Critique 203: Moderate alcohol intake may reduce, not increase, the risk of falls in the elderly – 7 August 2017

Ortolá R, García-Esquinas E, Galán I, Guallar-Castillón P, López-García E, Banegas JR, Rodríguez-Artalejo F. Patterns of alcohol consumption and risk of falls in older adults: a prospective cohort study. Osteoporosis International 2017, on-line publication. DOI 10.1007/s00198-017-4157-2.

Authors’ Abstract

Summary Falls are a major health problem in older adults, but their relationship with alcohol consumption in this population remains unclear.  In a cohort with 2170 older adults followed up for 3.3 years, both moderate drinking and the Mediterranean drinking pattern were associated with a lower risk of falls and injurious falls.

Introduction This study aims to examine the association between certain patterns of alcohol consumption, including the Mediterranean drinking pattern (MDP), and the risk of falls in older adults.

Methods A prospective cohort with 2170 community-dwelling individuals aged ≥60 years was recruited in Spain in 2008–2010 and followed up through 2012. At baseline, participants reported alcohol consumption and, at the end of follow-up, their falls during the previous year. The MDP was defined as moderate alcohol consumption (threshold between moderate and heavy intake was 40 g/day for men and 24 g/day for women) with preference for wine and drinking only with meals. Analyses were conducted with negative binomial or logistic regression, as appropriate, and adjusted for the main confounders.

Results Compared with never drinkers, the number of falls was lower in moderate drinkers (incidence rate ratio (95% confidence interval), 0.79 (0.63–0.99)) and drinkers with MDP (0.73 (0.56-0.96)).  Also, moderate drinkers and those with MDP showed a lower risk of ≥2 falls (odds ratio (95% confidence interval), 0.58 (0.38-0.88) and 0.56 (0.34-0.93), respectively) and of falls requiring medical care (0.67 (0.46-0.96) and 0.61 (0.39-0.96), respectively).

Conclusion Both moderate drinking and the MDP were associated with a lower risk of falls and injurious falls in older adults. However, sound advice on alcohol consumption should balance risks and benefits.

Forum Comments

Falls are common among the elderly, and markedly increase the subsequent risk of morbidity and mortality among subjects. Injuries occurring from falls (especially fractures and head injuries) can be the cause of the poorer health outcomes in such subjects; however, even if no serious injury occurs, the fall itself may be an indicator of poorer health to begin with.

There has been much written about the dangers of even light-to-moderate intake of alcohol among the elderly, with an increase in potential falls being one key reason cited. This may not be in the best interest of elderly subjects; the demonstrated protection of light-to-moderate alcohol intake against many of the diseases of ageing (especially coronary heart disease, diabetes, stroke, osteoporosis, dementia, a decrease in functional capacity, etc.) could outweigh any dangers from falls if the latter risk is not great.

The present study examined the association between certain patterns of alcohol consumption, including the Mediterranean drinking pattern (MDP), and the risk of falls in older adults. It is a well-done study, and in their analyses the investigators report that they were able to adjust for “sociodemographic and lifestyle-related factors: sex, age, educational level, tobacco smoking, cohabitation (living alone or with someone else), usual time spent watching TV, and overall physical activity (metabolic equivalent-h/week).  Nighttime sleep duration at night and during the day was obtained, and study participants were also asked if they had been previously diagnosed with cardiovascular disease (myocardial infarction, stroke, or heart failure), hypertension, diabetes, chronic respiratory disease (asthma or chronic bronchitis), osteomuscular disease (osteoarthritis or arthritis), cancer, or depression requiring treatment.  Additionally, participating subjects reported the number of medications (of any kind) and antihypertensive medications taken as well as the use of sleeping pills, which were checked against drug packages by study staff.”

The study found that up to moderate amounts of alcohol (defined as less than 40 grams of alcohol/day for men and less than 24 grams/day for women) did not only not increase the risk of falls, but actually resulted in a significant decrease of 20% or more in such risk. Specifically, the investigators report that “After a 3.3-year follow-up, 465 (21.4%) of study participants had experienced at least one fall, and 153 (7.1%) two or more falls, in the previous year,” and these were less common among moderate drinkers. Similar results were found for subjects reporting only one fall and those reporting 2 or more falls within the preceding year.  They report further that “Subjects with higher scores for a Mediterranean-type diet, that includes regular wine consumption, had similar or more impressive reduction in their risk of falls.”

The results are similar to many previous studies which indicate that while heavy drinking increases the risk of falls (and many other conditions), the risk appears to not be increased or even lower for subjects reporting light or moderate alcohol intake (Mukamal et al, Cawthon et al, Berg et al, Maraldi et al, Gale et al). Such findings should be taken into consideration when developing recommendations regarding alcohol intake in the elderly.

