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Open Access

Peer-reviewed

Research Article

A systematic review of self-report measures used in epidemiological studies to assess alcohol consumption among older adults

  • Kjerstin Tevik ,

    Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    kjerstin.e.tevik@ntnu.no

    Affiliations Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway

    ⨯
  • Sverre Bergh,

    Roles Methodology, Writing – original draft, Writing – review & editing

    Affiliations Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway, Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway

    ⨯
  • Geir Selbæk,

    Roles Methodology, Writing – original draft, Writing – review & editing

    Affiliations Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway

    ⨯
  • Aud Johannessen,

    Roles Methodology, Writing – original draft, Writing – review & editing

    Affiliations Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway, Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Vestfold, Norway

    ⨯
  • Anne-S. Helvik

    Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    Affiliations Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway

    ⨯

Abstract

Background

There is a lack of standardization regarding how to assess and categorize alcohol intake in older adults. The aim of this study was to systematically review methods used in epidemiological studies to define drinking patterns and measure alcohol consumption among older adults.

Methods

A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, EMBASE, and CINAHL databases for studies published from January 2009 to April 2021. Studies were included if they were observational studies with a quantitative design; the mean age of the participants was ≥ 65 years; questionnaires, screening tools, or diagnostic tools were used to define alcohol consumption; and alcohol consumption was self-reported.

Results

Of 492 studies considered, 105 were included. Among the 105 studies, we detected 19 different drinking patterns, and each drinking pattern had a wide range of definitions. The drinking patterns abstaining from alcohol, current drinking, and risk drinking had seven, 12 and 21 diverse definitions, respectively. The most used questionnaire and screening tools were the quantity-frequency questionnaire, with a recall period of 12 months, and the full and short versions of the Alcohol Use Disorders Identification Test, respectively.

Conclusion

No consensus was found regarding methods used to assess, define, and measure alcohol consumption in older adults. Identical assessments and definitions must be developed to make valid comparisons of alcohol consumption in older adults. We recommend that alcohol surveys for older adults define the following drinking patterns: lifetime abstainers, former drinkers, current drinkers, risk drinking, and heavy episodic drinking. Standardized and valid definitions of risk drinking, and heavy episodic drinking should be developed. The expanded quantity-frequency questionnaire including three questions focused on drinking frequency, drinking volume, and heavy episodic drinking, with a recall period of 12 months, could be used.

Citation: Tevik K, Bergh S, Selbæk G, Johannessen A, Helvik A-S (2021) A systematic review of self-report measures used in epidemiological studies to assess alcohol consumption among older adults. PLoS ONE 16(12): e0261292. https://doi.org/10.1371/journal.pone.0261292

Editor: Petri Böckerman, University of Jyvaskyla, FINLAND

Received: September 9, 2021; Accepted: November 29, 2021; Published: December 16, 2021

Copyright: © 2021 Tevik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In recent years, epidemiological studies on alcohol consumption in older adults have been carried out quite regularly, especially in the United States of America (USA) [1–5] and Europe [6–9]. Several studies have shown an increase in alcohol consumption and a decrease in the prevalence of abstention among older adults [10–12]. Older adults have also been found to drink more frequently than younger age groups [13, 14]. The reported prevalence of abstaining from alcohol [15, 16], current drinking [17, 18], elevated drinking [19], risk-drinking [20, 21], or heavy drinking [6, 22] among older adults varies within and between countries and between studies. Some of the variation in the findings may be due to the method used when questioning participants about alcohol consumption using different questionnaires. It may also be due to the definition used to categorize different drinking patterns. There is a lack of standardization regarding how to assess and categorize alcohol intake in older adults. The absence of standardized definitions of different drinking patterns makes it difficult to compare findings between studies [23]. In addition, there is no international standard for the number of grams of alcohol in one drink or unit of alcohol [24–26]. The USA uses the term standard drink [24], which is defined as 14 grams of alcohol [24, 27]. The United Kingdom (UK) uses the term unit of alcohol, which is defined as 8 grams of alcohol [24, 27]. This means that a unit of alcohol in the UK is equivalent to 0.564 (just over half) of a standard drink in the USA. In addition, a standard drink or unit of alcohol might be referred to as a beverage [16] or a glass of alcohol [28] in other studies. In this manuscript, we use the term “drink”, which corresponds to a standard drink in the USA and a unit of alcohol in the UK/Europe.

