Introduction
Older adults are the fastest-growing age group in Canada, comprising 16.9 per cent of the population in 2016 (Statistics Canada, 2017), and the majority of older adults drink alcohol. Based on 2015 Canadian Tobacco, Alcohol and Drugs Survey data (which exclude residents of the Yukon, Northwest Territories, and Nunavut), 66.2 per cent of adults aged 65 and older self-reported past-year alcohol use (70.4% of males and 62.7% of females) (Canadian Centre on Substance Use and Addiction and Canadian Centre on Substance Abuse, 2017). Moreover, although the prevalence of alcohol use disorders among middle-aged and older adults who drink is generally low (Blazer & Wu, Reference Blazer and Wu2009), evidence suggests that use of alcohol among older adults is increasing (Adlaf, Begin, & Sawka, Reference Adlaf, Begin and Sawka2005; Grant et al., Reference Grant, Chou, Saha, Pickering, Kerridge, Ruan and Hasin2017).
Utilizing a biopsychosocial framework, a number of challenges associated with alcohol use in later life can be understood as age-related physiological and psychosocial changes that put older adults at risk for negative outcomes. Physiologically, as a result of decreased body water and reduced alcohol metabolism, older adults are more sensitive to the effects of alcohol (Barnes et al., Reference Barnes, Moore, Xu, Ang, Tallen, Mirkin and Ettner2010; Substance Abuse and Mental Health Services Administration, 1998). As well, alcohol use may lead to complications for older adults who use multiple medications or live with co-morbid health conditions (Barnes et al., Reference Barnes, Moore, Xu, Ang, Tallen, Mirkin and Ettner2010; Substance Abuse and Mental Health Services Administration, 1998).
In addition to the physiological risk factors unique to older adults, there are psychosocial risk factors that contribute to increased drinking in later life including recent widowhood (Perreira & Sloan, Reference Perreira and Sloan2001) and having discretionary income (Brennan, Schutte, & Moos, Reference Brennan, Schutte and Moos1999), as well as involuntary retirement and expanded social networks in retirement (Kuerbis & Sacco, Reference Kuerbis and Sacco2012). Despite the increased risk for adverse outcomes from alcohol consumption in later life, alcohol use is common, both in social settings (Alexander & Duff, Reference Alexander and Duff1988; Liu et al., Reference Liu, Woodrow, Loucks-Atkinson, Buehler, West and Wang2013) and while alone (Schonfeld & Dupree, Reference Schonfeld and Dupree1991). Accordingly, the preexisting research demonstrates mixed findings on whether older adults’ loneliness is associated with reports of less frequent drinking (Canham, Mauro, Kaufmann, & Sixsmith, Reference Canham, Mauro, Kuerbis, Moore, Sacco and Zanjani2016) or more frequent drinking (Åkerlind & Hörnquist, Reference Åkerlind and Hörnquist1992).
Other considerations unique to older adults’ alcohol use revolve around how patterns of alcohol use change over the life course. Using longitudinal data to examine life course trajectories, Britton, Ben-Shlomo, Benzeval, Kuh, and Bell (Reference Britton, Ben-Shlomo, Benzeval, Kuh and Bell2015) have suggested that the quantity of alcohol consumed by both men and women is highest in one’s mid-20s, levels off in mid-life, and declines beginning around age 60. However, older adults, particularly men, may increase their frequency of use (daily or most days of the week) over time (Britton et al., Reference Britton, Ben-Shlomo, Benzeval, Kuh and Bell2015). Some variation across socio-demographic groups has been found as older men and women with higher wealth and education level consume alcohol in higher quantities and more frequently, whereas poor self-rated health is associated with declines in consumption frequency over time (Holdsworth et al., Reference Holdsworth, Frisher, Mendonca, De Oliveiria, Pikhart and Shelton2017).
Despite several decades of epidemiological scholarship on alcohol and older adults, limited research has explored nuanced perceptions of alcohol use among older adults themselves. In addition, experiences of and attitudes toward alcohol use evolve as new cohorts of older adults enter late life. Most of what we currently know about the experiences and perceptions of alcohol use among older adults is based on research with previous generations of older adults (Duncan, Nicholson, White, Bradley, & Bonaguro, Reference Duncan, Nicholson, White, Bradley and Bonaguro2010; Sorocco & Ferrell, Reference Sorocco and Ferrell2006). Over the past decade, as social attitudes have become more accepting of alcohol use, health promotion efforts have simultaneously highlighted the importance of low-risk consumption (Butt et al., Reference Butt, White-Campbell, Canham, Dowsett Johnston, Indome, Purcell and Van Bussel2020; Butt, Beirness, Gliksman, Paradis, & Stockwell, Reference Butt, Beirness, Gliksman, Paradis and Stockwell2011) and older adults’ opinions and decisions about how and when to use alcohol have likely shifted as well. To update our understandings of older adults’ experiences and perceptions of alcohol use, we initiated a community-based research project to explore older adults’ perspectives. Our guiding research questions were: What are older adults’ opinions about and experiences of using alcohol? And, how has this changed for older adults over time?
