Critique 204: Moderate drinking improves the chances for healthy survival to age 85 – 21 August 2017
Richard EL, Kritz-Silverstein D, Laughlin GA, Fung TT, Barrett-Connor E, McEvoy LK. Alcohol Intake and Cognitively Healthy Longevity in Community-Dwelling Adults: The Rancho Bernardo Study. J Alzheimer’s Dis 2017;9:803–814. DOI 10.3233/JAD-161153
To better understand the association of alcohol intake with cognitively healthy longevity (CHL), we explored the association between amount and frequency of alcohol intake and CHL among 1,344 older community-dwelling adults. Alcohol intake was assessed by questionnaire in 1984–1987. Cognitive function was assessed in approximate four-year intervals between 1988 and 2009. Multinomial logistic regression, adjusting for multiple lifestyle and health factors, was used to examine the association between alcohol consumption and CHL (living to age 85 without cognitive impairment), survival to age 85 with cognitive impairment (MMSE score >1.5 standard deviations below expectation for age, sex, and education), or death before age 85. Most participants (88%) reported some current alcohol intake; 49% reported a moderate amount of alcohol intake, and 48% reported drinking near-daily.
Relative to nondrinkers, moderate and heavy drinkers (up to 3 drinks/day for women and for men 65 years and older, up to 4 drinks/day for men under 65 years) had significantly higher adjusted odds of survival to age 85 without cognitive impairment (p’s < 0.05). Near-daily drinkers had 2-3 fold higher adjusted odds of CHL versus living to at least age 85 with cognitive impairment (odds ratio (OR) = 2.06; 95% confidence interval (CI): 1.21, 3.49) or death before 85 (OR = 3.24; 95% CI: 1.92, 5.46). Although excessive drinking has negative health consequences, these results suggest that regular, moderate drinking may play a role in cognitively healthy longevity.
[Note regarding potential conflict of interest. Two of the authors of this paper (Dr. Barrett-Connor, Dr. McEvoy) are members of the International Scientific Forum on Alcohol Research. Neither contributed to the discussion or had any input into the preparation of this critique, and have not had access to our completed critique prior to its publication on our web-site.]
A number of studies have shown that the risk of dementia appears to be reduced among elderly subjects who consume moderate amounts of alcohol (e.g., Anstey et al, Lee et al, Peters et al). Further, Neafsey and Collins reported in their meta-analysis: “The average ratio of risk for cognitive risk (all forms of dementia or cognitive impairment/decline) associated with moderate drinking of alcohol was 0.77, with nondrinkers as the reference group; both light and moderate drinking provided a similar benefit, but heavy drinking was associated with non-significantly higher cognitive risk for dementia and cognitive impairment.” They stated further: “The risk of dementia is lower for the consumption of up to 12.5 g of alcohol/day (about one typical drink/day), and risk was increased for consumers of more than 38 g/day (about 3 to 4 typical drinks/day).”
In some studies, a protective effect of light-to-moderate alcohol intake has been seen primarily among consumers of wine or sometimes beer/wine (Truelsen et al, Arntzen et al, Neafsey & Collins). Neafsey & Collins commented from their meta-analysis: “Although the meta-analysis also indicated that wine was better than beer or spirits, this was based on a relatively small number of studies.” Further, almost all well-done cohort studies have shown that moderate drinkers tend to have lower mortality risks and a longer lifespan (di Castelnuovo et al, Ronksley et al, Midlöv et al). And the opposite is seen when studying the quality of life: higher scores for subjects reporting moderate drinking and lower scores among both abstainers and those with heavy drinking (Schrieks et al, 2016).
The present study is based on a group of ageing subjects in California that had been observed closely for several decades; the average follow-up period for these particular analyses were about 14 years. Subjects in this cohort have had multiple assessments of cognitive ability and frailty, which is unusual (and helpful) for studies in elderly subjects. This study concludes that that subjects who reported moderate alcohol consumption in the late 1980s were more likely than non-drinkers to survive to age 85 years of age, and also to be more likely to survive to age 85 cognitively intact (without evidence of dementia).
