Alcohol misuse and risk factor for falls

Alcohol misuse in older individuals is common but can be missed both in primary and secondary care. There is a risk of adverse physical, cognitive, and psychological consequences. This includes an increased direct and indirect risk of falls and related physical injuries in older adults

A group of doctors are now campaigning to have alcohol misuse included as a risk factor for falls in older individuals in the updated NICE guidelines on falls in older people, due in August 2024.

Alcohol misuse is a significant problem in older individuals

Alcohol misuse in older people has increased significantly in the past 20 years and it is estimated that one in five older men and one in 10 older women are drinking enough to harm themselves.¹

Recently published statistics show that in 2018-19, there were 358,000 hospital admissions primarily related to alcohol misuse of which, nearly a third (28%) were in the 65 years and older age group.² The proportion of individuals drinking alcohol on five or more days in the week was highest among both men and women aged 65 to 74 (71% and 58% respectively). This age group (65+) also has a high risk of falls with one in three individuals older than 65 falling annually.³

Most falls are multifactorial in origin and a wide range of intrinsic and extrinsic physical and environmental risk factors contribute to the risk. Screening for alcohol misuse as a risk factor for falls in older people represents an opportunity to identify a potentially modifiable risk factor.

Direct and indirect increased risk of falls with alcohol misuse

Alcohol misuse is associated with a number of well documented adverse physical and neurocognitive effects in older age that are directly and indirectly associated with an increased risk for falls.

In older individuals a steep rise in blood alcohol concentration can occur at lower amounts of alcohol consumption. Age-related changes such as reduced muscle mass, lower body water content and reduced hepatic blood flow are the chief reasons. This impairs coordination, postural balance and corrective reflexes all of which significantly increases the risk of falls and injuries.⁴ Therefore, it is important to recognise that even moderate amount of alcohol consumption can increase the risk of falls in old age.

Alcohol misuse is a well-recognised risk for dementia and delirium in old age and both are independent risk factors for falls in elderly.⁵ Falls risk can be increased during acute alcohol intoxication as well as delirium precipitated by alcohol withdrawal.⁶ Wernicke’s encephalopathy describes a triad of acute confusion, ataxia and abnormal eye movements that are related to thiamine deficiency. Alcohol misuse remains underestimated and overlooked in cognitively impaired individuals and therefore a high index of suspicion must be maintained especially in context of falls occurrence in such individuals. Routine screening for alcohol misuse in cognitively impaired individuals is both feasible and acceptable.⁷

Loss of muscle strength, mass and function (sarcopenia) is a well-established and an important risk factor for falls. There is a high prevalence of sarcopenia in older individuals who misuse alcohol.^8,9 Poor nutrition,¹⁰ commonly seen with excess alcohol consumption and leading to protein energy malnutrition, may exacerbate muscle weakness leading to falls.

Peripheral neuropathy results from neurotoxic impact of alcohol often accompanied by Thiamine and Vitamin B12 deficiency. Peripheral neuropathy resulting in loss of sensation and foot drop and cerebellar degeneration cause gait abnormality (wide based ataxic gait) increasing the risk of falls.¹¹

Alcohol-medication interactions can lead to falls

Alcohol interacts with many commonly prescribed medications by affecting many aspects of drug pharmacokinetics (gastric emptying, small bowel transits and hepatic metabolism for example). Centrally acting medications such as anticonvulsants, opiates, benzodiazepines and other hypnotics are known to increase the risk of falls and their effect may be potentiated by concomitant alcohol misuse.¹²

Alcohol-related diuresis can exacerbate postural hypotension¹³ contributing to the risk of falls, especially when medications such as vasodilators (antihypertensive medications) or loop diuretics are being taken at the same time. A longitudinal study lasting four years reported that interactions due to alcohol-drugs acting on central nervous system associated with a 19% increase in risk for falling and an 8% increase in injurious falls at 4 years.¹⁴

Alcohol can also interact with oral hypoglycaemic agents in older individuals with diabetes increasing the risk of falls.

