drinkers and a

generations of older people
nue to drink at higher levels into cld age.

potential of more people who conti

Problems with drinking

Evidence of problems related to alcchol use ancng older people comes from several

types of sources with a range of criteria for the designation of a probler.
Cahalan (1970) utilized the self reporting of eleven types of problems, including
quantity/frequency and pattern of drinking, elements of physical and
psychological dependency, and interpersonal, social, health, economic and legal
problems. He reported that 12% of men age 60-69 had a current problem score of
7+, For age 70+, it was 1%. For women age 60-69, 1% had a current problem sccre
of T+; age 70+, less than one-half percent. These figures do represent a
drinking problems for men after age 50 but continuing until age
70. Further analysis involved the development of a social-psychological risk
score which included attitude toward drinking, environmental support for heavy
drinking, alienation and maladjustment, impulsivity and nen-conformity, looseness
of social controls, and unfavorable expectations. Data indicates that men 60+ of
highest risk score show almost the same problem score as those of younger age

groups.

tapering off of

A second community survey source of information on problems related to drinking
is the Epidemiologic Catchment Area Study which utilizes the NIMH Diagnostic
Interview Schedule. This schedule provides for assessment of alcohol abuse and
dependence based on the American Psychiatric Association's Diagnostic and
Statistical Manual, DSM-III {American Psychiatric Association 1980). Three sites
of the five in the study have presented information related to alcohol abuse and
dependence. The lowest rates of alcohol abuse and alcchol dependency were among
those 65+, ranging from 4% to 9% at sometime in their life. In terms of the
recent occurrence of problems (within the last 6 months!, 3% of males reported a
problem, 1% of females. Similar rates were found for blacks and whites, and
social class did not appear to have a large effect (Robins, 1984).

Warheit and Auth (1984), investigating concurrent alcohol and mental health
problems, found similar rates for alcohol problems within the older population.
In looking at the correlation between mental health concerns and alcchol use, an
alcohol risk score was developed and the sample divided into high and low alcohcl
risk groups. Items included were drinking in general, the frequency of
intoxication, problems related to drinking (personal, social and family), self-
perceptions regarding the appropriateness of alcohol use, and the use of alcohol
to face daily problems. For the older segment cf the sample, age 50+, the high
risk group generally gave more indications of poor mental and physical health
than the low alcohol risk group of the same age. Advancing age was highly
associated the increasing feelings of helplessness among the high risk group.
Self perception of pcocr health was more common in the alcohol high risk greup-
In reporting their present mental health, 39% of the high risk group responded
fair or poor; among the low alcechol risk group, only 92.1% reported fair or poor
mental health. Almost half (46.3%) of the high risk alcohol group reported at
least one hospital stay in the last three years, 14.6% had three or more
inpatient stays. This is contrasted with the low risk group that reported 28.7%
had one or two stays, 4.7% had three or more. Generally, Yarheit and Auth
concluded that alcchol use rather than age alone seemed to a better predictor of
the kinds of health problems that necessitate hospitalization.
Studies that report on the older population within institutions and medical
Settings provide additional information. McCusker et al. (1971) conducted a
prevalence study of newly admitted patients to the medical wards of a New York
City hospital serving a high proportion of blacks and Hispanics. Questionnaires
were utilized to gather information to rate alcohol related problems over the
past year. The moderate level of the scale, identified as the threshold for the
diagnosis of alcoholic, identifed frequent intcxication up to one or two times
per week and/or significant impairment in social, family, or occupational
functioning, or evidence of physical impairment related to alcohol. In the age
group 50-69, 63% of the males and 35% of the females met this criteria.

A study of 113 consecutive male admissions to acute medical wards was made by
Schuckit and Miller (1976) in a Veterans Administration Hospital. Interviews
established the patient's psychiatric diagnosis, organicity tests determined the
presence of organic impairments, chart reviews provided basic demographic
information, past and present physical and mental status, medication and drug and
alcohol history. A resource person validated the patient information. Of these
admissions, 18% (20) were diagnosed as alcoholic, with 55% (11) of these
considered inactive, or having had no alcohol related problem in the 6 months
prior to hospitalization, although 2? of the 11 still drank.

Data from psychiatric services provides other evidence: of 534 first admissions
of patients age 60+, 28% had serious drinking problems (Simon et al. 1968); in an
outpatient psychiatric program in Harlen Hospital, 12% of the elderly were noted
as having a drinking problem (Zimberg 1969); in a county psychiatric screening
ward, among 100 consecutive admissions of persons 60+, 44% were alcoholic (Gaitz
and Baer 1971); and in a medical home care program, 13% of the elderly patients
requiring psychiatric consultation were diagnosed as alcoholic (Zimberg 1971).

