Unhealthy Alcohol Use in Older Adults (eBook)

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Conceptualizing Unhealthy Alcohol Use Among Older Adults

This chapter explores different ways in which practitioners might conceptualize unhealthy alcohol use among older adults. This involves consideration of ways in which processing of alcohol changes with age, as well as the age of onset of the problem (early and middle adulthood vs. older adulthood) and life transitions. The chapter also considers theoretical models of substance use (e.g., biopsychosocial model, cognitive behavioral model) and how these models apply to older adults.

3.1  Age-Related Changes in Alcohol Processing

Older adults process alcohol differently because of physiological changes that are a typical part of the aging process (Ferreira & Weems, 2008). Owing to these physiological changes, tolerance for alcohol decreases with age. This means that older adults experience the effects of alcohol more quickly at lower quantities than when they were younger. Although an older person may say that they can “hold their liquor,” or that they have been “drinking the same amount for years,” older adults experience increased sensitivity to alcohol and therefore their tolerance is lower than it was in their younger years. 

The following physiological changes impact older adults’ ability to process alcohol, thereby increasing their sensitivity to alcohol and decreasing their tolerance: 

• |13|Decrease in muscle mass and subsequent reduction in total body water: When alcohol is consumed and processed, it is absorbed more quickly into muscle tissue than fat. With age, there is an overall decrease in muscle and an increase in fat. Over the course of adulthood, the amount of water in the body decreases by about 15% owing to a decrease in muscle mass (Malczyk et al., 2016). This means that alcohol remains in the bloodstream longer and the lengthier absorption time can also lead to higher BAC levels and increased effects, even when the person is consuming the same amount of alcohol as they did when they were younger. This decrease in total body water increases vulnerability to dehydration. Since alcohol is a diuretic, it raises further concerns about dehydration as well as contributing to lower tolerance and greater sensitivity to intoxication. 

• Longer time to digest alcohol: With age, the enzyme that metabolizes alcohol (gastric alcohol dehydrogenase) decreases (Parlesak et al., 2002). This change slows absorption, leading to a higher BAC and placing greater strain on the liver since fewer enzymes are available in the stomach to assist with processing alcohol.

Although this information is specific to alcohol consumption, age-associated physiological changes can also make older adults more sensitive to alcohol–medication interactions as well as to the effects of cannabis, benzodiazepines, and opioids (Breslow et al., 2015). This will be discussed further in Chapter 4 on common comorbid conditions. Use of these substances in combination with alcohol can significantly increase the risk of falls, cognitive impairment, and other serious health problems.

3.2  Early Versus Late Onset

When conceptualizing unhealthy alcohol use among older adults, consider whether unhealthy alcohol use is new or is the continuation of a behavior established in young adulthood. Existing research on early- vs. late-onset alcohol use defines these categories: early onset (less than 25 years old), late onset (between 25 and 44 years old), and very late onset (over age 45; Kist et al., 2014; Wetterling et al., 2003). Unhealthy alcohol use that starts in young adulthood tends to occur daily or almost daily and continues into later life, accompanied by consequences associated with use often across multiple domains of functioning. Unhealthy alcohol use that starts in older adulthood sometimes occurs in connection with stressful life events such as retirement, loss, or the onset of a new medical problem. Questions that practitioners might ask about the course of drinking are listed in Box 1.

Overall, these questions help to understand triggers and patterns of unhealthy alcohol use over time. In a qualitative study of unhealthy alcohol use among Danish adults whose unhealthy alcohol use began after age 60, Emiliussen and colleagues (2017) found three common patterns among older adults: 

• Older adults with unhealthy alcohol use in younger adulthood that was not detected until older adulthood. This represents early-onset use without receiving a diagnosis until older adulthood.

• Older adults who engaged in low-risk drinking when they were younger and increased their use to an unhealthy level or developed an AUD as they got older. This represents late-onset use.

• Older adults who either did not use alcohol earlier in life or had low-risk use, which continued into older adulthood.

Research into the early- versus late-onset distinction is limited. In terms of presenting symptoms, Kist and colleagues (2014) found that scores on cognitive tests related to executive functioning, attention, and short-term memory were in the low average range for all groups, including early onset unhealthy alcohol use (younger than age 25), late onset (25 – 44), and very late onset (45 and older), as compared with a healthy norm group of older adults. The results did not vary by age of initiation of unhealthy alcohol use, although the authors hypothesized that the early-onset group would have worse cognitive performance compared with the other two groups. Older women tend to be disproportionately represented in those with late-onset unhealthy alcohol use (Breslow et al., 2017), whereas older men are more likely to be in the early-onset category.

In a study of adults admitted to an inpatient detoxification unit, Wetterling and colleagues (2003) found that individuals in an early-onset group (aged 25 or younger) were more likely to meet criteria for a nicotine use disorder compared with the other two groups (onset between ages 25 – 44 and onset after age 45), were more likely to have alcohol-related psychosocial problems (i.e., job or relationships problems because of alcohol use), were less likely to report continuous abstinence 6- and 12-months postdetoxifi|15|cation, and were more likely to report binge drinking. These results suggest that late-onset unhealthy alcohol use may be less severe, though still may have consequences on cognitive functioning. For older adults with less severe alcohol use, practitioners might not consider the possibility of recently...