Age and Ageing 2020; 49: 307–308 © The Author(s) 2020.
2020. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi: 10.1093/ageing/afaa055 All rights reserved. For permissions, please email: journals.permissions@oup.com
Editor’s view
Health effects of alcohol
We are well aware of the dangers of excessive alcohol con-
sumption, but epidemiology consistently suggests that teeto-
tallers fare less well than ‘moderate’ drinkers across a range of
health outcomes. However, tolerance of alcohol diminishes
with age, interactions with medication may be problematic
and up to half of older drinkers may be putting themselves
at risk of harm. In this issue, van den Brandt and colleagues
report that 68- to 70-year-old participants in a cohort study
who drank 5–15 g of alcohol per day (half to one and a half
standard drinks or ‘units’) were 36% more likely to reach the
age of 90 than those who did not drink. The mechanism
of this association is argued. Former heavy drinkers who
abstain and ‘sick quitters’ who no longer drink introduce
a bias, but recent studies have worked to avoid this. The
beneficial effects persisted with consumption up to three
drinks per day for men, but not women, and binge drinking
(over six drinks a day) was harmful. In an editorial, Stott
urges caution, arguing that the underlying explanation is
likely to be confounding by socioeconomic class, health,
lifestyle or genetic factors. Current public health advice is
that no level of alcohol consumption is risk-free, although
the risks with moderate alcohol consumption are small, and
may be counterbalanced by subjective benefits. Bareham and
colleagues report that health and social care professionals’
express unease and uncertainty about discussing older adults’
alcohol use. They are reluctant to challenge social norms,
want to respect older peoples’ lifestyle choices, demonstrate
preconceptions about who might be a problem drinker
and are unsure about their professional remit in challeng-
ing possibly harmful drinking. The consequence is missed
opportunities to intervene to reduce the risk.
Diagnosing osteoporosis
We include a pair of editorials that debate current osteo-
porosis diagnosis with respect to treatment decisions. Over
the past 20 years, the approach to cardiovascular prevention
has switched from trying to reverse individual risk factors,
such as high blood pressure and cholesterol, to one that
suggests intervening in those at the highest baseline risk
of heart attacks, stroke and vascular deaths. If the same
logic is applied to osteoporosis, treatment will target older
people who fall rather than those with weak bones alone.
Treating bone densitometry-defined osteoporosis results in
very high numbers needed to treat to prevent one fracture.
Paskins and colleagues argue that definitions of osteoporosis
need updating and broadening. Talla and Gallacher argue
that evidence for treatment effectiveness is largely based on
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osteoporosis defined by bone densitometry, but agree that
evidence is emerging that anti-osteoporosis therapies are
beneficial for those who have had a hip or vertebral fracture,
or osteopenic women at high facture risk.
Nocturia
Nocturia is a troubling symptom, almost universal among
older people, little understood and often neglected by geria-
tricians. It results in daytime sleepiness, risk of falls at night,
carer strain and may contribute to a decision to enter a care
home. There is a wide medical differential diagnosis: think of
overactive bladder, insomnia, diabetes, alcohol, heart failure
and lithium treatment among many others. Many cases
are due to ‘age-related nocturnal polyuria’. Monaghan and
colleagues investigated the physiology of nocturnal polyuria,
concluding that ‘healthy older kidneys lose their circadian
rhythm of water and salt [handling] . . . including impair-
ment in renal concentrating capacity, decreased nocturnal
AVP secretion, partial resistance to AVP action, impaired
sodium conservation, decreased active plasma renin and
aldosterone and increased secretion of natriuretic peptides’.
These are theoretically amenable to drug (desmopressin,
diuretic) or behavioural (fluid intake) intervention but this
awaits definitive trial evidence.
Delirium
Delirium is also troublesome and poorly understood, but is
attracting considerable attention in both clinical practice and
research. Davis and colleagues updated a 2006 systematic
review on delirium occurrence in acute hospitals. Overall
prevalence was 15%, in-hospital incidence 9%, with no
change over the past 40 years despite changing definitions,
awareness and case complexity. It may be that prevalence is
increasing, with ageing and more complex in-patients, but
that systematic prevention, identification and management
regimens have mitigated this. Delgado and colleagues iden-
tified 55 risk factors from routine primary care electronic
records that predicted delirium and derived a predictive
index with excellent discriminative ability for delirium (or
death) occurring over the following year. This could be used
in targeting prevention programmes in both community and
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Editor’s view

hospital care. Delirium has a poor prognosis for survival, and
is a potent cause of distress, making it an important issue at
the end of life. In a commentary, Agar very nicely articulates a
palliative approach to delirium, including meticulous assess-
ment, proactive communication and family engagement,
shared decision-making and judgement about investigation
or treatment burden in seeking reversible causes. Mental
awareness is highly prioritised by patients and families, and
even at the end of life, half of cases have reversible causes.
There may be a trade-off between controlling symptoms
such as pain with opioids and drug-induced delirium, and
fine judgement is required in medical investigation and
management, and what is given the greatest priority.
Rowan H. Harwood
Email: rowan.harwood@nottingham.ac.uk

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