Comments from Forum members: Reviewer Ellison stated: “The results of this study, on the relation of alcohol intake to healthy survival to age 85, are based on a group of older community-dwelling adults who have been followed for many years. They have had multiple assessments of cognitive function as they aged. The investigators were able to take into account multiple potentially confounding lifestyle and health factors in their analyses. While this analysis is not based on a large number of subjects, the cohort has been very carefully monitored over a long period of time.”
The authors state: “Overall, 41% of the cohort died before reaching age 85; the regression-adjusted results indicate that drinkers classified as ‘moderate’ (≤1 drink/day for women and men over age 65, ≤2 drinks/day for men under age 54) and ‘heavy’ (>1-3 drinks/day for women and men over age 65, >2-4 drinks/day for men under age 65) had a significantly greater chance of survival than did non-drinkers. Moderate and heavy drinkers also showed a greater risk of survival without any evidence of cognitive impairment.” They add that there were 5 % of subjects who reported consuming more than 3 drinks/day (women and older men) or 4 drinks/day (younger men); these were were classified as ‘excessive’ drinkers, and also showed a lower risk of healthy survival, but no significant effect on survival with cognitive impairment. Subjects reporting that they consumed alcohol essentially every day had more favorable results than non-drinkers and those who drank less frequently.
Ellison comments: “It is interesting that none of the categories of subjects consuming alcohol showed poorer results than those of non-drinkers. However, it should be pointed out that this cohort consisted primarily of middle- to upper-middle- class subjects, and adverse health effects from alcohol drinking might well be expected for lower socioeconomic (SES) subjects, as has been shown by others (e.g., Probst et al, Katikireddi et al).”
Strengths of this study include the fact that this cohort consisted of a primarily upper SES community-dwelling elderly people; the lack of diversity in SES makes it easier to isolate effects more likely to relate to alcohol itself (as SES markedly modifies the effects of alcohol on health). (It is also recognized that this lack of diversity prevents the applicability of the reported results to the general population.) Further, the investigators had excellent data on height, weight, waist & hip circumference, education, smoking, exercise, marital status, depression, medication use, chronic diseases, and a number of blood tests (lipids, CRP, liver enzymes, etc.), all of which are known to be confounders of the relation of alcohol to health outcomes.
The self-reported alcohol intake of subjects showed good correlation with HDL-cholesterol and several liver function tests (GGP, AST, and ALA), providing some validity to assessments. While repeated assessments of alcohol have been carried out among this cohort, there has been found to be relative stability of intake patterns over the years (McEvoy et al) and the measure approximately 4 years prior to the assessment of cognitive function was used as the exposure variable. Appropriate statistical analyses, including multinomial regression, and appropriate sensitivity analyses were done.
The main weakness of this study is the small number of subjects, as only 157 (12%) of their cohort were non-drinkers; of these, only 28 (2.1%) were lifetime abstainers. Further, as the investigators point out, there were no cognitive assessments prior to the recording of alcohol intake, indicating that there is a possibility of reverse causation, i.e., poorer cognition leading to less alcohol consumption. However, the alcohol assessments were approximately 4 years before the neurological tests. Further, in sensitivity analyses, excluding subjects more than 74 years of age at baseline gave similar results.
Reviewer Finkel considered this to be a good paper, but objected to the parameters used to define various categories of drinking. Forum members note that while favorable effects were seen for subjects in the category of “heavy” drinkers, the definition of “heavy” was > 1-3 drinks/day (women and older men) and > 2-4 (younger men), while in many studies the “heavy drinkers” are defined as drinking more alcohol and my include alcoholics. In the present study, subjects in this category presumably did not contain many subjects with an alcohol use disorder or alcoholism. However, and interestingly, a similar effect on survival to age 85 without cognitive deficiency was also noted for the small number of subjects reporting “excessive” alcohol consumption.
