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Substance Abuse Resource Guide Older Americans: Studies, Articles, & Reports October 1997

Table of Contents

• The Scope of the Problem
• Risks and Consequences
• Prevention, Education, Diagnosis, and Treatment
• Research and Methodology

The Scope of the Problem

Research shows that although heavy drinking in the United States is less prevalent among older persons, some maintain or increase heavy drinking. Late-onset heavy drinking is believed to be related to stressors of aging such as retirement or bereavement, particularly when coping resources or social supports are inadequate. This study investigated that relationship. In 1990-91, a random-digit-dial telephone survey was conducted with 2,325 Erie County, NY, residents aged 60 or older. Heavy drinkers were oversampled. Questions included demographics, drinking quantity/frequency, alcohol dependence/problems, stressful life events, chronic stresses, coping resources, and social supports. Analyses were conducted to examine the relationship between drinking and stress. There was no bivariate correlation between average alcohol consumption and acute or chronic stress. Logistic regressions with interaction terms show that stress has no relationship to heavy drinking (average alcohol consumption of 2+ drinks/day) regardless of coping style or social supports. Logistic regressions predicting late-onset heavy drinking also produced negative results. Chronic stress was, however, positively related to alcohol dependence and problems. Treatment and prevention programs for the elderly should not be based on the assumption that life stresses are a direct cause of drinking, although they may exacerbate consequences of drinking.

This study examined and compared concomitants of prescription and non-prescription drug use of black and white community-dwelling elderly. Information on prescription and nonprescription drug use, demographic and health characteristics, and use of health services was obtained from a probability-based sample of black (n=2,152) and white (n=1,821) community-resident elderly in the Piedmont area of North Carolina. Descriptive statistics were calculated. Linear regression, in which sample weights and design effects were taken into account, was used for the final models. For prescription drug use, 37 percent and 32 percent of the variance was explained for whites and blacks, respectively (6 percent and 5 percent for nonprescription drugs). Health status and use of medical services were the strongest predictors of prescription drug use for both races (with Medigap insurance also important for whites and Medicaid important for blacks). Demographic characteristics and self-assessed health were significant factors in the use of nonprescription drugs. Race independently predicted use of both types of drugs but explained only a small proportion of the variance. Health status and use of health services are importantly related to prescription drug use. Non-prescription drug use is difficult to explain.

The authors analyzed over 800 patient records to identify factors related to problem drinking for older adults. Most importantly, the study found that some symptoms, such as those related to emotional distress and employment status, had an association with problem drinking in older adults. However, these findings suggest that alcohol abuse throughout life may simply be carried into old age. Finally, the research noted a distinct pattern of drinking for older females in contrast to that of older males. The reasons for these gender differences, as well as the role of retirement and the onset of drinking among older adults, are identified as topics for future research.

Evaluation and detection of alcoholism in the elderly is discussed. Section headings within this article include: (1) effects of alcohol in the elderly; (2) reasons for underdetection; (3) diagnosis; (4) patient history; and (5) clinical features. The effects of alcoholism compared with effects of aging and conditions common in the elderly are presented in table form.

The relationship between wine consumption and cognitive deficits was studied, with a focus on the elderly. The research data were derived from the "Paquid" study, which evaluated 3, 766 community residents 65 years of age or older living in the area of Bordeaux, France. The following results of the study were seen: (1) both mild and heavy consumption were related to cognitive performance; (2) moderate wine consumption was insignificantly related to a lower risk for cognitive deficit than was abstinence; and (3) moderate drinking was lower in housewives and those in domestic service than in farmers, blue-collar workers, farm managers, and those in other occupations. The study results indicate that moderate wine consumption has no significant effects on the elderly.

Recognizing the clinical signs of alcoholism in those aged 60 years and over is discussed. Section headings in this article include: (1) a widespread problem that is easy to miss; (2) physiologic changes; (3) nonspecific presentation; (4) social isolation; (5) adverse physical effects in the older alcoholic; (6) alcohol-drug interactions; (7) cognitive effects, alcohol-related brain injury; (8) organic brain syndrome; (9) alcoholic dementia; (10) late-onset alcoholism, often a response to life events; (11) diagnosis, clinical clues and useful screening tests; and (12) treatment, handling detox and withdrawal. Key concepts of alcoholism in older patients, clinical clues to active alcoholism in the older patient, and plans for use of benzodiazepines (lorazepam and oxazepam) for alcohol withdrawal are presented in table form.

Responses of 17 elderly persons and 20 Virginia inpatients with alcohol-abuse problems (all 60 years or older) to an Alcohol Attitude Survey administered by telephone and interview were examined. Inpatients felt more vulnerable, perceived higher costs in moderating drinking, and showed lower response efficacy. Inpatients consumed substantially more alcohol than the community-dwelling elders. Hypotheses for study were generated.

