Amount and type of alcohol and risk of dementia
The Copenhagen City Heart Study
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Abstract
Objective: To assess whether amount or type of alcohol is associated with risk of dementia.
Methods and subjects: Case-control nested in a cohort study among participants in the third Copenhagen City Heart Study (1991 to 1994), aged 65 years or more, who where screened using the Mini-Mental State Examination and subsequently examined for dementia. There were 83 subjects diagnosed with dementia and the remaining 1,626 nondemented subjects were included as controls. The two groups were compared with regard to alcohol intake and type of alcohol assessed 15 years before.
Results: Average weekly total alcohol intake had no significant effect on risk of dementia. Monthly and weekly intake of wine was significantly associated with a lower risk of dementia. For beer and spirits, only a monthly intake of beer was significantly associated with an increased risk of dementia. The effect of alcohol on risk of dementia did not differ between men and women.
Conclusions: Monthly and weekly intake of wine is associated with a lower risk of dementia. The results do not indicate that people should start drinking or increase wine consumption to avoid dementia, but instead suggest that certain substances in wine may reduce the occurrence of dementia.
Recent studies suggest that more than 3.2 million persons in the European Union aged more than 65 years have dementia, and with the aging population, the number of subjects who develop dementia is likely to increase.1,2⇓ Excessive alcohol intake is associated with an increased risk of dementia, with the suggested mechanisms being a direct neurotoxic effect or external causes such as malnutrition or trauma.3 However, the two most common types of dementia in Western populations are Alzheimer dementia (AD) and vascular dementia (VaD),2,4⇓ and the overall effect of alcohol intake on risk of dementia remains unsettled. Previous studies have not established a relationship between alcohol intake and risk of dementia.3,5-12⇓⇓⇓⇓⇓⇓⇓⇓ Moderate alcohol intake was, however, found to be associated with better cognitive function in the Zutphen study and the Honolulu Heart Program.13,14⇓
Oxidative stress may be important in the pathogenesis of aging and dementia15,16⇓ and intervention studies have tested the effect of administering antioxidants to elderly subjects.17,18⇓ Wine, especially red wine, contains flavonoids, which are natural compounds that have antioxidant effect,19,20⇓ which may reduce the occurrence of AD.21 The antioxidative effect of flavonoids has also been suggested to account for the lower occurrence of cerebrovascular diseases among wine drinkers,22 which could lower the incidence of VaD. Intake of wine may therefore be differently associated with risk of dementia than beer and spirits. Studies on wine and risk of dementia are few but in the French PAQUID study the authors found that the occurrence of dementia was significantly lower in subjects drinking wine.23,24⇓ However, the intake of other types of alcohol was not assessed as the study population was predominantly wine drinkers. In the current study we examine the association between amount and type of alcohol and risk of dementia in a large case control study nested in the Copenhagen City Heart Study (CCHS).
Subjects and methods.
The CCHS has previously been described in detail.25 In brief, the study was initiated in 1976; 19,698 persons living in central Copenhagen (Nørrebro and Østerbro) were invited to participate. The subjects were re-examined for the third study examination in 1991 to 1994, and those aged 65 years or more were invited to undergo the Mini-Mental State Examination (MMSE).26 There were 2,784 persons who at this examination were aged 65 years or older (figure). Seven eligible participants died and 832 did not respond to the invitation, giving a response rate of 70.0% (1,945/2,777). In 53 subjects the MMSE could not be evaluated because the person did not want to participate (21) or owing to severely impaired sight or hearing loss, or because the person was aphasic (32). Thus, 1,892 (68.1%) of the originally invited subjects were tested at the third CCHS examination, and of these, 277 (14.6%) were interviewed in their homes.
Figure. Flow chart for dementia examination in the Copenhagen City Heart Study, 1991–1994.