Compared with younger adults, older adults are more sensitive to alcohol due to reduced metabolism of alcohol and changed body composition with decreased body water and increased body fat, leading to higher blood alcohol concentration and a prolonged effect of alcohol [29–31]. Thus, lower levels of alcohol may cause more adverse health consequences in older adults than in younger adults [31]. Different levels of alcohol consumption in middle-aged and older adults have shown to increase the risk for death from coronary heart disease (alcohol intake ≥ 60 g/day in men and ≥ 20 g/day in women) [32], increase the risk of cancer (alcohol intake > 60 g/day in men and > 30 g/day in women) [33], and dementia and Alzheimer’s disease (drinking alcohol five or more times in the previous fortnight) [34].

The greater sensitivity to alcohol should affect how risk consumption is defined in older adults, but internationalized threshold values for risk consumption are not defined. However, alcohol consumption guidelines for older adults have been established in recent years in some Western countries [35]. The US guidelines developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) [36] recommend that adults over age 65 who are healthy and do not take medications should not drink more than three drinks on a given day or seven drinks in a week. Drinking above these limits for healthy older adults may cause health problems and be referred to as elevated drinking or risk drinking [36]. However, these recommendations are not internationalized. Because a high proportion of older adults have several chronic health conditions and use medication that may interact negatively in combined use with alcohol, it has been recommended that definitions of risk related to alcohol consumption in older adults include information regarding both current health status and use of medication [23, 37]. Due to the greater sensitivity to health risk of alcohol among older adults, the prevalence of binge drinking in older age is of interest [38, 39]. NIAAA defines binge drinking as consuming five or more drinks among men and four or more drinks among women in about two hours [39]. Assessment of binge drinking is relevant in alcohol surveys of older adults. Furthermore, it may be relevant to distinguish between binging (infrequent heavy) versus spacing (steady daily) drinking patterns [40], and especially among older adults drinking higher weekly volume (i.e., eight drinks or more). These opposite drinking patterns can produce the same weekly alcohol volume [40] but binge drinking may lead to higher risk of negative health consequences than steady daily drinking [41, 42]. In alcohol surveys of older adults, it may also be relevant to ask about the maximum number of drinks consumed in any day, the frequency of subjective drunkenness, drinking context, and duration of drinking occasions [25, 26, 40].

During the last decades there have been several international expert groups and meetings convened to discuss alcohol measurement and drinking patterns in the general adult population [24, 25, 40, 43, 44]. The aim of these expert groups has been to give an overview of the current knowledge on measuring frequency, quantity, and volume of drinking, and make consensus recommendations [24, 25, 40, 43, 44].

In epidemiological studies of alcohol consumption, it is recommended that participants be classified into one of three categories: lifetime abstainer, former drinker, or current drinker [24, 43, 45]. According to the World Health Organization (WHO), a lifetime abstainer can be defined as never having consumed alcohol in their life; a former drinker as not having consumed alcohol in the last 12 months but having consumed alcohol earlier; and a current drinker as drinking alcohol once a year or more [24]. Assessment of alcohol consumption in epidemiological studies can be done through personal face-to-face interviews, telephone interviews, or self-administered questionnaires [24, 43, 44]. The most commonly used methods to define drinking pattern and measure alcohol consumption are, 1) the quantity-frequency (QF) questionnaire, which includes two questions about drinking frequency and the usual number of drinks consumed on drinking days; 2) the graduated quantity-frequency (GQF) questionnaire which includes six questions about frequency of consuming various quantities of drinks; 3) the beverage-specific quantity-frequency (BSQF) questionnaire which includes 18 questions about drinking particular types of alcoholic beverages and the quantity; 4) the last seven days consumption questionnaire, which is a retrospective diary showing how much alcohol a person drank on each of the last seven days; 5) the last occasion questionnaire, which indicates the quantity of alcohol consumed on the last drinking occasion, and 6) the Yesterday method which asks questions about beverage types and sizes of drinks consumed the day before the interview [24, 26, 40, 43, 44, 46, 47].

The QF questionnaire has been widely used to measure alcohol consumption since the early 1950s [44]. The GQF and the BSQF questionnaires measure both volume of alcohol and patterns of drinking, have been used less, but have an advantage over the QF questionnaire which only measure the volume [44]. Previous studies have reported higher estimates of volume and prevalence of high-risk drinking using GQF compared to QF questionnaire and weekly drinking measures [46, 48]. A variation of the QF questionnaire (the ‘period-specific normal week’ assessment instrument) includes questions about drinking variability and asks about alcohol consumption during a normal week the last year [44]. The alcohol consumption during the week is separated between weekdays and on weekend (i.e., Friday, Saturday, and Sunday) [44]. This assessment instrument is relevant to use when exploring groups where weekend drinking may vary substantially from drinking during the week [44]. The Yesterday method may have some advantages in groups where daily drinking is common [47]. An Australian study of the general population found the Yesterday method to minimize under-reporting of overall alcohol consumption compared to the QF and GQF questionnaires, and recommended the Yesterday method as a supplement to the QF and GQF questionnaires [47].

