Alcohol consumption among the elderly in a general population, Erie County, New York

The Relationship Between Alcohol Consumption and Frailty Among Older Adults in China: Results From the Chinese Longitudinal Healthy Longevity Survey

INTRODUCTION

Alcohol consumption has an impact on the frailty, but current research in China lacks a detailed classification of alcohol use. This study aimed to explore the relationship between different drinking patterns and frailty in older adults.

METHODOLOGY

The data came from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS) study, which included older adults (aged ≧ 60). Their demographic data, drinking status, and frailty index were collected in CLHLS. Through logistic regression models to analyze the correlation between alcohol consumption and frailty.

RESULTS

A total of 14,931 participants were included in the analysis. The prevalence of frailty was 29.1%, 35.2%, and 14.9% among risk-free, past risky, and now risky drinkers, respectively. After adjusting for covariates, past risky drinking was a risk factor for frailty (p = .003).

DISCUSSION

High-risk alcohol consumption is positively correlated with frailty. Prevention and reduction of risky drinking in older adults may help protect them from developing frailty.

Prevalence and Correlates of Risky Drinking Among the Oldest-Old in China: A National Community-Based Survey

AIMS

To investigate the prevalence and correlates of risky drinking in Chinese elderly people aged 80 and over.

METHODS

Data were obtained from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted in 2018. A total of 10,141 respondents aged 80 years or older were included in this analysis. Risky drinking was defined as drinking > 2 drinks per day. The participants were divided into no risky drinking, past risky drinking, and current risky drinking groups. The prevalence of risky drinking, daily dosage, and type of alcohol beverages were assessed. The correlates of risky drinking were analyzed using logistic regression.

RESULTS

The prevalence of past and current risky drinking was 6.2 and 4.4%, respectively. A total of 12.2% of males and 2.1% of females reported past risky drinking, and 8.9% of males and 1.4% of females reported current risky drinking. The median of the daily dosage of the past risky drinking group was 4.5 and 4 drinks in males and females, respectively, and were 4 and 3.3, respectively, of the current risky drinking group. Strong liquor was the most popular alcohol beverage in all groups. Men who were older or had white-collar work were less likely to be past risky drinkers, while those with smoking in past or current or heart disease were more likely to be past risky drinkers. Women who smoked in the past were more likely to be past risky drinkers. Men with older age or living in the urban areas or with heart disease were less likely to be current risky drinkers. Women with higher education or with heart disease were less likely to be current risky drinkers. Women with current smoking were more likely to have current risky drinking.

CONCLUSIONS

Our findings indicated that risky drinking among the oldest-old was not rare in China. The correlates of past and current risky drinking were different. Men and women had various correlates of risky drinking as well. Those with higher socioeconomic status seemed less likely to be risky drinking. More attention should be given to risky drinking among the oldest old, and sex-specific intervention may be needed.

Alcohol Consumption and Age-related Macular Degeneration: A Systematic Review and Dose-response Meta-analysis

Purpose: To perform a systematic review on the association between alcohol consumption and risk of age-related macular degeneration (AMD) using a meta-analytical approach.Method: Systematic literature research was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Both categorical and dose-response meta-analysis was performed separately for early and late AMD. A fixed-effect model was used to calculate pooled effect estimates with 95% confidence interval (CI).Result: Seven studies were included in the analysis with 4,566 and 440 cases of early and late AMD, respectively. Compared to the nondrinkers or occasional drinkers, the pooled effect estimates for early AMD with moderate (1.19, 95% CI [1.03-1.37]) and heavy (1.24, [1.10-1.39]) alcohol consumption, but not light (0.95, [0.90-1.06]) alcohol consumption, were statistically significant. However, the pooled effect estimates for late AMD with light (1.03, [0.79-1.33]), moderate (1.13, [0.83-1.55]), and heavy (0.98, [0.63-1.53]) alcohol consumption were found to be insignificant. A linear dose-response relationship was established (P < .05) between alcohol consumption and risk of early AMD, and the pooled effect estimate for an increase in alcohol consumption of 10 g/day was 1.14 (1.08-1.21).Conclusion: Moderate and heavy alcohol consumption could increase the risk of early AMD, but not late AMD, with a linear dose-response relationship.

Alcohol use, depression, and life satisfaction among older persons in Jamaica

BACKGROUND

We aimed to determine the prevalence of alcohol use among older Jamaicans as well as to explore among this population the relationships between alcohol use and: age, sex, depressive symptoms, and life satisfaction. Although the nature of these relationships among the proposed study population were uncertain, in other settings alcohol use has tended to decline with increasing age, occur more commonly among men than women, and show non-linear relationships with depressive symptoms and life satisfaction.

METHODS

Data gathered by two-stage cluster sampling for a nationally representative health and lifestyle survey of 2,943 community-dwelling older Jamaicans, aged 60 to 103 years, were subjected to secondary analysis using the Student's t-test and χ 2 test as appropriate.

RESULTS

Current alcohol use was reported by 21.4% of the participants. It steadily declined with age and was six times more prevalent among men (37.6%) than women (6.2%). These findings were statistically significant as were associations of current alcohol use with comparatively lower levels of depressive symptoms. Current alcohol use was also more prevalent among persons who were either highly satisfied or highly dissatisfied with their lives, compared to others who had levels of life satisfaction between these two extremes.

CONCLUSIONS

Current alcohol use among older Jamaicans occurs primarily among men, declines with increasing age, and is associated with a relatively low likelihood of depression. It is also associated with very high and very low levels of life satisfaction.

Trajectories of Alcohol Consumption among Older Japanese Followed from 1987—1999

This study examined the longitudinal changes in alcohol consumption among elderly Japanese, characterized the subtrajectories within the aggregate trend, and examined potential predictors of these trajectories. Data come from a nationally representative survey of 2,566 persons in Japan, ages 60 to 96, followed over five waves between 1987—1999. Hierarchical linear modeling and cluster analysis were used to uncover trajectories of alcohol use. Multinomial logistic regression was employed to examine the predictors of trajectory association at baseline. Alcohol use appears relatively stable between ages 60 and 70, but declines thereafter. Further, there are three subtrajectories: stable, declining, and curvilinear (in addition to abstainers). Predictors of these trajectories varied by trajectory. Alcohol use may continue to be an important part of life at older ages. However, older drinkers appear to follow four drinking trajectories. Demographic characteristics and stressors may be associated with these trajectories. Knowledge of these trajectories may aid in targeting of interventions.