A total of 261 subjects had a MMSE score of 24 or less. They were all invited to a further detailed interview examining whether they had dementia. Fifty-one did not wish to continue, leaving 210 (80.5%) for the final dementia examinations. These included blood samples, the Cambridge Examination for Mental Disorders of the Elderly,27 the Hachinski Ischemia Score,28 the Hamilton Depression Scale,29 and the global deterioration scale for assessment of primary degenerative dementia.30 Dementia was diagnosed according to the American Psychiatric Association’s criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).31 AD was diagnosed according to the guidelines from the working group of the National Institute of Neurologic and Communicative Disorders and Stroke and the AD and Related Disorders Association.32 A diagnosis of VaD was given when the Hachinski Ischemia Score was ≥7 and according to the DSM-III-R criteria.31 The examiners for possible dementia were blinded to the answers the subjects gave at the first health examination.
Statistics.
Nested case-control analyses of data from subjects who had participated in the first CCHS (1976 to 1978) were used. Cases were defined as participants who were diagnosed with dementia, whereas controls were participants who were found not to have dementia at the third CCHS (1991 to 1994). Subjects who did not participate in the first study examination were excluded (n = 171). Seven subjects had had a stroke before the first study examination and were also excluded. Five subjects were missing data on intake of alcohol and type of alcohol but none of these were demented.
The following variables were included in the analysis: sex; age at date of the MMSE, grouped in intervals of 65 to 66 years, 67 to 68 years, 69 to 70 years, 71 to 72 years, 73 to 74 years, 75 to 76 years, 77 to 78 years, 79 to 80 years, and 81 years or older; systolic blood pressure (continuous); current smoker (yes/no); stroke (from time of first study examination to date of Mini-Mental State Examination); cohabitation status (living alone or not); education (less than 8 years, 8 to 11 years, more than 11 years); and income per month (less than 4,000 DKr, 4,000 to 10,000 DKr, more than 10,000 DKr). Uni- and multiple logistic regression analyses were made using the statistical software STATA.33 Comparisons of categorical variables were done using the χ2 test and continuous variables were compared using the Mann-Whitney test.
In the current study, the 51 subjects with a MMSE score of 24 or lower who did not wish to participate in further examinations have been included as not having dementia. Analyses excluding these subjects were no different from analyses including them. As a result, they have been included in the final analyses.
Alcohol and type of alcohol.
The participants were requested to describe their intake of alcoholic drinks. A drink was defined as one beverage containing 9 to 13 g alcohol and being equivalent to one bottle of beer, one glass of wine, or one measure of spirits. The choices were hardly ever/never, monthly, weekly, or daily. If a daily alcohol intake was reported, then the average number of beverages per week was recorded. The supplementary, nondaily alcohol intake was estimated and added to the daily intake.34 The subjects were then classified according to the total weekly intake of alcohol: less than one beverage per week, 1 to 7 units per week, 8 to 14 units per week, 15 to 21 units per week, and 22 or more units per week.
In the analyses of type of alcohol and risk of dementia an individual’s consumption of beer, wine, and spirits was entered simultaneously into the model in order to control for the effect of the two others.
Stroke definition.
All stroke events were validated according to the World Health Organization definition of stroke as “a sudden onset of focal (or at times global) neurologic deficits, with no other cause than a vascular reason.”35
The study was approved by the Ethics Committee.
Results.
A total of 83 cases with dementia were diagnosed; the remaining 1,626 were classified as controls. Out of those with dementia, 40 (48.2%) had AD, 15 (18.1%) VaD, 11 (13.3%) dementia from other causes, and in 17 (20.5%) the cause was unknown. There were a total of 1,062 women and 647 men, and 45 (4.2%) women and 38 (5.9%) men were demented.
Men had a higher weekly alcohol intake than women (table 1). One-third of the women consumed less than one unit of alcohol per week, as compared to only 7.4% of men reporting a low intake (p < 0.01). Especially for beer, men had a more frequent intake than women, of whom more than half reported never or hardly ever drinking beer (p < 0.01), and more men than women were drinking spirits (p < 0.01), whereas there was no significant difference for the intake of wine (p = 0.28). Cases were more often living alone, had fewer years of education, and, especially for women, there were few in the high income group.
