Aging, alcohol, and the liver

Alcohol and aging - An area of increasing concern

Alcohol use is increasing among adults 65 and older and the size of this population is expanding rapidly. Aging is associated with systemic inflammation, sleep disturbances, cancers, cognitive decline, and increased risk of injury and death from falls and other accidents. Alcohol misuse exacerbates and accelerates these age-related changes. Older drinkers are more sensitive to acute alcohol-induced impairments in memory, coordination, reaction time, and driving performance. Oxidative stress and DNA damage resulting from chronic heavy alcohol consumption contribute to an increased risk of cancer, liver disease, and cardiovascular disease. Medication use increases with age and many medications prescribed to older adults can interact negatively with alcohol. The rapid expansion of the population aged 65 and older, combined with higher levels of alcohol use and AUD in the Baby Boomer cohort than the preceding generation, could significantly increase the burden of alcohol on the healthcare system resulting from AUD and alcohol-related injuries and diseases. Screening and brief intervention for hazardous alcohol use among older patients along with education regarding potential interactions between alcohol and medications could substantially reduce the risk of harms from alcohol but currently is underutilized.

Drinking behaviour and alcohol-related harm amongst older adults: analysis of existing UK datasets

BACKGROUND

Older adults experience age-related physiological changes that increase sensitivity and decrease tolerance to alcohol and there are a number of age-related harms such as falls, social isolation and elder abuse, which are compounded by alcohol misuse. Despite this unique vulnerability and the fact that the number of older adults is increasing, the literature on drinking behaviour and alcohol-related harm in older adults is sparse. This article describes a secondary analysis of UK data to address this knowledge gap.

METHOD

Secondary analysis of national statistics on alcohol-related hospital admissions and alcohol-related deaths, and data on drinking behaviour from the General Lifestyle Survey. Trends were identified by calculating percentage changes between time periods. The association between drinking behaviour and selected age groups was investigated using one way analysis of variance or chi-square tests.

RESULTS

Older adults (aged 65 and over) drink less and are less likely to exceed the recommended drink limits than younger adults. However, they are more likely to be admitted to hospital for an alcohol-related condition than younger adults and the most significant increases in alcohol-related hospital admission rates in recent years have occurred in older age groups. Alcohol-related death rates are highest amongst those aged 55-74 years old. Alcohol consumption and the prevalence of exceeding the recommended drink limits has fluctuated but not significantly increased in older adults in recent decades.

CONCLUSION

Older adults experience high and increasing levels of alcohol-related harm and as the population ages, this is likely to put increasing pressure on health and social services. Careful monitoring and age-appropriate strategies to detect and treat older adults at risk of alcohol-related harm are required.

Perceived Agency in Retirement and Retiree Drinking Behavior: Job Satisfaction as a Moderator

Based on recent findings that post-retirement adjustment may be influenced by the conditions leading up to the decision to retire, we examine the impact of individual agency in the retirement decision on problematic drinking behavior, as well as the extent to which such an effect may itself depend upon the valence of the pre-retirement work experience. Using a sample of 304 blue-collar retirees, our findings indicate that, when controlling for pre-retirement drinking behavior, perceptions of retirement as the result of a more forced or involuntary decision are associated with greater alcohol consumption, while perceptions of retirement as the result of a more volitional or voluntary process are associated with lower levels of alcohol consumption and a lower risk of problematic drinking behavior. Our results also indicate that pre-retirement job satisfaction amplifies the former relationship, while attenuating the latter one.

The diagnostic usefulness of AUDIT and AUDIT-C for detecting hazardous drinkers in the elderly

We compare the diagnostic usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT alcohol consumption questions (AUDIT-C) for detecting hazardous drinkers between the populations over and less than 65 years in primary care settings. To assess weekly alcohol intake an interview on quantity-frequency was administered to 602 patients. Hazardous drinking was defined as a level of consumption of 280 g of alcohol per week for men and 168 g for women. The participants received AUDIT, AUDIT-C and CAGE questionnaires. Gamma-glutamyltransferase (GGT), mean corpuscular volume (MCV), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were also determined. Average weekly alcohol intake among the population aged 65 and older was 83 g, and 10% were hazardous drinkers. In this age group, the sensitivities of AUDIT and AUDIT-C for detecting this type of drinkers were 67% and 100%, whereas specificities were 95% and 81% respectively. In the younger patient group, the sensitivities were 84% and 100% and the specificities 95% and 79% respectively. In conclusion, both AUDIT and AUDIT-C perform well at detecting hazardous drinkers in the group older than 65 years and that their sensitivities and specificities are comparable to those in younger ages.

