Research letters
16. Cummings JL, Mega M, Gray K et al. The Neuropsychiatric
Inventory: comprehensive assessment of psychopathology in
dementia. Neurology 1994; 44: 2308–14.
17. O’Bryant SE, Waring SC, Cullum CM et al. Staging dementia
using clinical dementia rating scale sum of boxes scores. Arch
Neurol 2008; 65: 1091–5.
18. Cigolle CT, Ofstedal MB, Tian Z et al. Comparing models of
frailty: the Health and Retirement Study. JAGS 2009; 57:
830–839.
19. Radloff L. The CES-D Scale: a self-report depression scale
for research in the general population. Appl Psych Meas
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20. Fried LP, Tangen CM, Walston J et al. Frailty in older adults:
evidence for a phenotype. J Gerontol A Biol Med Sci 2001;
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21. Taylor H. A questionnaire for the assessment of leisure time
physical activities. J Chron Dis 1978; 31: 741–55.
22. Buchman AS, Boyle PA, Wilson RS et al. Frailty is associated
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23. Lipsitz LA. Dynamic models for the study of frailty. Mech
Ageing Dev 2008; 129: 675–6.
24. Rockwood K. Prevalence, attributes, and outcomes of fitness
and frailty in community-dwelling older adults: report from
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25. Boyd CM, Quin-Li X, Simpson C et al. Frailty, hospitalization
and the progression of disability in a cohort of disabled older
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26. Buchman AS, Schneider JA, Leurgans S et al. Physical frailty
in older persons is associated with Alzheimer disease pathology. Neurology 2008; 71: 499–504.
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doi: 10.1093/ageing/afr066
Published electronically 25 July 2011
© The Author 2011. Published by Oxford University Press on behalf
of the British Geriatrics Society. All rights reserved. For Permissions,
please email: [email protected]
Alcohol use of older adults: drinking
alcohol for medicinal purposes
SIR—Of Finnish adults aged 65–84 years, 54% of females
and 77% of males had consumed alcohol in the preceding
year in 2007 [1–3]. Older adults are sensitive to the effects
of alcohol as a consequence of the physiological changes
associated with ageing, a high prevalence of diseases and
the concomitant use of multiple drugs. Older adults also
experience higher blood alcohol concentrations for a given
amount of alcohol than younger adults due to changes in
body mass [4].
Research on older people’s use of alcohol has focused
mainly on problem-drinking and consequent health problems [5, 6]. However, there is also public awareness about
the possible health promoting effects of moderate alcohol
consumption demonstrated in epidemiological studies [7–
13]. Alcohol has been used throughout history for medicinal purposes; since antiquity, wine has been believed to
stimulate appetite and digestion [14].
Very few studies are available on how older people perceive the health effects of alcohol, and how they use
alcohol for medicinal purposes [15]. The aim of this study
was to investigate the medicinal use of alcohol by individuals aged 65 years and older. We investigated (i) the prevalence of alcohol consumption as self-medication, (ii)
associated factors and (iii) the reasons for which alcohol is
used to self-medicate.
Methods
In May 2007, a postal questionnaire was sent to computergenerated random sample of 2,100 older persons (≥65
years) from the Espoo Population Register, and re-sent
after 3 months to non-respondents. Espoo is a city with
240,000 inhabitants (10% >64 years olds). The number of
the potential respondents was 1973 when those in permanent institutional care (n = 92), deceased (n = 16), with
native language other than Finnish/Swedish (n = 31) or
with unknown address (n = 14) were excluded. Altogether
1,395 individuals returned the questionnaire (response rate
71.6%). The local ethics committee approved the study
protocol.
A structured questionnaire was piloted prior to the
postal survey on 17 elderly individuals to ensure that the
questions were easy to understand. The question items concerning demographics and health-related variables were
retrieved from our previous epidemiological studies [16–
18]. The questionnaire consisted of demographic and
health-related variables. In addition, respondents were
asked to list any medical diagnoses received from their
doctors. Some categorisations were made for health-related
factors and current use of medications. Charlson comorbidity index was constructed from medical diagnoses. It is a
weighted index taking into account the number and severity
of comorbid conditions [19]. To analyse the number of regularly prescribed drugs, participants were inquired to list
their prescribed drugs.
