Critique 256: Alcohol consumption and health outcomes among 70 year olds in Sweden – 22 August 2022

Ahlner F, Erhag HF, Johansson L, Fässberg MM, Sterner TR, Samuelsson J. Zettergren A, Waern M, Skoog  I.  Patterns of Alcohol Consumption and Associated Factors in a Population-Based Sample of 70-Year-Olds: Data from the Gothenburg H70 Birth Cohort Study 2014–16.  

Int. J. Environ Res Public Health 2022;19:8248; https://doi.org/10.3390/ijerph19148248

Abstract: Older adults of today consume more alcohol, yet knowledge about the factors associated with different consumption levels is limited in this age group.

Based on the data from a population-based sample (n = 1,156, with 539 men and 617 women) in The Gothenburg H70 Birth Cohort Study 2014–16, we examined sociodemographic, social, and health-related factors associated with alcohol consumption levels in 70-year-olds, using logistic regression. Total weekly alcohol intake was calculated based on the self-reported amount of alcohol consumed.  Alcohol consumption was categorized as lifetime abstention, former drinking, moderate consumption (≤98 g/week), and at-risk consumption (>98 g/week).  At-risk consumption was further categorized into lower at-risk (98–196 g/week), medium at-risk (196–350 g/week), and higher at-risk (≥350 g/week).

We found that among the 1,156 participants, 3% were lifetime abstainers, 3% were former drinkers, 64% were moderate drinkers, and 30% were at-risk drinkers (20% lower, 8% medium, 2% higher).  Among several factors, former drinking was associated with worse general self-rated health (OR 1.65, 95% CI 1.08–2.51) and lower health-related quality of life (measured by physical component score) (OR 0.94, 95% CI 0.91–0.97), higher illness burden (OR 1.16, 95% CI 1.07–1.27), and weaker grip strength (OR 0.96, 95% CI 0.94–0.98).  Higher at-risk drinkers more often had liver disease (OR 11.41, 95% CI 3.48–37.37) and minor depression (OR 4.57, 95% CI 1.40–14.95), but less contacts with health care (OR 0.32, 95% CI 0.11–0.92).

Our findings demonstrate the importance of classifications beyond abstinence and at-risk consumption, with implications for both the prevention and clinical management of unhealthy consumption patterns in older adults.

Forum Comments

It is usually recommended that elderly persons should consume lower amounts of alcohol than advised for younger subjects.  This is based on limited evidence that older people have slower alcohol metabolism and lower levels of total body water (as well as the frequent coexistence of a number of diseases of ageing and the usual intake of medications that may react to alcohol).   However, reviewer Skovenborg cites strong evidence that such recommendations for the elderly are based more on tradition than on science. 

Are our assumptions about drinking in the elderly valid?  Forum member Skovenborg states: “The size of reduction of total body water with age is exaggerated, the myth of slower alcohol metabolism is false, and the problems of disease and use of medication in old age is very diverse.”  He continues: “The population of adults aged 65 years or older is very varied, ranging from the most robust healthy individuals with excellent marathon performances to the frailest residents of assisted living facilities and nursing homes. No single formula can predict the alcohol metabolism, alcohol tolerance and consequences of drinking for this heterogeneous group.  However, essential information is presented in a recent review by Jones of the relevant scientific literature on alcohol, its absorption, distribution and metabolism.” 

Skovenborg describes the lack of evidence for marked changes in alcohol tolerance among the elderly.  He speaks first of total body water (TBW), where he states: “Evidence from Chumlea et al indicates that the change is total body water with age is not great:  Once in the bloodstream, alcohol is distributed into the total body water (TBW) compartment, which comprises around 55-60% of body weight in nonobese males and around 50-55% in females. In men, TBW declines from on average 45.6 liters (age 20 to 29 years) to 42.5 liters (age 80 to 89 years) = a loss of 3.1 liters (6.9 pct.) of TBW during 60 years.  In women TBW declines from 32.0 liters (age 20 to 29 years) to 30.2 liters (age 80 to 89 years) = a loss of 1.8 liters (5.6 pct.) of TBW during 60 years.” 

As for metabolism of alcohol, Skovenborg reports: “Vestal et al’s 1977 study of the effect of aging on the elimination of alcohol in a group of 50 healthy subjects ranging in age from 21 to 81 years found no influence by age on the rates of ethanol elimination.  A well-preserved hepatic ethanol elimination in old age has subsequently been confirmed in ten other studies.  For example, Beresford & Lucey studied the influence of age and gender on blood alcohol concentrations in 14 men and 14 women 21–40 years old and 14 men and 15 women ≥ 60 years old who were given the same amount of alcohol on three occasions; they found the downward sloping parts of the BAC curves (depicting alcohol metabolism) to be identical for young/old women and young/old men, whether fasting or after a meal.  After a light meal, the peak BACs are practically identical for young and old alike.  One study (Fiorentino & Moskowitz) even found a higher alcohol elimination rate for older subjects (51 to 69 years) than younger subjects (19 to 50 years).”

