Health Promotion and Aging
      "Alcohol"

           Erma Polly Williams, M-R-E.
Continuing Education Faculty, Rutgers Center of Alcohol Studies
   Consultant to the New Jersey State Division on Aging
Consultant to the New Jersey State Division on Alcoholism

Alcohol is here to stay.   Older people probably have  a better sense of the
meaning of that statement than younger people  since  anyone  over the age of 55
lived part of their life under Prohibition. Anyone over the age of 65 probably
remembers at least fragments of the "roaring twenties", and anyone over seventy
probably recalls Temperance slogans, speeches and rallies.  Older people are also
here to stay.   With people  over 65 representing approximately 12% of the
population, they are the fastest growing segment of the society, and include many
more people of increasingly advanced age.  As the quality of life for these older
people is strongly tied to  the maintenance of health, it is  appropriate  that
there should be a consideration of  the relationship of age and alcohol from a
health perspective.

Interest and concern about the incidence of  alcohol use and abuse by the older
portion of the population have increased dramatically over  the last 20 years.
This increase is  evident in  the  core of alcohol literature, as well as in the
publications of many disciplines, reflecting  the multidisciplinary dimensions of
the phenomenon.  It is being addressed in professional journals,  giving evidence
that the problem is being encountered by the  many systems and agencies that
provide services to older people.  Y?t despite  this  tide of attention, the area
of study and the level of response to the need do not seem to  gain much headway.
In view of  all  the needs of  older people in our society, problems related to
alcohol are relegated to a low place on  the  priority list.  And in the alcohol
field, the aged do not appear to generate the excitement and involvement of other
population groups.

The society is becoming increasingly sensitive to the presence of elderly people.
By sheer weight of numbers, it is becoming more imperative that issues related to
their health and well-being be addressed.  The pervasiveness of   the  use of
alcohol as a societal practice,  and the types of impact that this use can have on
the indjviduals and  the resources of the society,  require that it be one of the
areas addressed in relation to the older segment of the society-

BAZTC DEMOGRAPHIC AND POPULATION DATA

   Extent of drinking
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In considering the data available that indicates  the nature and the extent of the
problem,  it should be noted that the designaticns of   the  older   we   and   the
designations rzlaterl to alcohol  use and abuse arit specific to the individual
study,  and become  relative   terms  when used to discuss several studies that may
not have the same specific criteria.

Cross sectional studies of the use of alcohol  have provided information that,
when compared to  younger age groups,  the rates of abstainers  increase  and  the

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percentage of drinkers decrease in the older age groups.   Cahalan et al.  (19691,
using national household  survey data, reported the percentage abstainers by age
group: age 40-49, 29%; age 50-59, 40%; and age 60+, 47%.  The proporticn of heavy
drinkers for the same age groups were 15%,  10% and 6%, respectively.  For men,
Cahalan reported that more than half of the men o;`er 65 were not regular drinkers
(54% being either abstinent or infrequent drinkers) and the lowest percentage of
heavy drinkers were found in this age group.  In the age group of 60-64, 20% were
classified as heavy drinkers, representing 35% of those that drank. At age 65,
this figure dropped to 7%, cr 11% of those  that drank.   In the same study, for
women,  there was similar decline but evidenced at age 50.   Two  thirds of   women
aged 50 to 64 did not drink at   all or  infrequently .  After age fifty, the
percentage of heavy drinkers among women became inconsequential.

Similar tendencies were  reported by Barnes  (19791   from a  general population
survey in western New York state, by Christcpherson et al.  (1984) from a survey
in rural Arizona,  and by Meyers et al. (1981) from a household survey in Boston.
Barnes noted that while the regional rates  of heavy drinking are significantly
higher than the national rates, the trends holds. Rates cf abstinence increased
from 13% for  those age 50-59,  to 31% for age 60-96.  In addition,  Barnes refined
the age group of  60+ and reported that  24% 3f males  age 60-69 were hEaiTy
drinkers;  for those  age 70-96,  6% were in that category.  Among females,  heavy
drinkers accounted for none of those age 60-69, but ;I% of those age 70-30.

The reasons for   the   decrease  in the proportion of drinkers from the younger to
the older age categories has been considered  by sereral researchers _   Items were
included in several  studies  that inquired about previous drinking patterns or
problems.  Responses frequently  mentioned concerns for health or health problems
that were experienced as a reason to temper  the quantity and/or the frequency of
drinking _  Other responses   rsng,,d from eccnomic reasons,   changing   social
opportunities, and changing   response to  the  substance.  Gnmberg (1982) has
summarized possible explanations for the  decrease in social drinking as economic
(decrease in drinking may result from lower income). physiolcgy (change in
obtained blood alcohol levels with physical aging), effects of alcohol (resulting
impacts and behaviors   are no  longer worth th:: cost:, life cycle differences
(decrease a natural   occurrence 3s   cohorts  ages),  unique historical  aspects
(drinking habits of current  generation influenced by Prohibition,  Depression),
and medical problems (health status, with increased medical problems, cause older
pecple to limit or eliminate drinking! _
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Two additional items  shculd be kept in.  :ilind when considering this data.   The
cohorts of older people that are repcrted in  each of these studies are products
af the social and historical influences of their time:  xhich are then intertwined
with an array of unique individual experiences.  Subsequent generations  of older
pccple will, in   inany  r2spects, b;. very different from the ,:1der people of these
studies.  Specifically, it  should bt remembered   that   cross  sectional  studies
present data that evidence a lower percentage of abstainers   and an  increase in
the level of drinking in the younger age groups.

There is also  evidence in   surveys  that drinking  practices remain consistent
overtime with some people.  Christophorson  (1984) has presented data that there
is a tendency for people to carry drinking patterns into old age as long as
circumstan::Fs and health permit.   Data frsrr, th2 Normative Drinking Study confirms
this (Glynn et   31.  1984) - ?l?ri, originally surveyed in their IO's and 50's, ten
years later reported consistent drinking habits.    It would  aPpear that future


generations Of older people  would present a larger proportion of drinkers and a
potential of more people who continue to drink at higher levels into old age.

