Critique 237: Relation of alcohol consumption in the elderly to the chances of reaching 90 years of age — 2 March 2020

van den Brandt PA, Brandts L.  Alcohol consumption in later life and reaching longevity: the Netherlands Cohort Study.  Age and Ageing 2020;00:1–8 doi:10.1093/ageing/afaa003.

Authors’ Abstract

Background: whether light-to-moderate alcohol intake is related to reduced mortality remains a subject of intense research and controversy.  There are very few studies available on alcohol and reaching longevity.

Methods: we investigated the relationship of alcohol drinking characteristics with the probability to reach 90 years of age. Analyses were conducted using data from the Netherlands Cohort Study. Participants born in 1916–1917 (n =7,807) completed a questionnaire in 1986 (age 68–70 years) and were followed up for vital status until the age of 90 years (2006– 07).  Multivariable Cox regression analyses with fixed follow-up time were based on 5,479 participants with complete data to calculate risk ratios (RRs) of reaching longevity (age 90 years).

Results: We found statistically significant positive associations between baseline alcohol intake and the probability of reaching 90 years in both men and women.  Overall, the highest probability of reaching 90 was found in those consuming 5–<15g/d alcohol, with RR=1.36 (95% CI, 1.20–1.55) when compared with abstainers. The exposure-response relationship was significantly non-linear in women, but not in men. Wine intake was positively associated with longevity (notably in women), whereas liquor was positively associated with longevity in men and inversely in women. Binge drinking pointed towards an inverse relationship with longevity.  Alcohol intake was associated with longevity in those without and with a history of selected diseases.

Conclusions: The highest probability of reaching 90 years was found for those drinking 5–<15g alcohol/day.  Although not significant, the risk estimates also indicate to avoid binge drinking.

Forum Comments

 While essentially all prospective studies show that all-cause mortality is lower among light drinkers than among abstainers, the present study opens by questioning that relationship.  Its focus is to evaluate how alcohol consumption will affect the chances that an older subject will live to age 90.  It is from the very respected Netherlands Cohort Study with alcohol consumption data recorded at 68-70 years of age and follow up to age 90 among more than 5,000 participants.  The study found that the highest probability of reaching 90 was found in those consuming 5 – < 15 g/d alcohol (equivalent to about ½ to a little over 1 typical drink/day), with RR=1.36 (95% CI, 1.20–1.55) when compared with abstainers; thus, the moderate drinkers were 36% more likely to live to age 90.

Forum members considered this a well-done analysis that supports the often-demonstrated lower mortality risk associated with moderate alcohol intake.  Of the 2,591 men in their analyses, 16.7% survived to age 90; for the 2,888 women, 34.4% survived to age 90.  The paper shows that consumption even in late life (68-70 years of age) relates to greater chance of reaching age 90 years.  There was a tendency for binge drinkers to have a decreased chance of longevity. The authors conclude stating that “In this prospective study of men and women aged 68-70 years at baseline, we found the highest probability of reaching 90 years of age for those drinking 5 to < 15 grams of alcohol/day.”

Background:  Forum member Stockley gave a good overview of the topic.  “Cardioprotection and a reduced risk of death from all causes generally continues past 65 and 75 years of age (Simons et al, Perissinotto et al,  McCaul et al, Simons, 2014 ).  Simons et al, for example, in a population of 2805 non-institutionalised participants aged 60 years and older, observed that at 20 years of follow-up, there was significant protection from CVD for moderate alcohol consumers compared to both abstainers and heavy consumers.  In addition, men and women consuming any alcohol survived 12 months longer than their abstinent peers.  This relationship did not appear to be impacted or mediated by the CVD risk factors of diabetes, hypertension, obesity or the ratio of LDL to HDL cholesterol.

“Another Australian study of 24,159 individuals aged over 65 years also showed that the almost daily regularity of such alcohol consumption conferred a lower risk of all-cause mortality over 10 years compared with abstainers or very occasional drinkers (McCaul et al).  An examination of 2,805 individuals for 20 years in the Australian Dubbo Study of the Elderly also showed that in addition to lower all-cause mortality, the risk of cardiovascular disease, cancers, type 2 diabetes and dementia, was similarly decreased by any alcohol consumption; any alcohol consumption decreased all-cause mortality by 18% for men and 23% for women (Simons et al).  Moderate alcohol consumption has even been found to be associated with a lower risk of all-cause mortality in former problem drinkers (Holahan et al).

