The effect of alcohol abuse on the health status of older adults seen in the emergency department

Patient-reported outcome measure use among older adults after emergency department care: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.

METHODS

With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments.

RESULTS

Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.

CONCLUSIONS

PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

Gender difference in the association between alcohol consumption and depressive symptoms among the elderly in rural areas

To determine gender difference in the nature of the association between alcohol consumption and depressive symptoms in the elderly aged 60 and above in a rural community sample. A cross-sectional face-to-face survey conducted for community residents 60 years of age and older (n = 1,819). Alcohol consumption problems were measured by self-report of the Korean version of Alcohol Use Disorders Identification Test (AUDIT-K) scale. Depressive symptom was measured using the Korean Beck Depression Inventory (K-BDI) scale. Potential explanatory variables included MCS, PCS, and health-related behavior, socio-economics status, and democratic variables. Two gender-specific multivariate regression models were applied for the analysis. A U-shaped relationship between alcohol consumption and depressive symptoms was found, and the relationship did not differ by gender. Non-problem drinkers and hazardous and harmful drinkers were related to an increased risk of depressive symptoms for both men and women. Several correlates for the association were found. No gender difference was found in a U-shaped curvilinear relationship between alcohol consumption and depression found among the elderly aged 60 and above in rural communities in South Korea. The findings of this study suggest the need for further investigation of subgroup differences in the association by using samples of various age groups in rural and urban areas, and samples drawn from different cultural contexts than the studies conducted in Western countries.

Alcohol Use as Risk Factors for Older Adults' Emergency Department Visits: A Latent Class Analysis

INTRODUCTION

Late middle-aged and older adults' share of emergency department (ED) visits is increasing more than other age groups. ED visits by individuals with substance-related problems are also increasing. This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by examining their health/mental health status and alcohol use patterns.

METHODS

Data came from the 2013 National Health Interview Survey's Sample Adult file (n=15,713). Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis (LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year ED visits as indicators.

RESULTS

LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and, despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3 (37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4 (7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits, with the highest proportion of Blacks and the lowest proportions of college graduates and employed persons, indicating significant roles of these risk factors.

CONCLUSION

Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses self-management.

Associations of Mental Health and Substance Use Disorders With Presenting Problems and Outcomes in Older Adults' Emergency Department Visits

OBJECTIVES

The increasing prevalence of mental health and/or substance use disorders in older adults is a significant public health issue affecting their health, health care use, and health care outcomes. These disorders are especially prevalent in emergency department (ED) visits. This study examined the effect of mental health and substance use disorders on older adults' ED presenting problems and outcomes.

METHODS

Data were from the publicly available 2012 Nationwide Emergency Department Sample data set (unweighted n = 5,344,743 visits by the 65+ years age group). We used binary logistic regression analysis to test relationships between mental health and substance use disorders and suicide attempts, falls, and other injuries and multinomial logistic regression analysis to test relationships between the disorders and ED outcomes of death, hospital admission, transfer to institutional care, home health care, leaving against medical advice (AMA), or other or unknown destinations, as opposed to routine care.

RESULTS

Of ED visits by older adults, 5.1% involved anxiety disorders, 7.1% involved mood disorders, 10.45% involved delirium/dementia, 1.4% involved alcohol use disorders, and 0.6% involved drug use disorders; 0.2% were suicide-related, 12.0% involved falls, and 10.2% involved other injuries. Mental health and substance use disorders had large-to-medium effects on suicide attempts. Both dementia and delirium and alcohol use disorders had a small effect on falls. Drug use disorders had a small effect on other injuries. Anxiety disorder had a small effect on the risk of death in the ED or in the hospital, relative to routine care. Suicide attempts and drug use disorders had a medium effect on hospital admission. Suicide attempts had a large effect, delirium and dementia and other mental disorders had medium effects, and mood disorder had a small effect on the risk of transfer to another facility. Delirium and dementia, suicide attempts, and drug use disorders had small effects on the risk of discharge with home health care. Alcohol use disorders and drug use disorders had a small effect on the risk of leaving AMA. Finally, suicide attempts had a medium effect on the risk of other outcomes and unknown destinations.

