alcohol problems in old age: a review of recent epidemiological research

ALCOHOL PROBLEMS IN OLD AGE: A REVIEWOF RECENT EPIDEMIOLOGICAL RESEARCH

IAN JOHNSON*Senior Registrar and Lecturer in Old Age Psychiatry, Cossham Hospital and University of Bristol, UK

ABSTRACT

The subject of alcoholism in late life has received relatively little attention in the literature. This is despite the fact thatelderly people are particularly vulnerable to the adverse e�ects of alcohol. Demographic data predicts that in the ®rsthalf of the next century there will be an increase in the absolute number of elderly people with alcohol problems. Therecognition and treatment of alcohol problems are likely therefore to become more important as this populationexpands. High rates of comorbidity with physical and psychiatric illness mean that elderly alcoholics are liable tobe frequent users of health facilities. Concern has been expressed regarding the impact this trend will have uponhealth services, particularly the high costs of treatment and institutionalization. Previous researchers in this ®eld havebeen disadvantaged by a lack of standardized diagnostic criteria and the absence of age-validated screening tools.This paper reviews recent publications relating to the epidemiology of alcohol problems in the elderly and focuses oncomparing the prevalence rates of alcohol problems in various clinical settings. Epidemiological research is importantas it improves the understanding of the scope and impact of a disease as well as being a vital componentduring the planning stage for new services. This review highlights some ongoing limitations in recent research.Copyright # 2000 John Wiley & Sons, Ltd.

KEY WORDSÐalcohol; old age; epidemiology; prevalence

INTRODUCTION

Alcohol problems in the elderly are generallyaccepted to be less prevalent than in youngergroups. However, some of the lowest rates ofalcohol dependence are derived from cross-sectional general population surveys which usethe same diagnostic criteria across all age groups(Grant, 1993). Most of these classi®catory systemswere developed for use in younger age groups andmay not be valid in old age. These particularly lowprevalence rates are therefore probably an under-estimate.

Cross-sectional studies are also unable to takeinto account the cohort e�ect. Attitudes towardsdrinking have altered signi®cantly during thetwentieth century and the acceptability of alcoholto those people growing up after World War II maymean that at any given age they will show a higher

prevalence of alcohol problems than, for example,people ®rst exposed to alcohol in the 1920s(Beresford, 1995).

Prevalence rates also vary according to thegeographical population and culture studied. Todate, the majority of studies have been conductedon samples from North America, It is possiblethat these results cannot be generalized to othercountries or cultures. For example, it is concei-vable that the e�ect of prohibition may havein¯uenced the drinking practices of the cohort ofAmericans now entering old age. Similarly, theway in which subjects answer screening questionsmay di�er between North America and othercountries, a�ecting the relative sensitivities ofscreening instruments (Luttrell et al., 1997).

Older drinkers remain vulnerable to the adversee�ects of alcohol. Rates of physical illness amongelderly alcoholics are higher than would beexpected in a non-drinking population of similarage (Hurt et al., 1988). This may in part be due toincreased biological sensitivity to alcohol: withincreasing age there is a decrease in lean bodymass and total body water which leads to higher

Copyright # 2000 John Wiley & Sons, Ltd. Received 23 August 1999Accepted 30 September 1999

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriatr. Psychiatry 15, 575±581 (2000)

*Correspondence to: Dr I. Johnson, Cossham Hospital, LodgeRoad, Kingswood, Bristol BS15 1LF, UK. Tel: 0117 9671661ext. 5107. E-mail: [email protected]

Contract/grant sponsor: Southmead Hospital ResearchFoundation.

peak blood alcohol concentrations for a givendose (Vestal et al., 1977). However, older peoplewith drink problems are also susceptible tocomorbid psychiatric illness, especially depressionand dementia. Saunders et al. (1991) illustratedthat a history of heavy drinking in elderly menleads to a ®vefold increase in the risk ofdeveloping a psychiatric disorder. The predictedrise in the numbers of alcohol abusers in old ageis therefore likely to place an increased demandon the resources of health services.

A classi®cation has been developed whichsubdivides older problem drinkers into early-and late-onset cases. Early-onset cases are thoselifelong problem drinkers who have evadedpremature death and survived into old age. Incontrast, late-onset alcoholism refers to new caseswhich have emerged in later life, possibly inresponse to certain stressors such as retirementand bereavement. Although this classi®cation hasbeen used in earlier studies, the absence of anagreed cut-o� age for late-onset cases has madecomparisons di�cult.

