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. Author manuscript; available in PMC: 2019 Jun 1.
Published in final edited form as: Drug Alcohol Depend. 2018 Mar 31;187:48–54. doi: 10.1016/j.drugalcdep.2018.01.038

Prevalence and correlates of binge drinking among older adults with multimorbidity

Benjamin H Han 1,2, Alison A Moore 3, Scott Sherman 1,2,4,5, Joseph J Palamar 2,5
PMCID: PMC5959772  NIHMSID: NIHMS957323  PMID: 29627405

Abstract

Background

Binge drinking among older adults has increased in the past decade. Binge drinking is associated with unintentional injuries, medical conditions, and lower health-related quality of life. No studies have characterized multimorbidity among older binge drinkers.

Methods

We examined past 30-day binge alcohol use and lifetime medical conditions among adults age ≥50 from the National Survey on Drug Use and Health from 2005-2014. Self-reported lifetime prevalence of 13 medical conditions and medical multimorbidity (≥2 diseases) among binge drinkers were compared to non-binge drinkers. Multivariable logistic regression models were used to examine correlates of binge alcohol use among older adults with medical multimorbidity.

Results

Among adults aged ≥50, 14.4% reported past-month binge drinking. Estimated prevalence of medical multimorbidity was lower (21.4%) among binge drinkers than non-binge drinkers (28.3%; p <0.01). Binge drinkers were more likely to use tobacco and illegal drugs than non-binge drinkers (ps<.001). In the adjusted model, among older adults with multimorbidity, higher income (AOR=1.49, p <0.01), past-month tobacco use (AOR=2.42, p <0.001) and illegal drug use (AOR=2.55, p <0.001) was associated with increased odds of binge alcohol use.

Conclusion

The prevalence of multimorbidity was lower among current binge drinkers compared to non-binge drinkers, possibly because older adults in good health are apt to drink more than adults in poorer health. Current use of tobacco and substance use disorder were associated with an increased risk for binge drinking among older adults with multimorbidity. Binge drinking by older adults with multimorbidity may pose significant health risks especially with the concurrent use of other substances.

Keywords: Binge Drinking, Multimorbidity, Older Adults

1. Introduction

Binge drinking is increasing significantly among older adults (Han et al., 2017) and adults aged ≥65 years have a higher frequency of binge drinking compared to younger adults (Centers for Disease Control [CDC], 2012). Binge drinking is generally defined as ≥4 standard alcoholic drinks on one occasion for women or ≥5 for men (CDC, 2015; Naimi et al., 2003), although the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends lower thresholds for adults 65 and older: no more than 4 drinks on any given day for both men and women (NIAAA, 2016). The recent estimate for past-month binge drinking among adults aged 50-64 years is 19.1% and for adults ≥65 years of age is 9.0% (Han et al., 2017). Binge drinking is a risk factor not only for unintentional injuries such as falls (NIAAA, 2000), but it is also associated with lower health-related quality of life (Wen et al., 2012). In addition, binge drinking can cause, exacerbate, and complicate the management of medical diseases (CDC, 2015; NIAAA, 2000; Sull et al., 2010; Sundell et al., 2008; Piano et al., 2017), and can lead to early mortality (Holahan et al., 2014; Polednak, 2016). This is particularly relevant for older adults who have specific vulnerabilities to alcohol due to the physiological changes of aging (Oslin, 2000), increasing chronic disease burden (Moore et al., 2006), and medication use that can interact with alcohol (Moore et al., 2007).