Pharmacotherapy for Substance Use Disorders

This article reviews the current pharmacotherapy options available for the treatment of patients with substance use disorders. In the United States there are medications available to treat tobacco use disorders (nicotine replacement, bupropion, and varenicline), alcohol use disorders (naltrexone and acamprosate), and opioid use disorders (methadone and buprenorphine). These medications are likely underused and physicians should more readily prescribe for eligible patients.

Socioeconomic determinants of risk of harmful alcohol drinking among people aged 50 or over in England

OBJECTIVES

This paper looks into the socioeconomic determinants of risk of harmful alcohol drinking and of the transitions between risk categories over time among the population aged 50 or over in England.

SETTING

Community-dwellers across England.

PARTICIPANTS

Respondents to the English Longitudinal Survey of Ageing, waves 4 and 5.

RESULTS

(Confidence level at 95% or higher, except when stated): ▸ Higher risk drinking falls with age and there is a non-linear association between age and risk for men, peaking in their mid-60s. ▸ Retirement and income are positively associated with a higher risk for women but not for men. ▸ Education and smoking are positively associated for both sexes. ▸ Loneliness and depression are not associated. ▸ Caring responsibilities reduce risk among women. ▸ Single, separated or divorced men show a greater risk of harmful drinking (at 10% confidence level). ▸ For women, being younger and having a higher income at baseline increase the probability of becoming a higher risk alcohol drinker over time. ▸ For men, not eating healthily, being younger and having a higher income increase the probability of becoming a higher risk alcohol drinker. Furthermore, the presence of children living in the household, being lonely, being older and having a lower income are associated with ceasing to be a higher risk alcohol drinker over time.

CONCLUSIONS

Several socioeconomic factors found to be associated with high-risk alcohol consumption behaviour among older people would align with those promoted by the 'successful ageing' policy framework.

Geriatric alcohol use disorder: a review for primary care physicians

Alcohol use disorder in the geriatric population is a growing public health problem that is likely to continue to increase as the baby boomer generation ages. Primary care providers play a critical role in the recognition and management of these disorders. This concise review will focus on the prevalence, risk factors, screening, and clinical management of geriatric alcohol use disorder from a primary care perspective.

[Liver diseases in the elderly]

Liver diseases in the elderly have aroused less interest than diseases of other organs, since the liver plays a limited role in aging. There are no specific liver diseases of old age, but age-related anatomical and functional modifications of the liver cause changes in the frequency and clinical behavior of some liver diseases compared with those in younger patients. This review discusses the most important features of liver function in the healthy elderly population, as well as the features of the most prevalent liver diseases in this age group, especially the diagnostic approach to the most common liver problems in the elderly: asymptomatic elevation of serum transaminases and jaundice.

Liver physiology and liver diseases in the elderly

The liver experiences various changes with aging that could affect clinical characteristics and outcomes in patients with liver diseases. Both liver volume and blood flow decrease significantly with age. These changes and decreased cytochrome P450 activity can affect drug metabolism, increasing susceptibility to drug-induced liver injury. Immune responses against pathogens or neoplastic cells are lower in the elderly, although these individuals may be predisposed to autoimmunity through impairment of dendritic cell maturation and reduction of regulatory T cells. These changes in immune functions could alter the pathogenesis of viral hepatitis and autoimmune liver diseases, as well as the development of hepatocellular carcinoma. Moreover, elderly patients have significantly decreased reserve functions of various organs, reducing their tolerability to treatments for liver diseases. Collectively, aged patients show various changes of the liver and other organs that could affect the clinical characteristics and management of liver diseases in these patients.

Prevalence and Patterns of Alcohol Misuse in a Community-Dwelling Elderly Sample in Brazil

Objective: The aim of this study was to estimate prevalence and patterns of lifetime alcohol misuse. Method: This was a cross-sectional study of a representative sample of 1,078 individuals aged 60 or more. Structured interview included sociodemographic, lifestyle, health data, and the five alcohol misuse screening questions of the Self-Reporting Questionnaire. Results: Prevalence of misuse was 6.5%. Men, aged 60 to 69, low educational level, separated/divorced, and tobacco smoking were independently associated with lifetime alcohol misuse. Odds ratios show increasing association with levels of alcohol misuse groups in males, low-educated, and tobacco users. Persons aged 60 to 69, 4 to 7 education years, and non-White ethnicity were significantly associated with the major alcohol misuse score. Discussion: Younger elderly were more exposed to alcohol than previous cohorts. Thus, problems with alcohol in old age will possibly increase as they grow older. The results of this study call attention to a field of lacking evidence in alcohol-related problems of older persons.

Moderate alcohol consumption predicts long-term mortality in elderly subjects with chronic heart failure

OBJECTIVE

Moderate alcohol consumption is related to a reduction of mortality. However, this phenomenon is not well established in the elderly, especially in the presence of chronic heart failure (CHF). The aim of the study was to verify the effect of moderate alcohol consumption on 12-year mortality in elderly community-dwelling with and without CHF.

SETTINGS

community-dwelling from 5 regions of Italy.

PARTICIPANTS

A cohort of 1332 subjects aged 65 and older.

MEASUREMENT

Mortality after 12-year follow-up in elderly subjects (≥65 years old) with and without CHF was studied. Moderate alcohol consumption was considered ≤250 ml/day (drinkers).

