Assessment of alcohol consumption and alcoholism in the elderly

Alcohol, Vol. 11, No. 6, pp. 513-516, 1994 Copyright©1994ElsevierScienceLtd Printed in the USA. All rights reserved 0741-8329/94$6.00 + .00

Pergamon 0741-8329(94)00045-X

Assessment of Alcohol Consumption and Alcoholism in the Elderly CRISTINA

G E R O L D I , *l R E N Z O R O Z Z I N I , I " G I O V A N N I AND MARCO TRABUCCHI*

B. F R I S O N I *

Geriatric Research Group, Brescia, Italy, *Alzheimer's Disease Unit, S. Cuore Fatebenefratelli Hospital, Brescia, Italy, and tGeriatric Rehabilitation Ward, Gussago, Italy R e c e i v e d 2 F e b r u a r y 1994; A c c e p t e d 24 A p r i l 1994 GEROLDI, C., R. ROZZINI, G. B. FRISONI AND M. TRABUCCHI. Assessment of alcohol consumption and alcoholism in the elderly. ALCOHOL 11(6) 513-516, 1994.-This study evaluates characteristics associated with alcohol consumption or alcohol-related problems in an elderly population, as detected by CAGE questionnaire and self-reported alcohol intake respectively. Data were obtained from a multidimensional study carried out in a community-dwellingpopulation aged 70-75 (n = 1205, 389 males and 816 females) living in the city center of Brescia, in northern Italy. All information was gathered by self-report. Male gender, better mood, daily function, somatic health, not living alone, and being married were significantly associated with self-reported alcohol consumption. Male gender, poorer cognitive function, and income dissatisfaction were significantly associated with alcohol problems as detected by CAGE. Data suggest that self-report of alcohol intake, though intrinsicallyloaded with imperfect internal consistency, does not necessarily indicate risk of alcoholism; on the contrary, it can reveal the positive psychological attitude of the drinking habit. CAGE questionnaire, wich is sensitive to alcohol related problems, is associated with poor psychosocial conditions. Alcoholism

Self-reported alcohol consumption

CAGE

DESPITE increasing interest on alcoholism in the elderly in the last decade, little is yet known about alcohol consumption and alcohol-related problems among older people. What is known about the effects of alcohol in young adults does not necessarily apply to the elderly. The social and medical relevance of alcohol intake in the elderly is much less defined. Though a n u m b e r of cross-sectional studies have shown that alcohol intake and alcoholism-related problems decline with increasing age (1,7,13), there is evidence to believe that some population-based studies underestimated the prevalence of alcoholism in the elderly (6). In fact, elderly alcoholics usually show unspecific problems, such as repeated fails, incontinence, malnutrition, insomnia, malaise, impairment of cognitive function, and social isolation, which often disguise or precede the more c o m m o n physical health problems of alcoholism (2,8,23,25). Furthermore, such problems are often attributed to aging or to age-related diseases (14). The difficulty of a clinical assessment of alcohol-related problems in the elderly has led to the use of a n u m b e r of indices. Those most commonly used in epidemiologic research focus on either a m o u n t of alcohol intake or on its social and

Elderly

Alcohol abuse

behavioral sequelae. However, these indices have shown little concordance and sensitivity (5,11). In order to further investigate this issue, we compared physical, psychic, and social characteristics of patients scoring high on two different assessment instruments, evaluating selfreported alcohol intake and common behavioral problems of alcoholics (CAGE questionnaire) (9). METHODS Data were obtained from a multidimensional study carried out in a community-dwelling population aged 70-75 (n = 1205, 389 males and 816 females) living in the city center of Brescia, in northern Italy. The following data were collected at the subjects' home by ten previously trained physicians (general practitioners). In particular, the following aspects have been examined: (A) Demographic variables: gender, marital status, cohabitation status, and income satisfaction coded as: 1, good satisfaction; 2, sufficient satisfaction; 3, unsatisfaction.

1 Requests for reprints should be addressed to: Cristina Geroldi, M.D., Geriatric Research Group, Via Romanino 1, 25122 Brescia, Italy. 513

514

GEROLDI ET AL.