Individuals with multiple chronic conditions or multimorbidity, defined as having ≥2 concurrent chronic conditions (Fortin et al., 2006; Tinetti et al., 2012), experience many adverse health consequences and require complex health care management and decision-making (American Geriatrics Society [AGS], 2012). Age is the greatest risk factor for most chronic medical diseases and the risk of developing multimorbidity increases sharply with older age (St Sauver et al., 2015). Consequently, the confluence of an increase in the prevalence of multimorbidity in the older US population (Erdem, 2014; Freid et al., 2012; Ward and Schiller, 2013), and the increasing trends in binge drinking and alcohol use disorder among older adults (Han et al., 2017) have substantial public health implications. Previous work has shown an increasing trend of multimorbidity among older binge drinkers (Han et al., 2017); however, no studies have characterized the burden of medical conditions or multimorbidity among older binge drinkers.

Binge drinking is a risk factor for several medical diseases (Gupta et al., 2010; Moore et al., 2006; Piano et al., 2017), can exacerbate existing medical diseases particularly cardiovascular disease (Sull et al., 2010; Sundell et al., 2008), and can complicate the management of chronic diseases (CDC, 2015). Therefore, understanding binge drinking among older adults with a medical disease is vital for targeted public health screening and interventions. This study aimed to estimate the prevalence of medical disease and multimorbidity among older binge drinkers and to determine demographic and behavioral correlates of binge drinking among older adults with multimorbidity. We used cross-sectional data from the ten years (2005-2014) of a nationally representative sample of non-institutionalized individuals in the US—the National Survey on Drug Use and Health (NSDUH), focusing on binge drinkers age 50 and older.

2. Methods

2.1. Study Population

This study used data from the ten NSDUH cohorts from 2005 to 2014. NSDUH is an annual cross-sectional survey of non-institutionalized individuals in the fifty US states and the District of Columbia (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). A different cross-section of respondents is sampled every year and thus the years are independent of each other. NSDUH was designed to be a nationally representative sample of individuals living in the United States, and the sample was attained through four stages: Census tracts were first chosen within each state, then sections in each tract were selected, then household, and then respondents were selected for the sample each year. Surveys were administered through computer-assisted interviewing (CAI)—conducted by an interviewer and audio computer-assisted self-interviewing (ACASI). Sampling weights were provided by NSDUH to address unit- and individual-level non-response. Weights were adjusted to ensure that estimates are consistent with estimates provided by the US Census Bureau. Additional information regarding sampling and the survey can be found elsewhere (SAMHSA, 2013). The weighted interview response rates for 2005-2014 NSDUH ranged from 71.2-76.0%, and missing or incomplete data were imputation-revised.

2.2. Measures

2.2.1. Binge Alcohol Use, Binge Drinkers, and Non-Binge Drinkers

Past-month binge alcohol use was defined using SAMHSA's definition as drinking five or more drinks on the same occasion, which is defined as consuming this many drinks at the same time or within a couple of hours of each other (SAMHSA, 2013). Respondents who reported past-month binge alcohol use were categorized as a “binge drinker”, and all other respondents were categorized as a “non-binge drinker.”

2.2.2. Chronic Medical Disease and Multimorbidity

This study focused on lifetime physical health diseases. NSDUH asks respondents if a doctor or other medical professional had ever informed them that they have ever had the following 13 medical diseases: asthma, bronchitis, cirrhosis of the liver, diabetes, heart disease, hepatitis, hypertension (high blood pressure), lung cancer, HIV/AIDS, pancreatitis, sleep apnea, stroke, and ulcers. These 13 medical diseases are commonly considered as chronic conditions, and 12 are included in either the validated Katz chronic disease comorbidity questionnaire (Katz et al., 1996) or the Hierarchical Condition Category system (Pope et al., 2004). The one exception is obstructive sleep apnea, which is recognized as one of the most prevalent chronic respiratory disorders (Lee and McNicholas, 2011), and therefore included in our analysis. This approach to examining multimorbidity specifically with the NSDUH has been performed in other studies (Stanton et al., 2016; Swartz and Jantz, 2014). We assessed the number of medical conditions by binge drinker and non-binge drinker. To examine binge drinkers with multimorbidity, we computed a sum variable and recorded this into a binary variable indicating multiple self-reported chronic medical conditions (2 or more vs. 0-1 chronic conditions). Using this binary variable, we thus defined multimorbidity as the co-occurrence of two or more chronic conditions as is commonly described (Fortin et al., 2006; Tinetti et al., 2012). In addition, we performed specificity testing to look at differences in the prevalence of medical conditions, and sensitivity analysis using three or more medical conditions to define multimorbidity.