Methods
During October and November 2018, we held three dialogue workshops, designed as Knowledge Cafés, in three senior centres in Vancouver, BC. We chose Knowledge Café methodology because it uses a participatory method to bring together a diverse group of people to engage in an open, creative dialogue on a topic of mutual interest to exchange knowledge, share ideas and insights, and gain a deeper understanding of a topic and related issues (Brown, Homer, & Isaacs, Reference Brown, Homer, Isaacs, Holman, Devane and Cady2009). Senior centres were ideal locations to host the workshops as there was an intention to foster open and relaxed dialogue in a community space that could emulate a casual, comfortable setting with a café-like ambience and refreshments (Brown et al., Reference Brown, Homer, Isaacs, Holman, Devane and Cady2009).
Upon arrival to the workshop, participants sat at a self-selected table; present at each table was a member of the research team who facilitated that table’s discussion. The number of tables at each workshop varied (between three and four), depending on the number of participants who were in attendance. Each table was decorated with a different colour tablecloth (red, blue, green, or yellow), which assisted with the organization of collected data.
Participants
Older adults and senior-serving health and social service providers were recruited to participate in the workshops. Newsletter ads and posters detailing how to register for the workshops were disseminated to members and clients of each senior centre; senior centre program coordinators also promoted the workshops through word of mouth and social media. Additionally, the research team sent recruitment emails to an extensive network of individuals in health and social service sectors (e.g., senior housing and services providers, professionals in health authorities and home care), as well as the public sector (e.g., libraries).
In total, 66 older adults and service providers participated in one of the three workshops. Based on a brief four-question survey (see Table 1) of all participants, the majority self-identified as an older adult (n = 60; 91%), female (n = 50; 76%), and Caucasian (n = 34; 52%). The age range of participants was 51–86 years old (M = 70 years). All participants provided written informed consent and permission to be audio recorded; and all participants were provided a $25 cash honorarium. Ethics approval was obtained from a University Institutional Review Board, and participant names have been removed to protect identities.
Knowledge Café workshop participants
a Participants who indicated their race/ethnicity to be of European descent were categorized as Caucasian, and those who self-identified as Asian, Filipino, Persian, Egyptian, Indonesian, and South Asian were categorized as Asian.
Data Collection
During the 3.5-hour workshop, a lead researcher (first author) took on the role of “Café Host” and provided a brief presentation to participants outlining the goals of the workshop and highlighting the importance of engaging in respectful and open-minded discussions. The presentation was made as a way to set the stage for the workshop, explain the informed consent process, and outline proposed older adult-specific recommendations for alcohol use. Minimal information about alcohol was presented so as to not bias participants’ reports. Following the introduction presentation, table facilitators led four rounds of small group discussion using a semi-structured interview guide that was developed based on existing literature and goals of the dialogue sessions (supplementary Appendix A, available online). Example questions included: What is your opinion on using alcohol? Have your opinions changed over time? How has your personal use of and experiences with alcohol changed with age? Participants were prompted to provide experiential evidence about alcohol use, and discussions were captured by audio recorders (as well as by facilitator notes) at each table. In order to minimize participant fatigue from engagement in a 3.5-hour workshop, a refreshment break was scheduled after the first hour and lunch was served after the second hour. Participants were also encouraged to move around or take breaks as needed throughout the workshop.
Data Analysis
Data were inductively analysed using five phases of thematic analysis (Braun & Clarke, Reference Braun and Clarke2006) and organized with the data management support of NVivo software. Through inductive analyses, our goal was to allow themes to emerge from the data independent of the research teams’ preconceived ideas or areas of interest (Braun & Clarke, Reference Braun and Clarke2006). In Phase 1, two researchers became familiar with the data by independently reading and re-reading transcripts. Next, the two researchers collaborated to generate an initial set of codes based on descriptive coding of text with words that closely related to the text (Boyatzis, Reference Boyatzis1998). Both researchers then discussed this initial code list and examined patterns of meaning in the data. In Phase 3, the two researchers used an iterative process to label all data within each theme at the “sematic level”, which Boyatzis (Reference Boyatzis1998) described as identifying themes based on explicit meanings in the data. In this process, we re-arranged and re-organized the initial code list to align with feedback from the project team. In Phase 4, the two researchers engaged in a second review of the coding structure and emergent themes for further refinement and organization by removing, separating, and collapsing themes. Finally, in Phase 5, two additional researchers agreed upon a final set of defined and named themes.