Reviewer Thelle wrote: “My main problem with this paper is the exclusion of 584 subjects who reached the age of 85, but where there was incomplete information on cognitive function. The authors report that these people had a lower alcohol consumption than the study sample, were older and more likely to be female. My question is whether this skewed distribution compared to the original study cohort may induce biased results. If the true effect (unbiased) is nil, then the observed (biased) protective effect would imply that the non-participants should score higher on the cognitive function. This may seem unlikely but the authors have not, as far I see, it raised the issue whether participation fractions differ between the original cohort and the study sample.”
Forum member Mattivi commented: “This study addresses a very important aspect and I agree with the comments of other reviewers. However, I would add to the suggested weaknesses that it is of concern that the alcohol consumption was assessed during the 1984–87 visit and never repeated during the whole study. Considering that the cognitive function was first assessed at the first visit in 1988–92, and repeated every 4 years until 2009, this cover 22-25 years during which the individuals’ attitudes toward drinking could have significantly changed.” However, other Forum members noted that the investigators have previously reported (McEvoy et al) that the consumption of alcohol in this cohort was measured frequently throughout the study, stating that “Prevalence and frequency of alcohol intake were high across the 24-year follow-up period, with the majority of the cohort consuming alcohol at least weekly. Although the average amount of alcohol consumed per week decreased with advancing age regardless of health status, a substantial proportion of the cohort drank in excess of age- and sex-specific low-risk guidelines at each follow-up visit.” This and other studies (Bobo et al, Moore et al, Brennan et al) have pointed out the relative stability of alcohol intake over time in middle-aged and older adults.”
Should drinking guidelines for the elderly be revised? Forum member Skovenborg commented: “In my opinion this study is a very interesting and important study considering the growing number of very old people. I also agree that reduction of the limit for moderate drinking in men aged 65 and older from 2 drinks/day to 1 drink/day in current drinking guidelines is a mistake to the extent that it is based on the incorrect assumption of a 50% reduction of total body water in older men – whereas the correct reduction of total body water is similar between men and women and amounts to about 10 % (Chumlea et al). The favorable results for the so-called heavy drinkers in this study is one of many examples that the guideline for elderly men is unsubstantiated.” Other Forum members mentioned that Kirchner et al found no adverse effects on symptoms of depression or anxiety in their elderly subjects consuming up to 14 drinks/week.
Forum members consider that, even with certain limitations, the results from the Rancho Bernardo study provide additional support that not only increased longevity of life, but longevity without cognitive impairment, is associated with the intake of alcohol. Despite all of the warnings about the dangers of alcohol intake in older people, in this study moderate drinking enhanced the life of these elderly subjects. The fact that even those elderly subjects who were consuming more than the “recommended” amount of alcohol yet still showed longer lives and less cognitive dysfunction than did non-drinkers suggests that it may now be an appropriate time to review current guidelines for drinking among the elderly. After all, older people are at the stage of life when they are developing and dying from the “the diseases of ageing,” the risk of most of which are reduced by moderate alcohol consumption. As stated by reviewer Waterhouse, “This study is very notable because it appears to show that moderate alcohol consumption is not only associated with greater longevity, but with a higher quality of life. I would associate a reduced incidence of dementia with a higher quality of life!” As said by reviewer Finkel: It is time that “We free those formerly considered elderly from baseless restrictions of their rights to enjoy a healthful lifestyle!”
Comparison with another, similar long-term cohort study: Forum member Stockley compared the results from the present study with that of a similar study in Australia. She commented: “Results in the present study build very nicely on those reported by Simons et al (several papers between 2000 and 2014). A series of large longitudinal studies from 1988-2008 called the Dubbo Study of the Elderly looked at nutrition and healthy ageing in Australia. In that study, the majority of alcohol consumption was found to be moderate, that is, up to 14 standard drinks per week. It was observed that moderate alcohol consumption as part of a healthy diet and lifestyle reduced the risk of four non-communicable diseases – cardiovascular disease (CVD), diabetes, cancers and dementias, as well as all-cause mortality. CVD deaths in men were reduced from 20/100 (95% CI, 14-26) to 11/100 (95% CI, 9-13) and in women from 16/100 (95% CI, 13-19) to 8/100 (95% CI, 6-10), and moderate alcohol consumption specifically predicted a 34% reduced risk for cognitive impairment/dementias.”