2.2.3. Study Years, Demographics, And Health-Related Variables

We collapsed NSDUH study years into 2005-2006, 2007-2008, 2009-2010, 2011-2012, and 2013-2014. We then examined age (age 50-64 and ≥65, which were derived from predefined NSDUH categories), gender, race/ethnicity (i.e., white non-Hispanic, black non-Hispanic, Hispanic, other), educational attainment (i.e., <high school, high school, some college, college or more), annual total family income (i.e., <$20,000; $20,000-49,999; $50,000-$74,999; ≥$75,000), and marital status (i.e., married, widowed, divorced or separated, or never married).

Participants were asked to rate their general health; response options for perceived health were “excellent”, “very good”, “good”, “fair”, and “poor”. With regard to mental health, participants were asked whether they had experienced a depressive episode or anxiety within the past year. Past 12-months and prior 30-day tobacco use were queried; tobacco was defined as cigarettes, chewing tobacco, snuff, cigars, and pipe tobacco. Nicotine dependence was defined based on the dependence criteria of the Nicotine Dependence Syndrome Scale (NDSS) (Shiffman et al., 2004). Likewise, participants were asked about 12-month and 30-day use of a variety of illegal drugs (e.g., marijuana, cocaine, heroin, hallucinogens, non-medical use of prescription medications (opioid analgesics, tranquilizers/sedatives, and stimulants) and we utilized two separate binary variables indicating whether use of any illegal drug was reported in the past 12 months and the past 30 days. Substance use disorder for illegal drugs was ascertained by participant responses to a series of questions that established if criteria would meet DSM-IV abuse or dependence categories for each drug (American Psychiatric Association, 1994).

2.3. Statistical Analyses

These analyses focused on participants age 50 and older, who represented about 9.2%-16.2% of the full NSDUH sample each year. We aggregated data from all years into a single cross-section to compare demographic bivariate associations between older non-binge drinkers and binge drinkers. The aggregated prevalence of multimorbidity, depression, anxiety, tobacco use and nicotine dependence, substance use disorder, and the individual 13 chronic medical conditions were also compared between older non-binge drinkers and binge drinkers. To evaluate correlates of binge drinking among older adults with multimorbidity, using binary logistic regression, we first estimated odds of each covariate separately, which produced unadjusted odds ratios (ORs). We then fit all covariates simultaneously (including indicators for a year) using multiple logistic regression. The adjusted ORs (AORs) represent the odds of each category with all else in the model being equal.

We weighted all analyses to account for the complex survey design. Since our analyses utilized data from 10 cohorts, we divided the weights by 10 to obtain nationally representative estimates. Stata SE 13 (StataCorp, College Station, TX, 2009) was used for all analyses, and survey (“svy”) commands were utilized to provide accurate standard errors using Taylor series estimation methods (Heeringa et al., 2010). Secondary analysis of this publically available data was exempt for review by the New York University Langone Medical Center Institutional Review Board.

