ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH
Vol. 38, No. 11 November 2014
Drinking Behavior Among Low-Income Older Adults: A Multimethod Approach to Estimating Alcohol Use John D. Clapp, Mark B. Reed, Brandi Martel, Maria C. Gonzalez, and Danielle Ruderman
Background: Substance abuse is the fastest growing health concern for older adults. Heavy drinking among older persons is associated with an increased risk of health consequences such as diabetes, cognitive impairment, sleep issues, and depression. It is important to note, however, the prevalence estimates of alcohol use among older adults are often based on inconsistent methodology. To address these potential methodological shortcomings, this study examines drinking patterns among low-income older adults using both self-report and unobtrusive methods. Methods: The study was conducted in a low-income residential senior center in the United States. A total of 174 participants, aged 60 years or older, completed 2 self-administered cross-sectional surveys. A bogus recycling program was implemented to assess the amount of alcohol consumed by residents. Logistic regression analysis was utilized to model predictors of drinking status and to determine predictors of 3 category Alcohol Use and Disorders Identification Test scores. Bivariate associations that predicted associations with alcohol use were included in the final multivariate model. Alcohol containers collected from recycling were converted to standard drink estimates in order to calculate the capital consumption of residents. Results: About 40% of respondents reported consuming alcohol and 25% reported drinking at least once a week. On average, a total of 1,079 drinks were consumed per month. There were 3 significant predictors of drinking status: age, education, and diagnosis of diabetes. Additionally, there appears to be an increase in recycled alcohol containers coinciding with the time residents received their social security checks. Conclusions: Overall, the combination of self-report and unobtrusive measures of alcohol consumption has potential to highlight different aspects of drinking behavior with a population living in a single dwelling such as a senior center apartment complex, residential hall, and the like. Key Words: Older Adults, Drinking, Measurement, Recycling.
A
CCORDING TO THE Substance Abuse Mental Health Services Administration (SAMHSA; 2013), substance abuse is the fastest growing health concern for older adults, especially when the growth of this population is considered. SAMHSA (2013) reported 41.2% of older adults drink alcohol, 8.2% binge drink, and 2% consume heavy amounts of alcohol. Although binge drinking is most common for persons aged from 18 to 24, the Centers for Disease Control and Prevention (2010) reported that individuals aged 65 and older had the highest frequency of binge drinking at 5.5 episodes per month. Merrick and colleagues (2008) reported almost 1 in 10 older adults drank heavily, with 16% of men and 4% of women, respectively, reporting unhealthy drinking. Balsa and colleagues (2008) used the National Epidemiologic Survey on Alcohol and Related Conditions to
From the College of Social Work (JDC, DR), The Ohio State University, Columbus, Ohio; School of Social Work (MBR, MCG), San Diego State University, San Diego, California; and U.S. Center for Disease Control (BM), Atlanta, Georgia. Received for publication November 4, 2013; accepted August 11, 2014. Reprint requests: Dr. John D. Clapp, PhD, FAAHB, College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43210; Tel.: 614-292-6288; Fax: 614-292-6940; E-mail: [email protected] Copyright © 2014 by the Research Society on Alcoholism. DOI: 10.1111/acer.12550 2862
determine, on average, men drank for 134 days (1.8 drinks per day on average) of the year while women drank for 87 days (1.3 drinks per day on average). Heavy drinking among older persons is associated with an increased risk of health consequences such as cirrhosis of the liver, motor vehicle crashes, debilitating falls, and fatality (Breslow et al., 2003). Additionally, binge drinking in this population is associated with increased risk of diabetes, cognitive impairment, hypertension, and sleep issues (Blow and Barry, 2012; Sabia et al., 2014). Older adults who participate in heavy drinking also are at a greater risk of depression and other psychiatric conditions (Merrick et al., 2008). Unlike their younger drinking counterparts, older adults face unique risks related to alcohol consumption. With age, the liver is less efficient and the central nervous system becomes more sensitive. Consequently, older individuals achieve higher blood alcohol concentrations than younger adults when consuming the same amount alcohol (Blazer and Wu, 2009). Exacerbating these physiological changes, the majority of older adults take at least 1 prescribed medicine, often posing dangerous side effects if combined with even small amounts of alcohol (Blow and Barry, 2012). Compounding the comorbid use of alcohol and prescription drugs, adults who participate in more frequent binge drinking obtain fewer preventive services and attend fewer physician appointments (Jenkins and Zucker, 2010). As such, the Alcohol Clin Exp Res, Vol 38, No 11, 2014: pp 2862–2868
DRINKING BEHAVIOR AMONG LOW-INCOME OLDER ADULTS