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.

A statewide model detection and prevention program for geriatric alcoholism and alcohol abuse: increased knowledge among service providers

To facilitate the professional development of service providers, the Virginia project on geriatric alcohol abuse and alcoholism developed and used an informational booklet, brochure, and video in a "train the trainer" model. A core group received extensive training, and then trained colleagues in their local communities. Knowledge gains were documented among both trainers and trainees. Follow-up interviews with agency personnel revealed substantial impact on a broad spectrum of service systems and improvements in interagency coordination. Results are discussed in terms of the educational needs of professional service providers regarding the unique aspects of alcoholism and alcohol abuse in the older population.

Frequently missed diagnosis in geriatric psychiatry

Older adults are an important segment of the population that has specific health care needs. Their unique biopsychosocial characteristics impact the presentation, evaluation, and management of psychiatric illnesses. This article describes how common psychiatric disorders present in an aging population. Research in this area is relatively new and much more information is still needed. Close attention should be paid to new knowledge as it emerges about this growing population.

Interactions between alcohol and other drugs

More than 75% of people age 65 and older use medications. Of the drugs most commonly used by older people, many have potential to interact adversely with alcohol. The absorption, distribution, metabolism, and effects of drugs or alcohol may be affected. The major adverse clinical outcomes of drug-alcohol interactions are altered blood levels of the medication or of alcohol, liver toxicity, gastrointestinal inflammation and bleeding, sedation and delirium, disulfiram-like reactions, and interference with the desired effect of medications. Since alcohol is commonly used by elderly people, educating patients about the potential for these interactions should be a routine part of health care visits.

Potential for adverse drug-alcohol interactions among retirement community residents

OBJECTIVES

Medications and alcohol are both used commonly by older people. Thus, the potential for adverse drug-alcohol interactions is very high in this population, but data on actual concurrent use of alcohol and medicines likely to interact with alcohol are lacking. The objectives of this study were to determine the frequency of alcohol and medication use and the potential for specific adverse drug-alcohol interactions in residents of retirement communities.

DESIGN

Cross-sectional study using a mailed survey.

SETTING

Three retirement communities in suburban Milwaukee, Wisconsin.

PARTICIPANTS

All 454 independently living residents of the communities were surveyed. Of these, 311 residents (68%) returned completed questionnaires. Mean age of respondents was 83 +/- 6 years, 100% were white, 77% were female.

MEASUREMENTS

The questionnaire included alcohol use questions adapted from the Khavari questionnaire and the CAGE questionnaire to screen for alcohol abuse. Respondents were asked to list all prescription and nonprescription medications.

RESULTS

Thirty-eight percent of the population reported using both alcohol and a high risk medication. Six percent had seven or more drinks per week and took a high risk medication. High risk drugs commonly used by drinkers were antihypertensives in 50%, aspirin in 27%, nonsteroidal anti-inflammatory drugs in 20%, medication for congestive heart failure in 18%, antacids or H2 blockers in 16%, sedatives in 11%, narcotics in 5%, and warfarin in 5%.

CONCLUSIONS

Concurrent use of alcohol and medications is common in residents of these retirement communities. Many of the drugs taken by regular drinkers have potential for adverse drug-alcohol interactions even at moderate levels of alcohol use. This represents a strong possibility of adverse outcomes and a need for increased awareness on the part of both the public and physicians of the potential for interactions between drugs and alcohol.