3. Results

A total of 8,804 participants (14.4% of the entire sample age ≥50) met criteria for past-month binge drinking. Sample characteristics for non-binge drinkers and binge drinkers are presented and compared in Table 1. Binge drinkers were significantly younger, the male had a higher income, divorced or separated, and less likely to report “fair or poor” overall health (p<0.001 for all variables). The number of non-Hispanic whites was similar in the two groups, but there was a higher prevalence of African Americans and Hispanics and a lower prevalence of Asians among binge drinkers. Table 2 presents differences in multimorbidity, mental health, tobacco use, nicotine dependence, substance use disorder, and specific medical conditions between binge drinkers and non-binge drinkers. Non-binge drinkers had a significantly higher prevalence of multimorbidity (for ≥2 medical conditions, 28.3% vs. 21.4%, p<0.001). Specificity tests for ≥3 medical conditions found similar differences between the two groups (11.3% vs. 7.8%, p<0.001). For specific medical conditions, non-binge drinkers reported a significantly higher prevalence of asthma (9.9% vs 8.5%, p<0.001), bronchitis (12.4% vs 9.5%, p<0.001), diabetes (16.1% vs 10.5%, p <0.001), hypertension (40.9% vs 38.4%, p <0.001), sleep apnea (7.1% vs 6.3%, p=0.027), stroke (3.0% vs 1.9%, p <0.001), and ulcers (4.6% vs 3.3%, p <0.001). There were no significant differences in the remaining 5 chronic medical conditions. In regard to mental health, there were no significant differences in the prevalence of past-year major depressive episode or anxiety between the two groups. Binge drinkers also reported having higher use of past month tobacco use (39.2% vs 17.4%, p <0.001) and illegal drug use (9.6% vs 2.5%, p <0.001), nicotine dependence (14.0% vs 6.4%, p <0.001), and substance use disorder (1.7% vs. 0.5%, p <0.001).

Table 1.

Sample characteristics and bivariable associations among adults 50 and older with past-month binge drinking – United States 2005-2014, %a.

Characteristic Non-Binge Drinkers (n=52,436) Binge Drinkers (n=8,804) p-value
Survey year
2005-2006 18.3 16.2 0.001
2007-2008 19.0 18.5
2009-2010 19.7 20.1
2011-2012 21.2 21.5
2013-2014 21.8 23.7
Age group
50-64 56.5 75.0 <0.001
≥65 43.5 25.0
Sex
Female 57.4 29.8 <0.001
Race/ethnicity
Non-Hispanic White 76.1 76.3 <0.001
Non-Hispanic African American 9.8 10.7
Hispanic 8.5 9.1
Non-Hispanic Asian 3.7 1.8
Other 1.9 2.1
Education
<High School 16.2 14.7 <0.001
High School 31.5 36.0
Some College 22.8 24.2
College or more 29.6 25.0
Total family income
<$20,000 40.0 31.0 <0.001
$20-$49,999 35.7 37.2
$50,000-$74,999 12.0 14.6
≥ $75,000 12.3 17.1
Marital status
Married 62.7 63.5 <0.001
Widowed 14.6 7.5
Divorced or separated 16.4 21.7
Never married 6.3 7.4
Overall Health
Excellent 17.4 16.8 <0.001
Very Good 31.6 34.7
Good 30.4 31.0
Fair/Poor 20.6 17.6
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a

All percentages are weighted.

Table 2.

Chronic disease, medical and mental health conditions among binge drinkers 50 and older, United States 2005-2014, %a.

Characteristic Non-Binge Drinkers (n=52,436) Binge Drinkers (n=8,804) p-value
Chronic Medical Disease
No chronic conditions 35.4 40.8 <0.001
One chronic condition 36.3 37.8
≥2 chronic disease 28.3 21.4
≥3 chronic disease 11.3 7.8
Specific Medical Conditions
Asthma 9.9 8.5 <0.001
Bronchitis 12.4 9.5 <0.001
Cirrhosis of the liver 0.5 0.4 0.548
Diabetes 16.1 10.5 <0.001
Heart Disease 12.5 9.3 <0.001
Hepatitis 2.2 2.5 0.073
High blood pressure 40.9 38.4 <0.001
HIV/AIDS 0.2 0.2 0.774
Lung Cancer 0.5 0.4 0.141
Pancreatitis 0.8 0.6 0.232
Sleep apnea 7.1 6.3 0.027
Stroke 3.0 1.9 <0.001
Ulcers 4.6 3.3 <0.001
Mental Health
Past year major depressive episode 7.4 6.8 0.120
Anxiety in past year 4.6 4.6 0.816
Substance use
Tobacco use
Past month use 17.4 39.2 <0.001
Past year use 19.8 44.1 <0.001
Nicotine dependence b 6.4 14.0 <0.001
Illegal Drug
Past month use 2.5 9.6 <0.001
Past year use 4.4 15.1 <0.001
Substance use disorder c 0.5 1.7 <0.001
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a