National Institute on Alcohol Abuse and Alcoholism (NIAAA; 2013) recommends that adults aged 65 and older consume no more than 7 drinks per week or no more than 3 drinks per day. NIAAA defines binge drinking among this population to be more than 3 drinks per day for men and more than 2 drinks per day for women (NIAAA, 2009). In contrast, for young adults binge drinking is defined as 5 drinks for men and 4 drinks for women in a 2-hour period (NIAAA, 2009). Limited research has been conducted on the prevalence of drinking among low-income older adults. This population might be at a particular risk of problems due to limited access to medical care, adequate food, and consistent shelter. Cummings and colleagues (2013) surveyed 187 older public housing residents to determine prevalence of alcohol misuse. Almost one-quarter of the sample admitted to recent binge drinking or problem drinking behaviors. Race, gender, employment status, and drug use were predictors of problematic drinking. To date, there have been no attempts to study the seasonal or episodic nature (including patterns that may appear near holidays or particular times of the year) of drinking among older adults. Understanding these aspects of drinking can provide insight and can illuminate leverage points for prevention. This aspect has been a focus of research on the drinking environments of college students. Students displayed significantly higher breath alcohol concentrations during the winter and spring than those collected in autumn (Clapp et al., 2008a). It is important to note, however, the prevalence estimates of alcohol use and related problems among older adults is often based on inconsistent methodology and operational definitions of problematic drinking (Stelle and Scott, 2007). Most studies rely on self-report measures to determine consumption frequency given alcohol use problems are typically measured with questionnaires (Blazer and Wu, 2009; Choi and DiNitto, 2011; Cummings et al., 2013; Merrick et al., 2008; Sabia et al., 2014; Sacco et al., 2009). As illustrated within younger populations, the validity of self-reports can be suspect (Clapp et al., 2009) due to issues with people’s ability to count drinks. For the general population, the difference between self-reports and actual habits is apparent in the findings of The Garbage Project initiated in the early 1970s to analyze garbage collected in Tucson Arizona (Rathje, 1974). Researchers compared household surveys on drinking habits to alcohol refuse in nearby dumpsters and noticed a discrepancy. Residents of the Tucson area underreported alcohol use. Resnick and colleagues (2003) suggested social desirability bias also might be especially important to consider among older adults who may have been hesitant to disclose unhealthy lifestyle choices. Kerr and colleagues (2008) found a birth cohort effect that showed a decreased tendency to drink for older cohorts, perhaps illustrating increased acceptance of heavy drinking among younger populations. Older adults may feel less comfortable disclosing drinking habits because this behavior is less common. Within the older adult population, there is also
2863
the potential for significant short-term memory complications that can prevent participants from recalling the amount of alcohol consumed during a given period of time (Sabia et al., 2014). To address these potential methodological shortcomings, this study examines drinking patterns among older adults using both self-report and unobtrusive methods. The impetus for the study was the perception of social work and nursing staff, working at an urban residential center for low-income older adults, that residents of the centers were engaged in frequent heavy drinking. With the seminal work of Webb and colleagues (1966) in mind, this study measures alcohol consumption by unobtrusively collecting recycled bottles disposed in the residential center. The collection of waste materials has been utilized in previous research, although not commonly. The Garbage Project by Rathje (1992) is one example of collecting garbage as an unobtrusive method to study the lifestyle of people living in a community. In a 1995 case study by Clapp, residents of a large southern California city monitored drug paraphernalia found on the street to determine the effectiveness of their efforts to decrease drug use. Interestingly, we were unable to find research that has examined the seasonal or episodic nature of drinking among older adults and there is limited research on drinking among low-income older adults. Thus, the present study adds to the current literature by examining this population while testing a new and relatively simple means of assessing alcohol use at the environmental level. It is our expectation that the data collected in this study through the recycling program will confirm self-reported drinking levels, or yield higher estimates of heavy drinking (in light of response bias). Two rounds of an initial self-report survey (reported below) were conducted, followed by a longitudinal unobtrusive study. Combined, the 2 methods addressed the following research questions: 1. What predicts the quantity and frequency of heavy drinking among older adults residing in low-income housing settings? 2. What is the seasonal distribution of drinking among older adults residing in low-income housing settings? 3. What factors predict high-risk drinking among older adults residing in low-income housing settings? 4. How consistent are self-report and unobtrusive measures of drinking among older adults?
