Potential for adverse drug-alcohol interactions among retirement community residents

Prevalence of potentially serious alcohol-medication interactions in older adults in a community pharmacy setting: a cross-sectional study

OBJECTIVE

Previous prevalence estimates of POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) are based on in-home inventories of medications; however, this method is associated with under-reporting of medications when compared with dispensing records. This study aims to estimate the prevalence of POSAMINO among community-dwelling older adults using drug dispensing data from the community pharmacy setting.

DESIGN

Cross-sectional study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

1599 consecutive older adults presenting with a prescription to 1 of 120 community pharmacies nationwide; community-dwelling, aged ≥65 years, able to speak and understand English, with no evidence of cognitive impairment. The mean age of sample was 75.5 years (SD 6.5); 55% (n=884) female.

MEASURES

38 POSAMINO criteria were identified using participants' pharmacy dispensing records linked to self-reported alcohol consumption (beverage-specific quantity and frequency measures) over the last 12 months.

RESULTS

The overall prevalence of POSAMINO in the study population was 28%, with 10% at risk of at least one POSAMINO criteria and 18% at risk of two or more. Exposure to POSAMINO most commonly involved cardiovascular agents (19%) and central nervous system agents (15%). Exposure to a higher number of POSAMINO criteria was associated with younger age (adjusted incident rate ratio (AIRR): 0.97; 95% CI: 0.95 to 0.98), male sex (AIRR: 0.55; 95% CI: 0.45 to 0.67) and a higher number of comorbidities (AIRR: 1.05; 95% CI: 1.01 to 1.13).

CONCLUSION

This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol-medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.

'I take my tablets with the whiskey': A qualitative study of alcohol and medication use in mid to later life

Background

Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.

Methods

Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England.

Results

Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication.

Conclusions

As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use.

Consensus validation of the POSAMINO (POtentially Serious Alcohol-Medication INteractions in Older adults) criteria

OBJECTIVES

Older adults are particularly vulnerable to adverse effects from concurrent alcohol and medication use. However, there is limited evidence regarding the prevalence of these adverse outcomes among older adults, and there is a lack of consensus regarding what constitutes an alcohol-interactive medicine. The objective of this study was to develop an explicit list of potentially serious alcohol-medication interactions for use in older adults.

DESIGN

Following a systematic review, review of drug compendia and clinical guidance documents, a two-round Delphi consensus method was conducted.

SETTING

Ireland and the United Kingdom (UK), primary care and hospital setting.

PARTICIPANTS

The Project Steering Group developed a list of potentially serious alcohol-medication interactions. The Delphi panel consisted of 19 healthcare professionals (general practitioners, geriatricians, hospital and community pharmacists, clinical pharmacologists and pharmacists, and physicians specialising in substance misuse).

RESULTS

An inventory of 52 potentially serious alcohol-medication interactions was developed by the Project Steering Group. British National Formulary black dot warnings (n=8) were included in the final criteria as they represent 'potentially serious' interactions. The remaining 44 criteria underwent a two-round Delphi process. In the first round, 13 criteria were accepted into the POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) criteria. Consensus was not reached on the remaining 31 criteria; 9 were removed and 8 additional criteria were included following a review of panellist comments. The remaining 30 criteria went to round 2, with 17 criteria reaching consensus, providing a final list of 38 potentially serious alcohol-medication interactions: central nervous system (n=15), cardiovascular system (n=9), endocrine system (n=5), musculoskeletal system (n=3), infections (n=3), malignant disease and immunosuppression (n=2), and respiratory system (n=1).

CONCLUSIONS

POSAMINO is the first set of explicit potentially serious alcohol-medication interactions for use in older adults. Following future validation studies, these criteria may allow for the risk stratification of older adults at the point of prescribing.

Concurrent use of alcohol interactive medications and alcohol in older adults: a systematic review of prevalence and associated adverse outcomes

BACKGROUND

Older adults are susceptible to adverse effects from the concurrent use of medications and alcohol. The aim of this study was to systematically review the prevalence of concurrent use of alcohol and alcohol-interactive (AI) medicines in older adults and associated adverse outcomes.

METHODS

A systematic search was performed using MEDLINE (PubMed), Embase, Scopus and Web of Science (January 1990 to June 2016), and hand searching references of retrieved articles. Observational studies reporting on the concurrent use of alcohol and AI medicines in the same or overlapping recall periods in older adults were included. Two independent reviewers verified that studies met the inclusion criteria, critically appraised included studies and extracted relevant data. A narrative synthesis is provided.

RESULTS

Twenty studies, all cross-sectional, were included. Nine studies classified a wide range of medicines as AI using different medication compendia, thus resulting in heterogeneity across studies. Three studies investigated any medication use and eight focused on psychotropic medications. Based on the quality assessment of included studies, the most reliable estimate of concurrent use in older adults ranges between 21 and 35%. The most reliable estimate of concurrent use of psychotropic medications and alcohol ranges between 7.4 and 7.75%. No study examined longitudinal associations with adverse outcomes. Three cross-sectional studies reported on falls with mixed findings, while one study reported on the association between moderate alcohol consumption and adverse drug reactions at hospital admission.

CONCLUSIONS

While there appears to be a high propensity for alcohol-medication interactions in older adults, there is a lack of consensus regarding what constitutes an AI medication. An explicit list of AI medications needs to be derived and validated prospectively to quantify the magnitude of risk posed by the concurrent use of alcohol for adverse outcomes in older adults. This will allow for risk stratification of older adults at the point of prescribing, and prioritise alcohol screening and brief alcohol interventions in high-risk groups.

