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Misinterpretation in major surveys of alcohol use disorder as described by DSM-IV (American Psychiatric Association, 1994; Hasin et al., 2007) has raised serious question regarding the extent of alcohol use disorder, and the relationship between alcohol abuse and alcohol dependence. While the adverse social, physical and mental effects of alcohol misuse are well known (Council on Scientific Affairs, 1996), there is little information on the determinants of alcohol abuse (the societal impact of adverse alcohol use), alcohol dependence (the physiologic impact), and the combined presence of alcohol abuse and dependence. We therefore examined their separate associations with demographic, social, and health characteristics in a representative community-resident sample ≥60 years of age. We hypothesized that, while each of the three groups would be associated with demographic characteristics, abuse would be more closely associated with social characteristics, dependence with health characteristics, and the combined presence of abuse and dependence with both.
Data were gathered by carefully trained and monitored interviewers in1995 using face-to-face structured household surveys of 7920 representative community residents age ≥60 years, in nine regions covering the southernmost Brazilian state of Rio Grande do Sul -- a wine area. Information from one region was problematic and was dropped, resulting in a sample of 7040 persons, of whom 79 (1.1%) declined to participate, yielding an analysis sample of 6961 (Conselho Estadual do Idoso, 1997). The Ethics Committee of the Federal University of São Paulo approved the study.
Use of alcohol was determined by response (yes/no) to each of the following questions, translated from the Portuguese:
While nor constituting an established measure, the individual items are comparable to those commonly used in alcohol impact enquiry. A positive response to question 1, 3, or 4 was accepted as indicating lifetime abuse of alcohol. A positive response to question 2 or 5 indicated lifetime dependence (American Psychiatric Association, 1994; Hasin et al., 2007). Participants were not asked when the problem occurred. The sample was classified into four mutually exclusive groups: abuse only, dependence only, both abuse and dependence, neither abuse nor dependence.
Demographic -- gender, age (60–69, 70–79, 80+), education (0–3 years, ≥4 years), income (low income <US$200.00/month, high income ≥US$200.00/), race/ethnicity (Caucasian, African-Brazilian, Other), religious affiliation (Catholic, Evangelical, Other), and place of birth (urban vs. rural area).
Social characteristics -- marital status (married, never married, no longer married/cohabiting), living alone or with someone else, the presence of children, participation in social activities and religion-affiliated activities.
Health behaviour – exercise, assessed by asking: “In the last three months did you practice a regular physical activity?” (yes [≥once a week]/no); employment status (“employed” if still working [the type of work was immaterial], “not employed” if not working or did not know the answer); current use of tobacco (yes/no).
Inability to perform activities of daily living (ADL), assessed by a 5-item unidimensional scale. The number of impaired activities was recoded as 0, 1–2, ≥3.
Preliminary analyses of 18 self-reported health conditions indicated that only vascular conditions, respiratory problems, kidney problems, and osteoporosis were relevant.
The presence of a psychiatric condition was assessed by a validated Brazilian modification of the Short Psychiatric Evaluation Schedule (Blay et al., 1988).
Percentages were used to describe the sample, and χ2 to compare each of the three alcohol use groups with neither lifetime abuse nor dependence. Because of the small size of the abuse only group, separate blockwise logistic regression analyses were first run to identify the significant variables within each block (demographic, social, health characteristics). These significant variables were then entered into an initial multivariable polytomous logistic regression, and a final model run using only the variables found to be significant. Analyses were performed using SPSS 13.0.
Lifetime alcohol misuse was endorsed by 734 participants (10.6%), of whom 103 (1.5%) reported abuse only, 244 (3.5%) reported dependence only, and 387 (5.6%) reported both abuse and dependence. Two thirds of the sample were female, the majority was age 60–69, of low education and low income, rural birth, white (84%), and Catholic (75%) (Table 1). In univariate analyses (Table 1) the “abuse only” group differed from those expressing neither abuse nor dependence on five of 21 characteristics examined (male, use tobacco, married, less likely to participate in religion-affiliated activities, or to have osteoporosis). In addition to all these characteristics except osteoporosis, dependence only participants were more likely to be younger, of “Other” race/ethnicity, employed, have a respiratory condition, but less likely to report a vascular condition. Participants reporting abuse-and-dependence additionally had little education, were less likely to participate in social activities, and were more likely to have ADL, kidney, and psychiatric problems.