RESULTS

In the absence of CHF (n=947), mortality was 42.2% in drinkers vs. 53.7% in non-drinker elderly subjects (p=0.021). In contrast, in the presence of CHF (n=117), mortality was 86.5% in drinkers vs. 69.7% in non-drinker elderly subjects (p=0.004). Accordingly, Cox regression analysis shows that a moderate alcohol consumption is protective of mortality in the absence (HR=0.79; CI 95% 0.66-0.95; p<0.01) but it is predictive of mortality in the presence of CHF (HR=1.29; CI 95% 1.05-1.97; p<0.05).

CONCLUSIONS

Our data demonstrates that moderate alcohol consumption is associated with an increased long-term mortality risk in the elderly in the presence of CHF.

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.

Diagnosis and management of chronic liver disease in older people

Chronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.

How Gender and Religion Influence Alcohol Use in Elderly Korean Immigrants

This study examined the effects of religion and gender on drinking behaviors among a sample of 148 older Korean immigrants living in a metropolitan area in Canada. Face-to-face interviews were conducted using standardized questions. The mean age of the participants was 74 years (range: 60-97 years). Logistic regression models were used to assess the effects of religion on drinking and heavier drinking and gender differences in correlates of current drinking and heavier drinking. Results revealed that being married and having lower religiosity were significant correlates that increased the odds of being a current drinker. Older Korean men tend to engage in heavier drinking behavior. Higher religiosity, not mere affiliation to Protestant churches, decreased the odds of heavier drinking for both men and women. The odds of heavier drinking increased for depressed men. Study limitations and implications are presented in a cultural context.

Patterns and predictors of late-life drinking trajectories: a 10-year longitudinal study

This study examines the extent of group-level and intra-individual decline in alcohol consumption among adults as they traverse a 10-year interval spanning late-middle to early-old age. Further, it identifies key baseline predictors of these adults' 10-year drinking trajectories. Community residents (n = 1,291; age 55 to 65 years at baseline) were assessed at 4 points over a 10-year interval on demographic and health characteristics, coping responses, social context, and alcohol consumption. Descriptive cross-wave statistics, and multilevel regression analyses, indicated that in the sample overall, participants' 10-year patterns of alcohol consumption were relatively stable. However, men's patterns, and those of individuals drinking beyond recommended alcohol consumption guidelines at baseline, were more variable and showed steeper rates of decline, than did those of women and individuals drinking within recommended levels. Contrary to expectation baseline use of substances to reduce tension and heavier reliance on avoidance coping predicted faster rate of decline in alcohol consumption. Post hoc prospective mediation analyses suggested that this may have occurred because these and other baseline predictors heighten risk of developing new health problems which, in turn, motivate reduced alcohol consumption.

Patterns and predictors of late-life drinking trajectories: a 10-year longitudinal study

This study examines the extent of group-level and intra-individual decline in alcohol consumption among adults as they traverse a 10-year interval spanning late-middle to early-old age. Further, it identifies key baseline predictors of these adults' 10-year drinking trajectories. Community residents (n = 1,291; age 55 to 65 years at baseline) were assessed at 4 points over a 10-year interval on demographic and health characteristics, coping responses, social context, and alcohol consumption. Descriptive cross-wave statistics, and multilevel regression analyses, indicated that in the sample overall, participants' 10-year patterns of alcohol consumption were relatively stable. However, men's patterns, and those of individuals drinking beyond recommended alcohol consumption guidelines at baseline, were more variable and showed steeper rates of decline, than did those of women and individuals drinking within recommended levels. Contrary to expectation baseline use of substances to reduce tension and heavier reliance on avoidance coping predicted faster rate of decline in alcohol consumption. Post hoc prospective mediation analyses suggested that this may have occurred because these and other baseline predictors heighten risk of developing new health problems which, in turn, motivate reduced alcohol consumption.

Effect of a comprehensive lifestyle modification program on the bone density of male heavy drinkers

BACKGROUND

Heavy alcohol drinking is implicated in osteoporosis. Although abstinence is rapidly followed by a restoration of osteoblastic activity, little is known about the contributions of alcohol-related factors or the effectiveness of a lifestyle modification program (LMP) on bone density.

METHODS

We conducted a study of 138 male alcoholic patients to investigate whether drinking history and concurrent factors were associated with the bone density of the calcaneus. A 2.5-months LMP in an institutionalized setting was completed by 20 of them, and its effect on bone density, serum parathyroid hormone (PTH), and 1.25-(OH)(2) vitamin D levels were assessed.

RESULTS

The patients had a high prevalence of daytime drinking (93.5%), continuous drinking (84.1%), and current smoking (82.0%) with mean duration of alcohol abuse of 30.0 +/- 12.8 years. The patients had lower bone density than a reference control group (Z-scores: -0.45 +/- 1.02). Multiple stepwise regression analysis identified age, poor activities of daily living (ADL), continuous drinking, absence of liver cirrhosis, depression, and dementia as determinants of low bone density. The bone density of the 20 participants in the LMP improved 2.3% (p = 0.0003) with a more ameliorating effect on bone density than a conventional abstinence therapy (p = 0.014 for interventional effect). The upper normal range of PTH levels at baseline were significantly decreased, and 1.25-(OH)(2) vitamin D levels also had a trend toward decrease during the abstinence.

CONCLUSIONS

Alcoholic patients may have many complications such as poor ADL and dementia, which are independently associated with decreased bone density. The results of this study support the idea that comprehensive approach to lifestyle factors to minimize risk of osteoporosis is the best way to improve bone density.

At-risk alcohol drinking in primary care patients aged 75 years and older

BACKGROUND

Little is known about the prevalence and risk factors of alcohol problems among older people (especially those aged 75 years and more). The aims of this study were to report alcohol consumption patterns and to determine their association with socio-demographic variables and health characteristics.

METHOD

3224 non-demented subjects aged 75 and over and attending general practitioners (GPs) (n = 138) in an urban area of Germany were studied by structured clinical interviews including detailed assessment of alcohol consumption patterns distinguishing between abstainers, moderate drinkers and at-risk drinkers (>20 g of alcohol for women and >30 g of alcohol for men).