Assessing the Usability of Web-Based Alcohol Education for Older Adults: A Feasibility Study

BACKGROUND

Older adults can experience unfavorable health effects from drinking at relatively low consumption levels because of age-related physiological changes and alcohol's potentially adverse interactions with declining health, increased medication-use and diminishing functional status. At the same time, alcohol use in older adults may be protective against heart disease, stroke, and other disorders associated with aging. We developed "A Toast to Health in Later Life! Wise Drinking as We Age," a web-based educational intervention to teach older adults to balance drinking risks and benefits.

OBJECTIVE

To examine the intervention's feasibility in a sample of community-dwelling current drinkers ≥55 years of age and examine its effects on their quantity and frequency of alcohol use, adherence to standard drinking guidelines, and alcohol-related risks.

METHODS

Participants were recruited in person, by mail and by telephone between September and October 2014 from a community-based social services organization serving Los Angeles County. Once enrolled, participants were randomly assigned to the intervention or to a control group. The conceptual frameworks for the intervention were the Health Belief Model, models of adult learning, and the US Department of Health and Human Services guidelines for designing easy-to-use websites. The intervention's content focuses on the relationship between drinking and its effects on older adults' medical conditions, use of medications, and ability to perform daily activities. It also addresses quantity and frequency of alcohol use, drinking and driving and binge drinking. The control group did not receive any special intervention. Data on alcohol use and risks for both groups came from the online version of the Alcohol-Related Problems Survey and were collected at baseline and four weeks later. Data on usability were collected online from the intervention group immediately after it completed its review of the website.

RESULTS

The 49 intervention and 47 control participants did not differ at baseline in age, ethnicity, medication use, medical conditions, or alcohol use and both groups were mostly female, college-educated, and in good health. Of the intervention participants, 94% (46/49) had little or no difficulty using the website, with 67% (33/49) reporting that they will change the way they think about drinking because of their exposure to the education. At the 4-week follow-up, the intervention group reported drinking less (P=.02). No changes between groups were found in quantity and frequency, adherence to recommended guidelines, or risk status.

CONCLUSIONS

Community-dwelling older adults are receptive to online alcohol education. To be most effective, the education should be included as a component of a larger effort consisting of screening and counseling preferably in a health care setting.

Ethyl Glucuronide Positivity Rate in a Pain Management Population

Ethanol may be consumed by some patients as a means to manage their pain or psychiatric disorder. Consequently, there is the potential to consider ethanol a co-therapeutic in pain management. The purpose of this study was to perform a retrospective analysis to evaluate the rate of ethanol use in a population of patients in pain management programs that were evaluated by our in-house pain management drug panel test. Results from this retrospective study showed that 12.6% of patients in a pain management population were positive for the direct ethanol metabolite, ethyl glucuronide (EtG), by immunoassay. Furthermore, 86% of the individuals positive for EtG were also positive for prescription pain medication and illicit drugs. Results presented here suggest that ethanol use should be routinely monitored in pain management populations in an effort to determine any potential adverse effects of ethanol-drug interactions and as a way to further evaluate the effect of ethanol on pain management outcomes. Testing this population of patients suggests that ethanol use is prevalent and the risk of drug-ethanol adverse effects should be monitored in a pain management population.

Drinking behavior among older adults at a continuing care retirement community: affective and motivational influences

OBJECTIVES

The purpose of this pilot study was to describe patterns of alcohol consumption among continuing care retirement community(CCRC) residents and to explore the role of drinking motives and affective states on drinking context and consumption.

METHOD

We utilized a phone-based daily diary approach to survey older adults about their daily alcohol consumption, context of drinking (e.g. drinking alone), positive and negative affect, and their motives for drinking. Data were analyzed descriptively, and regression models were developed to examine associations between sociodemographic factors, affect, drinking context and motives, and alcohol consumption.

RESULTS

CCRC residents drank most frequently at home and were alone almost half of drinking days on average, although the context of drinking varied considerably by participant. Problem alcohol use was rare, but hazardous use due to specific comorbidities, symptoms and medications, and the amount of alcohol consumption was common. Respondents endorsed higher social motives for drinking and lower coping motives. Social motives were associated with decreased likelihood of drinking alone, but negative affect was associated with decreased likelihood of drinking outside one's home. Coping and social motives were associated with greater consumption, and higher positive affect was associated with lower consumption.

CONCLUSION

Among CCRC residents, alcohol use may be socially motivated rather than motivated by coping with negative affect. Future research should examine other motives for drinking in older adulthood. Evaluation of older adults living in CCRCs should include attention to health factors beyond problem use as other forms of hazardous use may be common in CCRCs.

Prevalence of alcohol-interactive prescription medication use among current drinkers: United States, 1999 to 2010

BACKGROUND

The majority of Americans consume alcoholic beverages. Alcohol interacts negatively with numerous commonly prescribed medications. Yet, on a population level, little is known about use of alcohol-interactive (AI) prescription medications among drinkers. The purpose of our study was to determine the prevalence of AI prescription medication use among current drinkers in the U.S. population.

METHODS

Data were from the National Health and Nutrition Examination Survey (NHANES 1999 to 2010); 26,657 adults aged ≥20 years had data on past year alcohol consumption and past month prescription medication use. Analyses were adjusted for covariates: age, race/ethnicity, education, marital status, and smoking. Statistical procedures accounted for survey stratification, clustering, and nonresponse. Analyses were weighted to be nationally representative.