Although it is not possible to determine the actual prevalence, the fact remains
that a sizable proportion of the elderly do evidence alcoholism and problem
drinking. While recognizing that older people do drink less, an estimate of the
prevalence of alcoholism among those who do drink approximates that of other
adults, nearly 8% (Nace 1984). Estimated rates in clinical practice with clder
people ranges from 10 to 20% with a higher propertion among the elderly who are
hospitalized and institutionalized (Schuckit and Pastor 1979, Zimberg 1982).

Different types of presentation

As early as 1968, there were attempts to develop a classification system of solder
alcoholics. It was recognized that there are sub-groups who presented similar
histories and symptoms. Simon et al. (1968) reported that among a qraup of firs

admission psychiatric patients with serious drinking problems, age 60 and older,
about 1/3 had become alcoholic after age 60, while about 2/3 had been alcoholic
before age 60 and had a long history of alcohol abuse. He also noted that a
little over 1/3 had chronic brain syndrome, but this diagnosis was not exclusive
to either group. The proportion of 1/3 late life and 2/3 long standing was
confirmed by Rosin and Glatt (1971) from studies of psychiatric home
consultations and admissions to alcoholism units and hospital geriatric units.
Schuckit and Miller (1976) also made a distinction between early-onset and late
on~set, using age 40 as the demarcation. Among the persons ages 65+ being
admitted to a medical ward, using this designation, the groups was almost equally
divided.

Carruth et al. (1973) noted three distinct types: individuals with no history of
problem drinking until one developed in response to age related stress, a second
group that had at times experienced problems but only developed severe and
persistent problematic drinking in old age, and a third group who had a long
history of alcoholism and continued to drink into old age. Gomberg (1982) also
recognized three groups, the survivors: alcoholic persons who have grown older;
those with intermittent histories of heavy drinking in response to severe stress;
and the reactive problem drinkers who are responding to the stresses and losses

of aging by drinking heavily.

The generally accepted division is that of early-onset and late-onset without a
specific age of onset. The distribution of 2/3 early-onset vs. 1/3 late onset
is generally confirmed by personnel in the field. Different terms are at times
used. Geriatric alcoholics (early-onset) are the stereotypic chronic alcohol
abusers who have continued to drink while aging, and geriatric problem drinkers
(late-onset) include those who had no _ history of a problem and those who
occasionally experienced problems, all of whom develop abusive patterns in

response to the stresses of aging (Dupree and Zimberg, 1984).

Recognizing this general classification facilitates the process of identification
and treatment. General characteristics of the early-onset individual include a
medical history that indicates extended severe drinking, mental pathologies and
personality characteristics related to chronic alcohol use, a social history that
indicates the impact of alcohol, such as a poor work history, a disrupted or
stressed social and family history, poor relationship skills, and fewer economic
resources. Late-onset characteristics generally include alcohol related medical
problems that may be acute but of shorter duration, better problem solving and
relationship skills, and more stable job, family and social histories. Problems
in these areas are usually of recent origin and of shorter duration.
Psychological problems are generally more focused upon issues related to age,
such as loneliness, depression, grief, poredom and pain.

The hidden older problem drinker

Observations have been made by several researchers that older problem drinkers
are a Ridden population. The high percentage of alcoholics among the older
populations in acute medical and psychiatric institutions is probably more
reflective of the debilitating and/or long term impact of alcohol on an older
person than it 1s of the sensitivity of the intervention mechanisms that exist.
Perceptions of service | providers indicate that the older person is
underrepresented in the alcohol treatment network. Many reasons are given for
the inadequate level of identification. There is a more subtle presentation of
symptoms of problem drinking and alcoholism in older people. Presenting symptoms
are inaccurately identified as being related solely to medical or psychological
problems associated with the aging process. Care providers, including medical
personnel, are reluctant to become involved in the identification/intervention
process. The elderly themselves may have a lack of awareness about the effects
of alcohol and are reluctant to self disclose. Denial and “enabling may exist
within family units. Due to the life stage, there is a lack of social and
occupational identifiers. Finally, significant others and care providers may
have the inaccurate perception that the drinking is a rational choice of
behavior, and further, may believe that it is logical given the age of the
person.

ALCOHOL, ALCOHOL USE AND HEALTH

The impact of alcohol and alcohol use on the health and well being of any one
older person has many dimensions. Of primary importance is the quantity and the
frequency of the drinking experiences. How much alcohol is taken into the system
and how frequently these occasions occur generally provide information that
allows for the description of light, moderate or heavy drinker. A second
consideration is the pattern and the duration of the drinking history. Movement
along the continuum of type of drinker at different periods in the life span
provides a variable to the current impact. Cultural and social norms. that
influence the designation of appropriate drinking occasions, such as with meals,
or at drinking oriented events, may ameliorate or exacerbate the effect of the
alcohol on any one occasion, and cumulatively, the effect of the use of alcohol
on the entire system. General physical condition, and all the elements that
support that condition, such as genetic factors, nutrition, the balance of rest
and physical activity, are important. The presence of chronic and acute medical
conditions plays a role, as does the existence of drug regimens, whether
monitored by a physician or self-prescribed. Generally, the more intense and
prolonged the use of alcoholic beverages, the greater the impact the substance
ethanol will have upon the health of the individual.