High risk of injurious falls and fractures with alcohol misuse

Falls causing traumatic injuries are an important and leading cause of hospital admission for older individuals.¹⁵

In a large outpatient based health survey in USA, Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; 0–12 points) was used to screen for alcohol misuse. AUDIT-C scores of 8–9 and 10–12 were associated with significantly increased risks for subsequent fractures, HR (95% CI) = 1.37 (1.03 to 1.83) and 1.79 (1.38 to 2.33) respectively.¹⁶

Fragility fractures are increased with alcohol misuse, a well-established link exists between alcohol misuse and occurrence of osteoporosis due to accelerated bone turnover in older individuals.¹⁷

Traumatic brain injury and chronic subdural haematoma with alcohol misuse

Head injuries and intracranial bleed may result from falls from a standing height in elderly. Alcohol intoxication is strong predictor of traumatic brain injury (TBI) and a substantial proportion of TBIs occur in intoxicated individuals.¹⁸

Fall from standing height was found to be the most common mode of head injury leading to chronic subdural haematoma (CSDH) in individuals older than 80 years old.¹⁹ Alcohol misuse alone can cause coagulopathy and moreover potentiate the effect of antiplatelet and anticoagulant medications thus increasing the risk of bleeding including CSDH in older individuals.²⁰ Even in absence of a trauma, spontaneous CSDH can occur with alcohol misuse in older individuals.²¹

Screening tools for alcohol misuse in older individuals

A worldwide increase in life expectancy equates to a global rise in absolute numbers of older people with alcohol use disorders and a silent epidemic maybe evolving.²² Alcohol misuse may remain undetected with clinical presentations such as falls and injuries, delirium and dementia mistakenly attributed to old age alone.²³

It is therefore important that all health and social care professional likely to come in contact with older individuals at risk of falls are familiar with age appropriate validated screening tools.

The CAGE questionnaire is a widely used screening tool for unhealthy alcohol use and has been studied in older adults with a sensitivity of 86% and a specificity of 78% to detect lifetime alcohol use disorders.²⁴ The limitations of the CAGE is that it does not identify binge nor distinguish between lifetime or current use.²⁵

Short Michigan Alcoholism Screening Test – Geriatric version [SMAST-G] is validated for detecting alcohol misuse in older adults. It asks questions that maybe relevant to the elderly population such as do you drink to ‘calm nerves’, ‘take mind off problems’, and ‘after a significant loss’.²⁶ The MAST-G, the original instrument from which this measure was derived, has a sensitivity of 93.9%, specificity of 78.1%, a positive predictive value of 87.2%, and a negative predictive value of 88.9%.

World Health Organisation (WHO) developed the Alcohol Use Disorders Identification Test (AUDIT), a 10-item screening questionnaire for detecting hazardous, harmful and dependent drinking in primary care.²⁷

An abbreviated, less time consuming version called AUDIT-C has been developed for use in both research and clinical setting. AUDIT-C cut-off score of ≥3 (women) and ≥4 (men) are recommended for detecting hazardous or harmful drinking. AUDIT-C has recently been validated as an effective tool in a UK based study on 143 older adults (mean age = 71). The authors conclude that AUDIT-C items 1 and 2 performed as well as item 3 in identifying unhealthy drinking among older people in this study.²⁸

NICE Public Health Guidelines contain details of other tools and measures to be taken for alcohol use disorders.²⁹

Interventions for alcohol misuse and falls

A positive opportunistic screening result using any of the tools as described above should be followed up by a Brief Intervention often completed in five minutes or less.³⁰

Older individuals should be given information, advice, and encouraged to consider the positives and negatives of their drinking behaviour. Additional support may be required to help cut down on their drinking by referring to the appropriate specialist services. Treatments such as cognitive behavioural therapy, group and family therapies and self-help groups are just as effective for older adults as they are for other age groups. Medicinal adjuncts are effective in the elderly, but compliance and careful monitoring of adverse effects are needed especially for those taking multiple medications.³¹

Recommendations for safer alcohol consumption in older individuals

The National Institute of Alcohol Abuse and Alcoholism (NIAAA, 2017), recommends that alcohol consumption for adults age 65 and older be limited to one standard drink (12 ounces of beer, 4-5 ounces of wine or 1 ounces of distilled spirits) per day or seven standard drinks per week and no more than three drinks per occasion.³²

Lower limits or abstinence are recommended for those taking medications that interact with alcohol and conditions exacerbated by its use.

Summary

Alcohol misuse in old age is an important modifiable risk factor for falls but maybe unrecognised by clinicians and family members. Even when consumed in low amounts, blood concentrations may reach high enough to diminish motor coordination, impair judgment, and lengthen reaction time predisposing to falls.

Alcohol misuse leading to sarcopenia, malnutrition, peripheral neuropathy, cognitive impairment and significant alcohol-drug interactions can lead to injurious falls. Age appropriate and validated screening tools are already available and should facilitate effective interventions to reduce or stop harmful amounts of alcohol consumed by older individuals.