RESULTS

The unadjusted total prevalence of AI medication use was 42.8% (95% confidence interval [CI] 41.5 to 44.0). Among current drinkers, adjusted prevalence was 41.5% (CI 40.3 to 42.7). Among participants aged ≥65 total prevalence of AI medication use was 78.6% (CI 77.3 to 79.9) and adjusted prevalence among current drinkers was 77.8% (CI 75.7 to 79.7). The AI medications most commonly used by current drinkers were cardiovascular agents, central nervous system agents, and metabolic agents.

CONCLUSIONS

Our results suggest that there could be substantial simultaneous exposure to alcohol and AI prescription medications in the U.S. population. Given the adverse health risks of combining alcohol with AI prescription medications, future efforts are needed to collect data to determine actual simultaneous prevalence.

Potential for alcohol and drug interactions in older adults: evidence from the Irish longitudinal study on ageing

BACKGROUND

Older adults are susceptible to adverse effects from the concomitant use of prescription medications and alcohol. This study estimates the prevalence of exposure to alcohol interactive (AI) medications and concomitant alcohol use by therapeutic class in a large, nationally representative sample of older adults.

METHODS

Cross-sectional analysis of a population based sample of older Irish adults aged ≥60 years using data from The Irish Longitudinal Study on Ageing (TILDA) (N = 3,815). AI medications were identified using Stockley's Drug Interactions, the British National Formulary and the Irish Medicines Formulary. An in-home inventory of medications was used to characterise AI drug exposure by therapeutic class. Self-reported alcohol use was classified as non-drinker, light/moderate and heavy drinking. Comorbidities known to be exacerbated by alcohol were also recorded (diabetes mellitus, hypertension, peptic ulcer disease, liver disease, depression, gout or breast cancer), as well as sociodemographic and health factors.

RESULTS

Seventy-two per cent of participants were exposed to AI medications, with greatest exposure to cardiovascular and CNS agents. Overall, 60% of participants exposed to AI medications reported concomitant alcohol use, compared with 69.5% of non-AI exposed people (p < 0.001). Almost 28% of those reporting anti-histamine use were identified as heavy drinkers. Similarly almost one in five, combined heavy drinking with anti-coagulants/anti-platelets and cardiovascular agents, with 16% combining heavy drinking with CNS agents. Multinomial logistic regression showed that being male, younger, urban dwelling, with higher levels of education and a history of smoking, were associated with an increased risk for concomitant exposure to alcohol consumption (both light/moderate and heavier) and AI medications. Current smokers and people with increasing co-morbidities were also at greatest risk for heavy drinking in combination with AI medications.

CONCLUSIONS

The concurrent use of alcohol with AI medications, or with conditions known to be exacerbated by alcohol, is common among older Irish adults. Prescribers should be aware of potential interactions, and screen patients for alcohol use and provide warnings to minimize patient risk.

The prevalence of harmful and hazardous alcohol consumption in older U.S. adults: data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES)

BACKGROUND

Alcohol consumption and its interaction with disease, medication use, and functional status may result in serious health problems, but little information exists about the national prevalence of alcohol-related health risk in older adults.

OBJECTIVE

To estimate the prevalence of harmful and hazardous alcohol use and the prevalence of consumption in excess of National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommendations, in people aged 65 and older, and by sex and race/ethnicity sub-group.

DESIGN

Cross-sectional, using data from the 2005-2008 National Health and Nutrition Examination Survey of the non-institutionalized U.S. population.

PARTICIPANTS

One thousand and eighty-three respondents aged 65 and older who consume alcohol.

MAIN MEASURES

Participants' alcohol consumption was classified as Harmful, Hazardous, or Healthwise, in the context of their specific health status, using the Alcohol-Related Problems Survey classification algorithm.

KEY RESULTS

Overall, 14.5 % of older drinkers (95 % CI: 12.1 %, 16.8 %) consumed alcohol above the NIAAA's recommended limits. However, when health status was taken into account, 37.4 % of older drinkers (95 % CI: 34.9 %, 40.0 %) had Harmful consumption and 53.3 % (95 % CI: 50.1 %, 56.6 %) had either Hazardous or Harmful consumption. Among light/moderate drinkers, the proportions were 17.7 % (95 % CI: 14.7 %, 20.7 %) and 28.0 % (95 % CI: 24.8 %, 31.1 %), respectively. Male drinkers had significantly greater odds of Hazardous/Harmful consumption than female drinkers (OR = 2.14 [95 % CI: 1.77, 2.6]). Black drinkers had worse health status and significantly greater odds of Hazardous/Harmful consumption than white drinkers (OR = 1.49; 95 % CI: 1.02, 2.17), despite having no greater prevalence of drinking in excess of NIAAA-recommended limits.

CONCLUSION

Most older Americans who drink are light/moderate drinkers, yet substantial proportions of such drinkers drink in a manner that is either harmful or hazardous to their health. Older adults with risky alcohol consumption are unlikely to be identified by health care providers if clinicians rely solely on whether patient consumption exceeds the NIAAA-recommended limits.

Development of an Australian version of the Alcohol-Related Problems Survey: a comprehensive computerised screening tool for older adults

AIM

The Alcohol-Related Problems Survey (ARPS) reliably classifies drinking as non-hazardous, hazardous or harmful using scoring algorithms that consider quantity and frequency of alcohol use alone and in combination with health conditions, medication-use and functional status. Because it has been developed using a 14-g US standard drink, it is not valid in Australia where a standard drink contains 10 g of ethanol.