Table 1 Baseline characteristics of cases and controls, 1976 to 1978
Alcohol and risk of dementia.
The association between weekly alcohol intake and risk of dementia is presented in table 2. In univariate analyses weekly intake of 15 to 21 units of alcohol was associated with an increased risk of dementia (OR = 2.26, 95% CI 1.09 to 4.69), whereas the remaining categories were not significantly different from the reference group of 1 to 7 units of alcohol.
Table 2 Odds ratios for risk of dementia related to weekly alcohol intake
The effect of weekly alcohol intake was then estimated adjusting for possible confounding variables. The estimates did not change substantially; however, none of the weekly alcohol intake categories was statistically significant. Analyses of men and women separately showed no difference, and there was no significant interaction between sex and alcohol intake (χ2 = 0.63, 4 df; p = 0.96).
Forty of the demented subjects had AD. In analyses including only this group of subjects with dementia, the estimates for weekly amount of alcohol was similar to that of all types of dementia combined. None of the differences was significant (results not shown).
Beer, wine, and spirits and risk of dementia.
The majority of subjects reported drinking beer, wine, and spirits. Among those who drank beer, 72.7% also drank wine and 71.1% reported also drinking spirits. For subjects reporting drinking wine, 73.6% also had intake of spirits.
The results of the analyses of drinking beer, wine, and spirits are presented in table 3. In univariate analyses beer was not significantly associated with risk of dementia. In contrast, intake of wine was associated with a lower risk of dementia than in subjects reporting never or hardly ever drinking wine. This was significant for both monthly and weekly intake but not for daily intake. The OR for daily intake of wine was very similar to the other two categories of wine intake and the wide CI may indicate low power to detect a difference for the daily intake comparison. Only monthly intake of spirits was significantly associated with a reduced risk of dementia.
Table 3 Odds ratios for dementia according to type of alcohol intake
In a model adjusting for confounding variables, monthly intake of beer was associated with a significantly higher risk of dementia when compared with never or hardly ever drinking beer. For wine, a significantly lower risk was observed for both monthly and weekly intake. Intake of spirits was without significant effect. Analyses of men and women separately, and for AD only, showed no difference (results not shown), and there was no significant interaction between sex and intake of type of alcohol (beer and sex χ2 = 1.97, 3 df, p = 0.58; wine and sex χ2 = 1.04, 3 df, p = 0.79; spirits and sex χ2 = 3.41, 3 df, p = 0.33).
Participants vs nonparticipants.
Of the 2,784 eligible subjects, 1,075 were not included in the analyses. Among these, 62.9% were women and 37.1% were men, which was not significantly different compared with participants (p = 0.69). The mean age of nonparticipants was 57.6 years, vs 57.0 years in participants (p = 0.04). There were 567 nonparticipants who had participated in the first CCHS examination. Owing to missing values, we had information on beer drinking in 561 subjects, on wine drinking in 555 subjects, and on intake of spirits in 559 subjects. There were 203 (36.2%) nonparticipants who had a weekly or daily intake of beer, which was not different from the consumption among participants (p = 0.64). Weekly or daily intake of wine was reported in 87 (15.7%) nonparticipants, which was marginally lower than in participants (p = 0.06). A weekly or daily intake of spirits were reported in 93 (16.6%) nonparticipants, which was not different as compared with participants (p = 0.13).
Discussion.
In this study, monthly intake of beer was associated with a significantly higher risk of dementia, whereas monthly and weekly intake of wine was associated with significantly lower risk of dementia. We failed to detect a significant association between weekly alcohol intake and frequency of spirits consumption on risk of dementia.