CONCLUSIONS

Late-life mental health and substance use disorders are significant risk factors for both intentional self-harm and unintentional injuries that bring older adults to the ED and contribute to ED dispositions and outcomes that involve more intensive and longer-term health care services. The findings underscore the importance of detection and treatment of these disorders among older adults before they end up in the ED.

Alcohol use, socioeconomic deprivation and ethnicity in older people

OBJECTIVES

This study explores the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation.

PARTICIPANTS

27,991 people aged 65 and over from an inner-city population, using a primary care database.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were alcohol use and misuse (>21 units per week for men and >14 for units per week women).

RESULTS

Older people of black and minority ethnic (BME) origin from four distinct ethnic groups comprised 29% of the sample. A total of 9248 older drinkers were identified, of whom 1980 (21.4%) drank above safe limits. Compared with older drinkers, older unsafe drinkers contained a higher proportion of males, white and Irish ethnic groups and a lower proportion of Caribbean, African and Asian groups. For older drinkers, the strongest independent predictors of higher alcohol consumption were younger age, male gender and Irish ethnicity. Independent predictors of lower alcohol consumption were Asian, black Caribbean and black African ethnicity. Socioeconomic deprivation and comorbidity were not significant predictors of alcohol consumption in older drinkers. For older unsafe drinkers, the strongest predictor variables were younger age, male gender and Irish ethnicity; comorbidity was not a significant predictor. Lower socioeconomic deprivation was a significant predictor of unsafe consumption whereas African, Caribbean and Asian ethnicity were not.

CONCLUSIONS

Although under-reporting in high-alcohol consumption groups and poor health in older people who have stopped or controlled their drinking may have limited the interpretation of our results, we suggest that closer attention is paid to 'young older' male drinkers, as well as to older drinkers born outside the UK and those with lower levels of socioeconomic deprivation who are drinking above safe limits.

Heavy/binge drinking and depressive symptoms in older adults: gender differences

OBJECTIVES

The purpose of this study was to examine gender similarity/difference in the association between depressive symptoms (11-item Center for Epidemiologic Scale for Depression (CES-D) scores), on the one hand, and frequency and amount of alcohol use, on the other, among older adults.

METHODS

Data came from the National Social Life, Health, and Aging Project (NSHAP), Wave 1, which included a nationally representative probability sample (n = 2924) of community-dwelling individuals aged 57-85. Heavy/binge drinking was defined as the consumption of 4+ drinks for men and 3+ drinks for women per drinking day. The relationship between CES-D scores and the frequency and amount of alcohol consumption was tested using gender-separate, 2-step ordinary least squares (OLS) regression analyses.

RESULTS

A significant proportion of both men (67.7%) and women (52.2%) had consumed alcohol in the preceding 3 months, and 12.3% of male and 8.4% of female drinkers were heavy/binge drinkers. Substantial differences between male and female heavy drinkers were found in sociodemographics, health status, and social support and social engagement. Regression results show that both frequency of drinking and heavy/binge drinking, as opposed to abstinence, were significantly positively associated with men's CES-D scores, but not with women's.

CONCLUSION

Heavy/binge-drinking older men may use alcohol to cope with depressive mood, and heavy drinking might also contribute to their social isolation and depressive symptoms. Depression screening and treatment for older men should be accompanied by alcohol screening and treatment and vice versa.

Office of National Drug Control Policy: a scientist in drug policy in Washington, DC

This essay describes how a basic scientist was thrust into the epicenter, the political cauldron of our national drug control policy, and how the experience altered her professional trajectory and perspective.

Alcohol consumption and health status in older adults: a longitudinal analysis

Objective. This longitudinal study examines the relationship of alcohol consumption to mortality and changes in mental and functional health in older adults. Method.In a national population health survey, 4,187 participants aged 50 and older at baseline provided information on alcohol consumption, potential confounders, and follow-up vital status. Logistic regression estimated the odds ratio for mortality, increase in psychological distress, and decline in functional health 10 years later. Results. Compared with lifelong abstainers, light and moderate drinkers were at nonsignificantly lower risk of mortality. Among survivors, alcohol consumption showed no consistent relationship with increases in psychological distress. Occasional and light drinkers had significantly reduced risk of a substantial functional health decline, whereas moderate drinkers had nonsignificantly reduced risk. Discussion. Findings suggest that light-to-moderate alcohol consumption reduces the risk of substantial functional health decline in older middle-aged drinkers.