Problems w$.JJ drinking

Evidence of problems related to alcohol use among older people comes from several
types of sources with a range of criteria  for the designation of a problem.
Cahalan (1970) utilized the self reporting of eleven typzs of problems, including
quantity/frequency and pattern of   drinking,   elements    of   physical   and
psychological dependency, and  interpersonal,  social,  health, economic and legal
problems. He reported that 12% of men age  60-69 had a current problem score of
7+.  For age 70+, it was 1%.  For women age 60-69, 1% had a current problem score
of 7+; age  70+,   less  than one-half percent.  These figures do represent a
tapering off of drinking problems fcr men after age 50 but continuing until age
70.  Further analysis involved the development of a social-psychological risk
score which included attitude toward drinking, environmental  support for heavy
drinking,  alienation and maladjustment,  impnlsivity and ncn-conformity, looseness
of social controls, and unfavorable expectations.  Data indicates that men 60t of
highest risk sccre show almost the  same problem score as those of younger age
groups.

A second community sur:Iey source of infcrmation on  problems related to drinking
is the Epidemiologic Catchment Area  Study which utilizes the WIMH Diagnostic
Interview Schedule.  This  schedule provides for assessment of alcohol abuse and
dependence based on  the American Psychiatric   Association's   Diagnostic and
Statistical Manual, DSM-III (Ameri'can Psychiatric Association 1980).  Three sites
of the five in the study have presented information related to  alcohol abuse and
dependence. The lowest  rates of alcohol abuse and alcchol dependency were among
those 65+,  ranging from 4% to 8% at sometime  in  their life.   In terms of the
recent occurrence of problems (within the last 6 months!, 3%  of males reported a
problem, 1% of females.   Similar rates  were found for blacks and whites, and
social class did not appear to have a large effect (Robins, 1994).

Warheit and Auth (19841, investigating concurrent alcohol and mental health
problems, found similar rates for alcohol problems within the older population.
In looking at  the correlation between mental health concerns and alcohol use, an
alcohol risk score was developed and the sample divided into high and lcw alcohol
risk groups.   Items  included   were  drinking in   general,
intoxication, problems related to drinking (personal, social   the frequency of
                                        and family), self-
perceptionS regarding the  appropriateness of alcohol use, and the use of alcohol
to face daily problems.  For the older segment of  the sample, age 50t, the high
risk group generally gave more indications of poor mental  and physical health
than the low alcohol  risk  group of   the same  age _  Advancing ag? bras highly
associated the increasing feelings of helplessness   among  the high  risk group.
Self perception of pcor health was more common in the alcohol high risk grcup.
In reporting their present mental health,  39% of the high risk group responded
fair or poor; among the low alcohol risk group, only 22.1% reported fair or poor
mental health.  Almost half (46.3%) of the high risk alcohol group reported at
least one hospital stay in the last   three   years,   14.6% had three or m?re
inpatient stays.  This is contrasted with the low risk group that reported 28.7%
had one or two stays,  4.7% had three or more.  Generally,  Warhei t  and Auth
concluded that alcchol  use rather than age alone seemed to a better predictor of
the kinds of health problems that necessitate hospitalization.

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Studies that report on  the older population  within  institutions and medical
settings provide additional information.   McCusker et al.   (1971) conducted a
prevalence study of newly admitted patients to the medical wards of a Nen York
City hospital serving  a high proportion of blacks and Hispanics.  Questionnaires
were utilized to gather information to  rate  alcohol related problems over the
past year.  The moderate level of the scale, identified as the  threshold for the
diagnosis of alcoholic,  identifed frequent  intcxication up to cne or two times
per week and/or  significant  impairment in  social,  family, or  occupational
functioning, or evidence of physical impairment related to alcohol.   In the age
group 50-69, 63% of the males and 35% of the females met this criteria.

A study of 113 consecutive male  admissions to acute medical wards was made by
Schuckit and Miller (1976) in a Veterans Administration Hospital.   Interviews
established the patient's psychiatric diagnosis, organicity tests  determined the
presence of organic impairments, chart reviews provided basic demographic
information, past and present physical and mental status, medication and drug and
alcohol history.  A resource person validated the patient information.  Of these
admissions, 18% (20) were diagnosed as alcoholic,  with 55% (11) of these
considered inactive, or having had no alcohol related problem in  the 6 months
prior to hospitalization, although 3 of the I1 still drank.

Data from psychiatric  services  provides other evidence: of 534 first admissions
of patients age 60+, 28% had serious drinking problems (Simon et al. 1968); in an
outpatient psychiatric program in Harlem  Hospital,  12% of the elderly were noted
as having a drinking problem (Zimberg 1369); in a county psychiatric screening
ward, among 100  consecutive admissions of persons 60+, 44% were alcoholic (Gaitz
and Baer 1971); and in a medical home care  program,  13% of the elderly patients
requiring psychiatric consultation were diagnosed as alcoholic (Zimberg 19711.

Although it is not possible to determine the actual prevalence,   the fact remains
that a sizable proportion of the  elderly do evident? alcoholism and problem
drinking.  While recognizing that older people do drink less, an estimate of the
prevalence of alcoholism among  those whc do drink approximates   that cf  ether
adults, nearly 8% (Nate 1984).  Estimated rates in clinical practice with older
people ranges from 10 to 20% with a higher proportion  among the elderly who are
hospitalized and institutionalized (Schuckit and pastor 1379, Zimberg 1982).