RESULTS

A high proportion (50.1%) of the sample were abstainers, 43.4% were moderate drinkers. The prevalence of at-risk alcohol consumption was 6.5% (95% CI 5.6-7.4). Rates were significantly higher for men (12.1%; 95% CI 10.2-14.0) compared to women (3.6%; 95% CI 2.8-4.4). After full adjustment for confounding variables we found that compared to moderate drinking abstaining from alcohol was significantly associated with female gender, lower education, and mobility impairment. Compared to moderate drinking at-risk drinking was significantly higher among men, individuals with a liver disease, and current smokers.

CONCLUSIONS

Multivariate analysis revealed that, apart from liver disease, at-risk drinking in a non-demented population aged 75 and over was associated with relatively good physical and mental health. Nevertheless, public prevention measures should focus on at-risk drinkers to make them aware of potential risks of high alcohol consumption in old age.

Prevalence and correlates of alcoholism in community-dwelling elderly living in São Paulo, Brazil

OBJECTIVES

To assess the prevalence of alcoholism in elderly living in the city of São Paulo (Brazil) and investigate associated risk factors.

METHODS

A total of 1,563 individuals aged 60 years or older, of both genders of three districts of different socioeconomic classes (high, medium and low) in the city of São Paulo (Brazil) were interviewed. The CAGE screening test for alcoholism was applied and a structured interview was used to assess associated sociodemographic and clinical factors. The tests Mini Mental State Examination, Fuld Object Memory Evaluation, The Informant Questionnaire on Cognitive Decline in the Elderly and Bayer-Activities of Daily Living Scale were used for cognitive and functional assessment.

RESULTS

Prevalence of alcoholism was 9.1%. Multivariate regression analysis showed that alcoholism was associated with male gender, 'mulatto' ethnicity, smoking, and cognitive and functional impairment. In addition, the younger the individual and the lower the schooling level, the higher the risk for alcoholism.

CONCLUSIONS

The results obtained in this study show that alcoholism is highly frequent in the community-dwelling elderly living in São Paulo, and that it is associated with socio-demographic and clinical risk factors similar to those reported in the literature. This suggests that alcoholism in the elderly of a developing country shares the same basic characteristics seen in developed countries. These findings suggest that it is essential for health services and professional to be prepared to meet this demand that will significantly grow in the next years, especially in developing countries, where the rates of population aging are higher than those of developed countries.

Correlates of lifetime alcohol misuse among older community residents in Brazil

BACKGROUND

Little is known about the sociodemographic correlates and health effects associated with lifetime alcohol misuse in community dwelling elderly people in Brazil.

METHOD

Data were obtained from a representative sample of 6961 residents aged 60+ in the state of Rio Grande do Sul, Brazil. The structured interview included a five-item lifetime alcohol use questionnaire addressing abuse and dependence, and questions regarding sociodemographic characteristics, lifestyle and social support, and health conditions.

RESULTS

In the interview, 10.6% respondents (25.3% men, 2.9% women) endorsed at least one lifetime alcohol misuse question. Controlled analyses comparing a gradient of alcohol misuse (none, one or more than one item endorsed), found that men, people aged 60-69 (compared to older persons) and tobacco users were more likely to endorse alcohol misuse items. Persons reporting lower income and who were of non-white race/ethnicity did not differ from their comparison groups with respect to endorsing one item, but they were more likely to endorse two or more items. Endorsing more than one item was associated with impaired activities of daily living, the presence of respiratory problems and psychiatric disorders, but was protective against vascular conditions.

CONCLUSIONS

Major lifetime alcohol misuse (defined as endorsing more than one of five items reflecting alcohol abuse or dependence) is more common in certain sociodemographic groups (men, younger elderly, lower income, non-whites). With the exception of vascular conditions, it is associated with smoking, poorer functional status, respiratory problems, and psychiatric disorder. Endorsing only one item has a reduced association, significant only for male gender, smoking, and psychiatric disorder.

A population-based study on binge drinking among elderly Brazilian men: evidence from the Belo Horizonte and Bambuí health surveys

OBJECTIVES: To assess the prevalence and factors associated with binge drinking in two populations of older adults (≥ 60 years). METHOD: A random sample of 685 subjects in the metropolitan area of Belo Horizonte (4.4 million inhabitants) and 643 subjects (92.7% from total residents) in Bambuí City (15,000 inhabitants), both in Southeast Brazil, participated in the study. The dependent variable was binge drinking (≥ 5 drinks on a single occasion in the last 30 days), and independent variables included sociodemographic characteristics, social network, health conditions and use of health services. RESULTS: The prevalence of binge drinking was higher in the metropolitan area of Belo Horizonte (27.0%) than in Bambuí (13.7%). In the multivariate analysis, worse self-rated health was the only variable associated with binge drinking in both populations (Prevalence ratios [PR] 0.62; 95%CI 0.45-0.85 and 0.57; (0.40-0.83), respectively). On the other hand, two important differences were found: 1) in the metropolitan area of Belo Horizonte, binge drinking was associated with higher school level [8+ years] (PR = 1.55; 95%CI 1.07-2.26) and functional disability (PR = 0.12); 95%CI (0.02-0.83) 2) in Bambuí, binge drinking was associated with being divorced or separated (PR = 2.49; 95%CI 1.55-3.99). CONCLUSIONS: Among older adults, differences of prevalence and factors associated with binge drinking can be found in a same country, probably due to sociocultural influences.

Alcoholic liver disease in the elderly

Although per capita alcohol consumption, and thus the prevalence of alcoholic liver disease, decreases generally with age in Europe and in the United States, recently an increase in alcohol consumption has been reported in individuals over 65 years. Reasons explaining this observation may include an increase in life expectancy or a loss of life partners and, thus, loneliness and depression. Although ethanol metabolism and ethanol distribution change with age, and an elderly person's liver is more susceptible to the toxic effect of ethanol, the spectrum of alcoholic liver diseases and their symptoms and signs is similar to that seen in patients of all ages. However, prognosis of alcoholic liver disease in the elderly is poor. In addition, chronic alcohol consumption may enhance drug associated liver disease and may also act as a cofactor in other liver diseases, such as viral hepatitis and nonalcoholic fatty liver disease.

