ARTIGO ARTICLE
Alcohol use and falls among the elderly
in Metropolitan São Paulo, Brazil
Consumo de álcool e ocorrência de quedas
entre idosos na Região Metropolitana
de São Paulo, Brasil
Maria Cristina Pereira Lima 1
Maria Odete Simão 1
Janaina Barbosa de Oliveira 2
Mariana Braga Cavariani 1
Adriana Marcassa Tucci 3
Florence Kerr-Correa 1
Faculdade de Medicina
de Botucatu, Universidade
Estadual Paulista “Júlio de
Mesquita Filho”, Botucatu,
Brasil.
2 Faculdade de Medicina de
Ribeirão Preto, Universidade
de São Paulo, Ribeirão Preto,
Brasil.
3 Departamento de Ciências
da Saúde, Universidade
Federal de São Paulo,
São Paulo, Brasil.
1
Correspondence
M. C. P. Lima
Departamento de Neurologia
e Psiquiatria, Faculdade
de Medicina de Botucatu,
Universidade Estadual
Paulista “Júlio de Mesquita
Filho”.
Distrito de Rubião Jr.,
Botucatu, SP
18618-000, Brasil.
mclima@fmb.unesp.br
Abstract
Introduction
The objectives of this study are to identify the
pattern of alcohol use among the elderly and to
analyze its association with falls. A populationbased survey was conducted in a sample of Metropolitan São Paulo, Brazil, using the GENACIS
questionnaire, Gender, Alcohol and Culture: An
International Study. Adjusted prevalence ratios
were calculated using Poisson Regression with
robust variance, and the dependent variable was
the occurrence of falls. Interviews were carried
out with 432 subjects whose average age was 69.5
years. Regarding alcohol use 50.9% were lifetime
abstainers, 25.5% had not drunk in the previous
year and 23.6% were current drinkers. Among
the latter, 14 (13.7%) were heavy drinkers. In the
previous year 24.5% people had falls, which were
associated with being a heavy drinker and being
older. Although a relationship between being a
heavy drinker and falls found in this survey does
not allow for inferences on causality, this association supports the hypothesis that alcohol abuse in
later life might be related with health problems.
Recently, the number of people aged over 60 has
markedly increased in many parts of the world,
particularly in low- and middle-income countries 1. In Brazil, it is estimated that by the year
2050 almost 20% of the population will be over 65
years of age 2, with a significant impact on financing the national health system 3.
Although alcohol consumption is usually lower among the elderly when compared to younger subjects, its negative consequences can be
higher, due to age-related physiological changes. The elderly have increased body fat and a
reduction of the body non-fat mass and water, as
well as a decrease in hepatic metabolism 4. As a
consequence, alcohol blood levels increase and
the elderly start to undergo adverse consequences of alcohol ingestion even without increasing
consumption 4. Another important problem is
related to the fact that a considerable proportion
of the elderly population is under some form of
medication with potential interactions with alcohol. Paskulin & Viana 5 studied elderly people in
Porto Alegre, Rio Grande do Sul State, Brazil, and
observed that only 23% of the sample did not use
any medication. The differences between young
adults and the elderly are so marked that it has
been suggested that the latter should drink no
more than only one drink per day, if there are no
absolute contraindications due to the presence
of some disease or use of medication 6. In spi-
Alcohol Drinking; Alcoholism; Accidental Falls;
Aged
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Lima MCP et al.
te of these higher risks, it is estimated that 9%
of elderly people in the USA have an unhealthy
drinking habit 7.
Even though alcohol-related problems are
quite frequent in Brazil, the extent of these problems among the elderly remains unknown. Brazilian general population surveys have targeted
younger people, and therefore the small number
of older people in the samples reduces the statistical power of analyses related to them. In Brazil,
with regional samples, authors have estimated
the prevalence of harmful drinking among elderly people to be between 4.3%, in both genders 8,
and 27%, just among men 9. In a cross-sectional
analysis of nationally representative data, Laranjeira et al. 10 observed about a ten per cent prevalence of harmful drinking in Brazil.