MATERIALS AND METHODS Procedures Design. We conducted a self-administered survey and an unobtrusive social indicator study to measure alcohol use and risk. Setting. The study was conducted in residential senior center located in a downtown area of a large city in the southwestern United States. Residents had to be 60 years of age and have an income near or below the poverty threshold to reside in the center.
CLAPP ET AL.
2864
Survey Data Collection. Participants completed 2 self-administered cross-sectional surveys. The first survey was administered in April 2009, and the second survey was administered in April 2010. For the survey, participants were asked to provide demographic information (i.e., gender, age, race, etc.), alcohol consumption, prescription drug taking behaviors, health conditions, gambling behavior, and geriatric depression. Over the 2 survey administrations, a total of 200 residents were asked to complete the survey. There were a total of 174 survey respondents (n = 78 in April 2009 and n = 96 in 2010) in both data collection periods for an overall response rate of 43.5%. Residents who responded to the first survey were not sampled during the second data collection period. There were no differences on drinking outcomes as a function of data collection periods; thus, the data from both data collection periods were combined for analysis. Study Measures. The following demographic variables were included in the present study: participant gender, age, race/ethnicity (White, African American, Asian, Pacific Islander, Hispanic/Latino, other), marital status (married, widowed, not married), level of education (less than high school, high school graduate, post high school education), monthly income (less than $900/month, $901 or more/ month), military service, and lifetime homeless status. Participants also indicated if they were currently taking any prescription medication or if they had a diagnosis of diabetes. We collapsed the race/ ethnicity categories into a dichotomous variable (White/non-White) for analyses. Participants also completed the Geriatric Depression Scale (GDS-s; Sheikh and Yesavage, 1986) which is comprised of 15 (yes/ no) items (“Are you basically satisfied with your life?,” “Do you often get bored?,” “Do you think it is wonderful to be alive now?”). Items endorsing depression were summed to form a total GDS-s score with higher scores indicating more depression. Reliability analyses showed the scale had satisfactory internal consistency (Cronbach’s a = 0.77). The Alcohol Use and Disorders Identification Test (AUDIT) was used to measure alcohol consumption behavior and alcoholrelated problems (Babor et al., 2001). The AUDIT is comprised of 10 items measuring alcohol consumption (quantity and frequency) as well as alcohol-related problems. The first 3 items of the AUDIT measure the frequency of alcohol consumption (“How often do you have a drink containing alcohol?”; 0 = never, 1 =
Vol. 38, No. 11 November 2014
Drinking Behavior Among Low-Income Older Adults: A Multimethod Approach to Estimating Alcohol Use John D. Clapp, Mark B. Reed, Brandi Martel, Maria C. Gonzalez, and Danielle Ruderman
Background: Substance abuse is the fastest growing health concern for older adults. Heavy drinking among older persons is associated with an increased risk of health consequences such as diabetes, cognitive impairment, sleep issues, and depression. It is important to note, however, the prevalence estimates of alcohol use among older adults are often based on inconsistent methodology. To address these potential methodological shortcomings, this study examines drinking patterns among low-income older adults using both self-report and unobtrusive methods. Methods: The study was conducted in a low-income residential senior center in the United States. A total of 174 participants, aged 60 years or older, completed 2 self-administered cross-sectional surveys. A bogus recycling program was implemented to assess the amount of alcohol consumed by residents. Logistic regression analysis was utilized to model predictors of drinking status and to determine predictors of 3 category Alcohol Use and Disorders Identification Test scores. Bivariate associations that predicted associations with alcohol use were included in the final multivariate model. Alcohol containers collected from recycling were converted to standard drink estimates in order to calculate the capital consumption of residents. Results: About 40% of respondents reported consuming alcohol and 25% reported drinking at least once a week. On average, a total of 1,079 drinks were consumed per month. There were 3 significant predictors of drinking status: age, education, and diagnosis of diabetes. Additionally, there appears to be an increase in recycled alcohol containers coinciding with the time residents received their social security checks. Conclusions: Overall, the combination of self-report and unobtrusive measures of alcohol consumption has potential to highlight different aspects of drinking behavior with a population living in a single dwelling such as a senior center apartment complex, residential hall, and the like. Key Words: Older Adults, Drinking, Measurement, Recycling.