Unfortunately, the development of this class-i®cation system has not assisted in the recogni-tion of cases in clinical settings. Poor rates ofdetection of alcohol problems in the elderly havebeen notedÐparticularly amongst in-patients,(McInnes and Powell, 1994). Even when casesare diagnosed, the referral rate for treatment islow compared with younger patients (Curtis et al.,1989). A failure to take adequate alcohol historieson elderly medical admissions has been proposedas one reason for this observation (Naik andJones, 1994). An alternative explanation is thatalcohol problems in this age group present indi�erent ways to those seen in younger alcoholics.Black (1990), considered that patients were morelikely to present with non-speci®c symptoms suchas falls, self-neglect, incontinence and malnu-trition than alcoholic liver disease.

For inclusion in this review, I have selectedpapers from the years 1995±99 using Medlineand Embase searches and the literature database ofthe National Institute on Alcohol Abuse andAlcoholism.

A number of recent articles have determinedthe prevalence of alcohol problems in varioussettings and these studies are summarized inTable 1. (The table includes some review articlesthat make reference to research published priorto 1995.) Each population will be considered inturn.

COMMUNITY SAMPLES

The reported prevalence of alcohol problems inearlier studies ranges between 1 and 22% inpopulation based surveys (Dufour and Fuller,1995). In general, rates are lower in women thanin men and appear lower when more restrictivediagnostic criteria are employed, i.e. the preva-lence of `heavy drinking' is higher than that foralcohol abuse or dependence. The de®nitions usedvary from `problem drinking' through to `heavydrinking', `alcohol abuse' and `alcohol depen-dence'. Some researchers have relied uponquantity±frequency measures to yield diagnoses,whilst others have preferred the use of operatio-nalized criteria. DSM-III-R criteria (AmericanPsychiatric Association, 1987) for dependencewere regarded as being particularly strict. Itcontinues to be a matter of some debate as towhether any of these criteria are valid for elderlysamples.

Graham et al. (1996a) published results of aCanadian national survey which focused onalcohol and drug misuse in women over the ageof 64. Their ®ndings were in keeping with earlierstudies, ®nding that, as expected, women drank lessthan men did at this age. More signi®cantly theyreported that this group had the highest rate of useof psychoactive prescription drugs, using morethan any other age±gender group. The potentialfor alcohol±drug interactions should therefore be aparticular concern for clinicians. The authors usedthe quantity±frequency method to determine ratesof daily drinking. This method, used in a numberof studies, has some limitations particularly as itrequires an intact short-term memory. It also givesno indication of the degree of medical or psycho-social impairment.

Chermack et al. (1996) o�ered a di�erentperspective when they reported the results of across-sectional survey which used a sample of443 individuals with a range of alcohol intakes.Their conclusions indicated that levels of consump-tion di�ered between sexes only for problemdrinkers. The authors did however use the strictcriteria of DSM-III-R and their sample wasperhaps not representative of older people ingeneral. The paper also called for the recom-mended limits for older adults to be less than thosecurrently set for younger adults. They suggestedthat a limit be set at an average daily consumptionof no more than one drink, (unit) per day, a levelwhich is in keeping with the conclusions of an

Copyright # 2000 John Wiley & Sons, Ltd. Int. J. Geriatr. Psychiatry 15, 575±581 (2000)

576 I. JOHNSON

inter-departmental working group on sensibledrinking (Department of Health, 1995).

Sangwan et al. (1997) interviewed a largecommunity sample. This was one of the few papersto give separate prevalence rates for men andwomen. They found higher rates of heavy drinkingin men and their sample contained a higherproportion of abstinent women.

Mirand and Welte (1996) surveyed New Yorkresidents by telephone. In this study, heavydrinking was de®ned as a mean daily intake ofmore than 1 oz of ethanol (or more than 2 drinksper dayÐand hence roughly equivalent to thede®nition used by Sangwan et al. 1997).