Ufferent types of presentation
                 -

As early as 1968, there were attempts to dr:ielop a classification system of older
alcoholics.   It was  recognized that there are sub-groups who  presented  similar
histories and symptoms.   Simon et al.  (1968) reported that among a uroup of first
admission psychiatric patients  with serious drinking problems, age 60 and older,
about l/3 had become alcoholic after age 60,  while about 2/3 had been a?coholic
before age 60  and had a long history of alcohol abuse. He   also  noted  that a
little over l/3 had chronic brain syndrome, but this diagnosis was not excl?;sive
to either group.  The proportion of :I! late life and 2/3 long standing was
confirmed by Rosin    and   Glat t   (1971) from studies of   psychiatric   home
consultations and admissions   :0  alcoholism  units and hospital geriatric units.
Schuckit and Miller (1976) also made a distinction betrreen early-onset and late
on-set, using age 40 as the demarcation. Among the Ferscns ages 65t being
admitted to a medical ward, using this designation, the groups was almcst equally

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divided-

Carruth et al.  (1973) noted three distinct types: individuals with no history of
problem drinking until one developed in response to age related stress, a second
group that had at  times  experienced problems but only developed severe and
persistent problematic drinking in old age,   and  a third group who had a long
history of alcoholism and continued to drink into old age. Gomberg (1982) also
recognized three groups, the survivors: alcoholic persons who  have grown older;
those with intermittent histories of heavy drinking in response to severe stress;
and the reactive problem drinkers who are responding to the stresses and losses
of aging by drinking heavily.

The generally accepted division is that of  early-onset and late-onset without a
specific age of onset.  The distribution of 2/3 early-onset vs.   l/3 late onset
is generally confirmed by personnel in the field. Different terms are at times
used.  Geriatric alcoholics (early-onset)   are  the stereotypic chronic alcohol
abusers who have continued to drink while aging, and geriatric  problem drinkers
(late-onset) include those who had no history of a problem and those who
occasionally experienced problems,   all of  whom develop  abusive patterns in
response to the stresses of aging (Dupree and Zimberg, 1984).

Recognizing this general classification facilitates the process of identification
and treatment.  General characteristics of the early-onset individual  include a
medical history that  indicates  extended severe drinking, mental pathologies and
personality characteristics related to chronic alcohol use, a social history that
indicates the impact of alcohol, such as a  poor  work history,  a disrupted or
stressed social and family history, poor relationship skills,  and fewer economic

resources.  Late-onset characteristics generally include alcohol related medical
problems that may be acute but of.shorter duration,  better problem solving and
relationship skills, and more stable job, family and social histories.   Problems
in these areas    are   usually of   recent  origin  and of  shorter duration.
Psychological problems are generally more  focused upon issues related to age,
such as loneliness, depression, grief, boredom and pain.

The hidden older Foblem drinker

Observations have been  made by several researchers that older  problem drinkers
are a hidden population.   The high percentage of  alcoholics among the older
populations in acute medical and psychiatric  institutions is probably   more
reflective of the debilitating and/or long term impact of  alcohol on an  older
person than it is  of the sensitivity of the intervention mechanisms that exist.
Perceptions of service   providers   indicate    that   the   older   person is
underrepresented in the alcohol treatment network.  Many reasons are given for
the inadequate level of  identification.  There is a more subtle presentation of
symptoms of problem drinking and alcoholism in older people.  Presenting symptoms
are inaccurately identified as -being related  solely  to medical or psychological
problems associated with the aging process. Care providers,  including  medical
personnel,  are reluctant to become  involved in the identific3tion/intervention
process.  The elderly themselves may have a  lack of awareness about the effects
of alcohol and are reluctant to self discbose.  Denial and  enabling   may  exist
within family units.    Due  to the life stage,   there  is a lack of social and
occupational identifiers-  Finally, significant  others  and  care providers may
have the inaccurate perception that  the drinking is a  rational  choice of

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behavior,  and further,  may believe that it is  logical given the age of the
person.

ALCOHOL, ALCOHOL USE AND HEALTH

The impact of alcohol and alcohol use on  the health and  well being of any one
older person has many dimensions.  Of primary importance is the quantity and the
frequency of the drinking experiences.  How much alcohol is taken into the system
and how frequently these occasions  occur generally provide information that
allows for the description of light,   moderate  or heavy drinker.   A second
consideration is the pattern and the duration of the drinking  history.   Movement
along the continuum of  type  of drinker  at different periods in the life span
provides a variable  to the current impact.   Cultural  and  social   norms  that
influence the designation of appropriate drinking occasions,  such as with meals,
or at drinking  oriented  events,  may ameliorate or exacerbate the effect of the
alcohol on any one occasion, and cumulatively,  the effect of the use of alcohol
on the entire  system.   General physical condition, and all the elements  that
support that condition,   such  as genetic factors, nutrition, the balance of rest
and physical activity, are important. The presence  of chronic and acute medical
conditions plays a  role,  as does  the existence of  drug  regimens,   whether
monitored by a physician or  self-prescribed.   Generally, the more intense and
prolonged the use of alcoholic beverages,  the greater  the impact the substance
ethanol will have upon the health of the individual.

The general process of aging brings its own contribution to health implications
for alcohol use.  Response to the aging process is highly individual, in terms of
persons and all of   the  components of  each person.   But there  are general
principles that apply.  Advancing age witnesses  a gradual lowering of the level
of the homeostatic   state.  This is accompanied by a lessening of  the physical
reserve of the  entire system and each of its parts.  All body systems and organs
tend to decrease in efficiency of operation   and  to loose  resiliency.   Stress,
whether physical, emotional or  environmental,  has a greater impact upon the
system and each of its parts.  Returning to the pre-stress state or finding a new
level of balance is more gradual,  taking  a longer period of time than when
younger.  Vulnerability to disease states increases with age and is compounded by
stress _  Disease states also increase the vulnerability of  older people to the
impact of alcohol.

It is `particularly important to remember that, as an individual   ages,   there are
greater mutual effects  that  operate between the physical, social and emotional
health of an individual. The older age stage of life brings unique developmental
tasks,  stresses and  age  related life crises.  In responding  to these  tasks,
stresses and crises,  the totality of the person is affected.

