Alcohol consumption/dependence and resilience in older adults with high blood pressure

ABSTRACT Objective: to evaluate alcohol consumption/dependence and resilience in older adults with high blood pressure and to analyze the factors associated with these variables. Method: a descriptive, cross-sectional, quantitative study developed with 300 older adult patients with high blood pressure from Family Health Strategy units in a municipality of Minas Gerais, Brazil. A semi-structured questionnaire called the Alcohol Use Disorder Identification Test and the Resilience Scale were used. Data were analyzed using the Pearson’s chi-square test, Fisher’s exact test, Cronbach’s alpha, odds ratio and logistic regression. Results: 89.3% of the interviewees were low-risk for consuming alcoholic beverages. The variables gender, age, smoking and disease duration were significantly associated with alcohol consumption/dependence. 36.7% of the people presented a low resilience. The variables family and individual monthly income, education level, physical activity and leisure had an association with resilience. No statistically significant association was observed between alcohol consumption/dependence and resilience. Conclusion: alcohol consumption and resilience can interfere with the physical and mental health of older adults with high blood pressure.


Introduction
The Brazilian population has undergone transformation processes characterized by significant changes in its demographic regime. The levels and patterns of vital events, fecundity and mortality experienced in all regions of the country have been changing rapidly in recent decades, implying in challenges and opportunities for society ( ¹ ) . Along with this phenomenon, the numbers of non-transmissible chronic diseases such as high blood pressure (HBP) (2) and alcohol consumption by the older adult population have also increased (3)(4)(5) .
North American data from 2015 established a relationship between HBP and acute myocardial infarction in 69% of cases, as well as in 77% of cases of hemorrhagic stroke, 75% of heart failure, and was also responsible for 45% of cardiac deaths and 51% of deaths due to hemorrhagic stroke. In Brazil, HBP affects approximately 36 million adult individuals and more than 60% of the older adult population, with high impact on loss of labor productivity and family income (6)(7) . Therefore, we can highlight the need for nurses to seek early identification of diseases and complications that may negatively impact adherence to HBP treatment, such as the presence of comorbidities (8) .
In this context, it should be noted that alcohol use among older adults is simultaneously increasing with the growth of this population. Thus, alcoholism can be responsible for serious social issues, representing a little studied and diagnosed public health problem in certain populations. Studies related to alcohol consumption are very concentrated among young people/adults, demanding new perspectives for this problem with the adoption of appropriate identification and treatment techniques among the older adult population (9) .
In many situations it is necessary for the individual to use strategies to cope with events in their life, including the onset of illness or changes to their lifestyle. Thus, the personality trait known as resilience is understood as the healthy and positive development of the individual influenced by social and intrapsychic processes, even when experiencing unfavorable experiences. In this sense, resilience involves interaction between adverse life events and internal and external protective factors of each individual (10) .
A study conducted with 2,024 adults in Atlanta, USA, assessed the relationship between alcohol and resilience, and found that individuals with low resilience presented higher rates of problems related to alcohol consumption/dependence, tobacco and other drugs (11) .
For older adults, resilience also appears as a protective factor for abuse of harmful substances such as alcohol consumption. In contrast, it has been identified as one of the factors which contribute to successful aging, which refers to the way the elderly achieve and maintain their sense of well-being despite the natural difficulties that appear with aging. At this stage of life, resilience is related to greater social engagement, greater optimism, and functional independence (8) .
Thus, if resilience in older adults with HBP is strengthened, they are expected to seek periodic followup for their chronic condition and to correctly follow drug and non-drug treatment, with the abandonment of alcoholism among the treatments, in order to achieve successful aging (9) .
Despite identifying the importance of this subject, studies that address resilience and alcohol consumption/ dependence in older adults with HBP are still scarce, which justifies the search for knowledge in this area in order to elucidate the prevalence and influence of these factors at this stage of life, and thus contribute to improving nursing care to this portion of the population.
Based on this information, nurses can develop actions to promote resilience such as stimulus to self-esteem, as well as contribute to preventing, reducing or abandoning the consumption of alcoholic beverages. All these actions will favor controlling blood pressure levels in the older adult population and contribute to their social and individual well-being, as well as improving the quality of life of this population.
Thus, the objective of the present study was to evaluate alcohol consumption/dependence and the resilience of older adults with high blood pressure attended by Family Health Teams of a municipality in the South of Minas Gerais, and to analyze the factors associated with these variables. The study population consisted of 1092 older adults who only presented HBP as a chronic disease.

