Older adult controlled drinkers and abstainers

loumal of Substance Abuse, 8(4), 453-462

(19%)

BRIEF REPORT

Older Adult Controlled

Drinkers and Abstainers Stephen T. Chermack VA Medical Center, Detroit, MI

Frederic C. Blow VA Medical Center, Ann Arbor, MI

Edith S.L. Comberg Sharon A. Mudd Elizabeth M. Hill University of Michigan

Little is known about the lifetime course of alcohol problems, especially during late adulthood. Many individuals with a history of alcohol problems achieve remission of their symptoms through abstinence or controlled drinking. This study examined 135 older adults with a prior history of alcohol diagnoses who were symptom free for at least the past year. Two groups were identified based on their alcohol consumption within the past year: abstinent individuals (n = 92) and controlled drinkers (n = 43). The groups did not differ in age, racial composition, education, income, or years since their last alcohol-related symptom, but they did differ in gender composition, indices of alcoholism severity, history of formal and informal treatment, as well as lifetime alcohol consumption patterns. Abstinent individuals had more severe alcohol problems, consumed higher amounts of alcohol on drinking days, bad more years of heavy alcohol consumption, and were more likely to have attended alcohol treatment and Alcoholics Anonymous (AA). The controlled drinkers had a longer history of moderate social drinking, and their current consumption habits appeared to be similar to symptom-free older adult drinkers. The results suggest that gender, alcoholism severity, history of formal and informal treatment, and past consumption patterns are associated with whether older adults with histories of alcoholism attain successful outcomes through abstinence or controlled drinking.

INTRODUCIlON There is evidence that many individuals with a history of alcohol achieve remission of their symptoms by modifying their use of alcohol 1983). Studies have found that both abstinence and controlled drinking common outcomes for young or middle-aged individuals with alcohol

problems (Marlatt, (CD) are problems

Supported by funds provided by Grants T32 AA 07477-06 and P50-AA47378 from the National Institute on Alcohol Abuse and Alcoholism. Correspondence and requests for reprints should be sent to Stephen Chermack, Psychiatry Service (116A), Detroit VA Medical Center, 6464 John R., Detroit, MI 48210. 453

454

S.T. Chermack,

F.C. Blow, E.S.L. Comberg,

S.A. Mudd,

and E.M. Hill

(Heather & Robertson, 1981; Lloyd & Salzberg, 1975; Marlatt, 1983; Pattison, Sobell, Sobell, 1978). The identification of factors associated with remission of alcohol problems through abstinence or CD has important implications regarding the nature and course of alcohol problems, the treatment of alcohol problems, and the matching of individuals to different treatment approaches and outcome goals (Rosenberg, 1993). However, there have been few attempts to study such issues with older samples (Moos, Brennan, & Moos, 1991). Controlled drinking has been defined in a number of different ways in the research literature (Heather & Tebbutt, 1989; Rosenberg, 1993). These definitions commonly specify that CD involves a pattern of alcohol consumption that does not produce negative consequences or symptoms of dependence. Despite controversy (McCrady, 1985; Rush & Ogborne, 1986), studies have demonstrated that in addition to being a common outcome (Heather & Robertson, 1981; Lloyd 8c Salzberg, 1975; Marlatt, 1983; Pattison et al., 1978), periods of CD are no more likely than are periods of abstinence to precede relapse (Watson & Pucel, 1985), and some individuals are able to sustain CD through lengthy follow-up periods (Miller 8c Baca, 1983; Pettinati, Sugarman, DiDonato, & Maurer, 1982; Polich, Armor, & Braiker, 1981; Vaillant & Milofsky, 1982). Nevertheless, relatively little is known about factors that are related to whether individuals with drinking problems achieve remission of their problems through abstinence or CD. According to literature reviews of studies with young and middle-aged samples (Heather & Robertson, 1981; Rosenberg, 1993), a number of variables appear to be related to whether problem drinkers become abstinent or develop a pattern of CD. These variables include the severity of alcohol dependence, history of treatment and AA attendance, previous alcohol consumption patterns, and certain demographic characteristics. Severity of alcohol dependence appears to be the most robust factor that discriminates between those with abstinent and CD outcomes (Rosenberg, 1993). The evidence that treatment history and AA attendance are associated with abstinent outcomes among young and middle-aged adults appears to be consistent (ElalLawrence, Slade, &Dewey, 1986; Finney & Moos, 1981; Maisto, Sobell & Sobell, 1980; Saunders & Kershaw, 1979; Vaillant, 1983). Findings regarding previous consumption habits and demographics are less clear. Some studies have found that individuals with CD outcomes have lower levels of previous alcohol consumption (drinks per drinking day) than those with abstinent outcomes (Finney & Moos, 1981)) and other studies have shown that controlled drinkers were more likely than abstainers to have a history of continuous drinking before treatment (Elal-Lawrence et al., 1986). Regarding demographics, some studies indicate that younger age is associated with a CD outcome (Polich et al., 1981; Vogler, Weissbach, & Compton, 1977), whereas others fail to find a relationship between age and CD outcomes (Finney & Moos, 1981; Helzer et al., 1985). Similarly, some researches have found female gender to be associated with CD (Elal-Lawrence et al., 1968 Helzer et al., 1985; Miller &Joyce, 1979)) whereas others have found no gender differences (Orford & Keddie, 1986)) or more male than female controlled drinkers (Bromet & MOOS, 1979). Although research with younger samples has provided important information about factors associated with abstinent and CD outcomes, the pattern of findings