“These observations in older adults are of importance given that compared with younger people, older individuals have a decreased ability to metabolize alcohol and an altered volume of distribution (due to reduced lean body mass and total body water), which contributes to a relative increase in blood levels for a fixed amount of alcohol consumed compared with younger adults. Combined with the high prevalence of medical comorbidity, it has been claimed by public health professionals that these changes could potentially increase the harm associated with moderate alcohol consumption at an older age.”

Reviewer Skovenborg disagreed with the statement by Stockley about the metabolism of alcohol in the elderly: “I agree that compared with younger people, older individuals have an altered volume of distribution (due to reduced lean body mass and total body water), which contributes to a relative increase in blood levels for a fixed amount of alcohol consumed compared with younger adults.  However, that older people have a decreased ability to metabolize alcohol is a myth, or you might even call it a zombie idea because even if the myth is killed by evidence, it turns up again and again.  All the studies that have investigated the alcohol metabolism in older people show that it is second to none – with three recent publications supporting considerable earlier research.  For example, Fiorentino & Moskowitz reported that mean (M) elimination rates (g/210 L/h) were found to be higher for older subjects (51–69 years, M = .0180) than younger subjects (19–50 years, M = .0161).   Also, Sklar et al, studied breath alcohol concentration, finding that there was no main effect of age or interaction between age and dose groups.  Further, Nixon & Lewis reported that age and sex differences in alcohol metabolism were controlled by standardizing alcohol dose on the basis of body water calculations.”

Comments on the present study:  Reviewer Finkel noted: “The record will show that I have long and consistently spoken and written that older individuals derive the same benefits as others from moderate drinking, and need not be treated as delicate  breakables tolerant of only token tastes, as is admirably documented by Skovenborg.  This paper is fine, though we probably knew the results already. But it’s comforting to many, yet likely will not penetrate a certain segment.”

Overall, reviewer Skovenborg considered this to be a very well-done analysis.  He stated: “The authors had detailed information on baseline alcohol use (however, only baseline) and information on many confounders.  They were able to exclude ex-drinkers, to look for effects of drinking pattern and to perform beverage specific analyses.  The percentage of never drinkers was high in the NLCS cohort, 15% in men and 35% in women, making residual confounding less likely.  The results are limited to alcohol drinking in later life because the study was aimed at measuring alcohol intake at 68-70 years; however, that is good news for the external validity for the many elderly people who enjoy a modest intake of wine or beer.

“My only objection is their selection of references:

  • Certain references (bv Wood et al, Stockwell et al, and Knott et al) have been duly criticized by our forum and others, and the reference by Barrett-Connor et al appears to be the only example that has been read and understood.
  • The authors state that ’The relationship between alcohol consumption and longevity has been investigated rarely,’ and the authors quote only five relevant studies. I have constructed a list with the five studies plus another 37 relevant studies I have found in the literature (e.g., Agahi et al, Burke et al, Ding et al, Goldberg et al, Grønbæk et al, Keyes et al, Paganini-Hill et al, Rozzini et al, Tevik et al, Tolvanen et al). It seems that the authors did not look very hard.  Fortunately the large majority of these studies have results similar to those in this study.
  • The authors reference to a study by Blow et al is unusual, as that is a study of how to diagnose and how to treat alcohol and substance abuse in the elderly and the study has no data of relevance to decreased tolerance in old age. That study useed AUDIT for screening with a score of ≥3 as limit which would put everyone who drinks one single glass of wine with his dinner every evening in the suspicious eye of his doctor.  A strange choice of reference for authors who have just found intake of 5-15 g alcohol per day associated with the highest probability of reaching 90 years.”

Forum member van Velden noted: “Skovenborg did a good job in reviewing this interesting paper.  It is not often that we come across a well-done study on this topic with valid conclusions, taking confounders into consideration.  All I can add is that moderation is the key to positive outcomes; we can kill people by drinking not only too much alcohol but too much water!  (This was the case where we recommended 800 ml of water intake/hour during marathon races; the back markers overhydrated!)”

Forum member McEvoy wrote: “I agree that this is a well done study.  The sample size is very large, with excellent follow-up, and they were able to examine associations with different types of alcohol use, and were able to investigate sex differences.  Their results are in accord with our prior findings in the Rancho Bernardo  cohort, where we found not only that regular drinkers were more likely to live to age 85 than non-drinkers, but that they were also more likely to be cognitively healthy at age 85 (Richard et al).

