The ageing population is rapidly increasing worldwide. A United Nations report (2015) estimated that the population of individuals aged 60 years or older would increase from 901 million people in 2015 to 2.1 billion by 2050, and could increase to 3.2 billion by 2100. This has important implications for the planning and delivery of health and social care (Clegg et al, 2013; Sacco et al, 2015). Ageing is a complex process that is considered to be the result of lifelong accumulation of molecular and cellular damage caused by multiple mechanisms. It is regulated by an intricate maintenance and repair network and influenced by genetic, environmental and epigenetic factors. Frailty is a consequence of a cumulative decline in multiple physiological systems that results in vulnerability to sudden health status changes triggered by relatively minor stressors (Clegg et al, 2013). Alcohol use, abuse or alcohol-use disorder (AUD) is one such environmental factor that may trigger or precipitate events that lead to acute decompensation (Kuerbis et al, 2014; Rao et al, 2015).
The alcohol-related burden of disease among the older population is increasing in most countries belonging to the Organisation for Economic Co-operation and Development (Lang et al, 2007; Rao et al, 2015). At-risk drinking is more prevalent than AUD among older adults and is likely to be responsible for a larger share of the harm to the health and wellbeing of older adults (Sacco et al, 2015). Of the general older population in England, 79% of individuals consume alcohol and 1.6 million individuals may have some level of dependence on alcohol (Office of National Statistics (ONS), 2014; Public Health England, 2016). A large European study found that in a community-dwelling population aged 65 years or more in London, the prevalence of current and lifetime AUD was 1.4% and 13.8%, respectively, which was among the highest recorded in the study (Munoz et al, 2018). Tolerance to the effects of alcohol is reduced with ageing, as well as with frequent polypathology and polypharmacy. This includes a reduction in the physiological tolerance to the effects of alcohol (Sorocco and Ferrell, 2006). Despite alcohol use being a growing problem given the growth of the older population and alcohol abuse within this population, very few studies have assessed AUD in older adults, especially those aged 70 years or more.
The main objective of the present study was to evaluate alcohol consumption in a population of community-dwelling individuals over 70 years of age who were independent. The secondary objective was to evaluate the perceptions and opinions about alcohol among these individuals.
Methods
Study setting and selection criteria
This preliminary descriptive quantitative study was conducted among people aged 70 years or over who visited a social activity centre for older people in the town centre of Brest (western France). This study was conducted over a period of 5 months (May–September) in 2014.
The selection criteria are listed in Table 1. The participants were enrolled from among those who visited the social centre regularly for various activities. Before the visitor began the activity (sport or cultural), they were screened, and cognitive disorders were an exclusion criteria for participation in these activities. All individuals who attended the activities at the social club during the study period and met the selection criteria were asked to answer a questionnaire.
| Inclusion criteria | Exclusion criteria |
|---|---|
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Questionnaire
The widely used Alcohol Use Disorders Identification Test (Saunders et al, 1993) was not considered suitable within the context of the present study about alcohol perceptions (Beullens and Aertgeerts, 2004). Therefore, a specially constructed questionnaire prepared by a study committee that included family practice physicians, researchers, a methodologist and psychiatrists who specialised in addictive disorders was used. This tool was specifically designed to encourage the older people visiting the social centre to participate. It was a self-administered questionnaire with four parts:
The questions in the first three parts were binary, while the items in part 4 involved rating using a Likert scale.
The main investigator was present every week during the study to explain the research to the participants at the social centre. Moreover, the three coordinators who organised the activities were explained the objectives of the study, and the methods and consent forms were discussed with them. When the main investigator was not present, the three coordinators were responsible for ensuring that visitors who met the selection criteria answered the questionnaire.
Ethics statement
This study was approved by the ethics committee of the University of Brest. Both oral and written consent was obtained for participation in the study. All data were anonymous.
Statistical analysis
For the descriptive analysis, anonymous data were entered tabulated in MS Excel. Quantitative data were expressed as means and standard deviation, and qualitative data as percentage and number. Statistical analysis was conducted using BiostaTGV (http://marne.u707.jussieu.fr/biostatgv/).