Stockley continued: “Moderate alcohol consumption was also associated with decreased total mortality in men up to 75 years and in women over 64 years, where risk was decreased by 18% for men and by 23% for women, but was increased by cigarette smoking, high blood pressure, diabetes, impaired peak expiratory flow, coronary heart disease at study entry in men, and physical disability. After almost 10 years’ follow-up, men consuming any alcohol lived on average 7.6 months longer, and women on average 2.7 months longer, compared with non-drinkers.”
References from Forum critique
Anstey KJ, Mack HA, Cherbuin N. Alcohol consumption as a risk factor for dementia and cognitive decline: meta-analysis of prospective studies. Am J Geriatr Psychiatry 2009;17:542–555.
Arntzen KA, Schirmer H, Wilsgaard T, Mathiesen EB. Moderate wine consumption is associated with better cognitive test results: a 7 year follow up of 5033 subjects in the Tromsø Study. Acta Neurol Scand 2010; Suppl 190:23-29.
Bobo JK, Greek AA, Klepinger DH et al. Alcohol use trajectories in two cohorts of U.S. women aged 50 to 65 at baseline. J Am Geriatr Soc 2010;58:2375–2380.
Brennan PL, Schutte KK, Moos RH. Patterns and predictors of late-life drinking trajectories: A 10-year longitudinal study. Psychol Addict Behav 2010;24:254–264.
Chumlea WC, Guo SS, Zeller CM, Reo NV et al. Total body water reference values and prediction equations for adults. Kidney Int 2001;59:2250-2258.
Di Castelnuovo A, Costanzo S, Bagnardi V, Benedetta Donati M, Iacoviello L, de Gaetano G. Alcohol Dosing and Total Mortality in Men and Women. An Updated Meta-analysis of 34 Prospective Studies. Arch Intern Med 2006;166;22:2437-2445. doi:10.1001/archinte.166.22.2437
Katikireddi SV, Whitley E, Lewsey J, Gray L, Leyland AH. Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data. Lancet Public Health 2017. Online publication May 10, 2017. http://dx.doi.org/10.1016/S2468-2667(17)30078-6
Kirchner JK, Zubritsky C, Cody M, et al. Alcohol Consumption Among Older Adults in Primary Care. J Gen Intern Med 2007;22:92–97. doi: 10.1007/s11606-006-0017-z
Lee Y, Back JH, Kim J, et al. Systematic review of health behavioral risks and cognitive health in older adults. Int Psychogeriatr 2010;l22: 174–187.
Midlöv P, Calling S, Memon AA, Sundquist J, Sundquist K, Johansson S-E. Women’s health in the Lund area (WHILA) – Alcohol consumption and all-cause mortality among women – a 17 year follow-up study. BMC Public Health 2016;16:22. DOI 10.1186/s12889-016-2700-2
Moore AA, Gould R, Reuben DB et al. Longitudinal patterns and predictors of alcohol consumption in the United States. Am J Public Health 2005;95:458–465.
Mukamal KJ, Chiuve SE. Rimm EB. Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles. Arch Intern Med 2006;166:2145-2150.
Neafsey EJ, Collins MA. Moderate alcohol consumption and cognitive risk. Neuropsychiatr Dis Treat 2011;7:465-484. doi: 10.2147/NDT.S23159.
Peters R, Peters J, Warner J, Beckett N, Bulpitt C. Alcohol, dementia and cognitive decline in the elderly: a systematic review. Age Ageing 2008;37:505–512.