This cross-sectional study examined the prevalence, geographic variation, and charges to Medicare of alcohol-related hospitalizations among elderly people in the United States. The study used 1989 hospital claims data from the Health Care Financing Administration (HCFA). Data included all hospital inpatient Medicare Part A beneficiaries aged 65 years and older in the United States in 1989. Results indicate that (1) the prevalence of alcohol-related hospitalizations among people aged 65 years and older nationally in 1989 was 54.7 per 10,000 population for men and 14.8 per 10,000 for women; (2) HCFA's Medicare Provider Analysis and Review Record (MEDPAR) data had a sensitivity of 77 percent to detect alcohol-related hospitalizations; (3) there was considerable geographic variation; prevalence ranged from 18.9 per 10,000 in Arkansas to 77.0 per 10,000 in Alaska; (4) a strong correlation was observed between alcohol-related hospitalizations and per capita consumption of alcohol by State (Spearman correlation coefficient, .64; P less than .0001); (5) the hospital-associated charges to Medicare for all admissions in 1989 where the primary diagnosis was alcohol-related (n=33,039) totaled $233,543,500; and (6) the median charge per hospital stay was $4,514. It is concluded that alcohol-related hospitalizations among elderly people are common, with rates similar to those for myocardial infarction as detected by the same method. The charges to Medicare for this preventable problem are considerable. Ecological analysis suggests that per capita consumption in the total U.S. population is a predictor of alcohol-related hospitalizations in the elderly population.

Why older persons engage in varying amounts of health maintenance activity is becoming both an increasingly important policy issue and a topic of interest to health services researchers. Such activity may help the elderly to delay the onset of the health-related problems associated with aging, maintain if not improve their functional abilities, and perhaps improve their quality of life. Using a conceptual model largely based upon the health belief model, this study sought to examine predictors of variability of health maintenance activity among older persons. The project included cross-sectional data drawn from the first phase of a multiyear panel study of elderly community residents. Results of ordinary least-squares and logistic regression analyses of seven types of health maintenance activity suggested that health beliefs were an important consideration but that other variables, namely, type of insurance plan and select sociodemographic factors, also had significant impacts. Another consistent finding was that each of the types of health maintenance activity was associated with different types of predictor variables. These findings suggest that in order for levels of health maintenance activity to be increased, intervention programs need to be targeted toward specific types of health beliefs and need to take into account the importance of social differences.

Data were analyzed from household interviews of four population-based cohorts comprising the Established Populations for Epidemiologic Studies of the Elderly to estimate the prevalence of prescription and nonprescription medication use among community-living elderly and to examine sociodemo-graphic and health factors related to medication use. Prescription drugs were used by 60-68 percent of men and 68-78 percent of women. Nonprescription drugs were used by 52-68 percent of men and 64-76 percent of women. Use of prescription medications generally increased with age, although use of non-prescription drugs was not associated with age. Men and women who smoked or used alcohol in the preceding year frequently took medications. Those who reported more depressive symptoms, impairments in physical functioning, hospitalizations, and had poorer self-perceived health status were most likely to take medications. However, 10-29 percent of respondents with fair or poor self-perceived health took no prescription medications, and 3-13 percent took neither prescription nor nonprescription medications. While further research appears warranted into potential overmedication of elders, particularly those with many depressive symptoms, these data suggest that studies of potential underuse among elders in poor health are equally important.

Risks and Consequences

The role of functional and cognitive limitations in the risk of pneumonia-related mortality in older adults was examined. As part of a cohort study in three communities (East Boston, MA; New Haven, CT; and Iowa and Washington Counties, IA), 6,234 women and 4,035 men ages 65 or older completed baseline interviews between 1981 and 1983 and were followed for up to 6 years. Sex-specific Cox proportional-hazards regression models were used to examine the association of baseline physical and cognitive functioning with report of pneumonia (International Classification of Diseases, ninth revision (ICD9)) as an underlying, immediate, or contributing cause of death. During followup, a total of 243 men and 160 women died with pneumonia. Adjusting for age, race, education, evidence of five chronic diseases, and smoking status, a significantly increased risk of pneumonia mortality (P less than 0.05) was found for limitations in activities of daily living and cognitive impairment among both men and women. Inability to walk a half mile, climb stairs, or perform heavy housework was significantly associated with increased risk of pneumonia mortality for women but not for men in the same multivariate models. Men and women whose body-mass default was above the median had significantly lower risk of pneumonia mortality compared with those in the lowest quartile. Further elucidation of the sequence between physical and cognitive impairment and risk of pneumonia will be important in reducing pneumonia-associated morbidity and mortality.

Septicemia is the 10th leading cause of death among older adults in the United States. Its mortality rate has steadily increased over the past decades. Little is known about factors that predispose the elderly to septicemia mortality. The authors investigated risk factors for septicemia-associated mortality in 10,269 older adults as part of a longitudinal study of three communities (East Boston, MA; New Haven, CT; and Iowa and Washington Counties, IA). During 6 years of followup, 177 persons (3.2 per 1,000 person-years) had septicemia (ICD9) reported on their death certificate. In a multivariate proportional-hazards model, septicemia mortality was significantly (P less than 0.05) and independently associated with age, male sex, his-tory of diabetes, history of cancer requiring hospitalization, smoking one pack of cigarettes per day or more, not drinking alcohol in the year prior to baseline, disability in activities of daily living, cognitive impairment, and missing cognitive testing score. These factors might be useful in developing an at-risk population for testing septicemia treatment or prevention strategies in a community setting. Further investigation is needed to explain underlying mechanisms of increased risk of septicemia.