Elderly, Alcoholics, and Remission

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with older samples could differ from those with younger samples for a number of reasons. It is possible that the presence of physical health problems among the elderly may be one of the most important variables related to an abstinent outcome (Hermos, LoCastro, Glynn, Boucharch, & De Labry, 1988). Furthermore, drinking outcome type in late adulthood also may be affected by biologically based changes associated with the aging process, such as increased sensitivity to the effects of alcohol and decreased tolerance (Vogel-Sprott & Barrett, 1984)) as well as develop mental psychosocial influences. This study examined variables associated with abstinent and CD outcomes among older adults with a prior history of alcohol diagnoses. The purpose was to identify differences between abstinent individuals and controlled drinkers with regard to history of alcohol consumption, severity of alcohol problems, history of formal and informal treatment, and background characteristics. Given the paucity of research in this area with older adults, and the fact that the proportion of elderly individuals in our society is increasing, it is important to obtain a more thorough understanding of the differences between individuals who maintain remission of alcohol symptoms with abstinence or CD.

METHOD Participants

The data were selected from a large database containing information about individuals recruited for studies at the University of Michigan Alcohol Research Center (UMARC). The large database included 641 individuals aged 55 and over and consisted of older adults recruited from a variety of alcohol treatment facilities and the community. Those individuals who had a previous history of alcohol abuse or dependence based on the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1991) and who reported that they were symptom-free for at least the past year were selected for the analyses. Thus, the final sample consisted of 135 participants (94 men and 41 women). The sample included participants with and without a history of treatment for alcoholism. The age of participants ranged from 55 to 82 (M = 63.93); 89.6% were Caucasian, and the majority of the remaining 10.4% was Black. Forty percent had a high school education or less, and 56.6% of participants had an annual income of less than $20,000. Two groups were identified for this study based on their reported alcohol consumption within the past year, abstinent individuals (n = 92) and controlled drinkers (n = 43).

Procedures

Participants completed interviews as part of procedures designed to recruit volunteers for studies conducted at the Alcohol Research Center. The interviews assessed demographics, medical history, and included the CAGE Questionnaire (Ewing, 1984) and the Michigan Alcoholism Screening Test (MAST Selzer, 1971). A semi-structured interview was used to assess participants’ lifetime and current drinking patterns (Skinner & Sheu, 1982). A number of drinking history variables

456

S.T. Chermack, F.C. Blow, E.S.L. Gomberg, S.A. Mudd, and E.M. Hill

were constructed from the semi-structured lifetime interview, including lifetime measures of average daily consumption, drinks per drinking day, years of social drinking, years of heavy drinking, and the number of heavy drinking patterns. The alcohol and mood disorders sections of the DIS (Robins et al., 1981) were used to assess DSM-III-R mood and alcohol symptoms, as well as the onset and recency of such symptoms.

