Royal College of Psychiatrists, London. Our invisible addicts. First Report of the Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists, College Report CR165. June 2011
The Royal College of Psychiatrists of London has published a report related primarily to problems of unrecognized alcohol misuse among the elderly. The report provides guidelines for psychiatrists and family physicians on how to find and how to treat elderly people with misuse of alcohol and drugs.
A few pages of the lengthy report concern the evidence base for a proposed reduction of sensible limits of alcohol intake for older people. Forum reviewers of the report point out inherent difficulties in providing drinking guidelines for a very non-homogenous group of individuals whose only criterion for inclusion is being above the age of 65 years. Such individuals vary from marathon runners to very sick, frail people. Reviewers thought that advice to lower “acceptable” levels of drinking for everyone in this age group was not appropriate and not based on reliable research.
The Forum reviewers were also struck by the absence of any discussion in the report of the demonstrated strong positive effects of moderate drinking on most of the diseases of ageing. Data are especially convincing for cardiovascular diseases and dementia, which are among the leading causes of morbidity and mortality in this age group.
Specific Forum Comments
Forum members consider it very important to identify abusive drinking among the elderly and this report provides specific and very reasonable recommendations to assist practitioners in both the identification and treatment of such problems. On the other hand, the report was conspicuously lacking in a discussion of the important role that the moderate intake of wine and other beverages can play in reducing the risk of coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis. Advising healthy people aged 65 years or older who are moderate, responsible drinkers to stop drinking or to markedly reduce their intake would not be in their best health interests, especially in terms of their risk of cardiovascular diseases.
Evidence is also accumulating that shows that the risk of Alzheimer’s disease and other types of dementia is lower among moderate drinkers than among abstainers. Neurodegenerative disorders are key causes of disability and death among elderly people. Epidemiological studies have suggested that moderate alcohol consumption, especially of wine, may reduce the incidence of certain age-related neurological disorders including Alzheimer’s disease.1-3 Furthermore, regular dietary intake of flavonoid-rich foods and/or beverages has been associated with 50% reduction in the risk of dementia,4 a preservation of cognitive performance with ageing,5,6 a delay in the onset of Alzheimer’s disease,7 and a reduction in the risk of developing Parkinson’s disease.8
Polyphenols may act to protect the brain in a number of ways, including the protection of vulnerable neurons, the enhancement of existing neuronal function, or by stimulating neuronal regeneration.9 For example, red wine antioxidants have been observed to protect hippocampal neurons against ethanol-induced damage10 and a moderate consumption of Cabernet Sauvignon attenuated Aβ-neuropathology in a mouse model of Alzheimer’s disease.11
Further, scientific data are consistent in demonstrating that quality of life is better and total mortality is lower among moderate drinkers than among abstainers. For example, analyses by Simons et al from a large population-based patient population in New South Wales demonstrated clearly that regular moderate alcohol consumption increases life span and quality of life for men up to 80 years of age and for women indefinitely.12,13
Health benefits from polyphenols in the diet
There was no reference in the Royal College report specifically regarding potential benefits of polyphenols in the diet in reducing the risk of certain diseases of ageing. As discussed above, wine is a substance high in polyphenols and has been shown to protect against stroke,14 and also protects the brain of the elderly.15 Moreover, wine polyphenols protect against Alzheimer’s disease.16-18 Because it is such a rich source of polyphenols and other substances, some Forum members consider wine as a “functional food.” While wine and other beverages that contain alcohol can obviously be abused, moderate drinking has been shown in many studies to be an important component of a “healthy lifestyle.”19,20
Drinking guidelines for individuals over age 65
There is no question that, on average, very elderly people may be more sensitive to the effects of alcohol (especially those individuals with chronic diseases, lower muscle mass, a poor diet, etc.) However, 65-year-olds are healthier than people of that age a generation ago, and advice should not be based on out-dated information. And contrary to what the newspapers and some “experts” tell us about our ageing populations, age-specific disability rates are decreasing, not increasing. Of more importance, the absolute risk for cardiovascular diseases increases markedly with age, and therefore the beneficial or protective effect of light to moderate drinking on cardiovascular diseases is greater in the elderly than in younger people.
