Alcohol complicates multimorbidity in older adults
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4304 (Published 27 June 2019) Cite this as: BMJ 2019;365:l4304
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I read the editorial on alcohol and multimorbidity in older adults with interest. The authors find drinking alcohol a particular concern among older people because metabolic efficiency is diminished with age quoting Meier et al - a review with the conclusion that alcohol is more toxic in the ageing organism because of changes in its metabolism, distribution and elimination.[1] Age-related differences in alcohol pharmacokinetics have not been studied extensively in humans, but of the 13 studies on the subject, that to my knowledge have been published between 1968 and 2014, Meier et al only include two studies as references.[2,3]
Gärtner et al found significantly higher blood ethanol concentrations in the elderly as compared to the younger following the ingestion of 0.3 g ethanol/kg body weight blood concentrations in six mother-daughter and six father-son pairs; however, the ethanol elimination rates of the four groups showed no significant difference.[2] In a study of 15 volunteers with a mean age of 71 ± 1 year and 16 volunteers with a mean age of 37 ± 2 years Oneta et al found increased First Pass Metabolism (defined as the difference between the serum ethanol concentration time curves after intravenous and oral administration) of ethanol in the elderly subjects with normal gastric morphology, probably due to a deceleration of the speed of gastric emptying leading to an increased contact time of alcohol with gastric alcohol dehydrogenase. The alcohol elimination curves were similar in the two groups.[3] Of the remaining 11 studies of age-related differences in alcohol pharmacokinetics two studies found higher elimination rates for older than younger subjects, [4,5] and 9 studies found no differences in alcohol elimination rates with increasing age. [6-14]
While a reduced volume of distribution in the elderly is a fact due to decreasing total body water with age, the repeated assertion of a diminished metabolic efficiency with increasing age is a myth.
1. Meier P, Seitz HK. Age, alcohol metabolism and liver disease. Curr Opin Clin Nutr Metab Care 2008;11:21-6.
2. Gärtner U, Schmier M, Bogusz M, Seitz HK. Blood alcohol concentrations after oral alcohol administration – effect of age and sex [in German]. Z Gastroenterol 1996; 34:675–679.
3. Oneta CM, Pedrosa M, Ruttimann S, et al. Age and bioavailability of alcohol. Z Gastroenterol 2001; 39:783–788.
4. Schweitzer H. Statistische Untersuchungen zur Alkoholelimination an 1512 Doppelentnahmen. Blutalkohol 1968;5:73-91.
5. Fiorentino DD, Moskowitz H. Breath alcohol elimination rate as a function of age, gender, and drinking practice. Forensic Science International 2013;233:278-82.
6. Vestal RE, McGuire EA, Tobin JD et al. Aging and ethanol metabolism. Clin Pharmacol Therapeutics 1977;21:343-54.
7. Jones AW, Neri A. Age-related differences in blood ethanol parameters and subjective feelings of intoxication in healthy men. Alcohol Alcohol 1985;20:45-52.
8. Hein PM, Vock R. Alcohol drinking experiments with male subjects over 60 years old. Blutalkohol 1989;26:98-105.
9. Wynne HA, Wood P, Herd B, Wright P, Rawlins MD, James OF. The association of age with the activity of alcohol dehydrogenase in human liver. Age Ageing 1992;21:417-20.
10. Tupler LA, Hege S, Elliwood Jr. EH. Alcohol pharmacodynamics in young-elderly adults contrasted with young and middle-aged subjects. Psychopharmacology 1995;118:460-70.
11. Wayne Jones A, Andersson L. Influence of age, gender, and blood-alcohol concentration on the disappearance rate of alcohol from blood in drinking drivers. J Forensic Sci 1996;41:922-6.
12. Lucey MR, Hill EM, Young JP, Demo-Dananberg L, Beresford TP. The influences of age and gender on blood ethanol concentrations in healthy humans. J Stud Alcohol 1999;60:103-10.
13. Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2004;57:6-14.
14. Sklar AL, Boissoneault J, Fillmore MT. Interactions between age and moderate alcohol effects on simulated driving performance. Psychopharmacology 2014;231:557-66.