The general process of aging brings its own contribution to health implications
for alcohol use. Response to the aging process is highly individual, in terms of
persons and all of the components of each person. But there are general
principles that apply. Advancing age witnesses a gradual lowering of the level
of the homeostatic state. This is accompanied by a lessening of the physical
reserve of the entire system and each of its parts. All body systems and organs
tend to decrease in efficiency of operation and to loose resiliency. Stress,
whether physical, emotional or environmental, has a greater impact upon the
system and each of its parts. Returning to the pre-stress state or finding a new
level of balance is more gradual, taking a longer period of time than when
younger. Vulnerability to disease states increases with age and is compounded by
stress. Disease states also increase the vulnerability of older people to the

impact of alcohol.

It is’particularly important to remember that, as an individual ages, there are
greater mutual effects that operate between the physical, social and emotional
health of an individual. The older age stage of life brings unique developmental
tasks, stresses and age related life crises. In responding to these tasks,
stresses and crises, the totality of the person is affected.

Of specific importance to the use of alcohol and other chemical substances are
general physiological changes. With age there is a decrease in the lean body
mass and an increase in fat storing tissue. Alcohol, being water soluble, is
distributed through less lean tissue, resulting in higher concentrations within
organs. Generally, when compared to younger people of equal weight and drinking
the same amount, older people may be expected to evidence a higher blood alcohol
level. Time and rate are also affected. Age has a tendency te slow both the
process of metabolism and of elimination. The blood alcohol level may be held
for a longer period of time. In addition, the elimination process may be
particularly affected by the presence of medications. The liver, being the
principal organ involved, may be operating at a less efficient level and may be
required to process multiple substances at the same time. All of these have
jmpact upon the tolerance level, which is generally characterized as decreasing
with age (Schuckit 1980, 1982, and Bosmann 1984).

There are medical and health and safety areas that need particular emphasis in
the concern of health and alcohol use 4s related to older people. It must be
emphasized that, although there is a wealth of material that addresses the
relationships that exist between specific areas and alcohol, the particular
emphasis upon the older person frequently has been inferred from other studies or
has been inconclusively explored to date. It should also be noted that
biomedical research has not thoroughly explored health problems in the older age
group, or among segments within that group.

The cardiovascular system

The implications of alcohol use for cardiovascular disease are particularly
important in relation to older people as hypertension and heart conditions
account for two of the four most common chronic conditions of non-
institutionalized elderly. Although the exact relationship between alcohol
consumption and the development of cardiovascular diseases has not peen
determined, there are areas that are important to consider. Generally, alcohol
can have a direct effect on the heart muscle leading to an increase in the
cardiac rate and output. In older people this may produce stress on the organ

itself and on the rest of the cardiovascular system because of a reduced level of
physiological reserve. In individuals with impaired cardiac functioning, this
may have the ultimate effect of decreased cardiac output and diminished
efficiency of the system. Alcohol can directly affect the heart as a cardiac
toxin and the cardiovascular system by increasing blood pressure. Excessive
amounts of alcohol have been strongly linked with the development of
hypertension, stroke, myocardial degeneration, arrhythmia, and cardiac failure.
Alcohol can also mask the symptoms of a disease state, such as angina pectoris.
Individuals frequently do not feel the associated pain in the chest while
drinking but the medical indications are that the affected tissue continues to
suffer from the lack of blood flow. Continued or increased activity may increase
the stress level although no pain is felt. (Gambert et al. 1984, Hermos et al.

1984, Kannel 1986, Schuckit 1982.)
a

There is, however, avidence of lower rates of congestive heart disease in
association with moderate alcohol intake. Regular use of alcohol appears to
have the effect of increasing high density lipoprotein cholesterol which may
retard the development of coronary artery disease (Barboriak et al. 1983, Kannel
1986). Non-drinkers had higher mortality rates than those who drank lightly {in
reference to the Normative Aging Study) and non-drinkers had higher blood
pressures than those who drank in small amounts (in reference to the Framinghan

Study) (Gordon 1984.)
The central nervous system
The relationship of the health of the central nervous system in the maintenance

of autonomy and independence makes it a particularly sensitive area to consider

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in relation to alcohol use and aging. There are changes that do take place with
age that result in variations in functioning compared to the time when the
individual was younger. But for healthy older people these changes do not
necessarily have to exert 4 deleterious ‘effect on the ability te manage their

life or to cope with their environment. Age frequently brings an increase in
reaction time and in the time needed to retrieve something from memory. Wath
age, there is also an increased tendency to exhibit confusion when under
physical, emotional or social stress. Cognitive processes may be slowed but

seldom become impossible tasks for healthy older people. Educational gerontology
has contributed much to the affirmation of the ability of older people to perform
learning tasks provided that the information is well organized, presented in a
way that compensates for sensory changes, that the stress of the learning
situation is reduced, and the risks associated with performing incorrectly are

minimized.