The harmful use of alcohol can be related with many health problems, including falls. According to information from the Centers for Disease
Control and Prevention (CDC), in the USA falls
ranked as the second most significant cause of
death for people aged between 55 and 74, and
first for those over that age bracket 11. Sorock et
al. 12 analyzed causes of death related to alcohol
in the USA, in a case-control study. They found
that drinking five drinks or more per sitting was
strongly associated with deaths due to falls, as
well as with car accidents and suicide. This
drinking pattern increased the risk of death by
70% due to those causes, even after adjustments
for age, gender, education and employment in
the year previous to the interview 12. Although it
has been described at length in other countries 13,
the association between alcohol use and falls has
not been sufficiently explored in Brazil. There has
been just one case-control study that researched
into falls and alcohol use in Brazil 14. This study
aimed to identify risk factors for falls related to
severe fractures among the elderly, but it did not
find associations with regular alcohol use.
This study was conceived in view of the absence of information about a possible association between alcohol use and falls among the
elderly in Brazil. Its aims are: (a) to identify the
pattern of alcohol use in subjects aged 60 years
and over in a general population sample from the
Metropolitan Area of São Paulo city, Brazil, and
(b) to analyze its possible association with falls
in the year previous to the interview. The hypotheses are advanced that alcohol consumption
use among elderly women is lower than among
elderly men, and that the pattern of alcohol use
and falls are associated.
Cad. Saúde Pública, Rio de Janeiro, 25(12):2603-2611, dez, 2009
Methodology
This study is part of the international Gender,
Alcohol, and Culture: an International Study
(GENACIS project), a collaborative study with
Pan American Health Organization (PAHO) support, conducted in different countries, among
them Brazil.
This cross-sectional study is based on the general population of the Metropolitan Area of São
Paulo city. According to data from the Instituto
Brasileiro de Geografia e Estatística (IBGE – Brazilian Institute of Geography and Statistics), in
2005 it had a population of 19,130,455 inhabitants, of which about 50% were aged 18 years and
above. The area itself comprises the capital city of
São Paulo State plus another 38 counties, with a
population of about two thirds of the whole State.
Additional details about sampling can be found
in the PAHO report 15.
Sample
The sampling was obtained through a two-stage
randomization: initially the census sector was
selected randomly with probability proportional
to size sampling. The households were then randomly selected as well. In this way, the sampling
unit was the household, in which all persons
aged 18 years and above, from the appropriate
selected gender, could be interviewed. The sample size was increased in order to allow for a 20%
non-response rate, with an over-representation
of subjects with at least 60 years of age, aiming at
specific analyses of this age group.
Assessment instrument
The GENACIS questionnaire was used. It has been developed by a group of researchers form several countries who are interested in comparing
alcohol consumption patterns across genders in
different contexts and cultures. It has been described elsewhere and used previously in Brazil 16;
it consists of 15 sections covering a variety of variables such as socio-demographic characteristics, job experience, social networking, general
health and life style, family history of alcohol,
mental health, smoking, and alcohol use (quantity, frequency, family context and consequences).
A variable labeled “in the workforce” included all
those with some form of paid activity, irrespective
of being in formal employment or not. The section on general health includes questions about
health care, use of medication and services, and
some events, such as falls, in the previous year.
Alcohol consumption variables included:
number of grams of ethanol consumed per day,
ALCOHOL USE AND FALLS AMONG THE ELDERLY
estimated from self-reported drinking frequency;
beverage type; and consumption amounts, based on the ethanol content of standard drinks.
Questions about alcohol consumption (beer, wine, liquor, etc.) were standardized to one drink
unit of 13g of ethanol, which is the average drink
size in Brazil. Abstainers were defined as those
who did not drink at all during the previous year.
Light consumption was defined as 1-2 drinks per
day, on average; moderate consumption, as 3-4
drinks per day; heavy consumption was defined
as 5 or more drinks per day. All of the above categories were treated as mutually exclusive.
