Proﬁle of Self-Care Capacity and Alcohol Use in Elderly Brazilians during the COVID-19 Outbreak: An Online Study

: Background: Preventive and positive online coping strategies are essential for harm reduction associated with alcohol abuse among older adults in pandemic and social isolation scenarios. The objectives were to examine the relationship between alcohol use/abuse and physical capacity/self-care to perform the physical activities of daily living or impairment of the functional capacity of the elderly in the COVID-19 pandemic. Methods: An online cross-sectional survey was carried out. One hundred and one elderly people in the city of S ã o Paulo, Brazil, participated in a community program. Results: Most participants (52.5%) showed excellent self-care skills. Approximately 12% of participants reported problems related to alcohol use/abuse. There was no association between self-care ability and abuse and probable alcohol dependence. Conclusions: Although most participants have excellent self-care and functional capacity and have not evidenced alcohol use/abuse, health professionals need to systematically provide information to prevent alcohol abuse, especially in scenarios of great emotional distress, such as in a pandemic. In addition, the online meetings held by the UAPI program were shown to be opportunities for social interaction and were essential to minimize the negative effects of the possible presence of alcohol use/abuse and the deteriorating performance of physical activities of daily living during a pandemic outbreak for the elderly.


Introduction
Public health recommendations during the coronavirus outbreak resulted in numerous restrictions on daily life, including quarantine, social distancing, isolation, and home confinement, especially for elderly people who are the population at risk [1]. Although these measures were imperative to reduce the spread of infection, the impact of these restrictions on health behaviors and lifestyle (alcohol consumption and the practice of physical activity) at home is undefined [2]. For example, a negative impact on physical activity levels and on the mental health of elderly people was demonstrated. This may result in increased alcohol consumption and reduced functional capacity among the elderly [3].
Due to low socialization and the consequent reduction in mental and physical stimulation during the pandemic, elderly people may have suffered significant loss of mental and functional ability [2]. Additionally, social isolation has been associated with an increased prevalence of vascular and neurological diseases as well as premature mortality among elderly people [4]. Social isolation and exclusion are also significantly associated with increased risks of cognitive impairment, which, in turn, increases the risk and accelerates the progression of Alzheimer's disease [4].
Although the strategies to limit gatherings, increase isolation, and enforce social distancing have been effective in reducing the dissemination-transmission-contagion of the coronavirus disease of 2019  and reducing mortality among elderly people, the resulting increased isolation and psychological suffering caused the increased adoption of negative coping habits such as the use and abuse of illegal and/or legal drugs, such as alcohol [5,6].
Before the pandemic, alcohol use disorders (AUD) in elderly people were acquiring growing interest around the world [7]. A cross-sectional survey was carried out in some European cities to assess the prevalence of alcohol use, abuse, and dependence among people aged 65-84 years (n = 3142) before the coronavirus pandemic. The observed prevalence of AUD was as follows: current (1.1%); 12 months (5.3%), and lifetime (8.8%) [7]. Another report indicates alcohol consumption and AUD being more prevalent in males [8]. The prevalence of lifetime alcohol consumption and AUD at 12 months tended to be lower in older people, but an increase in the use and abuse of alcohol during the COVID-19 pandemic during lockdown when compared to the pre-pandemic period has been reported across the age groups [9,10].
The Health and Alcohol Information Center analyzed the evolution of alcohol consumption in Brazil between 2010 and 2019 and found that total consumption dropped by 13% [10]. However, alcohol abuse and hospitalizations of elderly people increased in the midst of the pandemic [11].
A study carried out by Wang & Andrade in 2013 in the United States of America warned that the 2020/2030 decade would be marked by a higher proportion of elderly people in developing countries and that the use of substances, alcohol, and prescription psychotropic medications for this population would be a cause for concern. Although illicit drug use is low in this age group, it appears to be an emerging problem. Baby boomers, individuals born during the postwar period of 1946-1964, had more exposure to alcohol, tobacco, and illegal drugs in their youth. Over the same period, psychoactive medications became available as a widespread method for dealing with anxiety, pain, and stress. Challenges for the coming decades include instituting routine screening programs to meet the needs of the elderly, substance-using population [12].
Another American study shows that middle-aged and older adults show a higher rate of binge drinking and use of non-prescription medications, and that these two situations are underdiagnosed. Therefore, screening for alcohol problems in middle-aged and older adults should include questions about addiction symptoms. Screening for excessive alcohol consumption, nicotine dependence, and non-prescription medication use is necessary in these populations [13].
Reports on the frequency of alcohol abuse in the elderly vary according to the population studied. However, reports concur on a proportion of older individuals that regularly consumes alcohol; many drinks unhealthily or dangerously. Various studies examining older individuals have estimated that, of older adults, more than 40% drink alcohol, 10-20% drink at dangerous levels, and men tend to consume alcohol at dangerous levels more often than women [14][15][16]. In addition, the Centers for Disease Control and Prevention reported that the largest population of binge drinkers is people over 65 years of age [17].
Changes caused by the aging process, such as changes in liver metabolism and renal function, as well as in body composition (decrease in lean mass and increase in fat mass), with a greater tendency to dehydration due to low water consumption, reduces the tolerance of the body to alcohol due to a series of physiological changes associated with the aging process [6]. The harmful use of alcohol among the elderly promotes deficits in cognitive and intellectual functioning, impairments in global behavior, an increase in comorbidities, and aggravation of other common health problems of age, such as memory failure and impairment of functional ability [18], In addition, it could expose elderly people to a greater risk of falls and fractures and contribute to polypharmacy [11]. Harmful use and addiction to alcohol in many situations lead people to prioritize alcohol consumption at the expense of food, family life, and self-care, leading to social conflict, emergence or worsening of preexisting diseases, memory deficit, procrastination, difficulty in decision making and ability to absorb information, and marital violence [19].
Self-care ability is defined as what people can do for themselves based on their fundamental dispositions, abilities, and health conditions. It is the ability to perform basic or instrumental activities of daily living and understand both the need to change things and the self-care operations themselves. Self-care ability is being able to decide what to do and when to act to achieve change or achieve regulation and control of one's life [20].
The knowledge about the association of risk for alcohol dependence and the ability for self-care in the elderly is essential to formulate interventions aimed at preventing alcohol dependence and/or strategies to help the targeted population reduce or stop alcohol consumption and achieve healthier aging. Thus, the aim of this study is to verify the possible association (and dependence) of alcohol use/abuse with self-care and lifestyle variables among elderly people during the COVID-19 pandemic. This study hypothesizes that, during the COVID-19 pandemic, impaired self-care is associated with alcohol use/abuse in the elderly.