Data Analysis DrinkingHistory Multivariate analyses were used to investigate group differences in alcohol consumption history. Preliminary analyses included both gender and the recency of symptom remission as covariates. Gender was selected as a covariate due to evidence that gender is related to quantity and frequency of alcohol consumption (Adams, Garry, Rhyne, Hunt, & Goodwin, 1990; Fillmore et al., 1991). The recency of symptom remission was selected as a covariate because certain consumption variables (e.g., drinks per drinking day, average daily consumption) could be differentially affected by changes in consumption (abstinence or controlled drinking) associated with when symptoms remitted. The preliminary MANCOVA indicated that only the recency of symptom remission variable was a significant covariate. Thus, the analyses reported are from the MANCOVA with only recency of symptom remission as a covariate. Alcoholism Severity In order to assess for group differences in alcoholism severity, a one-way (group) MANCOVA with gender as a covariate was conducted on measures of alcohol problems. A preliminary MANCOVA with both gender and recency of symptom remission as covariates revealed that only gender was a significant covariate. Thus, the analyses reported are from the MANCOVA with gender as a covariate. In order to delineate further differences between the abstinent and controlleddrinking groups in terms of alcoholism severity, a chi-square analysis was used to determine whether the groups differed in the severity of their past DIS alcohol diagnoses. Furthermore, chi-square analyses were conducted to provide descriptive information regarding how the groups differed on specific alcohol-related problems as measured by the DIS. To control for Type I error in these analyses, the alpha level for each test was set by dividing the .05 level by the 18 tests conducted. Thus, the alpha for these analyses was set at the .002’7 level.

RESULTS Characteristicsof the Abstinent and Controlled-DrinkingGroups One-way ANOVAs and chi-square analyses were conducted on a number of demographic measures to investigate differences between the abstinent and controlled-drinking groups. The groups did not differ in age, education, racial composition, income, marital status, number of marriages, number of children, or current

Elderly, Alcoholics, and Remission

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living arrangement. However, the groups did significantly differ in gender composition, ~2 (1) = 4.13,p < .05. Sixty-three percent of the men were abstinent, compared to 80% of the women. The abstinent and controlleddrinking groups did not differ in the length of time since their last alcohol symptom (M = 10.9 years). Thus, both groups appeared to have achieved a stable remission from alcohol problems. The controlled drinkers had a current average daily consumption of approximately one drink per day. The abstinent and controlleddrinking groups also did not differ in history of mood-related symptoms as measured by the DIS. Andyses of Lifetime DrinkingPatterns According to the MANCOVA analysis with recency of symptom remission as a covariate, the abstinent and controlleddrinking groups differed significantly in measures of lifetime alcohol consumption, F(5, 118) = 12.98, p < .OOl. The means, adjusted means, and results of univariate Ftests (with recency of symptom remission as a covariate) for each of the lifetime consumption measures are presented in Table 1. Abstinent individuals had a history of a greater number of heavy drinking periods, more drinks per drinking day, and a trend towards having more years of heavy drinking. Controlled drinkers had a longer history of moderate social drinking. Adyses

of Alcoholism Severity

A one-way MANCOVA with gender as a covariate was performed to investigate whether the abstinent and controlleddrinking groups differed on measures considered to be related to the severity of alcoholism. According to the MANCOVA analysis, the abstinent and controlleddrinking groups differed significantly on indices of alcoholism severity, F(5, 120) = ‘7.93, p < .OOl. The means, adjusted means, and results of univariate F tests with gender as a covariate are presented in Table 2. Analyses were conducted to delineate further the nature of the differences between the abstainers and controlled drinkers in terms of alcoholism severity. The abstinent and controlleddrinking groups differed significantly in the severity of

Table 1. Means, Adjusted Means, and Results of UnivariateFTests With Recency of Symptom Remission as a Covariatefor Measures of Alcohol Consumption

Abstinent VariableName Average Daily Consumption Drinks per Drinking Day Years of Social Drinking N of Heavy Drinking Periods Years of Heavy Drinking

*p < .Ol.