An alternative method of diagnosis wasemployed by Callahan and Tierney (1995). Theyused the CAGE questionnaire (Cut down, annoyedby criticism, guilty about drinking, eye-openerdrinks) (Ewing, 1984). This questionnaire hasbeen reported to be an e�ective tool for thediagnosis of alcohol problems amongst elderlypopulations (Morton et al., 1996), despite itsdevelopment for use in younger samples ofdrinkers. The simplicity of being able to use justfour questions to screen for this disorder appear tomake this instrument particularly useful in primarycare settings.

Barker and Kramer (1996) studied patterns ofalcohol consumption in a community sample of282 older American Indians in California. This wasone of the few papers to investigate ethnicdi�erences in alcohol consumption in an elderlygroup. The average age of the sample was 61 years.They reported that the majority of individuals(73%) did not drink alcohol at all, with morewomen than men being teetotal. Those classi®ed asabstainers were not necessarily lifetime non-drin-kers and included some binge drinkers. Theauthors concluded that consumption patterns inthis sample were no di�erent from the generalelderly population.

HOSPITAL SAMPLES

A review of earlier work (Goldstein et al., 1996)illustrated a trend of rising prevalence going fromemergency department samples through to generalhospital admissions and psychogeriatric wards.The ®gures, however, may still be an underestimategiven that elderly substance misusers often goundetected during hospital admission (Luttrellet al., 1997). The indirect references to data

published 25 years earlier illustrate the lack ofrecent work in this ®eld.

NURSING HOME SAMPLES

Oslin et al. (1997) found that 29% of nursing homeresidents had a lifetime diagnosis of alcohol abuse.There were also high rates of clinically signi®cantcognitive impairment (60.6%) and major depres-sion (13.8%). Unfortunately, alcohol histories werenot obtained on all residents. The paper reportedthat the ability to carry out activities of daily livingimproved signi®cantly from the time of admissionto the time of follow-up (an average of 1.4 years)among those who were recently abusing alcohol,thus emphasizing the bene®ts of abstinence.

The rates of current alcohol abuse were low inthe sample of Herrmann and Eryavec (1996), whofound that although there was no correlationbetween a diagnosis of lifetime alcohol abuse andother psychiatric diagnosis, there was a signi®cantassociation between the intensity of the person'sWorld War II combat experience and the laterdevelopment of alcohol abuse. This may be animportant factor in identifying those at risk ofalcohol problems.

SUMMARY OF REVIEWARTICLES

In a thorough review of the literature recording thealcohol use of older people living in the commu-nity, Lakhani (1997) concluded that on average40% of elderly persons were non-drinkers. Abstin-ence was more frequently seen in women and in themost elderly age ranges. Commenting on theavailable longitudinal studies, the same authorre¯ected on the decline in alcohol consumptionwith increasing age, but stated that these studieshad not clari®ed whether this was related to agingor whether it represented a true cohort e�ect.

Mirand and Welte (1996) made reference to anumber of cross-sectional studies which alsodescribed a fall in alcohol consumption withincreasing age. They suggested that prematuremortality in heavy drinkers may be responsiblefor this observation. However, lower rates ofdrinking were also seen in longitudinal studiesthat did not support this particular theory. Melloret al. (1996) pointed out that some studies haverelied upon self-reporting of alcohol intake andmay therefore be underestimated.


ALCOHOL PROBLEMS IN OLD AGE 577

Table

1.Prevalence

ofalcoholproblemsin

theelderly

De®nitionofProblem

Drinking

Author

Prevalence

Comments

1.

Communitysurveys

Alcoholabuse

ordependence

(DSM-

IIIcriteria)

Problem

drinking(various

de®nitions)

AdamsandCox(1995)

AdamsandCox(1995)

2±4%

10%

Figuresderived

from

asummary

ofthereviewarticle.Thequoted

prevalence

ofproblem

drinkingisanestimatebasedonanumber

ofstudies.Althoughratesofupto

20%

are

reported

theauthors

criticizethesestudiesforusing`loose'de®nitionsorapplyingthem

tounrepresentative

populations.

Alcoholism

(CAGEpositive)

CallahanandTierney

(1995)

10.5%

3954subjects(60years

andover;31%

male)in

primary

care.

Alcoholabuse

(CAGE

positive)

Adamset

al.(1996)

9%

men,3%

women


andover;44%

male)in

primary

care

completedaquantity±frequency

questionnaireandtheCAGE.

Alcoholism

,alcoholabuse

or

problem

drinking(de®nitionsnot

speci®ed

forthese®gures)

AmericanMedical

Association(1996)

2±10%

Thiscouncilreport

quotes®guresfrom

anearlierstudy.