A
CCORDING TO THE Substance Abuse Mental Health Services Administration (SAMHSA; 2013), substance abuse is the fastest growing health concern for older adults, especially when the growth of this population is considered. SAMHSA (2013) reported 41.2% of older adults drink alcohol, 8.2% binge drink, and 2% consume heavy amounts of alcohol. Although binge drinking is most common for persons aged from 18 to 24, the Centers for Disease Control and Prevention (2010) reported that individuals aged 65 and older had the highest frequency of binge drinking at 5.5 episodes per month. Merrick and colleagues (2008) reported almost 1 in 10 older adults drank heavily, with 16% of men and 4% of women, respectively, reporting unhealthy drinking. Balsa and colleagues (2008) used the National Epidemiologic Survey on Alcohol and Related Conditions to
From the College of Social Work (JDC, DR), The Ohio State University, Columbus, Ohio; School of Social Work (MBR, MCG), San Diego State University, San Diego, California; and U.S. Center for Disease Control (BM), Atlanta, Georgia. Received for publication November 4, 2013; accepted August 11, 2014. Reprint requests: Dr. John D. Clapp, PhD, FAAHB, College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43210; Tel.: 614-292-6288; Fax: 614-292-6940; E-mail: [email protected] Copyright © 2014 by the Research Society on Alcoholism. DOI: 10.1111/acer.12550 2862
determine, on average, men drank for 134 days (1.8 drinks per day on average) of the year while women drank for 87 days (1.3 drinks per day on average). Heavy drinking among older persons is associated with an increased risk of health consequences such as cirrhosis of the liver, motor vehicle crashes, debilitating falls, and fatality (Breslow et al., 2003). Additionally, binge drinking in this population is associated with increased risk of diabetes, cognitive impairment, hypertension, and sleep issues (Blow and Barry, 2012; Sabia et al., 2014). Older adults who participate in heavy drinking also are at a greater risk of depression and other psychiatric conditions (Merrick et al., 2008). Unlike their younger drinking counterparts, older adults face unique risks related to alcohol consumption. With age, the liver is less efficient and the central nervous system becomes more sensitive. Consequently, older individuals achieve higher blood alcohol concentrations than younger adults when consuming the same amount alcohol (Blazer and Wu, 2009). Exacerbating these physiological changes, the majority of older adults take at least 1 prescribed medicine, often posing dangerous side effects if combined with even small amounts of alcohol (Blow and Barry, 2012). Compounding the comorbid use of alcohol and prescription drugs, adults who participate in more frequent binge drinking obtain fewer preventive services and attend fewer physician appointments (Jenkins and Zucker, 2010). As such, the Alcohol Clin Exp Res, Vol 38, No 11, 2014: pp 2862–2868
DRINKING BEHAVIOR AMONG LOW-INCOME OLDER ADULTS
National Institute on Alcohol Abuse and Alcoholism (NIAAA; 2013) recommends that adults aged 65 and older consume no more than 7 drinks per week or no more than 3 drinks per day. NIAAA defines binge drinking among this population to be more than 3 drinks per day for men and more than 2 drinks per day for women (NIAAA, 2009). In contrast, for young adults binge drinking is defined as 5 drinks for men and 4 drinks for women in a 2-hour period (NIAAA, 2009). Limited research has been conducted on the prevalence of drinking among low-income older adults. This population might be at a particular risk of problems due to limited access to medical care, adequate food, and consistent shelter. Cummings and colleagues (2013) surveyed 187 older public housing residents to determine prevalence of alcohol misuse. Almost one-quarter of the sample admitted to recent binge drinking or problem drinking behaviors. Race, gender, employment status, and drug use were predictors of problematic drinking. To date, there have been no attempts to study the seasonal or episodic nature (including patterns that may appear near holidays or particular times of the year) of drinking among older adults. Understanding these aspects of drinking can provide insight and can illuminate leverage points for prevention. This aspect has been a focus of research on the drinking environments of college students. Students displayed significantly higher breath alcohol concentrations during the winter and spring than those collected in autumn (Clapp et al., 2008a). It is important to note, however, the prevalence estimates of alcohol use and related problems among older adults is often based on inconsistent methodology and operational definitions of problematic drinking (Stelle and Scott, 2007). Most studies rely on self-report measures to determine consumption frequency given alcohol use problems are typically measured with questionnaires (Blazer and Wu, 2009; Choi and DiNitto, 2011; Cummings et al., 2013; Merrick et al., 2008; Sabia et al., 2014; Sacco et al., 2009). As illustrated within younger populations, the validity of self-reports can be suspect (Clapp et al., 2009) due to issues with people’s ability to count drinks. For the general population, the difference between self-reports and actual habits is apparent in the findings of The Garbage Project initiated in the early 1970s to analyze garbage collected in Tucson Arizona (Rathje, 1974). Researchers compared household surveys on drinking habits to alcohol refuse in nearby dumpsters and noticed a discrepancy. Residents of the Tucson area underreported alcohol use. Resnick and colleagues (2003) suggested social desirability bias also might be especially important to consider among older adults who may have been hesitant to disclose unhealthy lifestyle choices. Kerr and colleagues (2008) found a birth cohort effect that showed a decreased tendency to drink for older cohorts, perhaps illustrating increased acceptance of heavy drinking among younger populations. Older adults may feel less comfortable disclosing drinking habits because this behavior is less common. Within the older adult population, there is also