Case-control studies of the relation between alcohol intake and risk of dementia are potentially susceptible to recall bias, as is also the case when the information is obtained from close relatives. Prospective studies may present a better opportunity to examine the association between alcohol and type of alcohol consumption and risk of dementia. By conducting the case-control nested in a cohort study, we were able to specifically identify the demented subjects, while avoiding recall bias by using data collected 15 years before dementia was diagnosed.
Two longitudinal studies from the Honolulu Heart Program and the Zutphen Elderly Study found that subjects with a moderate intake of alcohol had a better cognitive status than abstainers and heavy drinkers.13,14⇓ In both studies the endpoint was cognitive function, which differs considerably from the diagnosis of dementia. For example, in our study, 210 had an MMSE score of 24 or less, but only 83 were eventually diagnosed with dementia. Subjects with a low MMSE score but who were not diagnosed with dementia were found to have other psychiatric conditions, such as depression and premorbid mental impairment. Others were normal. The MMSE test has a score range from 0 to 30; we used a cutoff point of 24, which has been reported to provide a good compromise between sensitivity and specificity, with values around 90% for both.36 The optimal cutoff score is likely to vary between studies depending on the educational level of the tested subjects.36,37⇓ Further examination of subjects with low MMSE scores increased the specificity, whereas some mildly demented subjects may not have been detected in the current study. This misclassification will most likely attenuate the associations examined.
The time lag between the first and the third study examination ensures that institutionalization of demented persons, which has been suggested as a potential bias in studies of wine intake and risk of dementia,38 is an unlikely explanation for the results in the current study. Nevertheless, as in other studies, nonparticipation in the examinations could introduce bias. The different associations between beer, wine, and spirits found in our study indirectly suggest that that has not occurred. If nonparticipation plays a role explaining our results, it would mean that subjects who drank wine and were demented did not participate in the third examination, whereas those who drank beer and spirits and were demented did participate. To further examine the possible effect of nonparticipation, we analyzed the differences between nonparticipants vs participants. There were no differences with regards to age, male to female ratio, or weekly or daily intake of beer and spirits. Weekly or daily intake of wine was marginally higher in participants, which could be expected as previous studies from the CCHS have shown that mortality is lower for people drinking wine and drinking moderately.39 This result suggests that an alternative hypothesis for the results, that people drinking wine have died before the third study examination, can be excluded. Based on these observations, nonparticipation seems an unlikely explanation for the results, although it should be noted that information on drinking habits is limited to those who participated in the first study examination.
In the French PAQUID study the authors found that intake of wine was associated with a lower risk of dementia.23 The follow-up period was limited to 3 years and it is possible that subjects who later were found to have dementia already had changed their drinking habits as a result of early cognitive deterioration. Dementia often has an insidious onset where the deterioration advances over several years. The olfactory system may be affected at an early stage,40 which can change dietary habits, and would affect the answers a person gives at a health examination. In this study the participants were asked about their type of alcohol intake years before the interview, and few if any demented subjects at the first study examination would have survived the time to the third study examination. Thus, the responses included in this study are likely to be unbiased with regard to possible dementia.
The weekly intake of alcohol was divided into five categories and none of them was significant in analyses adjusting for potential confounders. The rationale was to examine whether there was an indication of a J-shaped relationship between alcohol intake and risk of dementia. The current results do not support such a relation and it should be noted that although a high intake of alcohol was not significantly associated with increased risk of dementia this could merely be the result of low power to detect a significant difference rather than an indication of no relation. In fact, the point estimates suggest that there may be a higher risk of dementia in subjects drinking 15 units or more per week. Similar reservations should be directed to the results for intake of beer and spirits. For example, in the analyses of beer, only a monthly intake was significant, but the estimates for both weekly and daily consumption indicated a doubling of the risk of dementia. Also, the categorization of alcohol frequency intake raises the issue of multiple comparison as each consumption group was compared to the referent category. A formal test for multiple comparisons was not made as the current results mainly relate to the pattern between alcohol intake and risk of dementia rather than between specific intake frequencies and risk of dementia.