METHOD

We recalibrated the ARPS scoring algorithms for a 10-g Australian standard drink and updated the list of medications. The Australian ARPS (A-ARPS) was then administered to 50 non-treatment-seeking participants in waves of five.

RESULTS

The A-ARPS recalibrated scoring algorithms reliably classified all 50 individuals. Sixty-six per cent were classified as hazardous or harmful drinkers. Many were taking medications that interact with alcohol or had medical conditions that can be exacerbated by alcohol consumption.

CONCLUSION

The A-ARPS is available for use in Australia. Its utilisation could reduce the incidence of alcohol-related harms.

The Pharmacokinetics and Pharmacodynamics of Ximelagatran, an Oral Direct Thrombin Inhibitor, Are Unaffected by a Single Dose of Alcohol

Ximelagatran-a direct thrombin inhibitor rapidly converted to its active form, melagatran, after oral administration-is being developed for the prevention and treatment of thromboembolic disease. The pharmacokinetics, pharmacodynamics, and tolerability/safety of ximelagatran following a single 36-mg oral dose of ximelagatran +/- a single oral dose of alcohol (0.5 and 0.6 g ethanol/kg to women and men, respectively) were assessed in a randomized, open-label, two-way crossover study (n = 26). The 90% confidence intervals (CIs) and least squares mean estimates for the ratio of ximelagatran plus alcohol to ximelagatran alone for melagatran AUC (1.04 [90% CI = 1.00-1.08]) and C(max) (1.08 [90% CI = 1.03-1.14]) fell within the bounds demonstrating no interaction. Alcohol did not alter the melagatran-induced prolongation of the activated partial thromboplastin time or the good tolerability/safety profile of ximelagatran. In conclusion, the pharmacokinetics, pharmacodynamics, and tolerability/safety of oral ximelagatran were not affected by alcohol.

Prevalence of concomitant use of alcohol and sedative-hypnotic drugs in middle and older aged persons: a systematic review

OBJECTIVE

To systematically review the prevalence of concomitant alcohol and sedative-hypnotic use among middle-aged and older persons.

DATA SOURCES

A bibliographic search of English-language literature was performed using MEDLINE, EMBASE, and PsycINFO (January 1990-August 2012). The reference lists of all included articles were screened for additional relevant articles not identified by any of the bibliographic searches.

STUDY SELECTION AND DATA EXTRACTION

Population-based studies in which the mean age of participants was 40 years or older were included. For a study to be included in the review, alcohol use had to be reported in terms of the quantity or frequency consumed. Data from included articles were extracted using a standardized data extraction tool.

DATA SYNTHESIS

Five population-based studies conducted in North America, 10 in Europe, and 1 in Australia were included in the review. Up to 88% of men and 79% of women who used sedative-hypnotics also consumed alcohol. Up to 28% of those who consumed alcohol were concomitant users of sedative-hypnotics. Alcohol was consumed at higher levels among middle-aged than older persons. Risky drinking (eg, binge drinking, heavy drinking) was more prevalent among middle-aged than older persons. In contrast, sedative-hypnotic use was more prevalent among older persons.

CONCLUSIONS

Our review identified a higher prevalence of alcohol consumption among middle-aged than older persons. However, middle-aged persons may experience harm from alcohol/sedative-hypnotic drug interactions due to risky drinking behavior. Despite lower levels of alcohol consumption, older persons may be more susceptible to addictive central nervous system effects than younger persons because of physiologic changes in psychotropic drug and alcohol metabolism. Clinicians should consider patients' alcohol consumption patterns before prescribing sedative-hypnotic drugs.

Heavy drinking and use of sedative or anxiolytic drugs among aging men: an 11-year follow-up of the FinDrink study

BACKGROUND

Most studies on heavy drinking and sedative/anxiolytic drug use have been cross-sectional, and evidence for a possible temporal association is lacking.

OBJECTIVE

To prospectively investigate whether heavy drinking predicts initiation, continuation, or discontinuation of sedative/anxiolytic drugs at 4 and 11 years and, conversely, whether sedative/anxiolytic drug use predicts heavy drinking.

METHOD

This was a longitudinal population-based study conducted in Kuopio, Finland. An age-stratified random sample of 1516 men aged 42, 48, 54, and 60 years received a structured clinical examination at baseline (August 1986-December 1989). Follow-up clinical examinations were conducted at 4 (n = 1038) and 11 (n = 854) years. Multinomial logistic regression was used to compute odds ratios and 95% confidence intervals for the association between sedative/anxiolytic drug use and initiation, continuation, and discontinuation of heavy drinking (≥ 14 drinks/wk). The reverse association between heavy drinking and sedative/anxiolytic drug use was also investigated. Regression models were adjusted for age, working status, smoking, and depressive symptoms.

RESULTS

At baseline 12.9% (134/1038) of participants were heavy drinkers and 4.0% (41/1030) used sedative/anxiolytic drugs. In multivariate analyses, baseline heavy drinking predicted initiation of sedative/anxiolytic drug use at 4 years (OR 2.96; 95% CI 1.23 to 7.15). Conversely, baseline sedative/anxiolytic drug use predicted continuation of heavy drinking at 11 years in unadjusted analysis (OR 3.30; 95% CI 1.19 to 8.44). However, the association was not statistically significant in adjusted analyses (OR 2.69; 95% CI 0.86 to 8.44).