Of specific importance  to. the use of alcohol and other chemical substances are
general physiological changes.  with age  there is  a decrease in the lean body
mass and an  increase in fat storing tissue.  Alcohol, being water soluble, is
distributed through less lean  tissue, resulting in higher concentrations within
organs _  Generally, when compared to younger  people of equal weight and drinking
the same amount, older people may be espected to evidence a higher  blood alcohol
level _  Time and rate are also affected.  Age has a tendency to slow both the
process of metabolism and of elimination.   The blood alcohol level may be held
for a longer period of  time. In  addition, the elimination process may be

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particularly affected by the presence of medications.   The liver, being the
principal organ involved, may be operating at  a less efficient level and may be
required to process  multiple substances at the same time.   All of these have
impact upon the  tolerance level, which is generally characterized as decreasing
with age (Schuckit 1980, 1982, and Bosmann 1984).

There are medical and health and safety areas  that need particular emphasis in
the concern of health and alcohol use as related to older  people.   It must be
emphasized that, although  there is a wealth of  material that addresses the
relationships that exist  between specific areas   and  alcohol,  the particular
emphasis upon the older person frequently has been inferred from other studies or
has been inconclusively explored to date.   It should also   be noted that
biomedical research has  not thoroughly explored health problems in the older age
group, or among segments witbin that group.

The cardiovascular system

The implications of  alcohol use for cardiovascular disease are particularly
important in relation  to older people  as hypertension and heart conditions
account for two of   the   four   most    common   chronic  conditions of   non-
institutionalized elderly.  Although the   exact  relationship between alcohol
consumption and the development of cardiovascular diseases has   not   been
determined, there are areas  that are important to consider.  Generally, alcohol
can have a direct effect on the heart  muscle leading to an increase in the
cardiac rate and output.  In older people this may produce stress on the organ
itself and on the rest of the cardiovascular system because of a reduced level of
physiological reserve.  In individuals with impaired cardiac  functioning,   this
may have the   ultimate   effect of  decreased cardiac output and diminished
efficiency of the system.  Alcohol can directly affect the heart as a cardiac
toxin and the  cardiovascular  system by increasing blood pressure.   Excessive
amounts of alcohol   have   been   strongly   linked   with the development of
hypertension, stroke, myocardial degeneration,  arrhythmia,   and cardiac failure.
Alcohol can also mask the symptoms of a disease state, such as  angina pectoris.
Individuals frequently do  not   feel the  associated pain in  the chest while
drinking but the medical indications are that  the affected tissue continues to
suffer from the lack of blood flow.  Continued or increased activity may increase
the stress level although no pain is felt.  (Gambert et al. 1984, Hermos et al.
1984, Kannel 1986, Schuckit 1982.)

J

There is, however,   evidence of  lower rates of  congestive heart disease in
association with moderate alcohol intake.    Regular use of  alcohol appears to
have the effect of  increasing high density lipoprotein cholesterol which may
retard the development  of coronary artery disease (Barboriak et al. 1983, Kannel
1986).  Non-drinkers had higher mortality  rates than those who drank lightly (in
reference to the  Normative Aging Study)   and  non-drinkers had higher blood
pressures than those who  drank in small amounts (in reference to the Framingham
Study) (Gordon 1984.)

The central nervous system

The relationship of the health of the central   nervous  system in the maintenance
of autonomy and independence makes it a particularly sensitive  area to consider

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in relation to  alcohol use and aging.  There are changes that do take place with
age that result  in variations in functioning  compared to   the  time  when  the
individual was younger.   But for healthy  older people these  changes do not
necessarily have to  exert a  deleterious effect on the ability tc manage their
life or to cope with their environment.   Age frequently brings an increase in
reaction time and  in the time needed to retrieve something  from memory.   With
age, there is also an  increased tendency to exhibit  confusion  when  under
physical,  emotional or social stress.   Cognitive  processes  may be slowed but
seldom become impossible tasks for healthy older people.  Educational gerontology
has contributed much to the affirmation of the ability of older people to perform
learning tasks provided that the information is well organized,  presented in a
way that compensates for sensory changes,   that the stress of  the learning
situation is reduced,  and the risks associated  with performing  incorrectly are
minimized-

Ethanol affects the central nervous system.  It may have the short-term effect of
acting as a stimulant.  However,  the long-term effects are as a depressant.  This
may result in   respiratory   depression,   sedative-hypnotic   effect,   ataxia,
pronounced disinhibition, impaired motor skills, neuropathy, and unconsciousness.
Age related metabolic  changes  are generally accompanied by an apparent increase
in the sensitivity of the brain to all central   nervous  system depressing drugs,
including alcohol.  Very small amounts of alcohol can produce symptoms that are
commonly identified as  age-related  mental decrements, or may exacerbate age
related phenomenon.  The mis-reading of  the presentation  of an older person is
frequently responsible for non-identification of alcohol problems  (Bosmann 1984,
Schuckit 1982).

Much research has been conducted on the effect of alcohol upon the central
nervous system.  A prominent  theme' in   that   research is  the question of
accelerated or premature aging as an effect of alcohol use.   Functional  changes
that are related to aging and functional changes that are the result of alcohol
use are frequently very similar in their  presentation.   The processes of aging
and of alcohol  intoxication have much in common in the way that they affect
memory, learning, recognition   and   organizational   processes.    In a  "worst
scenario" of the aging process or from long  and  intense use of alcohol, similar
organic changes may take place in the brain and disease states   occur.    Current
research outcomes do not seem to support the theory of premature aging.  Although
chronic alcoholic drinking   appears   to increase the behavior defects  that
accomp'any aging, as yet, a common pathology,has not been identified.  Alcohol use
is responsible for some brain dysfunction, but the effects seem to be independent
of and parallel to the effects of normal  aging.   Studies do suggest that people
who use alcohol to excess appear to run an additional risk of  neuropsychological
impairment beyond what  might be expected from the aging process.  Further, since
some of the deficits related to alcohol   use   are  at least partially reversible,
continued research may illicit some value in terms of therapies   for  age related
problems.  (Blusewicz 1982, Bosman 1984, Lowe 1985, Parsons and Leber 1982,
Russell 1984.)