Ethanol affects the central nervous system. It may have the short-term effect of
acting as a stimulant. However, the long-term effects are as a depressant. This
may result in respiratory depression, sedative-hypnotic effect, ataxia,
pronounced disinhibition, impaired motor skills, neuropathy, and unconsciousness.
Age related metabolic changes are generally accompanied by an apparent increase
in the sensitivity of the brain to all central nervous system depressing drugs,
including alcohol. Very small amounts of alcohol can produce symptoms that are
commonly identified as age-related mental decrements, or may exacerbate age
related phenomenon. The mis-reading of the presentation of an older person is
frequently responsible for non-identification of alcohol problems (Bcsmann 1984,

Schuckit 1982).

Much research has been conducted on the effect of alcohol upon the central
nervous system. A prominent theme in that research is the question of
accelerated or premature aging as an effect of alcohol use. Functional changes
that are related to aging and functional changes that are the result of alcohol
use are frequently very similar in their presentation. The processes of aging
and of alcohol intoxication have much in common in the way that they affect
memory, learning, recognition and organizational processes. In a "worst
scenario" of the aging process or from long and intense use of alcchol, similar
organic changes may take place in the brain and disease states occur. Current
research outcomes do not seem to support the theory of premature aging. Although
chronic alcoholic drinking appears to increase the behavior defects that
accompany aging, as yet, a common pathology has not been identified. Alcohol use
is responsible for some brain dysfunction, but the effects seem to be independent
of and parallel to the effects of normal aging. Studies do suggest that people
who use alcohol to excess appear to run an additional risk of neuropsychological
impairment beyond what might be expected from the aging process. Further, since
some of the deficits related to alcohol use are at least partially reversible,
continued research may illicit some value in terms of therapies for age related
problems. (Blusewicz 1982, Bosman 1984, Lowe 1985, Parsons and Leber 1982,

Russell 1984.)

Medications and over-the-counter drugs

The use of alcohol combined with a regimen of over-the-counter or prescribed
medications is a common but potentially lethal occurrence. As one grows older,
the number of drugs one takes usually increase. A figure commonly cited is that
older people who are 12% of the population are using approximately 25% of the
prescribed medications. Further, it has been estimated that over-the-counter
preparations account for approximately 90% of all drugs taken by the elderly

(Baker 1985)-

The problem of drug use and misuse has many dimensions and is compounded when
drugs are used with alcohol. Alcohol interacts adversely with many drugs, 4a
situation that is particularly significant with other central nervous system
depressants. Polypharmacy is not uncommon among older people. Frequently, the
medical regimens are being prescribed by more than one physician, and older
people often have difficulty in correctly self-administering the medications.
The potential for drug interactions and adverse drug reactions is great under
such circumstances, particularly in view of the changing physiology with age.
All of these situations are intensified with the use of alcohol. Adverse drug
and alcohol interactions can be potentially life threatening to older people
pecause of the decrease in reserve in vital organs. Many older people have poor
or incorrect conceptualizations of how their bodies handle substances and need
education in order to practice healthful habits. Further, many professionals and
para-professionals who work with older people are unaware of the seriousness or
the extent of the problem. (Atkinson 1984, Glantz 1983, Schuckit 1980.)

Nutrition

Healthful nutritional practices among older people have been a concern of many
who work and have contact with the elderly. Nutritional practices are affected
by the totality of the life circumstances of older people. Social,
psychological, economic and physical factors are important to consider. Changing
circumstances within the family unit, such as the loss of a spouse, may affect
the pattern of food preparation and may precipitate all but minimal attention to
the activity. Depression, social isolation and physical incapacity can intensify
and make insurmountable the problems related to the maintenance of a good diet.
Life-long dietary practices, which may not have seened problematic at a younger
age, now become detrimental and debilitating. Physical changes that are age
related, coupled with the use of medications, may require modification of these
practices. The ability to make such changes may be limited by a lack of
information, minimal economic resources or lack of access to appropriate
facilities for shopping, storage or preparation of food.

Malnutrition has been long recognized as being caused by chronic alcohol use.
The impact of the use of alcohol on nutrition is seen as a result of a change in
ability to function as well as affecting the appetite, absorption, metabolism and
excretion of nutrients. When compounded with physiological aging, With the
reduction of functional reserves, the effect may be particularly detrimental. It
is widely recognized that the elderly user is much more susceptible to the
nutritional consequences of alcoholism. It is not as widely recognized that there
may be nutritional consequences for the more social user, particularly if there
are acute or chronic diseases present and medical drugs are being taken.