Current US guidelines define more than one drink/day for adults aged 65 or older as “at-risk drinking,” but there is little science to support this restriction. Instead, a number of studies suggest that a limit of no more than one drink per day for everyone in this age group may be unnecessary. A paper by Lang et al,21 based on two large population-based cohort studies (one in the US and one in England), found that people aged 65 or greater who consumed up to 2 drinks/day had no greater disability or mortality that subjects consuming up to 1 drink/day (and both groups had more favorable outcomes than non-drinkers).
In another paper, by Kirchner et al22 of almost 25,000 American adults over age 65 seen in primary care, those reporting between 8 and 14 drinks/week (defined by some as “at-risk” drinking) did not differ significantly in their characteristics from drinkers consuming 1-7 drinks/week. The two groups were also similar in three health parameters evaluated: depressive/anxiety symptoms, perceived poor health, and poor social support. Heavier drinkers and binge drinkers did not do as well. We thus have another paper suggesting that elderly drinkers who consume 8-14 drinks/week may not necessarily be “at risk” drinkers.
A particular interesting paper by White et al23 showed a direct dose-response relation between alcohol consumption and risk of death in women aged 16-54 and in men aged 16-34, whereas at older ages the relation is U shaped. These investigators used statistical models relating alcohol consumption to the risk of death from single causes to estimate the all-cause mortality risk for men and women of different ages. The authors state that their data suggest that women should limit their drinking to 1 unit a day up to age 44, to 2 units a day up to age 74, and to 3 units a day over age 75. Men should limit their drinking to 1 unit a day up to age 34, to 2 units a day up to age 44, to 3 units a day up to age 54, and to 4 units a day up to age 84.
Since the absolute effects of moderate drinking on cardiovascular disease are much greater in older people than in younger adults, the current limitations to intake for the elderly may not be appropriate. Attempting to persuade elderly people who currently drink moderately in the 1 to 2 drinks/day category to decrease their current intake may not be advisable since “over restrictive limits risk encouraging nihilistic response or fruitless clinical effort.21”
The Royal College of Psychiatrists of London has published a report related primarily to problems of unrecognized alcohol misuse among the elderly. The report provides guidelines for psychiatrists and family physicians on how to find and how to treat elderly people with misuse of alcohol and drugs. The report also mentions lower “sensible limits” for older people in comparison with younger people. The Forum reviewers point out, however, inherent difficulties in providing guidelines for a very non-homogenous group of individuals whose only criterion for inclusion is being above the age of 65 years. Such a group includes individuals varying from marathon runners to very sick, frail people. Forum reviewers thought that advice to lower limits of drinking for everyone in this age group is not based on reliable research, and would certainly not apply to all in this age group.
The Forum reviewers were also struck by the absence in the Royal College report of any discussion of the strong positive effects of moderate drinking on most of the diseases of ageing, especially cardiovascular diseases, diabetes, and dementia, which are leading causes of morbidity and mortality in this age group. For healthy moderate and responsible drinkers, advice to reduce or stop all alcoholic beverage intake would not be in the best health interests of such individuals.
References from Forum comments
1. Lindsay J, Laurin D, Verreault R, Hebert R, Helliwell B, Hill GB, McDowell I. Risk factors for Alzheimer’s disease: a prospective analysis from the Canadian Study of Health and Aging. Am J Epidemiol 2002;156:445-453.
2. Orgogozo JM, Dartigues JF, Lafont S, Letenneur L, Commenges D, Salamon R, Renaud S, Breteler MB. Wine consumption and dementia in the elderly: a prospective community study in the Bordeaux area. Rev Neurol (Paris) 1997;153:185-192.
3. Truelsen T, Thudium D, Gronbaek M. Amount and type of alcohol and risk of dementia: the Copenhagen City Heart Study. Neurology 2002;59:1313-1319.
4. Commenges D, Scotet V, Renaud S, Jacqmin-Gadda H, Barberger-Gateau P, Dartigues JF. Intake of flavonoids and risk of dementia. Eur J Epidemiol 2000;16;357-363.
5. Letenneur L, Proust-Lima C, Le GA, Dartigues JF, Barberger-Gateau P. Flavonoid intake and cognitive decline over a 10-year period. Am J Epidemiol 2007;165:1364-1371.
6. Morris MC, Evans DA, Tangney CC, Bienias JL, Wilson RS. Associations of vegetable and fruit consumption with age-related cognitive change. Neurology 2006;67:1370-1376.