Procedures
All interviewers had previous experiences with
household surveys and were specifically trained
and supervised monthly. Ten percent of interviews were double-checked by supervisors for
quality control. In order to encourage people to
reconsider refusals, letters with information on
the objectives, importance and expected impact
of the study, were sent as well the credentials and
contacts of the main researchers to those who
had refused to participate in a first approach.
The website address of the project (http://www.
viverbem.fmb.unesp.br/pesquisa) was also available for all subjects who wanted more detailed
information.
Data analysis
For the univariate analysis the chi-square test
was used (p < 0.05; confidence interval of 95% –
95%CI). The dependent variable was a fall in the
previous year. For the multivariate analysis Poisson regression was used, with robust variance,
thus obtaining adjusted prevalence ratios (PR) 17.
Age and use of medication were included in all
models of Poisson regression. Two models were
built. In the first model alcohol categories were
“drinkers” and “abstainers”, and in the second
model all categories of alcohol use were included: abstainers, light, moderate and heavy. Multivariate analyses were conducted separately for
each gender.
The project was approved by the Research
Ethics Committee of the Faculdade de Medicina
de Botucatu at the Universidade Estadual Paulista Júlio de Mesquita Filho on September 13th,
2004.
Results
Interviews were conducted between October
2005 and March 2007. The final sample included
432 subjects, with a response rate of 74.5%. The
average age was 69.5 (standard deviation – SD ±
7.6), with no differences across gender. The average income was 170 (SD ± 240) dollars per month, and it was noted that 40% of the elderly contributed 50% or more to total household income,
mainly due to retirement pensions.
Table 1 shows demographic characteristics
regarding gender. No gender differences were
observed in relation to age (p = 0.78). Women
had a lower educational level than men: 30.5% of
women reported having never attended school,
almost twice as many as men (16.7%); similarly, only 13% of women had completed mid-level
schooling, as compared to 22% of men. A majority of men (81.7%) were married, whereas among
women widowers predominated (45.6%), followed by those who were married (39.2%).
Table 2 compares the pattern and context of
alcohol use between genders. In relation to the
use of alcohol, more women (68.4%) than men
(23.6%) were lifetime abstainers. The frequency
of being a former drinker was higher among
men (38%) than among women (17.5%). Among
drinkers, there were more men than women in
all categories. Only men reported to be heavy
drinkers: 8.3% of them. There were also differences in relation to the drinking context: 40%
of men reported drinking during meals, weekly
or more, whereas only 18.9% of women reported
that pattern. Drinking in bars or pubs, once or
more a week, was reported by just 13.8% of men.
Table 3 shows the bivariate analysis for the
occurrence of falls reported by 106 subjects
(24.9%) in the year prior to the interview. There
were no associations between falls and gender
(p = 0.14), being in the workforce (p = 0.17), use of
psychoactive medication (p = 0.25) nor with pattern of alcohol use (p = 0.17). The only significant
variable was being over 70 years of age, which
increased the chance of falling (p = 0.03).
Table 4 shows the final models of the Poisson
regression with falls as the outcome. The multivariate analysis for women showed no association with alcohol use (p = 0.86). The models constructed for men showed an association between
falls and alcohol use just in the second model, in
which the categories were separated from one
another. The ingestion of five or more drinks on
a typical day tripled the risk for falls during the
previous year (PR = 3.12; 95%CI: 1.49-6.53).
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Table 1
Socio-demographic characteristics and alcohol use, by gender, among subjects aged 60 years or more in the Metropolitan
Region of São Paulo, Brazil.
Male
Female
Total
n
%
n
%
n
169
40.1
263
59.9
432
60-74
128
75.7
196
74.5
324
75 +
41
24.3
67
25.5
108
No schooling
28
16.7
80
30.5
108
Up to 11 years
103
61.3
148
56.5
251
12 years or more
37
22.0
34
13.0
71
Married
138
81.7
103
39.2
241
Widowed
16
9.5
120
45.6
136
Divorced/Separated
9
5.3
24
9.1
33
Single
6
3.5
16
6.1
22
Yes
51
30.2
30
11.4
81
No
118
69.8
233
88.6
351
Total
p value
Age (years)
0.78
Education *
0.001
Marital status
< 0.001
In the work force
< 0.001
* 2 subjects missing.