Skovenborg also commented on evidence for an altered responsiveness to alcohol of the brain in the elderly, stating: “Quillan, et al compared simulated driving performance of 14 middle-aged men (mean age 36 years) and 14 older men (mean age 69 years) while sober and when legally intoxicated (BAC > 80 mg/100 ml).  While both age and legal intoxication affected driving performance, older men were no more sensitive to alcohol in terms of peak BAC, driving performance or awareness/judgement than middle-aged men.”

Reviewer Finkel commented: “I am pleased that Skovenborg, in his usual erudite way, has remembered to correct the all too facilely accepted, long and widely repeated, but scientifically poorly based assumptions about our older populations’ toleration of alcohol.”  Reviewer di Gaetano agreed that we must always investigate traditional assumptions and test them with unbiased review of emerging data.

Definitions of “at-risk drinking”:  The present analyses are based on a population-based study in Sweden, and provide good information on the amount of alcohol consumed, the pattern of alcohol intake, and associations with health outcomes, among a large group of 70-year-old subjects.  It provides not only a valid overview of the drinking patterns of such subjects, but associates varying levels of what is commonly referred to as “at risk” drinking with health outcomes.  The results indicate that it is not appropriate to group all subjects consuming more than the recommend level of alcohol, thus classified as “at-risk” drinkers, into a single category.  Health outcomes are less favorable for ex-drinkers and at-risk drinkers reporting larger amounts than they are for moderate drinkers and those classified as at-risk drinkers but consuming lower amounts of alcohol. 

Reviewer Ellison noted: “This paper is mainly a descriptive picture of the factors associated with alcohol consumption in a group of 70-year-old men and women.  It demonstrates very well how a large number of social, biological, mental and physical factors relate to alcohol consumption, and may modify the effects of drinking on health.  We have recognized for many years how socio-economic status, however measured by education, occupation, and income, can modify the effects of alcohol, but many of the conditions studied in this analysis are generally not considered in most epidemiologic studies, and information on such are not readily available. 

“The relations reported on the effects of various levels of drinking emphasize how defining ‘at-risk’ can be tricky.  As often shown in epidemiologic studies, subjects reporting levels that barely exceed the amounts of alcohol ‘recommended’ do not show the same health effects as for really ‘heavy drinkers.’  While the results of this study cannot give definitive answers on what could be considered ‘safe’ levels of consumption, they support many previous studies that suggest some people whose drinking is considered ‘at-risk’ do not have adverse effects on health from their alcohol intake.”    

Forum member Mcevoy wrote:  “I think this study is valuable in demonstrating the variety of factors that differ across drinking groups in the absence of any potential confounding by age or birth cohort. It also clearly illustrates that it is not appropriate to lump all “at risk” drinkers in the same category since those who drink closer to guidelines show few differences from moderate drinkers. 

Skovenborg added: “I agree with the comments by others that ‘it is not appropriate to lump all “at risk” drinkers in the same category since those who drink closer to guidelines show few differences from moderate drinkers’.  The large majority of this group of elderly people from Sweden are very moderate drinkers indeed: the median consumption was 32 g alcohol per week among moderate drinkers and 135 g among the lower risk drinkers. The lower at-risk drinkers had higher life satisfaction, had myocardial infarction and diabetes less often, had better grip strength and had higher MMSE scores. To most people the word “risk” means “danger” – the chance that something bad will happen to you – and the above results seem to give the significance of  “low risk” a whole new dimension. The drinkers were classified according to alcohol intake (g/week) with no information about drinking pattern which is an important limitation. A drinker with a weekly consumption of 135 g with a drinking pattern of regular intake of wine or beer with a meal most days of the week should not be in the same risk category as a person with a drinking pattern of weekend drinking of 135 g consumed in 2 days = 67.5 g/day, which amounts to a binge drinking pattern.” 

Reviewer Goldfinger wrote: “Further, this paper underscores the value of looking more closely at historical drinking pattern, particularly in the older population where history has consumed many decades of influence, and in this particular population where current drinking patterns may have more immediate implications.  As we have been emphasizing for decades, ex-drinkers who no longer consume alcohol must never be placed in the same category as never drinkers, as many of the former may have stopped drinking due to adverse health effects, so may be classified as ‘sick quitters’.