All percentages are weighted.

b

Based on the Nicotine Dependence Syndrome Scale (NDSS)

c

Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

Table 3 shows results from the multivariable logistic regression model with past-month binge drinking as the outcome variable for participants in the study with multimorbidity (n=8,804). Results from the adjusted model suggest that among adults with multimorbidity, older adults (AOR 0.57, p <0.001) and females (AOR 0.33, p <0.001) had a lower odds of reporting past-month binge drinking. While respondents are reporting higher household incomes ≥$75,000 (AOR 1.44, p <0.01), and past-month use of tobacco (AOR 2.55, p <0.001) or substance use disorder for illegal drugs (AOR 1.80, p <0.05) had a higher odds of reporting past-month binge drinking. Sensitivity analyses using a different cut-off to define multimorbidity (≥3 instead of ≥2 chronic medical conditions) gave comparable findings in the logistic regression model.

Table 3.

Multivariable logistic regression analysis of demographic and substance use factors associated with bingedrinking among adults age ≥50 with multimorbidity- 2005-2014.

Characteristic ORb (95% CI) AOR (95% CI)
Survey year
2005-2006 1.00 1.00
2007-2008 1.06 (0.87, 1.30) 1.06 (0.87, 1.30)
2009-2010 1.02 (0.84, 1.23) 0.99 (0.81, 1.20)
2011-2012 1.22* (1.01, 1.46) 1.18 (0.97, 1.43)
2013-2014 1.21* (1.03, 1.44) 1.17 (0.98, 1.39)
Age group
50-64 1.00 1.00
≥65 0.47*** (0.40, 0.54) 0.57*** (0.48, 0.66)
Sex
Male 1.00 1.00
Female 0.31*** (0.27, 0.35) 0.33*** (0.29, 0.39)
Race/ethnicity
Non-Hispanic White 1.00 1.00
Non-Hispanic African American 1.08 (0.88, 1.32) 1.12 (0.89, 1.41)
Hispanic 1.01 (0.78, 1.30) 1.16 (0.88, 1.53)
Non-Hispanic Asian 0.51* (0.28, 0.95) 0.61 (0.33, 1.12)
Other 0.96 (0.70, 1.32) 0.89 (0.63, 1.26)
Education
<High School 1.00 1.00
High School 1.25* (1.01, 1.54) 1.21 (0.96, 1.53)
Some College 1.20 (0.98, 1.47) 1.04 (0.84, 1.30)
College or more 1.02 (0.83, 1.24) 0.82 (0.65, 1.04)
Total family income
<$20,000 1.00 1.00
$20-$49,999 1.29*** (1.12, 1.48) 1.07 (0.91, 1.26)
$50,000-$74,999 1.30** (1.07, 1.58) 0.92 (0.72, 1.19)
≥ $75,000 2.04*** (1.65, 2.51) 1.44* (1.09, 1.90)
Marital status
Married 1.00 1.00
Widowed 0.54*** (0.42, 0.68) 0.98 (0.75, 1.27)
Divorced or separated 1.13 (0.98, 1.32) 1.10 (0.93, 1.30)
Never married 1.20 (0.95, 1.51) 1.16 (0.91, 1.46)
Tobacco use
Past-month use 3.11*** (2.66, 3.64) 2.55*** (2.16, 3.00)
Illegal Drug
Substance use disorder c 3.63*** (2.37, 5.54) 1.80* (1.08, 3.01)
Overall Health
Excellent 1.00 1.00
Very Good 1.20 (0.78, 1.55) 1.06 (0.75, 1.52)
Good 1.05 (0.78, 1.41) 0.96 (0.71, 1.29)
Fair/Poor 0.92 (0.68, 1.23) 0.79 (0.57, 1.08)
Mental Health
Past year major depressive episode 0.92 (0.77, 1.09) 0.88 (0.71, 1.09)
Anxiety in past year 0.95 (0.75, 1.19) 1.00 (0.74, 1.35)
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a