Findings
We organized data into three broad categories: (a) reasons older adults use alcohol; (b) personal experiences of alcohol use; and (c) older adults’ perceptions of alcohol use outcomes.
1. Reasons Older Adults Use Alcohol
Participants described a range of reasons why older adults consume alcohol. Familial upbringing and culture were identified as influential on the frequency and quantity of alcohol consumed, whereas for other older adults, drinking is a habitual part of their day, or social expectations and peer pressure lead to alcohol use. Finally, social isolation, loneliness, and the desire to self-medicate with alcohol were also identified by participants as reasons that older adults use alcohol.
Cultural and Familial Influences on Alcohol Use. Participants highlighted the influence of different cultures and one’s family teachings on the acceptability of alcohol use. These sociocultural influences were reported to influence one’s drinking behaviours. For instance, one female participant (Red table, Workshop 3 [W3]) stated, “I’m from a family where alcohol was available … We weren’t encouraged, but we could have a little taste of the beer when we were kids and so it was just a part of our life.” In comparison, another female participant (Blue table, W1) said, “I grew up in the United Church. I grew up in a family that didn’t drink, actually. But when I was 12 years old I signed a pledge that I would never drink in my life! Which was terrible.” Similarly, participants reported on the influence of Muslim culture and teachings on alcohol use.
I was brought up in a society where there’s no drinking, at all … I am Muslim, and [in] the Muslim religion you don’t drink. You’re not allowed to drink at all. And there is no social events like here [in Canada] that promote drinking. – male participant (Yellow table, W3)
When compared to participants raised in families where religious practices discouraged alcohol use, some participants from European countries reflected on the normative consumption of alcohol in their family.
It becomes, perhaps, a cultural thing. I’m originally from Denmark, and I’m now close to 80. Ever since I was a little boy … we have had either beer or wine at the table, and I have had it in small amounts even as a child. – male participant (Green table, W3)
Participants considered Canadian culture to be particularly accepting of alcohol use, as alcohol is readily available, including in grocery stores in some provinces. Advertisements of alcohol use were considered influential in promoting social acceptance of alcohol. As one female participant (Yellow table, W1) observed, “If you look at the advertising for alcohol, at least in Canada, they show: It’s wonderful, it’s just wonderful to be a drinker.”
A challenge reported to stem from acceptance of alcohol use in some families is the denial of harmful drinking patterns and the inability for some family members to intervene. As one female participant (Blue table, W1) noted,
My cousin died … only a few months ago. I come from a family, a family history, one side of my family, that they’re drinkers. But they’re totally in denial … Sometimes it’s difficult … It’s like the elephant-in-the-room thing where they’ll actually protect that pattern where they enabled him to drink … and all his friends drank … And so, there’s no one there really to tell him to put on the brakes because they’re with their drinking buddies. And if they’re not with their drinking buddies they don’t even have a social life … People do not want intervention.
Alcohol Use Is a Habitual Part of One’s Day. Participants described alcohol use as part of the everyday lived experience of older adults – a feature that has become ritualized for some.
I do have a drink pretty well every day. And recently I’ve been feeling, well, maybe I should really try not to do that. It’s just, like, my ritual. But I’m pretty healthy and I don’t have any problems, so I think I’m OK. – female participant (Blue table, W2)
It was suggested that the everyday use of alcohol is something that participants developed a habit of in their younger years. As one male participant (Red table, W1) stated, “People drinking alcohol, when they are young they like to drink, then when they get older they drink the same [as before].” Similarly, a female participant (Yellow table, W3) commented, “I think it started as a habit, because we came home from work and we had a drink while we’re getting dinner, and it’s a nice habit. I still do it. I have a drink every day.”
Participants recognized that with too much regular, habitual use, tolerance to alcohol could develop, which could lead to alcohol dependence.
People that drink regular – whether it’s 5 days a week or 7 days a week – they build up a tolerance to that alcohol. So, one drink isn’t going to be the same as it was if you just had one drink a week. So now you’re going to have to kick it up to two drinks a week or three drinks a week, right? Because of the tolerance. – male participant (Red table, W2)
Social Experiences and Pressure to Consume Alcohol in Later Life. Participants discussed a variety of opinions about and experiences surrounding external expectations to consume alcohol. Drinking was reported to commonly occur when older adults were with friends and family for dinner or out at a pub or restaurant; during special occasions or gatherings, such as birthdays, weddings, and holidays or when singing karaoke or dancing; and, finally, some participants reported regularly drinking at home alone. There was wide variation between participants, however, as some reported no longer going out to bars or seldom going to parties, while others reported that it has been years since they drank alcohol at home and they only drink in social settings. One male participant (Blue table, W2) reported feeling different effects from alcohol depending on the setting: “I find I have a glass of wine at home and there’s absolutely no effect, whereas when I go to a party and somebody has a bottle of wine from the liquor store, that has a different effect.”