When it comes to questions about drinking frequency, it is preferable to ask in terms of prespecified frequency range categories such as twice a day, daily, 5–6 times a week/nearly every day, 3–4 times a week, 1–2 times a week, 2–3 times a month, once a month, 6–11 times a year, and 1–5 times a year [25]. Furthermore, it is recommended to ask the question in terms of number of drinks per day and not per occasion, since a day may be a more ‘objective’ measure [25]. Continued drinking past midnight should be defined in the day [25].

According to the WHO and other expert groups, studies of alcohol consumption in general populations should contain items for measuring drinking pattern, volume of consumption, and prevalence and volume of high-risk consumption [24, 25]. The minimum required method is an expanded QF questionnaire that includes three questions asking about 1) abstention (lifetime and past 12 months) and drinking frequency, 2) usual number of drinks on drinking days, and 3) the frequency of heavy episodic drinking occasions in the last year (i.e., consuming five or more drinks [> 60 g alcohol] in a single day) [24, 25]. Including question about heavy episodic drinking can counter underestimates of alcohol consumption from the traditional QF questionnaire [40]. Volume of alcohol consumption and threshold values for risk consumption may be set by using the expanded QF, the GQF, and the BSQF questionnaire [24, 43]. In addition, in alcohol surveys, it is recommended to include some questions on alcohol-related problems, such as the screening tool Alcohol Use Disorders Identification Test (AUDIT) [24, 43]. The AUDIT, with 10 structured questions, aims to identify individuals with hazardous and harmful drinking patterns [49]. The short version of the AUDIT (AUDIT-C) consists of the three first questions of the AUDIT [50].

The length of the period for which the respondents are asked about alcohol consumption is called the recall period. The recall period may vary from the last day to lifetime and influences the responses given and the representativeness of the actual consumption [24, 26, 45]. A recall period of 12 months is recommended when using QF, GQF, or BSQF questionnaires because this recall period provides a more comprehensive picture of alcohol consumption [24, 43]. Especially when linking alcohol consumption with alcohol-related consequences, a recall period of at least 12 months is of importance [25]. Shorter recall period is more prone to miss intermittent heavy drinkers [26]. Seasonal variability will also be minimized with 12 months recall period [26].

Even though there have been several previous efforts regarding the standardization of methods to assess, define, and measure alcohol consumption in the adult general population [24, 25, 40, 43, 44], the standardization has so far almost been absent for the aged population. It is important to increase the attention around the need for standardized methodology in alcohol surveys in the aged population. Thus, the aim of this study is to systematically review methods used in epidemiological studies to define drinking patterns and measure alcohol consumption among older adults.

Material and methods

The PRISMA 2009 statement was used as a guideline for writing this review [51]. A PRISMA checklist is provided in S1 Checklist. We do not have a published protocol for this systematic review.

Search strategy and study selection

A librarian conducted a systematic, computerized search in the MEDLINE, PubMed, PsycINFO, EMBASE, and CINAHL databases for articles published from January 2009 to April 2021. The last search was performed April 13, 2021. The following terms were used for searching the databases: ‘alcohol drinking’[MeSH Terms] OR (‘alcohol’[All Fields] AND ‘drinking’[All Fields]) OR ‘alcohol drinking’[All Fields]/trends[MeSH Subheading] OR ‘alcohol drinking/epidemiology’ AND ‘Aged: 65+ years’. Articles were exported and managed using EndNote Version 20. In addition, reference lists of included studies were screened to find studies that were not detected in the systematic searches. Studies were included in the review if the following criteria were met:

  • Mean age of participants ≥ 65 years
  • Observational studies with quantitative design (longitudinal or cross-sectional)
  • Questionnaires, screening tools, or diagnostic tools used to define alcohol consumption
  • Self-reported use of alcohol consumption
  • Published in a scientific referee-based journal and written in English

Studies were excluded from the review if they were

  • Theoretical, qualitative, editorial articles or comments on studies
  • Studies conducted in the general population/sample (≥ 18 years, mean age < 65 years) with subgroup analysis of older adults
  • Intervention studies
  • Review/meta-analysis studies

Identification of relevant studies

After identification of studies through searching in bibliographic databases and examining reference lists to identify relevant publications not detected through the computerized search, each title and abstract was screened by the first and last author (KT or ASH) to determine potential eligibility. The full-text versions were obtained if it was unclear whether the study met the inclusion criteria. Any uncertainty regarding study eligibility was resolved through discussion between two authors (KT/ASH).