Medications and over-the-counter drugs

The use of  alcohol combined with a regimen of  overTthe-counter or  prescribed
medications is a common but potentially lethal occurrence.    As one grows older,
the number of drugs one takes usually increase.  A figure commonly cited is that

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older people who  are 12% of the population are using approximately 25% of the
prescribed medications.  Further, it has been estimated  that over-the-counter
preparati0nS account for  approximately 90% of all drugs taken by the elderly
(Baker 1985).

The problem of  drug use and  misuse has many dimensions and is compounded when
drugs are used  with alcohol. Alcohol interacts adversely with many drugs, a
situation that is  particularly significant with other central nervous system
depressants.  Polypharmacy is not  uncommon among older people.  Frequently, the
medical regimens are being prescribed  by more than one physician,   and older
people often have difficulty  in correctly self-administering  the medications.
The potential for drug interactions and  adverse drug reactions is great under
such circumstances, particularly in view of  the changing physiology with age.
~11 of these  situations are intensified with the use of alcohol.   Adverse drug
and alcohol interactions  can be potentially life  threatening to older people
because of the decrease in reserve in vital organs.  Many older people have poor
or incorrect conceptualizations  of how their bodies handle substances  and need
education in order to practice healthful habits.  Further, many professionals and
para-professionals who work with  older people are unaware of the seriousness or
the extent of the problem.  (Atkinson 1984, Glantz 1983, Schuckit 1980.)

Nutrition

Healthful nutritional practices among older  people have been a concern of many
who work and have contact with the elderly.  Nutritional practices are affected
by the totality of   the   life   circumstances of   older people.   Social,
psychological, economic and physical factors are important to consider,  Changing
circumstances within the family unit, such as  the loss of a spouse, may affect
the pattern of food preparation and may precipitate all but minimal  attention to
the activity-  Depression, social isolation and physical incapacity can- intensify
and make insurmountable  the problems related to the maintenance of a good diet.
Life-long dietary practices, which may not  have  seemed problematic at a youn$er
age, now become detrimental and debilitating. Physical changes that are age
related, coupled with the use of medications, may require modification of these
practices.  The ability  to make such  changes  may be limited by a lack of
information,  minimal economic   resources or  lack of access to   appropriate
facilities for shopping,  storage or preparation of food.

Malnutrition has been long recognized  as being caused by chronic alcohol use.
The impact of the use of alcohol on nutrition  is seen as a result of a change in
ability to function as well as affecting the appetite, absorption, metabolism and
excretion of nutrients.   When compounded with physiological  aging,  with the
reduction of functional  reserves ,' the effect may be particularly detrimental. It
is widely recognized that the elderly user is  much   more  susceptible to the
nutritional consequences of alcoholism. It is not as widely recognized that there
may be nutritional consequences for the more social user, particularly if  there
are acute or chronic diseases present and medical drugs are being taken.

There are many specific nutrition-alcohol interrelationships that should be kept
in mind both in the maintenance of healthful practices  and in the treatment of
alcoholism in elderly people.  One will illustrate the weight of  the area of
consideration.   The cwurse of normal  aging brings a reduction in bone mass as
well as reduction of the capacity of the gastrointesinal tract to absorb calcium.

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The presence of metabolic acidosis, a common  result of consuming alcoholic
beverages, may further aggravate a negative  calcium balance.  The development of
osteoporosis, a frequently  identified condition  in older people,  particularly
women, may be  aggravated by alcohol use.   Adequate  calcium levels are also
required to maintain the transmission of   nerve  impulses  at appropriate levels.
These processes are  also  negatively  affected by age and by the presence of
ethanol, and may be subjected to a compounded effect.  (Gambert 1984, Mishara and
Kastenbaum 1980, Russell 1985.)

Carcinoma

The question of  the carcinogenic effects of alcohol use have been of concern for
several years.  It does appear that there is a tendency for the chronic alcoholic
to develop squamous cell carcinoma in the region of the pharynx.  Carcinoma of
the esophagus is frequently  detected in those who are diagnosed as alcoholic,
representing over half of all cases of esophageal cancer.  There is some evidence
that alcohol abuse  may also be associated in the development of carcinoma in the
mouth.

However, there are methodological problems in  the research in  this area. It
becomes extremely difficult  to distinguish between the effects of  alcohol  and
other factors that    are   frequently present,   such as  smoking,  exposure to
pollutants and malnutrition.  It has been estimated that  approximately 90% of
alcoholics are also smokers, and the role of smoking to the  development of some
kinds of carcinoma has been well documented.  Research has also indicated that
there may be carcinogenic implications  related  to the way  cells  respond to
ethanol.   It does  not appear, however, that alcohol has an equal role in the
development of all types of   cancer,   and  where  there does appear to be a
relationship,  additional research is still desired.  (Bosmann 1984, Bambert 1984,
Mishara and Kastenbaum 1980.)

Safety

Problems related to safety and alcohol use are many,  from pedestrian accidents to
the interference of an alcohol-induced state in performing simple  chores  in the
kitchen.  Stress for older people who are  injured  in accidents has the same
ripple effect on their health and mental outlook as disease states.  Older people
seem paPticularly susceptible  to falls.   Hingson  and Howland (1987) report
figures from the Center for Disease Control, indicating that each year 200,000
older Americans experience hip fractures associated with falls.  Older people are
also disproportionately represented  in deaths from falls,  over one-half of fatal
falls involve persons over 75 years of age.   There  is a strong link between the
use of alcohol  and falls.  In fact, one of the items frequently  included in a
list of clues of a drinking problem is the experience of falling.  Although there
is substantial evidence   that   alcohol  increases the risk of falls, studies have
not yet provided information that is specific  to the elderly.  However, from a
perspective of maintaining safe practices, the potential effect of  the use of
alcohol on the incidence of falls among older people should not be neglected
(Hingson and Howland 1987).