There are many specific nutrition-alcohol interrelationships that should be kept
in mind both in the maintenance of healthful practices and in the treatment of
alcoholism in elderly people. One will illustrate the weight of the area of
consideration. The course of normal aging brings a reduction in bone mass as
well as reduction of the capacity of the gastrointesinal tract to absorb calcium.
The presence of metabolic acidosis, a common result of consuming alcoholic
beverages, may further aggravate a negative calcium balance. The development of
osteoporosis, a frequently identified condition in older people, particularly
women, may be aggravated by alcohol use. Adequate calcium levels are also
required to maintain the transmission of nerve impulses at appropriate levels.
These processes are also negatively affected by age and by the presence of
ethanol, and may be subjected to a compounded effect. (Gambert 1984, Mishara and

Kastenbaum 1980, Russell 1985.)

Garcinoma

The question of the carcinogenic effects of alcohol use have been of concern for
several years. It does appear that there is a tendency for the chronic alcoholic
to develop squamous cell carcinoma in the region of the pharynx. Carcinoma of
the esophagus is frequently detected in those who are diagnosed as alcoholic,
representing over half of all cases of esophageal cancer. There is some evidence
that alcohol abuse may also be associated in the development of carcinoma in the

mouth.

However, there are methodological problems in the research in this area. It
becomes extremely difficult to distinguish between the effects of alcohol and
other factors that are frequently present, such as smoking, exposure to
pollutants and malnutrition. It has been estimated that approximately 90% of
alcoholics are also smokers, and the role of smoking to the development of some
kinds of carcinoma has been well documented. Research has also indicated that
there may be carcinogenic implications related to the way cells respond to
ethanol. It does not appear, however, that alcohol has an equal role in the
development of all types of cancer, and where there does appear to bea
relationship, additional research is still desired. (Bosmann 1984, Bambert 1984,

Mishara and Kastenbaum 1980.)

Safety

Problems related to safety and alcohol use are many, from pedestrian accidents to
the interference of an alcohol-induced state in performing simple chores in the
kitchen. Stress for older people who are injured in accidents has the same
ripple effect on their health and mental outlook as disease states. Older people
seem particularly susceptible to falls. Hingson and Howland (1987) report
figures from the Center for Disease Control, indicating that each year 200,000
older Americans experience hip fractures associated with falls. Older people are
also disproportionately represented in deaths from falls, over one-half of fatal
falls involve persons over 75 years of age. There 1s a strong link between the
use of alcohol and falls. In fact, one of the items frequently included in a
list of clues of a drinking problem is the experience of falling. Although there
is substantial evidence that alcohol increases the risk of falls, studies have
not yet provided information that 1s specific to the elderly. However, from a
perspective of maintaining safe practices, the potential effect of the use of
alcohol on the incidence of falls among older people should not be neglected
(Hingson and Howland 1987).

In discussing burns of older persons, Anous and Heimback (1986) noted that
frequently burns tend to be deeper because of delayed reaction times, impaired

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senses and the fact that many older burn patients live alone. The reduced
capacity of the older physical system has special import in dealing with the
stress related to the burn experience as well as affecting the process and time
of healing. It was also noted that older cases with documented alcohol problems
tended to be loners and to have a higher percent TBSA (Total Body Surface Area)
purn. (Anous and Heimbach 1986.)

Benefits from alcohol use

The beneficial use of alcohol with older persons has been a recurring theme in
the literature that relates to aging and alcohol. Stories of the prescribing of
spiritus frumenti have been documented in many case histories and in studies of
practices within care facilities for older people. Common conditions that are
addressed in this manner are loss of appetite, as an aid to digestion, as a
nutritional supplement, as a relaxant, sedative and a sleeping aid. Most studies
of the use of alcohol generally conclude that there 1s a therapeutic value to the
serving of alcoholic beverages in institutional settings. Some note that, under
such conditions, the medication levels may be reduced. In many of the studies,
there was an effort to provide a varied or special setting for the events of
drinking, as well as there being additional staff and others present who were
involved in exchanges with the residents of the facility. These factors make it
difficult to identify the exact source of the benefits observed (Mishara and
Kastenbaun, 1980). In reporting on their own research, Mishara et al. (1975)
stated that the amount of alcohol that was consumed was smal] and that there was
an effect of the social setting that supported drinking. There was evidence of
psychological benefits in terms of morale, improved sleep and a general sense of
improved well-being. It was particularly noted that the participation in the
study was voluntary and that a physician's approval had been obtained for each

participant.