Probst C, Roerecke M, Behrendt S, Rehm J. Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis. Int J Epidemiol 2014; 43: 1314–27.
Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671; doi:10.1136/bmj.d671.
Schrieks IC, Wei MY, Rimm EB, Okereke OI, Kawachi I, Hendriks HFJ, Mukamal KJ. Bidirectional associations between alcohol consumption and health-related quality of life amongst young and middle-aged women. J Intern Med 2016;279:376-387. doi: 10.1111/joim.124532015.
Simons LA, et al. Moderate alcohol intake is associated with survival in the elderly: the Dubbo Study. The Medical journal of Australia, 2000. 173(3): p. 121-124.
Simons LA, et al. Lifestyle factors and risk of dementia: Dubbo Study of the elderly. The Medical Journal of Australia, 2006. 184(2): p. 68-70.
Simons LA, et al. Predictors of long-term mortality in the elderly: the Dubbo Study. Intern Med J, 2011. 41(7): p. 555-60.
Simons LA. Alcohol intake and survival in Australian seniors: the Dubbo study. Nutrition and Aging, 2014. 2(2-3): p. 85-90.
Truelsen T, Thudium D, Grønbæk M. Amount and type of alcohol and risk of dementia. The Copenhagen City Heart Study. Neurology 2002;59:1313-1319. doi: http://dx.doi.org/10.1212/01.WNL.0000031421.50369.E7.
A number of studies have shown that the risk of cognitive impairment appears to be reduced among elderly subjects who consume moderate amounts of alcohol; most studies indicate that both light and moderate drinking are associated with a lower risk of dementia, but heavy drinking is often shown to be associated with higher cognitive risk for dementia and cognitive impairment. In some studies, a protective effect of light-to-moderate alcohol intake has been seen primarily among consumers of wine, or sometimes beer/wine. Further, almost all well-done cohort studies have shown that moderate drinkers tend to have longer lifespans.
The present study is based on a group of ageing subjects in California that had been observed closely for several decades; the average follow-up period for these particular analyses were about 14 years. Subjects in this cohort have had multiple assessments of cognitive ability and frailty. The authors conclude that their subjects who reported moderate alcohol consumption in the late 1980s were more likely than non-drinkers during follow up to survive to age 85 years of age, and also to be more likely to survive to age 85 cognitively intact (without evidence of dementia). Also, daily or near-daily drinkers had better health outcomes than those of non-drinkers or less-frequent drinkers.
The Forum considers this to be a well-done study; while it is not based on a large cohort, it provides new data by having extensive evaluation over time in a cohort of community-dwelling elderly subjects. The results support data from most other studies of survival and dementia among moderate drinkers, but adds specific information on survival to age 85 without cognitive impairment.
This study and the review of prior scientific data on this subject led Forum members to also raise a question about the typical guidelines for alcohol consumption for the elderly: generally less or no alcohol consumption is advised. Given that current scientific data show that the risks of the common disease outcomes of older subjects (e.g., coronary artery disease, ischemic stroke, osteoporosis, dementia, mortality) are lower among moderate drinkers than among non-drinkers, it may be time to reevaluate such restrictions that are based on age alone.
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Contributions to this critique by the International Scientific Forum on Alcohol Research have been provided by the following members:
Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy
R. Curtis Ellison, MD, Professor of Medicine & Public Health, Boston University School of Medicine, Boston, MA, USA
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Tedd Goldfinger, DO, FACC, Desert Cardiology of Tucson Heart Center, University of Arizona School of Medicine, Tucson, AZ, USA
Fulvio Mattivi, MSc, Head of the Department of Food Quality and Nutrition, Research and Innovation Centre, Fondazione Edmund Mach, in San Michele all’Adige, Italy
Creina Stockley, PhD, MSc Clinical Pharmacology, MBA; Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway
Dag S. Thelle, MD, PhD, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Norway; Section for Epidemiology and Social Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
Andrew L. Waterhouse, PhD, Department of Viticulture and Enology, University of California, Davis, USA