Because the public health literature contains few analytic studies of modifiable behavioral risk factors for dental disease among older community-dwelling populations, the New England Elders Dental Study was undertaken as an epidemiologic study of the oral health status of a representative sample of older adults living within the six New England States. Five dentists conducted comprehensive in-home oral health examinations on 1,156 community-dwelling adults aged 70 and older to determine whether lifetime use of tobacco products was a significant risk factor for tooth loss, caries, and periodontal disease. Among New England elders, tobacco use was more common among men (18.1 percent) than women (7.9 percent), with a combined rate of 12.3 percent. Further, 64.7 percent of men and 36.6 percent of women were previous tobacco users. Years of exposure to tobacco products was a statistically significant risk factor for tooth loss, coronal and root caries, and periodontal disease, regardless of other social and behavioral factors. Lifelong tobacco use is a modifiable risk factor for poor dental health among older adults. Dental practitioners need to intervene with all their adult patients to discourage use of tobacco products for oral as well as general preventive health care.

The association between cigarette smoking and bone mineral density was examined prospectively in a population-based study of older Caucasian men and women. Smoking patterns were determined at a 1972-1974 baseline evaluation and again, 16 years later when 544 men and 822 women had bone mineral density measurements taken. Men and women who were cigarette smokers at baseline demonstrated significantly reduced bone mineral density of the hip compared with nonsmokers. Baseline smoking was not associated with significantly lower bone density at non-hip sites. Women demonstrated a significant dose-response relationship between baseline smoking status at all hip sites measured. Both sexes exhibited significant dose-response relationship between hip bone mineral density and change in smoking status between baseline and followup, demonstrating that smoking cessation in later life was beneficial in halting bone density loss associated with smoking. Smoking was positively and significantly associated with decreased hip bone mineral density in old age. Bone loss associated with smoking would be expected to predict an increased risk of hip fracture in those who do not succumb earlier to another complication of tobacco use.

A study was conducted to investigate the relationships between cigarette smoking and pulmonary function in elderly men and women. Subjects were 5,201 non-institutionalized men and women aged 65 years and older. Pulmonary function was determined by means of forced expiratory volume in one second (FEV1) and forced vital capacity and prevalence of low FEV1 levels. The prevalence of cigarette smoking was found to be from 10 percent to 20 percent and higher in women than men and in African Americans than whites. Forced vital capacity and FEV1 levels were related positively to height and white race and negatively to age and waist girth. Age- and height-adjusted FEV1 means were 23 percent and 18 percent lower in male and female current smokers, respectively, than in those who had never smoked, but not reduced in never-smokers currently living with a smoker. Smokers who quit before the age of 40 years had FEV1 levels similar to those who had never smoked, but FEV1 levels were lower by 7 percent and 14 percent in smokers who quit at ages 40 to 60 years, respectively. Lung function was related inversely to pack-years of cigarette use. Prevalence rates of impaired lung function were highest in current smokers and lowest in those who had never smoked. Regression co-efficients for the smoking variables were smaller in persons without cardiovascular or respiratory conditions than in the total cohort. It is concluded that cigarette smoking is associated with reduced pulmonary function in elderly men and women; however, smokers who quit, even after the age of 60 years, have better pulmonary function than continuing smokers.

Self-efficacy has a well-established, beneficial effect on health behavior and health status in young and middle-aged adults, but little is known about these relationships in older populations. The authors examined this issue as part of a randomized trial to determine the cost savings and changes in health-related quality of life associated with the provision and reimbursement of a preventive services package to 2,524 Medicare beneficiaries enrolled in Group Health Cooperative of Puget Sound. Baseline self-efficacy data were collected for all participants in five behavioral areas: exercise, dietary fat intake, weight control, alcohol intake, and smoking. Results reveal that efficacy and outcome expectations for these health behaviors are not independent. Correlational and factor analyses indicate two dimensions of efficacy expectations, one consisting of exercise, dietary fat, and weight control, and another consisting of smoking and alcohol consumption. Outcome expectations of the five behaviors form a single dimension. Older adults with high self-efficacy had lower health risks in all behaviors and better health. Regression analyses detected a positive association between socioeconomic status and health-related quality of life (p less than .02), but the strength of the association declined (p less than .11) after the self-efficacy measures entered the model, indicating that self-efficacy explains part of the association between socioeconomic status and health status. Interventions aimed at improving self-efficacy also may improve health status.

