ArticleAlcohol-drinking history and fatal injury in older adults
Introduction
Older adults are particularly susceptible to the ill effects of alcohol consumption. Age-related physiological changes, such as decreased gastric alcohol dehydrogenase and reduced total body water content, result in higher blood alcohol levels per amount consumed in older adults compared to younger adults (Vestal et al., 1977). Older adults also have increased central nervous system sensitivity and decreased tolerance to alcohol (Blow, 1977). At the same peak level of blood alcohol concentration (BAC), the postural balance of older adults is twice as impaired as younger adults (Vogel-Spratt & Barrett, 1984). Over time, severe alcoholism can cause degeneration of the cerebellum and can produce marked disturbances in gait (Gilman et al., 1998). Comorbidity and subsequent medication use increase with age, thus increasing the likelihood of drug interactions with alcohol in late life. Although most clinical guidelines for older adults allow for one drink a day in persons without a history of alcoholism, diabetes, or cardiovascular disease, alcohol has both short-term and chronic effects that can contribute to fatal injury by altering the risk of the initial injurious event and the risk of subsequent fatal sequelae (Moore, 2003).
Our earlier work found that drinking history was associated with a significantly increased risk of all types of fatal injury (Chen et al., 2005); however, the relationship between alcohol use and fatal injury among older persons has yet to be explored. Falls, motor vehicle crashes, and suicide were the three leading causes of injury death among persons aged 65 years and older, comprising 64% of the 40,321 injury deaths in 2002 (National Center for Injury Prevention and Control, 2005). Using two national surveys, the aim of this case–control study was to determine the associations between drinking history and fatal injuries in the elderly, mainly from falls, motor vehicle crashes, and suicides.
Alcohol consumption is associated with falls in the total population (Hingson & Howland, 1993), but its role in the elderly is less clear. For instance, there are seven studies of nonfatal falls in the elderly that show either no statistical association or an inverse association between regular alcohol consumption and fall risk (Iliffe et al., 1991, Lord and Ward, 1993, Mukamal et al., 2004, Nelson et al., 1992, O'Loughlin and Robitaille, 1993, Sheahan and Coons, 1995, Tinetti et al., 1988). Among fatal falls, 59% occurred in persons aged 75 years or older, who comprise only 5% of the population (Baker et al., 1992). Potential mechanisms of death include fatal cerebral injuries and hip fractures, which are both associated with chronic alcohol use (Felson et al., 1988, Kirkpatrick and Pearson, 1978).
Studies of motor vehicle deaths in the elderly have shown weak associations with alcohol use. One study reported that 4% of 71 fatally injured drivers had a detectable BAC of <0.05 g/100 ml, which was below the legal limit in Sweden (Sjogren et al., 1993). Another study reported that one of 110 killed or injured elderly drivers had a BAC over 0.08 g/l00 ml (Holubowycz et al., 1994). Risk of a crash for elderly drivers has been associated with diabetes (odds ratio [OR] = 2.6, 95% confidence interval [CI] = 1.4–4.7), but only marginally with alcohol abuse (OR = 2.1, 95% CI = 0.8–6.0) (Koepsell et al., 1994). Of 4,073 older adult cases in a state-wide trauma registry over a 6-year period 1995–2001, 8.5% tested positive for blood alcohol: 5% of persons injured in motor vehicle crashes and 13% of fall victims (Selway, 2004).
Data from the National Mortality Follow-Back Survey indicated that moderate or heavy alcohol use was associated with suicide in the elderly (Grabbe et al., 1997). Compared with deaths from noninjury causes, moderate (one to two drinks/day) and heavy alcohol use (three or more drinks/day) increased the risk of suicide by about nine times. An autopsy study of alcohol use and suicide found alcohol present in 15% of adults aged 64–73 years, and in 6% of adults aged 74 years and older (Conwell et al., 1990). Adults aged 65 years or older who have more than seven drinks per week may be at risk for alcohol-related problems, including suicide (Blow et al., 2004).
Despite the different mechanisms of injury, a drinking history may represent a point at which a clinician can intervene. For this reason, we evaluated the relationship between drinking history and the causes of two-thirds of all fatal injury in older persons.
Section snippets
Data
Data came from two nation-wide surveys: the 1993 National Mortality Follow-Back Survey (NMFS) (NCHS, 1998) and the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) (NIAAA, 1992). The NMFS provided national estimates of alcohol usage and demographic information among people who died from injuries. The NLAES provided national estimates of alcohol usage for the general public.
A stratified random sample of 22,957 death certificates representing 2,215,000 adults aged 15 years or older
Results
Thirty-six percent of 1,735 cases and 29% of 13,381 controls consumed 12 or more drinks in the prior 12 months (Table 1). Cases were older on average especially those dying from falls (mean age 80 years) than controls (mean age 68 years). A higher percentage of men than women committed suicide or died in motor vehicle crashes. The percentage of cases who died in falls was higher for women than men but similar in proportion to controls. Being married was associated with reduced occurrence of all
Discussion
Having 12 or more drinks a year was associated with a 50–70% increase in risk of motor vehicle crashes, suicides, and falls. The risk associated with alcohol may be due to the direct effects of alcohol, as well as detrimental health-related behaviors that may be linked with drinking. Alcohol use together with comorbid conditions and concomitant medications may increase the risk of a crash and subsequent fatal injury. Even if the older adult is not a driver, hazardous, harmful, and at-risk
Acknowledgments
This research was supported by CDC National Center for Injury Prevention and Control grant H400-888-2152. Ms. Edith Jones prepared the manuscript.
References (40)
- et al.
Drinking history and risk of fatal injury: comparison among specific injury causes
Accid Anal Prev
(2005) - et al.
Age, sex, and blood alcohol concentration of killed and injured drivers, riders and passengers
Accid Anal Prev
(1994) - et al.
Epidemiology of late-life mental disorders
Clin Geriatr Med
(2003) - et al.
An epidemiological study of falls in older community-dwelling women: the Randwick falls and fractures study
Aust J Public Health
(1993) - et al.
Drinking history in fatally injured drivers
Inj Prev
(2002) - et al.
The Injury Fact Book
(1992) - et al.
The association of depression and mortality in elderly persons: a case for multiple independent pathways
J Gerontol A Biol Sci Med Sci
(2001) - et al.
Role of alcohol in late-life suicide
Alcohol Clin Exp Res
(2004) - Blow, F. C., Consensus Panel Chair. Substance abuse among older adults. Treatment Improvement Protocol (TIP) series 26....
- et al.
A case-crossover study of acute alcohol use and suicide attempt
J Stud Alcohol
(2004)
Completed suicide at age 50 and older
J Am Geriatr Soc
Volume of Ethanol Consumption: Effects of Different Approaches to Measurement. Alcohol Consumption and Problems in the General Population: Findings from the 1992 National Longitudinal Alcohol Epidemiologic Survey
Alcohol consumption and hip fractures: The Framingham Study
Am J Epidemiol
Cerebral injury from severe chronic alcoholism
The health status of elderly persons in the last year of life: a comparison of deaths by suicide, injury and natural causes
Am J Public Health
Primary versus proxy respondents: comparability of questionnaire data on alcohol consumption
Am J Epidemiol
Alcohol and non-traffic unintended injuries
Addiction
Alcohol consumption by elderly people: a general practice survey
Age Ageing
Fatal cerebral injury in the elderly
JAGS
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