Bias in estimates of alcohol use among older people: selection effects due to design, health, and cohort replacement.

BACKGROUND: There is a growing awareness of the need to include the oldest age groups in the epidemiological monitoring of alcohol consumption. This poses a number of challenges and this study sets out to examine the possible selection effects due to survey design, health status, and cohort replacement on estimates of alcohol use among the oldest old. METHODS: Analyses were based on three repeated cross-sectional interview surveys from 1992, 2002 and 2011, with relatively high response rates (86 %). The samples were nationally representative of the Swedish population aged 77+ (total n = 2022). Current alcohol use was assessed by the question "How often do you drink alcoholic beverages, such as wine, beer or spirits?" Alcohol use was examined in relation to survey design (response rate, use of proxy interviews and telephone interviews), health (institutional living, limitations with Activities of Daily Living and mobility problems) and birth cohort (in relation to age and period). Two outcomes were studied using binary and ordered logistic regression; use of alcohol and frequency of use among alcohol users. RESULTS: Higher estimates of alcohol use, as well as more frequent use, were associated with lower response rates, not using proxy interviews and exclusion of institutionalized respondents. When adjusted for health, none of these factors related to the survey design were significant. Moreover, the increase in alcohol use during the period was fully explained by cohort replacement. This cohort effect was also at least partially confounded by survey design and health effects. Results were similar for both outcomes. CONCLUSIONS: Survey non-participation in old age is likely to be associated with poor health and low alcohol consumption. Failure to include institutionalized respondents or those who are difficult to recruit is likely to lead to an overestimation of alcohol consumption, whereas basing prevalence on older data, at least in Sweden, is likely to underestimate the alcohol use of the oldest old. Trends in alcohol consumption in old age are highly sensitive for cohort effects. When analysing age-period-cohort effects, it is important to be aware of these health and design issues as they may lead to incorrect conclusions.

Alcohol abstinence, non-hazardous use and hazardous use a decade after alcohol-related hospitalization: registry data linked to population-based representative postal surveys.

BACKGROUND: Although there is evident association between alcohol-related hospitalization and alcohol use, the relationship has not been well examined. This study analyzed the extent of alcohol abstinence, non-hazardous use and hazardous use among people who had experienced alcohol-related hospitalization during the preceding decade. METHOD: Registry data concerning alcohol-related hospitalizations between 1996 and 2007 were linked to two representative surveys, in 2006 and 2007, of residents of Stockholm County. Relevant contrasts were modeled, using logistic regression, in the pooled sample (n = 54 955). Ages were 23-84 years at follow-up. RESULTS: Among persons previously hospitalized (n = 576), half reported non-hazardous use. Non-hazardous use was less prevalent than in the general population--and the extent of non-hazardous use did not change over time following hospitalization. There were no significant age differences, but non-hazardous use was less frequent among people with repeated episodes of care. One in six was abstinent. Abstinence was more common among the old, while hazardous use (exceeding 14 drinks per week for men, and 9 drinks per week for women) decreased with age. Abstinence also increased over time; among persons hospitalized ten years ago, the abstinence rate was twice that of the general population. Associations with hazardous use over time were less conclusive. Hazardous use among those previously hospitalized decreased over time in one sample but not in the other. After pooling the data, there were indications of a decrease over time following hospitalization, but more prevalent hazardous use than in the general population. CONCLUSIONS: Following alcohol-related hospitalization, abstinence increased, and there was no evidence of regression towards the mean, i.e., towards non-hazardous use. Abstinence was also more widespread among previously hospitalized persons of older ages. With advancing age, changing hazardous alcohol habits among previously hospitalized appears to yield a trend towards promotion of abstinence.

The beliefs about pros and cons of drinking and intention to change among hazardous and moderate alcohol users: a population-based cross-sectional study.

BACKGROUND: Fundamental to supporting hazardous alcohol users are the rationales for reducing alcohol intake highlighted by the users themselves. This study analyses the relative importance of beliefs about pros and cons of drinking in relation to having an intention to reduce intake among both hazardous and moderate alcohol users. METHODS: Intention to change was assessed in a representative sample of Stockholm's population (n = 4278, response rate 56.5%). Alcohol use was assessed using the Alcohol Use Disorders Identification Test measure. A decisional balance inventory was used to examine various beliefs about the pros and cons of drinking, which covered affect changes, social gains and losses, and possible adverse effects. Independent correlations were determined by logistic regression using a backward exclusion procedure (P > 0.05). RESULTS: Higher ratings of importance were generally related to intent, whether or not the contrast was with having no intent or already having made a reduction. This was especially true for hazardous users. Only two beliefs were independently correlated with change among hazardous users: 'Drinking could get me addicted' and 'Drinking makes me more relaxed/less tense' (pseudo-R2 < 0.1). Among moderate users, there was no uniform pattern in the relationships. CONCLUSIONS: Unexpectedly, hazardous users with an intent to change rated pro arguments as more important than those with no intent to change. Of the investigated pros and cons, only a few were independently related to intention to change drinking behaviour. These arguments provide interesting topics in consultations. Little support was found for any rational decision making behind the intention to reduce alcohol intake.