Materials and Methods
This cross-sectional study was carried out at the Open University for the Elderly (UAPI) located on the São Paulo Campus of the Federal University of São Paulo (UNIFESP), São Paulo-SP, Brazil, from August 2020 to February 2021. The UAPI (UNIFESP) aims to help the elderly to achieve a better physical and mental quality of life through health promotion, education, and cultural, social, and intergenerational integration. It is not an undergraduate, technical and/or professional course. It is a continuing multidisciplinary university education program offered to people 60 years of age and older, so that they can update their knowledge and achieve new perspectives. No diploma or certificate of training and education is required for admission. The courses last for one academic year (8 months) with classes twice a week. To receive the certificate and remain in the UAPI program, a final attendance in 75% of classes is required.
One hundred and one elderly people enrolled in UAPI aged over 60 years were included in our study (a convenience sample). Elderly people were invited to take part in the study during one of the classes in which people were gathered in a virtual classroom (Zoom). After that, the UAPI coordination staff sent the form with the Informed Consent Form to the group's WhatsApp group, for reading and verification of agreement. Questionnaires were structured in Google forms for reading and answering.
The instruments used for the research were a structured form with information about age, gender, education, marital status, occupation, family income, and presence of morbidities. In addition, questions were also asked to identify alcohol use/abuse and dependence using the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) [21]. The Scale to Assess Self-Care Abilities (SASCA) [22] was also applied.
The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) has been translated and validated in Brazil and consists of 24 questions with dichotomous answers (yes or no). Each yes answer is worth one point. A score between 0 and 4 points means that there is no evidence of alcoholism, while a sum equal to or above 5 points indicates problems related to alcohol use.
The Scale to Assess Self-Care Abilities (SASCA) has been translated, validated in Brazil, and consists of 24 items, with the answer options: totally disagree (1 point); disagree (2 points) neither agree nor disagree (3 points); agree (4 points); and I totally agree (5 points). The scoring range is between 24 and 120 points. The assessment of self-care ability can be classified according to the score obtained: 24 to 40 points: very bad; 41 to 56 points: bad; 57 to 72 points: regular; 73 to 88 points: good; 89 to 104 points: very good and 105 to 120 points: excellent.
The study was approved by the Research Ethics Committee of the Federal University of São Paulo (Protocol No. 4,017,762) and complies with Brazilian Resolution No. 466, of 12 December 2012, which discusses research involving human beings. Participants in this research were provided with no financial incentive. Research-related risks were minimal, such as embarrassment and discomfort when answering the questionnaire questions.