Alcohol consumption was charted with several questions
developed from the clinical guidelines for alcohol use in
older adults [20] and the AUDIT (alcohol use disorders
identification test) [21]. Quantity and frequency were ascertained by asking: ‘How often do you have a drink containing alcohol, including beer, cider, wine, or liquor; spirits?’,
and ‘On a typical day when you drink, how many drinks do
you have?’ (1 drink = can or bottle (330 ml) of beer, 12 cl
of wine, 4 cl of liquor; spirits (one shot-glass), or 8 cl of
sherry or madeira or aperitif. Alcohol-related problems
were inquired: (i) ‘Have you forgotten to take your medication when you have used alcohol (never/sometimes/
often)?’; (ii) ‘Has any of your relatives or friends been
633
Research letters
concerned about your drinking or suggested that you
should cut down your drinking (never/yes, but not during
the last year/yes, during the last year)?’ and (iii) ‘Have you
been concerned about your own drinking (yes/no)?’.
Alcohol consumption for medicinal purposes was determined by the question ‘Do you use alcohol for medicinal
purposes (yes/no), if so, for what conditions?’ Thus, the
question regarding the purposes of medicinal use of
alcohol was open-ended. Respondents could give more
than one condition. From the open-ended responses, we
constructed eight most common conditions for consuming
alcohol for medicinal purposes.
Data were presented with statistical variables including
frequencies and percentages. The Chi-square test was used
to compare categorical variables and the Mann–Whitney
test to compare continuous, non-normally distributed variables. Logistic regression analysis was used to determine
whether diagnoses or medical problems were independently
associated with alcohol use for medicinal purposes.
Confidence intervals were calculated as described [22].
Results
Of the total sample (n = 1,395), 241 persons (17.3%)
responded that they used alcohol as a medicine (Table 1).
The medicinal consumption of alcohol was more common
in the oldest age group. Both genders used this selfmedication equally. Marital status did not differ between
those who used alcohol as a medicine and those who did
not. High income was associated with a lower frequency of
using alcohol for medicinal purposes.
The frequency of alcohol consumption was higher
among those using alcohol for medicinal purposes than
Table 1. Sociodemographic and health-related factors and use of alcohol as a medicine
Uses alcohol for medicinal
purposes, % (n = 241)
Does not use alcohol for
medicinal purposes, %
(n = 1,153)
P-value
Difference between means or
proportions (95% confidence
intervals)
....................................................................................
Females
Age group
65–70 years
71–80 years
81–90 years
≥91 years
Marital status
Married or common-law relationship
Widowed
Single, unmarried or divorced
Education
<7 years
7–12 years
>12 years
Income
High
Moderate
Low
Self-reported health status unhealthy or quite
unhealthy
Mean Charlson comorbidity index (SD)
Mean number of medication (SD)
Frequency of using alcohol
Less than or equal to once a month, or not at all
More than once a month but <3 times/week
More than three times a week
Amount of alcohol used
Less than or equal to one portion
Two portions
Three to four portions
Greater than or equal to five portions
Has forgotten to take medications because of alcohol use
Sometimes
Often
Relatives or friends have been worried about
respondent’s alcohol use during the last year
Respondent has been concerned about his/her own
drinking
a
63.0
0.649a
13.3
34.4
33.2
19.1
21.3
39.7
30.4
8.5
≤0.001a
49.2
37.8
13.0
53.0
34.3
12.7
0.722a
−3.8 (−10.8 to 3.1)
3.5 (−3.2 to 10.3)
0.3 (−4.4 to 5.0)
31.5
47.7
20.7
29.7
49.4
20.9
0.842a
1.8 (−4.6 to 8.3)
−1.7 (−8.6 to 5.3)
−0.2 (−5.8 to 5.5)
25.0
70.8
4.2
31.2
36.5
60.0
3.5
22.9
0.003a
1.10 (1.2)
4.4 (3.3)
634
0.90 (1.2)
3.8 (3.2)
−8.0 (−13.0 to −3.2)
−5.3 (−11.9 to 1.4)
1.8 (−3.8 to 9.3)
10.6 (5.4 to 15.8)
0.008a
−11.5 (−17.7 to −5.4)
10.9 (4.5 to 17.3)
0.6 (−2.1 to 3.4)
8.3 (1.9 to 14.7)
0.008b
0.002b
0.2 (0.04 to 0.36)
0.7 (0.2 to 1.1)
28.2
48.3
23.5
55.8
37.1
7.0
<0.001a
70.1
19.5
8.7
1.7
66.4
21.8
10.2
1.7
0.73
5.9
0.0
8.8
2.9
0.4
4.1
0.003a
3.4
4.5
0.47a
Differences between the groups were tested with Chi-square test or Fisher exact test.