Specific comments by Forum members 

Forum member Ellison pointed out that the results of the present study are generally consistent findings from a summary of studies on the topic by Anderson et al from the The European project VINTAGE (which describes itself as “A systematic review of scientific literature was undertaken to document the evidence base on the impact of alcohol on the health and well-being of older people, and on effective policies and preventive approaches to face the problem in this steadily increasing segment of the population).” Anderson et al state: “Many, but not all, studies have shown that some alcohol intake decreases osteoporosis.  There were mixed findings between alcohol intake and the risk of fractures, with some studies finding no relationship (Lin et al) , and others finding that light drinking protects against the risk of fractures, whilst problems drinking increases the risk of fractures (León-Muñoz et al).”

In regards to alcohol and falls, the VINTAGE report states: “Reid et al found 26 studies, four of which found an increased risk for falls or fall injuries associated with exposures ranging from daily use to an average weekly consumption of > 21 drinks when compared with non-drinkers or individuals consuming <1 drink per week (alcohol content of drinks not defined).  Twenty-one studies found no association between increased alcohol use and falls or fall injuries.  In contrast, one study found that participants who reported daily use of alcohol had decreased risk for falls compared with non-drinkers.”  Forum member Ellison concluded: “The general finding seems to be that an increase in risk of falls occurs primarily among heavier drinkers; on the other hand, light-to-moderate drinking is the level of consumption associated with many health benefits among the elderly.”

The summary article from VINTAGE also quotes Reid et al as commenting on the risk of motor vehicle accidents associated with alcohol: “As might be expected, older drivers with a diagnosis of alcohol dependence have a higher relative risk of a motor vehicle accident than drivers without such a diagnosis (Marshall).  Other studies (Sorock et al) have suggested that drinkers have an increased risk of death from a motor vehicle accident than non-drinkers, but such studies often suffer for failing to take into account the amount of driving (it may be that drinkers drive more than non-drinkers and are thus more likely to have an accident).  Data from Great Britain show that drink drive accidents amongst drivers aged 60 years or over are a tiny proportion (4%) of all accidents per license holder, even accounting for distance driven (Dept of Transport, Great Britain).”

Forum member Van Velden did not think that this study added much to our understanding of the health benefits of moderate drinking. “At most, alcohol abuse is still considered to increase the risk of falls.  The moderate drinkers may just follow a healthier lifestyle, and may have a stronger musculoskeletal system than heavy and binge drinkers.  The cognitive benefits may play only a minor role in the prevention of falls.”

Reviewer Pajak had some questions about the study: “Is it plausible that abstainers have similar chance for falls as heavy drinkers? The reference group is a problem.  I do not know much about Spain but in other countries people abstain due to health problems or because having an alcohol problem (not necessary reported).  The authors adjusted for a long list of health variables but interactions between them were not assessed.  Having them all in one model could influence the final result.  There were only 2170 participants.  Sensitivity analysis after exclusion of the first year events was not attempted probably due to the short follow-up time.”

Forum member Skovenborg stated: “I agree with the previous comments that it is difficult to substantiate a lower risk for moderate alcohol intake, however, I applaud the inclusion of drinking pattern, especially the regular intake of modest amounts of wine with meals, as a category – that should be done in all observational studies of alcohol and health.”

Forum member de Gaetano agrees with the comments by Pajak, especially on the relatively low number of subjects studied and the lack of variable interactions. He also supports Ellison’s comment that the protection of light-to-moderate alcohol intake against many of the diseases of ageing (especially coronary heart disease, stroke, osteoporosis, dementia) could outweigh any possible negative effect of alcohol on dangers from falls. De Gaetano stated: “Showing now that moderate alcohol not only is not dangerous but may even prevent a number of falls in the elderly is of great public health importance.”

References from Forum critique

Anderson P, ScafatoI E. Galluzzo L, for the VINTAGE project Working Group. Alcohol and older people from a public health perspective.  Ann Ist Super Sanità 2012;48, n.3, Roma.  http://dx.doi.org/10.4415/ANN_12_03_04

Berg KM, Kunins HV, Jackson JL, Nahvi S, Chaudhry A, et al. Association Between Alcohol Consumption and Both Osteoporotic Fracture and Bone Density.  Am J Med 2008;121:406–418.  doi:  10.1016/j.amjmed.2007.12.012

 Cawthon PM, Harrison SL, Barrett-Connor E, Fink HA, Cauley JA, Lewis CE, et al. Alcohol intake and its relationship with bone mineral density, falls, and fracture risk in older men.  J Am Geriatr Soc 2006;54:1649-57.  http://dx.doi.org/10.1111/j.1532-5415.2006.00912.x

Department for Transport. Reported road casualties Great Britain 2008: Annual Report. UK; UK National Statistics; 2009.  Available from: www.dft.gov.uk/pgr/statistics/datatablespublications/accidents/casualtiesgbar/rrcgb2008.