NICE has already recognised alcohol misuse as a risk factor for falls in elderly.³³ We would strongly recommend inclusion of alcohol misuse in older individuals as a significant, potentially modifiable risk factor for falls in their updated guidelines for falls.

---

Dr Sanjay Suman, Consultant Geriatrician and Clinical Director (Elderly Care Services), Medway NHS Foundation Trust, Kent

---

Endorsements

This letter has been reviewed and is supported by the following people:

Professor Tahir Masud, Consultant Physician Geriatric Medicine, Nottingham University Hospitals NHS Trust, Recent Past President, British Geriatrics Society (BGS), Secretary, Clinical Section, International Association of Gerontology & Geriatrics (IAGG)-European Region, Past President, European Union of Medical Specialists (UEMS)- Geriatric Medicine Section

Professor Jonathan Chick, Consultant Psychiatrist, Medical Director Castle Craig Hospital, Chief Editor Alcohol and Alcoholism Journal

Dr Fiona Wisniacki, Consultant in Emergency Medicine, London North West University Healthcare NHS Trust, National Clinical Lead – SDEC (Same Day Emergency Care) and Acute Frailty Hospitals Team, NHS England and NHS Improvement (National Team), Medical Advisor – Health and Justice NHS England and NHS Improvement NHSEI (London Region)

Dr Kalyan Seelam, Consultant Psychiatrist in Memory Assessment and Support Services, Medical Clinical Lead – Older Persons Services (Community and in-patient) – Barnsley and Wakefield. South West Yorkshire Partnership NHS Foundation Trust

Mrs Ann Taylor, Substance Misuse Specialist Nurse, Wirral University Teaching Hospital NHS Foundation Trust

Mr Anthony Gartland, Lead Alcohol Nurse, Royal Surrey County Hospital

Mrs Amanda Marklew, Lead Alcohol Transformation Nurse, The Rotherham & Barnsley Foundation Trusts

Mrs Arlene Copland, Nurse Consultant, Sandwell & West Birmingham NHS Trust, Alcohol Care Team Specialist Advisor NHS England and NHS Improvements (NHSEI)

Dr Mark Buchanan, Consultant in Emergency Medicine, Wirral University Teaching Hospital NHS Foundation Trust

Dr Julia Lewis, Consultant Addiction Psychiatrist, Aneurin Bevan University Health Board, South Wales., Clinical Director for Adult and Specialist Mental Health Services, Clinical Lead, Gwent Specialist Substance Misuse Service, Newport, Wales, Member of working group for “Drug Misuse and Dependence: UK Guidelines on Clinical Management”, Advisor to Welsh Government Advisory Panel on Substance Misuse (APoSM)