The final controlled analysis (Table 2), yielded a more restricted set of significant variables, but showed a similar increase in number and type of associates, going from “abuse only” to “dependence only” to “abuse-and-dependence”. The significant associates of “abuse only” were male sex and tobacco use. “Dependence only” was additionally associated with “Other” race/ethnicity (as compared to White), increased likelihood of respiratory and psychiatric problems, and decreased odds of vascular conditions. The same associates held for “abuse-and-dependence”, but with more marked odds ratios.
Data come from a large community-resident sample ≥60 years of age, representative of the state of Rio Grande do Sul in Brazil, who provided information on multiple aspects of aging. The included 5-item questionnaire permitted rough assessment of lifetime alcohol abuse (three items), and alcohol dependence (two items). According to response to these items, 10.6% of the sample (men -- 25.4%, women -- 2.9%), reported alcohol-related problems, with 1.5% reporting abuse only, 3.5% dependence only, and 5.6% abuse-and-dependence.
Comparison with other studies in Brazil is difficult. Focus on lifetime use is infrequent; the samples rarely include participants age ≥60; are often small, resulting in questionable findings; and have used multiple different measures to assess alcohol use. Our findings of 10.6% compare with reports ranging from 2.7% in Campinas, Southeastern Brazil (based on 93 sample members age 60 and over) (Barros et al., 2007), to 12% for frequent or heavy drinkers in a subsample 60 years and over in a national survey (Laranjeira et al., 2007).
Our findings on demographic and health associates of alcohol misuse are comparable to other published reports that implicate male sex, younger age, tobacco use, adverse physical health conditions except for vascular status, and adverse psychiatric status (National Institute on Alcohol Abuse and Alcoholism, 2002), providing confidence that the 5 alcohol questions have both content and criterion validity.
We hypothesized that “abuse only” would be associated with demographic and social variables, and “dependence only” with health-related characteristics. In controlled analyses, our hypothesis regarding “abuse only” held, but characteristics associated with dependence included both health conditions (as hypothesized) and characteristics encompassed by “abuse only”. The same “dependence only” characteristics held for “abuse-and-dependence”, but the associations were stronger.
Our findings also address the question of whether “abuse only”, “dependence only”, and “abuse-and-dependence” are hierarchically associated, or whether they represent unique, nonprogressive, manifestations of alcohol misuse. We argue for hierarchical association based on the finding that, in these older persons, dependence is uniquely associated with health effects in addition to the effects associated with alcohol abuse, and that these associations are intensified among those reporting abuse-and-dependence. We argue for the possibility of nonprogression by noting that nearly half of those reporting lifetime alcohol misuse report only lifetime abuse, or only lifetime dependence. Since lifetime alcohol misuse has consistently been reported to decline with age (a finding further confirmed even in this older age sample), we assume (but cannot confirm) that alcohol misuse occurred at an earlier time, and may not necessarily progress. In support, Hasin et al. (1990) found that, over four years, only 30% progressed from alcohol abuse only to alcohol dependence, while 39% with alcohol dependence had remitted.
Our data have significant limitations. Our measure does not meet diagnostic criteria, so our findings must be interpreted cautiously. Information is self-reported, however self-report has been found to be valid for alcohol use and problems (Bonger & Van Oers, 1998), and for various health conditions (Beckett et al., 2000). We have no information on when problems with alcohol use occurred, and whether they are still present. With this cross-sectional design we can rarely distinguish cause and effect.
Nevertheless, these data suggest that, while there is a gradient of associations and of adverse effect going from abuse to dependence to abuse-and-dependence, progression to a more serious stage need not necessarily occur.
We thank Dr. Sergio Antônio Carlos – President of the State Council of the Elderly (Conselho Estadual do Idoso), for allowing us to use the dataset of the “Elderly of RS – a multidimensional study of their living conditions” study.
Role of funding source: This study was supported by grants from Conselho Estadual do Idoso, Secretaria do Trabalho, Cidadania e Assistência Social; and by Governo do Estado do Rio Grande do Sul. Dr. Fillenbaum was partially supported by National Institute on Aging grant number 1P30 AG028716-01 Claude D. Pepper OAIC. None of these sources had a role in the current study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Conflict of interest: All authors declare that they have no conflicts of interest.
Description of authors’ roles: Conception and design, analysis and interpretation of data – Sergio Baxter Andreoli MD, PhD; Fábio Leite Gastal MD, PhD, Sergio L. Blay, MD, PhD; Gerda G. Fillenbaum, PhD
Drafting article and critical revision – Sergio L. Blay, MD, PhD; Gerda G. Fillenbaum, PhD
Final approval of version to be published: Sergio L. Blay, MD, PhD; Gerda G. Fillenbaum, PhD; Sergio Baxter Andreoli MD, PhD; Fábio Leite Gastal MD, PhD