Participants reported that at social gatherings where alcohol is served, it is generally expected that one will drink. A female participant (Yellow table, W1) said:
I think social pressure, also. You go to social events, whatever that social event may be, and it’s like “Oh, here, have a drink, have a drink.” And, it’s like, “No, I don’t want to have a drink.” Like, somehow you have to participate.
This social pressure to drink was reported to be a motivating factor in drinking alcohol for one female participant (Red table, W3): “Peer pressure, absolutely, I’ve learned not to give in to it. Peer pressure is always there, ‘Oh, just have – one isn’t good enough, come on, take it.’”
Participants also reported feeling stigmatized when they choose not to drink. One female participant (Blue table, W1) declared:
I wish I could drink. I would like to be a drinker. I think there’s more of a stigma not to drink than there is to drink. People say, “What’s wrong with you?” I find it difficult if people are having a glass of wine because I don’t drink … They might assume that I’ve been a big drinker and now I’m not, but I simply can’t tolerate it.
Participants described how the lack of participation in alcohol consumption activities in social settings could lead to a sense of isolation.
The problem with alcohol for me is because if I’m in a social situation and everybody’s drinking and I’m not, I get sort of isolated, so that makes it a problem … “What’s wrong with you, you’re not drinking?” … I think people are afraid to admit they don’t drink. That’s the sense I get. – female participant (Blue table, W3)
To resist social pressure to drink in social settings, participants reported that they will make excuses, such as needing to drive, as one female participant (Green table, W1) reported: “Yes, there is a pressure but … I usually say I’m driving or something and they don’t press me so that’s a good excuse. Maybe I’ll have one drink, or something. After that, I’ll say I’m driving.” Despite the ongoing social pressure to drink in later life, some participants felt that the pressure to drink was stronger when they were in their 20s or when they were working (e.g., during business lunches).
Loneliness, Social Isolation, and Boredom Lead to Alcohol Use. In contrast to the use of alcohol in social settings, participants also reported that some older adults will use alcohol when they are feeling lonely, isolated, or bored. Notably, reports that older adults use alcohol as a coping mechanism for loneliness or isolation were not self-reports, but reflections based on participants’ observations of other older adults.
With some people it gets worse as they get older. They start to drink more out of loneliness. And I’m seeing that with my sister who’s looking after my almost 97-year-old mother … She lost her husband a year and a half ago, and the poor kid … has not had one second to grieve because he died suddenly and all of a sudden she’s there by herself against my mum. – female participant (Yellow table, W1)
I work with some of the folks who are living alone … I’ve known some people who start their day with beer … Maybe, loneliness, I’m not sure, but yeah, some folks are drinking from the morning. And oftentimes those folks are housebound. They just stay at home all day, every day, not many visitors or interactions with any outside contacts … Alcohol is kind of their friend. – female participant (Blue table, W2)
Participants reported particular concern about isolation experienced by older men, while women were considered more socially engaged and active, as one female participant (Red table, W1) noted: “Unfortunately, it’s usually men who get more alone. Women – we seem to be able to join clubs, and do things together. But men sort of tend to go off by themselves as they get older, and I think that is a problem.” This isolation was thought to contribute to more alcohol use among men.
This old man … he drinks, excessively, at home and he lives alone … We go visit him, and [we] said “Why you drink too much?”’ Cause, he said, all his friends are gone, his friends pass away, so now he has nobody to go out with. Yeah, he needs somebody to talk to, but his friends pass away already, so all his friends are gone. He outlived his friends, and that’s how he started drinking. – female participant (Green table, W2)
Self-medication with Alcohol to Cope with Distress, Anxiety, Depression, Sleep Problems, and Pain. Participants reported that motivations to use alcohol include the desire to alleviate distress and anxiety and to cope with sleep problems, physical pain, and tight muscles. As one male participant (Green table, W3) described it:
If I’ve had a heavy day and I’m busy, I need a drink, so I have one … And also, with old folks, when I was in practice as a medical doctor, the elderly could not sleep with sleeping pills if they had sleeping problems, so they always had a brandy every night, and it worked like a charm.
Participants agreed that alcohol can improve older adults’ ability to cope with stress and anxiety, as summarized by a female participant (Green table, W1): “I think sort of with anxiety sometimes, like a glass of wine can maybe help with anxiety.” Other participants endorsed this sentiment; some revealed their own challenges with anxiety:
I have alcohol around, and if my heart is racing or I feel anxiety, I will drink like almost medicinally. Maybe if I drink one gin and tonic it will calm me down a bit, and my heart would stop racing … On most occasions I find it beneficial …it’s stress relieving. – female participant (Blue table, W1)
One female participant (Green table, W1) described consuming alcohol “as an escape”, while another female participant (Green table, W2) said that drinking helps her relax and forget: “For me, alcohol – it depends how you drink it. For me, if I [have] a problem, I drink alcohol so I can feel at ease and relaxed. And I forget all the bad things that have happened to me.” At the same workshop table, another female participant (Green table, W2) suggested that some older adults drink alcohol to forget past trauma:
The uncle of my best friend – he drinks, he smokes. Maybe it’s because of the things he saw in the war … but when he’s drunk, he just sleeps, and he’s there and he’s not bothering anybody … The reason there may be that he wants to forget what he saw during the war. So that’s why we try to understand that he’s drinking – because he was traumatized.
Participants described specific times in older adults’ lives that could cause distress and lead to alcohol use as self-medication, including divorce, the loss of loved ones, and caregiving responsibilities. When asked if there was a time when she felt more inclined to drink, one female participant (Yellow table, W3) recalled: “Yes, I did when my husband was sick with Alzheimer’s, I was drinking more then, during the earlier stages.” Similarly, another female participant (Blue table, W3) described drinking more in recent years when she was at risk for losing her housing.
When I was younger I hardly ever drank. I didn’t actually like the taste of it, but I enjoyed it socially – you relax, you get a little bit friendlier … but when I had a personal problem with housing [in later life], I found myself self-medicating with wine.
While acknowledging that people of all ages use alcohol to cope with life’s challenges, one female participant (Red table, W2) felt that younger individuals were more likely to engage in self-medication with alcohol than older adults:
I think when you’re younger and you encounter some problems in life and you’re sad … you resort to alcohol just to ease the pain … It does change with age because when we are younger maybe we’re more emotional and susceptible to resorting to alcohol as a pacifier. When you are older – depends on your situation, if you have all [your] ducks in a row, maybe – then you might not go back to alcohol.
2. Personal Experiences of Alcohol Use
Reduced Alcohol Consumption. Although some participants reported on the increased use of alcohol, most did not. Instead, discussions indicated that older adults generally consume lower levels of alcohol in later life. Reflecting on their own experiences, participants reported drinking less than when they were younger for a number of reasons: (a) they are now more aware and educated about alcohol use; (b) alcohol is expensive; (c) they feel the effects of alcohol more quickly; (d) alcohol negatively impacts their health; (e) they use medications; and (f) they socialize differently from when they were young. As one female participant (Blue table, W3) stated, “When you’re young it’s okay, but as you age it looks really silly to be drunk in public when you’re older, you know?” A male participant (Green table, W1) described the difference between his younger and older social group engagement, which has influenced his reduced alcohol use:
I don’t hang out a lot with people who are partying like when I was young and doing what young people tend to do. But now, the question [of drinking alcohol] hardly ever arises because the people I associate with today, most of them don’t drink either. That’s just the way it works. I used to gravitate towards the partying and now I don’t.
Although participants wanted additional information on low-risk drinking in later life, they also reported having become more knowledgeable about health behaviours over time, which has influenced their alcohol use.
Haven’t you guys all noticed as you aged that your habits kind of changed? Like, I don’t drink as much as I used to … We don’t drink the same way because we’re self-aware. You’re self-aware that when three drinks used to be [the norm], now it’s one, right? – male participant (Red table, W3)
Participants also agreed that the high cost of alcohol influenced their decisions to consume less in later life.
Drinks are getting expensive now. In one way it’s good because a lot of people can’t afford to drink anymore where in the old days – in the 70s – alcohol was really cheap, … but a lot of people can’t afford to drink, which is good in some ways. – female participant (Blue table, W3)
Furthermore, living on a limited income was reported to influence decisions to reduce alcohol consumption among older adults. As one female participant (Green table, W2) noted, “We don’t have much money to spend on alcohol, we are not working anymore … especially right now – we have like, a rent increase, and of the commodities you bought, it’s more expensive now.”
For the most part, participants reflected that their reduced use of alcohol in later life was the result of changing health, the increased use of medications, and the physical effects they felt following alcohol use. One female participant (Green table, W2) summarized this sentiment:
I’m finding now that I go for a smaller glass because I really feel the effect faster and I think it’s the body reacting. My older body is more sensitive to the effects of it, so just a few sips is fine for me now.
Similarly, other participants described alcohol as making them feel dizzy and drowsy, which was reported to increase their risk for falls and injury (female participant, Green table, W3): “You can get injured when you drink alcohol; you can fall down, you can get hurt; you don’t want to injure yourself.” In addition, a host of health conditions (e.g., gout, diabetes) were described as influencing participants’ reductions in alcohol use, as noted by a female participant (Green table, W3): “Health issues, like people have gout. Once they have gout they just cannot tolerate the pain and they stop drinking … or kidney stones.”