Assessment of smoking behaviors and alcohol use in the national social life, health, and aging project

OBJECTIVES

The National Social Life, Health, and Aging Project (NSHAP) assessed smoking behaviors and alcohol use as factors directly related to physical health, well-being, and social relationships. We describe self-report measures of tobacco and alcohol use, as well as an established biological marker of tobacco exposure, cotinine, collected in Wave 1 of NSHAP.

METHODS

We compare smoking behaviors and alcohol use by gender and age group. We report on derived measures of alcohol consumption and tobacco exposure widely used in medical and substance use literature, compare current and past users, and describe associations between self-reported smoking status and cotinine.

RESULTS

Men are more likely than women to report alcohol use, potential problem drinking, and ever smoking. Alcohol use and smoking are lower among older age groups. Although current smoking is less prevalent than in the general U.S. adult population, 50% of current and 29% of past smokers have lifetime exposure of 40 pack-years or more. Cotinine is directly related to number of cigarettes per day but with considerable unexplained variation. Cotinine levels contradict self-report in fewer than 4% of nonsmokers.

CONCLUSION

NSHAP provides data useful for investigation of smoking and alcohol use and their association with health and social factors.

Alcohol consumption and health among elders

PURPOSE

This article estimates the effects of alcohol consumption on self-reported overall health status, injuries, heart problems, emergency room use, and hospitalizations among persons older than the age of 65.

DESIGN AND METHODS

We analyzed data from the first wave of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative study. We used multivariate regression and instrumental variables methods to study the associations between alcohol consumption (current drinking, binge drinking, and average number of drinks consumed) and several indicators of health status and health care utilization.

RESULTS

Alcohol consumption by women was associated with better self-perceived health status, improved cardiovascular health, and lower rates of hospitalizations. We detected no significant negative or positive associations for older men.

IMPLICATIONS

These findings suggest that light to moderate alcohol use by older women may have beneficial health effects. Experimental trials, however, are needed to more rigorously assess the potential benefits of alcohol use by elders due to the inherent biases of observational studies.

Psychiatric Emergencies in the Elderly Population

This article reviews the most common behavioral emergencies in the geriatric population. Psychiatric emergencies are seen frequently by emergency physicians who face the challenge of assessing and managing patients presenting with psychosis, severe depression, agitation, suicidal intent, and substance abuse in the emergency department. The evaluation is frequently complicated by the necessity to investigate numerous domains such as underlying medical conditions, prior psychiatric disorders and substance abuse, as well as psychosocial factors. It is crucial to rule out organic causes for what appears to be psychiatric disease in the elderly. The assessment might be further complicated by the patient's limited ability to recall pertinent aspects of the history due to either cognitive impairment or acute distress. Emergency department personnel might have inadequate expertise in assessing emergencies in elderly persons, further impeding the ability to appropriately manage behavioral complications in geriatric patients. Availability of high-quality emergency care and tight collaboration with primary care providers, psychiatric consultants, and social services is crucial to optimal outcomes from acute psychiatric decompensations in the elderly.

Acute poisoning in old and very old patients: a longitudinal retrospective study of 5883 patients in a toxicological intensive care unit