Competing interests: No competing interests
This editorial highlights the need for an holistic approach where alcohol misuse meets multiple medical comorbidities in older adults. This has to begin with our clinical approach - ask the question and ask it properly.
Too often a substance misuse history is an after thought in older people and paid lip service at best. The fact is that culturally drinking is ‘more normal’ for the older generations, and as clinicians we need to be aware of this and ask the question.
Competing interests: No competing interests
The point of this article is that alcohol complicates the comorbidity rate of the elderly.
First of all, there is doubt about whether there is a limit on the amount of alcohol here. Checking the latest guidelines shows that unless it is harmful, it is not mentioned. For elderly patients with comorbid conditions, a drink can complicate the comorbidity.
Furthermore, in addition to the objective factors that affect alcohol metabolism, which directly affects organs and drug metabolism, should we consider the psychological and social factors of alcohol dependence in elderly patients with comorbidities? As general practitioners, we should pay more attention to early prevention. Whether the psychological reasons for alcohol dependence are loneliness, lack of entertainment in life, or long-term medical treatment, the mental aspects need to be identified, and alcohol then becomes an item that can be released. So whether you can find something to replace alcohol, such as nuts, candy, etc., or a behavior, when you want to drink, you can start some kind of exercise, stimulate the brain to forget, divert attention.
Furthermore, it is the social environment. We can do some health promotion. The long-term social concept is that a small amount of drinking contributes to health, and etiquette and customs advocate drinking. Therefore, we need to continue to carry out missions, break the conventional thinking, and jump out of bondage.
Competing interests: No competing interests
As the authors indicated, alcohol consumption not only does harm to the body's metabolism, but also interacts with drugs, especially among elderly people with multimorbidity. The latest studies show that even a drop of alcohol is harmful to our health, and the more the worse it gets. Despite this research, the idea that drinking moderately is good for our health is embedded in people's minds. Additionally, a drinking culture has a long history in China. It is difficult to get people to stop drinking.
We should take measures to enhance the propaganda of alcohol prevention to change people’s conceptions about drinking. As GPs, we are expected to pay more attention to alcohol consumption among patients, especially those who live with multimorbidity. Last but not least, finding a way to reduce the pain of alcohol withdrawal is largely important in helping people addicted to alcohol to quit drinking.
Competing interests: No competing interests
The article indicates that alcohol is complicating multimorbidity in older people. One of the reason is that alcohol interacts with a variety of drugs. It is also a commom unaware problem among doctors. I think it is high time for the people with multiple conditions to keep away from drinking. On one hand, we should improve patients' awareness of the hazards about alcohol consumption and gradually reduce to drink or even get rid of it. On another hand, the healthcare professionals should improve their knowledge and diagnosis of alcohol abuse and alcoholism and provide proper clinical therapy. So wheather more effective auxiliary tools need to be developed first?
Competing interests: No competing interests
Previous studies have shown that moderate drinking has a protective effect on cardiovascular disease, but now more studies have revealed that alcohol has a negative effect on multimorbidity in older adults. It can be seen that there may be selection bias in previous studies , and the present studies also suggest that there are uneven results。We suggest that more detailed clinical studies on the interaction between alcohol and multiple drugs are needed in the future.
In addition, the alcohol intervention of multimorbidity in older adults is an important lifestyle intervention, but it is very difficult to carry out the intervention under the background of current Chinese wine culture. In addition to publicizing the dangers of alcohol, general practitioners should be more careful in explaining lifestyle interventions for the elderly in the community and making more careful choices in drug treatment.
Competing interests: No competing interests
As for the topic of drinking and health, I think that wine culture has a unique position in human communication. With the aging of society, the prevalence of diseases is becoming more and more common among the elderly. This also makes us pay more attention to the damage to health caused by alcohol consumption, especially in elderly people with multiple diseases. We may not know why everyone drinks. Everyone's behavior changes are a complex process. It is difficult for us to let patients stop drinking for a while. But it is necessary to raise public awareness and let them understand the harmfulness of alcohol and its adverse effects on diseases. We can formulate appropriate propaganda plans to guide the public to recognize the seriousness of drinking problems through scales and negative cases, and guide patients to abstain from drinking in a standardized and gradual manner.