Data extraction

From the included studies, the first author (KT) extracted information about year of publication; year of data collection; study country; study population/sample; study design; number of participants; age and gender of participants; questionnaires, screening tools, diagnostic tools or guidelines used to define drinking pattern; recall period; definition of drinking pattern; definition of alcohol content (i.e., grams) in one drink; and measure of alcohol consumption. The present review refers to the measure used by the authors in the original articles in the tables.

Quality assessment

The quality assessment of the included studies was assessed according to nine predefined criteria (see Table 1) [52, 53] by two authors independently (KT and ASH). Disagreement was resolved by discussion between these two authors. A score of 1 was given for +, and a score of 0 was given for both −(minus) and ? (? = unclear). The sum score of the quality assessment of each study could vary between 0 and 9.

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Table 1. Criteria for assessing quality.

https://doi.org/10.1371/journal.pone.0261292.t001

An overall methodological quality percentage was calculated. Studies who scored ≥ 80% of the maximum obtainable points (≥ 8 points) were considered to have strong quality, studies with a score of 70–79% of the maximum obtainable points (7 points) were considered to have good quality, 50–69% fair quality (5 or 6 points) and < 50% poor quality (≤ 4 points) [54].

Risk of bias in individual studies

We did not assess risk of bias of individual studies as this is a systematic review regarding methods used to define, and measure alcohol consumption and not regarding interventions, prognosis, or etiology.

Ethics

Ethical approval was not required because the study used secondary data.

Results

Literature search and selection

The bibliographic database search identified 2816 articles. After duplicates were removed, 1279 studies were identified. We found 15 additional records in the reference lists of included studies that were not detected through the systematic searches. Each title and abstract of the 1294 studies were screened by two authors (KT or ASH), and the full texts of 492 studies were considered for possible inclusion. Of the 492 full-text studies considered, 105 were included. Fig 1 presents the PRISMA flow diagram [51], which gives an overview of the search strategy and detailed information about studies that were identified, screened, assessed for eligibility, and included in the review.

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Fig 1. Flow diagram depicting study identified, screened, assessed for eligibility, and included in this review [51].

https://doi.org/10.1371/journal.pone.0261292.g001

Settings and samples

The characteristics of the included studies (N = 105) are presented in one large sample (S1 Table). The sample size of individual studies ranged from 25 to 36,136,889. The mean age of the participants was from 65.0 to 87.4 years, and the age range was 18 to 105 years. Men and women were included in almost all studies, except for six that included only men [15, 55–59] and two that included only women [60, 61].

In total, 81 of 105 studies included community-dwelling participants. Eleven studies recruited participants from different health care settings such as hospitals, old-age psychiatry clinic, an adult psychiatry clinic, and public centers [18, 19, 62–70]. Three studies included both non-institutionalized and institutionalized participants [6, 71, 72], and one study included only Veteran Affairs patients [73]. The study setting and the participants were not clearly described in nine studies [1, 74–81]. In total, 42 of the studies were conducted in Europe, 28 in the USA, 10 in Australia/New Zealand, eight in Latin/South America, 14 in Asia, and one in Africa. Two studies were conducted in both Norway and China.

Design

Forty-one of the studies had a longitudinal design, and 64 had a cross-sectional design.

Quality assessment of the included studies

A description of the quality assessment of the included studies is provided in Table 2. Twenty-eight studies received ≥ 8 points indicating strong quality, 38 studies received 7 points (good quality), 36 studies received either 5 or 6 points (fair quality), and three studies received 4 points (poor quality).