CONCLUSIONS

The main finding of this study was the association between heavy drinking and subsequent initiation of sedative/anxiolytic drugs that was not fully explained by baseline depressive symptoms. This may inform strategies to optimize the use of sedative/anxiolytic drugs, and assist in the early identification of patients at risk of heavy drinking. Clinicians should consider a patient's alcohol consumption prior to prescribing or dispensing sedative/anxiolytic drugs. Clinicians should also monitor patients prescribed sedative/anxiolytic drugs for subsequent heavy drinking.

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.

Alcohol use among older adults

Alcohol use is common in older adults and is associated with numerous health and social problems. Recent evidence suggests that in addition to level of alcohol consumption, drinking pattern may also be important. Moderate alcohol intake may confer some cardiac benefits, while heavy episodic drinking seems particularly problematic. Detecting alcohol misuse in older adults is difficult since clinical acumen is often poor, screening questionnaires have serious limitations and laboratory tests are not diagnostic. Brief alcohol interventions to reduce alcohol consumption appear useful in younger populations, but are less studied in older adults. While there is increasing research into the issue of alcohol use among older adults, clinicians and policy-makers must rely on limited evidence when making clinical decisions.

Older adults' health and late-life drinking patterns: a 20-year perspective

OBJECTIVES

This study focused on the associations between older adults' health-related problems and their late-life alcohol consumption and drinking problems.

METHODS

A sample of 719 late-middle-aged community residents (55-65 years old at baseline) participated in a survey of health and alcohol consumption and this survey was followed 10 years and 20 years later.

RESULTS

Health-related problems increased and alcohol consumption and drinking problems declined over the 20-year interval. Medical conditions, depressive symptoms, medication use, and acute health events were associated with a higher likelihood of abstinence; acute health events were also associated with less alcohol consumption. In contrast, reliance on alcohol to reduce pain was linked to more alcohol consumption. Moreover, an individual's overall health burden and reliance on alcohol to reduce pain were associated with more drinking problems. Reliance on alcohol to reduce pain potentiated the association between health burden, alcohol consumption and drinking problems.

CONCLUSION

Older adults who have more health problems and rely on alcohol to manage pain are at elevated risk for drinking problems. Health care providers should target high-risk older adults, such as those who drink to reduce pain, for screening and brief interventions to help them identify new ways to cope with pain and curtail their drinking.

Treated and untreated remission from problem drinking in late life: post-remission functioning and health-related quality of life

OBJECTIVE

To evaluate the post-remission status of older remitted problem drinkers who achieved stable remission without treatment.

METHOD

The post-remission drinking behavior, health-related functioning, life context, coping, and help-seeking of older, untreated (n=330) and treated (n=120) former problem drinkers who had been remitted for a minimum of 6 years were compared twice over the course of 6 years to each other and to lifetime nonproblem drinkers (n=232). Analyses considered the impact of severity of drinking problem history.

RESULTS

Untreated remitters were more likely than treated remitters to continue to drink, exhibited fewer chronic health problems and less depressive symptomatology, and were less likely to smoke. Untreated remitters' life contexts were somewhat more benign than those of treated ones, and they were less likely to describe a coping motive for drinking and engage in post-remission help-seeking. Although untreated remitters more closely resembled lifetime nonproblem drinkers than did treated remitters, both untreated and treated remitter groups exhibited worse health-related functioning, more financial and interpersonal stressors, and more post-remission help-seeking than did lifetime nonproblem drinkers.

CONCLUSIONS

Regardless of whether late-life remission was gained without or with treatment, prior drinking problems conveyed a legacy of health-related and life context deficits.

Alcohol use and testing among older trauma victims in Maryland

BACKGROUND

Few studies have examined alcohol use in the older trauma population. The purpose of the present study was to examine blood alcohol level testing and results among older trauma patients.

METHODS

All patients aged 65 years or older directly admitted from the injury scene and entered into the Maryland Trauma Registry during a 6-year period were reviewed.

RESULTS

The annual proportion of directly admitted patients of age 65 or older increased by 44% from 1996 to 2000. Blood alcohol concentration (BAC) was measured for 66% of older patients; 9% were alcohol positive, and 81% had BAC > or = 80 mg/dL. Mean BAC was 165 mg/dL for all alcohol-positive patients. The highest mean BAC was noted in patients with fall-related injuries, followed by pedestrians struck, then by those in a motor vehicle crash. The most common cause of injury was motor vehicle crash (47%). Among all injury causes, patients with fall-related injuries had the greatest proportional increase from 28% in 1996 to 44% in 2000. Alcohol positive status was most frequent (13%) and mean BAC was highest among patients admitted because of fall-related injuries.

CONCLUSION

Identifying and addressing alcohol use problems remains an important injury prevention measure for the older trauma population.