Table 2
Pattern of alcohol use and context among elderly in the Metropolitan Region of São Paulo, Brazil (n = 432).
Male
Female
Total
p value
n
%
n
%
n
%
40
23.6
180
68.4
220
50.9
Pattern of alcohol consumption (per day)
Lifetime abstainer
0.001
Former drinker
64
38.0
46
17.5
110
25.5
1-2 drinks
40
23.6
37
14.1
77
17.8
3-4 drinks
11
6.5
0
-
11
2.6
5 or more drinks
14
8.3
0
-
14
3.2
Less than weekly
39
60.0
30
81.1
68
67.0
Weekly or more
26
40.0
7
18.9
33
33.0
Less than weekly
56
86.2
37
100.0
92
92.8
Weekly or more
9
13.8
0
-
9
8.2
Frequency of drinking at meals *
0.03
Frequency of drinking in a bar or pub *
* Only among drinkers (101 subjects).
Cad. Saúde Pública, Rio de Janeiro, 25(12):2603-2611, dez, 2009
0.02
ALCOHOL USE AND FALLS AMONG THE ELDERLY
Table 3
Prevalence of falls in the previous 12 months among the elderly by covariates, Metropolitan Region of São Paulo,
Brazil (n = 106).
Falls
Total
n
%
n
Male
33
20.7
169
Female
73
28.0
263
60-69
53
20.9
146
70 or more
53
30.5
185
Yes
15
19.5
81
No
91
26.2
351
No
91
24.1
382
Yes
15
32.1
49
p value
Gender
0.11
Age (in years)
0.03
In the work force
0.17
Use of medication
0.25
Pattern of alcohol consumption (per day)
0.17
Abstainer
83
25.8
1-2 drinks
14
17.2
330
77
3-4 drinks
3
25.0
11
5 or more drinks
6
45.2
14
Table 4
Results of Poisson regression for falls in the previous year among the elderly, by gender and pattern of alcohol use,
in Metropolitan Region of São Paulo, Brazil.
Variables
PR adjusted *
95%CI
p value
1.00-1.04
0.08
Female (model 1)
Age
1.02
Pattern of alcohol consumption (per day)
Abstainer
1,00
-
-
Drinker
0.95
0.53-1.69
0.86
1.05
1.01-1.09
0.007
Male (model 1)
Age
Pattern of alcohol consumption (per day)
Abstainer
1.00
-
-
Drinker
0.75
0.39-1.41
0.37
1.05
1.01-1.11
0.001
Male (model 2)
Age
Pattern of alcohol consumption (per day)
Abstainer
1.00
-
-
1-2 drinks
0.65
0.22-1.92
0.41
3-4 drinks
2.79
0.90-8.65
0.08
5 or more drinks
3.12
1.49-6.53
0.002
PR: prevalence ratio.
* Adjusted by use of medication, age (in years) and alcohol use (with two different classifications of alcohol use).
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Discussion
The main finding is the confirmation of a difference in alcohol usage between men and women.
In the present study, women were the majority of
abstainers and their average alcohol consumption was 1-2 drinks per day. Throughout the lives
of most of the women interviewed, drinking was
a predominantly male activity, as well as attending school and having a paid job outside the home. Women included the highest frequencies of
un-schooled subjects and most of them did not
have paid jobs. The association between alcohol
use and being male is a constant finding in the
literature and attributed more to cultural than
biological factors 18.
The prevalence of heavy drinking in the total sample (3.2%) and just among men (8.3%)
were similar to the one found in other Brazilian
studies. Mendoza-Sassi & Beria 8 found 4.3% of
heavy drinking among subjects older than 65,
using the Alcohol Use Disorders Identification
Test (AUDIT), in Rio Grande, Rio Grande do Sul
State. Almeida Filho et al. 19, found 6% prevalence
in Salvador, Bahia State, Brazil, in their older category that included subjects aged 55 or more. In
a recent general population survey Laranjeira et
al. 10 reported that 10% of the elderly had five or
more drinks per sitting. Although the percentage
of heavy drinkers among men is lower that the
one found by Prais et al. 9, this figure is far from
irrelevant. In our study, as well as in Laranjeira et
al.’s 10, the elderly reported drinking more often at
home than in bars. In so far as this happens, the
elderly are less vulnerable to car accidents and
fights, but still vulnerable to other consequences
of drinking, such as falls, since the likelihood that
they occur at home is higher 20.