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Table 2. Quality assessment of included studies.

https://doi.org/10.1371/journal.pone.0261292.t002

Assessment of alcohol consumption

Alcohol consumption was assessed using the QF questionnaire in 34 studies, the BSQF questionnaire in six studies, and the GQF questionnaire in one study (see Tables 3 and 4). Thirty-six of the studies used either screening tools, diagnostic tools, or guidelines to define different drinking patterns (Tables 3 and 4). In total, eight different screening tools were used, and the AUDIT (4 studies) and short version of the AUDIT (AUDIT-C, 9 studies) were the most used tools. A cutoff value of eight or more was used by three studies applying the AUDIT to define risk drinking [105, 133, 136]. Four of the studies using the AUDIT-C chose a cutoff of four or more in men and three or more in women for hazardous drinking [18, 84, 132] and elevated alcohol consumption [19], respectively (S1 Table). Another study using the AUDIT-C showed a sensitivity and specificity of 94% and 80%, respectively, with a cutoff value of four or more when screening for heavy drinking [50].

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Table 3. Method and measure of alcohol consumption in older adults.

https://doi.org/10.1371/journal.pone.0261292.t003

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Table 4. Methods used to define drinking pattern.

https://doi.org/10.1371/journal.pone.0261292.t004

The recall period varied from the last week to lifetime (see Table 3). Most of the studies used the last 12 months (N = 34), last month (N = 16), or last week (N = 12) as a recall period. Recall periods of three and six months were used by six studies and one study, respectively. A lifetime recall period was used by four studies. Thirty-five studies did not report the recall period. All studies used self-report to assess alcohol consumption.

A high proportion of the included studies (N = 67) used drinks, units, beverages, or glasses per day, week, or month to measure alcohol consumption (see Tables 3 and 5). In total, 39 of these studies (N = 67) defined the alcohol content in one standard drink, unit, or beverage. The definition of one standard drink, unit, or beverage varied from 8 grams of alcohol to 50 grams of alcohol. The alcohol content in one standard drink or unit was defined as 8 grams, 10 grams, and 12 grams in 6, 16, and 8 studies, respectively. In four studies, a standard drink or unit was defined as 13 and 15 grams of alcohol, respectively, while six studies defined a standard drink or unit as 14 grams of alcohol. Studies conducted in China [109] and Japan [59, 70, 111] defined a standard drink of unit as 50 grams of alcohol [109] and 20–23 grams of alcohol [59, 70, 111], respectively. Three studies used several definitions of one standard drink [59, 99, 118], whereas two studies defined the alcohol content in one drink in ounces [60, 88]. Twenty-eight studies (N = 28) used grams of alcohol per day or week as a measure.

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Table 5. Different measures of alcohol consumption.

https://doi.org/10.1371/journal.pone.0261292.t005

In total, 19 different drinking patterns were detected, which ranged from abstaining to alcohol abuse (see Table 6). Each drinking pattern had diverse definitions. The drinking patterns abstaining from alcohol, current drinking, risk drinking, and heavy drinking had, for example, seven, 12, 21, and 25 diverse definitions, respectively (Table 6). The definitions of abstaining from alcohol ranged from not drinking alcohol at all in their entire life to drinking less than one unit a week. Twenty-three studies separated abstainers from former drinkers when defining abstainers. Current drinkers were defined as drinking alcohol in the last 12 months to consuming ≥ 60 grams of alcohol per day. The definition of risk drinking ranged from drinking eight or more drinks per week for both women and men to drinking 35 and 50 drinks per week for women and men, respectively. Table 6 describes the range of definitions for other drinking patterns. Twenty-one studies defined heavy episodic drinking/binge drinking, and the most used definition was drinking five or more drinks on any occasion within the past 30 days.

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Table 6. Definitions of different pattern of alcohol consumption.

https://doi.org/10.1371/journal.pone.0261292.t006

Discussion

This systematic review has reviewed different ways of asking about alcohol consumption in older adults to define and measure alcohol consumption and drinking patterns in epidemiological studies. No consensus was found regarding methods used to assess, define, and measure alcohol consumption in older adults. Among the 105 studies included, we detected 19 different drinking patterns, and each drinking pattern had a wide range of definitions. The drinking patterns abstaining from alcohol, current drinking, and risk drinking had seven, 12, and 21 diverse definitions, respectively. The most used questionnaire and screening tools were the QF questionnaire, with a recall period of 12 months, and the AUDIT/AUDIT-C, respectively. The volume of alcohol intake was more frequently presented in standard drinks than in grams, and the definition of one standard drink varied from 8 grams of alcohol to 50 grams of alcohol.

Definition of drinking patterns

Abstainers and drinkers.