Reviewer Ellison noted: “There are many strengths to this study, perhaps the most important ones being that alcohol intake was estimated using validated methods, statistical methods were appropriate (including spline regression to account for amounts of consumption), and especially that intake of alcohol was assessed at 68-70 years of age.  Thus, we are indeed talking about alcohol intake in the elderly and subsequent mortality.  Further, these cohorts had adequate numbers of non-drinkers who were not classified as ex-drinkers (about 10-15% of men and more than 30% of women) to use as controls.

“While not extensive, the potential confounders considered by the authors included smoking, height, BMI, physical activity, history of selected diseases, education, vocation, and energy intake.  Adjusting for all of these variables in spline analyses, a clear inverse J-curve was seen, with higher risk of living to age 90 for both men and women drinkers of up to about 2 drinks/day (statistically significant up to about 1 ½ drinks/day).”

Are there differences according to type of beverage?  Ellison addded: “As in many other studies, the mortality advantage associated with alcohol was somewhat greater for wine than for other beverages, especially among women.  Binge drinkers had a tendency to not reach 90 years of age, but the associations were not statistically significant.  In their beverage-specific analyses, the point estimates for relation with longevity for beer were close to 1.0 (no effect) for men and women, while the effects for wine tended to be increased for longevity for all alcohol categories for both men and women.  The effects of liquor were interesting, suggesting protection for men but adverse effects for women.”

Commented reviewer de Gaetano, “An interesting study, indeed and well performed.  I noticed that wine appeared to be more effective in a generally beer-drinking country.  I wonder thus whether wine-preferring people (mainly women) might have been a ‘selected’ subgroup who would have also more frequently consumed a Mediterranean diet and/or followed other healthy lifestyles.  I could not find data on whether or not clarity of mind paralleled survival.”

References from the Forum critique

 Agahi N, Kelfve S, Lennartsson C, Kåreholt I. Alcohol consumption in very old age and its association with survival: A matter of health and physical function. Drug Alcohol Depend 2016;159:240-245.

Barrett-Connor E, de Gaetano G, Djoussé L, et al.  Comments on moderate alcohol consumption and mortality. J Stud Alcohol Drugs 2016;77:834–836.

Blow FC, Barry KL.  Alcohol and substance misuse in older adults. Curr Psychiatry Rep 2012;14:310–319.

Burke GL, Arnold AM, Bild DE, Cushman M, Fried LP, Newman A, Nunn C, Robbins J. Factors associated with healthy aging: the cardiovascular health study. J Am Geriatr Soc 2001;49:254-262.

Ding D, Rogers K, van der Ploeg H, Stamatakis E, Bauman AE.  Traditional and Emerging Lifestyle Risk Behaviors and All-Cause Mortality in Middle-Aged and Older Adults: Evidence from a Large Population-Based Australian Cohort. PLoS Med 2015;12:e1001917.

Fiorentino DD, Moskowitz H.  Breath alcohol elimination rate as a function of age, gender, and drinking practice. Forensic Science International 2013;233:278-282.

Goldberg RJ, Burchfiel CM, Reed DM, Wergowske G, Chiu D.  A prospective study of the health effects of alcohol consumption in middle-aged and elderly men. The Honolulu Heart Program. Circulation 1994;89:651-659.

Grønbæk M, Deis A, Becker U, Hein HO, Schnohr P, Jensen G, Borch-Johnsen K, Sørensen TI. Alcohol and mortality: is there a U-shaped relation in elderly people? Age Ageing. 1998;27:739-744.

Holahan CJ, Schutte KK, Brennan PL, Holahan CK, Moos BS, Moos RH.  Late-life alcohol consumption and 20-year mortality. Alcohol Clin Exp Res 2010;34:1961–1971.

Keyes KM, Calvo E, Ornstein KA, Rutherford C, Fox M5, Staudinger UM, Fried LP.  Alcohol Consumption in Later Life and Mortality in the United States: Results from 9 Waves of the Health and Retirement Study.  Alcohol Clin Exp Res 2019;43:1734-1746.

Knott CS, Coombs N, Stamatakis E, et al.  All cause mortality and the case for age specific alcohol consumption guidelines: pooled analyses of up to 10 population based cohorts. BMJ 2015;h384:350.

McCaul KA, Almeida OP, Hankey GJ, Jamrozik K, Byles JE, Flicker L.  Alcohol use and mortality in older men and women. Addiction 2010;105:1391-1400.

Nixon SJ, Lewis B.  Clarifying the neurobehavioral sequelae of moderate drinking lifestyles and acute alcohol effects with aging.  Int Rev Neurobiol 2019;148:39-78.