Method
The following inclusion criteria were adopted: being 60 years old or more; belonging to a population assigned to one of the five urban Family Health Teams of this municipality; presenting high blood pressure; and not having any another chronic diseases. A proportional stratified random sample for each of the five ESFs was calculated based on these criteria and the total population, thus totaling a sample of 300 people. The sample size was calculated using 95% confidence and Dullius AAS, Fava SMCL, Ribeiro PM, Terra FS. 5% error, and the BioEstat 5.3 program was used for the random selection of the older adults who composed this sample.
To perform the data collection, the nurses of the ESF under study were asked to list all the older adults with HBP who are part of the coverage area of each team. The people who composed the sample and who were invited to participate in the present study were then randomly drawn based on this list and according to the sample size calculation. After the draw, the researcher subsequently communicated with the selected individuals to schedule the best time to apply the instruments.
It should be noted that the interviews for data collection were carried out at the interviewee's home due to the fact that the study population consisted of older adults who could present visual or reading difficulties or difficulties in filling out the instruments. latest version was used in the present study (12) . The classification based on the sum of the ten answers is: a score between 0 to 7 points as low-risk use; a score between 8 to 15 points as risky use; a score between 16 to 19 points as harmful use; and a score between 20 to 40 points as probable dependence.
A third instrument called the Resilience Scale, developed in 1993 in English and translated and validated in Portuguese in 2005, was used to evaluate resilience (13) . The instrument has 25 items, positively described with Likert-type responses ranging from 1 (totally disagree) to 7 (totally agree). The scoring on this scale can vary from 25 to 175 points, corresponding to: values greater than 145 indicate moderately high to high resilience; 125 to 145 refer to moderately low to moderate resilience levels; and values equal to or less than 124 points correspond to low resilience (14) .
The data collected by the instruments were inserted by double entry into the Statistical Package for Social Science (SPSS) version 20.0 software in order to avoid transcription errors and for descriptive and inferential statistical analysis.
To assess the reliability of the AUDIT Scale and the Resilience Scale, Cronbach's Alpha Coefficient was used to evaluate the internal consistency and whether the data collected correlated to one another.
In order to facilitate the statistical analysis of the data and the comparisons, some independent variables were regrouped. It should be noted that the variable alcohol consumption/dependence was recoded as two categories for the associations: low risk use x risky use.
Likewise, the resilience variable was also recoded as two categories with the same intention: low resilience x moderately low to moderate resilience, and moderately high to high resilience.
In addition, Pearson's Chi-square test or Fisher's exact test were used to verify the association between alcohol consumption/dependence and independent variables, the resilience measurement with the independent variables, and also the alcohol consumption/ dependence variable and the resilience.
The study adopted a significance level of 5%, meaning all data were statistically significant for P<0.05.
After these analyzes, the odds ratio of the independent variables with alcohol consumption/ dependence and resilience was estimated. Next, the logistic regression model of the independent variables with alcohol consumption/dependence and resilience was used.