Dailydrinking(quantity±frequency

data)

Graham

etal.(1996b)

16%

826subjects(65years

andover;35%

male);communitysample.

Interviewed

athome.

Heavydrinking(m

ore

than2drinks

per

day)

MirandandWelte

(1996)

6%


andover;34%

male);communitysample.

Telephoneinterviewsincluded

quantity±frequency

estimates

of

alcoholintake.

Alcoholabuse

(de®nitionsnot

speci®ed

forthese®gures)

Gambert(1997)

3±15%

Areview

article

referringto

earlierresearch.

Alcoholproblems(various

de®nitions)

Lakhani(1997)

5.1%

(mean)

Meta-analysisofcommunity-basedstudies.

Heavydrinking(m

ore

than13drinks

per

week)

Sangwanet

al.(1997)

17%

men,2%

women


andover);communitysample.


578 I. JOHNSON

2.

Hospitalsurveys

Alcoholism

(de®nitionnotspeci®ed)

Alcoholism


Alcoholism


Goldsteinet

al.(1996)

Goldsteinet

al.(1996)

Goldsteinet

al.(1996)

14%

(emergency

department)

18%

(medicalinpatients)

23±44%

(psychiatric

inpatients)

Thisreview

article

makes

reference

towork

published

between

1989and1992whichin

turn

refers

backto

researchpublished

in

1971.

Alcoholism


Fleischmann(1997)

9.9%

over55

114subjectsfrom

asampleof1153inpatientalcoholics

wereaged

55andover(81%

ofcasesweremale).

Problem

drinking(C

AGEpositive)

Friedmannet

al.(1998)

11%

792subjects(65years

andover);em

ergency

departmentsample.

3.

Nursinghomesurveys

Activeproblem

drinking(structured

surveyÐ

seecomments)

Lifetim

eproblem

drinking

(structuredsurveyÐ

seecomments)

Josephet

al.(1995)

Josephet

al.(1995)

26%

45.5%

154subjects(50years

andover);nursinghomesample.The

authors

constructed

criteria

for`probable'or`possible'lifetime

active

alcoholproblems.Datawerecollectedusingaretrospective

notesreview

design.

Alcoholism


Goldsteinet

al.(1996)

11%

See

comments

above

relatingto

thesamereview

article.The

prevalence

quotedrefers

toanursinghomesample.

Lifetim

ealcoholabuse

(structured

clinicalinterview

forDSM-III-R

)

Currentalcoholabuse

(structured

clinicalinterview

forDSM-III-R

)

Herrm

annandEryavec

(1996)

Herrm

annandEryavec

(1996)

53%

8%

62subjects(66±90years,100%

male

WorldWarII

veterans);

sample

drawnfrom

along-term

care

facility.Cognitivelyintact

residentswerescreened

usingtheStructuredClinicalInterviewfor

DSM-III-R

,(SCID

).Alcoholabusers

hadsigni®cantlymore

intense

combat

experiences.

Lifetim

ealcoholabuse

(DSM-III

criteria)

Oslin

etal.(1997)

29%

160subjects(m

eanage74years,98%

male);nursinghome

sample.Interviewed

usingthemodi®ed

Schedule

forA�ective

DisordersandSchizophrenia.Alcoholhistories

wereavailablefor

110subjects.



The concept of classi®cation of drinking pro-blems in this age group continued to receiveattention in the literature for the years surveyed.Liberto and Oslin (1995) reviewed the issue ofearly- and late-onset alcoholism in an article whichsummarized ®ndings from earlier research stretch-ing back to 1959. They found that the percentage ofcases falling under the category of late-onsetalcoholism varied across 16 studies and that thelate-onset age cut-o� similarly was not standard-ized (varying between 40 and 65 years). Never-theless, on average, 37% of cases were de®ned asbeing late-onsetÐa similar ®gure was also arrivedat in a review by Dufour and Fuller (1995). Libertoand Oslin (1995) calculated that the incidence oflate-onset problem drinking in the general popula-tion ranged between 0.2 and 4% per year.