Paganini-Hill A, Kawas CH, Corrada MM.  Type of alcohol consumed, changes in intake over time and mortality: the Leisure World Cohort Study.  Age Ageing 2007;36:203-209.

Perissinotto E, Buja A, Maggi S, Enzi G, Manzato E, Scafato E, Mastrangelo G, Frigo AC, Coin A, Crepaldi G, Sergi G, ILSA Working Group.  Alcohol consumption and cardiovascular risk factors in older lifelong wine drinkers: the Italian Longitudinal Study on Aging. Nutr Metab Cardiovasc Dis 2010;20: 647-655.

Richard E, 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 Alzheimers Dis 2017;59:803-814. doi: 10.3233/JAD-161153

Rozzini R, Ranhoff A, Trabucci M.  Alcohol beverage and long-term mortality in elderly people living at home. Journal of Gerontology 2007;62:1313-1314.

Sklar AL, Boissoneault J, Fillmore MT.  Interactions between age and moderate alcohol effects on simulated driving performance. Psychopharmacology 2014;231:557-566.

Simons L, McCallum AJ, Friedlander Y, Ortiz M, Simons J.  Moderate alcohol intake is associated with survival in the elderly: the Dubbo Study. Med J Aust 2000;173:1211–1224.

Simons L.  Alcohol intake and survival in Australian seniors: the Dubbo Study. Nutr Aging 2014;2:85-90.

Stockwell T, Zhao J, Panwar S et al. Do “moderate” drinkers have reduced mortality risk?  A systematic review and metaanalysis of alcohol consumption and all-cause mortality.  J Stud Alcohol Drugs 2016;77:185–198

Tevik K, Selbæk G, Engedal K, Seim A, Krokstad S, Helvik AS. Mortality in older adults with frequent alcohol consumption and use of drugs with addiction potential – The Nord Trøndelag Health Study 2006-2008 (HUNT3), Norway, a population-based study. PLoS One 2019;14:e0214813.

Tolvanen E, Seppä K, Lintonen T, Paavilainen P, Jylhä M.  Old people, alcohol use and mortality. A ten-year prospective study. Aging Clin Exp Res 2005;17:426-433.

Wood AM, Kaptoge S, Butterworth AS et al.  Risk thresholds for alcohol consumption: combined analysis of individual participant data for 599912 current drinkers in 83 prospective studies.  Lancet 2018;391:1513–1523

Forum Summary

An interesting and well-done study from a cohort of aging men in the Netherlands that evaluated how alcohol consumption data collected at 68 – 70 years of age related to the risk that the individual would survive to age 90.   The authors report that “The highest probability of reaching 90 was found in those consuming 5–<15g/d alcohol, with RR=1.36 (95% CI, 1.20–1.55) when compared with abstainers.”  Further, the authors noted that “Wine intake was positively associated with longevity (notably in women), whereas liquor was positively associated with longevity in men and inversely in women.”  They also noted that there was a tendency for a lower chance of living to age 90 for subjects reporting binge drinking.

Forum members were unanimous in considering this to be an excellent study.  It adds information on alcohol consumption collected in the elderly (ages 68-70 in this study) and subsequent longevity of life.  It tends to counter fears expressed by some that the very elderly must be “protected” from alcohol, as it suggests that there are still health benefits from moderate drinking at all ages.  Further, a reduction in risk of cardiovascular diseases would be especially important in the elderly, when such diseases generally occur and are the leading causes of death.  This Forum critique provides references to a multitude of research reports that strengthen the conclusions of the authors that, even among very elderly subjects, moderate drinking is associated with a greater longevity of life. 

This critique by the International Scientific Forum on Alcohol Research was based on comments from the following members:

Andrew L. Waterhouse, PhD, Department of Viticulture and Enology, University of California, Davis, USA

David Van Velden, MD, Dept. of Pathology, Stelenbosch University, Stellenbosch, South Africa

Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway

Creina Stockley, PhD, MSc Clinical Pharmacology, MBA; Adjunct Senior Lecturer at the University of Adelaide, Australia

Erik Skovenborg, MD, specialized in family medicine, member of the Scandinavian Medical Alcohol Board, Aarhus, Denmark

Linda McEvoy, PhD, Department of Radiology, University of California at San Diego (UCSD), La Jolla, CA, USA

Harvey Finkel, MD, Hematology/Oncology, Retired (Formerly, Clinical Professor of Medicine, Boston University Medical Center, Boston, MA, USA)

R. Curtis Ellison, MD, Professor of Medicine, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA

Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy