Use of Medications, Use of Medications, Alcohol, and Smoking Alcohol, and Smoking in Elderly Japanese-in Elderly Japanese-

American Men in American Men in HawaiiHawaii

A Report From the Honolulu-Asia Aging Study A Report From the Honolulu-Asia Aging Study (HAAS)(HAAS)

Lon WhiteLon White

Pacific Health Research Institute and the Kuakini Medical Center.Pacific Health Research Institute and the Kuakini Medical Center.September 2004September 2004

Honolulu-Asia Aging Honolulu-Asia Aging StudyStudy

An ongoing longitudinal study An ongoing longitudinal study of older Japanese-American of older Japanese-American men, focused largely on men, focused largely on pathogeneses of Alzheimer’s pathogeneses of Alzheimer’s disease, Parkinson’s disease, disease, Parkinson’s disease, related degenerative brain related degenerative brain diseases, cerebrovascular diseases, cerebrovascular disease, and brain aging. disease, and brain aging.

Honolulu-Asia Aging StudyHonolulu-Asia Aging Studystaff and key collaboratorsstaff and key collaborators

HonoluluHonolulu: : L White, H Petrovitch, GW Ross, K L White, H Petrovitch, GW Ross, K Masaki, Masaki, R Abbott, J Hardman, J R Abbott, J Hardman, J Uyehara-ock, J Nelson, Uyehara-ock, J Nelson, and : clinic and : clinic team, “A” team, team, “A” team, histopathology, histopathology,

geneticsgenetics, , and administration.and administration.

NIA NIA L Launer, R Peila, D Foley.L Launer, R Peila, D Foley.

Kentucky Kentucky Wm Markesbery, D Davis.Wm Markesbery, D Davis.

NIOSH/Morgantown NIOSH/Morgantown J O’Callaghan, D J O’Callaghan, D Miller, Miller,

C Burchfiel, D SharpC Burchfiel, D Sharp.. USCUSC C Zarow, H Chui C Zarow, H Chui

THE HONOLULU HEART THE HONOLULU HEART PROGRAMPROGRAM

SERIAL EXAMINATIONSSERIAL EXAMINATIONSEXAMS YEAR NExam I 1965-68 8006

Exam II 1968-70 7498

Lipo I 1970-72 2780

Exam III 1971-74 6860

Lipo II 1975-78 2386

Lipo III 1980-82 1965

Mail Quest. 1988 4664

HONOLULU HEART PROGRAM Began in 1965 with the examination of 8006 Japanese-American men Born 1900 through 1919. Follow-up exams 1967-69, and 1971-74 Extensive information collected related to heart disease, stroke, cancer.

HONOLULU ASIA AGING STUDY Began in 1991 with the examination of 3734 HHP cohort members Focus on dementia, cognitive impairment, and other aging-related brain Diseases. Followup exams 1994-96, 1997-98, 1999-00, 2001-current

ASSESSMENT S OF COGNITION / DEMENTIA Cognitive Abilities Screening Instrument (developed by E. Teng, et al). Range of 0-100, CASI 74 ~ MMSE 21; CASI 65 ~ MMSE 17-18. Standardized neurological exam, significant other history, and CERAD neurosych. Battery. DSMIII-R criteria for dementia, ADRDA-NINCDS criteria for AD, and California criteria for VsD.

HONOLULU-ASIA AGING HONOLULU-ASIA AGING STUDY EXAMINATION CYCLESSTUDY EXAMINATION CYCLES

exam YEAR age range Nexam YEAR age range N

HHP/HAAS 4HHP/HAAS 4 1991-93 71-93yr 3741 1991-93 71-93yr 3741 HHP/HAAS 5 1994-96HHP/HAAS 5 1994-96 74-95 74-95 2705 2705 HHP/HAAS 6 1997-99HHP/HAAS 6 1997-99 77-98 1991 77-98 1991 HHP/HAAS 7 1999-00 79-100 1523HHP/HAAS 7 1999-00 79-100 1523 HHP/HAAS 8 2001-03 81-103 1200HHP/HAAS 8 2001-03 81-103 1200 HHP/HAAS 9 2004- 83+ ?HHP/HAAS 9 2004- 83+ ?

How many prescription How many prescription meds do these men meds do these men

take?take? Based on data from the baseline HAAS Based on data from the baseline HAAS

exam, 1991-93. exam, 1991-93. Limited to 3413 men with normal Limited to 3413 men with normal

cognitive functioning.cognitive functioning. Based on examining bottles and pills, Based on examining bottles and pills,

and on answers to questions.and on answers to questions.

% of men using 0-7 different % of men using 0-7 different medsmeds

0

5

10

15

20

25

30

none 1 2 3 4 5 6 7+

number of Rx meds used

% of HAAS men aged % of HAAS men aged 71-7471-74

according to # of meds according to # of meds usedused

0

5

10

15

20

25

30

none 1 2 3 4 5 6 7+

number of meds used

% of HAAS men aged 75-% of HAAS men aged 75-8484

according to # of meds according to # of meds usedused

0

5

10

15

20

25

30

none 1 2 3 4 5 6 7+

number of meds used

% of HAAS men aged % of HAAS men aged 85-9385-93

according to # of meds according to # of meds usedused

0

5

10

15

20

25

30

none 1 2 3 4 5 6 7+

number of meds used

What were the most What were the most commonly prescribed commonly prescribed

meds?meds? For hypertension and/or cardiovascular For hypertension and/or cardiovascular

disease (used by more than 50% of men)disease (used by more than 50% of men)

Aspirin, NSAIDS, TylenolAspirin, NSAIDS, Tylenol

Meds for asthma, chronic lung diseaseMeds for asthma, chronic lung disease

laxativeslaxatives

PERCENT of HAAS men PERCENT of HAAS men using Psychoactive meds using Psychoactive meds

(1999, n=1383)(1999, n=1383) SSRI antidepressantsSSRI antidepressants 1.2 %1.2 % Other antidepressantsOther antidepressants 0.7 %0.7 % AmbienAmbien 0.4 %0.4 % BenzodiazepineBenzodiazepine 1.2 %1.2 % Other sedative Other sedative 0.3 %0.3 % Neuroleptic Neuroleptic 0.2 %0.2 % TrazodoneTrazodone 0.1%0.1%

– totaltotal 4.2%4.2%

Use of psychoactive Use of psychoactive medsmeds

3.9% of men used one 3.9% of men used one 0.4% (5/1375) used two0.4% (5/1375) used two

– 2 used a benzodiazepine + a sedative2 used a benzodiazepine + a sedative– 1 used an SSRI antidepr + a tricyclic 1 used an SSRI antidepr + a tricyclic – 1 used an SSRI antidepr + another 1 used an SSRI antidepr + another

antidep. antidep. – 1 used an SSRI antidepr + benzodiazepine 1 used an SSRI antidepr + benzodiazepine

Only 8 men were taking an opiate, and none Only 8 men were taking an opiate, and none were taking a second psychoactive medwere taking a second psychoactive med

Is there evidence of Is there evidence of abuse or overuse of abuse or overuse of

prescription or OTC meds prescription or OTC meds in the HAAS cohort?in the HAAS cohort?

NONO

Is there evidence of Is there evidence of excessive intake of alcohol, excessive intake of alcohol,

or of smoking?or of smoking?

YESYES

ACQUISITION OF ACQUISITION OF INFORMATIONINFORMATION

Alcohol – self report: frequency and Alcohol – self report: frequency and size -- units of beer, saki, wine, and size -- units of beer, saki, wine, and liquor; oz/mo of alcohol calculated liquor; oz/mo of alcohol calculated 1965, ‘71, ‘87, and ’911965, ‘71, ‘87, and ’91

Cigarettes – self report: Cigarettes – self report: ever/never/now cigs/day, with pack-ever/never/now cigs/day, with pack-years calc. 1965, ’71, ’87, and ‘91years calc. 1965, ’71, ’87, and ‘91

% of HAAS men in 7 strata of alcohol % of HAAS men in 7 strata of alcohol intakeintake

(N=3268; aged 71-93; 1991-93)(N=3268; aged 71-93; 1991-93)

0

10

20

30

40

50

60

70

none 1 --19 20 --39 40 --59 60 --79 80 -- 99 >= 100

alcohol intake, ounces/ month

3-DColumn 1

% of HAAS men reporting high monthly % of HAAS men reporting high monthly alcohol intake, 1965 dataalcohol intake, 1965 data

0

2

4

6

8

10

12

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-82 85+

60+ oz40-59 oz

% of HAAS men reporting high monthly % of HAAS men reporting high monthly alcohol intake, 1971 dataalcohol intake, 1971 data

0

2

4

6

8

10

12

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-82 85+

60+ oz40-59 oz

% of HAAS men reporting high monthly % of HAAS men reporting high monthly alcohol intake, 1987 dataalcohol intake, 1987 data

0

2

4

6

8

10

12

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-82 85+

age

60+ oz

40-59 oz

% of HAAS men reporting high monthly % of HAAS men reporting high monthly alcohol intake, 1991 dataalcohol intake, 1991 data

0

2

4

6

8

10

12

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-82 85+

60+ oz

40-59 oz

% OF MEN RECEIVING % OF MEN RECEIVING ANTIDEPRESSANT MEDS ANTIDEPRESSANT MEDS ACCORDING TO LEVEL OF ACCORDING TO LEVEL OF DEPRESSIVE SYMPTOMSDEPRESSIVE SYMPTOMS

1.5 1.3 2.5 2.9

05

101520253035404550

0 TO 4 5 TO 8 9 TO 13 14+

CES-D 11 (depression symptoms)

Predictors and correlates of Predictors and correlates of alcohol intake among HAAS men alcohol intake among HAAS men who reported any consumptionwho reported any consumption

Older age (inverse p<0.0001)Older age (inverse p<0.0001) Education (inverse p<0.0001) Education (inverse p<0.0001) HDL-cholesterol level (direct p<0.001)HDL-cholesterol level (direct p<0.001) Smoking (pack years, direct p<0.0001)Smoking (pack years, direct p<0.0001) Depressive symptoms (direct p<.05)Depressive symptoms (direct p<.05) # of persons available when lonely (inverse # of persons available when lonely (inverse

p<0.05)p<0.05) # of children (direct p<0.01)# of children (direct p<0.01) Widowed, divorced, or never married (p=0.004)Widowed, divorced, or never married (p=0.004)

Factors Factors NOTNOT significantly significantly associated with alcohol intake associated with alcohol intake

among HAAS men who reported among HAAS men who reported any consumptionany consumption

obesityobesity Heart disease or stroke Heart disease or stroke Poor cognitive test scoresPoor cognitive test scores # of relatives seen /month# of relatives seen /month # of Rx meds# of Rx meds

Heavy alcohol drinking in Heavy alcohol drinking in elderly Japanese-American elderly Japanese-American

menmen It does occur, and high intake is It does occur, and high intake is

associated with specific risk factors.associated with specific risk factors.

The decrease with advanced age is The decrease with advanced age is modest.modest.

The % of men consuming >60 ounces The % of men consuming >60 ounces of alcohol / month remains at 1-4% of alcohol / month remains at 1-4% even among men in their 80s.even among men in their 80s.

late-life heavy drinkers – 4 late-life heavy drinkers – 4 typestypes

“ “new” late-life heavy drinkernew” late-life heavy drinker

“ “established” late-life heavy drinkerestablished” late-life heavy drinker

“ “recidivist” late-life heavy drinkerrecidivist” late-life heavy drinker

Life-long heavy drinkerLife-long heavy drinker

““NEW” late-life heavy NEW” late-life heavy drinkerdrinker

< 10 oz /mo in 1965< 10 oz /mo in 1965

< 10 oz/mo in 1971< 10 oz/mo in 1971

< 10 oz/mo in 1987< 10 oz/mo in 1987

> 60 oz/mo in 1991> 60 oz/mo in 1991

““established” late-life established” late-life heavy drinkerheavy drinker

< 10 oz/mo in 1965< 10 oz/mo in 1965

< 10 oz/mo in 1971< 10 oz/mo in 1971

> 10 oz/mo in 1987> 10 oz/mo in 1987

> 60 oz/mo in 1991> 60 oz/mo in 1991

““recidivist” late-life recidivist” late-life heavy drinkerheavy drinker

> 10 oz/mo in either 1965 or 1971> 10 oz/mo in either 1965 or 1971

< 10 oz/mo in 1987< 10 oz/mo in 1987

> 60 oz/mo in 1991> 60 oz/mo in 1991

WHO ARE THESE GUYS? WHO ARE THESE GUYS?

WHY ARE THEY WHY ARE THEY

DRINKING SO MUCH? IS DRINKING SO MUCH? IS

IT REALLY BAD FOR IT REALLY BAD FOR

THEM?THEM?

““lifelong” late-life lifelong” late-life heavy drinkerheavy drinker

> 10 oz/mo in either 1965 or 1971> 10 oz/mo in either 1965 or 1971

> 10 oz/mo in 1987> 10 oz/mo in 1987

> 60 oz/mo in 1991> 60 oz/mo in 1991

late-life heavy drinkers – 4 late-life heavy drinkers – 4 typestypes

N %N %

newnew late-life heavy drinker 88 3.9 late-life heavy drinker 88 3.9

established established late-life heavy drinker 26 0.8 late-life heavy drinker 26 0.8

recidivistrecidivist late-life heavy drinker 70 2.5 late-life heavy drinker 70 2.5

life-longlife-long heavy drinker 71 2.5 heavy drinker 71 2.5

new new and and establishedestablished late- late-lifelife

heavy drinking -- risk heavy drinking -- risk factorsfactors

Depressive symptomatology (CES-D 11)Depressive symptomatology (CES-D 11) Widowed, divorced, or never marriedWidowed, divorced, or never married Greater number of children Greater number of children

RecidivistRecidivist and and life-longlife-long late late life heavy drinkers – risk factorslife heavy drinkers – risk factors

Level and consistency of drinking during Level and consistency of drinking during middle lifemiddle life

Lifetime smokingLifetime smoking High hdl-CHigh hdl-C

Did late-life heavy drinking Did late-life heavy drinking have a significant impact on have a significant impact on

survival?survival? ““new” late-life heavy drinkers: NO new” late-life heavy drinkers: NO

““established” late-life drinkers: N0established” late-life drinkers: N0

““recidivist” late-life drinkers: YESrecidivist” late-life drinkers: YESOR 2.6 (1.45-4.63) for death within 10 yrs*OR 2.6 (1.45-4.63) for death within 10 yrs*

Life long drinkers: MARGINALLife long drinkers: MARGINALOR 1.5 (0.91-2.63) for death within 10 yrs*OR 1.5 (0.91-2.63) for death within 10 yrs*

**controlling for age, heart disease, stroke, cognitive test score, controlling for age, heart disease, stroke, cognitive test score, smoking (packyears), midlife blood pressure, midlife and smoking (packyears), midlife blood pressure, midlife and latelife BMI, midlife and late life cholesterol, diabetes/blood latelife BMI, midlife and late life cholesterol, diabetes/blood

glucose, and HDL.glucose, and HDL.

Does late life alcohol intake Does late life alcohol intake cause dementia?cause dementia?

Only rarely. Only rarely. In this cohort, late life EthOH intake is not a In this cohort, late life EthOH intake is not a

risk factor for cognitive test scores, or for risk factor for cognitive test scores, or for decline, or for prevalent or incident decline, or for prevalent or incident dementia.dementia.

Also not associated with lesions of Also not associated with lesions of Alzheimer’s disease, Parkinson’s disease, or Alzheimer’s disease, Parkinson’s disease, or for aging-related atrophy. for aging-related atrophy.

Heavy drinking in late Heavy drinking in late life -- conclusionslife -- conclusions

It occurs often enough to be an It occurs often enough to be an important public health matter.important public health matter.

There appear to be definable There appear to be definable subgroups having different subgroups having different pathogeneses, implying a need pathogeneses, implying a need for different case-finding and for different case-finding and intervention strategies.intervention strategies.

Heavy drinking Heavy drinking andand smoking in late lifesmoking in late life

% smoking ------- never past % smoking ------- never past currentcurrent

New drinkers 12 81 7New drinkers 12 81 7

Established drinkers 8 77 15Established drinkers 8 77 15

Recidivist drinkers 7 80 13Recidivist drinkers 7 80 13

Lifelong drinkers 16 67 17Lifelong drinkers 16 67 17

other and non-drinkers 40 54 6other and non-drinkers 40 54 6