Age, alcohol metabolism and liver disease

PURPOSE OF REVIEW

Alcohol consumption among the elderly has increased. Alcohol metabolism changes with age and the elderly are more sensitive to the toxic effects; this increased consumption is therefore of great clinical relevance.

RECENT FINDINGS

Metabolism of ethanol changes with advancing age because activity of the enzymes involved, such as alcohol and acetaldehyde dehydrogenase and cytochrome P-4502E1, diminish with age. The water distribution volume also decreases with age. Both lead to increased blood concentrations of ethanol. Also, elderly people take more drugs, and ethanol and these drugs may interact; therefore, alcohol consumption can modify serum drug concentrations and their toxicity. Finally, elderly people may suffer more frequently from other types of liver disease, and alcohol may exacerbate these.

SUMMARY

Over recent decades alcohol consumption has increased among those who are older than 65 years. Alcohol is more toxic in the ageing organism because of changes in its metabolism, distribution and elimination, which lead to central nervous system effects at lower levels of intake; also, ageing organs such as brain and liver are more sensitive to the toxicity of alcohol. For these reasons, alcohol should be used in moderation, especially among those of older age.

Substance abuse

Alcohol abuse poses special risks for increased morbidity and mortality among older adults, contributing to the heightened use of medical resources and the related increase in medical costs. Although the prevalance of alcohol use disorders in the older adults is generally less than that found in younger groups, it is expected to increase with the aging of the "baby-boom" generation. In spite of this, little attention has focused on developing, and evaluating the efficacy of, treatment programs for older adults with alcohol related disorders. This article discusses the availability of effective treatment strategies for older alcohol abusers and reviews the epidemiological and outcomes research literatures related to alcohol abuse and older adults. The few empirical studies that examine outcomes associated with the treatment of older substance abusers reveal positive outcomes, especially when "age-specific," cognitive-behavioral, and less confrontational treatment approaches are employed.

Liver diseases in the elderly: an update

Although there are no liver diseases specific to advanced age, the clinical course and management of liver diseases in the elderly may differ in several aspects from those of younger adults. During the last decade an explosion of new knowledge in liver disease has provoked increasing enthusiasm among hepatologists. On the other hand, the development of new emerging conditions (e.g. non-alcoholic steatohepatitis) and novel therapeutic approaches has made it increasingly difficult to validate and assimilate information to be applied in clinical practice. Some liver diseases in the elderly need to be revisited, particularly non-alcoholic fatty liver disease, chronic hepatitis C, alcoholic liver disease, and hepatocellular carcinoma. Moreover, some therapeutic approaches, especially antiviral therapy and liver transplantation, should be discussed also in selected groups of elderly patients.

Longitudinal trajectories of heavy drinking in adults in the United States of America

AIMS

To estimate age, period, cohort and other demographic influences on heavy alcohol consumption and trajectories of heavy drinking in American adults.

DESIGN

Prospective cohort of 14 127 participants, aged 25-74 years at baseline. Generalized estimating equations to model longitudinal change in the probability of heavy drinking and its association with demographic factors. Setting National, population-based sample of non-institutionalized civilians.

MEASUREMENTS

Heavy alcohol consumption (usual number of drinks per occasion >or= five for men; >or= four for women) at baseline (1971-74) and three follow-ups until 1992.

FINDINGS

Heavy alcohol consumption declined with increasing age (age effect) and tracked national average consumption (period effect). There was no cohort effect. Higher probability of heavy drinking was associated with male gender (relative risk: RR = 2.4), being not married (RR = 1.4), having less than high school education (RR = 1.7), having annual income below the median (RR = 1.5), not living in the South-east (RR = 1.7), and smoking (RR = 3.4). Getting married and quitting smoking during the study were each associated with reduction in heavy drinking (RR = 0.55 and 0.61, respectively). Slower age-related decline in the probability of heavy drinking was seen in men (P < 0.0001), married individuals (P = 0.03), and smokers (P = 0.05).

CONCLUSIONS

Demographic predictors of trends in heavy drinking are different from those for trends in average alcohol consumption. The likelihood of heavy drinking declined more slowly with increasing age in men and smokers, suggesting that the negative health effects of alcohol in older ages may be greatest in these groups.

Ten-year patterns of alcohol consumption and drinking problems among older women and men

AIMS

This study focused on changes in 10-year patterns of alcohol consumption among older women and men, late-life and life history predictors of drinking problems, and gender differences in these predictors.

DESIGN, SETTING, PARTICIPANTS

A sample of late-middle-aged community residents (N = 1291) who had consumed alcohol in the past year or shortly before was surveyed at baseline and 1 year, 4 years and 10 years later.

MEASUREMENTS

At each contact point, participants completed an inventory that assessed their alcohol consumption, drinking problems and health-related and life context factors. Participants also provided information about their life history of drinking.

RESULTS

Over the 10 years, the proportion of individuals who consumed alcohol declined. Among individuals who continued to drink, women and men showed comparable declines in alcohol consumption, minor concomitants of alcohol consumption and drinking problems. In addition to the amount of alcohol consumption, smoking, friends' approval of drinking and avoidance coping consistently predicted late-life drinking problems. With respect to life history factors, heavy drinking, drinking problems and increased drinking in response to life events were related to a higher likelihood of late-life drinking problems; obtaining help from family members and friends and, among men, participation in Alcoholics Anonymous, were related to a lower likelihood of problems.

CONCLUSION

Older women and men show comparable declines in alcohol consumption and drinking problems. Specific late-life social context and coping variables, and life history indices, are risk factors for late-life drinking problems among both women and men.

Epidemiology of late-life mental disorders

This article reviews the prevalence and incidence of mental disorders in older adults. The authors outline the epidemiologic challenges in determining the frequency of mental disorders in late-life and discuss issues that are critical for understanding the prevalence of the disorders and for reviewing the evidence from epidemiologic studies of mental disorders in this population. The authors summarize the epidemiologic data for depression, anxiety, dementia, schizophrenia, and alcoholism. Also included is a discussion of risk factors and outcomes of these disorders and a discussion of the implications of these epidemiologic findings for geriatric medicine.