Differences between the groups were tested with Mann–Whitney U test.
b
−1.6 (−8.3 to 5.2)
61.4
0.003a
−27.6 (−34.1 to −21.1)
11.1 (4.1 to 18.2)
16.5 (10.8 to 22.1)
1.8 (−2.8 to
−2.3 (−8.1 to
−1.5 (−5.6 to
0.0 (−1.8 to
10.5)
3.4)
2.6)
1.8)
3.0 (−0.2 to 6.2)
0.4 (−0.4 to 1.3)
4.7 (0.9 to 8.6)
−1.1 (−3.7 to 1.6)
Research letters
among others. However, the typical amount of alcohol consumed did not differ between the groups. Those using
alcohol for medicinal purposes had more often forgotten
to take their daily medications than those not using alcohol
as a medicine. In addition, their relatives or friends had
more often been concerned about their drinking during the
last year than those not using alcohol as a medicine
(Table 1).
Those considering themselves unhealthy or very
unhealthy used alcohol more often for medicinal purposes
than those considering themselves healthy or very healthy.
Those who used alcohol for medicinal purposes had a
higher Charlson comorbidity index and higher mean
number of regularly used drugs (Table 1). Using alcohol
for medicinal purposes was associated with prior myocardial infarction, asthma, rheumatoid arthritis/osteoarthritis,
dementia and depression. Those using alcohol to selfmedicate had fallen during the last 6 months or suffered
from a fracture in adulthood more often than the others
(Table 2). However, in logistic regression analysis adjusted
for age and income, only depression remained statistically
significantly associated with using alcohol for medicinal
purposes (OR: 1.6 (95% CI: 1.1–2.4)).
The most common conditions for which participants
responded using alcohol as a medicine were cardiovascular
diseases (34.4%), sleep disturbances (22.1%), common cold
(19.9%) and indigestion (14.0%). It was also used for
Table 2. Respondents’ use of alcohol as self-medication
and their reported diagnoses and medical problems
Diagnoses,
conditions and
symptoms
Uses alcohol
as a
medicine (%)
(n = 241)
Does not use P-value Difference between
alcohol as a
means or proportions
medicine (%)
(95% confidence
(n = 1,153)
intervals)
........................................
Diabetes
Myocardial
infarction
Coronary heart
disease
Hypertension
Stroke
Peptic ulcer
Asthma
Rheumatoid
arthritis or
osteoarthritis
Dementia
Depression
Cancer
Parkinson’s
disease
Has fallen
during the
last 6 months
Fracture in
adulthood
Sleep
disturbances
20.0
10.8
18.7
6.4
0.698
0.048
1.3 (−5.3 to 7.8)
4.4 (−0.7 to 9.4)
34.1
29.4
0.217
4.6 (−2.9 to 12.2)
48.4
1.9
2.6
23.2
56.3
49.1
4.1
4.8
14.8
38.2
0.863
0.177
0.219
0.007
≤0.001
−0.7 (−8.6 to 7.2)
−2.2 (−4.8 to 0.3)
−2.2 (−5.2 to 0.7)
8.5 (1.6 to 15.3)
18.1 (10.4 to 25.9)
16.8
24.6
21.0
2.2
8.5
14.7
18.1
2.2
0.001
0.001
0.356
0.996
8.2 (2.3 to 14.2)
9.9 (3.0 to 16.8)
2.9 (−3.5 to 9.3)
−0.0 (−2.4 to 2.4)
26.5
18.2
0.004
8.4 (2.2 to 14.6)
50.3
37.5
0.002
12.8 (4.7 to 20.9)
16.1
14.6
0.561
1.5 (−3.7 to 6.7)
relaxation (6.8%), stimulation (6.3%), pain (3.2%) and
general prevention of illnesses (3.6%). Other reasons
(8.6%) included doctor’s prescription, vertigo, faintness,
hangover and red wine for anaemia.