Participants also reported having reduced or discontinued their alcohol use based on their doctors’ recommendations. A female participant (Red table, W1) reported that “Some doctors say that if you are on medication, don’t drink … you have to lower your drinks.” Moreover, participants understood that abstinence or limited alcohol use was recommended if certain medications are being used. As a female participant (Yellow table, W3) said, “Alcohol isn’t compatible with many of the medications we take. But also, I think as we become older, and not as stable [health-wise], it becomes a bit frightening to drink.”
Moderation in Alcohol Use. Participants held various opinions about their alcohol use consumption levels, recognizing that there is a wide range in the amount of alcohol different people consume – from abstinent non-users to heavy drinkers. For instance, a female participant (Blue table, W1) remarked, “I’m not going to go and buy a big bottle of wine and drink the whole thing and get drunk, but some people would. Once they start drinking that’s it, they’re off.” In comparison, another female participant (Blue table, W2) reported not being able to limit herself to one glass if she has opened a bottle of wine, “If I have a bottle of wine I’ll have more than one glass.” Some participants felt that men drink more than women, both because they are more socially isolated than women and because when they socialize it is in settings where alcohol is consumed.
By and large, participants agreed that moderate alcohol use was acceptable. One male participant (Blue table, W3) stated, “[While] less is better, everything in moderation is okay.” In addition, it was consistently reported that if people can control their alcohol consumption and use in moderation, they found little harm in drinking. One female participant (Yellow table, W3) commented, “As long as you control it, it doesn’t control you … there’s nothing wrong with using it in moderation.” In agreement, another female participant (Green table, W2) stated, “I think if you drink moderately, it’s okay, but if you drink too much you might lose control of yourself.” The ability to self-moderate one’s alcohol intake was described as a personal responsibility (female participant, Red table, W3): “Everything in moderation – it’s up to you to know when you’ve had too much.” A female participant (Red table, W3) further described the importance of moderating one’s alcohol use with increasing age to avoid potential negative consequences:
Several years ago – probably five – I realized it’s not a good idea to have [alcohol] every night, so I go off and on and off and on. I probably have about five drinks like that a week and then pace it. Or, I might have two in one night and not have any more.
3. Older Adults’ Perceptions of Alcohol Use Outcomes
Participants detailed various opinions about the outcomes they attribute to alcohol use – both positive and negative.
Positive Perceptions of Alcohol Use. Participants’ opinions on positive outcomes of alcohol use included potential health benefits of moderate consumption, as well as having fun and enjoyable experiences when drinking. For instance, participants highlighted the enjoyment they experience when they drink and describe drinking as a “fun” activity. Simply stated by one female participant (Red table, W1): “For me, I enjoy it. I enjoy drinking.” Similarly, another female participant (Yellow table, W3) agreed: “I think it’s fun. It’s fun to experiment … to find different kinds of wine and experiment with the flavours. Because the flavours … you don’t get those flavours anywhere else – only in wine.” Participants also described alcohol as a treat; as one female participant (Red table, W3) described it: “It’s like having chocolate for me.”
A common sentiment shared by participants was that they had been informed by their doctors that consuming a small to moderate amount of alcohol, particularly red wine, can have certain health benefits. A female participant (Red table, W1) said simply, “For me, drinking red wine is good for your health, like the heart.” In addition, participants reported that alcohol helps them sleep, stimulates their appetite, or serves as a relaxant or mood enhancer easing their ability to socialize.
Negative Perceptions of Alcohol Use. Participants’ negative perceptions of alcohol use included alcohol’s effects on one’s health, the risk for tolerance and addiction, and the potential of harming others as a result of use. Although participants reported little knowledge of the negative health effects of small to moderate amounts of alcohol, heavy alcohol use was understood as detrimental to one’s health. One female participant (Green table, W1) observed, “Cumulative use, overuse, [and] over-abuse of alcohol has serious issues with your body.” Furthermore, it was acknowledged that heavy alcohol use was a factor in premature mortality: “A lot of people die early in our country because of drinking (Red table, W1).” One male participant (Green table, W3) identified the decisions individuals have to make about their own use and personal risk tolerance amid knowledge of potential harm:
Let’s be honest, alcohol is toxic to your brain, your gut, and cancer and all kinds of things, so we know you’re doing yourself harm when you drink. Now, how much harm you can stand is up to you. I don’t like to think of it, I like to go into denial when I think of that.