Income and education as predictors of return to working life among younger stroke patients.

BACKGROUND: Socioeconomic conditions are not only related to poor health outcomes, they also contribute to the chances of recovery from stroke. This study examines whether income and education were predictors of return to work after a first stroke among persons aged 40-59. METHODS: All first-stroke survivors aged 40-59 who were discharged from a hospital in 1996-2000 and who had received income from work during the year prior to the stroke were sampled from the Swedish national register of in-patient care (n = 7,081). Income and education variables were included in hazard regressions, modelling the probability of returning to work from one to four years after discharge. Adjustments for age, sex, stroke subtype, and length of in-patient care were included in the models. RESULTS: Both higher income and higher education were associated with higher probability of returning to work. While the association between education and return to work was attenuated by income, individuals with university education were 13 percent more likely to return than those who had completed only compulsory education, and individuals in the highest income quartile were about twice as likely to return as those in the lowest. The association between socioeconomic position and return to work was similar for different stroke subtypes. Income differences between men and women also accounted for women's lower probability of returning to work. CONCLUSIONS: The study demonstrates that education and income were independent predictors of returning to work among stroke patients during the first post-stroke years. Taking the relative risk of return to work among those in the higher socioeconomic positions as the benchmark, there may be considerable room for improvement among patients in lower socioeconomic strata.

Recurring alcohol-related care between 1998 and 2007 among people treated for an alcohol-related disorder in 1997: a register study in Stockholm County.

BACKGROUND: Inpatient care for alcohol intoxication is increasing in Sweden, especially among young women. Since it is well known that alcohol disorder is a chronic relapsing illness, this study examines the extent to which people return for more care. METHOD: All inpatients with alcohol-related diagnoses in Stockholm County during 1997 were followed prospectively to 2007 through registers. The proportion reappearing for the same diagnosis, other alcohol-related inpatient, or outpatient care each year after baseline, as well as the number of years the inpatients reappeared were calculated (n = 2735). Three diagnoses were examined separately; alcohol dependence, harmful use of alcohol, and alcohol intoxication. RESULTS: Three out of five inpatients with an alcohol diagnoses reappeared for more alcohol-related inpatient care during the following decade. The proportion returning was largest the year after baseline and then decreased curvilinearly over time. The inclusion of outpatient care increased proportions, but did not change patterns. Of those with an alcohol dependence diagnosis at baseline 42 percent returned for more alcohol-related inpatient care the first, 28 percent the fifth, and 25 percent the tenth year. Corresponding proportions for harmful use and intoxication were smaller. One in five among those with an alcohol dependence returned for more than five of the ten years. Ordered logistic regressions confirmed that besides diagnosis, age and gender were independently related to the number of years returning to care. CONCLUSIONS: While middle-aged males with alcohol dependence were in a revolving door, young female inpatients with intoxication diagnosis returned to a comparably lower degree.

Continuity of leisure participation from middle age to old age.

OBJECTIVE: Continuity in habits, activities, and roles is important upon entering old age according to the continuity theory of aging. Few studies have investigated patterns of leisure participation over an extended period of time among older adults. This study examines changes in nine different leisure activities in a nationally representative sample of individuals followed over a 34-year period in Sweden. METHODS: We used longitudinal data from three waves of an interview survey that followed 495 individuals from 1968 to 2002. Individuals were aged 43-65 in 1968 and 77-99 in 2002. We conducted logistic regression analyses on each of the leisure activities. RESULT: For the panel followed, a decline in participation rates was the most common pattern over time. Analyses at the individual level showed that late-life participation was generally preceded by participation earlier in life. Previous participation, both 10 and 34 years earlier, predicted late-life participation. The modifying effect of functional status in late life was small. DISCUSSION: In accordance with the continuity theory of aging, leisure participation in old age is often a continuation of previous participation. However, there is considerable variation among both activities and individuals.

Health changes among Swedish oldest old: prevalence rates from 1992 and 2002 show increasing health problems.

BACKGROUND: The health of the elderly population is of utmost importance for planning policy and resources for care services. Most surveys of the health of the elderly population show improvement, suggesting support for the compression of morbidity hypothesis. This study examines changes in the health of the Swedish population (aged 77+) from 1992 to 2002. METHODS: Two nationally representative surveys of the elderly population (n = 537 and 563, respectively), including both community-based and institutionalized persons were used. Outcomes include self-reported diseases, symptoms, and activities of daily living, as well as objective tests of physical capacity, lung function, vision, and cognition. RESULTS: None of the indicators showed improvement. A number of health indicators showed significant worsening, with or without adjustment for changes in the age and sex distribution from 1992 to 2002. Among self-reported indicators, there were significant increases in several diseases and symptoms. The objective function tests also showed significantly worse results in 2002 compared to 1992 for physical capacity, lung function, and cognition. No significant differences in activities of daily living limitations were found. CONCLUSIONS: In light of several recent studies, we expected to observe improvements in the health of the elderly population. However, this study showed no signs of improvement. On the contrary, we found a pattern of worsening health. The study included objective tests of function, implying that results are not due solely to raised expectations or changes in reporting. Possible explanations are discussed.