Discussion
Of the total sample, 17.3% responded that they used
alcohol for medicinal purposes. The medicinal consumption of alcohol was more common in the oldest age group
and in persons with chronic conditions. Those using
alcohol for medicinal purposes consumed it more frequently than others. The most commonly mentioned conditions for which alcohol was used were cardiovascular
diseases, sleep disturbances, common cold and indigestion.
Strength of this study is the large, representative sample
of the home-dwelling elderly including very old age groups.
A high response rate (71.6%) supports the validity of study.
Our study also has some limitations. It relies on selfreporting of alcohol consumption and diagnoses.
Self-reported alcohol consumption is likely to be underestimated to some extent in drinking surveys [23]. Diagnoses
were also assessed through self-report, which assume that
individuals are aware of them. The cross-sectional nature of
this study limits our ability to fully explore the associations
identified.
The most commonly mentioned medical conditions for
which alcohol was used were strikingly similar to a previous
study [15] in which the material was also collected in
Finland. To our knowledge, this is the only previous study
reporting medicinal alcohol use at the community level in
older adults. In Aira’s study [15] alcohol was used for cardiovascular diseases (38%), sleep disturbances (26%), mental
problems (23%) and common cold (10%). Our respondents did not mention mental conditions as a reason to use
alcohol even though diagnosis of depression was associated
with using alcohol for medicinal purposes. Previous studies
have revealed that alcohol may be used to relieve
depression and anxiety [23–27]. However, those mentioning
alcohol as a relaxant (6.8%) or stimulant (6.3%) may
include individuals using alcohol for mental problems. The
use of alcohol to treat a common cold (19.9%) or indigestion (14.0%) was more common in our population. Some
(3.6%) of our respondents mentioned using alcohol to
prevent illnesses. Some studies have investigated the use of
alcohol to treat pain in the general population [28] which
was rare in our population.
The use of alcohol for medicinal purposes was associated with more frequent use but the amount used on a
typical day does not differ between the groups. Thus, it
seems that older adults use alcohol for medicinal purposes
typically in small quantities. However, use of alcohol for
medicinal purposes was associated with forgetting to take
medicines, relatives’ worries, as well as falls and fractures.
Older people may have misbelieves about the medicinal use
of alcohol that leads them to regular use of alcohol. Older
635
Research letters
adults have simultaneously many chronic conditions and
take medicines that may have interactions with alcohol.
They may be unaware of the risky consequences of using
both alcohol and medicines. Our findings emphasise the
need for healthcare professionals to educate and monitor
older adults concerning alcohol consumption and use of
medication.
Key points
• Older adults, especially very old age groups, use alcohol
as a medicine.
• Older adults used alcohol for cardiovascular diseases,
sleep disturbances, common cold and indigestion.
• Older adults have many chronic conditions for which they
take medicines that may have interactions with alcohol.
Acknowledgements
We thank statistician Hannu Kautiainen for his kind help.
Funding
This work was supported by the Yrjö Jahnsson Foundation
SIRPA IMMONEN1,2,3,*, JAAKKO VALVANNE4, KAISU H. PITKÄLÄ3,5
1
Services for the Elderly, City of Espoo, Finland
2
Network of Academic Health Centers, University of Helsinki,
Helsinki, Finland
3
Unit of General Practice, Helsinki University Central Hospital, PO
Box 202, FIN-02070 City of Espoo, Finland
4
Tampere Medical School, University of Tampere, Lääkärinkatu 1,
FIN-33014 Tampere, Finland
5
Department of General Practice and Primary Health Care,
University of Helsinki, PO Box 41, FIN-00014 Helsinki, Finland
Tel: (+358) 9 8162 3329; (+358) 9 8162 3790.