2863
the potential for significant short-term memory complications that can prevent participants from recalling the amount of alcohol consumed during a given period of time (Sabia et al., 2014). To address these potential methodological shortcomings, this study examines drinking patterns among older adults using both self-report and unobtrusive methods. The impetus for the study was the perception of social work and nursing staff, working at an urban residential center for low-income older adults, that residents of the centers were engaged in frequent heavy drinking. With the seminal work of Webb and colleagues (1966) in mind, this study measures alcohol consumption by unobtrusively collecting recycled bottles disposed in the residential center. The collection of waste materials has been utilized in previous research, although not commonly. The Garbage Project by Rathje (1992) is one example of collecting garbage as an unobtrusive method to study the lifestyle of people living in a community. In a 1995 case study by Clapp, residents of a large southern California city monitored drug paraphernalia found on the street to determine the effectiveness of their efforts to decrease drug use. Interestingly, we were unable to find research that has examined the seasonal or episodic nature of drinking among older adults and there is limited research on drinking among low-income older adults. Thus, the present study adds to the current literature by examining this population while testing a new and relatively simple means of assessing alcohol use at the environmental level. It is our expectation that the data collected in this study through the recycling program will confirm self-reported drinking levels, or yield higher estimates of heavy drinking (in light of response bias). Two rounds of an initial self-report survey (reported below) were conducted, followed by a longitudinal unobtrusive study. Combined, the 2 methods addressed the following research questions: 1. What predicts the quantity and frequency of heavy drinking among older adults residing in low-income housing settings? 2. What is the seasonal distribution of drinking among older adults residing in low-income housing settings? 3. What factors predict high-risk drinking among older adults residing in low-income housing settings? 4. How consistent are self-report and unobtrusive measures of drinking among older adults?
MATERIALS AND METHODS Procedures Design. We conducted a self-administered survey and an unobtrusive social indicator study to measure alcohol use and risk. Setting. The study was conducted in residential senior center located in a downtown area of a large city in the southwestern United States. Residents had to be 60 years of age and have an income near or below the poverty threshold to reside in the center.
CLAPP ET AL.
2864
Survey Data Collection. Participants completed 2 self-administered cross-sectional surveys. The first survey was administered in April 2009, and the second survey was administered in April 2010. For the survey, participants were asked to provide demographic information (i.e., gender, age, race, etc.), alcohol consumption, prescription drug taking behaviors, health conditions, gambling behavior, and geriatric depression. Over the 2 survey administrations, a total of 200 residents were asked to complete the survey. There were a total of 174 survey respondents (n = 78 in April 2009 and n = 96 in 2010) in both data collection periods for an overall response rate of 43.5%. Residents who responded to the first survey were not sampled during the second data collection period. There were no differences on drinking outcomes as a function of data collection periods; thus, the data from both data collection periods were combined for analysis. Study Measures. The following demographic variables were included in the present study: participant gender, age, race/ethnicity (White, African American, Asian, Pacific Islander, Hispanic/Latino, other), marital status (married, widowed, not married), level of education (less than high school, high school graduate, post high school education), monthly income (less than $900/month, $901 or more/ month), military service, and lifetime homeless status. Participants also indicated if they were currently taking any prescription medication or if they had a diagnosis of diabetes. We collapsed the race/ ethnicity categories into a dichotomous variable (White/non-White) for analyses. Participants also completed the Geriatric Depression Scale (GDS-s; Sheikh and Yesavage, 1986) which is comprised of 15 (yes/ no) items (“Are you basically satisfied with your life?,” “Do you often get bored?,” “Do you think it is wonderful to be alive now?”). Items endorsing depression were summed to form a total GDS-s score with higher scores indicating more depression. Reliability analyses showed the scale had satisfactory internal consistency (Cronbach’s a = 0.77). The Alcohol Use and Disorders Identification Test (AUDIT) was used to measure alcohol consumption behavior and alcoholrelated problems (Babor et al., 2001). The AUDIT is comprised of 10 items measuring alcohol consumption (quantity and frequency) as well as alcohol-related problems. The first 3 items of the AUDIT measure the frequency of alcohol consumption (“How often do you have a drink containing alcohol?”; 0 = never, 1 =
