Thomas Jordan, MD, MPH
Contributing writer to the Carlat newsletters
Dr. Jordan has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
How much can our older patients safely drink? And what does “safe” or “low-risk” drinking actually mean? The National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is the branch of the NIH that focuses on problems related to alcohol, has released guidelines for low-risk drinking limits in older patients. Let’s take a look at their recommendations and the rationale/evidence for them.
NIAAA recommendations The NIAAA low-risk recommendations are based upon both daily and weekly limits. The daily limit is 4 standard drinks for men and 3 drinks for women; while the weekly limit is 14 drinks for men and 7 drinks for women. NIAAA defines a standard drink as 5 ounces of wine or 12 ounces of a 5% alcohol beer. Five ounces of wine is only about a third of a large wine glass, and craft beers are often more in the range of 6%–8% alcohol. Keep this in mind when you are trying to convert your patients’ alcohol intake into “standard drinks,” as the NIAAA definitions are quite a bit lower than what many of our patients would consider a “drink.”
The NIAAA based their recommendations primarily on a survey of 43,000 people in the community. They found that of those who were drinking within both the daily and weekly limits, only 2% qualified for an alcohol use disorder (AUD). For those drinking more than either the daily or weekly limits, 20% met AUD criteria. Of those drinking more than both limits, 50% met AUD criteria (Hasin DS and Grant BF, Soc Psychiatry Psychiatr Epidemiol 2015;50(11):1609–1640). It makes sense that patients who drink less are less likely to have a problem with alcohol. However, the data also tell us that up to half of people drinking more than both the daily and weekly limits did not meet AUD criteria. Additionally, keep in mind that anyone drinking alcohol will have an increased risk of acute accidents, falls, assaults, medication interactions, sleep problems, and so on.
To complicate matters further, recent findings convincingly demonstrate that no level of drinking is completely safe—consuming alcohol at any level can increase the risk of cancer and cardiovascular events, leading some to argue that the NIAAA cutoff may be too lenient. This is definitely a move away from the touted benefit that moderate drinking can reduce the risk of heart disease, a statement that seems to have been exaggerated. A recent Lancet study from April 2018 argues for the low-risk threshold to be set at 7 standard drinks per week for anyone. Consuming more than this weekly limit was associated with increased risk of all-cause mortality, stroke, and non–myocardial infarction heart disease including hypertension, heart failure, and aortic aneurysm (Wood AM et al, Lancet 2018;391(10129):1513–1523).
Alcohol limits: Men vs women Why are there different guidelines for men and women? The effects of alcohol are based upon a person’s water weight, which is the total amount of water in the intracellular and extracellular spaces (vasculature, interstitial fluid, etc). The higher the water weight, the more distributed the alcohol becomes, and the lower the blood alcohol concentration. Men generally have a higher percentage of water weight—up to 70%—while women typically contain around 60% water. Men also have more alcohol dehydrogenase, the enzyme that metabolizes alcohol, than women. So, for a man and a woman who weigh the same amount and are drinking the same amount of alcohol, the man’s blood alcohol content will be lower than the woman’s and decrease faster over time (https://ireta.org/resources/low-risk-drinking-guidelines-where-do-the-numbers-come-from/).
Considerations for older patients The NIAAA identifies older adults age 65+ as a special population with their own risks. The percentage of water weight and amount of alcohol dehydrogenase both decrease as a person ages. For that reason, the NIAAA recommends that everyone over age 65, regardless of gender, abide by the daily and weekly limits for women (no more than 3 standard drinks in a day and 7 standard drinks in a week). Also consider the individual health needs of older patients, such as their risk of falling and whether their medications may become dangerous when mixed with alcohol. If your patients have problems with memory loss, depression, or high blood sugar, be sure to screen them for alcohol problems.
Screening older patients How do we screen older adults for alcohol problems when appointment times are already so tight? The NIAAA has a clinician’s guide supporting the Alcohol Use Disorders Identification Test (AUDIT) (https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf). AUDIT is a 10-question screening tool that can be completed by the patient in the waiting room. But if the patient is already in the appointment with you, the shorter NIAAA single-item screen is the way to go—you simply ask the patient, “How many times in the past year have you had 5 or more drinks in one day (or 4 or more drinks in one day, for women and all adults older than 65)?” (Saitz R et al, J Stud Alcohol Drugs 2014;75(1):153–157).
If the patient has never exceeded the daily limit within the past year, then affirm your patient’s behavior and recommend continuing to stay within the limits or drinking even less (eg, for people at risk for interactions or health problems affected by alcohol—as well as pregnant patients, who should abstain from drinking completely). But if the patient has exceeded the daily limit on one or more days, this is a positive screen for at-risk drinking, and you should then assess whether your patient meets the DSM criteria for AUD. If the criteria are not met, advise and assist the patient to cut down or quit drinking. If the criteria are met, then start AUD treatment and refer the patient if needed.
Many older patients may say they’ve had the same pattern of alcohol use for decades—that can be a big barrier to recovery in their mind. But the first hope for recovery may start with you. Linking to appropriate resources (including age-specific 12-step groups), employing motivational interviewing techniques, and using appropriate medication management (such as naltrexone and acamprosate) for AUD are all good first steps to take.
CATR Verdict: NIAAA has guidelines on low-risk drinking limits, including for older adults. Yet “low risk” does not mean “no risk.” Know how to educate your older adult patients and tailor your interventions appropriately.