Risk drinking behavior among psychotropic drug users in an aging Finnish population: the FinDrink study

Psychotropic drug use and alcohol consumption is increasing among aging Finns. Alcohol use is not recommended with benzodiazepines and some other psychotropic medicines. Concomitant use may lead to accidents and other serious consequences. The aim of this study was to analyze the drinking behavior of psychotropic drug users in an aging Finnish population. This study is part of the ongoing epidemiologic FinDrink study. Self-reported data on alcohol consumption and psychotropic drug use were collected from the Kuopio Ischaemic Heart Disease Risk Factor Study examinations conducted in 1998-2001. Overall, 854 men and 920 women participated in the study. A total of 204 (11.5%) individuals used psychotropic drugs regularly (14.2% of women and 8.5% of men; P<.001). Three quarters of the study population had used alcohol weekly during the preceding year (68.9% of women and 87.5% of men; P<.001). Men who use anxiolytics and sedatives were more likely to drink alcohol at least twice a week (odds ratio=2.42; 95% confidence interval=1.30-4.51), to be binge drinkers (odds ratio=1.86; 95% confidence interval=1.01-3.43) and to be heavy alcohol consumers (odds ratio=2.22; 95% confidence interval= 1.13-4.39) than men not using psychotropics. In women, alcohol consumption and drinking patterns were same between the groups. Our results indicate the potential for alcohol-related health risks among aging Finnish men and women using psychotropic drugs.

The use of alcohol and medicines among Australian adults

OBJECTIVE

To collect Australian population-based data on concurrent use of conventional medicines, complementary/alternative medicines (CAM), and alcohol.

METHOD

National survey administered in December 2005 to 816 Australian adults.

RESULTS

71% of respondents reported recent (last 24 hour) use of conventional medicine or CAM. 24% had recently consumed alcohol and conventional medicine, 17% alcohol and CAM and 13% alcohol and both types of medicines. Use of blood pressure and arthritis medicines was significantly more likely among daily drinkers than less than daily drinkers and non-drinkers.

CONCLUSIONS

Concurrent use of medicines and alcohol is common, particularly among older people.

IMPLICATIONS

Use of alcohol may have an impact on the stability of chronic illness managed by medicines or other types of interactions with medicines, such as sedation. Health care professionals should routinely inquire about such use to be able to incorporate appropriate safety strategies into clinical management.

Risks of combined alcohol/medication use in older adults

BACKGROUND

Many older adults (ie, those aged >65 years) drink alcohol and use medications that may be harmful when consumed together.

OBJECTIVE

This article reviews the literature on alcohol and medication interactions, with a focus on older adults.

METHODS

Relevant articles were identified through a search of MEDLINE and International Pharmaceutical Abstracts (1966-August 2006) for English-language articles. The following medical subject headings and key words were used: alcohol medication interactions, diseases worsened by alcohol use, and alcohol metabolism, absorption, and distribution. Additional articles were identified by a manual search of the reference lists of the identified articles, review articles, textbooks, and personal reference sources.

RESULTS

Many older adults drink alcohol and take medications that may interact negatively with alcohol. Some of these interactions are due to age-related changes in the absorption, distribution, and metabolism of alcohol an medications. Others are due to disulfiram-like reactions observed with some medications, exacerbation of therapeutic effects and adverse effects of medications when combined with alcohol, and alcohol's interference with the effectiveness of some medications.

CONCLUSIONS

Older adults who drink alcohol and who take medications are at risk for a variety of adverse consequences depending on the amount of alcohol and the type of medications consumed. It is important for clinicians to know how much alcohol their older patients are drinking to be able to effectively assess their risks and to counsel them about the safe use of alcohol and medications. Similarly, it is important for older adults to understand the potential risks of their combined alcohol and medication use to avoid the myriad of problems possible with unsafe use of these substances..

Alcohol consumption among older adults in primary care

BACKGROUND

Alcohol misuse is a growing public health concern for older adults, particularly among primary care patients.

OBJECTIVES

To determine alcohol consumption patterns and the characteristics associated with at-risk drinking in a large sample of elderly primary care patients.

DESIGN

Cross-sectional analysis of multisite screening data from 6 VA Medical Centers, 2 hospital-based health care networks, and 3 Community Health Centers.

PARTICIPANTS

Patients, 43,606, aged 65 to 103 years, with scheduled primary care appointments were approached for screening; 27,714 (63.6%) consented to be screened. The final sample of persons with completed screens comprised 24,863 patients.

MEASUREMENTS

Quantity and frequency of alcohol use, demographics, social support measures, and measures of depression/anxiety.

RESULTS

Of the 24,863 older adults screened, 70.0% reported no consumption of alcohol in the past year, 21.5% were moderate drinkers (1-7 drinks/week), 4.1% were at-risk drinkers (8-14 drinks/week), and 4.5% were heavy (>14 drinks/week) or binge drinkers. Heavy drinking showed significant positive association with depressive/anxiety symptoms [Odds ratio (OR) (95% CI): 1.79 (1.30, 2.45)] and less social support [OR (95% CI): 2.01 (1.14, 2.56)]. Heavy drinking combined with binging was similarly positively associated with depressive/anxiety symptoms [OR (95%): 1.70 (1.33, 2.17)] and perceived poor health [OR (95% CI): 1.27 (1.03, 1.57)], while at-risk drinking was not associated with any of these variables.

CONCLUSIONS

The majority of participants were nondrinkers; among alcohol users, at-risk drinkers did not differ significantly from moderate drinkers in their characteristics or for the 3 health parameters evaluated. In contrast, heavy drinking was associated with depression and anxiety and less social support, and heavy drinking combined with binge drinking was associated with depressive/anxiety symptoms and perceived poor health.

A Drink to Healthy Aging: The Association Between Older Women's Use of Alcohol and Their Health-Related Quality of Life

OBJECTIVES

To assess the relationship between alcohol intake and mortality in a cohort of women aged 70 and older and to explore the relationship between level of alcohol use and changes in physical and mental health-related quality of life.

DESIGN

National longitudinal surveys from 1996 to 2002.

