Risk Drinking Among Older Adults: the Project SHARE Study
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ALCOHOLISM:CLINICAL AND EXPERIMENTAL RESEARCH Vol. 39, No. 7 July 2015 Examining the Impact of Separate Components of a Multicomponent Intervention Designed to Reduce At-Risk Drinking Among Older Adults: The Project SHARE Study Obidiugwu K. Duru, Haiyong Xu, Alison A. Moore, Michelle Mirkin, Alfonso Ang, Louise Tallen, Chi-Hong Tseng, and Susan L. Ettner Background: Health promotion interventions often include multiple components and several patient contacts. The objective of this study was to examine how participation within a multicomponent intervention (Project SHARE) is associated with changes in at-risk drinking among older adults. Methods: We analyzed observational data from a cluster-randomized trial of 31 primary care physi- cians and their patients aged ≥60 years, at a community-based practice with 7 clinics. Recruitment occurred between 2005 and 2007. At-risk drinkers in a particular physician’s practice were randomly assigned as a group to usual care (n = 640 patients) versus intervention (n = 546 patients). The interven- tion included personalized reports, educational materials, drinking diaries, in-person physician advice, and telephone counseling by health educators (HEs). The primary outcome was at-risk drinking at fol- low-up, defined by scores on the Comorbidity Alcohol Risk Evaluation Tool (CARET). Predictors included whether a physician–patient alcohol risk discussion occurred, HE call occurred, drinking agree- ment with the HE was made, and patients self-reported keeping a drinking diary as suggested by the HE. Results: At 6 months, there was no association of at-risk drinking with having had a physician– patient discussion. Compared to having had no HE call, the odds of at-risk drinking at 6 months were lower if an agreement was made or patients reported keeping a diary (odds ratio [OR] 0.58, 95% confi- dence interval [CI] 0.37 to 0.90), or if an agreement was made and patients reported keeping a diary (OR 0.52, CI 0.28 to 0.97). At 12 months, a physician–patient discussion (OR 0.61, CI 0.38 to 0.98) or an agreement and reported use of a diary (OR 0.45, CI 0.25) were associated with lower odds of at-risk drinking. Conclusions: Within the Project SHARE intervention, discussing alcohol risk with a physician, making a drinking agreement, and/or self-reporting the use of a drinking diary were associated with lower odds of at-risk drinking at follow-up. Future studies targeting at-risk drinking among older adults should consider incorporating both intervention components. Key Words: Alcohol Use, Older Adults, Physician–Patient Discussion, Drinking Diary, Drinking Agreement. PPROXIMATELY 30 to 40% of American adults ing has different risks and benefits for older adults compared A aged 65 years and over drink alcohol regularly (Blazer with younger populations (Chan et al., 2009; Cooper et al., and Wu, 2011; Kirchner et al., 2007). While heavy drinking 2009; Reid et al., 2002). Several observational studies have is less common with advancing age, light or moderate drink- found that older adults who drink moderately have better cognitive function, a reduction in cardiovascular disease, and decreased mortality compared with nondrinkers (Byles et al., From the Division of General Internal Medicine & Health Services 2006; Karlamangla et al., 2009; Lang et al., 2007a,b; Reid Research (OKD, HX, MM, AA, LT, C-HT, SLE), Department of Med- et al., 2006; Townsend et al., 2009). Conversely, age-related icine, David Geffen School of Medicine at University of California, Los physiologic changes in older adults elevate blood alcohol lev- Angeles, Los Angeles, California; Division of Geriatrics (AAM), Depart- els per amount of alcohol consumed and increase brain sensi- ment of Medicine, University of California, Los Angeles, Los Angeles, tivity to the effects of alcohol, thereby increasing the California; Ahava Center for Spiritual Living (LT), Lexington, Ken- tucky; and Fielding School of Public Health (SLE), University of Cali- potential risk of injury (Gilbertson et al., 2009; Vestal et al., fornia, Los Angeles, California. 1977). Compared with younger persons, older adults also Received for publication July 8, 2014; accepted April 14, 2015. have more comorbid conditions and use more medications, Reprint requests: Obidiugwu K. Duru, MD, MSHS, Associate Profes- including those that may increase risks with alcohol (e.g., sor of Medicine, David Geffen School of Medicine at University of Cali- nonsteroidal anti-inflammatories and warfarin) (Moore fornia, Los Angeles, 10940 Wilshire Blvd., Suite 700, Los Angeles, CA 90024; Tel.: 310-794-8138; Fax: 310-794-0723; E-mail: kduru@mednet. et al., 2007). Current practice guidelines recommend that ucla.edu adults be asked about their alcohol consumption as part of routine examinations as well as prior to prescribing medica- Copyright © 2015 by the Research Society on Alcoholism. tions that interact with alcohol (U.S. Department of Health DOI: 10.1111/acer.12754 & Human Services