Habit of a lifetime – alcohol and age

The sober truth is that Older Australians’ love affair with alcohol is impacting their health and their behaviour.

Eric Martin reports

Even though there is evidence that Australians’ consumption of alcohol has declined over the past two decades – predominantly driven by people under 30 – there are growing concerns about the health implications of drinking for our ageing population.

This comes with evidence of increasing use and related harm among older age groups who may have maintained those high-risk drinking patterns learned over a lifetime.

Recent estimates using data from 2018 show that the total intangible costs of alcohol were $48.6 billion that financial year, and with the addition of hard data such as 5219 deaths, about 127,000 hospitalisations ($2.1 billion), $3.1 billion in costs to the justice system, and $2.4 billion in traffic accidents, the total estimated social and economic cost of alcohol in Australia was $66.8 billion.

Professor Tanya Chikritzhs

Professor Tanya Chikritzhs, lead for the Alcohol Policy Research team at the National Drug Research Institute based at Curtin University, says the impact of the nation’s love affair with alcohol continues to be reflected on the rates of accidents and falls, self-harm and violence.

“While the proportion of alcohol-caused crashes still hovers between 26% and 30% Australia wide, that is predominantly dictated by broader societal policy and practice such as the legislation around drink driving or the minimum drinking age, and the extent to which that’s policed and enforced,” Professor Chikritzhs said.

“Unfortunately, the proportion of injuries that are caused by alcohol also remains stable. ED presentations still hover around 30%, and that is directly linked to how much people are drinking.

“And for some age groups, particularly older Australians, that percentage appears to be increasing, which is interesting because they seem to have brought their drinking patterns from youth and middle age with them. They haven’t slowed down to the same extent as you would expect over the life course.

“While young people seem to be going in the opposite direction.”

Professor Chikritzhs said that years of observation had shown that, normally, people drank less alcohol as they got older due to greater rates of ill health.

“For most people, when you feel sick the last thing you want to do is have a drink of alcohol. But these days, we’re getting so good at managing and screening age-related illness with medications that this natural slowdown has been countered to some extent,” she said.

“As such, we have a situation where the last National Drug Strategy household survey told us that the group increasingly most likely to drink above the National Health and Medical Research Council guidelines was older people.

“Older age groups are now drinking at greater risk than they have been in decades of drinking above low risk guidelines, yet more than 10 standard drinks a week is not good news for an ageing population.”

And with that, there were serious healthcare complications associated with alcohol consumption in this age group, including ED presentations for injuries from alcohol-related falls and hospitalisations for long-term impacts.

U-shaped curve 

“There has always been what we call a U-shaped curve in terms of alcohol and hospitalisation, and it’s not just true of younger people but of older people too,” Professor Chikritzhs said.

“Alcohol is a neurotoxin, it’s a central nervous system depressant and at high enough doses, it results in loss of consciousness. The brain will even start to use acetaldehyde, the metabolite of alcohol, as a fuel rather than glucose, which has major impacts on balance centres and contributes to the implication of alcohol in falls.

“For a much older person who may suffer an alcohol-related hip fracture, they may end up in hospital for a month or longer and that could result in a downward spiral in terms of overall health.

“And for some people, there’s no coming back from that.” 

Professor Chikritzhs pointed out that polypharmacy use was an issue that could often complicate alcohol consumption for older Australians.

“One of the fastest growing areas of health care expenditure is prescriptions, which is a major problem when it comes to alcohol,” Professor Chikritzhs said.

“In the 60-plus age group, most people are taking two or more, or five or more pharmaceutical medications and very few people are heeding the instructions, which is that most medication is not to be taken with alcohol.

“The irony is that in many cases, these people may already be on medications addressing health problems directly related to alcohol consumption. For example, hypertension is one of the biggest killers in the world today and is commonly treated with medication, yet alcohol is a major cause.

“On top of that, we’re notoriously bad at monitoring our own alcohol consumption and measuring how many standard drinks we’ve had, especially for beverages like wine, where you pour them into a glass but rarely measure the content.”

Low level pain

Professor Chikritzhs explained that traditionally, when we think of alcohol and injury, we tend to think of high levels of alcohol consumption and intoxication, but it also exists at low levels. 