The main argument for a possible relation between wine and dementia is through an effect of flavonoids and their antioxidation activity,21 and not because of the alcohol content. A previous study showed that the inverse association between wine consumption attenuated after adjustment for flavonoids suggesting that it was an intermediate variable between wine and dementia.15 Flavonoids are also found in other food items such as tea, fruits, and vegetables, and we had no data on the participants’ dietary habits. Previous studies from a large Danish cohort have shown that wine drinkers have a healthier diet than that of subjects drinking beer or spirits.41 They had a higher intake of fruit, fish, vegetables, and salad, tended not to use fats on bread, and used olive oil for cooking more frequently. To our knowledge, no studies have supported a strong effect of diet on risk of dementia,42 but it remains a hypothetical bias. Also, subjects who frequently drink beer often have low intake of especially B vitamins, where especially thiamine deficiency is associated with an increased risk of dementia. However, although beer and spirits drinkers had a more unhealthy diet as compared to wine drinkers in the Danish study, there were only minor differences between the two groups. Should diet alone explain the results in the current study, a substantial difference in dietary habits between beer and spirits drinkers would be expected. We have no satisfactory explanation for the increased risk of dementia associated with intake of beer, whether it is directly related to the consumption or some unmeasured bias.
As our aim of this study was to assess the relation between intake and type of alcohol and risk of dementia, we included all types of dementia. The pathology of the different types of dementia varies considerably, and although we used standard criteria to differentiate among subjects with AD, VaD, and dementia from other causes, it should be emphasized that these diagnostic criteria allow only a diagnosis of probable AD. It is known that a proportion of patients diagnosed with VaD using these criteria have additional Alzheimer changes at autopsy. The results of our subanalyses including only AD were suggestive of no difference as compared to all dementias combined, but they were not conclusive.
Drinking patterns are likely to differ for the intake of beer, wine, and spirits. Whereas wine consumption often is associated with meals and a moderate intake, beer and spirits may more often be consumed at other times during the day or on certain days of the week. It is possible that a sudden high intake of alcohol may have especially deleterious effects on cognitive function. Unfortunately, we had no information on drinking patterns, but a recent study from Copenhagen suggested that binge vs steady drinking of beer and wine was not a strong confounder.43 It could also be hypothesized that the association for wine could be due to no intake of beer or spirits. However, our study population was characterized by a considerable overlap of intake of beer, wine, and spirits, and absence of intake of one type of alcohol is an unlikely explanation for the results.
In this study, a moderate intake of wine was inversely associated with risk of dementia, whereas there was no association between intake of spirits or weekly alcohol consumption. It is emphasized that these results do not suggest that the population should start drinking wine or increase wine consumption. Especially in the elderly, alcohol intake may be deleterious owing to the normal loss of lean body mass in which to distribute water-soluble alcohol and the risk of interactions between medication and alcohol.44 The results suggest, however, that there might be substances in wine that can reduce the occurrence of dementia.
Acknowledgments
Supported by grants from Danish National Board of Health, Danish Ministry of Health, the University of Copenhagen, “Else og Mogens Wedell-Wedellsborgs Fond,” the Danish Health Insurance Foundation, the Danish Insurance Association, the Medical Scientific Foundation for the Copenhagen Region, the Faroe Islands and Greenland, Chief Physician, DMSc Torben Geill’s Fund, and the Centenary Fund of the Copenhagen Municipality Hospital.
Acknowledgment
The authors thank G. Jensen, J. Nyboe, A.T. Hansen, and P. Schnohr, who initiated and conducted the Copenhagen City Heart Study. They acknowledge M. Appleyard for her support and assistance and thank Claus Holst for his support in finalizing the analyses.
Footnotes
-
See also page 1300
- Received November 26, 2001.
- Accepted July 4, 2002.
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