“Past drinkers, or new abstainers, often have serious co-morbidities, particularly in the older population, that leads to the decision to stop drinking.  Excessive drinking over the course of many years would be expected to have its greatest risk in later years.  Moderation, as it is with most things in life, supports healthy ageing.  Inasmuch as teasing out these subsets in the elderly are important in understanding the influence of alcoholic consumption with respect to health and making accurate observations, I would suspect the same may be said for younger subjects.”  Reviewer Finkel wrote: “I think we need more studies of this sort, which explore these various facets and others of the relationship between alcohol consumption and health.  Here, we see patterns of health associated with different patterns of drinking among a relatively uniform population. The authors are restrained in extracting conclusions.” 

Reviewer Stockley agreed with other Forum members that regular, moderate alcohol intake among the elderly may have beneficial health effects; she presented an interesting summary of experiences in Australia and in the US and other countries.  “Alcohol consumption in later life has reportedly increased in Australia and internationally, and despite public health recommendations to reduce all alcohol consumption with increasing age, such recommendations may be misleading.

“The US Health and Retirement Study published in 2019 conducted multiple, bi-annual assessments of alcohol consumption over 16 years, that is, data on frequency and quantity, and whether there was binge drinking, and other time-variable factors for 7,904 participants. This was so that changes in consumption could be evaluated.  Even after adjustment for confounders, former drinkers who were current abstainers after age 56 years (subsequently aged 79-89 years) had the highest risk of subsequent mortality, consistent with sick quitters.  Moderate alcohol consumption was associated with a lower mortality rate compared with occasional drinking. Moderate consumption for men was reporting 1-3 drinks/day without binge drinking and for women reporting 1-2 drinks/day without binge drinking.  Quantitative bias analyses further indicated that omitted confounders would need to be associated with approximate four-fold increases in mortality rates for men and approximate nine-fold increases for women to change the results (Keyes, et al).

“It has also been previously shown that although older moderate alcohol consumers, aged over 55 years, may have better risk factor profiles than abstainers, including higher socioeconomic status and fewer functional limitations and psychosocial factors (which explain some of the survival advantage associated with alcohol consumption), moderate alcohol consumers still maintain their survival advantage even after adjustment for these factors (Lee, et al; Holahan et al).  Moderate alcohol consumption was even associated with a lower risk of all-cause mortality in former problem drinkers (Holahan, et al).

“It has also been previously shown that women surviving to age 70 years and older who were moderate alcohol consumers generally had less disability and disease, and more signs of ‘successful ageing’ (Sun, et al). For ‘regular’ moderate alcohol consumers (on 5-7 days/week), there was an approximately 50% greater chance of such successful ageing when compared with non-drinkers.

“In addition, the US Health and Retirement Study has previously reported that moderate alcohol consumption independently confers reduced frailty risk for both older men and women (Shah, et al), predicts fewer depressive symptoms among older adults (Paulson, et al) where social interaction is essential to the seemingly beneficial effect of moderate alcohol consumption on depressive symptomatology and functional ability (Scott, et al).  Quality of life is a relatively little considered factor in epidemiological studies of successful ageing and alcohol consumption, yet we know from the US Rancho Bernardo Study of Healthy Ageing, and indeed from the Australian Dubbo Study of the Elderly, that a higher quality of life is associated with higher cognitive, mental and physical health and generally, longevity (Simons, et al. 2006; Simons, et al 2014; Richard, et al).”

References from Forum critique

Beresford TP, Lucey MR.  Ethanol metabolism and intoxication in the elderly. In Alcohol and Aging (eds T. Beresford & E. Gomberg): pp. 117–127. Oxford University Press, 1995.

Chumlea WC, Guo SS, Zeller CM, Reo NV, et al. Total body water reference values and prediction equations for adults.  Kidney Int 2001;59:2250-2258.

Fiorentino DD, Moskowitz H.  Breath alcohol elimination rate as a function of age, gender, and drinking practice.  Forensic Science International 2013;233:278-282.

Holahan CJ, Schutte KK, Brennan PL, Holahan CK, Moos BS, Moos RH. Late-life alcohol consumption and 20-year mortality. Alcohol Clin Exp Res 2010;34:1961–1971.

Jones AW.  Alcohol, its absorption, distribution, metabolism, and excretion in the body and pharmacokinetic calculations. WIREs Forensic Sci 2019;e1340.

Keyes KM, Calvo E, Ornstein KA. Rutherford C. Fox MP, Staudinger UM, Fried LP.  Alcohol Consumption in Later Life and Mortality in the United States: Results from 9 Waves of the Health and Retirement Study.  Alcoholism: Clin Exp Res 2019;43:1734-1746.