Postoperative delirium in the elderly

Postoperative delirium is common in the elderly in the postoperative period. It can result in increased morbidity, delayed functional recovery, and prolonged hospital stay. In surgical patients, factors such as age, alcohol abuse, low baseline cognition, severe metabolic derangement, hypoxia, hypotension, and type of surgery appear to contribute to postoperative delirium. Anesthetics, notably anticholinergic drugs and benzodiazepines, increase the risk for delirium. Despite the above recommendations, postoperative delirium in the elderly is poorly understood. Clearly, further studies are needed to determine the risk and long-term outcome of delirium in the elderly population. Research is also needed to define the effects of hypoxemia on cerebral function and whether oxygen therapy has any benefits. The geriatric-anesthesiologic intervention program of pre- and postoperative geriatric assessment, early surgery, thrombosis prophylaxis, oxygen therapy, prevention and treatment of perioperative decrease in blood pressure, and vigorous treatment of any postoperative complications showed some promise, but further definitive studies are needed.

Studies on vocal fold injection and changes in pitch associated with alcohol intake

The current study was carried out with particular emphasis on the association between phonetic function tests and alterations in the appearance of the hypopharyngeal and laryngeal mucosa, such as capillary dilatation, edema, and vocal fold injection after alcohol intake. The results demonstrated the occurrence of previously unrecognized pathophysiological changes associated with synchronous phonetic functions in the vocal pathway after alcohol intake. Serum ethanol and aldehyde concentration levels were evaluated hourly for 2.5 h after ingestion of alcohol. When an electronystagmogram showed the typical pattern of alcohol intake, the study was initiated. Occasionally, rhinography was performed on subjects complaining of a stuffy nose after alcohol intake.

Alcohol use and potential risk for alcohol-related adverse drug reactions among community-based elderly

This paper documents the frequency of alcohol consumption and concurrent use of alcohol and medications in a random sample of elderly community dwellers. Further, a profile of older persons who are likely to be drinking alcohol is developed and the extent to which they are at potential clinical risk due to their concurrent use of alcohol with prescription and over-the-counter medications is explored. While approximately 43 percent are abstainers, the majority of older respondents reported using alcohol. Older drinkers who take one or more drugs which place them at potential risk for negative drug-alcohol interactions represent one-quarter of this sample but are often overlooked in estimating the extent of alcohol problems in the elderly. By far, the most common risk was from the use of OTC pain medications and alcohol (19 percent). The multivariate analyses revealed that sex, educational attainment, and religious affiliation are important factors to consider in developing a profile of older people who are at risk for alcohol-related ADRs. Implications for health care and social service professionals who work with elderly community-dwellers are discussed.

Alcohol and blood pressure. The effects of age. Findings from the Italian Nine Communities Study. The Research Group ATS-RF2 of the Italian National Research Council

This report analyzes the role age in the association between alcohol consumption and blood pressure in a large sample (n = 6165) of Italian men and women, aged 20 to 59 years, who participated in a multicenter study on risk factors for arteriosclerosis. Age-stratified analysis indicated that both men and women aged 50 to 59 years showed the strongest positive association between alcohol consumption and blood pressure. While in men the association between systolic blood pressure and alcohol consumption increased linearly with age, in women the association between systolic blood pressure and alcohol increased sharply in the oldest (50 to 59 year) age group.

Intraacinar profiles of alcohol dehydrogenase and aldehyde dehydrogenase activities in human liver

The intraacinar activity profiles of alcohol dehydrogenase and the aldehyde dehydrogenases (I, I plus II, and total) were determined, using liver biopsy samples from eight male and eight female patients. Microchemical assays were performed in microdissected tissue samples from the whole length of the sinusoid. Alcohol dehydrogenase activity in men less than 53 years of age showed a maximum in the intermediate zone, whereas in women less than 50 years of age an increase in the gradient toward the perivenous zone was observed. Furthermore, alcohol dehydrogenase activity in the livers of women was significantly higher than in men. After the age of 53 in men and 50 in women, the sex specificity of the distribution profiles was no longer apparent. The intraacinar profiles of aldehyde dehydrogenase isoenzymes showed only minor variations in the different groups; they were not statistically significant. This is also true for low-Michaelis constant (Km) aldehyde dehydrogenase, which is most important for acetaldehyde oxidation in vivo. Thus, of the variations in zonal heterogeneity of ethanol-degrading enzymes, it is mainly the activity of alcohol dehydrogenase that may contribute to the sex- and age-related susceptibility of liver parenchyma.

