Alcohol complicates multimorbidity in older adults

Health risks

Drinking alcohol increases risks to health in a largely dose-response manner.3 It is a particular concern among older people because metabolic efficiency is diminished with age. As a toxic and addictive drug, alcohol can make existing health problems worse by posing direct risks of organ damage3 as well as by compromising treatment effectiveness and the safety of prescribing. For older patients prescribed medications for multiple conditions, the potential for non-adherence, adverse events, and drug interactions requires careful management.4

This is made more challenging by changes to the absorption, distribution, and metabolism of alcohol in older age groups, which make interactions with medications more likely.5 Interactions can occur across a range of common medications for long term conditions, including cardiovascular diseases, pain, depression, diabetes, musculoskeletal conditions, infections, and cancer.6 Medications that interact with alcohol are widely prescribed to people who drink alcohol.7 Alcohol can also have a direct and adverse effect on many conditions for which medications are prescribed, even when consumption is lower than that which is defined as low risk in drinking guidelines.3

The damaging effects of alcohol consumption on the health of older people in the UK are evident in higher alcohol related hospital admissions and mortality among people aged over 65 than in younger people.8 The situation is deteriorating, with substantial increases in alcohol specific deaths among 55-79 year olds since 2001.9 As the prevalence of multimorbidity grows, the burden of alcohol consumption can be expected to increase further, particularly in more deprived communities where multimorbidity is most prevalent1 and alcohol’s health damage greatest.10 Alcohol complicates health inequalities across the lifecourse.1

The NHS, like other health systems, is poorly designed to meet the challenges of an ageing population.11 Understanding the relationships between multiple conditions in older adults is intrinsically complex, and most treatments and clinical guidelines are based on evidence from trials for single conditions, conducted among younger and fitter populations taking fewer medications than older people with multimorbidity.4 The Academy of Medical Sciences has identified research into risk factors associated with common clusters of long term conditions, and how these interact, as a priority.11

Clinicians must contend with major gaps in the research evidence,11 and there are limitations in the clinical guidance available to practitioners. Although the guidance says that identification of hazardous drinking is important, it carries no specific recommendations on how alcohol consumption should be managed in relation to potential effects on multimorbidity.4

Research on the complexities of multimorbidity in older adults is urgently required as health systems struggle to cope with rising demand. For example, dedicated approaches to multimorbidity evaluated in a recent Cochrane review offer little or no improvement in clinical outcomes, health service use, and medication adherence but have some benefits for mental health.12 Support for effective interventions for unhealthy drinking in older adults is more meagre still, with mixed results from a small number of trials of low-to-moderate quality.13 Worldwide, there are no trials evaluating interventions that tackle drinking in older people with multimorbidity.

Missed opportunity

Progress requires that alcohol consumption becomes integral to societal and health system responses to multimorbidity, particularly in countries like the UK where alcohol is culturally embedded but not prominent in debates about health service reform. The NHS long term plan14 provides an example of a missed opportunity to reconsider what preventing alcohol related harm means in the context of an ageing population characterised by multimorbidity.

The plan identifies alcohol consumption and other modifiable risk behaviours as standalone risk factors, and thus as discrete targets for intervention.14 The focus on hospital admissions related to alcohol dependence ignores the complexity of health problems in older adults and the need for holistic approaches to management.11 Attention to the insidious ways in which alcohol is implicated in health problems is required in a system-wide perspective on how to help older people live longer and improve their quality of life.15 Integrating attention to alcohol within routine care for long term conditions could help place prevention at the heart of health systems.14 First, however, we need new thinking about prevention.