Drinking

M

Adiusted M

M

Adjusted M

FValue

3.62 7.49 18.65 2.20 12.88

3.56 7.54 18.46 2.18 12.70

2.65 4.87 36.15 1.09 8.13

2.70 4.82 36.34 1.11 8.31

1.80 7.60* 49.42* 10.47* 4.02

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Chermack,

F.C. Blow, E.S.L. Gomberg,

S.A. Mudd, and E.M. Hill

Table 2. Means, Adjusted Means, and Results of Univariate F Tests With Gender as a Covariate for Indices of Alcoholism Severity Abstinent VariableName

M

Lifetime N of Dependence Symptoms Age of Onset Age of Regular Alcohol Use CAGE Score MAST Score

6.53 28.04 20.94 3.09 27.86

Drinking

AdjustedM

M

AdjustedM

FValue

6.49

4.67

4.71

19.30*

27.24 20.58 3.07 28.09

22.03 17.31 2.08 12.11

22.83 17.67 2.10 12.11

4.46 4.20 20.56* 27.11*

*p < .Ol.

their lifetime DSM-III-R alcohol diagnoses, x* (3) = 18.60, p < .OOl. For the abstinent group, 42.4% and 51.1% had histories df moderate and-severe alcohol dependence, respectively. For the controlled-drinking group, 55.8% and 18.6% had histories of moderate and severe alcohol dependency, respectively. Alcohol-Related

Problems

In order to assess for group differences on specific alcohol-related problems, chi-square analyses were conducted on questions assessing lifetime history of specific alcohol-related problems as measured by the DIS. The results are presented in Table 3. As can be seen in Table 3, the groups differed significantly on three out of four items focusing on signs of physiological dependence, two of five items assessing negative consequences, one of six items assessing loss of control over drinking, and one of three questions focusing on heavy alcohol consumption. History of Formal and Informal Treatment Additional analyses revealed that the abstinent and controlled-drinking groups differed in history of alcohol treatment, ~2 (1) = 20.10, p < .OOl. Fifty-two percent of the abstinent group had a positive history of alcohol treatment, compared to 10% of the controlled drinkers. The groups also differed in history of AA attendance, ~2 (1 df) = 27.92, p < .OOl. Seventy-two percent of the abstinent group had attended AA compared to 22% of the controlled drinkers. DISCUSSION There have been very few studies focusing on the remission of alcohol problems among older adults (Moos et al., 1991) and the differences between those who as-e abstinent and those who continue to drink. The pattern of findings in this study was similar in many respects to findings based on younger drinkers (Rosenberg, 1993). The results provide evidence that the severity of alcoholism, as well as a history of informal (AA) and formal treatment, was associated with whether older adults with

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Table 3. Percentage of Abstinent and ControIIed Drinkers With a Positive History of Specific DIS Alcohol Symptoms Abstinent Group (%)

ControlledDrinkingGroup (%)

x2 Value

PhysiologicalDependence Signs Withdrawal symptoms A.M. drinking to prevent hangovers/shakes Tolerance, increased amount to get an effect Need drink to help function

60.9 56.5 66.3 46.7

20.9 20.9 46.5 14.3

18.70* 15.00* 4.80 13.10*

Negative Consequences Serious health problems from drinking Emotional problems from drinking Injured self after drinking Drinking kept you from working or child care Arrest or accident from drinking

38.0 57.6 47.8 25.0 39.1

7.0 18.6 20.9 11.6 25.6

14.00* 18.00* 8.90 3.20 2.40

Loss of Control Reduced/given up activities in order to drink So much time. . . little time for anything else Drank much more than expected Tried to quit/cut down on drinking more