Gale CR, Cooper C, Sayer AA. Prevalence and risk factors for falls in older men and women: The English Longitudinal Study of Ageing.  Age and Ageing 2016;45:789-794. DOI: 10.1093/ageing/afw129.

León-Muñoz LM, Guallar-Castillón P, García-Esquinas E, Galán I, Rodríguez-Artalejo F. Alcohol drinking patterns and risk of functional limitations in two cohorts of older adults.  Clin Nutr 2016; doi:10.1016/j.clnu.2016.05.005

Lin JC, Guerrieri JG, Moore AA. Drinking patterns and the development of functional limitations in older adults: longitudinal analyses of the health and retirement survey. J Aging Health 2011;23:806–821. doi:10.1177/0898264310397541

Maraldi C, Harris T, Newman AB, Kritchevsky SB, Pahor M, Koster A, et al, for the Health ABC study. Moderate alcohol consumption and risk of functional decline: is there a causal relationship? The Health, Aging, and Body Composition Study.  J Am Geriatr Soc 2009;57:1767-1775. doi: 10.1111/j.1532-5415.2009.02479.x

Marshall SC. The role of reduced fitness to drive due to medical impairments in explaining crashes involving older drivers. Traffic Inj Prev 2008;9:291-298. http://dx.doi.org/10.1080/15389580801895244.

Mukamal KJ, Mittleman MA, Longstreth WT Jr, Newman AB, Fried LP, Siscovick DS. Self-reported alcohol consumption and falls in older adults: cross-sectional and longitudinal analyses of the cardiovascular health study.  J Am Geriatr Soc 2004;52:1174-1179.

Reid MC, Boutros NN, O’Connor PG, Cadariu A, Concato J. The health-related effects of alcohol use in older persons: a systematic review.  Subst Abus 2002;23:149-164.  http://dx.doi.org/10.1080/08897070209511485

Sorock GS, Chen LH, Gonzalgo SR, Baker SP. Alcohol drinking history and fatal injury in older adults. Alcohol 2006;40:193-199. http://dx.doi.org/10.1016/j.alcohol.2007.01.002.

Forum Summary

Falls are common among the elderly, and markedly increase the subsequent risk of morbidity and mortality.  There has been much written about the dangers of even light-to-moderate intake of alcohol among the elderly, with an increase in potential falls being one key reason cited.  This may not be in the best interest of many elderly subjects; the demonstrated protection of light-to-moderate alcohol intake against many of the diseases of ageing (especially coronary heart disease, stroke, osteoporosis, dementia) could outweigh any dangers from falls if the latter risk is not great.

The present study examined the association between certain patterns of alcohol consumption, including the Mediterranean drinking pattern (MDP), and the risk of falls in more than 2,000 elderly subjects over 3.3 years; at the end of follow up, 21.4 % of subjects reported at least one fall in the previous year. The study found that up to moderate amounts of alcohol (defined as less than 40 grams of alcohol/day for men and less than 24 grams/day for women) did not increase the risk of falls, but actually resulted in a significant decrease of 20% or more in such risk.  The risks for having multiple falls or those requiring medical care were also lower for moderate drinkers. The investigators report further that subjects with higher scores for a Mediterranean-type diet, that includes regular wine consumption, had similar or more impressive reduction in their risk of falls.

The specific reasons for such protection are not fully known, but a number of favorable effects on health of moderate drinking (e.g., less osteoporosis, less cardiovascular disease, less dementia, greater functional capacity, etc.) may play a role. While the investigators of this study were able to adjust for many factors known to be associated with falls, residual confounding is always a possibility to explain these results.

To summarize, while previous studies have often reported an increase in risk of falls for heavy drinkers, the present study supports results of many previous studies indicating that light-to-moderate alcohol intake does not increase the risk, and often is shown to decrease the risk of falls and fractures. In the present study, even with adjustments for most known lifestyle factors affecting risk, moderate drinking was associated with at least a 20% decrease in the risk of falls when compared with abstainers.  This is a message that needs to be incorporated into drinking recommendations for the elderly.

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The following members of the International Scientific Forum on Alcohol Research provided contributions to this critique:

Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy

R. Curtis Ellison, MD, Professor of Medicine & Public Health, Boston University School of Medicine, Boston, MA, USA

Professor Andrzej Pająk, Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland

Erik Skovenborg, MD, specialized in family medicine, member of the Scandinavian Medical Alcohol Board, Aarhus, Denmark

Creina Stockley, PhD, MSc Clinical Pharmacology, MBA; Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia

Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway

Dag S. Thelle, MD, PhD, Department of Biostatistics, Institute of Basic Sciences, University of Oslo, Norway; Section for Epidemiology and Social Medicine, Sahlgrenska Academy. University of Gothenburg,

David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa

Andrew L. Waterhouse, PhD, Department of Viticulture and Enology, University of California, Davis, USA