Multimorbidity defined as ≥2 of the following: Asthma, Bronchitis, Cirrhosis, Diabetes, Heart Disease, Hepatitis, High Blood Pressure, HIV/AIDS, Lung Cancer, Pancreatitis, Sleep Apnea, Stroke, Ulcers

b

Unadjusted odds ratios were replicated including year of survey but are presented as odds ratios without year.

c

Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

4. Discussion

In this large and nationally representative survey, we characterized the burden of chronic disease among binge drinkers and examined correlates for binge drinking among older adults with multimorbidity. These results build on previous research on the increasing trends of multimorbidity among older binge drinkers (Han et al., 2017) and the risks of alcohol and comorbidity among older adults (Moore et al., 2006). These findings are alarming because of the potentially dangerous effects of binge drinking on older adults with multiple chronic diseases.

While the prevalence of multimorbidity was higher among non-binge drinkers compared to binge drinkers, it was still common among binge drinkers (21.4%). The lower prevalence of multimorbidity and nearly all the specific chronic diseases among binge drinkers in our study are likely due to selection biases common in observational studies of alcohol use (Naimi et al., 2016). The “sick quitter” hypothesis states adults may stop drinking due to sickness or because of interactions of alcohol with prescribed medications, and therefore this group is not included as individuals with alcohol-related problems even though alcohol may have contributed to their illnesses (Shaper et al., 1988). This is especially relevant for older adults. While studies have suggested cardiovascular protection of alcohol for older drinkers, further stratified analyses from a recent meta-analysis reveals that any protection is likely due to the accumulation of lifetime selection biases that leads researchers to compare a highly selected population of healthy older drinkers to unhealthy non-drinkers (Naimi et al., 2016; Zhao et al., 2017). Therefore, while research suggests that unhealthy drinking is associated with having better overall health status (Merrick et al., 2008; Platt et al., 2010), this indicates that older adults in good health are likely to drink more alcohol than older adults in poorer health (Kuerbis et al., 2014). Studies support this have shown that older adults with declining health (e.g., indicated by increased hospitalizations or disabilities) tend to drink less or stop drinking (Merrick et al., 2008; Perriera et al., 2001). Therefore, it is likely that the lower rate of multiple chronic diseases among binge drinkers in our study sample is not causal but likely represents a selection bias.

The risks of binge drinking in general for older adults have been studied in a small number of studies and include an increase risk in total mortality (Holahan et al., 2014), unintentional falls (CDC, 2015; Sorock et al., 2006), and insomnia (Canham et al., 2014). However, the dangers of binge drinking by older adults with chronic medical conditions are particularly worrisome. While our study found that compared to non-binge drinkers, past-month binge drinkers did not have a higher percentage of any individual chronic medical condition aside from hepatitis (possibly due to selection biases), the prevalence of hypertension (38.4%), diabetes (10.5%), and heart disease (9.3%) were not low among current binge drinkers. This has very specific health implications as binge drinking has known impacts on the cardiovascular system. Binge drinking is associated with increases in blood pressure and increases one's risk for hypertension (Piano et al., 2017), and binge drinkers with existing hypertension have an elevated cardiovascular mortality risk (Sull et al., 2010). Binge drinking has also been associated with cardiac arrhythmias (Ettinger et al., 1978), most commonly with atrial fibrillation (Larson et al., 2014; Liang et al., 2012). Several studies including a meta-analysis have shown that particularly heavy binge drinking is associated with an acute risk (within 24 hours) of myocardial infarction (Leong et al., 2014; Mostofsky et al., 2016) and mortality after myocardial infarction (Mukamal et al., 2005). Binge drinking is also associated with an increased risk for stroke, including ischemic stroke (Sundell et al., 2008) and stroke mortality (Sull et al., 2010). Finally, binge alcohol use has also been associated with an increased risk of abnormal blood glucose regulation and an increased risk for diabetes (Cullman et al., 2012; Nygren et al., 2017). Taken together, binge drinking may have devastating effects on older adults with chronic medical conditions, especially with adults at risk for or with the underlying cardiovascular disease. In addition, studies have shown a poorer self-rated health-related quality of life among binge drinkers (Okoro et al., 2004; Tsai et al., 2010; Wen et al., 2012).