Statistical Analysis
Descriptive analysis was used for sociodemographic and economic characterizations. The Mann-Whitney test and Fisher's exact test or the likelihood ratio test were used to compare the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) with continuous and categorical sociodemographic variables, respectively. For continuous variables, the mean, standard deviation, median, minimum, and maximum were calculated, and for categorical variables, the frequency and percentage. To compare MAST-G with the Scale to Assess Self-Care Abilities (SASCA), the likelihood ratio test was used. Normality was assessed for the Mann-Whitney test case. The Kolmogorov-Smirnov test was used, which indicates the non-normality of the data. Fisher's exact test or the likelihood ratio did not fit the normality test because only categorical variables were considered. Normality test is used only for continuous variables. A significance level of 5% was considered, and the program used for the analysis was the Statistical Package for the Social Sciences, version 19 (IBM, USA).

Results
The age of the volunteers ranged from 60 to 85 (median = 66) years, most were female (81.1%), married (47.5%), retired or pensioners (85.1%), with an average of 15.47 (SD = 3.15) years of education and average monthly income of USD 1160.84 (SD = USD 935.07), with arterial hypertension being the most prevalent systemic morbidity (34.7%). Table 1 shows that most of the participants did not show evidence of alcoholism, but 11.9% reported problems related to alcohol use. Most of the participants also reported excellent self-care ability. Table 1. Evaluation of alcohol use/abuse (MAST-G) and self-care abilities (SASCA) of elderly people enrolled at the Open University for Elderly People (n = 101).
It is noted in Table 2, that males had a higher percentage of problems related to alcohol use than females.  Gender ** n (%) Men 6 (50%) 6 (50%) 12 Table 3 shows there was no significant influence of the sociodemographic variables (age, sex, education, self-reported skin color, marital status, family income and occupation) on the domains of the Self-Care Ability Scale (SASCA) (good, very good and excellent).   Table 4 below shows that there was no significant association between the domains of the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) and the Self-Care Ability Scale.

Discussion
The aim of this study was to verify the relationship between alcohol use, abuse, and possible dependence with self-care ability in the elderly during the coronavirus outbreak. Most of the participants were female, with good education, income level, and self-care ability. In total, approximately 12% had problems related to alcohol use. Elderly males had a higher level of problems related to alcohol use than females. There was no significant association between sociodemographic variables and the domains of the Self-Care Ability Scale. There was also no significant association between the domains of the MAST-G and SASCA.
In this research, the volunteers had a high socioeconomic level. This may have influenced the results found. Frequency of eating, drinking, and the type of alcohol consumed tends to vary according to the socioeconomic group. Lower socioeconomic status groups tend to consume less alcohol and are more likely to be abstainers than high socioeconomic status groups. However, low socioeconomic status groups tend to suffer more alcohol-related harm. This is mainly due to non-standard differences in alcohol consumption. Low socioeconomic status groups may consume less alcohol overall but are more likely to engage in harmful drinking [23].
The health risks associated with heavy alcohol consumption increase in older people because their physiological tolerance to alcohol decreases. Additionally, the prevalence of some of the main risk factors for alcohol use disorders, such as financial, social, medical, and psychological stressors, is increased in this stage of life [7]. Approximately 12% of older people in our survey reported problems related to alcohol abuse. This result draws attention to the need to invest in mental health treatment programs and provide support for alcohol consumption reduction among the elderly.
Most of the elderly people interviewed showed excellent self-care ability; they displayed knowledge, skills, and experiences to have better autonomy and independence. This could be attributed to being part of a program such as UAPI, which may cause greater empowerment among the elderly as well as increase their capacity to perform activities of daily living. This comes into play in situations where the promotion and maintenance of health and quality of life is important, such as an acute event (a fall, for example) or a chronic condition (living with hypertension, for example) [19,20,22].
In our study, elderly males had a higher percentage of problems related to alcohol consumption when compared to elderly females. Of the total of 12 (100%) men who participated in the study, 6 (50%) had problems with alcohol consumption, whereas of 89 (100%) women who participated in the study, 6 (6.7%) had problems with alcohol consumption. Men consume more alcohol than women, drink more frequently, and are more likely to be hazardous drinkers. The male style of drinking is often more public, less constrained, and more often associated with aggressive or risk-taking behavior and social problems compared to females. Conversely, women are likely to drink at home, with a friend, or with a partner; prefer types of alcoholic beverages with lower alcohol content, such as wine and beer; and have a more controlled style of drinking. Women also become intoxicated less frequently. Women who have children are less likely to engage in alcohol consumption than their male counterparts. Traditionally, gender role attitudes are associated with higher abstinence rates and lower alcohol consumption among women and lower abstinence rates and heavier drinking among men [24]. This result is expected in the context of Brazilian society, since Brazilian men tend to go to places to socialize and drink alcoholic beverages [25]. Alcohol consumption is accepted as a way to learn culturally and socially accepted male codes of conduct [26]. However, currently, the abusive consumption of alcohol is also increasing among women [27,28]. Age, gender, education level, health status, socio-cultural orientation, access to health care, family system, standard of living, environmental aspects, and the availability and adequacy of financial resources may influence the capacity for self-care [18]. However, in this sample, there was no significant association between the sociodemographic variables and the domains of the Self-Care Ability Scale [29].
Abusive alcohol consumption exposes elderly people to greater risks of vulnerability to the development of physical, psychological, and social problems that can negatively impact their self-care ability [30]. However, in this study, there was no significant association between the domains of MAST-G (alcohol consumption) and SASCA (perception of selfcare), in a sample of well-educated, financially stable older adults. This result may be related to the fact that most respondents are women. It is known that men consume a greater amount of alcoholic beverages and present with more damage to health due to alcohol when compared to women [30]. It has also been shown that alcohol use affects people with a low level of education and income to a greater extent [27,28,30]. It should be noted that the elderly people in this study had good education and income. The worst perception of self-care in the elderly community is more present among low-income men. In general, men seek health services less frequently than women; additionally, those with lower incomes tend to adopt lifestyle habits that are harmful to health, because they have a more limited access to information. Additionally, their living conditions may favor the incorporation of behaviors considered unhealthy (such as alcohol abuse). The above reasons all may contribute to worse self-care perceptions [31].
For this study, we used the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G). The results found for the Brazilian version of the MAST-G indicate that this instrument is quite robust and reliable for detecting problems associated with alcohol abuse or dependence in the elderly. In evaluating the reliability of the MAST-G, a Cronbach's Alpha value of 0.7873 was found. The translation of the instrument into Portuguese did not change the specificity and sensitivity observed in the MAST-G in English [21].
The Alcohol Use Disorder Identification Test (AUDIT) has also already been validated in Brazil and allows for the early identification of people at risk for alcohol use. The validated study in Brazil provided a sensitivity and specificity of 91.8 and 62.3%, respectively [32]. We chose the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) because it has the advantage of addressing perceptions about the health and risk behaviors of the elderly, as well as the damage caused by alcohol consumption, in addition to having been developed especially for seniors [32].