8. Checkoway H, Powers K, Smith-Weller T, Franklin GM., Longstreth WT Jr, Swanson PD. Parkinson’s disease risks associated with cigarette smoking, alcohol consumption, and caffeine intake. Am J Epidemiol 2002;155:732-738.
9. Youdim KA, Joseph JA. A possible emerging role of phytochemicals in improving age-related neurological dysfunctions: a multiplicity of effects. Free Radical Biology and Medicine 2001;30:583-594.
10. Assuncao M, Santos-Marques MJ, De Freitas V, Carvalho F, Andrade JP, Lukoyanov NV, Paula-Barbosa MM. Red wine antioxidants protect hippocampal neurons against ethanol-induced damage: A biochemical, morphological and behavioural study. Neuroscience 2007;146:1581-1592.
11. Wang J, Ho L, Zhao Z, Seror I, Humala N, Dickstein DL, Thiyagarajan M., Percival SS, Talcott ST, Pasinetti GM. Moderate consumption of Cabernet Sauvignon attenuates Aß neuropathology in a mouse model of Alzheimer’s disease. Faseb Journal 2006;20:2313-2320.
12. Simons LA, Friedlander Y, McCallum J, Simons J. Predictors of mortality in the prospective Dubbo Study of Australian Elderly. Aust NZ J Med 1996;26:40-48.
13. Simons LA, Simons J, FriedlanderY, McCallum J. Predictors of long-term mortality in the elderly: the Dubbo Study. Int Med J 2009. doi: 10.1111/j.1445-5994.2009.02106.x
14. Truelsen T, Grønbaek M, Schnohr P, Boysen G. (1998). Intake of beer, wine, and spirits and risk of stroke : the Copenhagen City Heart Study. Stroke 1998;29:2467-2472.
15. Orgogozo JM, Dartigues JF, Lafont S, et al. Wine consumption and dementia in the elderly: a prospective community study in the Bordeaux area. Rev Neurol [Paris] 1997;153:185-192.
16. Ono K, Yoshiike Y, Takashima,A, et al. Potent anti-amyloidogenic and fibril-destabilizing effects of polyphenols in vitro: implications for the prevention and therapeutics of Alzheimer’s disease. J Neurochem 2003;87:172-181.
17. Savaskan E., Olivieri G, Meier F, et al. . Red wine ingredient
resveratrol protects from beta-amyloid neurotoxicity. Gerontology 2003;49:380-383.
18. Marambaud P, Zhao H, Davies P. Resveratrol promotes clearance
of Alzheimer’s disease beta-amyloid peptides. J Biol Chem 2005;280: 37377-37382.
19. Mukamal KJ, Chiuve SE, Rimm EB. Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles. Arch Intern Med 2006;166:2145-2150.
20. Khaw K-T, Wareham N, Bingham S, Welch A, Luben R, Da N. Combined impact of health behaviours and mortality in men and women: The EPIC-Norfolk Prospective Population Study. www.plosmedicine.org 0002 January 2008;5:e12.
21. Lang I, Guralnik J, Wallace RB, Melzer D. What level of alcohol consumption is hazardous for older people? Functioning and mortality in U.S. and English national cohorts. J Am Geriatr Soc 2007;55:49–57.
22. Kirchner JE, Zubritsky C, Cody M, Coakley E, Chen H, Ware JH, Oslin DW, Sanchez HA, Durai UNB, Miles KM, Llorente, MD, Costantino G, Levkoff S. Alcohol consumption among older adults in primary care. J Gen Intern Med 2007;22:92–97.
23. White IR, Almann DR, Nanchahal K. Alcohol consumption and mortality: modelling risks for men and women at different ages. BMJ 2002;325:191 doi: 10.1136/bmj.325.7357.191.
* * *
Comments on the present report were provided by the following members of the International Scientific Forum on Alcohol Research:
David Vauzour, PhD, Senior Research Associate, Department of Nutrition, Norwich Medical School, University of East Anglia, Norwich, UK.
Pierre-Louis Teissedre, PhD, Faculty of Oenology – ISVV, University Victor Segalen Bordeaux 2, Bordeaux, France.
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway.
Creina Stockley, clinical pharmacology, Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia.
Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark.
Maritha J. Kotze, PhD, Human Genetics, Dept of Pathology, University of Stellenbosch, Tygerberg, South Africa.
Ulrich Keil, MD, PhD, Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA.
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA.
Giovanni de Gaetano, MD, PhD, Research Laboratories, Catholic University, Campobasso, Italy.