In alcohol surveys, it is important to ask about drinking frequency to identify those who are abstainers and drinkers [43]. This review detected seven and 12 different definitions of abstainers and current drinkers, respectively. The wide variation in definitions will have a significant impact on how these drinking patterns are classified [45]. When the definitions are not identical, we are not able to make a valid comparison between studies of the prevalence of abstainers and current drinkers in older adults.

Twenty-three of the included studies separated abstainers from former drinkers when defining abstainers. It is recommended that individuals in alcohol studies be divided into lifetime abstainers, former drinkers, and current drinkers [24, 43]. This is especially important in studies investigating the health consequences of alcohol consumption. If former drinkers are included in the abstaining category, the health benefits of light-to-moderate drinking may be exaggerated [45]. Former drinkers might have quit drinking due to health problems [45, 141], and if they are included in the abstainer category, it may not be the absence of alcohol that elevates their risk for negative health consequences, but rather their poor health [141]. The definitions provided by the WHO [24] for lifetime abstainers (never having consumed alcohol in their life), former drinkers (not having consumed alcohol in the last 12 months, but having consumed alcohol earlier), and current drinkers (consuming alcohol once a year or more) could be used in alcohol surveys conducted in samples of older adults.

Risk drinkers.

This review detected 21 different definitions of risk drinking among older adults. However, a commonly used definition was drinking above seven drinks a week, which is in line with the US alcohol guidelines for older adults developed by the NIAAA [36]. Even so, to our knowledge, this definition has not been validated in a sample of older adults.

The WHO has suggested an international threshold value for high-risk drinking as greater than 60 grams of alcohol (equivalent to 4.3 standard drinks in the USA) on any given day for men and greater than 40 grams of alcohol (equivalent to 2.9 standard drinks in the USA) for women [24]. These values are estimated for the general population, and not for the older population, who might experience negative health consequences at lower alcohol consumption than younger adults due to alcohol-related physiological changes [31].

An international threshold value for risk drinking has not been set for the older population, but it is highly warranted. A risk-drinking definition for older adults should be developed and validated in epidemiologic observation studies among older adults. In addition, whether a risk definition for older adults should include questions about both health condition and use of medications should be considered. Several authors have recommended that a risk definition for older adults should account for both current health status and use of medication [23, 37, 142].

Heavy episodic drinking.

Of the 21 studies including a definition of heavy episodic drinking/binge drinking in their assessment of alcohol consumption, the most used definition was consuming five or more drinks of alcohol on any occasion within the past 30 days. It is highly recommended to assess heavy episodic drinking [24], but there is little agreement on how heavy episodic drinking should be defined for older adults. For example, “is drinking on any occasion” the best wording? Others have pointed out that “occasion” is difficult to understand, and the definition could rather use drinks within “one day” to increase precision and comprehensibility [25, 43]. Furthermore, it is important to develop a standardized definition including the number of drinks needed to define heavy episodic drinking for older adults, especially because tolerance is reduced in older adults [29–31].

Assessment of alcohol consumption

Questionnaires.

Most (N = 34) of the studies used the QF questionnaire to assess alcohol consumption. This questionnaire is commonly used in assessment of alcohol consumption [44, 143], but has been criticized for underestimating alcohol consumption compared with the GQF questionnaire [46, 143, 144]. Assessing alcohol consumption only with the use of the QF questionnaire, could lead to heavy episodic drinkers not being identified [46, 145]. A previous study by Rehm et al. [46] has also shown that the GQF questionnaire was superior to QF questionnaire and weekly diary in capturing risky and harmful drinking volumes. Thus, the WHO recommends that with the use of the QF questionnaire, a question about heavy episodic drinking should be included when estimating the volume of alcohol consumption and the proportion of risk drinking. As already mentioned in the introduction, this questionnaire is called the expanded QF questionnaire [24]. Only two studies in this review followed the WHO’s recommendation when using the QF questionnaire [57, 58]; thus, there is room for improvement in studies using the QF questionnaire to assess alcohol consumption in older adults.

In the present study, we found that few studies used the GQF (N = 1) and BSQF (N = 6) questionnaires. With the GQF questionnaire, the proportion of older adults engaging in risk consumption can be estimated without any additional questions [24], and the GQF is recommended by the WHO and other expert groups for use in the general population [24, 40]. As the GQF (six questions) and the BSQF (18 questions) questionnaires include more questions than the expanded QF (three questions) questionnaire, it will be more time consuming for older adults to respond to all questions in the GQF and the BSQF questionnaires. In addition, older adults might find it difficult to answer the questions included in the GQF and BSQF, such as frequencies of consuming various quantities of drinks and drinking particular types of beverages. Thus, the response rate might be lower with the use of the GQF and BSQF questionnaires than with the expanded QF questionnaire. The results will be systematically biased if older adults do not respond to difficult questions regarding alcohol intake, or if they answer them in a systematically biased way [146]. A review has examined how aging affects self-report questionnaires in general [146], and the authors found that the completeness of self-report questionnaires among older adults decreased with increasing difficulty of questions. To ensure higher response rate and accuracy in alcohol surveys in older adults, the best approach might be to use the expanded QF questionnaire.