Goldstein et al. (1996) identi®ed the followingrisk factors for the development of late-onsetalcoholism: high intake in earlier life, more timeand opportunity to drink and physical illnessescausing pain or insomnia. In contrast, in a study of134 patients aged over 60 years with alcoholdependence (Scholz et al., 1995), depression,anxiety, loneliness, lack of social support andboredom were the most frequently reported pre-cipitants to alcohol problems in old age. Thedistinction between early- and late-onset drinkersappears to be a valid one as the prognosis in late-onset cases continues to be considered morefavourable (American Medical Association, 1996).

SUMMARY

Over the last 5 years researchers in the ®eld ofelderly alcohol misuse have employed a number ofdi�erent methodologies. The variations seen in theprevalence rate can be attributed in part to theseinconsistencies. For example, the range of de®-nitions and age cut-o�s used render direct com-parisons di�cult. No one screening tool isrecognized as the de®nitive diagnostic instrument,although the CAGE seems to have potential as auser-friendly questionnaire. In addition, the di�er-ing gender mix is relevant as predominantly femalesamples are likely to show lower rates of problemdrinking. Many studies fail to give separateprevalence rates for men and women.

Variations in prevalence also exist betweenclinical settings. As one might expect, in-patientsamples have higher rates of problem drinking thanthose recorded in the community. However, the

high prevalence of alcohol problems in nursinghomes is of special concern as these facilities oftenlack in-house alcohol policies and may sell alcoholon the premises.

The following areas would appear appropriatefor future research:

. Further longitudinal studies will help determinethe relevance of the cohort e�ect.

. The study of subgroups of the elderly, particu-larly women and ethnic minorities.

. The investigation of comorbidity of alcoholproblems with functional illness and dementia.

. Further re®nement of age-validated screeningtools could improve detection rates in medicalsettings.

ACKNOWLEDGEMENTS

A grant from Southmead Hospital ResearchFoundation is acknowledged with appreciation. Iam grateful to Dr Mike Nowers for his commentson an earlier draft of this paper.

REFERENCES

AdamsWL, Barry KL, Fleming MF. 1996. Screening forproblem drinking in older primary care patients.JAMA 276(24): 1964±1967.

Adams WL, Cox NS. 1995. Epidemiology of problemdrinking among elderly people. Int. J. Addiction30(13,14): 1693±1716.

American Medical Association. 1996. Alcoholism in theelderly. JAMA 275(10): 797±801.

American Psychiatric Association. 1987. Diagnostic andStatistical Manual of Mental Disorders. 3rd edn,revised (DSM-III-R). APA: Washington, DC.

KEY POINTS

. Alcohol problems are often underdiagnosedin the elderly.

. The number of older problem drinkers is setto rise.

. Variations in methodology yield a range ofprevalence rates of problem drinking.

. More than one quarter of nursing homeresidents may have symptoms of activeproblem drinking.


580 I. JOHNSON

Barker JC, Kramer BJ. 1996. Alcohol consumptionamong older urban American Indians. J. Stud. Alcohol57(2): 119±124.

Beresford TP. 1995. Alcoholic elderly: prevalence,screening, diagnosis and prognosis. In Alcohol andAging, T Beresford, E Gomberg (eds). Oxford; p. 4.

Black DA. 1990. Changing patterns and consequences ofalcohol abuse in old age. Geriatr. Med. 20: 19±20.

Callahan CM, Tierney WM. 1995. Health services useand mortality among older primary care patientswith alcoholism. J. Am. Geriatr. Soc. 43(12):1378±1383.

Chermack ST, Blow FC, Hill EM, Mudd SA. 1996.Relationship between alcohol symptoms and con-sumption among older drinkers. Alcohol Clin. Exp.Res. 20(7): 1153±1158.

Curtis JR, Geller G, Stokes EJ, Levine DM, Moore RD.1989. Characteristics, diagnosis and treatment ofalcoholism in elderly patients. J. Am. Geriatr. Soc.37: 310±316.

Department of Health. 1995. Sensible drinking. Thereport of an inter-departmental working group.

Dufour M, Fuller RK. 1995. Alcohol in the elderly. Ann.Rev. Med. 46: 123±132.

Ewing JA. 1984. Detecting alcoholism: the CAGEquestionnaire. JAMA 252: 1905±1907.

Fleischmann H. 1997. Alkoholismus bei alterenmenschen in einem psychiatrischen krankenhaus(Alcoholism in older people in a psychiatric hospital).Sucht. 43(4): 232±246.