Mobility limitations 1974-1991: period changes explaining improvement in the population.

The proportion of people with mobility limitations (difficulties with running, walking and stairs) decreased between 1968 and 1991 in the Swedish population aged 18-75. The distribution of predictors of late life morbidity, e.g., social class, health behaviour and childhood conditions, also changed during this period. This study explored whether the changes in these predictors over time were related to the decrease in the proportion of the population with mobility limitations. In two nationally representative interview samples (n=4468) from 1974 and 1991 of persons aged 45-71 the odds for limitations were cross-sectionally compared in ordered logistic regression models. In addition, predictors for the mobility outcome in 1974 were collected from an earlier 1968 survey and predictors for the 1991 outcome were collected from 1981. In 1974 the odds for limitations in the population was 50% higher than in 1991. Had the population composition regarding social class and housewives in 1991 been identical to 1974, the odds for limitations would have been similar in 1974 and 1991. Period improvement in social classes with poorer mobility also contributed to the overall period improvement. Health behaviours were examined as possible mediating factors. The increase of physically active people between 1968 and 1974 was related to the period improvement in mobility between 1974 and 1991. Smoking showed an increased association with mobility limitations during the period, indicating that mobility improvement would have been greater if everyone had been a non-smoker. Results indicate how sensitive disability rates may be for cohort or period effects.

The national alcohol helpline in Sweden: an evaluation of its first year.

BACKGROUND: Telephone helplines are easily available and can offer anonymity. Alcohol helplines may be a potential gateway to a more advanced support protocol, and they may function as a primary support option for some. However, although telephone helplines (quitlines) make up an established evidence-based support arena for smoking cessation, few studies have described such telephone-based alcohol counseling. METHODS: This study describes the basic characteristics of callers (n = 480) to the Swedish Alcohol Helpline during its first year of operation, and assesses aspects of change in alcohol behavior in a selected cohort of clients (n = 40) willing to abstain from anonymity and enter a proactive support protocol. RESULTS: During the study period, 50% of callers called for consultation regarding their own alcohol use (clients), a third called about relatives with alcohol problems, and the others called for information. The clients' average age was 49 years, and half were females. The clients' average AUDIT score at baseline was 21 (std. dev. =7.2). Approximately a quarter had scores indicating hazardous alcohol use at baseline, while the others had higher scores. In a follow-up pilot study, the average AUDIT score had decreased from 21 to 14. While clients reporting more severe alcohol use showed a significant decrease at follow-up, hazardous users exhibited no change during the study period. CONCLUSION: The study indicates that telephone helplines addressing the general public can be a primary-care option to reduce risky alcohol use. A randomized controlled study is needed to control for the effect of spontaneous recovery.

Non-response bias and hazardous alcohol use in relation to previous alcohol-related hospitalization: comparing survey responses with population data.

BACKGROUND: This study examines whether alcohol-related hospitalization predicts survey non-response, and evaluates whether this missing data result in biased estimates of the prevalence of hazardous alcohol use and abstinence. METHODS: Registry data on alcohol-related hospitalizations during the preceding ten years were linked to two representative surveys. Population data corresponding to the surveys were derived from the Stockholm County registry. The alcohol-related hospitalization rates for survey responders were compared with the population data, and corresponding rates for non-responders were based on the differences between the two estimates. The proportions with hazardous alcohol use and abstinence were calculated separately for previously hospitalized and non-hospitalized responders, and non-responders were assumed to be similar to responders in this respect. RESULTS: Persons with previous alcohol-related admissions were more likely currently to abstain from alcohol (RR=1.58, p<.001) or to have hazardous alcohol use (RR=2.06, p<.001). Alternatively, they were more than twice as likely to have become non-responders. Adjusting for this skewed non-response, i.e., the underrepresentation of hazardous users and abstainers among the hospitalized, made little difference to the estimated rates of hazardous use and abstinence in total. During the ten-year period 1.7% of the population were hospitalized. CONCLUSIONS: Few people receive alcohol-related hospital care and it remains unclear whether this group's underrepresentation in surveys is generalizable to other groups, such as hazardous users. While people with severe alcohol problems--i.e. a history of alcohol-related hospitalizations--are less likely to respond to population surveys, this particular bias is not likely to alter prevalence estimates of hazardous use.