REGARDING “ALCOHOL USE, COMORBIDITY, AND MORTALITY”

Abstract

To the Editor: The article by Moore et al.1 addresses an important topic, namely, the effects of alcohol use on older adults who have specific chronic conditions and use certain medications, but the measure of at-risk drinking cited by the authors as the basis for their findings2 is inappropriate for the study's purposes. Moore et al. use the Comorbidity–Alcohol Risk Evaluation Tool (CARET) to identify older adults who are at risk for adverse effects from their alcohol use because of alcohol consumption alone or of alcohol consumption in the presence of select comorbidities. The CARET, apparently an alternative name for the short Alcohol-Related Problems Survey (ShARPS),2 is derived from the Alcohol-Related Problems Survey (ARPS).2-4 I am one of the original contributors to the development of the ARPS and one of the authors listed.2 As a result of my knowledge of the ARPS and ShARPS, I have concerns over the validity of the ShARPS/CARET and question any conclusions based on its use in research. The ARPS is a screening survey and education system that provides detailed information to older adults and their physicians on the consequences of alcohol use alone and together with chronic disease affected by alcohol, medication use, and declining functional status.4 Neither the ARPS nor the ShARPS/CARET has been validated as a method of assigning patients to drinking-risk categories based on their responses to some other survey instrument (in this case the National Health and Nutrition Examination Survey questionnaires). Nevertheless, this is exactly what Moore and colleagues have done. However, they do not provide information on how they validated the new use of the scoring system, nor do they describe their method of assigning risk. As a consequence of the lack of specification, other investigators cannot hope to replicate their findings, a key criterion for a scientific study. At the time that I signed off as an author on Beyond Alcoholism: Identifying Older, At-Risk Drinkers in Primary Care2 in 2002, Dr. Moore assured me that an article was forthcoming that described the criteria used to reduce the number of items in the ARPS to create the ShARPS (e.g., factor analysis or other criteria for selecting items) and that also compared performance of the ARPS and ShARPS in separate databases rather than in the single one from which they are both derived. I have not seen this article, nor can I find it in the published literature. Its absence raises serious concerns about the appropriateness of using the ShARPS/CARET in this research. The ShARPS/CARET classifies drinkers into those who are at risk and those who are not. The ARPS classifies older individuals as nonhazardous, hazardous, and harmful drinkers using World Health Organization (WHO) definitions.5 The three categories are inherent in the ARPS and WHO logic. Nonhazardous drinking means no known risk; it does not mean not at risk, as the ShARPS/CARET indicates. Also in accordance with the WHO, the ARPS distinguishes between hazardous (at risk for problems) and harmful drinkers (presence of problems) rather than combining them into a general at-risk category. No evidence is available that justifies the value of combining hazardous and harmful drinking, as was done in the ShARPS/CARET. Since the original panel created the ARPS scoring algorithms in 1999, my colleagues and I have done extensive reviews of the literature and consulted with experts to incorporate new knowledge about alcohol use in older people and to refine the scoring system. The substantively revised and updated ARPS4 is selective about the medications it includes, so that it distinguishes between drinking levels and sedating and nonsedating antihistamines, for example, and includes newer types of medications, including muscle relaxants, sleeping medications, and antidiabetic agents. The ShARPS/CARET focuses on general medication categories (e.g., for allergies). Important comorbidities such as depression and diabetes mellitus and functional decline are not included in the ShARPS/CARET, although they are in ARPS, because the evidence and the experts agree that they are essential in accurately evaluating alcohol's effects in older persons. Table 1 summarizes some of the differences between the measures. Why is all of this important? Study integrity is only part of the answer. The effect of inappropriate conclusions can be substantial. We need valid methods to measure the determinants and outcomes of alcohol use in older adults so that we can better understand and manage hazardous and harmful drinking. It is essential that researchers and clinicians use the ARPS (or any measure) and its derivatives only for their validated purposes. I would advise readers not to make decisions regarding alcohol use in older adults solely on the basis of this study. Financial Disclosure: No financial arrangements. Both Drs. Moore and Beck received consultant fees during the development of the ARPS. Author Contributions: J. C. Beck is responsible for the entire contents of this letter. Sponsor's Role: None.