Addressing Unhealthy Alcohol Use in Older Populations in Primary Care Alison A. Moore, MD, MPH Chief, Division of Geriatrics Departments of Medicine and Psychiatry

Guidelines for Low-Risk Drinking Men under age 65 < 4 drinks on any day and < 14 drinks per week Nonpregnant women and men 65 and over < 3 drinks on any day and < 7 drinks per week Differences in recommended amounts reflect gender differences and age-related differences. USDHHS, PHS, NIAAA

Why do guidelines differ by gender and age? Women: Lower body size and reduced activity of gastric dehydrogenase Women and Older Adults: Lower percentage of body weight composed of water which results in a higher blood alcohol level for given amount of alcohol intake Older Adults: Increased psychomotor effects, comorbid conditions, medications used Women have lower body size, and reduced activity of gastric alcohol dehydrogenase. Also women and older adults have a lower percentage of body weight composed of water. All of these result in higher blood alcohol level for a given level of alcohol intake. Older adults have additional risks for harm from alcohol including increased psychomotor effects from a given dose of alcohol that may impair balance and cognition and more frequent comorbid conditions that may be worsened by alcohol use and increased use of medications that could interact negatively with alcohol or be less efficacious with alcohol.

At-risk or unhealthy drinking in older adults Often defined as exceeding low risk drinking guidelines Older adults have alcohol-related risks that differ in some respects from those of younger adults Older adult-relevant definition is: use of alcohol that increases risk for harm, due both to the amount consumed and concurrent use of alcohol with medications and comorbidities. My work has focused on the concept of at-risk drinking in older adults which includes those who exceed low risk drinking limits and those who may be drinking below these limits but who have comorbidities or take medications that increase the risks of alcohol consumption. As part of this effort we developed the CARET –I am proud to say, is cited in UptoDate! The intervention consisted of personalized feedback given to participants in a written and verbal format by their doctors including some of you in the audience as well as up to 3 follow up phone calls by a health educator to further educate participants about their risks and provide encouragement to change. The control group was given an educational booklet that included low risk drinking limits but also other topics. Moore et al. Med Care 1999, Moore et al, J Stud Alcohol 2002

Alcohol consumption and multiple comorbidity increases mortality NHANES 1971 and NHEFS 1992 data from adults aged > 60 years At-Risk Drinker Abstainer Subjects Adjusted Hazard Ratios for Death All 1.12 (0.97-1.30) 1.08 (0.98-1.19) Men 1.20 (1.01-1.41) NS Women 0.87 (0.61-1.24) Now I will talk about some risks related more to older adults. Remember earliier that moderate alcohol use appeared to be beneficial among individuals who had comorbiditeis like diabetes and stroke that were prevented by mod alcohol use. Here I wanted to look at whether even moderate levels of alcohol use would be beneficial among those who had multiple comorbidities. Moore et al, JAGS 2006

Comorbidity Alcohol Risk Evaluation Tool (CARET) Questionnaire that identifies older persons who may be at-risk or unhealthy drinkers Includes items on medical conditions (7), symptoms (6), medications (11), alcohol use (3), others’ concern about individual’s drinking (1) and driving after drinking (1) Criterion standard:Sensitivity 93%, Specificity 66% CIDI: Sensitivity 100%, Specificity 39%:AUDIT Sensitivity 28%, Specificity 100%: SMAST-G Sensitivity 52%, Specificity 96% Moore et al. Aging: Clin Exp Res 2000, Fink et al. Arch Gerontol Geriatr 2002, Moore et al. JAGS 2002, Moore et al. J Stud Alcohol 2002

Examples of At-Risk Drinkers Identified by the CARET 72 year old man who drinks three drinks four times a week and also having hypertension, often having problems sleeping, and taking medications for blood pressure and sleep. 68 year old woman who drinks two drinks daily and who feels sad or blue often and who takes ibuprofen regularly. 84 year old man who drinks three drinks daily and sometimes having heartburn and takes ulcer medication Criterion standard:Sensitivity 93%, Specificity 66% CIDI: Sensitivity 100%, Specificity 39%:AUDIT Sensitivity 28%, Specificity 100%: SMAST-G Sensitivity 52%, Specificity 96%

Healthy Living as You Age Study Design & Project SHARE (2 R01s) Baseline Visit ‘At-risk’ drinkers aged ≥ 55 years determined by CARET Randomization to Control or Intervention Intervention Group Healthy Drinking as You Age Booklet Personalized Risk Report Brief Physician Advice 3 Health Educator Calls Control Group Healthy Living as You Age Booklet 3-mo and 12-mo Follow-Up Re-administration of CARET

Results: HLAYA and SHARE Baseline Risks N=631 and 1186 Type of Risk % of sample Alcohol use with medications 73/61 Alcohol use with symptoms 60/46 Alcohol use with comorbidity 50/39 Alcohol use alone 47/36 Drinking 4+ drinks at once 24/20 Drinking and driving 24/32 Others concerned about drinking 17/29

Average # risks, SD = 2.95 (1.67)/ 2.62 (1.83) Most Common Risks n (%) Comorbidity Hypertension 193 (31) Depression 78 (12) Symptom Problems Sleeping 243 (39) GI Symptoms 152 (24) Memory Problems 142 (23) Medications Antihypertensives 200 (32) Ulcer Medications 115 (18) NSAIDS 113 (18) Antiplatelets 109 (17) Average # risks, SD = 2.95 (1.67)/ 2.62 (1.83)

Follow-Up Data: At-risk Drinking Dec 50-60% *p<.05 at the time point

Baseline and Follow-Up Data: Amount of drinking both groups, prevalence of at-risk drinking declined by 50-60%, amount of drinking by 30-40%, and heavy drinking days 30-70%. *p<.05 at the time point Moore et al. Addiction 2011, Ettner et al. JSAD 2014

Another CARET-based study Mailed CARET to primary care patients aged 50 and older. Those identified as at-risk (n=86) were randomly assigned to receive: a) mailed personalized feedback, educational booklet and Rethinking Drinking booklet or b) nothing. At three months, fewer intervention participants were at-risk drinkers (66% vs 88%), binge drinkers (45% vs 68%) and used alcohol with comorbid conditions (3% vs 17%) or symptoms (29% vs 49%). Criterion standard:Sensitivity 93%, Specificity 66% CIDI: Sensitivity 100%, Specificity 39%:AUDIT Sensitivity 28%, Specificity 100%: SMAST-G Sensitivity 52%, Specificity 96% Kuerbis et al. JAGS 2015

Conclusions Older at-risk drinkers have multiple risks, most because of combined use of alcohol and medications and/or use of alcohol in the presence of comorbidity Data suggest that advice can reduce alcohol consumption and unhealthy drinking in older populations More work needs to be done in other venues than primary care and using other means to address unhealthy alcohol and other substance use in older adults

Cheers to non-unhealthy drinking!