Moreover, underestimation of alcohol consumption, especially among heavy drinkers, is well known [147] and will influence the validity of the results. In addition, older adults who do not drink alcohol at all or who do so at very low levels, might not answer the questions about alcohol consumption, as they might consider the questions to be irrelevant. Older adults might not answer alcohol questions due to stigma associated with drinking [148, 149], and answers to alcohol questions by older adults are prone to recall bias due to cognitive impairment and memory errors [150–152]. Thus, the validity of the results might increase with a face-to-face interview when using the QF, GQF, or BSQF questionnaire, where the interviewer can help the participants to complete the questions and to recall the number of alcohol drinks consumed. The use of pictures of standard drinks might be valuable in this context [24, 26]. A face-to-face interview is also recommended in the general population [43]. However, in large population-based studies, face-to-face interviews might not be feasible as they are more time consuming and costly than self-administered questionnaires [153].

Screening tools.

In total, eight different screening tools were used to assess alcohol consumption, the most common of which were the AUDIT and AUDIT-C. A cutoff value of eight or more was used by several studies included in this review [105, 133, 136]. A meta-analysis [154] has also shown that there is strong evidence for the diagnostic accuracy of the AUDIT with a cutoff value of eight or more in elderly patients [154]. However, the WHO [49] recommends a cutoff value of seven or more for women and men 65 years or older which will increase the sensitivity for this population [49]. The short version of the AUDIT (AUDIT-C) might have an optimal cutoff value of four or more, as one of the included studies showed high sensitivity and specificity with the use of this cutoff value when screening for heavy drinking [50].

In alcohol surveys including older adults, the AUDIT or AUDIT-C work well and are recommended [49, 50]. However, the screening tool CARET (Comorbidity Alcohol Risk Evaluation), which includes both health condition and use of medication when assessing alcohol risk, could also be relevant to use in an elderly sample [83, 132].

Guidelines

Several of the included studies (N = 11) used alcohol guidelines to assess and define the drinking pattern of older adults. However, alcohol guidelines are not internationally standardized [35]. Some of the studies used guidelines for the general population [20], whereas other used guidelines for older adults [126]. Because a drink of alcohol is not standardized, it might also be difficult to standardize alcohol guidelines for older adults.

Recall period

Several studies (N = 34) included in this review used a recall period of the last 12 months, which is in line with the WHO’s recommendation [24]. It is suggested that a recall period of the last 12 months will give the most valid assessment of alcohol consumption [24, 26, 43]. However, 28 studies used a recall period of the last month or last week. A shorter recall period minimizes problems of memory loss [45], which is important when studying alcohol consumption in older adults. Older adults might find it difficult to recall their alcohol consumption in the last 12 months [43], and a shorter recall period could yield a more reliable assessment of alcohol consumption [24]. However, a recall period of the last week or last month might not represent older adults’ typical drinking pattern in the last year, as older adults might be irregular drinkers and might not have been drinking during the last month [43]. Consequently, older adults with an infrequent drinking pattern might be misclassified as abstainers with the use of a short recall period [44, 45]. Infrequent heavy episodic drinkers could also be wrongly classified with the use of a short recall period [24]. Moreover, in studies assessing alcohol-related problems, it is particularly important to use a long recall period, as alcohol-related problems only can be measured with sufficient precision over a period of at least one year [25, 45]. Thus, a recall period of the last 12 months seems desirable in studies assessing alcohol consumption in older adults.

However, an unexpected high number of the included studies (N = 35) did not report the recall period at all. Missing information regarding the recall period will complicate the interpretation of the importance of alcohol consumption for health and well-being in older adults.