National Institute of Health National Alcohol Clin Exp Res, Vol 39, No 7, 2015: pp 1227–1235 1227 1228 DURU ET AL. Institute on Alcohol Abuse and Alcoholism, 2007). However, component. We further hypothesized that patients who par- physicians infrequently screen their existing patients for alco- ticipated in the HE component, specifically those who (i) hol use and misuse, because they have limited time or because received a call from the HE but did not keep a drinking diary they simply may not remember to do so (Aira et al., 2003; or make a drinking agreement, (ii) either made an agreement Friedmann et al., 2000; Johansson et al., 2005; McCormick or self-reported that they kept a diary, and (iii) both made an et al., 2006). As a result, there has been significant interest in agreement and self-reported that they kept a diary, would developing effective interventions to reduce at-risk drinking have lower odds of being classified as at-risk drinkers at 6 in this population, and several intervention protocols have and at 12 months of follow-up, as compared to patients who been implemented with varying degrees of success (Fink did not participate at all in the HE intervention component. et al., 2005; Jonas et al., 2012; Lin et al., 2010a,b; Moore et al., 2011; Saitz et al., 2003; Whitlock et al., 2004). While the evidence suggests that multicomponent inter- MATERIALS AND METHODS ventions for at-risk adult drinkers are more successful than Study Design/Setting single brief interventions in reducing risky alcohol use (Jonas The Project SHARE study population was drawn from primary et al., 2012; Whitlock et al., 2004), there is significant hetero- care physicians, and their patients aged 60 years and over at San- geneity in how these interventions have been designed. These sum Clinic, a community-based group practice with 7 clinics in and interventions typically involve between 2 and 4 contacts with near Santa Barbara, California. The Project SHARE study was approved by the Institutional Review Board of the University of the patient over a period of several months and often com- California, Los Angeles. bine several different components such as personalized coun- seling, drinking diaries to quantify alcohol consumption, and Sample—Primary Care Providers and Their Patients goal setting to reduce drinking to less harmful levels. How- ever, some of these interventions are delivered entirely by pri- All 43 Sansum Clinic physicians were approached about the study, and 31 (72%) agreed to participate. As shown in Fig. 1, San- mary care physicians, while others include nonphysicians, sum Clinic staff then identified patients (n = 12,573) of these 31 phy- typically nurses or health educators (HEs). Some are limited sicians who were aged 60 years and older. From these lists, to face-to-face patient contacts, while others include tele- providers indicated which patients should be excluded due to severe phone calls. These reports do not frequently describe cognitive impairment, terminal illness, whether they were known to whether specific, individual components of these interven- be moving out of the area within the next year, or inability to speak and understand English. Of the remaining patients not excluded by tions are each linked to reductions in at-risk drinking. Distin- the physicians, 9,476 were mailed recruitment letters and 6,919 guishing whether different intervention components (e.g., (73%) agreed to participate. They were then screened by telephone patient–physician discussions, keeping a drinking diary, etc.) to verify the self-reported absence of these same exclusion criteria are linked to reductions in at-risk drinking may help to iden- and to confirm that they were current drinkers (consumed at least 1 tify the essential intervention components for future efforts drink in the prior 3 months). Potentially eligible patients then completed a written survey to translate clinical trials into practice. including demographic and clinical information as well as the We recently conducted a large cluster-randomized clinical CARET. The CARET, an updated and revised version of the Alco- trial, designed to evaluate the effectiveness of a multicompo- hol-Related Problems Survey (Fink et al., 2002; Moore et al., 2011), nent intervention designed to reduce at-risk drinking among identifies older adults at risk for harm from their alcohol consump- older adults, and defined by scores on the Comorbidity Alco- tion based on their responses to a set of questions about their clinical status, medication use, symptoms consistent with increased risk, and hol Risk Evaluation Tool (CARET) (Moore et al., 2011). drinking habits (see the Appendix). Patients who completed the Project SHARE (Senior Health and Alcohol Risk Education) baseline survey and were classified as at-risk drinkers (n = 1,186) by found a statistically significant decrease in at-risk drinking the CARET were included in the Project SHARE intervention study among older adults at 12-month follow-up (Ettner et al., and were randomized at the level of the primary care physician into 2014).