Diagnosis and treatment of alcohol dependence in older alcoholics

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.

Alcohol Use in a Continuing Care Retirement Community

The purpose of this study was to explore alcohol use among older adults living in a continuing care retirement community (CCRC) and to consider differences in overall health, number of chronic illnesses, falls, age, and exercise behavior between those who drink moderately versus those who do not. A one-time face-to-face interview was conducted with a total of 316 residents living in an urban CCRC in the northeast. The participants were 86.6 6 6.3 years of age, and the majority were women (79%), unmarried (75%), White (9%), and middle to upper socioeconomic status (100%). The majority of these individuals (63%) drank moderately, consuming at least one drink daily. No difference was found between men's and women's drinking behaviors (chi 2 = .47, p > .05). Adults who drank moderately were older (F = 8.7, p < .05), more likely to exercise regularly (chi 2 = 27, p < .05), and were more likely to have had a fall (F = 3.7, p < .05). No statistically significant difference was found between the groups related to perceptions of overall health, number of chronic illnesses, number of medications, overall or number of medications that interact with alcohol, or cognitive status. Although not statistically significant, a greater percentage of individuals who drink moderately had fractures (12%) when compared to the percentage of individuals who do not drink at least moderately (7%). Recognizing both benefits and risks to alcohol use in older adults suggests that an individual approach to educating these individuals about their use of alcohol should be conducted.

Late onset alcoholism

Rather high prevalence rates of alcohol abuse in the elderly have been reported in the literature. However, there is some evidence that many elderly persons with alcohol problems are not identified, probably due to the nonspecificity of alcohol-related presentations in old individuals. Thus, there is an ongoing discussion on appropriate diagnostic criteria for alcohol dependence in elder people who frequently begin to abuse alcohol in late life. This study was aimed to explore whether alcoholics with late onset (beginning after the age of 45) differ from those with an early onset (prior the age of 25). Two hundred and sixty eight subjects consecutively referred to a ward of a general hospital specialized for alcohol detoxification were divided into three groups by the age at onset of harmful alcohol consumption. The duration of harmful drinking was rather similar in all groups. However, alcohol dependence according to the ICD-10 criteria (three or more have to be fulfilled) was diagnosed in 94.1% of the alcoholics with an early onset (</= 25 years), but only in 62.2% of those with late onset (P < 0.0001). Significant differences between these groups were found for the following criteria: preoccupation with drinking (P < 0.0001), impaired capacity to control drinking (P < 0.01), strong desire to drink alcohol (P < 0.01), and a trend towards a lower rate of lifetime psychiatric comorbidity. The alcoholics with late onset reported fewer previous detoxifications and a lower actual alcohol consumption. Moreover, they showed a higher rate of abstinence in the 12 month follow-up. Regarding the difficulties in comparing groups of different ages at onset of harmful alcohol use our results suggest that the alcoholics with late onset differ in many ways from those with early onset.

Alcohol, aging, and cognitive performance: a cross-cultural comparison

This study investigated the relationship between alcohol consumption and cognitive performance in two culturally diverse community-based populations. METHODS. A cross-sectional analysis was used including Japanese Americans (n = 1,836) and Caucasians (n = 2,581) aged 65 and older. Cognitive performance was measured using the Cognitive Abilities Screening Instrument (CASI) (0 to 100 point scale) and reaction time. RESULTS. Multivariate analysis revealed significant cultural and gender differences with cognitive performance. Compared to abstainers, Caucasian drinkers scored higher than Japanese American drinkers on the CASI (adjusted means = 93.4 versus 91.6). In contrast, Japanese American drinkers scored faster than Caucasian drinkers on choice reaction time (adjusted means = 505 versus 579 milliseconds). DISCUSSION. Results showed that current drinking was associated with better cognition in both the Caucasian and Japanese American groups. Longitudinal studies are needed to support the possible protective effects of alcohol on cognition and explore whether culture may modify this apparent benefit.

Treatment of tobacco dependence in alcoholics

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Screening for health behaviors in ambulatory clinical settings: does smoking status predict hazardous drinking?

Although a link between alcohol consumption and smoking behavior is well documented, the majority of studies have focused on individuals dependent on both alcohol and nicotine. The present study examined the likelihood of hazardous drinking as a function of smoking status, gender, age, ethnicity, and education in a sample of 676 medical and dental patients whose drinking covered the spectrum from abstinence to high levels. We hypothesized that hazardous drinking would be more common among young, male respondents who were current smokers and that past smokers would show a risk of hazardous drinking that was intermediate between that of current smokers and nonsmokers. Results showed that younger age, fewer years of education, male gender, and current smoking status were significant predictors of hazardous drinking. However, there was no relationship between a past history of smoking and current risk of hazardous drinking. Evaluation of the Fagerstrom Tolerance Questionnaire (FTQ) showed that it was no more useful as a screening instrument than a single question that elicited current smoking status. These findings suggest that patients who report current smoking should routinely be asked about their current alcohol consumption. Interventions should then be tailored to address smoking and, if appropriate, hazardous drinking as well.

On the empirical association between poor health and low socioeconomic status at old age

Epidemiologic studies using mortality rates as indicators of health fail to find any meaningful association between poor health and low socioeconomic status in older age-groups, whereas economic studies using self-assessed health consistently find a significant positive correlation, even after controlling for self-reporting errors. Such contradictory results have not been reported for working age individuals. A simple explanation might be that the elderly samples on which the epidemiologic and economic studies are based come from different populations. However, this paper shows that similar contradictory results are obtained even when the same samples are used, simply by switching between self-assessed health and mortality as health indicators. An alternative explanation is proposed, namely that these health indicators yield different results because they relate to different ranges of the latent health variable at old age.