Other studies have been conducted with non-institutionalized older people. In

his study, Kastenbaum reported on the effects of the use of one or two 3 ounce
servings of wine on self-sufficient older people living in the community. It was
noted that the changes, both those that were subjective and self-reported, and
those that were determined by psychological assessment procedures, were generally
in the positive direction. On the subjective items, participants reported
improved subjective status in terms of morale, improved sleeping patterns,
reduced chronic fatigue, anxiety and depression. In objective tests, there was a
tendenty for those with relatively better functioning to show improvement in
behaviors and performances that have strong cognitive components. (Mishara and

Kastenbaum 1980.)

Health issues in treatment

For the older person, entry into the treatment system is frequently through a
health care agency, usually the acute care hospital. Compared to younger people
the older person often presents in a more debilitated condition. Because of the
number of pathological conditions that may develop as a <xesult of long term
alcohol use, it is not infrequent that the older persons enter the system for
treatment of other diagnosed conditions, and then in the process of medical
treatment, are encouraged to confront the reality of the relationship that
alcohol use has to the current condition and to the prognosis for recovery.

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While recognizing that all systems of the body are affected by the use of aicohol
and have the potential of reacting adversely, there are certain medical

conditions that are indicative of long term use. Cirrhosis of the liver,
gastritis, chronic or acute pancreatitis, with accompanying abdominal pain,
weight loss and diabetes are significant risks of long term use. Other

conditions frequently associated are atrophy and weakness of the muscles,
polyneuropathy, the inability of the body to fend off infections or to support
healing, malnutrition and dehydration. Pneumonia and pulmonary tuberculosis also
occur more frequently among alcoholics. In advanced cases, sever neurological
damage may be seen as Korsakoff's psychosis and Wernicke's disease (Mishara and
Kastenbaum, 1980). Generally, the late-onset individual presents with fewer and
less severe medical complications, although Schuckit and Miller (1986) do point
out that this type drinking is during the medically vulnerable years and may
cause disproportionate medical problems.

Because of the greater likelihood of the older person entering treatment for
related health conditions before entering alcoholism rehabilitation programs, the
role of the health care professional in identification and intervention must be
recognized. Most older people trust medical personnel and hold them in high
regard. Being able to accurately access the situation, to interpret the
presenting symptoms correctly and to use the medical record to facilitate
breaking through the denial make the health professional a vital link in the
network of treatment. The value that many older people place on their health
often facilitates and provides motivation for engaging in the process. (Mishara
and Kastenbaum 1980, Schuckit 1982, Sherouse 1983.)

There are many medical and health issues that need to be considered in the course.
of treatment. There is no agreement on the use of medications in the process of
treatment, with particular concern focusing on minor tranquilizers and sedatives
(Gomberg, 1982). Monitoring the physical conditions and the medication regimen
is an ongoing process. In the course of treatment, with medical care, good
nutrition including vitamin therapy, and appropriate rest, there is frequently an
improvement in the physical well-being of the older person, and specific medical
conditions may abate in their severity. However, a parallel Situation may also
develop. Conditions whose presence and pain are masked by the anesthetic quality
of the alcohol become evident. After the alcohol is out cf the system, dental
problems, urinary tract infections, venereal disease and other conditions may be
identified in the course of rehabilitation.

Because of poor physical condition and lack of reserve, older people may require
more direct nursing care and help with meals, bathing and personal care. The
daily schedule of the treatment program may tax their strength and endurance, and
the requirements may have to be modified to allow for more rest. Attendence to
medical needs, perhaps even readmittance to an acute care facility, may interrupt
the treatment schedule and necessitate decisions or adjustments in administrative
policies. The need for a wheel chair, crutches, or assistance in movement
affects the participation of the client and requires additional concern on the
part of the staff. Attention to hearing aids, teeth, eye glasses, and similar
devices, facilitates the recovery process in terms of participation, self-image,
and the development cf good health habits (Williams 1985).

Other relevant treatment issues

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The issue of the responsibility of providing treatment services for the older
alcoholic generally focuses on the questions of which service system, age Or
alcohol treatment, should carry primary responsibility, and whether there should
be specialized programs within existing systems. Little has been done _to
evaluate the effectiveness of different systems or different treatment modalities
with older people. Treating within the alcohol service system has been the
general approach, with the recommendation that there be some adaptations and 4a
specialized outreach program to reach the older person (Janik and Dunham 1983) -
Emphasis upon social supports and peer groups appears to jncrease positive

outcomes (Kofoed et al. 1987, Zimberg 1982).

payment for treatment requires that there be an appropriate mesh between the
treatment needs of the individual, the types of alcoholism services that are
available and acceptable to that person, and the regulations that govern the
hat may be tapped, whether Medicare, Medicaid, private third party,
veterans benefits or others. Working with an older person in need of treatment
often requires unusual orchestration abilities on the part of the service
provider in order that access to all phases of treatment becomes financially

available.

resources t

Prevention

opportunities for prevention programs do exist. Two excellent possibilities
exist through the development of self-help groups for older people and the
preretirement and retirement planning groups that are often 4 part of personnel
services in industry and business, labor and professional groups and
organizations (Gomberg, 1982). Such programs would be of primary benefit to

jndividuals who.may at be at risk for the development of late-onset problems.
Self-help groups could be developed in the community under the sponsorship of
senior centers, community mental health programs, voluntary organization and
others. These groups would have the advantage of peing holistic in their
approach, providing life-coping skills and support systems. By including
substance use within their concerns, put avoiding the label, these groups would
be more appealing to older people who frequently feel stigmatized by the words

probien drinker or alcoholic.

Secondary prevention services could be provided by the development of programs
that would. sensitize and provide skills .to service providers of older people,
whether in medical or social services. Intervention at the earliest possible
stage precludes the further exacerbation of medical, psychological and social
problems, optimizing the possibilities of successful treatment within the context
of continuing support systems. Tertiary prevention js an integral part of
treatment, targeted to the successful completion of treatment and the prevention
of future problems. This approach must also include the development of life
skills to help the older alcoholic successfully adjust to the realities of

his/her life stage-

There are many programs that have been developed to address prevention issues on
all leveis. Only a few examples will be sited. The Senior Alcohol Services of
Vancouver, Washington, provides community training and information as well as
treatment that includes aftercare, couples’ counseling and family groups- The
Massachusetts Housing Finance Agency through its Tenant Assistant Program (TAP)

A - 13
provides education, information and referral services in a program that
concentrates on outreach to improve the quality of life of the tenants. Elements
of the program address all three levels of prevention. The Michigan Office of
Substance Abuse Services and the Michigan Office of Services to the Aging
sponsored the development of a three volume guide, Older Adult Substance Abuse,
designed to foster a team approach to prevention. The three volumes are A
Resource Manual, Prevention Program Development, and Medications Information.
(Resch and Christensen, 1983.) The Wisconsin Department of Health and Social
Services issued a planning guide, Examination of Problems and Solutions Related
to the Chronic “Revolving Door" Alcohol Abuser. The final report contains 26
recommendations to break the cycle and to provide for meaningful alternatives.
(Wisconsin Department of Health and Social Services 1981) The AAA Foundation for
Traffic Safety of Falls Church, VA, has developed a film with guide, Senior
Adults, Traffic Safety and Alcohol, which provides information for older people
about the substance and the effects of alcohol and problems that it may generate.

A SAMPLE OF NATIONAL EFFORTS

There have been efforts by several agencies and groups to address the concern of
aging and alcohol use on a national level. The four that are mentioned are by no
means the only efforts, but do illustrate the variety of the efforts that have
been made, representing a public policy effort, research, and a treatment related

project.

Blue Ribbon Study Commission on Alcoholism and Aging

The Blue Ribbon Study Commission on Alcoholism and Aging, sponsored by the
National Council on Alcoholism, was convened in the fall of 1979 with the
Honorable Wilbur D. Mills as chairperson. The Commission was composed of a broad
range of representatives from government, academia, voluntary organizations and
the health and social service sectors. The stated goals of the Commission were:
1. to gather and evaluate present knowledge concerning alcoholism and aging:

2. to identify and analyze the information needed for thorough understanding of
the problem through defining specific issues; 3. to identify and evaluate the
options open as to what can be done to resolve these issues successfully; and

4. to disseminate the information gathered to the American public and to groups
and individuals directly involved in the policy and implementation process. (News
release of the National Council on Alcoholism, February 22, 1980.)

The outcomes of the Commission are three. 1. The Commission sponsored a two day
tract, The Aging and Alcohol Abuse, at the 1980 National Alcoholism Forum of the
National Council on Alcoholism. 2. It organized and sponsored a Mini-Conference
on Aging and Alcoholism, held at Wingspread, Racine, WI, in conjunction with the
1981 White House Conference on Aging. 3. It prepared a report, with
recommendations, to be included in the proceedings of the 1981 White House
Conference on Aging. Six categories of recommendations were included: research
and development, education and training, increasing the utilization of services,
ensuring and improving the effectiveness of treatment, increasing the
availability and access of services and protection of patients’ rights.

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Research center on aging and alcohol established

In December 1982, the National Institute on Alcohol Abuse and Alcoholism funded
the Alcohol Research Center at the University on Gainesville, one of nine
pational research centers. This center is specifically designated to conduct
research into the causes and the consequences of alcohol use and abuse by the
elderly. As a interdisciplinary center, the research agenda includes a multi-
faceted approach to the subject. An extensive educational program for a broad
spectrum of health professionals is a major component of the activities.

