A total of 24,863 people age 65 years and older completed screening; 56% were between 65 and 75 years and 44% were 75 years or older. The median age was 72 years and the range was 65 to 103 years. Eighty-one percent were male, reflecting the substantial participation from VA Centers. Seventy-two percent identified themselves as white, 16.1% African American, 4.9% Chinese American, 5.4% Hispanic/Latino American, and 1.4% Native American, mixed or “other.” Nineteen percent had symptoms of depression/anxiety, about 5% reported that they did not feel loved and cared for, and 25.6% lived alone. Of the sample, 42% reported fair or poor health; and 10.7% were currently smoking.
Seventy percent of the sample did not consume alcohol, 21.5% were moderate drinkers (1–7 drinks per week), 4.1% were at-risk drinkers (8–14 drinks per week), and 4.5% were heavy drinkers or bingers. Applying the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guideline for persons over the age of 65 (no more than 1 drink a day equivalent to a cutoff of 7 drinks per week), resulted in 9.2% of the men and 2.1% of the women, or 7.9% overall, drinking in excess of the guideline.16
As shown in Table , the proportion of elders reporting drinking declined with age. However, more than 20% of adults, 85 or older, reported consuming at least 1 drink/week, though less then 1% were heavy drinkers or bingers. Men (33%) were more likely to drink than women (17%) and were 8 times more likely to binge (P
.0001). Drinking was more common among whites (35%) and African Americans (23%) than among Hispanics/Latinos (11%) and Chinese Americans (3%) (P
.0001). Binge drinking was most common among African Americans. Overall, the frequency of smoking was 11%, but was more common in elders who had heavy or binge drinking patterns (19.1% and 27.9%, respectively; P
.0001). In our sample, 26.5% of nondrinkers, 21.1% of moderate drinkers, 12.3% of at-risk drinkers, 25% of heavy drinkers, and 32% of binge drinkers lived alone (P
.0001; data not shown). Among drinkers, 24% had at least 1 recent episode of binge drinking. Although relatively common, binging is also associated with higher per week consumption (Table ).
Demographic Characteristics of Patients Seen in Primary Care by Alcohol Consumption Patterns*
To identify the health impact of drinking, we examined the association between drinking patterns and self-rated depression/anxiety symptoms, general health status, and social support (see Table ). Compared with moderate drinkers, nondrinkers were more likely to report symptoms of depression/anxiety, fair or poor general health, and lower social support. Similarly, those with heavy drinking or binging reported more symptoms of depression/anxiety and lower social support compared to moderate drinkers (2-sample t
.001). Also, in these unadjusted analyses, binge drinking was associated with reporting general health as fair or poor. At-risk drinkers, conversely, reported rates of general health that were not statistically different from those of moderate drinkers (2-sample t
Association Between Drinking Pattern and Self-rated Health Status and Social Support
To examine the health impact of drinking relative to other associated factors and to control for site variation, multivariate logistic regression models were developed (Table ). In these models, binging was not a significant predictor of health status, unless it was further stratified by weekly drinking level. Table presents the binge category modeled as 2 groups, those who drank ≤14 drinks/week and those who drank >14 drinks/week. Compared to moderate drinkers, nondrinkers, heavy drinkers, and bingers with heavy drinking were at significantly increased risk of reporting depressive/anxiety symptoms. Nondrinkers and bingers with heavy drinking were both at increased risk for rating their health as fair or poor. Nondrinkers and heavy drinkers were both at increased risk for feeling not loved and cared for. At-risk drinkers and bingers (≤ 14 drinks/week) did not differ significantly in health ratings when compared to moderate drinkers. Thus, after controlling for site, demographics, and smoking, binging combined with heavy drinking was associated with poorer heath outcomes, whereas binging without heavy drinking was not.
Logistic Regression Models of Health Status and Social Support as Predicted by Alcohol Consumption Pattern (OR and 95% confidence interval)
Female gender, smoking, living alone, and increased age were independently associated with depression/anxiety symptoms and a health rating of fair or poor. African Americans were more likely than whites to rate their health as fair or poor. Women were less likely to report not feeling loved and cared for than men.
In this sample of 24,863 patients screened at 36 primary care clinics, 4 findings emerged: 7.9% of older adults drank in excess of the NIAAA guidelines; binge drinking was common among all persons who consumed alcohol, not just heavy drinkers; heavy drinking was associated with an increased risk for depression/anxiety; and whites reported a higher rate of moderate drinking than African Americans.
We found that 9.2% of men and 2.1% of women drank in excess of the NIAAA guidelines for persons over 65. Other studies have used alternative definitions of “at-risk” drinking.7
Using cut points of >7 drinks/week for women and >14 drinks/week for men, Adams found screen positive rates of 15% and 12% for men and women, respectively. Blow, using “at-risk” cut points of 9 or more drinks/week for women and 12 or more drinks/week for men, identified that more than 10% of the men and 3% of the women in an older primary care population drank at levels considered at-risk for alcohol problems.17
Results from these studies are consistent with drinking rates in our white and age 65 to 75 groups. However, the results from this study offer a more ethnically and racially diverse cohort, including those in the oldest age group.