Although morbidity and mortality of acute poisoning are increased in elderly compared to younger patients, little has been published on this topics in the last years (Medline search). To investigate the influence of age on the clinical course of acute poisoning with different toxic agents, a longitudinal retrospective study at the Toxicological Intensive Care Unit (ICU) of the 2nd Department of Internal Medicine (Klinikum Nürnberg, Germany) was performed.A total of 5883 patients treated at our toxicological ICU were enrolled into the study, including all patients of the years 1982, 1992, and 1997. These three years were selected to investigate possible time-dependent changes of intoxication characteristics and quality of therapy at our ICU over a time span of 15 years. For each patient the following data were obtained from a standardized toxicological record: age, gender, toxic agents responsible for acute poisoning, and length of stay at the toxicological ICU. For a subgroup of 3740 patients, the cause of acute poisoning and the clinical outcome was also recorded. As compared with younger patients, mean length of stay at the ICU, indicating a more serious course of acute poisoning, was prolonged in elderly and, i. e., in very old patients (p <0.001). However, this prolongation of time at the ICU was only observed in elderly patients poisoned with drugs or with mixed poisoning including drugs, while mean length of stay was not prolonged in elderly patients poisoned with alcohol, with illegal drugs, chemicals, animal/plant poison, or other toxic agents. Patients with the highest risk of dying in the ICU after acute poisoning were elderly patients attempting suicide with drugs. Mortality in 3740 patients with acute poisoning was 0.24%, while it was 2.17% in the 184 patients being 65 years old or older. Thus, mortality was 9-fold higher in the elderly. Mean length of stay at the ICU decreased significantly from 1982 to 1992 and to 1997 (p <0.001) indicating an improvement of the therapeutical ICU management of acute poisoning and/or less dangerous toxic agents (i. e. less barbiturates). The age-dependent increase of the length of stay at the ICU until very old age (> 80 years) was most pronounced in 1982 and also declined markedly until 1997.Age, suicide attempt, and ingestion of (multiple) drugs seem to be risk factors for a higher mortality and a prolonged stay in the ICU after acute poisoning. Although in general the clinical course after poisoning has more complications and an impaired prognosis in old age, each category of toxic agents (drugs, alcohol, chemicals, etc.) has its own special "risk profile" for elderly patients. However, due to advances in modern ICU medicine the general prognosis of acute poisoning is good in old and even in oldest old patients.

Alcohol Screening Results in Elderly Male Veterans: Association with Health Status and Mortality

OBJECTIVES

To evaluate the association between alcohol screening results and health status or mortality in elderly patients.

DESIGN

Cross-sectional and longitudinal cohort studies.

SETTING

Primary care clinics at seven Veterans Affairs medical centers.

PARTICIPANTS

A total of 16,958 male patients aged 65 and older.

MEASUREMENTS

Alcohol screening questionnaires were used to divide patients into four mutually exclusive groups: drinkers who screened negative or positive for problem drinking and nondrinkers (in the previous year) who screened negative or positive for problem drinking. A subset of patients (n=12,491) completed a measure of health status, the Medical Outcomes Study Short Form (SF-36). All-cause mortality was ascertained using Veterans Affairs data over a mean follow-up of 2.8 years.

RESULTS

Forty-eight percent of participants reported drinking in the previous year. Half of the drinkers and nondrinkers screened positive for problem drinking. The SF-36 item scores were consistently higher for drinkers than for nondrinkers and for patients who screened negative for problems than for those who screened positive. Similarly, survival was consistently better in drinkers than nondrinkers (mortality hazard ratio (HR)=0.74, 95% confidence interval (CI)=0.68-0.82) and in patients who screened negative for problem drinking than in those who screened positive (mortality HR=0.87, 95% CI=0.80-0.95). Nondrinkers who screened positive for problem drinking had the poorest health status and survival, whereas drinkers who screened negative for problem drinking had the best health status and survival.

CONCLUSION

Elderly patients who reported drinking alcohol and those who screened negative for problem drinking had consistently better health status and survival than those who did not drink and those who screened positive.

Alcohol Use in a Continuing Care Retirement Community

The purpose of this study was to explore alcohol use among older adults living in a continuing care retirement community (CCRC) and to consider differences in overall health, number of chronic illnesses, falls, age, and exercise behavior between those who drink moderately versus those who do not. A one-time face-to-face interview was conducted with a total of 316 residents living in an urban CCRC in the northeast. The participants were 86.6 6 6.3 years of age, and the majority were women (79%), unmarried (75%), White (9%), and middle to upper socioeconomic status (100%). The majority of these individuals (63%) drank moderately, consuming at least one drink daily. No difference was found between men's and women's drinking behaviors (chi 2 = .47, p > .05). Adults who drank moderately were older (F = 8.7, p < .05), more likely to exercise regularly (chi 2 = 27, p < .05), and were more likely to have had a fall (F = 3.7, p < .05). No statistically significant difference was found between the groups related to perceptions of overall health, number of chronic illnesses, number of medications, overall or number of medications that interact with alcohol, or cognitive status. Although not statistically significant, a greater percentage of individuals who drink moderately had fractures (12%) when compared to the percentage of individuals who do not drink at least moderately (7%). Recognizing both benefits and risks to alcohol use in older adults suggests that an individual approach to educating these individuals about their use of alcohol should be conducted.

