Perspectives in Disease Prevention and Health Promotion Surgeon General's Workshop on Health Promotion and Aging: Summary Recommendations of the Alcohol Working Group

In recent decades, the number and proportion of the U.S. population greater than or equal to 65 years of age have increased remarkably. Between 1950 and 1980, this age group doubled from 12.5 million to 25.5 million (1). Persons greater than or equal to 85 years of age experienced the largest increase, from 577,000 in 1950 to more than 2.2 million in 1980. The population greater than or equal to 65 years old currently constitutes 12% of the total population. By the year 2030, this proportion is expected to reach 21.1% (2). As the number of older persons in the United States increases, the role of health promotion needs further exploration as a means of improving activity levels and productivity during the later years and of extending functional life spans. To meet these challenges, health professionals need to better understand the health needs of the elderly and the available preventive interventions.

The "Surgeon General's Workshop on Health Promotion and Aging" met in Washington, D.C., in March 1988 to help define unmet health promotion needs for the aging. Cosponsored by the Administration on Aging, the Public Health Service*, the Brookdale Foundation, and the Henry J. Kaiser Family Foundation, the workshop provided the health professional community with recommendations and proposals for health promotion activities that directly address the needs of the elderly.

The workshop emphasized preventive health services, medications, dental health, injury prevention, mental health, alcohol, smoking cessation, nutrition, and physical fitness and exercise. These topics were selected because 1) scientific information is sufficient to identify actions necessary to make positive impacts, 2) constituencies are available to implement recommendations, and 3) substantial interest in the topic areas exists. Experts were commissioned to produce papers on these nine topics (3), and working groups at the workshop used these background papers in their deliberations. The resulting 365 recommendations (4) were organized by topic under the general headings of education and training, research, service, and policy.

One priority area for recommendations was alcohol abuse among the elderly. Although it is not possible to determine the prevalence of alcohol abuse, reported drinking appears to decline as the population ages; the estimated prevalence of alcoholism among older persons who drink approximates that of other adult populations (nearly 8%) (5).

The recommendations from the alcohol working group are summarized below. Recommendations from other selected working groups may be summarized in subsequent issues of MMWR. SUMMARY RECOMMENDATIONS OF THE ALCOHOL WORKING GROUP Education and Training oIncreased training and continuing medical education opportunities are needed that emphasize patterns of alcohol use and/or abuse among older persons, risks and potential benefits of such use, effective detection of alcohol abuse, techniques for intervention, and effective communication with patients about alcohol use. oSocial service providers, home-health aides, and other providers should be informed about the potential for alcohol abuse among older clients, about methods for identifying and referring these clients, and about how to advise family members of elderly clients with problems of alcohol abuse. oFederal agencies, national membership and voluntary organizations, and other associations should be encouraged to develop and disseminate information about problems of alcohol abuse among older adults. Service oTreatment and reimbursement patterns for alcohol abuse among the elderly should reflect community-based versus hospital-based alternatives, as well as length of treatment. oDevelopment of broad-based community-level programs is needed to address alcohol problems among older persons and efforts to include an alcohol-use component (e.g., alcoholism counseling, when appropriate) in the delivery of federally sponsored preventive services. oState and local governments and other community-based programs should strengthen relationships with alcohol-related networks (e.g., mental health centers, drug rehabilitation programs) to improve identification, referral, and treatment of older alcoholics. Research oCross-sectional and longitudinal studies of drinking patterns among older adults, including studies using indirect measures and qualitative methods, should be expanded to determine quantity, frequency, and duration of alcohol intake. oNational data sets should be examined to characterize patterns of alcohol use among older adults. oAnalysis of drinking patterns in the elderly should focus on socioeconomic groups, minority groups, and women. oStudies of the association between alcohol consumption and cardiovascular disease--particularly hypertension and stroke--should be expanded. oStudies of alcohol metabolism in older persons should be extended, and animal model and human studies should be used to determine patterns of sensitivity to alcohol among older persons. oThe interplay of the aging process and alcohol abuse on cognitive functioning and the role of alcohol use in injuries common to older adults (e.g., burns and fall-related fractures) should be examined. oClinical investigators should study the alcohol withdrawal syndrome and the relationship between alcohol and nutrition in the elderly and should expand research on the role of alcohol in osteoporosis. oThe role of alcohol in family violence, in the behavior of violent older offenders, in the risk of suicide, and in victimization among older persons should be examined. oPossible beneficial effects of small amounts of alcohol on eating behavior, mood, sleeping patterns, and social functioning among older adults should be further examined. oResearch should be conducted on the effect of alcohol on misuse of prescription and over-the-counter medications and interactions between medication and alcohol. Reported by: Office of the Surgeon General, Public Health Svc. Cardiovascular Health Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The 1990 health objectives for the nation included only two objectives specifically concerned with alcohol use among the elderly (6). In contrast, the year 2000 objectives will contain a separate set of objectives for the elderly, including several that pertain to alcohol use, which will incorporate workshop recommendations.