(B) Alcohol consumption, evaluated by an ad-hoc questionnaire inquiring the amount of wine, beer, and other alcoholic drinks consumed during the previous day. On the basis of these beverage intakes, the total amount of alcohol was computed in grams. (C) Drinking problems, evaluated by CAGE questionnaire (9), consisting of four brief questions: "Have you ever felt you should Cut down on your drinking?," "Have other people Annoyed you by criticizing your drinking?," "Have you ever felt Guilty about drinking?.... Have you ever taken a drink in the morning to steady your nerves or get rid of hangover?" (Eye opener). A CAGE cutoff was set to one or more to detect drinking disorders in the population under study (22). (D) Indicators of social activities were evaluated by the six social items from the SELF-scale (Self Evaluation of Life Function) (19). The scale gives a score ranging from 0 (poor social interactions) to 36 (good social interactions). (E) Psychic function: cognition was assessed with MSQ by Kahn (16), providing a score ranging from 0 (good cognitive status) to 10 (poor cognitive status). Mood was evaluated with Beck's Depression Inventory Scale modified (12), giving a score ranging from 0 (good mood) to 66 (poor mood). (F) Somatic health status was evaluated by the 5 somatic items from the SELF-scale (19). Scores range from 5 (good health) to 20 (poor health). Number of somatic symptoms was also recorded. (G) Functional status: self-reported Basic and Instrumental Activities of Daily Living (BADLs and IADLs) were assessed with the Katz (17), and Lawton and Brody scales (18). IADL assesses eight functions; three of these (cooking food, doing housekeeping, and laundry) were not considered for men living with a spouse or with others, and in women who had housekeepers.

TABLE 2 MULTIPLE LINEAR REGRESSIONANALYSISO1~ SELF-REPORTED ALCOHOL CONSUMPTIONON SEX, ADL AND IADL FUNCTION, DEPRESSION SCORE, NUMBER OF SYMPTOMS, SOMATIC HEALTH SCORE. LIVING ALONE, AND MARITALSTATUS Model Variables Gender (male) Somatic health score IADL (functions lost) Depression score Not married* Symptoms (n)* Living alone*

B 16.793 - 0.926 -- 1.284

95% C.i.

i.'

14.5181o 19.068 0.000 1.522 to -- 0.330 0.024 2.309 to - 0.259 0.014 0.279 0.072 O.733 0.303

*Variables tested in the bivariate linear regression analysis and found not to contribute to explained variance in the multiple model at p < 0.05. p is the value of the associated t statistics~

Statistical analysis was performed with the statistical package S P S S / P C + (24). Associations of self-reported alcohol consumption with the other variables were assessed with bivariate and multivariate linear regression analysis. Associations of presence of alcohol-related problems as detected with CAGE were assessed with bivariate and multivariate logistic regression analysis. Beta (B) and Exp(B) parameter estimates were computed in linear and logistic regression respectively, together with 95% confidence intervals. B represents the change of self-reported alcohol consumption for a one umt change of the independent variable, and E ~ ( B ) represents the change in the risk of having alcohol problems: for a unit change of the independent variable. RESULTS

TABLE 1 DEMOGRAPHIC AND PSYCHOSOCIALCHARACTERISTIC OF 1096 NOT DEMENTED AND NOT DEPRESSED 70-75-YEAR-OLD SUBJECTS LIVING AT HOME Variable

Freq

°70

Males Females Marital status married Income satisfaction good sufficient not sufficient Living alone MSQ Depression score (BDI) > 23 (mild depression) < 23 (not depression) Somatic health score Symptoms (n) BADL (functions lost) IADL (functions lost) Social activity score <_ 6 (high level) 7-18 (intermediate level) >_ 19 (low level)

365 731

33.3 66.7

441

40.2

Mean (StdDev)

227 20.7 503 45.9 357 32.6 403 36.8 15.79

(0.61) (11.5)

5.78 0.43 0.15 0.41 18.57

(1.81) (0.82) (0.66) (1.05) (8.00)

0.52

279 817

72 468 556

25.5 74.5

6.6 42.7 50.7

Thirty-six subjects had severe cognitive impairment (MSQ _> 3), 67 had severe depression (BDI > 45), and 6 had both severe cognitive impairment and severe depression, and were excluded from the analysis for the possible effect of such conditions on reliability of self-report and access to alcoholic beverages. Table 1 reports the demographic and psychosocial characteristics of the subjects. CAGE questionnaire with a cut-off of one or more was able to detect 82 subjects (7.50/0, 37 males and 45 females) with alcohol problems. Self-reported alcohol consumption was 31.2 :t: 25.7 gr/day in males and 14.6 +_ 12.9 gr/day in females. On the basis of self.reported alcohol consumption, subjects were classified as drinkers (intake higher than 60 g/day and 40 g/day in males a n d females, respectively) or nondrinkers. These cutoffs were the alcohol intake values defining the highest 10%0 of the population (1,10,20). About one-tenth of the sample (n = 101; 9.2%) were drinkers, with higher prevalence in males (n = 53; 14.5%) than in females (n = 48; 6.6%). The population of elders classified as drinkers by self-reported alcohol consumption very partially overlapped with that with alcohol problems detected by CAGE: only 24 subjects (24.8% of self-reported positives, and 29.3% of CAGE positives) were positively classified by both methods. In order to evaluate characteristics associated with alcohol consumption or alcohol-related problems, the following analyses were then performed. Bivariate linear regression of self-reported alcohol consumption on variables commonly believed to be associated