Study Limitations
The limitations of this research are related to the cross-sectional design of the study, which makes it impossible to identify the temporal precedence of the factors studied, compromising cause-and-effect relationship conclusions. In addition, another limiting factor is not having the volunteers' data before the coronavirus pandemic to be able to compare and assess whether the pandemic has worsened the scenario. The other factor is that our sample, like other programs for the elderly, is composed predominantly of female participants. Women, in general, take better care of themselves than men and also use less alcohol. It should be noted that in this study, alcohol abuse was higher among men. This is a result that shows the importance of working on this situation of alcohol abuse in the male population during the aging process. Our sample, because it was for convenience, can be biased since we evaluated elderly people linked to a health promotion and education program that is recognized as extremely efficient in Brazil, the UAPI. In this program, during the pandemic, elderly people took online classes twice a week, which allows for social interaction, information about various aspects of life, including health, empowerment, and the importance of self-care. Such limitations suggest caution when interpreting the results and extrapolating them to different populations. On the other hand, it reinforces the importance of health promotion and education programs for the elderly.

Practical Applications
This study contributes to the knowledge about the use and abuse of and probable dependence on alcohol among elderly people assisted by a community program. Users evaluated at UAPI had good educational and economic status, which are very important factors for self-care ability and good lifestyle habits. Despite this, approximately 12% of the elderly people in the program reported problems related to alcohol abuse. This may be associated with, to some extent, the difficulties elderly people faced during the coronavirus pandemic. Alcohol abuse could be employed as a negative coping strategy. Preventive and harm-reduction strategies associated with alcohol abuse among the elderly are very important. Health professionals and services that aim to serve the elderly population need-in addition to adapting their services and interventions in accordance with the new guidelines for the prevention of the transmission of the new coronavirus-to implement effective health promotion strategies aimed at the elderly for adoption and/or maintenance of self-care, such as telephone consultations, video calls, or stimulating online social interaction opportunities, such as the UAPI, to monitor this population.

Conclusions
Although we did not observe any significant association between the domains of the MAST-G and the domains of the Capacity for Self-Care Scale, it is important to emphasize the need to have educational and promotional programs for health aimed at the elderly population for the prevention and tracking of non-daily alcohol abuse in this normal population. These programs face even more challenging scenarios such as the COVID-19 pandemic, having to account for social/psychological stressors involved. This may cause the adoption of negative lifestyle strategies, such as alcohol abuse.
One hypothesis to be tested, based on the results of this study, is to compare elderly people using UAPI with those who do not, as our findings may be related to the fact that elderly people attend a health promotion and education program and consequently tend to have healthier life habits, such as a lesser frequency of alcohol use and abuse, and a consequently reduced rate of morbidity, greater autonomy, and increased independence.