In discussing burns of  older persons,   Anous and  Heimback (1986) noted that
frequently burns tend to be deeper because of delayed reaction times, impaired

A - 10


senses and the  fact that many older burn patients live alone. The reduced
capacity of the older physical system has  special  import  in dealing with the
stress related to the burn experience as well as affecting the  process  and time
of healing.  It was also noted that older cases with documented alcohol problems
tended to be loners and to have a higher  percent  TBSA (Total Body Surface Area)
burn.  (Anous and Heimbach 1986.)

Benefits from alcohol use

The beneficial use of alcohol with older persons has been a recurring theme in
the literature that  relates to aging and alcohol.  Stories of the prescribing of
spiritus frumenti have been documented in  many  case histories and in studies of
practices within care  facilities for older people. Common conditions that are
addressed in this   manner  are loss of appetite,  as an aid to digestion, as a
nutritional supplement, as a relaxant,  sedative and a sleeping aid.  Most studies
of the use of alcohol generally conclude that there is a therapeutic value to the
serving of alcoholic beverages in institutional  settings.  Some note that, under
such conditions, the medication levels may be reduced.  In many of  the studies,
there was an  effort  to provide a  varied or special setting for the events of
drinking, as well as there being additional  staff  and  others present who were
involved in exchanges with the .residents of the facility.  These factors make it
difficult to identify the exact   source of  the benefits observed (Mishara and
Kastenbaum, 1980).  In reporting on their own  research,  Mishara et al. (1975)
stated that the amount of alcohol that was consumed was small  and that there was
an effect of  the social setting that supported drinking.  There was evidence of
psychological benefits in terms of morale,  improved sleep and a general sense of
improved well-being.   It was  particularly noted that the participation in the
study was voluntary  and   that  a physician's approval had been obtained for each
participant.

Other studies have been conducted with non-institutionalized older people. In
his study, Kastenbaum reported on the effects of  the use of one or two 3 ounce
servings of wine on self-sufficient older people living in the community.   It was
noted that the changes, both those that were subjective and self-reported,   and
those that were determined by psychological assessment procedures, were generally
in the positive direction.   On the subjective items,  participants reported
improved subjective status in  terms of morale,  improved  sleeping patterns,
reduced chronic fatigue, anxiety and depression.  In objective tests, there was a
tendency for those  with  relatively better functioning to show improvement in
behaviors dnd performances  that have  strong cognitive components. (Mishara and
Kastenbaum 1980.1

Health issues in treatment
       ___-  _____

For the older person,  entry into the treatment  syst,em is  frequently through a
health care agency, usually the acute care hospital.  Compared to younger people
the older person  often presents in a more debilitated condition.   Because of the
number of pathological conditions that  may develop as a ;esulP of long term
alcohol use, it  is not infrequent that the older persons enter  the  system for
treatment of other diagnosed conditions,   and   then  in  the process of medical
treatment,  are encouraged  to confront  the reality of the  relationship  that
alcohol use has to the current condition and to the prognosis for recovery.

A - 11


While recognizing that all systems of the body are affected by the use of alcohol
and have the   potential of reacting adversely,  there are certain medical
conditions that are  indicative  of long   term use.   Cirrhosis of  the liver,
gastritis,  chronic or   acute  pancreatitis,  with  accompanying  abdominal pain,
weight loss and   diabetes are significant risks of long term use.   Other
conditions frequently associated   are   atrophy  and  weakness of  the muscles,
polyneuropathy, the inability of the body to fend off infections or to support
healing, malnutrition and dehydration.  Pneumonia and pulmonary tuberculosis also
occur more frequently among  alcoholics.   In advanced cases, sever neurological
damage may be seen as Korsakoff's psychosis  and Wernicke's disease (Mishara and
Kastenbaum, 1980).  Generally,  the late-onset individual presents  with fewer and
less severe medical complications,  although Schuckit and Miller (1386) do point
out that this type drinking is during the  medically  vulnerable years  and may
cause disproportionate medical problems.

Because of the greater likelihood  of the older person entering  treatment for
related health conditions before entering alcoholism rehabilitation programs, the
role of the health care professional in identification and intervention must be
recognized.  Most older people trust medical personnel  and hold them in high
regard.  Being able to accurately access  the situation,   to interpret  the
presenting symptoms correctly and   to use  the medical  record  to facilitate
breaking through the denial make the health professional a vital  link in the
network of treatment.   The value that many older people place on their health
often facilitates and provides motivation for engaging in the process.   (Mishara
and Kastenbaum 1980, Schuckit 1982, Sherouse 1983.)

There are many medical and health issues that need to be considered in the course
of treatment,  There is no agreement on the  use of medications in the process of
treatment, with particular concern focusing on minor tranquilizers  and sedatives
(Gomberg, 1982).  Monitoring the physical conditions and the medication regimen
is an ongoing process.   In the course of treatment, with medical care, good
nutrition including vitamin therapy, and appropriate rest, there is frequently an
improvement in the physical well-being of  the older person, and specific medical
conditions may abate in their severity-  However,  a parallel  situation  may also
develop.  Conditions whose presence and pain are masked by the anesthetic quality
of the alcohol become evident.   After the alcohol is out cf the system, dental
problems,  urinary tract infections, venereal  disease and other conditions may be
identified in the course of rehabilitation.

