Welcome to the second edition of the Oregon Center of Excellence for Behavioral Health & Aging (OCEBHA) Older Adult Behavioral Health newsletter! This quarterly newsletter highlights important topics related to behavioral health and aging, with special emphasis on emerging research and innovative programs to support the behavioral health needs of older adults. In this issue, we highlight some of the latest research related to older adults and alcohol use.  

A recent study by Substance Abuse and Mental Health Services Administration (SAMHSA) found that 57% of Americans aged 65 years of age and older consumed alcohol in the past year, with 12% of these users reporting binge drinking in the past month. Alcohol use is associated with worsening of existing health problems such as diabetes, high blood pressure, mood disorders, and cancer. Because older adults are more sensitive to the effects of alcohol due to changes in metabolism, there is an increased risk of confusion, falls and injury.

More than half of individuals who use alcohol-interactive medication reported drinking alcohol, which means older adults could be taking commonly used alcohol-interactive medications, like heart or circulatory medications, diuretics, seizure medications, anti-anxiety medications, muscle relaxers, pain relievers, diabetes medications and antidepressants. Older adults are at a greater risk than the general population for harmful side effects from prescription drug use, as  more than half of adults 65 and older (54%) report taking four or more prescription drugs (Kaiser Family Foundation, 2019). Side effects are more likely due to aging-related changes in how the body processes medications. There may be over the counter and other drug interactions, plus alcohol and other substances compound risk.

According to the U.S. Centers for Disease Control and Prevention (CDC), 38% of all alcohol-related deaths in 2020 and 2021 were people ages 65 years of age or older.

In 2020, sales of alcohol increased by 2.9%, the largest annual increase in over 50 years.

Perceived Risk of Binge Drinking Among Older Alcohol Users: Associations with Alcohol Use Frequency, Binge Drinking, Alcohol Use Disorder, and Alcohol Treatment Use (Choi et al., 2024)

In 2020, sales of alcohol increased by 2.9%, the largest annual increase in over 50 years since a 3.4% jump in 1968 (Slater & Alpert, 2022). 40% of older alcohol users perceived binge drinking 1-2 times per week as highly risky, with no significant difference between age groups 50-64 and 65+. People who drank nearly daily engaged in binge drinking or had mild AUD were less likely to perceive binge drinking as high risk, suggesting possible rationalization of their drinking habits. This study also found negative associations between binge drinking risk perception and cannabis use/nicotine dependence among older alcohol users, indicating those who use multiple substances may have lower risk perception overall. Women and minority groups showed higher risk perception regarding binge drinking compared to men and non-Hispanic white people, influenced by various social and cultural factors.

Treatment rates were alarmingly low, with only about 10% of older adults with AUD seeking any form of treatment, despite the availability of effective behavioral and pharmaceutical interventions.

Increased alcohol use during the COVID-19 pandemic: The effect of mental health and age in a cross-sectional sample of social media users in the U.S. (Capasso et al., 2021)

This study analyzed data from 5,850 US adults who consumed alcohol, collected through Facebook surveys in March and April 2020. 29% of survey respondents reported increased alcohol use during the early stages of the COVID-19 pandemic in the United States (US), highlighting how stress events can drive alcohol consumption. During COVID-19, women were more likely than men to report increased alcohol use, despite men being more likely to use alcohol overall.

Younger adults (18-39) were more likely to increase drinking compared to middle-aged (40-59) and older adults (60+), showing an inverse age gradient. Age modified the impact of mental health on drinking: older adults with anxiety or depression showed markedly higher probability of increased drinking compared to their peers without these symptoms. People experiencing symptoms of anxiety (47% of respondents) and depression (30% of respondents) had significantly higher odds of reporting increased alcohol use.

Interestingly, people who perceived themselves at higher risk for COVID-19 or believed it would be more severe were slightly less likely to increase their drinking.

The study sample was predominantly white and educated, limiting generalizability to other demographic groups in the US, but the study findings suggest a need for age-tailored public health messaging and focused substance use prevention efforts, particularly for those who may be vulnerable to COVID-19, stress events, and problem drinking. The authors recommend early intervention and innovative treatment delivery methods (such as telehealth) to address potential increases in problem drinking during the pandemic.

In community-dwelling, 26.9% of older adults with persistent/recurrent pain reported regular alcohol use.

Hazardous Alcohol Use Among Community-Dwelling Older Adults With Persistent or Recurrent Pain: Findings From the Health and Retirement Study (LaRowe, et al., 2024) 

In a study focused on community-dwelling older adults, researchers found 26.9% of older adults with persistent/recurrent pain reported regular alcohol use (drinking ≥ weekly). Among regular drinkers, 42.5% engaged in hazardous alcohol use, either excessive drinking or binge drinking.

32.1% of regular drinkers exceeded the recommended daily limits of >2 drinks/day for men, >1 drink/day for women), and about 22.4% of regular drinkers reported binge drinking (≥4 drinks on one occasion) in the past 3 months. Among those who used opioids in the past 3 months, 47.6% reported hazardous drinking patterns, showing no reduction compared to non-opioid users (40%).

These findings highlight concerning rates of hazardous alcohol use among older adults with pain, particularly given the risks of alcohol-opioid interactions and other health complications.

Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors (Ortolá et al., 2024)

This study included 135,103 older UK participants, with a median age 64 years, 50.1% women, who were current alcohol users. They found that high-risk alcohol use was associated with higher mortality rates, including 33% higher all-cause mortality, 39% higher cancer mortality, and 21% higher cardiovascular mortality. Moderate-risk alcohol use was linked to a 10% higher all-cause mortality and 15% higher cancer mortality, while low-risk drinking was associated with 11% higher cancer mortality in the overall sample.

Among individuals without socioeconomic or health-related risk factors, low and moderate-risk alcohol use showed no significant associations with mortality. For those with health-related risk factors, low-risk alcohol use was associated with 15% higher cancer mortal, moderate-risk drinking was linked to 10% higher all-cause mortality and 19% higher cancer mortality,

Among those with socioeconomic risk factors, low-risk alcohol use showed 14% higher all-cause mortality and 25% higher cancer mortality, while moderate-risk drinking showed 17% higher all-cause mortality and 36% higher cancer mortality.

Wine preference (>80% of alcohol from wine) showed small protective associations with mortality, particularly from cancer, and drinking with meals was associated with reduced mortality risk. Both wine preference and drinking with meals helped attenuate the excess mortality associated with high, moderate, and low-risk drinking, but only in alcohol users with socioeconomic or health-related risk factors.

24.68% of men and 27.04% of women did not receive any alcohol screening or have discussions about alcohol use with their healthcare providers during healthcare visits. 

Gender differences in any alcohol screening and discussions with providers among older adults in the United States, 2015 to 2019 (Mauro et al., 2021)

This study analyzed data from 9,663 US adults aged 65 years and older who used alcohol and had healthcare encounters between 2015-2019, using the National Survey on Drug Use and Health. They found a significant portion of older adults who consume alcohol (24.68% of men and 27.04% of women) did not receive any alcohol screening or have discussions about alcohol use with their healthcare providers during healthcare visits. Men were more frequently asked about their alcohol use habits (frequency, amount, and alcohol-related problems) compared to women. While women were 22% more likely to receive basic alcohol screening, they were 18% less likely than men to have detailed discussions about alcohol use with their healthcare providers

The findings highlight a concerning gender disparity in alcohol-related healthcare discussions, particularly given the increasing rates of unhealthy alcohol use among older women. The authors conclude that given the increased health risks associated with alcohol use in older adults, there needs to be more consistent screening and counseling for all older adults who consume alcohol, regardless of gender.

Alcohol misuse is strongly linked to increased suicide risk.

Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders (Rizk et al., 2021) 

This study finds that alcohol misuse is strongly linked to increased suicide risk, with a linear relationship between alcohol consumption and suicide rates, and alcohol use disorder (AUD) associated with a 10-fold higher suicide risk. Two forms of alcohol use contribute to suicide risk: acute alcohol intoxication (which increases immediate suicide risk) and chronic alcohol use/dependence (which creates long-term vulnerabilities). Other shared risk factors between alcohol misuse and suicide include childhood maltreatment, externalizing traits, impulsivity, stress-reactive behaviors, and social isolation.

Neurobiologically, both alcohol use disorder and suicidal individuals show similar characteristics, including impaired serotonin transmission, genetic variations in serotonin-related genes, and brain morphometric alterations. The hypothalamic-pituitary-adrenal (HPA) axis dysfunction is common in both alcohol users and suicidal individuals, potentially contributing to increased risk of risky or impulsive behavior.

Treatment recommendations include inpatient care for individuals with co-occurring alcohol misuse and suicidal ideation, with a focus on acute stabilization and preventing post-discharge relapse. Pharmacological interventions include SSRIs, which can modestly reduce alcohol consumption, and medications specifically approved for alcohol use disorder like disulfiram, acamprosate, and naltrexone. Psychotherapeutic approaches such as Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), and brief interventions like Safety Planning Intervention (SPI) show promise in addressing co-occurring suicidality and alcohol use disorder. 

Combination treatments involving both psychotherapy and pharmacological interventions may provide more comprehensive support for individuals with co-occurring suicidality and alcohol use disorder.

Patients with SUD, especially those with multiple drug and alcohol use disorders, experienced a 50-100% increase in psychiatric hospitalization rates compared to those without SUD.

Morbidity and mortality in schizophrenia with comorbid substance use disorders (Lähteenvuo et al., 2021) 

The study examined substance use disorders (SUD) prevalence among people with schizophrenia across Finland and Sweden, investigating their impact on psychiatric hospitalization and mortality. The research analyzed 45,476 individuals with schizophrenia, finding SUD prevalence ranging from 26% to 31%, with multiple drug use and alcohol use disorders being most common.

Patients with SUD, especially those with multiple drug and alcohol use disorders, experienced a 50-100% increase in psychiatric hospitalization rates compared to those without SUD. Mortality risks were also significantly higher for individuals with SUD, with elevated risks particularly notable for suicides and other external causes of death. These findings underscore the critical need for improved detection and tailored treatments for SUDs in schizophrenia patients, as these comorbidities are often underdiagnosed and undertreated.