Results
Participation
A total of 180 persons aged 70 years or over visited the social centre during the study period. Of these, 105 provided consent to participate and filled out and returned the questionnaire. Thus, the response rate was 58.3%. However, seven questionnaires had to be excluded because of missing data; thus, 98 questionnaires were completed and included in the subsequent analysis, representing a 54.4% response rate. Most of the participants included were female (71%), and the average age was 79 years (range, 70–97 years; SD=6).
Descriptive analysis
Alcohol consumption
The results related to alcohol consumption are presented in Table 2, while Table 3 presents the perceptions of the participants regarding what is considered excessive alcohol consumption and the most important area in which alcohol consumption can cause damage. Of the sample population administered the questionnaire, 58% reported regular (weekly) alcohol consumption. Further, 34% reported alcohol consumption of two standard units or more during weekdays, while 53% reported this level of consumption during the weekend.
| Question | Responses | Percentage responders (n) |
|---|---|---|
| Regular (weekly) alcohol consumption | Yes | 58% (56) |
| No | 38% (37) | |
| No answer | 4% (5) | |
| Daily consumption of at least two standard units | Weekday (Monday–Thursday) | 34% (33) |
| Weekend (Friday–Sunday) | 53% (52) | |
| Daily consumption during the week (in standard units of alcohol) | 0 | 43% (42) |
| 1 | 22% (21) | |
| 2 | 20% (20) | |
| 3 | 9% (9) | |
| 4 or more | 5% (5) | |
| No answer | 1% (1) | |
| Daily consumption during the weekend (in standard units of alcohol) | 0 | 27% (26) |
| 1 | 20% (20) | |
| 2 | 36% (34) | |
| 3 | 13% (13) | |
| 4 or more | 4% (4) | |
| No answer | 1% (1) |
| Question | Responses | Percentage responders (n) |
|---|---|---|
| What do you consider as excessive daily consumption (standard unit of alcohol)? | 1 | 1% (1) |
| 2 | 15% (15) | |
| 3 | 49% (48) | |
| 4 or more | 25% (24) | |
| No answer | 10% (10) | |
| What is the most important aspect in which alcohol consumption can cause damage? | Familial | 69% (67) |
| Social or financial | 57% (56) | |
| Physical | 61% (60) | |
| Psychological | 60% (59) |
In response to the question ‘what do you consider as excessive daily consumption?’, 49% of the sample population cited three standard units while 25% cited four standard units.
Factors responsible for alcohol use
The study participants cited the following as the main motivating factors for alcohol consumption or the positive effects of alcohol use in their experience: mood improvement (22%, n=21), ease of distress (31%, n=30) and that it helps them forget (29%, n=28). On the other hand, 72% (n=70) of the participants said that alcohol definitely did not reduce pain, and 56% (n=54) said it did not help them sleep.
The main negative perceptions about alcohol consumption were the risks: 73% (n=71) of the participants considered alcohol dangerous, and 66% (n=64) considered it to be associated with illness. Similarly, a majority of 58% (n=56) considered alcohol a drug.
Among the study participants, 74% (n=72) believed that alcohol consumption should be reduced with age, with two primary motivating factors: drug interactions (83%, n=81) and a fear of falling when drunk (50%, n=49).
Perception of AUD
A total of 41% (n=40) of the participants believed that alcohol consumption might be a risk regardless of the type of alcohol consumed, while 39% (n=38) considered the risk to be greater if the drink contained a high percentage of alcohol.
Study participants most commonly listed the following as criteria that help distinguish between AUD and alcohol use: time spent in searching for and drinking alcohol and recovering from drinking (72%), an irresistible need to drink alcohol (craving) (75%), the inability to stop alcohol consumption (64%), and excessive daily consumption of alcohol (64%).
Alcohol consumption screening
When asked about whether they had ever discussed their alcohol use with their GP, an overwhelming 72% (n=70) of the participants said that they had never done this.