Lee SJ, Sudore RL, Williams BA, Lindquist K, Chen HL Covinsky KE.  Functional limitations, socioeconomic status, and all-cause mortality in moderate alcohol drinkers. J Am Geriatr Soc 2009;57:955–962.

Paulson D, Shah M, Herring D, et al.  The relationship between moderate alcohol consumption, depressive symptomatology, and C-reactive protein: the Health and Retirement Study. Int J Geriatr Psychiatry 2018;33:316-324.

Quillian WC, Cox DJ, Kovatchev BP, Phillips C.  The effects of age and alcohol intoxication on simulated driving performance, awareness and self-restraint. Age Ageing 1999;28:59-66.

Richard EL, Kritz-Silverstein D, Laughlin GA, Fung TT, Barrett-Connor E, McEvoy LK. Alcohol Intake and Cognitively Healthy Longevity in Community-Dwelling Adults: The Rancho Bernardo Study. J Alzheimers Dis 2017;59:803-814.

Scott RG, Wiener CH, Paulson D.  The Benefit of Moderate Alcohol Use on Mood and Functional Ability in Later Life: Due to Beers or Frequent Cheers?  Gerontologist 2018; doi: 10.1093/geront/gny129.

Shah M, Paulson D, Nguyen V. (2018) Alcohol Use and Frailty Risk among Older Adults over 12 Years: The Health and Retirement Study. Clin Gerontol 2018;41:315-325.

Simons LA, Simons J, McCallum J, Friedlander Y. (2006) Lifestyle factors and risk of dementia: Dubbo Study of the elderly. Med J Aust. 2006:184:68-70. || doi: 10.5694/j.1326-5377.2006.tb00120.x.

Simons, L.A. (2014) Alcohol intake and survival in Australian seniors: The Dubbo Study.  Nutr Aging 2014;2:85-90.

Sun Q, Townsend MK, Okereke OI, et al.  Alcohol consumption at midlife and successful ageing in women: a prospective cohort analysis in the Nurses’ Health Study.  PLoS Med 2011;8:e1001090.

Vestal RE, McGuire EA, Tobin JD, Andres R, et al. Aging and ethanol metabolism. Clin Pharmacol Therapeutics 1977;21:343-354.

Forum Summary

In a population-based cohort of 70-year-old men and women recruited in Gothenburg, Sweden, in 2014-2016, the authors of this paper have presented a detailed listing of many social, environmental, and biological factors that relate to non-drinking, former drinking, or current drinking of varying amounts of alcohol.  Our Forum critique raises some questions about the traditional belief that the elderly should consume markedly less alcohol than younger subjects, and that the limitations placed on subjects related sorely to their age may often not be appropriate. 

The paper emphasizes how a very large number of factors may modify the association between the amount of alcohol consumed and measures of health and disease.  Many of these, such as indices of socio-economic state, are usually adjusted for in epidemiologic studies.  Data on other factors that relate to alcohol consumption (such as self-related health, having a partner, grip strength, having others worried about their drinking, religiosity, gait speed, life satisfaction, etc.) represent data usually not collected in epidemiologic studies.

Forum members thought that these analyses show that subjects whose reported alcohol intake is only slightly above the recommended “safe” levels for subjects of this age should not be classified as “at-risk” drinkers.  Most of their features match those of subjects reporting intake within current recommendations; certainly, they do not match the characteristics of heavier drinkers.     

Forum members also pointed out that in addition to improved mortality associated with truly moderate drinking, as seen in essentially all epidemiologic studies, these analyses demonstrate that many other components of “successful ageing” are also associated with regular, moderate consumption of alcohol.

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Comments on this critique by the International Scientific Forum on Alcohol Research have been provided by the following members:

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

R. Curtis Ellison, MD, Professor of Medicine, Emeritus; Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA

Harvey Finkel, MD, Hematology/Oncology, Retired (Formerly, Clinical Professor of Medicine, Boston University Medical Center, Boston, MA, USA)

Tedd Goldfinger, DO, FACC, Desert Cardiology of Tucson Heart Center, University of Arizona School of Medicine, Tucson, AZ, USA

Dominique Lanzmann-Petithory, MD, PhD, Nutrition Geriatrics, Hôpital Emile Roux, APHP Paris, Limeil-Brévannes, France 

Linda McEvoy, PhD, Department of Radiology, University of California at San Diego (UCSD), La Jolla, CA, USA

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

Creina Stockley, PhD, MSc Clinical Pharmacology, MBA; Principal, Stockley Health and Regulatory Solutions; Adjunct Senior Lecturer, The University of Adelaide, Adelaide, Australia

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