Participants believed that while a small to moderate amount of alcohol could be beneficial, more regular, heavy use could lead to the development of tolerance and, for some, addiction. For instance, one female participant (Blue table, W3) stated, “It’s kind of sad to see people with drinking problems because a little bit of alcohol is good for your health.” Participants described knowing family members (parents, siblings, etc.) and neighbours who consumed large quantities of alcohol who they felt had alcohol use disorders. On a related note, participants described their personal negotiations with drinking alcohol, identifying times when they felt they were drinking too much and having changed their consumption patterns as a result. Conversations about problematic alcohol use led to some debate on whether or not individuals were predisposed toward alcohol use disorders – some believed that people are predisposed to alcoholism because of personality traits or genetics, but others disagreed. Others simply acknowledged that some people are heavier alcohol consumers than some others, as exemplified by one female participant (Blue table, W1): “Obviously, some people cannot restrict themselves. I don’t know what causes that.”
Finally, participants highlighted that some individuals may be put at risk from an older adult’s alcohol use, including when they might be caregiving for another person or driving after consuming alcohol.
It could be dangerous, like especially when you are driving. When you’re taking care of others you might be putting at risk the other person because you’re drunk, which is not good. – male participant (Red table, W1)
Discussion
This study engaged with older community members and service providers to update our understandings of older adults’ experiences and perceptions of alcohol use and explore how these may have changed over their lives. Participants reported on their own experiences and beliefs, as well as their knowledge about other older adults. Although study findings align with earlier research, as new cohorts of individuals enter late life, updated information continues to be needed on whether and how attitudes and understandings of alcohol use have shifted. In particular, the baby boomer generation has been characterized as having more lenient and accepting perceptions of alcohol use compared to earlier generations (Duncan et al., Reference Duncan, Nicholson, White, Bradley and Bonaguro2010; White, Duncan, Bradley, Nicholson, & Bonaguro, Reference White, Duncan, Nicholson, Bradley and Bonaguro2011), which are anticipated to influence their use of alcohol in late life. Moreover, even though attitudes may change, there remain age-related physiological and psychosocial factors that differentially impact older adults and that older adults need to consider as they consume alcohol (Barnes et al., Reference Barnes, Moore, Xu, Ang, Tallen, Mirkin and Ettner2010; Butt et al., Reference Butt, White-Campbell, Canham, Dowsett Johnston, Indome, Purcell and Van Bussel2020; Substance Abuse and Mental Health Services Administration, 1998). Thus, it is critical to regularly update what is known about older adults’ experiences with and perceptions of alcohol. Indeed, for health promotion efforts and interventions to be effective in reducing older adults’ alcohol-related harms, practitioners need to meet their patients and clients “where they are at” (O’Rourke, Ruiz, & Allen, Reference O’Rourke, Ruiz and Allen2015). Workshop dialogues offered a unique method for accessing this information in a comfortable and non-judgmental way (Canham, Humphries, Kupferschmidt, & Lonsdale, Reference Canham, Humphries, Kupferschmidt and Lonsdale2019).
Building upon prior epidemiological research that has examined life course trajectories of alcohol use, participants in the present study described nuanced experiences of alcohol use over their lives. Reflecting on life course patterns of drinking, participants described their use or non-use as part of lifelong habits that developed in their younger years which were, in part, influenced by religious and sociocultural backgrounds. Although some participants were encouraged to not drink alcohol from a young age, particularly those from certain religious traditions, others reported being raised in families and cultures that are widely accepting of alcohol use. Such reports support existing literature that has found lower alcohol use among older persons who are more religious (Graham, Carver, & Brett, Reference Graham, Carver and Brett2010). In addition, participants’ reports suggest that the sociocultural influences on late-life alcohol use should be considered not only at a single point in time, but as part of a life course trajectory of socialized patterns of alcohol use. Early life experiences and teachings, exposure to cultural messaging that glorifies or demonizes alcohol use, and experiences of peer pressure or social isolation and loneliness all influence alcohol-use decisions in later life.
As described by the workshop participants, older adults use alcohol as a result of social expectations to drink alcohol in certain settings. Although much research has investigated the influence of peer pressure and perceived norms on drinking habits of youth and college age students (Borsari & Carey, Reference Borsari and Carey2001; Roberson, McKinney, Walker, & Coleman, Reference Roberson, McKinney, Walker and Coleman2018), peer pressure to drink has received little attention in older populations. Future research is needed to explore the role of social networks on older adults’ perceptions of drinking norms.