Because of `poor physical condition and lack of reserve, older people may require
more direct nursing   care  and help  with meals, bathing and personal care.   The
daily schedule of the treatment program may tax their strength and endurance, and
the requirements may have  to be modified to allow for more rest.  Attendence to
medical needs, perhaps even readmittance to an acute care facility, may interrupt
the treatment schedule and necessitat? decisions.or adjustments in administrative
policies.  The need for a wheel chair,  crutches,  or assistance in  movement
affects the participation of  the client and requires additional concern on the
part of the staff.  Attention to hearing aids,  teeth,  eye glasses, and similar
devices,  facilitates the recovery process in terms of participation,  self-image,
and the development of good health habits (Williams 1985).

Other relevant treatment issues
                        -__-

A - 12


The issue Of  the responsibility  of providing treatment services for the older
alcoholic generally focuses on the questions of  which service  system,   age or
alcohol treatment, should carry primary responsibility, and whether  there should
be specialized programs within existing systems.   Little has been done to
evaluate the effectiveness of different systems or different treatment modalities
with older People.  Treating within the alcohol service system has been the
general approach, with the recommendation that there be some  adaptations  and a
specialized outreach program  to reach the older person (Janik and Dunham 1983)-
Emphasis upon social supports and peer groups appears to increase positive
outcomes (Kofoed et al. 1987, Zimberg 1982).

Payment for treatment requires  that there be an appropriate mesh between  the
treatment needs of  the individual,   the  types  of alcoholism services that are
available and acceptable to that person,  and the regulations  that govern the
resources that may be tapped, whether Medicare, Medicaid, private third party,
veterans benefits or  others.   Uorking with an older person in need of treatment
often requires unusual  orchestration  abilities on  the part  of the service
provider in order  that   access  to all phases of treatment becomes  financially
available.

Prevention

opportunities for prevention  programs do exist.   Two excellent possibilities
exist through the development of self-help groups for older people and the
preretirement and retirement planning groups that are often a part of personnel
services in industry   and  business,   labor   and   professional   groups  and
organizations (Gomberg, 1982).  Such programs would be of primary benefit to
individuals who.may at be at risk for the  development of  late-onset problems.
Self-help groups could be developed in the community under the sponsorship of
senior centers, community  mental health programs,  voluntary  organization and
others.  These groups  would have the  advantage of  being holistic in their
approach, providing life-coping  skills  and support  systems.    BY  including
substance use within their  concerns, but avoiding the label, these groups would
be more appealing to older people who frequently feel  stigmatized by the words
problem drinker or alcoholic.

Secondary prevention services  could be provided by the development of  programs
that would-sensitize and .provide  skills .to service providers of older people,
whether in medical or social services.   Intervention at  the earliest possible
stage precludes the further exacerbation of medical, psychological and social
problems, optimizing the possibilities of successful treatment within the context
of continuing support  systems.   Tertiary prevention is an integral part of
treatment,  targeted to  the successful completion of treatment and the prevention
of future problems.  This approach must  also  include the development of life
skills to help the older alcoholic successfully adjust to the realities of
his/her life stage.

There are many programs that have been developed to address prevention issues on
all levels. Only a few examples will be sited.  The Senior Alcohol Services of
Vancouver, Washington, provides community training and information as well as
treatment that includes  aftercare, couples' counseling and family groups-   The
Kassachusetts Housing Finance  Agency through its Tenant Assistant Program (TAP)

A - 13


provides education, information   and   referral   services in  a program that
concentrates'on outreach to improve the quality of life of the tenants.  Elements
of the program address all three levels of  prevention.   The Michigan Office of
Substance Abuse Services  and  the Michigan Office of Services  to the Aging
sponsored the development of  a three volume guide, Older Adult Substance Abuse,
designed to foster  a team approach to prevention.   The three volumes are A
Resource Manual, Prevention Program Development,   and Medications  Information.
(Resch and Christensen, 1983.)   The Wisconsin Department of Health and Social
Services issued a planning guide, Examination of  Problems and Solutions Related
to the Chronic  "Revolvinq Door" Alcohol Abuser _  The final  report  contains 26
--
recommendations to break  the cycle  and to provide for meaningful alternatives.
(Wisconsin Department of Health and Social  Services 1981) The AAA Foundation for
Traffic Safety of Falls Church,  VA, has developed a film with guide,   Senior
                                                                           ____
Adults, Traffic Safety and Alcohol, which provides information for older people
about the substance and the effects of alcohol and problems that it may generate.

A SAMPLE OF NATIONAL EFFORTS

There have been efforts by several agencies  and groups to address the concern of
aging and alcohol use on a national level.  The four that are mentioned are by no
means the only efforts, but do illustrate the variety of the efforts that have
been made, representing a public policy effort, research, and a treatment related
project _

Blue Ribbon Study Commission on Alcoholism and Aging
--                    -

The Blue Ribbon Study Commission on Alcoholism and Aging,  sponsored by the
National Council on Alcoholism, was convened in the fall of  1979 with the
Honorable Wilbur D. Mills as chairperson.  The Commission was composed of a broad
range of representatives from government, academia, voluntary  organizations  and
the health and social service sectors. The stated goals of the Commission were:
1. to gather and evaluate present knowledge concerning alcoholism and aging:
2. to identify and analyze the information needed  for thorough understanding of
the problem through defining specific issues; 3. to identify and evaluate the
options open as to what can be done to resolve these issues successfully; and
4. to disseminate  the information gathered to the American public and to groups
and individuals directly involved in the policy and implementation process. (News
release! of the National Council on Alcoholism, February 22, 1980.)

The outcomes of the Commission are three.   1. The Commission sponsored a two day
tract, The Aging and Alcohol Abuse,  at the 1980 National Alcoholism  Forum of the
National Council on Alcoholism.  2. It organized and sponsored a Mini-Conference
on Aging and Alcoholism, held at Wingspread,  Racine, WI, in conjunction with the
1981 White House   Conference on Aging. 3.  It prepared a   report,   with
recommendations, to be included in  the proceedings of  the 1981 White House
Conference on Aging. Six categories of recommendations  were included: research
and development,  education and training,  increasing the utilization  of services,
ensuring and improving   the   effectiveness of   treatment,   increasing   the
availability and access of services and protection of patients' rights.