The majority (22%) of the alcohol users were moderate drinkers, although reported episodes of binge drinking were common amongst all drinkers (24%), demonstrating that binge drinking occurs across all categories. In our sample, frequent binge drinkers who were also heavy drinkers were more likely to report fair or poor health. Older adults’ increased susceptibility to alcohol’s toxic effects make these binge drinking findings critical because of the potential interactions of binging, medications, and co-occurring illness.4
In multivariate logistic models including African Americans and whites, heavy drinking, with and without binging, was associated with increased risk of depressive/anxiety symptoms and feelings of social isolation, even after controlling for age, gender, race, smoking status, and living arrangement. In accord with previous studies, nondrinking was associated with poorer health parameters, compared to moderate drinking.18–20
This may be a complex interaction in which older individuals who once drank gave up drinking for health reasons, suggesting that their current nondrinking is a consequence of, rather than, a causal factor of poor health. Alternatively, moderate drinking might be a “protective” behavior for physical and social health.21
Alcohol-use patterns were consistent with earlier findings for gender,7
with men reporting drinking more often (33%) than women (16.7%). There were also significant differences among ethnic groups with whites reporting moderate or at-risk drinking more frequently than African Americans, Hispanic/Latino Americans, and other ethnic minority elders. These findings are consistent with recent findings of male veterans in primary care.22
Also consistent with previous findings, alcohol frequency and quantity declined with age.2,23–26
This may represent a survival bias, with heavy drinkers either dying or stopping alcohol use at an earlier age. Heavy drinking and binging were consistently lower for Chinese-Americans and Hispanics. The absence of heavy drinking or binging among elderly Chinese Americans is consistent with other studies.27,28
Policy implications from this study for recommended alcohol intake are congruent with existing public health recommendations, which recommend no more than 1 drink per day.19
Interestingly, in this study population, at-risk drinkers (8–14 drinks per week) did not differ significantly from moderate drinkers (1–7 drinks per week) in their characteristics or for the 3 variables evaluated—depression/anxiety symptomatology, perceived health, and perceived social support. Poor health parameters were more likely to be associated with heavy drinking and/or frequent alcohol binging, therefore, alcohol interventions are recommended for this group. These findings are consistent with findings by Chermack who noted that episodes of heavy drinking (5 or more drinks in 1 day) influenced the rate of patients who reported alcohol symptoms even when controlling for average daily consumption.29
These results imply that patterns of use may be more important than daily or weekly use.
Limitations of this study are: (1) findings may not be nationally representative of all elders in usual care and (2) information was collected on alcohol use only in the 12 months preceding the study and did not ascertain reasons for abstinence. Thus, the population of nondrinkers may be a combination of those who stopped drinking for health reasons and those who never drank. The cross-sectional nature of this study limits our ability to fully explore the associations found in the study. In addition, although there is some support for single-item assessment of health and social parameters, some of the outcomes are based on more comprehensive measures (e.g., the GHQ) than others (the perception of general health). Site and ethnic diversity were confounded; 1 site contributed 90% of the Chinese Americans, and another site contributed 75% of the Hispanic/Latino Americans; therefore, these older adults could not be included in the multivariate analysis. Data were not collected on education and income, 2 factors that have been shown to be associated with alcohol use patterns. Our initial question, “Do you use alcohol (yes/no)?” may have limited accurate reporting because multiple modes of screening were used or there may have been social desirability bias, both of which would have resulted in underestimation of at-risk drinking. However, 30% responded affirmatively to this question, suggesting that these were not substantial limitations. Finally, statistical significance must be interpreted within the context of the large sample size in which statistical significance may be associated with small relative differences.
This study is the largest reported convenience sample of elderly primary care patients with documented alcohol use, including the largest sample of primary care elderly, 75 and older. The study includes different ethnic populations and draws from diverse primary care settings, including public health clinics, academically affiliated clinics, large health systems, and VA clinics across multiple regions of the country. Though the majority of the older sample were nondrinkers, this study provides evidence that alcohol use in the elderly is common. The majority of alcohol users consumed moderate or at-risk amounts of alcohol based on total weekly consumption cut points, yet, patterns of abuse were frequent. While men were more likely than women to drink and drink heavily, women did use and abuse alcohol. Finally, in both bivariate and multivariate analyses, at-risk drinkers did not differ significantly from moderate drinkers in their characteristics or for the 3 health parameters evaluated. In contrast, heavy drinking was associated with depression and anxiety and less social support, and heavy drinking combined with binge drinking was associated with depressive/anxiety symptoms and perceived poor health.