International inequalities in drinking and related outcome

Posted 18.07.2017

international inequalities in drinking

Older drinkers tend not to set cars on fire, riot, or urinate in your garden on a Saturday night. Perhaps this is why, despite being one of the worlds’ most at-risk group for alcohol-related harm, older drinkers receive very little media or political attention. This lack of attention also ensures that older adults continue to remain our invisible addicts.

In a century characterised by rapid population ageing we urgently need to understand the patterns of older adults drinking, the predictors of such patterns, and the likely ramifications of drinking on the health of older adults. This would be the perfect point for us to review what it is that we know about older adults drinking, what critical gaps in our knowledge still exist, and what we can do to fill those gaps.

What we already know

What do we already know? Alcohol is clearly linked to over 200 health conditions and accounts for almost 6% of deaths worldwide (WHO, 2014). Older adults are specifically at greater risk of alcohol-related harm than younger cohorts for three key reasons. First, physiological ageing reduces our ability to process ethanol, making us more susceptible to its effects (Heuberger, 2009). Second, as we age we are more likely to develop health conditions related to (or impacted by) alcohol use, and use medication that might interact poorly with alcohol (Moore et al, 2007). Third, despite being an at-risk population for alcohol use older adults are less likely to be screened for alcohol use meaning that many alcohol-related issues remain undetected in this population (Duru et al, 2010). In addition to these risk factors the baby boomer generation appears to be drinking more than previous cohorts of retirees (Savage, 2014) and almost half could be classified as ‘hazardous’ drinkers (Towers et al, 2011).

Does moderate drinking help our health? Short answer: no. We recently found that while older moderate drinkers seem to be healthier than heavy or non-drinkers this is mainly because they are wealthier and can likely afford healthier lifestyles (Towers et al, 2016). In fact a growing body of research now shows that the presumed health benefits of moderate drinking actually reflect simple differences between drinkers and non-drinkers in general (e.g., wealth, health, education) and not the influence of alcohol itself (Chikritzhs et al, 2015). Despite this finding it is still clear that many older adults still self-medicate with alcohol assuming that it is beneficial for their health (Aira et al, 2008).

What we don’t know

What don’t we know? Although it sounds like we know a lot about older drinkers this is not necessarily the case. Much of our research is done by isolated research teams conducting distinct studies in different countries around the world, the results of which are not often comparable. We have no idea whether older adults in the United Kingdom have the same patterns of drinking and health outcomes as their counterparts in North American, Africa or Australasia. We also have no idea whether any trends in drinking might reflect factors that are country-specific (e.g., drinking cultures, inequalities in sub-populations) or global (e.g., wealth, policy approaches).

So, what’s the problem?

What’s the problem? A lack of collaborative international research makes it difficult even to identify the simple prevalence of drinking patterns across borders and can, in fact, confuse the general public. For example, depending on the study you are reading estimates of unhealthy drinking in older adults range anywhere from 9% of older adults (Merrick et al, 2008), to 20% (Hoeck & van Hal, 2014), and even up to almost 50% (Towers et al, 2011). This is largely because research teams in this area often focus on different sub-populations of older adults (i.e., community-dwelling vs. treatment-seeking), use different measures of drinking (i.e., days drinking vs. standardised assessments), and work on different notions of unhealthy consumption (i.e., binge, heavy, hazardousness, harmful, risky). These differences make it effectively impossible to compare results across studies (i.e., less like comparing apples with apples; more like comparing apples with Kiwifruit).

Can we solve it and what’s been done so far?

Is there a solution? Government-funded longitudinal studies of ageing currently offer our greatest hope for finally understanding older adult drinking patterns around the world. Many countries now have longitudinal studies of ageing (e.g., England, the United States, and New Zealand) and the World Health Organisation conducts the 6-country Study on global AGEing and adult health (SAGE). The similarities in research methodology across such studies offer opportunities to use this data to compare health and wellbeing trend in older adults across borders.

What has been done so far? A collaboration of researchers from New Zealand, Europe, the United States and the World Health Organisation recently used data from longitudinal studies of ageing to explore older adult drinking trends across nine countries: England, the US, New Zealand, China, Ghana, India, Mexico, Russian Federation and South Africa. With funding from the New Zealand Health Promotion Agency and the US National Institutes of Health this team were able to identify quite stark differences across countries in simple drinking trends. This report is currently embargoed pending publication but we can let you know some of the general findings. First, the proportion of older adults who drank in each country varied quite considerably; from 91% of men and 84% of women in England to only 29% of men and 2% of women in India. Second, the frequency of usual drinking ranged widely as well. In some countries it was most common for older drinkers to consume only one or two days per week (e.g., Russian Federation, Mexico) while in others it was apparent that older drinkers commonly consumed alcohol on four or more days per week (e.g., England, New Zealand, Ghana, China). This research in currently in publication and a link will be made available soon on the New Zealand Health Promotion Agency website.

While this collaborative study provides new insight into the patterns of older adult drinking around the world it has its limitations. Each study used different measures of alcohol which required significant statistical harmonisation of this data in order to compare drinking patterns. This makes it impossible to apply standardised thresholds for harm (e.g., the AUDIT-C hazardous drinking threshold) in order to explore what proportion of older drinkers in each country are at harm. Also, none of the current longitudinal studies utilise the same predictors variables as other studies (i.e., health, socioeconomic status, education). This makes it very difficult to harmonise these factors across studies and investigate their influence on drinking trends.

What do we still need to do?

What still needs to be done? We need to explore older adults drinking across different countries using the same set of questions and the same set of predictor variables. There are a large number of longitudinal studies of ageing currently in place around the world, covering upwards of 30 different countries, and freely sharing their data through such portals as the Gateway to Global Aging Data. If we are able to coordinate all of these studies to use the same three questions on alcohol use (i.e., the AUDIT-C frequency, quantity and binge drinking questions) this would offer the world’s most comprehensive assessment of global trends in older adults drinking. Furthermore, as many of these studies already appear to use comparable indicators of health and wellbeing this would open the door to extensive exploration of the roll that alcohol plays in shaping the health of older adults around the world.