Friedmann PD, Jin L, Nerney M, Mulliken R, Walter J,Cox-Hayley D, Miller A, Chin MH. 1998. E�ect ofproblem drinking on health outcomes of elderlypatients in the emergency department. Subst. UseMisuse 19(3): 133.

Gambert SR. 1997. Alcohol abuse: Medical e�ects ofheavy drinking in late life. Geriatrics 52(6): 30±37.

Goldstein MZ, Pataki A, Webb MT. 1996. Alcoholismamong elderly persons. Psychiatr. Serv. 47(9):941±943.

GrahamK, Carver V, Brett PJ. 1996a. Alcohol and drugsuse by older women: results of a national survey. Can.J. Aging 14(4): 769±791.

Graham K, Clarke C, Bois C, Carver V, Dolinki L,Smythe C, Harrison S. 1996b. Addictive behaviour ofolder adults. Addict. Behav. 21(3): 331±348.

Grant BF. 1993. Comparison of D.S.M.-III-R andD.S.M.-IV alcohol abuse and dependence in a generalpopulation sample. Addiction 88: 1709±1716.

Herrmann N, Eryavec G. 1996. Lifetime alcohol abuse ininstitutionalized World War II veterans. Am. J.Geriatr. Psychiat. 4(1): 39±45.

Hurt RD, Finlayson RE, Morse RM, Davis IJ. 1988.Alcoholism in elderly persons: medical aspects ofprognosis of 216 inpatients. Mayo. Clin. Proc. 63:753±760.

Joseph CL, Atkinson RA, Ganzini L. 1995. Problemdrinking among residents of a VA nursing home. Int.J. Geriat. Psychiat. 10: 243±248.

Lakhani N. 1997. Alcohol use amongst community-dwelling elderly people: a review of the literature.J. Adv. Nurs. 25: 1227±1232.

Liberto JG, Oslin DW. 1995. Early versus late onset ofalcoholism in the elderly. Int. J. Addiction 30(13,14):1799±1818.

Luttrell S, Watkin V, Livingston G, Walker Z, D'Ath P,Shergill S, Dain A, Bielawska C, Katona C. 1997.Screening for alcohol misuse in older people. Int. J.Geriat. Psychiat. 12: 1151±1154.

McInnes E, Powell J. 1994. Drug and alcohol referrals:are elderly substance abuse diagnoses and referralsbeing missed? Brit. Med. J. 308: 444±446.

Mellor MJ, Garcia A, Kenny E, Lazerus J, Conway JM,Rivers L, Viswanathan N, Zimmerman J. 1996.Alcohol and aging. J. Gerontol. Soc. Work 25(1,2):71±89.

Mirand AL, Welte JW. 1996. Alcohol consumptionamong the elderly in a general population, Erie county,New York. Am. J. Public Health 86(7): 978±894.

Morton JL, Jones TV, Manganaro BS. 1996. Perform-ance of alcoholism screening questionnaires in elderlyveterans. Am. J. Med. 101: 153±159.

Naik PC, Jones RG. 1994. Alcohol histories taken fromelderly people on admission. Brit. Med. J. 308: 248.

Oslin DW, Streim JE, Parmelee P, Boyce AA, Katz IR.1997. Alcohol abuse: a source of reversible functionaldisability among residents of a VA nursing home. Int.J. Geriat. Psychiat. 12(8): 825±832.

Sangwan N, Damesyn M, Reuben D, Greendale G,Moore A. 1997. Lifetime alcohol use and alcohol-related conditions in older persons. J. Am. Geriatr.Soc. 45(9): s5.

Saunders P A, Copeland JR, Dewey ME, Davidson IA,McWilliam C, Sharma V, Sullivan C. 1991. Heavydrinking as a risk factor for depression and dementiain elderly men. Findings from the Liverpool longi-tudinal community study. Brit. J. Psychiat. 159:213±216.

Scholz H, Zingerle H, Quantschnig B. 1995. Alcohol anddrug abuse and dependence in elderly people. WeinerZeitschrift fur Suchtforschung 18(1,2): 65±74.

Vestal RE, McGuire EA, Tobin JD, Andres R, NorrisAH, Mezey E. 1977. Aging and ethanol metabolism.Clin. Pharmacol. Ther. 21: 343±354.



alcohol problems in old age: a review of recent epidemiological research

Documents