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Brief physician advice reduced drinking in older adults

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Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. Brief physician advice for alcohol problems in older adults. A randomized community-based trial. J Fam Pract. 1999 May;48:378-84.

Question

In older adults with potentially excessive drinking, does brief physician advice reduce alcohol use?

Design

Randomised, single-blind (patient), controlled trial with 12- month follow-up.

Setting

24 primary care practices in Wisconsin, USA.

Patients

158 patients who were 65 years of age (66% men) and consumed > 11 drinks/wk (> 132 g of alcohol) (> 8 drinks/wk for women), had 2 positive responses to the CAGE questionnaire, or had 4 drinks per occasion 2 times in the previous 3 months ( 3 drinks for women). Exclusion criteria were attendance at an alcohol treatment pro-gramme or reported symptoms of alcohol withdrawal in the previous year, physician advice to decrease alcohol use in the previous 3 months, drinking > 50 drinks/wk, or thoughts of suicide. Physicians (43 family physicians and internists) and patients received financial incentives for participating. 92.4% of patients completed follow-up.

Intervention

Patients were allocated to a brief intervention group (n = 87) or a control group (n = 71). Both groups received a general health booklet and follow-up at 3, 6, and 12 months. Each intervention-group patient also received a workbook from the physician with feedback on health behaviour, problem drinking prevalence, drinking cues, and a drinking agreement. The 2 intervention visits occurred 1 month apart with a follow-up telephone call 2 weeks after each visit.

Main outcome measures

Change in alcohol use.

Main results

Intervention-group patients had a greater decrease in alcohol consumption than did control-group patients. During the 12-month follow-up, intervention-group patients had fewer mean drinks/wk (P < 0.001), fewer episodes of binge drinking (> 4 drinks/occasion in men [> 3 in women]) (P < 0.025), and fewer episodes of excessive drinking (> 20 drinks/wk in men [> 13 in women]) (P < 0.005) (Table). Binge and excessive drinking increased in control-group patients.

Conclusion

In older adults, brief advice from their primary care physicians reduced excessive and binge drinking.

Sources of funding: National Institute on Alcohol Abuse and Alcoholism; American Academy of Family Physicians; Dean Foundation for Health Research and Education.

For correspondence: Dr. M. Fleming, 777 S. Mills Street, Madison, WI 53715, USA. FAX 608-263-5813.

Abstract and Commentary also published in Evidence-Based Mental Health. 1999 Nov.

Brief intervention vs control for potentially excessive drinking in older adults*

Outcomes at 12 mo Intervention Control Mean difference

(baseline) (baseline) (95% CI)

Number of drinks in 9.92 16.27 6.35 (3.15 to 9.55)

previous 7 d (15.54) (16.58)

RRR (CI) NNT (CI)

Binge drinking in 31% 49% 38% (6.2 to 59) 6 (3 to 40)

previous 30 d (49%) (40%)

Excessive drinking 15% 34% 55% (18 to 76) 6 (3 to 20)

in previous 7 d (29%) (30%)

*Abbreviations defined in Glossary; mean difference, RRR, NNT, and CI calculated from data in article.

Commentary

Effective public health approaches for alcohol problems target whole populations or large numbers of persons who are drinking "not much too much" because this is the group in which most of the harm occurs. Most studies support the idea of the "J-shaped curve," where moderate consumption of alcohol reduces mortality because of the reduction in some forms of cardiovascular disease (1). This effect is seen in persons > 50 years of age and means that reductions in moderately heavy drinking towards "safe" levels may have disproportionate health gains in this group.

The study by Fleming and colleagues targets an appropriate group of patients. All are well over 50 years of age (this study is a welcome extension of previous work into elderly populations), and the selection criteria require that they are all drinking "not much too much." In this sample, the least severely affected are drinking within "safe" limits, and many of them will be the "pre-problem drinkers" that we should be targeting. The sample is heterogeneous, but this is an advantage because it covers most types of potentially harmful drinking.

These patients were recruited through opportunistic screening and subsequently treated in general practice, but the methods would be applicable in any community setting. The intervention itself is simple, brief, and comfortingly translatable to the "real world." The results at 1 year are worthwhile, and it will be interesting to see if they are sustained in the longer term. The control group shows that general health advice does not translate into changes in drinking behaviour, and specific advice related to alcohol in the context of the patient's own use is necessary. Further, in the control group, some evidence showed that untreated problem drinking worsened.

This study should encourage both primary care workers and community mental health providers to make screening for alcohol use and brief intervention part of the normal package of care. A little goes a long way!

Pete Sudbury, BM, BCh

Wexham Park Hospital

Wexham, Slough, England, UK

References

1. Chou SP, Grant BF, Dawson DA. Medical consequences of alcohol consumptionUnited States, 1992. Alcohol Clin Exp Res. 1996;20:1423-9.

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