The varied health effects of alcohol range from the acute effects of physical and cognitive impairment to the long-term effects of certain chronic diseases and social and psychologic dysfunction. As the workshop recommendations emphasize, these negative effects coexist with the possible beneficial effects of the use of small or moderate amounts of alcohol. These dose-related, but divergent, effects of alcohol are most striking in the case of cardiovascular disease (CVD), the most common cause of death and disability among Americans greater than or equal to 65 years of age (7). Coronary artery disease (CAD) exists in an estimated 3.6 million persons in this age group (7). Hypertension, a known risk factor for both CAD and stroke, affects greater than 54% of persons greater than or equal to 65 years of age and is most prevalent among elderly persons in minority groups (8,9). Recent studies have confirmed the dose-response relationship of alcohol use and blood pressure (10,11). Other studies have demonstrated a possible beneficial link between moderate levels of alcohol intake and CAD (12,13), although this relationship is controversial. One suggested explanation for this relationship relates to the apparent effect of alcohol in raising the plasma levels of high-density lipoprotein cholesterol, the antiatherogenic fraction of plasma cholesterol (14,15). However, before a comprehensive public health policy can be established, more information is needed regarding the relationship between alcohol and CVD. The workshop recommendations emphasize the need for improved and expanded epidemiologic studies of alcohol consumption patterns and health outcomes and for specific investigations of the relationship between alcohol and CVD. These recommendations will need to be implemented in time to meet the challenge of the current demographic trends in the United States.

References

1. Taeuber CM. America in transition: an aging society. Washington,

DC: U Department of Commerce, Bureau of the Census, 1983. (Current population reports; special studies series P-23, no. 128).

2. Spencer G. Projections of the population of the United States, by age, sex, and race: 1983 to 2080. Washington, DC: US Department of Commerce, Bureau of the Census, 1984. (Current population reports; series P-25, no. 952).

3. Abdellah FG, Moore SR, eds. Surgeon General's Workshop: Health Promotion and Aging-- background papers. Washington, DC: Office of the Surgeon General, Public Health Service, 1988. 4. Abdellah FG, Moore SR, eds. Surgeon General's Workshop: Health Promotion and Aging-- proceedings. Washington, DC: Office of the Surgeon General, Public Health Service, 1988.

5. Nace EP. Epidemiology of alcoholism and prospects for treatment. Ann Rev Med 1984; 35:293-309.

6. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980.

7. NCHS, Dawson DA, Adams PF. Current estimates from the National Health Interview Survey: United States, 1986. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1987; DHHS publication no. (PHS)87-1592. (Vital and health statistics; series 10, no. 164).

8. NCHS. Blood pressure levels in persons 18-74 years of age in 1976-80, and trends in blood pressure from 1960 to 1980 in the United States: data from the National Health Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1684. (Vital and health statistics; series 11, no. 234).

9. Working Group on Risk and High Blood Pressure. An epidemiological approach to describing risk associated with blood pressure levels: final report. Hypertension 1985;7:641-51. 10. Friedman GD, Klatsky AL, Siegelaub AB. Alcohol intake and hypertension. Ann Intern Med 1983;98(pt 2):846-9. 11. Gruchow HW, Sobocinski KA, Barboriak JJ. Alcohol, nutrient intake, and hypertension in U.S. adults. JAMA 1985;253:1567-70. 12. Blackwelder WC, Yano K, Rhoads GG, Kagan A, Gordon R, Palesch Y. Alcohol and mortality: the Honolulu Heart Study. Am J Med 1980;68:164-9. 13. Klatsky AL, Armstrong MA, Friedman GD. Relations of alcoholic beverage use to subsequent coronary artery disease hospitalization. Am J Cardiol 1986;58:710-4. 14. Hulley SB, Gordon S. Alcohol and high-density lipoprotein cholesterol: causal inference from diverse study designs. Circulation 1981;64(suppl 3 pt 2):III57-63. 15. Haskell WL, Camargo C Jr, Williams PT, et al. The effect of cessation and resumption of moderate alcohol intake on serum high-density-lipoprotein subfractions: a controlled study. N Engl J Med 1984;310:805-10. *Public Health Service cosponsors were the Food and Drug Administration, the National Institute on Aging, the Office of Minority Health, the Office of Disease Prevention and Health Promotion, the Centers for Disease Control, the National Institute of Mental Health, and the National Institute on Alcohol Abuse and Alcoholism.

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