Discussion
In the decade spanning 2005 to 2015, the number of older adults consuming alcohol, or those with AUD, has increased tenfold in women and fourfold in men, and the alcohol-related burden of disease is increasing, especially among older individuals (Lang et al, 2007; Rao et al, 2015; Rao et al, 2016). In the present sample, more than half the participants reported regular (weekly) alcohol use. Further, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) (5th edition; American Psychiatric Association (APA), 2013), AUD is defined on the basis of 11 criteria, and a diagnosis of moderate or severe AUD is based on four criteria. One of these criteria is ‘spending a considerable amount of time in activities to obtain, use or recover from drinking alcohol. The older adults in this study were aware of the potential addictive risks of alcohol consumption and the criteria underlying AUD (APA, 2013), especially alcohol craving (‘needing to drink’) and the time spent on alcohol consumption. They also considered the potential damage caused by alcohol use to be serious, especially to family life, as well as the risk of severe physical and psychological damage caused by alcohol.
Alcohol-related mortality is the highest in older age groups and is increasing in the population even though it is stabilising in younger age groups (Frisher et al, 2015). Data from the ONS (2014) show that the highest age-specific alcohol-related mortality rates were for the age group 55–74 years, at 40.1 per 100 000 for men and 19.8 per 100 000 for women (Frisher et al, 2015). Alcohol abuse also carries high risks of morbidity—malnutrition, in particular—and deterioration in health status (Almeida et al, 2017), as well as gastrointestinal and ear, nose and throat pathologies, especially cancer. The low-risk drinking guideline released by the UK Chief Medical Officer in 2016 recommend that to limit the health risks from alcohol, consumption should be kept below 14 standard units a week on a regular basis. Further, women over the age of 55 years gain the maximum health benefit when limiting alcohol consumption to around five standard units a week (Department of Health, 2016). These guidelines are similar to the French national recommendations (Lang et al, 2007; Rolland et al, 2016). The findings of the present study showed that the reported level of consumption was higher than the recommended levels: 34% of the older adults who participated consumed at least two standard units of alcohol per day during the week, and 53% consumed at least two standard units per day during the weekend. According to the literature, 10.8% of older American men, 28.6% of older English men, 2.9% of older American women, and 10.3% of older English women drink more than the limit recommended by the US National Institute on Alcohol Abuse and Alcoholism for people aged 65 years and over (Lang et al, 2007).
The findings underscore the importance of screening for alcohol among older adults. In the last 10 years, issues related to alcohol consumption among older adults have been better identified, underpinned by the increased prevalence of late-onset AUD, conventionally classified as an ‘age-related’ disorder (Sorocco and Ferrell, 2006). Older adults are willing to discuss alcohol misuse when invited to participate in an evaluation, as was reported in a study conducted in a general acute care hospital (Knightly et al, 2016). In the present study as well, anonymous data could be recorded without difficulty at the social centre. However, 72% of the individuals who responded to the questionnaire reported that they had never talked about their alcohol consumption with their GP. This finding highlights a real problem concerning the screening of alcohol use among older adults. Several reasons could underlie the inadequacies in screening for alcohol use among older adults. The first limitation in identifying AUD is sociocultural. In the general population in France, alcohol consumption has become normalised. Alcohol marketing is regulated by the Evin Law, but since 1991, and particularly recently, several changes to this law have made alcohol marketing strategies more lenient (Gallopel-Morvan et al, 2017). Public health authorities in Europe are concerned about these changes (Hessari et al, 2018; Petticrew et al, 2018), more so with regard to older adults, a population that seems to consume far more alcohol than the standard. The older the person is (from 75–85 years of age), the greater is their deviation from the current standard (Menecier and Rotheval, 2017). There may be a discrepancy between what was considered the norm when this population group was growing up and the current norm. This may lead to older adults underestimating the age-related differences in problems related to alcohol use or the damage to health caused by alcohol consumption. At times, for caregivers as well as for the older person themselves, drinking alcohol is viewed as one of the few pleasures remaining in life. The objective is not to prohibit alcohol consumption but to attempt, with the cooperation of the individual, to think about improving quality of life (Samaras et al, 2010). Some caregivers have noted the fear of offending older people or a lack of time or legitimacy when discussing alcohol use (Rica et al, 2017). However, simple questions can help start the process: ‘Have you had an alcoholic drink today?’, ‘What sort of alcoholic drink do you usually have?’, ‘What do you drink with meals?’ (Bogenschutz et al, 2011). Guidelines in Europe advocate targeted identification of AUD in people over the age of 65 years: individuals who have certain predictors of alcohol misuse are considered to be at high risk, for example, male gender, tobacco dependency and social problems (Tadros et al, 2015). Certain factors such as a history of AUD and chronic pain have also been identified to increase the risk of alcohol misuse (Brennan et al, 2005). Onen et al (2005) recommend that the identification of clinical symptoms such as sleep disorders, falls, malnutrition, signs of anxiety or depression, cognitive difficulties or chronic pain should prompt screening for AUD. The disadvantages of these warning signs is that they are nonspecific and frequently encountered in primary care. Nonetheless, identification of alcohol consumption should prompt a brief intervention by GPs. A previous study showed that alcohol was the least-discussed lifestyle theme among smoking, physical activity and dietary habits in Dutch primary healthcare (Noordman et al, 2013). Such interventions, especially in primary care, are well suited to older individuals and have been shown to be effective in reducing the frequency of weekly alcohol consumption, the number of acute episodes of heavy drinking and the percentage of older people who consume alcohol in excess (Blow et al, 2007).
In the present study, the authors collected information about alcohol use among individuals aged 70 years or more. To the best of the authors' knowledge, data on alcohol abuse in Europe are virtually non-existent for the population in this age group. Nonetheless, this study has some limitations. The questionnaire was self-reported by the participants, and alcohol use was not objectively measured. Additionally, the scale used to assess alcohol use was not a validated one. Selection bias may have arisen from the inability to assess all the potentially eligible participants. Lastly, the results presented here are from 2014, and do not reflect social changes that have occurred in the last 5 years. Therefore, the results may not be easily generalised. The authors intend to overcome these limitations in future research, which will include a larger population of older adults, including those receiving primary care. Future studies will also include GPs and community nurses, and a validated scale, such as the AUDIT, or DSM V criteria to evaluate AUD. Lastly, they will be conducted via face-to-face interviews and include a cognitive evaluation.
Implications for practice
In order to help older adults achieve control over abusing this substance, the first step is to screen for alcohol use. Primary care seems to be the ideal setting for opportunistic screening for alcohol consumption (Tam et al, 2016). GPs and nurses should play a central role in assessing people who abuse alcohol and in any intervention to correct this, in addition to working with housing and social services to improve medical and social care (Blazer and Wu, 2011). It seems essential that facilitators be trained and educated in the identification of alcohol consumption and AUD in older adults. Implementing national programmes of screening and brief interventions in primary healthcare would be a cost-effective means of reducing alcohol-attributable morbidity and deaths in most European countries (Angus et al, 2017).
According to the guidelines of the National Institute for Health and Care Excellence (NICE), a combination of medical and psychological treatments is the best treatment option for mental disorders in older adults (2011). With brief advice and motivational therapy, older people become motivated to reduce or give up alcohol consumption, responding well to these interventions (Crome and Crome, 2018). Psychological awareness programs could be implemented in the primary care setting to identify psychological disorders and AUD. This could encourage stepped interventions (Bosmans et al, 2014), which have positive effects even if they are simple (Kelly et al, 2018).
Conclusion
This small study suggests that some older people attending a social centre in west France were consuming too much alcohol for a healthy lifestyle. These findings may indicate a wider issue of inappropriate levels of alcohol consumption elsewhere in northern Europe, including the UK. It was interesting that the sample reported that they rarely had their alcohol consumption assessed and that they rarely discussed their alcohol consumption with their GP. This suggests that there are missed opportunities to assess alcohol consumption and for healthcare professionals including district nurses to discuss alcohol consumption with care recipients and to agree on strategies to enable a healthier lifestyle with appropriate alcohol consumption. This may include a referral to a specialist in AUD. The objective of caregivers must remain the reduction in harm related to alcohol consumption and AUD, to enable an improvement in the patient's quality of life irrespective of age.