SETTING

Community based.

PARTICIPANTS

A national random sample of 12,432 Australian women aged 70 to 75 at baseline.

MEASUREMENTS

Alcohol consumption was the factor of interest, and the main outcome measures were survival and health-related quality of life, with adjustment for potential confounders.

RESULTS

Women who did not consume alcohol or who drank rarely were more likely to die (nondrinkers' hazard (HR) = ratio 1.94, 95% confidence interval (CI) = 1.4-2.6; rare drinkers' HR = 1.58, 95% CI = 1.2-2.1) than women in the low-intake reference category (1-2 drinks per day, 3-6 days per week), or if they survived, they had lower health-related quality-of-life scores on the General Health and Physical Functioning subscales of the Medical Outcomes Study 36-item Short Form Survey after adjustment for smoking, comorbidity, education, body mass index, and area of residence. Nondrinkers also scored lower on the Mental Health and Social Functioning subscales.

CONCLUSION

Being a nondrinker of alcohol was associated with greater risk of death and poorer health-related quality of life. Results for other levels of intake were consistent with current Australian alcohol consumption recommendations for women and indicated that moderate alcohol intake may carry some health benefits for older women in terms of survival and quality of life.

The diagnostic usefulness of AUDIT and AUDIT-C for detecting hazardous drinkers in the elderly

We compare the diagnostic usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT alcohol consumption questions (AUDIT-C) for detecting hazardous drinkers between the populations over and less than 65 years in primary care settings. To assess weekly alcohol intake an interview on quantity-frequency was administered to 602 patients. Hazardous drinking was defined as a level of consumption of 280 g of alcohol per week for men and 168 g for women. The participants received AUDIT, AUDIT-C and CAGE questionnaires. Gamma-glutamyltransferase (GGT), mean corpuscular volume (MCV), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were also determined. Average weekly alcohol intake among the population aged 65 and older was 83 g, and 10% were hazardous drinkers. In this age group, the sensitivities of AUDIT and AUDIT-C for detecting this type of drinkers were 67% and 100%, whereas specificities were 95% and 81% respectively. In the younger patient group, the sensitivities were 84% and 100% and the specificities 95% and 79% respectively. In conclusion, both AUDIT and AUDIT-C perform well at detecting hazardous drinkers in the group older than 65 years and that their sensitivities and specificities are comparable to those in younger ages.

Moderate alcohol consumption and safety of lovastatin and warfarin among men: the post-coronary artery bypass graft trial

PURPOSE

Although moderate drinking has been associated with lower mortality among patients with coronary heart disease, its safety among patients taking common cardiac medications is unknown.

SUBJECTS AND METHODS

We studied 1244 men enrolled in the Post-Coronary Artery Bypass Graft (CABG) Trial who had undergone previous coronary bypass surgery. Participants were randomly assigned to lovastatin in low (mean 4 mg) or high (mean 76 mg) doses and to low-dose warfarin (mean international normalized ratio [INR] 1.4, goal INR <2.0) or placebo in a factorial design. Participants underwent routine measurement of alanine aminotransferase (ALT) and INR levels every 6 to 12 weeks for 4 to 5 years. We categorized weekly alcohol intake as abstention (<1 drink), light (1-6 drinks), moderate (7-13 drinks), and heavier (> or =14 drinks).

RESULTS

During follow-up, 66% of men taking warfarin had an INR of 2.0 or higher, and 7% of men had an ALT of 80 IU/L or higher. Maximum INR (P = .72) and ALT (P = .51) levels did not differ across categories of alcohol intake. The risks of an INR of 2.0 or higher were 67%, 66%, 68%, and 61% among non-, light, moderate, and heavier drinkers (P = .86), respectively. The corresponding risks of an ALT of 80 IU/L or more were 8%, 10%, 9%, and 6% (P = .70), respectively.

CONCLUSION

Moderate drinking did not adversely influence the safety of low-dose warfarin or even high-dose lovastatin among men in this randomized trial, as measured by INR and ALT levels.

Geriatric alcoholism

BACKGROUND

The authors reviewed the clinical features, epidemiology, diagnosis, medical treatment, orofacial findings and dental treatment of geriatric patients with alcoholism.

TYPES OF STUDIES REVIEWED

The authors conducted MEDLINE searches for the period 1995 through 2004 using the terms "alcoholism," "geriatric," "pathophysiology," "treatment" and "dentistry." They selected reports published in English in peer-reviewed journals for further review.

RESULTS

Physiological changes associated with aging permit the harmful effects of drinking alcohol to arise at lower levels of consumption than in younger people. Excessive use of alcohol exacerbates the medical and emotional problems associated with aging and predisposes the person to adverse drug reactions with medications controlling these illnesses.

CLINICAL IMPLICATIONS

The incidence of dental disease in this population is extensive because of diminished salivary flow and a disinterest in performing appropriate oral hygiene techniques. Concurrent abuse of tobacco products worsens dental disease and heightens the risk of developing oral cancer. Identification of patients who abuse alcohol, a cancer-screening examination, preventive dental education, and use of saliva substitutes and anticaries agents are indicated. Clinicians must take precautions when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol.

Potential for alcohol and prescription drug interactions in older people

OBJECTIVES

To examine the patterns and prevalence of concomitant alcohol and alcohol-interactive (AI) drug use in older people.

DESIGN

Cross-sectional analysis of survey and prescription claims data.