In addition, building upon Canham and Mauro’s (Reference Canham, Mauro, Kuerbis, Moore, Sacco and Zanjani2016) conceptual model of alcohol self-medication, the workshop participants reported that older adults use alcohol as a coping mechanism for feelings of distress and anxiety, as well as to cope with health issues, including sleep problems and pain, which aligns with previous literature (Canham & Mauro, Reference Canham, Mauro, Kuerbis, Moore, Sacco and Zanjani2016). Participants perceived outcomes of alcohol use for older adults to include improved health and enjoyment. These positive alcohol use expectancies do not stem from individuals who reported heavy alcohol use, as in prior research (Cooper, Russell, & George, Reference Cooper, Russell and George1988). Rather, the participants perceived that when alcohol is used in moderation, they can experience benefits. In contrast, potential negative outcomes of older adults’ alcohol use included risks of harming oneself or others. Thus, within a sociocultural milieu of alcohol acceptance and marketing campaigns to promote use (Moriconi, Nadeau, & Demers, Reference Moriconi, Nadeau and Demers2012), alcohol can be perceived as beneficial for managing day-to-day stressors and disengaging from traumatic memories among older adults or a risk to older adults’ health. Although alternate stress reduction interventions may also be helpful (Lenze et al., Reference Lenze, Hickman, Hershey, Wendleton, Ly, Dixon and Wetherell2014), alcohol use was considered largely a socially accepted tool for emotional and behavioural self-management for older adults in this study. Ultimately, participants suggested that cultural messaging that focuses on the positive effects of alcohol use and which normalizes alcohol use can make it challenging to intervene when someone is engaged in problematic consumption.
Findings from this research have a number of implications. First, findings can inform health promotion efforts for older adults. In general, participants agreed that moderate alcohol use is appropriate and that, over time, participants have reduced their alcohol consumption as they have learned more about the negative effects of alcohol and perhaps also experienced the negative effects firsthand. Potentially, additional health promotion opportunities offered through community dialogue sessions modelled after those used in this study could further educate older adults on low-risk alcohol use. Dialogues may also be offered in other venues, such as faith communities, retirement communities, or support groups.
Second, modifications are needed to alter the ways in which Western culture glorifies the use of alcohol and also modify the messaging that promotes alcohol use as necessary to social engagement. A cultural shift in ideas about benefits of alcohol could be targeted to both older and younger age groups, as participants suggested that their consumption patterns were formed from a young age. Third, alternate opportunities for social engagement where alcohol use is not expected are needed so that older adults can benefit from social interaction without feeling pressured to drink alcohol (Hunter & Gillen, Reference Hunter and Gillen2006). Finally, there is the need for access to counselling services that specialize in the treatment of older adults who may be using alcohol as a form of self-medication. Through counselling and therapeutic interventions, older adults can be supported in developing healthier coping strategies (Blow, Walton, Chermack, Mudd, & Brower, Reference Blow, Walton, Chermack, Mudd and Brower2000; Lemke & Moos, Reference Lemke and Moos2002).
Several limitations to this study should be noted. First, the reports offered by participants may have been influenced by desires to provide socially acceptable responses. However, participants self-selected to participate in the dialogue sessions and presented as being open to discussing a range of experiences related to their alcohol use, including prior experiences of heavy alcohol use. A second potential limitation was our selection of the senior centres where the workshops were hosted, as these organizations were an important source of participant recruitment. The selection of specific senior centres potentially resulted in the recruitment of older adults who are actively engaged with their communities. Future research should attempt to engage older adults who may be homebound or unknown to community organizations. Another potential limitation was our data collection method of Knowledge Cafés, as opposed to surveys or interviews which would have provided more in-depth individualized data on older adults. However, acquiring in-depth data was not our goal and we are unaware of any prior research that has utilized Knowledge Café methods to understand experiences and perceptions of alcohol use among older adults.
Finally, our research team is monolingual, and was therefore limited to collecting data in English. Future research should collect data on experiences and perceptions of alcohol use in late life in languages other than English, particularly as Canada is a diverse, multicultural country and the City of Vancouver is home to older adults from a mosaic of different ethnocultural backgrounds. Collecting ethnoculturally diverse data is an important consideration given that our findings suggest that sociocultural and familial backgrounds have an important role in late-life alcohol use, yet there is limited research on alcohol use among older adults from different sociocultural backgrounds.
Conclusion
Participants of three community dialogue workshops highlight the wide range of use patterns and opinions about alcohol, and findings from this study provide a baseline from which to launch additional research. Amid evolving cultural understandings of what it means to age and what is acceptable in late life, updates to what we know about older adults’ perceptions and experiences of using varying amounts of alcohol can inform how providers and clinicians might best support clients and patients to age well. Attention to these issues is required for health care and social service providers who work with and provide care to older adults, particularly as their approach to the promotion of low-risk alcohol use and intervention in at-risk use should acknowledge older adults’ evolving cultural understandings and opinions regarding alcohol use.
Supplementary Material
To view supplementary material for this article, please visit https://doi.org/S0714980820000306.