Eqüidade em áreas sócio-econômicas com impacto na saúde em países da União Européia

Pode ser eventualmente mais adequado corrigir desigualdades no domínio da educação, estilos de vida ou nutrição do que no domínio da saúde. O presente artigo propõe-se medir as desigualdades existentes, em países da União Européia, em áreas sócio-econômicas com impacto na saúde da população. Utilizou-se o coeficiente de Gini para quantificar as desigualdades entre países da União Européia no que respeita a educação e atividades culturais, estilos de vida, nutrição, desemprego, utilização de serviços de saúde e despesa em saúde. Os indicadores que apresentam coeficientes de Gini mais elevados são a percentagem da população com ensino secundário elevado, o consumo per capita de manteiga e o consumo per capita de embalagens de medicamentos. Consiste motivo de preocupação para o setor saúde que a área da educação apresente uma tão grande desigualdade em relação à percentagem de inscritos no ensino secundário elevado, em países da União Européia. A desigualdade que existe no consumo per capita de manteiga é igualmente de salientar por causa do impacto que a nutrição tem, por exemplo, na incidência de doenças cárdio e cerebrovasculares e do peso que essas doenças têm na estrutura de mortalidade.

Alcohol abuse, cognitive impairment, and mortality among older people

OBJECTIVES

To estimate the prevalence of alcohol abuse, the association of alcohol abuse with cognitive impairment, and the contribution of alcohol abuse to short-term mortality in a cohort of older people screened for dementia.

DESIGN

Using the Canadian Study of Health and Aging (CSHA)--a representative, national cohort study of 10,268 older persons (> or = 65 years) from communities and long-term care institutions conducted in 1991--alcohol abuse and dementia were diagnosed during clinical examinations. Death was determined by telephone interview 18 months after baseline and verified by vital statistics records.

SETTING

36 regional community and 17 regional institutional populations in Canada.

PARTICIPANTS

The 2,873 individuals from the clinical sample of the CSHA.

MEASUREMENTS

Diagnosis of alcohol abuse (questionable, definite, none), diagnosis of dementia.

RESULTS

The prevalence of clinically detected definite alcohol abuse was 8.9% (95% confidence interval (CI) 7.9-9.9) and of questionable alcohol abuse was 3.7% (95% CI 3.0-4.4). Definite or questionable alcohol abuse was associated with a younger average age compared with no such abuse history, and men were significantly more likely than women to comprise definite and questionable diagnostic groups as compared with the group without alcohol abuse. The occurrence of all types of dementia except probable Alzheimer's disease was higher in those with definite or questionable alcohol abuse. Mortality at 18 months was higher among those with definite (14.8%, 95% CI 13.5-16.1) or questionable (20.0%, 95% CI 18.5-21.5) alcohol abuse, as compared with those with no alcohol abuse history (11.5%, 95% CI 10.3-12.7), and alcohol abuse (definite or questionable) conferred a 56% additional risk of short-term mortality (odds ratio (OR) 1.56, 95% CI 1.11-2.20) after adjusting for age, sex, and a diagnosis of dementia.

CONCLUSIONS

Alcohol abuse among older people is common and occurs more frequently among men. It is associated with cognitive impairment and independently with short-term mortality. Physician screening for alcohol abuse can yield a group of older people at risk for adverse health outcomes.

Are older hazardous and harmful drinkers less likely to participate in health-related behaviors and practices as compared with nonhazardous drinkers?

OBJECTIVES

To describe the (1) prevalence of at-risk drinking and participation in health-related behaviors and practices and (2) associations of at-risk drinking with other health-related behaviors and practices among older persons completing a health-risk appraisal for the elderly (HRA-E).

DESIGN

Cross-sectional study using data from a self-administered, mailed survey sample.

SETTINGS

Persons from three organizations were surveyed: (1) the American Association of Retired Persons; and (2) a large medical group and (3) a community-based senior health center in southern California.

PARTICIPANTS

1,889 persons age 55 years and older.

MEASUREMENTS

The HRA-E included items on health characteristics, drinking behaviors (including amount of alcohol use and two alcoholism screening measures: the CAGE (Cut down, Annoyed, Guilty, Eye opener) and Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G), and participation in selected health-related behaviors and practices. Social drinkers were defined as those who drank fewer than 14 drinks weekly and screened negative on the CAGE (defined as two or more "no" responses) and SMAST-G. Hazardous drinkers drank fewer than 14 drinks weekly and screened negative. Harmful drinkers drank fewer than 14 drinks weekly and screened positive. Possible at-risk drinkers drank 14 or more drinks weekly and screened positive. Least squares regression models were used to assess the effects of hazardous, harmful, and possible at-risk drinking on each of the health-related practices and behaviors. We also conducted these analyses using three other definitions of social, possible at-risk, hazardous, and harmful drinking.

RESULTS

Of all respondents, 40% were social drinkers, 3% were harmful drinkers, 2% were hazardous drinkers, and 11% were possible at-risk drinkers. Hazardous, harmful, and possible at-risk drinkers commonly reported driving after drinking or being driven by someone who had been drinking (67%, 76%, and 64% respectively). Harmful and possible at-risk drinkers were more likely than social drinkers to smoke and were less likely to use seatbelts regularly. These findings were observed regardless of how the drinking groups were defined.

CONCLUSION

All groups of at-risk drinkers more commonly engaged in selected adverse health-related behaviors and practices than did social drinkers.

Alcohol problems in old age: a review of recent epidemiological research

The subject of alcoholism in late life has received relatively little attention in the literature. This is despite the fact that elderly people are particularly vulnerable to the adverse effects of alcohol. Demographic data predicts that in the first half of the next century there will be an increase in the absolute number of elderly people with alcohol problems. The recognition and treatment of alcohol problems are likely therefore to become more important as this population expands. High rates of comorbidity with physical and psychiatric illness mean that elderly alcoholics are liable to be frequent users of health facilities. Concern has been expressed regarding the impact this trend will have upon health services, particularly the high costs of treatment and institutionalization. Previous researchers in this field have been disadvantaged by a lack of standardized diagnostic criteria and the absence of age-validated screening tools. This paper reviews recent publications relating to the epidemiology of alcohol problems in the elderly and focuses on comparing the prevalence rates of alcohol problems in various clinical settings. Epidemiological research is important as it improves the understanding of the scope and impact of a disease as well as being a vital component during the planning stage for new services. This review highlights some ongoing limitations in recent research.