“For example, it’s well-established that key impairments to a person’s ability to pay attention and reaction response time occurs even at a breath alcohol concentration of 0.02, which was the original limit for probationary drivers,” she said.

“There is impairment in those key physiological and pharmacological pathways even at very low levels of alcohol, as well as key physiological differences between men and women, which are reflected in the guidelines for drinking.”

Professor Chikritzhs said the NHMRC guidelines aimed to maintain a risk level of less than one in a 100 for adverse outcomes, and highlighted that at low levels of consumption, the risks started out as comparatively equal for both sexes. 

“It’s currently the same for men and women at a low level because the additional risk-taking behaviours that tend to go with being male, and the physiological factors that make women more susceptible to the impacts, such as having less mass and more hormones, tend to cancel each other out at two drinks,” she said. 

“But starting just above that level, the harm for women accelerates much faster. And these factors are important as we age. For example, holding less water in the body can lead to more rapidly accelerating blood alcohol concentrations.

“The other issue is tolerance. A person with an alcohol use disorder who drinks regularly will probably have a better physiological tolerance to the effects of alcohol than somebody who drinks heavily once a month. 

“The person who drinks heavily once a month is more prone to injury, and the person who drinks at regular levels of exposure is more prone to chronic effects such as cancers, stroke and CVD.

“And let’s not forget, one of the greatest contributors to alcohol related injury is interpersonal violence. This is obviously a huge issue for young men and increasingly so for young women.”

Violence follows

While the involvement of alcohol was not recorded, throughout 2020-21 there were 23,000 hospitalisations in Australia due to assault, and while most of these involved male victims (62%), 49% of female victims reported being assaulted by a spouse or domestic partner.

Professor Chikritzhs added that alcohol was also frequently implicated in drownings and suicides.

“We know that a lot of people who suicide successfully have consumed alcohol at the time and, worldwide, it’s about 50% of cases,” she said.

“But establishing a clear relationship between alcohol and depression it is not just about monitoring an individual’s drinking in the moment, but looking at how regular exposure over time is having an impact on that person’s mental health.”

She highlighted that the ‘goon bag,’ or cask wine, has had a long history of being a highly problematic beverage in Australia (especially the NT, QLD, and northern WA), not just for Aboriginal communities but also more broadly for certain socioeconomic groups, because it offered ‘the best bang for your buck.’

“And I mean high alcohol content at a very cheap price. Port was very popular as well for quite a while and we are also dealing with cleanskins. You can now buy wine at a cheaper price than bottled water,” Professor Chikritzhs said.

“Interestingly, Australia tends to get higher levels of drinking at both ends of the social spectrum, but for different reasons. 

At the lower socioeconomic end, you get higher levels of consumption – they tend to drink the cheaper beverages, and due to generally less access to health care and other socioeconomic factors, they tend to suffer greater levels of problems from alcohol use. 

“At the other end of the spectrum, those in higher socioeconomic groups drink heavily because they can afford to. High levels of disposable income not only provide greater availability but can also help insulate against more broad-reaching financial impacts, which is probably true of other drugs as well.”

How GPs can help

Professor Chikritzhs said that one of the most important things doctors can do to help their patients with alcohol-related issues was to have an awareness and understanding of the NHMRC drinking guidelines.

“No more than 10 standard drinks a week – and if you can, recommend to your patients, especially if they like to drink, to take just a couple of days off – even one day off a week – which can make a big difference in terms of their tolerance,” she said.

“And we are not just talking about physiological tolerance, but psychological tolerance, which is also important. Having a glass of alcohol is often the first thing we do when we come home from a hard day’s work and need to de-stress, or deal with the kids.

“And that often turns from one drink to two and so on – we all know it happens.”

Professor Chikritzhs said that surprisingly, one of the facts that her research uncovered was that very few medical doctors either knew about or believed the link between alcohol and depression, a situation that the research team attributed to cognitive dissonance.

“One of the reasons we found why doctors don’t ask their patients how much they’re drinking, is because it causes them to have to reflect on their own alcohol consumption,” she said.