43.5 50.5 80.4 81.5

18.6 27.9 55.8 65.1

7.90 6.10 8.90 4.40

than once Made rules to control drinking Continued to drink despite problems

54.3 95.1

23.3 100

11.50* 1.90

Heavy Consumption Indices Had > 2 weeks of drinking 7 or more drinks Had > 2 months where at least once/week drank

74.4 86.0

52.5 65.0

6.00 7.40

7 or more drinks Had blackouts

83.7

51.2

15.90*

Criteria (DIS Item)

*p < .0027.

histories of alcohol problems were abstinent should be noted that a substantial proportion

or controlled drinkers. However, it of the controlled drinkers (18.6%)

had a history of severe alcohol dependence, suggesting that controlled drinking is not restricted only to individuals with mild alcohol problems. The results also revealed that the abstinent and controlled drinkers differed in their past alcohol consumption patterns. These findings indicate that female gender may be more strongly associated with an abstinent outcome for older adults with a history of alcohol problems. This appears to be inconsistent with a number of studies with younger samples (ElalLawrence et al., 1986; Helzer et al., 1985; Miller &Joyce, 1979; Orford & Keddie, 1986). It has been argued that sensitivity to stigma associated with drinking and increased susceptibility to negative consequences among older women may increase the likelihood of abstinence relative to younger age groups (Gomberg, 1988,1995). Additional research is needed on the relationship between gender, outcome type, and aging in order to assess whether age-related differences are due to cohort effects or other factors associated with aging.

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ST. Chermack, F.C. Blow, E.S.L. Comberg S.A. Mudd, and E.M. Hill

It should be noted that both the abstinent and controlleddrinking groups ap peared to have attained a stable remission from alcohol symptoms. The current alcohol consumption levels of the controlled drinkers (average daily consumption of approximately one drink per day) was similar to recommended consumption limits for problem-free drinking by older adults (e.g., Dufour, Archer, & Gordis, 1992) and appeared to be lower than the consumption levels of younger samples of controlled drinkers (approximately 1.7 drinks per day; Sanchez-Craig, Wilkinson, Phil, 8c Davila, 1995). These findings are consistent with the evidence that there is a general decline in alcohol consumption associated with aging (Fillmore et al., 1991), and that heavy drinkers tend to reduce alcohol consumption with age (Adams et al., 1990; Stall, 1986). These results may provide useful clues for identifying which individuals are candidates for successful outcomes with either abstinence or CD. For example, these findings suggest that individuals with less severe alcohol-related problems and histories of lower levels of consumption may be more capable of maintaining controlled drinking with remission of alcohol problems than individuals with more severe alcohol problems and heavier consumption histories. Because of substantial gaps in our knowledge regarding who is at risk for major relapse, more research is needed to confirm this possibility. Thus, these results should be interpreted with caution. Furthermore, future research should focus on other variables potentially related to whether older adults with alcohol problems become abstinent or continue to drink, such as health-related problems, whether or not individuals view themselves as “alcoholic,” and participation in formal and informal treatment. The methodology employed in this study has some inherent limitations. For example, the sample was not selected with the intent of being representative of the population of older adults with histories of alcohol problems and no current symptoms. The sample size also placed some restrictions on examining certain issues in more depth, such as gender differences. For these reasons, caution should be exercised in generalizing the results to the population of older adults with histories of alcohol problems in remission. In addition, this study relied on retrospective self-report data concerning alcohol consumption, alcohol symptoms, other alcohol-related consequences, and the length of time since symptom remission. This raises the possibility that the pattern of findings may have been influenced by memory problems or recall bias associated with outcome type. Longitudinal studies are needed to understand better the causal influences related to different drinking patterns associated with remission. Nevertheless, given that relatively few studies have examined alcohol problems among the elderly, the findings provide important information about this growing but under-researched population.

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and E.M. Hill

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