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I know a little Elizabeth, I think she is about a year old now. She has a sister named Catherine. They go by Elizabeth and Catie.

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I know lots and lots and lots who are all 20+ years old. Almost all of the ones aged 20-40 go by Lizzie exclusively. A few go by Ellie. I also know one who goes by Libby.

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Of the ones who are 40+ many go by Beth or Liz. I also know one who goes by Betty.

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The little one year old is the only one who goes by her full name. I think you don't hear the full name very much and the reason why it stayed common for so long is because the nicknames went in and out of style and the full name stayed a classic without sounding dated.

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Personally I think it is starting to sound a bit tired, kind of like Katherine. I also think that like Katherine and Mary which were common for ages it will soon fall.

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Ohhh and I wouldn't use it as a middle name, it is one of the most common middle names ever together with Rose, Anne and Marie. I know so many! I know two Ava Elizabeths who were born recently, and many many more. It is THE filler middle name of the 80s and 90s, in my opinion, and still being used a lot.

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Alice Elizabeth - Alice needs a more interesting middle name. It doesn't flow well because of the -li sounds that are repeated in the combo and sound very similar.
Ophelia Elizabeth - this works because Ophelia is uncommon and it flows. But it is still overused in the middle in general.
Imogen Elizabeth - same
Elizabeth Margot - this works
Elizabeth Caroline - this doesn't because Caroline is also common. I would always pair Elizabeth with something a bit unusual.

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Oh and I am surprised it was still in the top 10 or 20 in the past 20 years because pretty much all the Elizabeths I know are 20+.