Email: [email protected]
*To whom correspondence should be addressed
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doi: 10.1093/ageing/afr089
Published electronically 22 July 2011
© The Author 2011. Published by Oxford University Press on behalf
of the British Geriatrics Society. All rights reserved. For Permissions,
please email: [email protected]
Effect of resistance training on physical
performance and fear of falling in elderly
with different levels of physical well-being
SIR—Several factors are involved in the maintenance of
activities of daily living (ADL) in older adults. Skeletal
muscle mass and strength are important factors for maintaining independence and quality of life in elderly. Several
recent cross-sectional studies have shown the associations
of muscle strength with physical fitness and disability [1, 2].
Loss of muscle mass (sarcopenia) is prevalent in older
adults [3] and represents an impaired state of health with
mobility disorders, increased risk of falls and fractures,
impaired ability to perform ADL, disabilities and loss of
independence [4–6].
Fear of falling is common in older adults. The prevalence varies from 21 to 85%, is higher in women than in
men, and increases with age [7]. The risk factors of fear of
falling are shown to be physical frailty [8], perception of
poor health [9], obesity, cognitive impairment, depression,
poor balance [10] and history of at least one fall [7].
Resistance training is an effective intervention to
improve the physical function in older adults by increasing
strength and physical performance [11]. However, it is still
controversial whether resistance training is effective for all
levels of elderly people. For example, we reported that
decreased muscle power is a reliable predictor of falls only
in frail elderly [12].
We hypothesised, therefore, that there is a differential
effect of resistance training on physical performance
according to the level of physical well-being. The aim of
this study was to compare the effects of resistance training
on skeletal muscle mass, physical performance and fear of
falling in robust and frail elderly.
Methods
Participants
Participants were recruited by an advertisement in a local
press. We used the following criteria to screen participants
in an initial interview: aged ≥65 years, community dwelling,
has visited a primary care physician within the previous 3
years, score of ≥8 by Rapid Dementia Screening Test [13],
able to walk independently, willing to participate in group
exercise classes for at least 6 months, access to transportation and no regular exercise in the previous 12 months.
We also used the interview to exclude participants based
on the following exclusion criteria: severe cardiac, pulmonary, or musculoskeletal disorders, pathologies associated
with an increased risk of falls (i.e. Parkinson’s disease or
stroke) and use of psychotropic drugs. We obtained written
informed consent from each participant in accordance with
the guidelines approved by the Kyoto University Graduate
School of Medicine and the Declaration of Human Rights,
Helsinki, 1975.
Frailty definition
The frailty classification was based on a composite of previous work. The Timed Up and Go (TUG) is a simple test
developed to screen basic mobility performance and has
been shown to be significantly associated with ADL in frail
older adults [14]. It has been reported that elderly with a
TUG score greater than 13.5 s can have an increased risk
of falling [15]. Frailty was defined as a TUG score >13.5 s.
Based on key components of the screening examination
(TUG score greater than 13.5 s), 159 elderly adults were
classified as the frail group, whereas 178 elderly adults were
classified as the robust group because they had a TUG
score of ≤13.5 s.
Resistance training
All participants underwent resistance training sessions twice
a week for 50 weeks. All participants performed the seated
row, leg press, leg curl and leg extension exercises on
resistance-training machines. Training loads were chosen
using the 10-repetition maximum (10-RM, the maximal
weight that can be lifted 10 times). Participants used the
10-RM for 3 sets of 10 repetitions for each machine exercise. Participants were required to adjust the training weight
to ensure failure at the 10-RM. It took approximately 1 h
to finish all sessions, with 15-min warm-up at the beginning
and 10-min cool-down stretch at the end.
Bioelectrical impedance analysis measurement
A bioelectrical impedance data acquisition system (Physion
MD; Physion Co. Ltd, Kyoto, Japan) was used to determine
637