Research conference

In November, 1983, a national research conference was convened on The Nature and
Extent of Alcohol Problems Among the Elderly. The conference was sponsored by the
National Institute on Alcohol Abuse and Alcoholism in collaboration with the
National Institute of Mental Health and the National Institute on Aging. The
conference produced a monograph by the same title, edited by George Maddox,
Ph.D., Lee N. Robins, Ph.D., and Nathan Rosenberg, Ph.D.. In the preface it 1s
stated that “the workshop at Washington University was intended as 4 beginning
point ina systematic NIAAA effort to stimulate research interest and activity in
the alcohol-aging area." (p. v.) The keynote address of the conference by Robert
Straus (pp.7-28) focused on factors of change as related to both aging and
alcohol, the need to develop a biomedical perspective in relation to the topic,
and stated that both alcohol studies and gerontology were entering a
biobehavioral era of scientific thought and activity. The conference was
organized to present key issues and current evidence of mental health and social
correlates of alcohol use, presented from research of the Alcohol Research Center
of the University of Gainesville, FL, longitudinal data of alcohol problems among
the aged from studies in St. Louis and from the Normative Aging Project of the
Veterans Administration, and research data from the Epidemiological Catchment
Area Studies. Future research needs were addressed by most participant in the
course of their papers, emphasizing the need for more current and more extensive
research that is specific to the older population.

A demonstration project related to treatment

The Health Care Financing Administration Alcoholism Project was a three year
demonstration project targeted to evaluate the cost effectiveness of
reimbursement under Medicare of treatment in non-hospital settings. of the six
states involved in the project, most also included the provision of reimbursement
under the state funded medical assistance program or Medicaid. Because of the
source of the reimbursement funds, in most agencies, there was the added benefit
of stimulating the entry of the elderly into treatment. In addition to
collecting data related to the reimbursement effect, agencies who participated
increased and expanded their experiences with the elderly, and developed and
adapted treatment modalities to meet the need of this population. A report on
this additional benefit of the project was prepared by the Rutgers University
Center of Alcohol Studies, New Brunswick, New Jersey. The evaluation of the data
related to the reimbursement study has not yet been completed.

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A LOOK TowakD fdE FUTURE

The identification of “what needs to be done" frequently has the quality of
confused time sequence. Research of the problem area should precede the
development of policy which would in turn give impetus to program development.
But it is impossible to begin again. The reality is that movement on all fronts
is needed and must proceed as best possible.

The relationship of research in the field of aging and alcohol to the development
of public policy has been addressed by Stall (1987). Stall proposes a particular
value of long-term perspective research as an integrative and interpretive tool
for reassessing the data from both retrospective and cross sectional studies.
Such research would make it possible to test and evaluate the hypotheses that
have been advanced to explain the data, and would provide direction for the
development of public policy. Ruben (1986) points out that elements of
incongruence are present between public policy and what we do know about the
nature and the scope of the problem. Future development of policy would benefit
from consideration of these observations.

In relation to health and aging, there are many avenues of research that have
been opened but not fully addressed. Enumeration of specific areas is repetitive
and more adequately done by those whose expertise is within the specific areas of
study. However, in reviewing studies, it becomes very evident that much of what
we understand is based on studies that are not age and/or alcohol specific.
Whereas, there is justification for applying the results of such research to the
aged or to alcohol problems, additional studies that are focused on the problem
area would provide a firmer foundation for the development of policy and the
implementation of programs of prevention and treatment.

Programs, and ultimately people, who are coping with the problems of aging and
alcohol abuse, are impacted by policies in the fields of aging, alcohol
treatment, health, social services, housing, transportation, and innumerable
other areas of governmental responsibility. How these policies intermesh is a
prime concern for the issue of aging and alcohol. The perspective from the field
frequently is that policies interact in ways that are more prohibitive than
facilitating. In considering what policies should be enacted, this concern
should be addressed. For example, these questions might be discussed:

Whaf weight should be given to current epidemiological projections in the
consideration of policies related to the development of programs of
prevention and treatment?

What effect do current health care policies, such as the DRG's, have upon
the provision of the level and the extent of medical care needed by the
older person who may have multiple and extensive needs related to alcohol

abuse?

What policies would facilitate the development of primary prevention
programs in the arenas that are most utilized by those at high risk? What
incentives might be offered to encourage the private sector to be involved
in the provision of prevention programs related to late-onset alcoholism?

In what areas should policies be developed to address the high cost of
providing institutional care for those severely disabled by alcohol? Are

A - 16
other options possible tnat would allow for a more optimal quality of life?

What policy provisions are possible that would encourage and support
linkages between alcoholism treatment and age services to actualize the
concept of continuity of care?

Based on evaluative research of treatment modalities, what policy decisions
should be considered to support specialized components to provide treatment

for oider persons?

Are federally sponsored programs for volunteer service appropriate avenues
for involving older people in the process of addressing the need for
education and prevention in relation to alcohol use and health?

The range of exploration is limitless. And the time is now.

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