Studies on the age-dependent effects of galactosamine in primary rat hepatocyte cultures

Galactosamine (GalN) has been known to induce liver injury by depletion of uracil nucleotides. The objective of the present work was to examine age-dependent toxicity of GalN in primary hepatocyte cultures. Hepatocytes from fetal (Day 20 of gestation), neonatal (2.5-day), adult (5-month), and aged (30-month) rats were established as monolayered cultures. LDH leakage, cell viability, UTP, UDP, and UMP were measured as end points of toxicity in cultures exposed to 5 mM GalN. LDH leakage was increased and cell viability was decreased in adult rat hepatocytes at 48 and 60 hr after treatment. Although similar effects were observed in hepatocytes from aged rats, these cells appeared resilient to GalN toxicity as indicated by significantly less LDH leakage and cell death. Fetal and neonatal rat hepatocytes also exhibited greater resiliency to GalN based on the same end points. The UTP, UDP, and UMP levels of aged hepatocytes (30-month) were higher than control adult levels to begin with and dropped after GalN treatment. The level of UMP at 60 hr was similar to that of normal adult cells, but the UTP and UDP levels were significantly higher in aged hepatocytes in comparison to those of adult hepatocytes. The levels of uracil nucleotides in the fetal and neonatal cells were the same as those in adult cells, but did not decrease significantly after exposure to GalN. These findings show that aged rat hepatocytes have a higher set point for uracil nucleotides, which is consistent with the relative resiliency of these cells to GalN injury. Neonatal and fetal cells have the same set point for these nucleotides as adult rats, but are relatively resistant to GalN-induced depletion. In conclusion, the differences in toxicity of GalN may reside in age-related differences in the regulation of uracil nucleotide biochemistry.

Effects of ethanol on microsomal drug metabolism in aging female rats. II. Inhibition

The effect of aging on the inhibition by ethanol of drug metabolism activity was examined in liver microsomes of female Fischer 344 rats aged 4, 14 and 24 months. Inhibition of aniline hydroxylase activity in microsomes from 4-month-old females occurred at low concentrations of ethanol (0.1 mM) and was predominantly competitive. Aging was associated with a significant increase in apparent Km for aniline in the absence of ethanol (24 +/- 2, 20 +/- 2 and 32 +/- 1 microM in microsomes from 4-, 14- and 24-month-old rats, respectively) and a change from competitive to non-competitive inhibition by ethanol. Inhibition of benzphetamine N-demethylase activity occurred only at high concentrations of ethanol (100 mM) and was non-competitive in nature. There were no significant effects of aging on the kinetics of the reaction or the type of inhibition produced by ethanol. Microsomal ethanol oxidation rates were measured in liver microsomes of 4-, 15- and 25-month-old Fischer 344 rats of both sexes. Ethanol oxidation in males was greater than in females and was decreased significantly in old age. Ethanol oxidation in female rats was unaffected by aging. The results suggest that significant changes in drug/ethanol interactions can occur as a consequence of aging.

Effects of ethanol on microsomal drug metabolism in aging female rats. I. Induction

The purpose of this study was to determine how aging affects the induction by ethanol or acetone of the hepatic microsomal monooxygenase system of female Fischer 344 rats. Young-adult, middle-aged and old rats (4, 14 and 25 months) were fed an ethanol-containing or control liquid diet for 15 days. Cytochrome P-450, cytochrome c reductase, aniline hydroxylase, nitrophenol hydroxylase, nitroanisole O-demethylase and benzphetamine N-demethylase activities were measured in hepatic microsomes. All of the drug metabolism activities except benzphetamine N-demethylase were 20-35% lower in old than in young-adult rats fed the control diet. In addition, the increase in drug metabolism produced by feeding the regular ethanol diet (36% of calories as ethanol) was 50-60% lower in the old rats. However, there was no difference in the magnitude of ethanol induction when ethanol intakes were matched. The effects of chronic acetone consumption (1.2g/day per kg body weight for 15 days) paralleled those of ethanol consumption, except that the extent of induction was greater with acetone. Acetone-induced levels of hepatic microsomal cytochrome P-450, nitrophenol hydroxylase, nitroanisole O-demethylase and aniline hydroxylase were similar in all three age groups. The results of this study indicate that induction of hepatic microsomal drug metabolism by ethanol or acetone is unaffected by the aging process.