As based on Bureau of the Census population projections and age-specific cancer incidence rates for 1985 to 1989 from the National Cancer Institute's Surveillance, Epidemiology and End Results program, the number of incident cancers diagnosed annually in the United States among persons aged 65 and over is projected to reach 1.5 million by the year 2030, or 2.4 times the number estimated for 1990. The projections, which may be conservative because birth cohort patterns (based on Connecticut rates) suggest possible future increases in incidence rates for all cancer sites combined, have implications for planning expanded primary prevention efforts, such as smoking cessation (especially for women) and dietary modification programs, and for projecting health care needs and costs.

Compared with alcohol-abstaining, normal, postmenopausal women, estradiol levels are known to be statistically increased in normal postmenopausal women who consume alcoholic beverages moderately, and to be even further increased in alcoholic postmenopausal women with cirrhosis. This study was undertaken to evaluate whether or not there is a spectrum of changes in levels of sex steroids and pituitary hormones associated with alcohol abstinence, alcohol use, and alcohol-induced cirrhosis in the absence of current alcohol abuse. For levels of estradiol and testosterone, as well as for the estradiol to testosterone ratio, all three groups differed significantly from each other; for the pituitary hormones, levels in the abstainers and alcohol users were similar and statistically different from levels in the alcoholic cirrhotic women. Compared with the alcohol-abstaining women, the relationships of age and estradiol with levels of the other hormones were disturbed for 4 of 11 correlations examined among the alcohol users, and for 9 of 11 correlations evaluated among the alcoholic cirrhotic women. These findings suggest that not only are hormonal rela-tionships markedly disrupted among alcoholic cirrhotics, but also that alcoholic beverage consumption in the range of 0.1-28 total weekly drinks results in detectable perturbations of the normal hormonal relationships expected in postmenopausal women.

Alcohol use and abuse were studied in 103 frail, homebound elderly individuals cared for in a long-term home health care program from July 1991 to February 1992. Their average age was 80.63 years. Eighty-four percent were abstinent at the time of the study, including 25 (25 percent) past heavy drinkers. Two persons were current heavy drinkers and 14 continued to drink socially. Previous alcohol use or abuse was associated with a history of smoking, cardiovascular morbidity, social isolation, and anxiety or agitation. Current social drinking was associated with sedative-hypnotic use as well as smoking. Twenty-three of 25 past heavy drinkers remained sober without the use of formal alcohol treatment. Abstinence is known to increase with age, appears to be fostered by the homebound setting, is feasible for homebound elderly persons, and is often accepted.

Late onset alcoholism is discussed, with a focus on stress. The research sample included 60 male patients, over 60 years of age, from 6 Midwest treatment centers. Onset of drinking before age 40 was defined as early onset, between 40 and 60 as quasi-late onset, and after age 60 as late onset. The subjects completed a modified version of the Veteran's Alcoholism Screening Test (V.A.S.T.), and the Drinking Practices Survey. The results of the study revealed a significant relationship between alcoholism and marital status only, with more married subjects in the early onset group. It is therefore suggested that the late onset of problem drinking may have more to do with the loss of a spouse who may help regulate drinking than it has to do with stress.

The effects of benzodiazepine dependence on ability to learn and remember were studied. The research sample included 20 detoxified, benzodiazepine-dependent patients 55 years of age or older, who were enrolled in a drug-dependence rehabilitation program, 20 matched non-benzodiazepine-dependent alcohol-dependent patients, and 22 controls. The subjects underwent neuropsychologic testing 6 to 10 days after complete detoxification. The results of the study revealed greater difficulty in learning tests and short-term and delayed recall for benzodiazepine-dependent subjects than for alcohol-dependent or control subjects. It is concluded that benzodiazepine dependence in older people may cause memory impairment that may persist into the early drug-free period.

To determine the frequency of and risk factors for falls and injurious falls in the noninstitutionalized elderly, the authors conducted a followup study of 409 community dwelling persons aged 65 years or more in west-central Montreal, Quebec, Canada, from May 1987 to October 1988. Following an initial at-home interview, each subject was telephoned every 4 weeks for 48 weeks for collection of data on falls experienced since the last contact. Each of the 12 followup interviews was completed by at least 90 percent of the subjects eligible for interview. Data were also collected in the followup interviews on time-varying exposures. Twenty-nine percent of the subjects fell during followup; 17.6 percent fell once, and 11.5 percent fell two or more times. The incidence rate for falls was 41.4 falls per 1,000 person-months. The majority of the falls resulted in no injury or in minor injury only. Potential risk factors investigated included sociodemographic variables, physical activity, alcohol consumption, acute and chronic health problems, dizziness, mobility, and medications. Multivariate analyses showed that the following factors were statistically significantly associated with an increased rate of falls: dizziness (incidence rate ratio (IRR)=2.0), frequent physical activity (IRR=2.0), having days on which activities were limited because of a health problem (IRR=1.8), having trouble walking 400 M (IRR=1.6), and having trouble bending down (IRR=0.6), daily alcohol consumption (IRR=0.5), having days spent in bed be-cause of a health problem (IRR=0.5), and taking heart medication (IRR=0.6). Risk factors for injurious falls were similar.