Falls are quite frequent events among the elderly, with an impact on their physical health
that can result in a series of incapacities 20, including fear of falling 21. Ribeiro et al. 21 noted
that falls have an influence upon the quality of
life of elderly people. Also, 88.5% of them referred to a fear of falling after the incident 21. In a
follow-up study of old aged people conducted
in São Paulo city, Perracini & Ramos 22 found
a prevalence of 32.7% of falls in the year prior
to the interview. Risk factors advanced by the
authors include absence of a partner, previous
fractures and difficulties with daily life activities,
among others. Besides these risk factors, alcohol use could also be a predictive factor for falls.
In a longitudinal study conducted in four communities in the USA, Mukamal et al. 23 analyzed
5,841 old people and noticed that drinking 14
drinks and more per week increased the risk of
falls by 25%. In Brazil, Coutinho et al. 14 did not
Cad. Saúde Pública, Rio de Janeiro, 25(12):2603-2611, dez, 2009
find such an association. However they only have information about the frequency of alcohol
use and no about quantity. It is important to highlight in our study that there is no association
between being a drinker and there being a higher risk of a fall. The higher risk was found just
for those who reported a higher use of alcohol.
The association between falls and alcohol
seems to be more important than with other
psychoactive substances, such as benzodiazepines. In this study, the inclusion of medication in
the models of Poisson regression did not change
the PR. Kurtzthaler et al. 24 measured the blood
level of benzodiazepines and alcohol in old people in emergency rooms after falls; they found
that among people aged over 70, alcohol was a
more important factor than benzodiazepines. In
the present study, 24.9% of subjects reported a
fall in the year prior to the interview; however the
corresponding percentage reached 45.2% among
heavy drinkers, with a clear dose-response gradient across the different patterns of alcohol use.
The small number of papers that examined
the association between falls and alcohol among
the elderly could have a parallel in clinical settings, with a resulting under identification of the
problem. McInnes & Powell 25 found a tendency
to under-diagnose alcohol-related problems in
the elderly in three Australian hospitals. According to these authors, there could be many reasons for this under-diagnosing: (i) doctors may
perceive their role as treating only acute problems, but not the chronic problems associated with
alcohol use; (ii) there could be an uneasiness in
dealing with the latter; (iii) the investigation of
alcohol use may be made difficult by the presence of other health problems; (iv) diagnosis could
be influenced by the availability of treatment 22.
In favor of this last explanation is the fact that
settings with services specialized in substance
dependence had the highest rates of identification 25. Changes in the metabolism of alcohol observed in the elderly, in addition to the prevalence of hazardous drinking, could justify including
specific screening strategies as part of the usual
routines of health care staff 26.
This study has some methodological limitations. The first one is the impossibility of inferring causality from cross-sectional studies, since
the outcome and risk factors are assessed simultaneously 27. A second limitation relates to the
fact that the functional impairment and altered
gait were not assessed in this survey and could
be confounders in the association between alcohol and falls. Gama & Gómez-Conesa 28, in a
systematic review of studies on multiple risk factors for falls in the elderly, observed that those
problems were important risk factors. Also, in a
ALCOHOL USE AND FALLS AMONG THE ELDERLY
case-control study, Carvalho & Coutinho 29 showed elderly people with dementia had a higher
risk of several bone fractures. Finally, a frequent
bias in cross-sectional studies is the refusal to
participate. In the present study the response
rate was slightly lower than expected (74.5%),
even though it was lower than that observed in
a recent cross-sectional study conducted in the
same area 10. In large Brazilian cities, household
surveys are becoming more and more problematic due to the levels and fear of urban violence,
in spite of measures taken to minimize refusals.
