FROM THE APA ANNUAL MEETING

ATLANTA (FRONTLINE MEDICAL NEWS) Early findings from the ongoing Vitamin D and Omega-3 Trial–Depression Endpoint Prevention (VITAL-DEP) study are bringing to light the “invisible epidemic” of alcohol use among older adults.

“Alcohol use in the older population is a growing public health problem, and it’s going to get worse as baby boomers age,” Dr. Grace Chang said during an update on the study at the annual meeting of the American Psychiatric Association. “[The problem] has been described as an invisible epidemic because of the very, very low rates of identification.”

“But this counterculture generation is bringing its alcohol and drug habits into old age,” said Dr. Chang, professor of psychiatry at Harvard Medical School, Boston.

Dr. Chang cited national survey data and statistics in her presentation. Accidental drug overdose death rates tell part of the story; the rates are highest among adults aged 45-60 years, at 18.67 per 100,000, compared with 18.66 in those aged 25-44 years, and 10.52 in those aged 55-74 years, she noted, adding that “it’s a problem just on the verge of exploding.”

In a subset of 1,045 subjects from among the more than 18,000 enrolled in the large, randomized VITAL-DEP study of older adults at risk for late-life depression, more than half scored 3 points or higher on the Alcohol Use Disorders Identification Test (AUDIT-C), a three-item alcohol screen that helps identify those who are hazardous drinkers or who have active alcohol use disorders.

VITAL-DEP

VITAL-DEP is the depression prevention ancillary study to the ongoing VITAL randomized trial (NCT 01169259), which looks at the effects of Vitamin D and fish oil on preventing heart disease, cancer, and stroke in a cohort of nearly 26,000 adults. VITAL-DEP is assessing the ability of the agents to prevent depression and improve mood among older adults, according to the principal investigator, Dr. Olivia I. Okereke of Brigham and Women’s Hospital, Boston.

The study, involving a “one-of-a-kind late-life depression prevention cohort” has successfully completed enrollment and randomized above target, with more than 18,000 subjects. Thus far, follow-up and tracking are 95%, and the study promises to serve as an invaluable resource on the topic of late-life depression and late-life emotional health beyond treatment outcomes, Dr. Okereke said.

In Dr. Chang’s update on the early findings with respect to alcohol use, she noted that one reason why the matter of alcohol use is of concern is that aging can lower the body’s tolerance to alcohol, and could explain in part the increased risk for falls, motor vehicle accidents, and unintentional injuries among older adults. Alcohol use also can increase the risk of angina and coronary heart disease, diabetes, hypertension, congestive heart failure, liver disease, osteoporosis, memory problems, and mood disorders. In addition, alcohol can interact with medications, including seemingly benign over-the-counter medications like herbal remedies, aspirin, and acetaminophen, she said.

Further, a history of alcohol use disorder increases the risk for chronic medical conditions, even after 5 years of stable remission, she noted.

In VITAL-DEP, alcohol use was measured in two ways – using AUDIT-C and by measuring habitual alcohol use.

AUDIT-C

That more than half of the subjects scored 3 or more on the AUDIT-C is particularly concerning, because among women, a score of 3 on the 0- to 12-point scale is considered positive for hazardous drinking or active alcohol use disorders, and for men a score of 4 is considered positive, Dr. Chang said.

Even in men, a score of 3 or more could indicate a problem, she said.

The score distribution was 8% each for scores of 5 and 6, 15% each for scores of 1 and 3, 26% for a score of 4, and 28% for a score of 2, she said, reiterating that the findings likely represent an underestimate of the problem.

Younger age (50-59 and 60-69 years) was associated with a high score of 5 or 6+ points, and older subjects (aged 80+ years) were less represented in the very low (0 or 1) and very high (5 or 6 points or above) score groups; most were in the 2- to 4-point range.

Further, men who completed the AUDIT-C were more likely than women to be heavier drinkers (prevalence of higher scores was 24% vs. 7% among women), Asian subjects were most represented among those with low scores (61% in the 2-point category), and black and Asian subjects were less represented in the very high point range.

Findings also varied by education level and income. For example, those who did not complete high school were overrepresented at the low and high score levels, and high scores (6+) were more represented among those with lowest and highest income levels (less than $30,000/year, more than $120,000/year).

Lifestyle factors also played a role; smokers were more likely to have higher scores, and higher pack-years were associated with higher scores. Some surprises emerged as well, Dr. Chang said, noting that higher levels of physical activity were associated with midrange scores. Reasons for this are unknown, but speculative possibilities include that exercise and moderate drinking may be correlated lifestyle patterns or perhaps those with higher physical activity think that exercise attenuates the effects of alcohol.

As for depression, a past history of that illness was associated with higher prevalence in the low-score groups, and current mild depression was associated with the lowest- and highest-score categories.

The U-shaped curve persisted after adjusting for confounders, although the magnitude in the higher-score group was attenuated, she noted.

Habitual alcohol consumption

Habitual alcohol consumption was measured in all VITAL study subjects, and the preliminary findings also suggest that non-Latino whites (vs. other racial/ethnic groups) and men have the highest prevalence of daily alcohol consumption, and that black and Asian participants have lower prevalence of daily alcohol consumption and are more likely to report never or rarely using alcohol.

Interestingly, in multivariable models adjusting for demographic and other lifestyle and health factors, weekly or daily alcohol use was associated with lower likelihood of mild depressive symptoms when compared with rare use and nonuse of alcohol, and with lower likelihood of problems with interest, sadness, low energy, appetite or weight change, concentration, and psychomotor activity.

As for the relationship between alcohol consumption and mood, there were no significant interactions by age, and generally none by gender, but the threshold for an association between alcohol frequency and scores on the Patient Health Questionnaire (PHQ) – a tool, based in part on DSM criteria, for screening, diagnosing, monitoring, and measuring the severity of depression – did differ by gender. Specifically, weekly use and daily use were significantly associated with lower PHQ scores in men, but only monthly and weekly use were associated with lower PHQ scores in women, she said.

Dr. Chang noted, however, that while the number of subjects who didn’t provide complete information was small (less than 2%), it is important, because those with heavy and problem drinking often do not report their alcohol intake.

These early findings underscore the complexity of alcohol use and its effects on older adults. Understanding of the subject and its relationship with depression and anxiety is evolving.

“We’re getting clues,” she said, adding that “this study will really help us a lot, but it’s not a straightforward relationship. … It’s obviously impacted by clinical and personal factors, and we desperately need much greater clarity, because I think that alcohol and drug use will certainly compromise the treatment of depression and anxiety in later life.”

“It’s something that we really need to be aware of,” she said.

Sponsors/collaborators for this study are Brigham and Women’s Hospital and the National Institute of Mental Health. Dr. Chang reported receiving royalties from Up to Date, but had no other relevant disclosures.

sworcester@frontlinemedcom.com

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