To determine whether smoking habits and alcohol consumption are related to changes in cognitive function, the authors conducted a prospective, community-based study of persons aged 65 years and over in East Boston, MA. In 1982 and again in 1985, the subjects were given three brief tests of cognitive function; immediate memory, digit span, and a mental status questionnaire, which primarily assessed orientation. The 1,201 individuals who performed well in 1982 were included in linear regression analyses of 3-year change in performance, adjusted for age, sex, education, and income. Relative to non-smoking, current smoking, past smoking, and pack-years were not significantly related to change in immediate memory. None was significantly related to change in orientation. Only pack-years was significantly related to normal change score in digit span (normal change score change per unit of predictor=0.001, 95 percent confidence interval 0.0003-0.002). Low-to-moderate alcohol consumption during the month preceding baseline testing was not significantly related to a subsequent 3-year change in performance in two of the three tests. However, people who consumed a very small amount of alcohol had a normal change score that was 0.088 (95 percent confidence interval 0.015-0.160) better for digit span than did nondrinkers. This study provides evidence that the reported levels of smoking and alcohol use among older persons are not consistent or substantial predictors of the longitudinal change in cognitive function observed in a community.

This study examined the prevalence of current alcohol abuse and links between it and current psychiatric problems in 179 men and 335 women over the age of 65 years living in their own homes in a relatively deprived inner-city electoral district. CAGE questionnaire was used to detect possible alcohol abuse in this community survey. Results indicate that only three subjects were CAGE-positive and thus at risk of alcohol abuse. The results suggest that current alcohol abuse does not underlie neuropsychiatric conditions in the elderly, and fears of significant rates of alcohol abuse are probably unfounded, at least in English populations of this type.

A population-based, case-control study was conducted from 1985 to 1989 in western Washington State to assess the relation between nutrients and the incidence of colon cancer in men and women aged 30-62. A food frequency questionnaire was used to document the usual diet 7 years before diagnosis for 424 cases and at a similar time for 414 controls. Alcohol consumption was strongly related to the risk of colon cancer in both men and women, with age-adjusted odds ratios (ORs) of colon cancer=1.0, 1.9, 1.7, and 2.6 for 0, less than 10, 10-29, and, greater and equal to 30 g/day intake for men and adjusted odds ratios=1.0, 1.3, 1.8. and 2.5 for the same categories for women. The trend odds ratio associated with a one-category increment in the four-level alcohol consumption variable was 1.3 (95 percent confidence interval (CI) 1.0-1.5) in men and 1.4 (95 percent CI 1.0-1.7) in women. For both sexes, higher dietary fiber intakes were associated with lower relative risks for colon cancer, with age-, energy-, and alcohol-adjusted odds ratios=1.0, 0.9, 0.8, and 0.6 across quartiles of consumption for men and adjusted odds ratios=1.0, 0.9, 0.5, and 0.5 for women. In men, this was mostly attributable to intake of cereal fiber (trend OR=0.8. 95 percent CI 0.6-1.0) while, in women, this association mostly reflected the effect of fruit fiber (trend OR=0.8, 95 percent CI 0.6-0.9) and vegetable fiber (trend OR=0.8. 95 percent CI 0.7-1.0). Calcium was associated with a decreased risk of colon cancer among women only (adjusted OR across quartiles=1.0. 0.5, 0.6, 0.3; trend OR=0.7. 95 percent CI 0.6-1.0). There was no indication of an association between colon cancer and fat or protein consumption or dietary vitamins.

A growing literature supports genetic contributions to familial resemblance for alcohol use characteristics, but few studies have focused on the mechanisms underlying alcohol use among older persons. This study reports patterns of alcohol use in a U.S. volunteer sample of 3,049 female and 1,070 male twins age 50 to 96. Significant gender and age effects were found for self-report measures of current and lifetime alcohol use, with greater intake among males and current and lifetime abstinence more common among older participants. Comparisons with data obtained 4 years previously revealed high stability for quantity and frequency of alcohol consumption. Twin pairs with more frequent social contact tended to be more similar for lifetime and current alcohol use. Biometrical genetic modeling results indicate that use of alcohol is highly familial, with both genetic and shared environmental factors contributing to initiation of alcohol use among men and women. Among drinkers, however, the degree of twin resemblance for consumption behaviors is low to moderate and appears to be regulated by shared genes rather than shared environments. These data are consistent with a multi-dimensional process, suggesting that the determinants of whether one drinks in older age differ from those underlying how much or how often alcohol is consumed.

Consistent maximum-likelihood heritability estimates of consumption of alcoholic beverages were observed at three separate times during a 14- to 18-year period in adult twin males initially aged 42-56 years in 1969-1973. Log transformation of the average number of drinks/week of the returnees to all three examinations was examined relative to potential covariates representing both antecedents of drinking alcohol and consequences of alcohol consumption. Significant relationships were noted for 38 of the covariates at one or more of the separate examinations, including posi-tive correlations with smoking, coffee consumption, high-density lipoprotein cholesterol, mean corpuscular volume, systolic blood pressure, uric acid and behavioral measures, and negative correlations with blood urea nitrogen, red blood cell count, tea consumption, and triceps skinfolds. Analysis of the average alcohol consumption adjusted for nine independent covariates selected from multiple stepwise regression resulted in a modest decline in maximum-likelihood heritability estimates compared with unadjusted data, but little difference from heritability estimates obtained when abstainers from alcohol were excluded. The most striking effect of omitting abstainers from alcohol was the decline in the intraclass correlations in dizygotic twins. Bivariate analyses of alcohol and individual covariates revealed the phenotypic correlation between alcohol consumption and a measure of hostility was primarily environmental, that for high-density lipo-protein, smoking and coffee drinking with alcohol was primarily genetic, and that the phenotypic correlation between alcohol consumption and mean corpuscular volume had both significant genetic and environmental correlations. Comparison with other twin studies in males suggested relatively consistent estimates of genetic variance, despite wide variation in subject characteristics, study design and methods, and measure of alcohol consumption.

The relationship between religious affiliation and psychiatric disorder was examined among Protestant members of the baby-boom generation who resided in the Piedmont area of North Carolina. Data were obtained on 6-month and life-time rates of major psychiatric disorders among 853 Protestant baby boomers during wave II of the National Institute of Mental Health's Epidemiologic Catchment Area survey, conducted in 1983-1984. Participants were grouped into three categories based on religious affiliation: mainline Protestants, conservative Protestants, and Pentecostals. Rates of disorder were compared across denominational groups, controlling for sex, race, physical health status, and socioeconomic status and stratifying by frequency of church attendance. The analyses were repeated for 1,826 middle-aged and older Protestants born between 1889 and 1944, and the results were compared with the findings for baby boomers. Among the baby boomers, Pentecostals had significantly higher 6-month and lifetime rates of depressive disorder, anxiety disorder, and any DSM-III disorder. Mainline Protestants had the lowest six-month and lifetime rates of anxiety disorder and the lowest 6-month rates of any DSM-III disorder, whereas conservative Protestants had the lowest 6-month and lifetime rates of depressive disorder and the lowest life-time rates of any DSM-III disorder. These relationships among baby boomers were weaker among middle-aged and older Protestants, although a new association with alcohol abuse or de-pendence emerged among older Pentecostals. It is concluded that Pentecostals in the Piedmont area experienced high rates of psychiatric disorder more than middle aged or older Pentecostals. Infrequent churchgoers appeared to be at greatest risk, although they seldom sought professional help for their problems.

The health effects of alcohol consumption by middle-aged and elderly men were evaluated in a prospective study. The Honolulu Heart Program evaluated the association in 6,069 Japanese-American males between reported alcohol consumption and total mortality, mortality from selected causes, and incident nonfatal chronic disease during an approximate 15-year followup period. The following results of the study were seen: (1) a J-shaped curve for total mortality in relation to alcohol consumption; (2) lower rates of occurrence of combined fatal and nonfatal coronary heart disease with increasing alcohol consumption; (3) increased risk of fatal and nonfatal strokes with increasing alcohol consumption in middle-aged males; (4) increased risk for fatal and nonfatal strokes in elderly light and moderate drinkers; and (5) increased risk for fatal and nonfatal malignant neoplasms with heavy drinking in both middle-aged and elderly groups. It is concluded that heavy alcohol consumption is associated with increasing risks of diseases of public health importance. It is suggested that recommendations for increasing levels of alcohol consumption be made cautiously.

Psychiatric disorders of elderly Koreans in the United States were studied. The research sample included 100 male and female Korean elderly living in Los Angeles, CA, who responded to 1-hour, face-to-face, structured interviews. The following results of the study were seen: (1) low prevalence of most Diagnostic and Statistical Manual of Mental Disorders (DSM-III) with the exception of alcohol abuse and alcohol dependence; (2) high rate of alcoholism among elderly Korean males; (3) no significant difference in the prevalence of mental disorder of elderly Koreans in Los Angeles and in St. Louis, with the exception of alcohol abuse and alcoholism; and (4) higher lifetime prevalence of DSM-III disorders among Koreans in Korea than in elderly Koreans in Los Angeles. It is concluded that local health and mental health agencies serving Korean immigrants should develop culturally appropriate treatment and prevention programs.

This study describes mortality rates and predictors of mortality among late-middle-aged and older (55+) substance abuse inpatients (n=21,139) in Department of Veterans Affairs (VA) Medical Centers in the 4 years after an default episode of care. A total of 24 percent of the patients died; this mortality rate was 2.64 times higher than expected. Predictors of earlier mortality included older age and nonmarried status, alcohol psychosis and organic brain disorder diagnoses, and several medical diagnoses, including neoplasms, liver cirrhosis, respiratory, endocrine and metabolic, and blood system disorders. Three proxy indicators of illness severity also predicted mortality: more prior inpatient and outpatient medical care and an default episode in an extended care unit. In contrast, more prior outpatient mental health care and remitted status predicted lower mortality. These diagnostic and treatment indicators can be used to identify patients at heightened risk for premature mortality. Moreover, they show that intensive mental health aftercare and remission of substance abuse may delay mortality, even among older patients who have long-standing substance abuse problems.

Prevention, Education, Diagnosis, and Treatment

There is little information on how best to provide health promotion and disease prevention services to elderly persons. This paper reports participants' perceptions of the effectiveness of a health promotion program consisting of health education classes and case management services. A single-group, posttest only design was used for the county-wide program, which operated independent of participants' primary care physicians. Each person received a thorough screening evaluation, was invited to health education classes, and was assigned a case manager for a 2-year health promotion period. Community residents 64-71 years of age were recruited; 475 entered the study; and 378 (79.6 percent) completed the followup evaluation interview. Only one-third of the participants attended at least one class, but a majority of those attending each class rated it very or extremely effective in increasing knowledge. To determine the effectiveness of the case managers, each participant identified the three health problems that were of greatest concern to him or her and indicated which of these priority problems were discussed with the case manager. Discussion with the case manager was significantly associated with continuing to see a personal physician for the problem, following the physician's recommendations, the problem's being under control, and the problem's improving over the 2-year followup. The classes and case management services benefited the participants who used them. How to best deliver these services to the target group needs further study.

Lifestyle Enrichment for Senior Adults (LESA) is a special counseling and group program for men and women 55 years and older experiencing problems associated with their use of alcohol and other psychoactive drugs. The program includes a direct service component and a community education component. The treatment approach incorporates knowledge about the normal aging process, drug dependency, and holistic health, along with techniques of intervention drawn from addiction treatment, holistic health care, nursing, and social work. The LESA program is described in depth.

Screening for problem drinking by elderly patients is discussed. The research sample included 110 consecutive admissions to an acute unit for the elderly mentally ill. The patients responded to a questionnaire. The following results of the study were seen: (1) a prevalence of problem drinking of 19 percent; (2) one-third of problem drinkers had not been detected during routine medical assessment; and (3) a highly significant difference in alcohol consumption between the problem drinkers and the rest of the group. It is concluded that 14 or more units of alcohol per week may be useful as a marker of problem drinking in the elderly. The consumption of alcohol on 3 or more days per week was associated with a high risk of adverse consequences.

The article addresses recognition and treatment of substance abuse in the elderly. A significant number of older adults abuse alcohol and prescription drugs and, to a lesser extent, street drugs. Difficulties in detecting substance abuse, age-related physiologic changes, and substances most frequently used by the elderly, are also discussed. It is suggested that the elderly should be treated as aggressively as their younger counterparts, with slow, careful detoxification, and use of some form of group therapy.

This naturalistic study uses data based on clinical records to examine treatment utilization and 1-year readmission rates among three diagnostic subgroups of late-middle-aged and older substance abuse inpatients in Department of Veterans Affairs (VA) Medical Centers: inpatients with only an alcohol or drug dependence diagnosis (n=11,652); inpatients with an alcohol or drug psychosis (n=3,510); and inpatients with an alcohol or drug disorder and a concomitant psychiatric disorder (n=5,977). As expected, substance abuse patients in the latter two subgroups received more treatment before, during, and following an default episode of care than did patients with only an alcohol or drug dependence diagnosis. From a broad perspective, these results indicate a match between treatment services and patient needs. However, relatively few older substance abuse patients received outpatient mental health aftercare; this was true especially of patients with alcohol or drug psychosis diagnoses. The l-year readmission rate in the group overall was higher than that usually reported in younger and mixed-age groups of substance abuse patients. Readmission was predicted by unmarried status (a predisposing factor) and need, as defaulted by several diagnostic and treatment characteristics.

A retrospective chart review of older (n=48; mean age=69) and younger (n=36; mean age=30) patients who were admitted to residential/inpatient treatment for alcohol withdrawal and dependence was conducted. Although the two age groups did not differ in terms of recent drinking history, the elderly group had significantly more withdrawal symptoms for a longer duration than the younger group. The elderly group also had more symptoms of cognitive impairment, daytime sleepiness, weakness, and high blood pressure. Finally, no significant differences were found between age groups in either the dosage or number of days of detoxification medication, although a trend was found for more days of medication in the elderly than in younger persons. Accordingly, treatment may take longer and should target the specific profile of symptoms that characterize alcohol withdrawal in the elderly.

Alcohol and substance abuse in older adults until recently has received little empirical attention in the literature. However, in light of the increasing number of older adults in the population, clinicians and researchers alike are recognizing the importance of evaluating specific assessment and treatment strategies for such older substance abusers. Because distinctive biological, cognitive, and psychosocial variables appear to be correlated with substance abuse in older adults, evaluation and intervention methods employed with younger cohorts may be inappropriate or ineffective with individuals 55 and over. This article, therefore, examines these characteristics as they pertain to the unique problems and service needs of the elderly. Relevant diagnostic and assessment strategies are reviewed. Finally, suggestions for future work in this area are outlined.

At significant risk for alcohol and drug abuse are both the adolescent and elderly populations. Both groups exhibit attitudes, behaviors, feelings, and reasons for abuse that appear to be similar. Recent literature suggests that the study of pediatrics can play a role in the development of the geriatric movement by sharing common issues of both groups. When applying Erikson's stages of development, a similarity of needs between the adolescent and the elderly becomes clear. Therefore, when considering drug and alcohol use and abuse in both populations, it may be possible to draw a correlation between the two groups. Awareness of these similarities can make a difference for those treating the adolescent and elderly drug abuser.

In this article the authors discuss the prevalence and problems with identifications, and issues in treatment of substance abuse among women, ethnic minorities, and the elderly. Treatment strategies for elderly alcoholics appear to be effective interventions when applied appropriately. With expected increases in the older adult population of the U.S. in the coming decades, it is crucial that the problem of alcoholism among the elderly be addressed now in order to develop a course of action for targeting future alcoholism prevention and treatment efforts. With regard to ethnic minorities, the authors believe it is a realistic goal for the present to ensure cultural sensitivity to minority concerns in existing treatment programs. Among any minority group one important source of nontraditional treatment that should not be overlooked is the use of native healers. Every attempt should be made to incorporate culture-specific beliefs and concepts about healing and recovery into treatment programming.

This study examines the diagnoses and treatment received by a cohort of late-middle-aged and older substance abuse patients. More than 23 percent of substance abuse inpatients admitted to Department of Veterans Affairs (VA) Medical Centers in fiscal year 1987 were 55 years of age or older. Most of these patients had multiple health problems. More than 90 percent had an alcohol-related diagnosis. Almost 30 percent were diagnosed with a psychiatric disorder. More than 80 percent had a medical disorder. Compared with their younger counterparts, older substance abuse patients were less likely to receive specialized inpatient or outpatient treatment specifically directed toward their substance abuse or psychiatric problems. In general, older substance abuse patients receive services oriented more toward medical management than toward rehabilitative substance abuse or psychiatric care. These findings imply a need to develop treatment programs tailored to the characteristics and substance abuse problems of older patients and to encourage more use of specialized outpatient aftercare services by these individuals.

This naturalistic study examines treatment, diagnoses, and readmission among late-middle-aged and older (age 55+) substance abuse inpatients (n=16,066) in Department of Veterans Affairs Medical Centers. Over an interval extending from 4 years before to 4 years after an default episode of care, older substance abuse patients used substantial amounts of inpatient and outpatient treatment. Service use was heaviest among patients with a concomitant psychiatric disorder, and there was no evidence that it declined over time in the overall group. Four-year readmission rates in three diagnostic subgroups (alcohol or drug dependence diagnosis only, alcohol or drug psychoses, substance dependence and/or psychoses with one or more psychiatric diagnoses) were very high (57 percent to 70 percent); however, they were somewhat lower among patients with less chronic substance abuse problems. Readmission and multiple readmission were predicted by younger age, unmarried status, more prior service use, alcohol psychosis or psychiatric diagnoses, treatment in a psychiatric unit, and shorter hospital stay. These factors may be used at admission and discharge to identify patients at risk for rehospitalization; inpatient treatment and aftercare can be planned accordingly.

Research and Methodology

Despite beliefs that surveys involving older persons are less valid than those with other groups (due to memory loss, etc.), empirical verifications do not support this. Certain factors related to reduced validity must be considered (e.g., little education) and the confounding factors of cohort and time of measurement must be evaluated. Persons presumably suffering from dementia and institutional residents may be needlessly excluded. Methods suggested for improving validity include: sampling techniques, proxy respondents, administration and instrumentation, and interviewer variables. It is important to cross-validate data from surveys by using several concurrent methods. Instruments developed with younger subjects may be inappropriate or invalid with elders.

The reliability and validity of a retrospective, self-report measure, the Concordia Lifetime Drinking Questionnaire (CLDQ), were assessed with a group of 72 elderly Canadian men. The CLDQ includes quantity and frequency questions on current beverage-specific alcohol use and a series of questions about the start of alcohol use. The innovative features of the CLDQ include requiring subjects to collaborate with the interviewer in drawing a graph that represents their lifetime drinking patterns and encouraging more accurate recall by the use of salient events in the subject's life history. Drinking was assessed on two occasions approximately 33 months apart. Forty-six wives responded to questions about their husband's drinking. The reliability coefficient for life-time drinking was .78. A comparison of the two graphs every fifth year from 1945 to 1985 yielded significant correlations that ranged from .65 to .87. Validity was tested by comparing each wife's rating of her husband's drinking at present and at time of marriage with similar points on the husband's graphs. The correlations were .87 and .72, respectively. Moderate correlations were obtained between the MAST and the CLDQ. The CLDQ was judged to be a reliable and valid measure of lifetime drinking, appropriate for use with the elderly. The longitudinal lifetime drinking patterns appeared similar to those found in cross-sectional studies.