Measure of alcohol consumption

Most of the studies (N = 67) reported the total volume of alcohol consumption in standard drinks, units, or glasses, whereas 27 studies reported the volume of alcohol consumption in grams. Presenting the volume in grams might be difficult for the reader to interpret, whereas presenting the results in drinks could be problematic, as drinkers frequently do not consume standard drinks. In addition, many are not familiar with the concept of standard drinks, which makes it difficult to estimate the number of consumed drinks [24, 25, 27]. Participants are likely to report drink sizes they actually consume which differ from the size of standard drinks [26]. Thus, as already mentioned, pictures of a standard drink of beer, wine, or liquor could be helpful for older adults when estimating how much they have been drinking [24, 26]. This method was used by Nuevo and colleagues [118], who examined older adults’ drinking patterns in 14 European countries. The interviewers showed the participants a card with pictures representing one drink of alcohol according to the standard for each country [118].

In this systematic review, the definition of one standard drink varied from 8 grams of alcohol to 50 grams of alcohol. Thus, using the term drinks in alcohol surveys will complicate international comparisons [24]. The question has been raised of whether an international universal standard of drinks should be established [24]. In the meantime, the WHO suggests that alcohol consumption should be reported in grams of alcohol for the sake of international comparison [24].

Strengths and limitations

The strengths of our review include the use of five widely recognized bibliographic databases: MEDLINE, PubMed, CINAHL, PsycINFO, and EMBASE.

One limitation of this review is the exclusion of studies published in a language other than English and older studies published before 2009. Thus, there could be studies written in other languages and older studies that used other definitions that are not reported in this review. Even so, this review detected a wide range of definitions of different drinking patterns.

In alcohol surveys, it is recommended to ask about the drinking context, which focuses on drinking with meals or not, drinking alone or not (e.g., with family members, friends, work colleagues, etc.), drinking on a weekday or on a weekend, and drinking in public (bars and restaurants) or at home [24, 25, 43]. The drinking context seems to be an important factor explaining alcohol consumption and the risk of alcohol consumption [43]. However, in this systematic review, we did not assess drinking context in the included studies. It is desirable that coming studies ask about drinking context when assessing alcohol consumption in older adults [24, 43].

Implications

We want to acknowledge the previous expert groups and alcohol epidemiologists for their effort to standardize the alcohol methodology in adult general population surveys [24, 25, 40, 43, 44]. However, it seems thus far that they have failed to fully achieve a standardization, and especially for the subgroup of the aged population. Different aims, traditions, and simple research group preferences may have resulted in the variety of measures and definitions found in this systematic review. Future research should work toward establishing a standardized assessment and definition of drinking patterns in older adults, especially risk drinking and heavy episodic drinking. Methodological studies are needed to study the reliability and validity of different assessment instrument and definitions [46]. Standardized assessments and definitions will contribute to improving the comparison of findings between studies and countries and to drawing firm conclusions about the prevalence and health effect of different drinking patterns. Use of a standardized and concise methodology in alcohol surveys of older adults could also lead to more informed and evidence-based policymaking to reduce alcohol’s burden on health and economy [43].

Conclusions

Several previous expert groups and alcohol epidemiologists have had an aim of standardizing the alcohol methodology in adult general population surveys. However, so far it seems that they have failed to fully achieve a standardization, and especially in the subgroup of the aged population. This systematic review shows that the included studies (N = 105) varied widely in the questionnaire applied, definitions, and measures to define drinking patterns in older adults. Different aims, traditions, and simple research group preferences may have resulted in the variety of measures and definitions found in this systematic review. Identical assessments and definitions need to be developed and used to make valid comparisons of alcohol consumption in older adults. In total, we detected 19 different drinking patterns, and each drinking pattern had a wide range of definitions. We recommend that alcohol surveys in older adults define the following drinking patterns: lifetime abstainers, former drinkers, current drinkers, risk drinking, and heavy episodic drinking. The definitions used by the WHO for lifetime abstainers, former drinkers, and current drinkers are recommended to be used for older adults. Standardized and valid definitions of risk drinking and heavy episodic drinking should be developed. The expanded QF questionnaire including three questions with a focus on drinking frequency, drinking volume, and heavy episodic drinking, with a recall period of 12 months, could be used.

Supporting information

S1 Checklist. PRISMA 2009 checklist.

https://doi.org/10.1371/journal.pone.0261292.s001

(DOC)

S1 Table. Self-report measures used in epidemiological studies to assess alcohol consumption among older adults.

https://doi.org/10.1371/journal.pone.0261292.s002

(DOCX)

Acknowledgments

We would like to acknowledge Vigdis Knutsen, the librarian at the Norwegian National Advisory Unit on Ageing and Health, who developed and executed the search strategy.

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