---

References

1. Royal College of Psychiatrists. https://www.rcpsych.ac.uk/mental-health/problems-disorders/alcohol-and-olderpeople (accessed 20/06/23)
2. NHS. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-onalcohol/2020/part-1 (accessed 20/06/23)
3. NHS. https://www.nhs.uk/conditions/falls/ (accessed 20/06/23)
4. Chiung M C, Young-Hee Y. Usual Alcohol Consumption and Risks for Nonfatal Fall Injuries in the United States: Results From the 2004–2013 National Health Interview Survey. Substance Use & Misuse 2017; 52(9): 1120-1132 DOI: 10.1080/10826084.2017.1293101
5. Andersen K, Bogenschutz MP, Buhringer G, et al. Outpatient treatment of alcohol use disorders among subjects 60+ years: design of a randomized clinical trial conducted in three countries (Elderly Study). BMC Psychiatry 2015; 15
6. Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgraduate Medical Journal 2004; 80: 388-93
7. Randall-James J, Wadd S, Edwards K, Thake A. Alcohol Screening in People With Cognitive Impairment: An Exploratory Study. Journal of Dual Diagnosis 2015; 11: 1: 65-74 DOI: 10.1080/15504263.2014.992095
8. Yoo JI, Ha YC, Lee YK, et al. High prevalence of sarcopenia among binge drinking elderly women: a nationwide population-based study. BMC Geriatr. 2017; 17(1): 114 doi:10.1186/s12877-017-0507-3
9. Onishi S, Miyai N, Zhang Y, et al. Excessive alcohol intake and liver fibrosis are associated with skeletal muscle mass reduction in elderly men: the Wakayama study. Aging Clin Exp Res 2021 https://doi.org/10.1007/s40520-021-01902-2
10. Klein S, Iber FL. Alcoholism and associated malnutrition in the elderly. Nutrition. 1991 Mar-Apr;7(2):75-9. PMID: 1802200.
11. Rigler KS. Alcoholism in the Elderly. Am Fam Physician. 2000 Mar 15;61(6):1710-1716.
12. NHS Scotland. https://www.nhsinform.scot/healthy-living/preventing-falls/causes-of-falls (accessed 20/06/23)
13. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med 2010; 77(5): 298-306 doi:10.3949/ccjm.77a.09118
14. Holton A, Boland F, Gallagher P, et al. Potentially serious alcohol–medication interactions and falls in community dwelling older adults: a prospective cohort study Age and Ageing, 2019; 48(6): 824–31 https://doi.org/10.1093/ageing/afz112
15. Rau CS, Lin TS, Wu SC, et al. Geriatric hospitalizations in fall-related injuries. Scand J Trauma Resusc Emerg Med 2014, 22: 63
16. Harris A, Chris L, Bryson CL, Sun H, et al. Alcohol Screening Scores Predict Risk of Subsequent Fractures. Substance Use & Misuse 2009; 44:8: 1055-1069 DOI: 10.1080/10826080802485972
17. Jang H-D, Hong J-Y, Han K, et al. Relationship between bone mineral density and alcohol intake: A nationwide health survey analysis of postmenopausal women. PLoS ONE 2017; 12(6): e0180132 https://doi.org/10.1371/journal.pone.0180132
18. Weil ZM, Corrigan JD, Karelina K. Alcohol Use Disorder and Traumatic Brain Injury. Alcohol Res 2018; 39(2): 171-180 PMID: 31198656; PMCID: PMC6561403
19. Rauhala M, Luoto TM, Huhtala H, et al. The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population. Journal of Neurosurgery JNS 2020; 132(4): 1147-57
20. Hamrick WJ. Drug induced bleeding. US Pharm 2015; 40(12): HS17-HS21. https://www.uspharmacist.com/article/druginduced-bleeding
21. Kostić A, Kehayov I, Stojanović N, et al. Spontaneous chronic subdural hematoma in elderly people – Arterial hypertension and other risk factors. J Chin Med Assoc 2018; 81(9): 781-86. doi: 10.1016/j.jcma.2018.03.010. Epub 2018 Jun 19. PMID: 29929831.
22. O’Connell H, Chin A, Cunningham C, Lawlor B. Alcohol use disorders in elderly people–redefining an age old problem in old age. BMJ 2003; 327: 664 doi:10.1136/bmj.327.7416.66
23. Rao R, Crome BI, Crome P. Managing older people’s alcohol misuse in primary care,British Journal of General Practice 2016; 66 (642): 6-7. DOI: https://doi.org/10.3399/bjgp16X683041
24. Stewart D, Oslin DW. Recognition and treatment of late-life addictions in medical settings. J Clin Geropsychol 2001; 7(2): 145–58
25. Han BH, Moore AA. Prevention and Screening of Unhealthy Substance Use by Older Adults. Clin Geriatr Med 2018; 34(1): 117-129 doi:10.1016/j.cger.2017.08.005
26. Blow FC, Gillespie BW, Barry KL, et al. Brief screening for alcohol problems in the elderly populations using the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G). Alcohol Clin Exp Res 1998; 22(Suppl): 131A.
27. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT—the alcohol use disorders identification test: guidelines for use in primary care. Second edition edition. Geneva: World Health Organization; 2001.
28. Stewart D, Hewitt C, McCambridge J. Exploratory Validation Study of the Individual AUDIT-C Items among Older People, Alcohol and Alcoholism 2021; 56(3): 258–265, https://doi.org/10.1093/alcalc/agaa080
29. NICE. https://www.nice.org.uk/guidance/ph24/resources/alcoholuse-disordersprevention-pdf-1996237007557 (accessed 20/06/23)
30. Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract 1999; 48(5): 378–84
31. Barrick C, Connors GJ. Relapse Prevention and Maintaining Abstinence in Older Adults with Alcohol-Use Disorders. Drugs Aging 19: 583–94 (2002). https://doi.org/10.2165/00002512-200219080-00004
32. National Institute of Alcohol Abuse and Alcoholism. Older Adults. NIAAA; Bethesda, MD: 2016. Available from: https://www.niaaa.nih.gov/alcohol-health/specialpopulations- co-occurring-disorders/older-adults (accessed 20/06/23)
33. NICE CKS. https://cks.nice.org.uk/topics/falls-risk-assessment/background-information/riskfactors/ (accessed 20/06/23)