Comparing the alcohol-related problems survey (ARPS) to traditional alcohol screening measures in elderly outpatients

Older drinkers may incur alcohol-related risks at low consumption levels, but commonly used screening measures do not address alcohol's effects among persons with declining health and increased medication use. We compared the newly developed Alcohol-Related Problems Survey (ARPS) to three validated alcohol screens: the Cut down, Annoyed, Guilty, Eye-opener (CAGE), Short-Michigan Alcohol Screening Test (SMAST), and Alcohol-Use Identification Test (AUDIT). The ARPS classifies drinking as non-hazardous, hazardous or harmful. Non-hazardous drinking is defined as consumption with no known risks for adverse physical or psychological health events. Hazardous drinking is consumption with such risks. Harmful drinking results in adverse events. The AUDIT screens for hazardous and harmful drinking; the CAGE and SMAST identify abusive (e.g. failure to fulfill social obligations) and dependent (e.g. having withdrawal symptoms) drinkers. In this study of 574 current drinkers 65 years and older who completed the ARPS and AUDIT in primary care clinics, half were randomly assigned to complete the CAGE and half, the SMAST. Drinkers who screened positive on the CAGE, SMAST or AUDIT were correctly classified by the ARPS as hazardous or harmful drinkers 91, 75, and 100% of the time, respectively. The majority of ARPS-identified hazardous or harmful drinkers did not screen positive on the CAGE, SMAST or AUDIT. These drinkers had medical conditions or used medications that placed them at risk for adverse health events, none of which was addressed in these three screens. In this study, the ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers not identified by these measures.

Alcohol consumption by non-institutionalised elderly women: the EPIDOS Study

The prevalence of alcohol use declines with age, but studies suggest that between 2% and 4% of the elderly population have a particularly high alcohol consumption. The objective of this study was to verify or refute this finding and identify clinical or social characteristics associated with alcohol consumption. We measured alcohol consumption by autoquestionnaire in 7575 women, aged 75 or older, recruited at five centers in France. The alcohol consumption was computed taking account of the number of beer, wine or liquor (or spirits) drinks consumed per day. The mean age of the respondents was 80+/-6 y. Forty percent used some alcohol and 2.5% drank more than 30 grams per day. Smoking, good health status, higher socioeconomic status or single marital status were factors whose percentages increased significantly with increasing alcohol use. Despite the advanced age of this population, regular alcohol intake was prevalent but not heavy and abusive consumption drinking. Drinking appears to be associated with some medical or social characteristics and possibly with better health status.

Early revisit, hospitalization, or death among older persons discharged from the ED

The purpose of this study to determine predictors of revisit, hospital admission, or death among older patients discharged from the emergency department (ED). We performed a prospective study of patients aged 65 or older in an urban ED. The primary outcomes were ED revisit, hospital admission, or death 30 or 90 days after discharge from an index ED visit. Of the 463 eligible patients, 75 (16%) experienced ED revisit, hospitalization, or death within 30 days, and 125 (27%) within 90 days. In multivariate proportional hazards models, physical functioning and mental health in the lowest tertile, and lack of supplemental insurance predicted revisit, hospitalization, or death within 30 days after ED discharge. Poor physical functioning, missing mini-mental state examination, comorbidity, and ambulance transport to the initial ED visit predicted 90-day outcome. Problems with physical functioning, mental health and supplemental insurance are potentially remediable precursors of early morbidity among older patients after ED discharge. Future research should examine whether addressing these issues among the elderly population will lessen ED return visits, hospitalization, and mortality.