The significant demographic correlates of binge alcohol use among older adults with multimorbidity determined in this study included younger age, male, a high family income (≥$75,000), current tobacco use, and substance use disorder of illegal drug use. These are similar to results of associations of binge drinking among general older populations from previous studies (Barnes et al., 2010; Blazer and Wu, 2009; CDC, 2015; Han et al., 2017; Parikh et al., 2015). These findings, however, do point to a particularly high-risk population of older adults with multimorbidity and polysubstance use (binge alcohol use with tobacco and/or illegal drug use). Unhealthy substance use and substance use disorders are themselves are considered chronic diseases characterized by relapses that can have physiological changes in the brain and need for ongoing treatment (Hser et al., 2007). The added burden of substance use along with binge drinking highlights the need for a syndemic framework, where attention is given to how multiple health conditions are adversely affected by behavioral, psychiatric, biological, and social conditions (Bhugra and Ventriglio, 2017; Singer et al., 2017), to better understand chronic disease management for older adults with unhealthy substance use. The identification and awareness of syndemics, such as the impact of binge drinking and other substances on medical diseases, are urgently needed to identify intervention strategies to reduce harms and improve the management of multimorbidity.

Aging involves physiological changes that place older adults with multimorbidity at risk for the negative effects of alcohol, especially when consuming alcohol in amounts exceeding NIAAA recommended drinking limits (Moore et al., 2006). Older adults living with multimorbidity often have complicated medication regimens and a wide range of non-pharmacologic therapy that requires careful ongoing, daily management (Boyd et al., 2005; Tinetti et al., 2012). Medical care that involves high complexity places patients at risk for medication management errors, adverse drug-drug interactions and drug events (Flaherty et al., 2000; Juurlink et al., 2003). In addition, many older adults are prescribed medications that can interact with alcohol at a high rate (Breslow et al., 2015) that can lead to dangerous effects (Moore et al., 2007). Therefore, binge drinking may easily complicate the complex management of living with multimorbidity. Therefore, recommendations have been advised to lower recommended drinking limits (including daily drinking) based on comorbidities for older adults (Moore et al., 2006), which will become increasingly relevant as the trend of increased binge alcohol use among older adults with multimorbidity will likely continue with the aging baby boomer generation.