Competing interests: No competing interests
The authors have critically questioned the long-term health plan issued by the NHS and believe that the link between drinking and the overall health of the elderly is not fully recognized.
China still has a drinking culture, especially in some third-tier cities. People regard drinking as a social and entertainment essential. They think that there is no wine, no chat, no business, no recognition of the danger of wine, even if it is true. I am sick, I have chronic diseases, and it is very difficult to completely quit. On the one hand, I am accustomed to problems. On the other hand, I have not received a good education. I don’t know how to drink long-term in combination with chronic disease. It is necessary to study in depth how to teach people the dangers of drinking and how to make people deeply understand the dangers.
Competing interests: No competing interests
As we know, there are so many people believe that drinking moderately is good for health, even though doctors told them just a drop of alcohol is harmful to health. It is a challenge task to change people's concepts. On the other hand, elder patients with comorbidities always have to face the problem about the complicated drug use.
Author illustrates that alcohol complicates comorbidities in older people and GPs should pay more attention about alcohol dependent patients in routine care. In our daily clinical work, we should try our best to grab any opportunity to let patient realize that the hazard of drinking to health is beyond what they can afford which may help them decide to stop drinking. However, the most important thing is to find a workable method to release the pain of alcohol withdrawal after they quit drinking.
Competing interests: No competing interests
Negative influence of alcoholism in multimorbidity older adults
Alcohol, from the Arabic kahul (essence or spirit), as a substance of the fruit fermentation process, appeared at the end of the Mesolithic period and the beginning of the Neolithic period, and coincides with the development of handicrafts and ceramics that endowed man with containers for storing sugary liquids.
The first references of its consumption in India date back to 2000 B.C. Society did not approve of its consumption especially in the Buddhist era. Hippocrates in the year 460 B.C. talked about alcoholic madness and commented on the relationship between liver cirrhosis and wine abuse.
The distillation process was discovered 800 years B.C. in Arabia; this is how it emerges in the history of mankind. Distilled beverages include spirits such as brandy and rum, among others.
Since the seventeenth century there have been references to the consumption of alcohol in excessive quantities. The scientists of that time were concerned about the manifestations and consequences of it as a disease.
Alcoholism was the first disease and the second social problem (after the murder of Cain) included in the Holy Bible, pointing to Noah as a victim of this toxin with conflicts with his son Ham as the first family impact of a drug.
Alcoholism is the most widespread drug dependence in the world, with the characteristics of being the only institutionalized addictive substance that society handles freely. Alcohol reduces life expectancy by approximately ten years and produces more deaths than the abuse of any other substance. Registers every year record more than 200 thousand deaths related to its use.
Alcoholism shows a significant tendency to proliferation worldwide. In the western countries, a lifestyle characterized by exaggerated consumption has developed. As a result, about 70% of the world's population ingest drinks in different proportions and approximately 10% of them will become alcoholics in the course of their life.
In the United States of America, a country of 280 million inhabitants, more than 20 million alcoholic patients are quantified, of which 5 million are women. This drug addiction ranks third in the list of health problems in that country. The annual economic impact of the consumption of this drug is 100 billion dollars and is linked to 200 000 deaths per year.
The situation in Latin America is also catastrophic with the current existence of some 40 million alcoholic patients; about 6% of Mexico's population has alcoholism, in Argentina there are more than 2.5 million people affected.
Most authors point out that society and the individual are integrated as a system to age better or worse. Worse ageing is associated with drug use, specifically alcohol, which acquires the character of porter drug addiction, a term that metaphorically expresses its facilitating action on the consumption of other medical and illegal substances. This increases the appearance of repercussions of greater severity in the different aspects of the life of the individual, the family and society.
These problems are not exclusive to alcoholism in the elderly, but in them, diseases and complications that evolve towards chronicity become more easily incurable. With the polymorbidity that further complicates the weakened health at this age the body becomes more alcohol sensitive. A dose of alcohol has different consequences in young and old people probably because of the vulnerability to its harmful effects.
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Competing interests: No competing interests