Acamprosate. Pharmacoeconomic implications of therapy

Acamprosate is thought to reduce the craving for alcohol. The drug helps to maintain abstinence in alcohol-dependent patients who have successfully undergone detoxification. Abstinence rates during 3 to 12 months' treatment with acamprosate were approximately double those with placebo in most clinical trials, although abstinence rates were generally still < 50% in patients assigned to receive acamprosate. The drug is generally well tolerated, with the most common adverse effect being diarrhoea. In a German cost-effectiveness model, a treatment programme including acamprosate was the dominant strategy, producing a lifetime cost saving of 2602 Deutschmarks (1992 to 1995 values) per additional abstinent patient compared with treatment without acamprosate. In a Belgian pharmacoeconomic model, total direct medical costs over 2 years were 21,301 Belgian francs (1997 values) per patient lower with a treatment programme including acamprosate than treatment without acamprosate in alcohol-dependent patients. The main factors in the cost savings with acamprosate in these models were reduced costs for acute hospitalisation and rehabilitation/follow-up. The results of a cost-benefit analysis that considered both direct and indirect costs for the total alcohol-dependent population in Spain were consistently in favour of acamprosate. The lifetime net benefit for acamprosate over placebo (the incremental benefit) ranged between 61,642 million and 99,069 million pesetas (1996 values) in various scenarios with 40 to 60% of patients receiving treatment.

Atypical antipsychotics in older adults

Psychotic symptoms are common in older adults and reflect a variety of psychiatric and medical conditions. Antipsychotic drugs form the core of the treatment of these symptoms; however, treatment of the elderly is complicated by a high frequency of comorbid medical illnesses, risk of side effects, and age-related changes in pharmacodynamics and pharmacokinetics. The superior safety and efficacy of atypical antipsychotics makes them first-line agents for managing psychotic patients with schizophrenia. Their uses now extend to other conditions such as schizoaffective disorders, delusional disorder, and mood disorders with psychotic features. Although the drugs have been studied extensively in young subjects, well-designed, double-blind, placebo-controlled studies are relatively lacking in the elderly. Our knowledge of their safety, efficacy and dosage in older adults is based on a few studies with small samples or extrapolated from studies of younger patients. Several psychiatric and medical conditions that are associated with psychotic symptoms in older people are reviewed, as well as how these patients may benefit from treatment with these agents.

Drinking habits among older persons: findings from the NHANES I Epidemiologic Followup Study (1982-84). National Health and Nutrition Examination Survey

OBJECTIVES

To describe alcohol use and its sociodemographic correlates among persons aged 65 years and older in a US probability sample.

DESIGN

Cross-sectional analysis of a national probability sample-based cohort study.

SETTING

Multiple sites throughout the United States.

PARTICIPANTS

A total of 3448 persons aged 65 and older who participated in the first wave of the NHANES I Epidemiologic Followup Study (1982-84).

MEASUREMENTS

We describe the alcohol use behaviors and demographic characteristics of 3448 persons aged 65 and older. Least squares regression models were used to assess associations between older persons' sociodemographic characteristics and alcohol use.

RESULTS

Sixty percent of the sample reported having 12 or more drinks of alcohol in at least 1 year of their lives. Seventy-nine percent of these older drinkers were currently drinking. Twenty-five percent of all drinkers drank daily (31% men, 19% women). Using gender-specific definitions (men >2 drinks/day; women >1 drink/day), 16% of men drinking alcohol and 15% of women drinking alcohol were heavy drinkers. Younger age, male gender, and higher income were associated with greater alcohol use.

CONCLUSIONS

Most older persons who ever drank alcohol in their lifetimes were currently drinking. In addition, a substantial number of older persons were drinking currently at levels that may place them at risk of adverse health consequences.

Prevalence and correlates of alcohol use among older adults

BACKGROUND

The 1990 Health Promotion and Disease Prevention supplement to The National Health Interview Survey was used to develop point-prevalence data about drinking for four age groups, 55-64, 65-74, 75-84, and over 84, and to assess the impact of sociodemographics, health status, and health belief variables on light, moderate, and heavy alcohol consumption. The number of observations in the unweighted sample was 12,819, and the weighted sample contained 51,046,521 observations.

METHODS

The chi 2 and Cohran-Mantel-Haenszel tests were used to investigate prevalence patterns, and odds ratios were generated from logistic regressions.

RESULTS

Eighty percent of the sample had had at least 12 drinks during their lifetime, and 46% reported drinking during the survey year. The modal category for the number of days a respondent drank during the survey was 1-4 days, and the modal amount consumed on days that a person drank was 1-3 drinks. Age, gender, race, education, city size, labor force participation, geographic region, health status, having diabetes, and health beliefs about the adverse effects of excessive drinking and being overweight were associated with alcohol consumption, although their effects were different by drinking level.

CONCLUSIONS

Analyses of health behaviors among older adults must recognize the diversity within this age group. Studies of drinking should differentiate between the amount consumed. Health beliefs need to be included in subsequent studies of health behaviors among older adults.

Alcohol's Role in Work-Force Entry and Retirement

Employment and drinking behavior interact in intriguing ways both upon entrance to and departure from the labor force. Teenagers who work are more likely to drink than their unemployed peers, possibly offsetting the expected advantages of gaining early job experience. For young people in general, early heavy drinking can curtail continuing education and stifle opportunities for career advancement. At the opposite end of the age spectrum, some retirees may turn to alcohol to fill leisure time and cope with the stresses associated with retirement as a major life change. Other retirees, however, may cut back on drinking once they are freed from job-related stress, leave a work environment that encourages alcohol use, or experience financial constraints. Although tolerance to alcohol's effects wanes with advancing age, older adults who remain employed are more apt than retirees to drink heavily. Alternatively, older workers may decide to restrict their drinking to keep pace with younger colleagues.