ALCOHOLISM IN THE ELDERLY

515

with alcohol consumption showed that male gender (B = 16.553, 95°70 C.I.: 14.268 to 18.830), fewer depressive symptoms (B = -0.234, 95% C.I.: - 0 . 3 4 0 to -0.128), lower disability (B = -1.601, 95°/o C.I.: -3.361 to - 0 . 1 5 9 for BADL; B = -1.416, 95% C.I.: -2.533 to - 0 . 2 9 9 for IADL) better somatic health (B = - 0 . 6 6 1 , 95% C.I." - 1.308 to -0.014), fewer somatic symptoms (B = - 1.479, 95°7o C.I.: -2.908 to -0.050), not living alone (B = 3.569, 95% C.I.: 1.148 to 5.990), and being married (B = 5.771, 95°7o C.I.: 3.436 to 8.108), were indeed significantly associated with higher self-reported alcohol consumption. Association with cognitive functions, social activities, and income satisfaction was not significant. Depression, cohabitation and marital status, and number of symptoms proved no longer significant when tested in a multiple model (Table 2). Association of alcohol problems as detected by CAGE with somatic, psychic, and social variables was assessed with bivariate logistic regression analysis, showing significant associations with male gender (Exp(B) = 1.698, 9507o C. I.: 2.710 to 1.090, poorer cognitive function (Exp(B) = 2.397, 95o70 C. I.: 1.721 to 3.336), and income dissatisfaction (Exp(B) = 1.951, 95o7o C. I.: 1.312 to 2.732). All variables proved significant when tested in a multiple model (Table 3). DISCUSSION

A similar proportion of the 70-75-year-old community dwelling elders was classified as drinkers by self-reported alcohol intake (9.2%) or as having drinking problems by CAGE (7.507o). However, the two populations only marginally overlapped, confirming that the two methods are not concordant, and suggesting that they may tap different facets of alcohol consumption and recognize populations with different characteristics. We considered "drinkers" those subjects reporting an alcohol consumption higher than 60 g/day (40 g/day in females). The cutoff of 60 g/day for males and 40 g/day for females that we employed is higher than those reported by other studies (1,10,20,21). However, in our population, average alcohol consumption is higher. Alcohol consumption is largely affected by sociocultural factors, and alcoholism cannot be univocally defined cross-culturally. In our sample, elderly people reporting higher alcohol intake had a generally higher level of well-being: they were married, healthier, less depressed, and less cognitively and functionally impaired. Thus, self-reported alcohol consumption in the community-dwelling elderly might be a marker of wellbeing. It could be hypothesized that subjects with cognitive

TABLE 3 MULTIPLE LOGISTICMODEL SHOWING THE ASSOCIATIONOF SEX, MSQ, AND INCOME SATISFACTIONSCORE WITH ALCOHOL-RELATED PROBLEMS DETECTED BY CAGE Variable

Exp(B)

95% C.I.

p

Gender (male) MSQ score Income satisfaction

2.062 2.382 1.733

3.521to 1.359 1.680to 3.377 1.220to 2.462

0.001 0.000 0.002

p is the value of the associated Wald statistics. impairment could forget the amount of ingested alcohol (15). Moreover, MSQ results were not significantly associated with self-reported alcohol consumption, whereas poor cognition was independently associated with behavioral problems as detected by CAGE. Our data suggest that self-report does not necessarily indicate risk of alcoholism; on the contrary, it can reveal the positive psychological attitude of the drinking habit. CAGE questionnaire detects problems and symptoms associated with alcohol abuse, and seems sensitive to alcoholism (3). In our study, subjects detected by CAGE had higher impairment of mental health and greater social disadvantage. Some limitations of our study should be pointed out. First, all the information was obtained by self-report, and a low level of consistency is possible. Second, data reporting alcohol consumption were referred to the alcoholic intake of the previous day, possibly missing detection of binge and weekend drinking. However, these are very unusual occurrences in the elderly (21). Third, it should be underlined that though the two alcohol assessment methods are differentially sensitive to medical and psychosocial features, their validity versus an external outcome (e.g., hospitalization, use of medical services, etc.) is undetermined. Our data support the view that the problem of alcoholism assessment in the elderly is far from settled: neither amount of alcohol ingestion nor behavioral problems should be separately taken into account in the evaluation of the at-risk elderly person. From a gerontological perspective, a comprehensive assessment is needed, which should reflect the psychic, somatic, and social change induced by long lasting alcohol consumption (4,22). Such integrated data can be valuable in the appraisal of the social relevance of alcoholism in the elderly and in the planning of therapeutic and preventive interventions.

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