4.1. Limitations

There are limitations to this study, and several involve the limits of self-reported, cross-sectional national surveys. The NSDUH responses are based on self-report and therefore are subject to social-desirability bias and recall bias; although the survey attempts to limit the former via audio computer-assisted self-interviewing (SAMSHA, 2013). There are also issues of generalizability since the NSDUH samples the civilian, non-institutionalized population, it does not include active members on the military, homeless, incarcerated, or institutionalized adults who may have different binge alcohol use patterns compared to respondents in the study. In addition, the cross-sectional study design of NSDUH does not assess when a respondent experienced a medical condition, but only asks for lifetime prevalence. Therefore, respondents may have had a health condition many years before being, surveyed and that condition could have been cured or resolved and not overlap with their current binge drinking, however most of the conditions asked (i.e., hypertension, sleep apnea, heart disease, cirrhosis, HIV, stroke, asthma) tend to be lifelong. Likewise, given the cross-sectional analysis of this study it possible that participants may have developed specific chronic diseases contributed by binge alcohol use (i.e., cirrhosis, pancreatitis, ulcers), but now no longer engage in alcohol use; therefore, we cannot establish causality in this study. Therefore, lacking the ability to know when medical conditions were diagnosed, this study cannot make distinctions of the possible impact of binge alcohol use on medical disease and vice versa. But this study does describe the burden of multimorbidity and specific medical diseases among current binge drinkers. Another important limitation includes the utilization of variables based on SAMHSA's definition for binge drinking as drinking 5 or more alcoholic drinks on the same occasion for at least 1 day in the previous 30 days (SAMHSA, 2013). The CDC and NIAAA, however, use a different cutoff for binge drinking, defined as a pattern of drinking that brings blood alcohol concentration to 0.08 g/dL, or 5 drinks for men and 4 drinks for women in roughly a two-hour period (NIAAA, 2004). The NIAAA also recommends lower thresholds for adults 65 and older: no more than 4 drinks on any given day for both men and women (NIAAA, 2016). Since our analysis used the higher cutoff for the binge drinking criteria for women and older adults (≥65), our study is likely to have underestimated the prevalence for binge drinking among women and adults over the age of 65 compared to using the NIAAA thresholds. Finally, as discussed earlier, this study suffers from the selection bias of the “sick quitter hypothesis” as the non-binge drinking group in our study is likely heterogeneous, including individuals ranging from life-long abstainers to adults with a history of unhealthy alcohol use including binge drinking. However, the focus of this study is understanding the potential impact of current binge drinking on existing chronic disease, and not how alcohol causes medical disease

5. Conclusion

This study is among the first to examine the burden of multimorbidity among older binge drinkers in the United States. The high prevalence of cardiovascular disease, hypertension, and diabetes among older binge drinkers has important health consequences. In addition, the use of concurrent tobacco and illegal drugs with binge alcohol use is especially dangerous for older adults with multimorbidity. Older adults with chronic disease and their providers need to be aware of the potential risks of binge drinking and recognize recommended lower drinking thresholds. Future studies are needed to better evaluate the risks of binge drinking with older adults with comorbidities.

Highlights.

  • First study of multimorbidity among older binge drinkers using national data.

  • Multimorbidity was common among binge drinkers.

  • Tobacco/drug use was associated with binge drinking by adults with multimorbidity.

Acknowledgments

The authors would like to thank the Inter-University Consortium for Political and Social Research for providing access to these data (http://www.icpsr.umich.edu/icpsrweb/landing.jsp).

Role of Funding Source: This research was funded by several grants through the National Institutes of Health: NYU CTSA grant 1KL2 TR001446 from the National Center for Advancing Translational Sciences (Han), K24AA15957 from the National Institute on Alcohol Abuse and Alcoholism (Moore), K01 DA-038800 from the National Institute on Drug Abuse (Palamar), and 1K24DA038345 from the National Institute on Drug Abuse (Sherman). The National Institutes of Health provided financial support for the project and the preparation of the manuscript but did not have a role in the design of the study, the analysis of the data, the writing of the manuscript, nor the decision to submit the present research. The Inter-University Consortium for Political and Social Research and National Survey on Drug Use and Health (NSDUH) principal investigators had no role in analysis, interpretation of results, or in the decision to submit the manuscript for publication.

Footnotes

Contributors: All authors are responsible for this reported research. BH conceptualized and designed the study, helped interpret results, drafted the initial manuscript, and revised the manuscript. JP designed the study, conducted the statistical analyses, helped interpret results, and critically reviewed the manuscript. AM helped interpret results and critically reviewed the manuscript. SS helped conceptualize the study, interpret results, and critically reviewed the manuscript. All authors edited and approved the final manuscript as submitted.

Conflict of Interest: No conflict declared.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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