Results
The sample mostly consisted of female older When assessing the distribution of older adults with HBP according to the classification of the AUDIT scale, it was possible to verify that 89.3% of the interviewees had low-risk consumption of alcoholic beverages, 6.0% had risky consumption and 2.0% had harmful consumption. It should be noted that 2.7% of the older adults presented a probable dependence for alcohol consumption.  literacy. In addition, respondents who did not perform physical activity were 3 times more likely to have lower resilience than those who did. And finally, the subjects who experienced some significant event in their life were approximately 2 times less likely to present low resilience than those who did not experience any of these events.
Dullius AAS, Fava SMCL, Ribeiro PM, Terra FS. Table 3 shows the analysis of the association between alcohol consumption/dependence with resilience.
When assessing the association between the variables alcohol consumption/dependence and resilience among the older adults with HBP, no significant association was observed between these two variables (p=0.205). However, it is possible to identify that an expressive percentage of the evaluated subjects had risky consumption of alcoholic beverages and presented low resilience (46.9%).  influenced the low alcohol consumption among these women after the aging process (18) .
Regarding the age group, it should be mentioned that there is a decrease in alcohol consumption in old age, and the greater the age, the lower the frequency of its consumption. This is due to some factors such as premature death of people who have used alcohol throughout their lives, moderation or discontinuation in consuming the substance due to increased sensitivity to the effects of alcohol or aspects that influence older adults not reporting their alcohol consumption, and/or decreased investigation by the health team (19) .
Similarly to alcohol consumption, smoking can harm older adult's health, resulting in various social and economic problems in the country. The literature establishes an association between alcohol consumption and tobacco (20) .
Another research further revealed that there are a growing number of older adults who have comorbidities such as HBP and diabetes mellitus, and take daily medications to control these diseases, but who (also) consume alcoholic beverages as a coping strategy for their health condition (21) .
In the present study, an association between alcohol consumption/dependence and the fact that some subjects presented a HBP diagnosis for over 20 years was also observed. This finding possibly occurred because people who had a more recent HBP diagnosis were found to be in the initial age group bracket, since consumption of alcoholic beverages decreases with advancing age and HBP diagnosis consequently becomes more frequent in individuals over the years, reaching close to 100% in individuals over 80 years of age (22) . Thus, the older the person is, the longer the they will have been affected by HBP, and therefore the lower the alcohol consumption.
Given this information, it is necessary that nurses understand that the aging process is accompanied by changes in physical, psychological and social aspects of the individual, and that these changes often lead older adults to feeling powerless for depending on family members, generating hopelessness and depression, which makes them more vulnerable to consuming alcoholic beverages (23) . Thus, establishing a relationship of trust between the nursing professional and older adults is essential for detecting inadequate life habits, and with this the necessity of implementing actions to promote the health of this population.
This research found that the variables of education level, individual monthly income, monthly family income, thereby indicating that these are events with a negative connotation in the lives of these individuals. However, some authors clarify that negative experiences can make the person more resilient (28) .
Although no significant association between alcohol consumption/dependence and resilience was found in the study population, it is important to establish the relationship between these variables identified in the literature.
Alcohol consumption can often be considered a coping strategy for stressful life events (29) , especially in people with changes in their mental health such as anxiety, depression and self-esteem (30) . In this context, resilience is an important feature to moderate the association between stress and negative emotions by providing the individual with the ability to adapt to stressful circumstances while maintaining their mental well-being (31) . It should be noted that few studies have been developed to directly verify the relationship between alcohol consumption/dependence and resilience, especially in the older adult population, but those found in the literature indicate an inverse relationship between these two variables, since resilience has been identified as a protective mechanism associated with a reduced risk of consuming alcoholic beverages (31)(32)(33) .
In this context, it is perceived that stressful events are inevitable in life, however the "resilience" characteristic is key for explaining individual differences in psychological and behavioral improvement in confronting these events (31) . Thus, establishing a relationship between changes in self-esteem and negative events in life with alcohol consumption/dependence becomes clear, while resilience appears as a protective mechanism for these events that affect mental health and mitigate the impact of negative emotions, and thus reduce the consumption of alcoholic beverages (33) . This statement was not confirmed in the present study since a relationship between alcohol consumption/dependence and resilience in the older adults with HBP was not observed; a fact that can be explained by the different sociodemographic and economic characteristics of the study population, thus suggesting that new studies be conducted in different older adult populations.
It is worth mentioning that resilience can be improved through active learning. However, we point out that until now it has only been slightly stimulated in health services for preventing and treating alcohol consumption/dependence (34) .
As a limitation of the study we can point out the cross-sectional design of the research, which does not enable verifying the cause-effect relationship of the results found; however, it was possible to characterize and associate independent variables with dependent variables by observing the situation of the older adults Rev. Latino-Am. Enfermagem 2018;26:e3024.
with HBP at that moment. Another aspect that presented limitations refers to sampling, since a collection was not performed with all older adults with HBP; nevertheless, conducting a study with the total population would be difficult due to the high number of people with these characteristics. We emphasize that a sample calculation using a statistical program was adopted, thereby selecting a representative sample for this population.

Conclusion
It has been found that most of the evaluated older adults are at low-risk for consuming alcoholic beverages.
However, older adults who present risky consumption, harmful alcohol use and even a likely dependency for consuming alcohol have been identified. In addition, it was found that most of these people have moderately low to moderate resilience. It should be emphasized that a relevant percentage of those interviewed were classified with low resilience. No statistically significant association between alcohol consumption/dependence and resilience were identified in the present study.
We additionally emphasize that this study may