Examining the Impact of Separate Components of a Multicomponent Intervention Designed to Reduce At‐Risk Drinking Among Older Adults: The Project SHARE Study

Approximately 30–40% of American adults aged 65 years and over drink alcohol regularly (Blazer & Wu 2011; Kirchner et al. 2007). While heavy drinking is less common with advancing age, light or moderate drinking has different risks and benefits for older adults compared to younger populations (Cooper et al. 2009; Chan et al. 2009; Reid et al. 2002). Several observational studies have found that older adults who drink moderately have better cognitive function, a reduction in cardiovascular disease, and decreased mortality compared to non-drinkers (Townsend et al. 2009; Reid et al. 2006;Lang et al. 2007a; Lang et al. 2007b; Karlamangle et al. 2009; Byles et al. 2006 ). Conversely, age-related physiologic changes in older adults elevate blood alcohol levels per amount of alcohol consumed and increase brain sensitivity to the effects of alcohol thereby increasing the potential risk of injury (Vestal et al. 1977; Gilbertson et al. 2009). Compared to younger persons, older adults also have more comorbid conditions and use more medications, including those that may increase risks with alcohol (e.g., nonsteroidal anti-inflammatories and warfarin) (Moore et al. 2007). Current practice guidelines recommend that adults be asked about their alcohol consumption as part of routine examinations as well as prior to prescribing medications that interact with alcohol (Department of Health & Human Services National Institute of Health National Institute on Alcohol Abuse and Alcoholism 2007).. However, physicians infrequently screen their existing patients for alcohol use and misuse, because they have limited time or because they simply may not remember to do so (McCormick et al. 2006; Friedmann et al. 2000; Aira et al. 2003; Johansson et al. 2005). As a result, there has been significant interest in developing effective interventions to reduce at-risk drinking in this population, and several intervention protocols have been implemented with varying degrees of success (Fink et al. 2005; Moore et al. 2011; Lin et al. 2010; Saitz et al. 2003; Whitlock et al. 2004; Jonas et al. 2012). While the evidence suggests that multi-component interventions for at-risk adult drinkers are more successful than single brief interventions in reducing risky alcohol use (Whitlock et al. 2004; Jonas et al. 2012), there is significant heterogeneity in how these interventions have been designed. These interventions typically involve between 2 and 4 contacts with the patient over a period of several months, and often combine several different components such as personalized counseling, drinking diaries to quantify alcohol consumption, and goal-setting to reduce drinking to less harmful levels. However, some of these interventions are delivered entirely by primary care physicians while others include non-physicians, typically nurses or health educators. Some are limited to face-to-face patient contacts while others include telephone calls. These reports do not frequently describe whether specific, individual components of these interventions are each linked to reductions in at-risk drinking. Distinguishing whether different intervention components (e.g., patient-physician discussions, keeping a drinking diary, etc.) are linked to reductions in at-risk drinking may help to identify the essential intervention components for future efforts to translate clinical trials into practice. We recently conducted a large cluster randomized clinical trial, designed to evaluate the effectiveness of a multi-component intervention designed to reduce at-risk drinking among older adults, defined by scores on the Comorbidity Alcohol Risk Evaluation Tool (CARET) (Moore et al. 2011). Project SHARE (Senior Health and Alcohol Risk Education) found a statistically significant decrease in at-risk drinking among older adults at 12 month follow-up (Ettner et al. 2014)..While the intervention included several different components, including a physician component that involved physician-patient discussions of alcohol-related risk, as well as a health educator component that involved health educator telephone calls and encouragement to keep a drinking diary and/or make an agreement to cut down on alcohol intake, the specific mechanism/s that resulted in reductions in at-risk drinking are not clear. Therefore, we conducted an analysis to investigate to what extent participation in the different intervention components may be associated with the observed behavior change. We hypothesized that Project SHARE patients with greater participation in the physician intervention component would have lower odds of being classified as at-risk drinkers at 6 months and at 12 months of follow-up, as compared to patients who did not participate in this intervention component. We further hypothesized that patients who participated in the health educator component, specifically those who 1) received a call from the health educator but did not keep a drinking diary or make a drinking agreement, 2) either made an agreement OR self-reported that they kept a diary, and 3) both made an agreement AND self-reported that they kept a diary, would have lower odds of being classified as at-risk drinkers at 6 months and at 12 months of follow-up, as compared to patients who did not participate at all in the health educator intervention component.