In Brazil, problems related to alcohol use by
the elderly remain relatively unknown, since there have been few studies about this topic among
this age group. The interest in studying drinking
patterns and related problems in youth is understandable; however, studies of the elderly are
also needed. The magnitude of alcohol-related
problems in the elderly is not negligible and, moreover, can be prevented. Additionally there is
evidence that early diagnosis and treatment are
effective for the elderly 30.
Longitudinal studies are needed for exploring
alcohol use among the elderly, identifying morbidity and mortality associated with this behavior, and studying in greater detail the patterns
of alcohol use. Such studies could also help in
defining what pattern can be considered “risky”
for the elderly, since there is no consensus in the
literature in this respect, either 31.
Conclusion
The prevalence of heavy drinking in this age
group was found to be similar to the one found
in other Brazilian surveys. It was also possible to
confirm the hypothesis of an independent association between falls and drinking five or more
drinks on a typical day among elderly men that
remained significant even after adjusting for age
and medication use. Alcohol abuse among the
elderly can have serious consequences for their
health and an important impact on the health
system. With the increase in life expectancy, particularly in low- and middle-income countries
health problems among the elderly have become
more relevant. It is crucial not to ignore alcohol
use by the elderly. It is also important that it receive the appropriate attention not only in clinical
examinations but also in politicians’ and researchers’ agendas.
Resumo
Este estudo se propõe a identificar o padrão de uso
de álcool entre idosos e analisar sua associação com
quedas. Foi conduzido um estudo transversal, de base
populacional, com amostra estratificada da Região
Metropolitana de São Paulo, Brasil, utilizando-se o
questionário Gênero, Álcool e Cultura: Um Estudo
Internacional (GENACIS). A análise estatística utilizou o teste de qui-quadrado e a regressão de Poisson,
com variância robusta. A ocorrência de quedas foi
considerada a variável dependente. Entrevistas foram
conduzidas com 432 sujeitos, com idade média de
69,5 anos. Em relação ao uso de álcool, 50,9% nunca
haviam feito uso, 25,5% não bebeu no último ano e
23,6% fizeram uso de álcool no último ano. Entre os
bebedores, 14 (13,7%) relataram uso de risco de álcool.
No ano anterior, 24,5% relataram quedas, que se associou a uso de risco de álcool e a ser mais velho. Embora
a relação entre uso de risco de álcool e quedas encontrada neste estudo não permita inferir causalidade, tal
associação sustenta a hipótese de que abuso de álcool
entre idosos pode estar relacionado a problemas de
saúde.
Consumo de Bebidas Alcoólicas; Alcoolismo; Acidentes
por Quedas; Idoso
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Contributors
Acknowledgments
M. C. P. Lima was responsible for the study design, statistical analysis and interpretation of data, as well as
organizing and writing the paper. M. O. Simão and A.
M. Tucci were responsible for the study design, supervision, and data collection, assisted with the analysis and
interpretation of the data, and drafted the paper. J. B.
Oliveira and M. B. Cavariani assisted with the analysis, interpretation of the data, and writing the text. F.
Kerr-Correa was responsible for the study design, supervision, and data collection, and also assisted with
the analysis, interpretation of data and writing of the
paper.
This work was only possible thanks to the support of the
Pan American Health Organization (PAHO) and financial support from the São Paulo State Research Foundation (FAPESP; 04/11729-2). J. B. Oliveira received a fellowship from FAPESP (07/56124-9) and M. B. Cavariani
from the Brazil Higher Education Consortia Program
(CAPES). M. C. P. Lima received a post-doctoral fellowship from CAPES (BEX 3552/07-1). Comments and suggestions by Albina Rodrigues Torres, Ana Teresa Abreu
Ramos-Cerqueira, José Manoel Bertolote and Jürgen
Rehm in different phases of the study were of great
value.
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Submitted on 12/Jan/2009
Final version resubmitted on 04/Aug/2009
Approved on 03/Sep/2009
Cad. Saúde Pública, Rio de Janeiro, 25(12):2603-2611, dez, 2009
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