A - 14


Research center on aging and alcohol established

In December 1982,  the National Institute on Alcohol Abuse and Alcoholism funded
the Alcohol Research Center  at the University on Gainesville,  one of  nine
national research centers.   This center is specifically designated to conduct
research into the   causes  and the consequences of alcohol use and abuse by the
elderly -  As a interdisciplinary center,   the research  agenda includes a multi-
faceted approach to the subject.  An extensive educational program for a broad
spectrum of health professionals is a major component of the activities.

kesearch conference

In November, 1983,  a national research conference was convened on The Nature and
Extent of Alcohol Problems Among the Elderly. The conference was sponsored by the
National Institute on Alcohol Abuse and Alcoholism in collaboration with the
National Institute of Mental Health and the National Institute on Aging.   The
conference produced a  monograph by the same title,  edited by George Maddox,
Ph.D., Lee N.,Robins, Ph.D., and Nathan Rosenberg, Ph.D.. In the preface it is
stated that "the workshop at Washington University was intended as  a beginning
point in a systematic NIAAA effort to stimulate research interest and activity in
the alcohol-aging area." (p. v-1  The keynote address of the conference by Robert
Straus (pp.7-28) focused on factors of change as related to both aging and
alcohol, the need to develop a biomedical perspective in relation to the topic,
and stated that   both   alcohol studies  and gerontology    were   entering a
biobehavioral era of   scientific  thought  and  activity.   The conference was
organized to present key issues and current  evidence of mental health and social
correlates of alcohol use, presented from research of the Alcohol Research Center
of the University of Gainesville, FL, longitudinal data of alcohol problems among
the aged from studies in St. Louis and from the Normative Aging Project of  the
Veterans Administration, and research data from  the Epidemiological Catchment
Area Studies.  Future research needs were addressed by most participant in the
course of their papers, emphasizing the need for more current  and more extensive
research that is specific to the older population.

& demonstration project related to treatment

The Health Care Financing  Administration Alcoholism Project was a three year
demonstration project targeted to   evaluate    the   cost   effectiveness of
reimbursement under Medicare of treatment in non-hospital settings.   Of the six
states involved in the project, most also included the provision of reimbursement
under the state funded medical  assistance program or Medicaid.  Because of the
source of the reimbursement funds, in most  agencies, there was the added benefit
of stimulating the  entry of  the elderly  into  treatment.    In addition to
collecting data related  to the reimbursement effect, agencies who participated
increased and expanded their experiences  with the elderly,  and developed and
adapted treatment modalities `to meet the need of this population.   A report on
this additional benefit of  the project  was prepared by the Rutgers University
Center of Alcohol Studies, New Brunswick, New Jersey.  The evaluation of the data
related to the reimbursement study has not yet been completed.

A - 15


The identification of  "what needs  to be done"  frequently has the quality of
confused time sequence.   Research of   the problem area should precede the
development of policy  which would in turn give impetus to program  development.
But it is  impossible to begin again.  The reality is that movement on all fronts
is needed and must proceed as best possible.

The relationship of research in the field of aging and alcohol to the development
of public policy has been addressed by Stall (1987).  Stall proposes a particular
value of long-term perspective research as  an integrative and interpretive tool
for reassessing the data from both retrospective and cross sectional studies.
Such research would make it  possible  to test and evaluate the hypotheses that
have been advanced to explain the data,   and  would provide direction for the
development of public policy.   Ruben (1986) points out   that   elements of
incongruence are present  between public policy  and what we do know about the
nature and the scope of the problem,  Future development of policy would benefit
from consideration of these observations.

In relation to health and aging,  there are many avenues of  research that have
been opened but not fully addressed.  Enumeration of specific areas is repetitive
and more adequately done by those whose expertise is within the specific areas of
study.  However, in  reviewing studies,  it becomes very evident that much of what
we understand is based on studies that   are  not   we  and/or  alcohol  specific.
Whereas, there is justification for applying the results of such research to the
aged or to  alcohol problems, additional studies that are focused on the problem
area would provide a firmer foundation  for the development of policy and the
implementation of programs of prevention and treatment.

Programs, and ultimately people, who are coping with the problems of  aging  and
alcohol abuse, are   impacted by policies  in the fields of aging,   alcohol
treatment, health, social services,  housing,  transportation,   and  innumerable
other areas of governmental responsibility.  How these policies intermesh is a
prime concern for the issue of aging and alcohol.  The perspective from the field
frequently is that policies interact in ways that  are more prohibitive than
facilitating.  In considering what policies should be enacted,   this concern
should be addressed.  For example,  these questions might be discussed:

Whaf weight should be given to current epidemiological projections in the
consideration of   policies  related to  the development of  programs of
prevention and treatment?

What effect do current health care policies,   such  as the DRG's, have upon
the provision  of the level and the extent of medical   care  needed by the
older person  who  may have multiple and extensive needs related to alcohol
abuse?

What policies  would facilitate the   development of  primary prevention
programs in the arenas that are most utilized by those at high risk? What
incentives might be  offered to encourage the private sector to be involved
in the provision of prevention programs related to late-onset alcoholism?

In what areas should policies be developed to address  the high cost of
providing institutional care for those severely disabled by alcohol?    Are

A - 16


other options possible tnat would allow for a more optimal quality of life?

What policy provisions are possible that would encourage and support
linkages between alcoholism treatment and age services to actualize the
concept of continuity of care?

Based on evaluative research of treatment modalities, what policy decisions
should be  considered to support specialized components to provide treatment
for older persons?

Are federally sponsored programs for volunteer  service appropriate avenues
for involving  older people in  the process of addressing  the need for
education and prevention in relation to alcohol use and health?

The range of exploration is limitless.  And the time is now.

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