SETTING

The Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PA-PACE) program, a state-funded program providing prescription benefits to older people with low to moderate incomes.

PARTICIPANTS

A total of 83,321 PA-PACE cardholders (age range 65-106) who were using any prescription medications at the time of survey completion.

MEASUREMENTS

All AI drugs were identified using a database of medication warning labels obtained from First DataBank. Prescription drug claims were used to characterize AI drug exposure according to therapeutic class of prescription drug use. A mail survey of PA-PACE cardholders was used to examine alcohol use, as well as sociodemographic and health factors associated with concomitant use of alcohol and AI drugs.

RESULTS

Seventy-seven percent of all prescription drug users were exposed to AI medications, with significant variation in exposure and concomitant alcohol use according to therapeutic class. Overall, 19% of AI drug users reported concomitant alcohol use, compared with 26% of non-AI drug users (P<.001). Multinomial logistic regression analyses showed that certain groups of older people, including younger older people, men, and those with higher educational levels, were at greater risk for concomitant exposure to alcohol and AI drugs.

CONCLUSION

Many older people use alcohol in combination with AI prescription drugs. Clinicians should warn every patient who is prescribed an AI drug about alcohol-drug interactions, especially those at high risk for concomitant exposure.

An evaluation of an intervention to assist primary care physicians in screening and educating older patients who use alcohol

OBJECTIVES

To evaluate whether providing physicians and older patients with personalized reports of drinking risks and benefits and patient education reduces alcohol-related risks and problems.

DESIGN

Prospective comparison study.

SETTING

Community primary care.

PARTICIPANTS

Twenty-three physicians and 665 patients aged 65 and older.

INTERVENTION

Combined report, in which six physicians and 198 [corrected] patients received reports of patients' drinking classifications and patients also received education; patient report, in which 245 patients received reports and education, but their five physicians did not receive reports; and usual care.

MEASUREMENTS

Assessments at baseline and 12 months later to determine patients' nonhazardous (no known risks), hazardous (risks for problems), or harmful (presence of problems) classifications using the Computerized Alcohol-Related Problems Survey (CARPS). The CARPS contains a scanned screening measure and scoring algorithms and automatically produces patient and physician reports and patient education.

RESULTS

At baseline, 21% were harmful drinkers, and 26% were hazardous drinkers. The patient report and combined report interventions were each associated with greater odds of lower-risk drinking at follow-up than usual care (odds ratio=1.59 and 1.23, respectively, P<.05 for each). The patient report intervention significantly reduced harmful drinking at follow-up from an expected 21% in usual care to 16% and increased nonhazardous drinking from 52% expected in usual care to 58%. Patients in the combined report intervention experienced a significantly greater average decrease in quantity and frequency.

CONCLUSION

Older primary care patients can effectively reduce their alcohol consumption and other drinking risks when given personalized information about their drinking and health.

Alcohol abuse and dependence in elderly emergency department patients

Although elderly people are particularly vulnerable to the adverse effects of alcohol, alcohol use disorders in late life have received relatively little attention in the literature. Our objectives were to assess the prevalence of alcohol use disorders (abuse and dependence), the medical profile and psychosocial characteristics in elderly people visiting emergency department (ED). A cohort of 2405 patients aged over 60 who came to the ED of a university hospital during a 3-month period was studied. Alcohol use disorder diagnosis (DSM-IV), medical profile and social characteristics were collected from retrospective review of patient files. The data derived from 128 patients (mean age, 69.8+/-6.8 years; 87% males) with alcohol use disorders and 128 non-alcoholic controls. The prevalence of current alcohol use disorder was 5.3%. The most common current alcohol-induced disorders were alcohol intoxication and alcohol-induced mood disorder. Social factors associated with alcohol use disorders were being homeless, living alone, being divorced and never married. Falls and delirium were frequent ED admission circumstances in elderly drinkers. Drinkers more commonly presented with gastrointestinal disorders. In conclusion, alcohol use disorders among older patients admitted in ED are common and occur more frequently among men. Falls and delirium are the main ED admission circumstances in elderly drinkers. Alcohol use disorders are also associated with gastrointestinal problems.

Community prevalence of alcohol use and concomitant use of medication--a source of possible risk in the elderly aged 75 and older?

AIMS

To explore alcohol use and concomitant use of prescription and over the counter (OTC) medicines in people aged 75 years or over.

DESIGN

Community-based randomized survey of home-dwelling elderly persons, Setting: the City of Kuopio, Finland.

PARTICIPANTS

Population-based random sample of 700 persons aged 75 years or over, of whom 601 participated (86%). Only home-dwellers (n = 523) were included in this study.

MEASUREMENTS

Alcohol use based on responses to questions concerning quantity and frequency, and CAGE questions. Use of prescription and non-prescription medicines. Mean corpuscular volume.

RESULTS

Of the participants, 44% used alcohol. Most alcohol drinkers used medications on a regular basis (86.9%) or as needed (87.8%), among them medicines known to have some potential interactions with alcohol. Elevated mean corpuscular volume was more widespread among alcohol drinkers than non drinkers.

CONCLUSION

Theoretical risks posed by alcohol use are not minimal in the older elderly, though the quantity of alcohol use is not considerable. Physicians and nurses should pay attention to chronic diseases and medications when counselling aged people about alcohol consumption. The question of clinical importance of alcohol-medication interactions needs to be studied further.

The alcohol-related problems survey: identifying hazardous and harmful drinking in older primary care patients

OBJECTIVES

Older adults can incur problems at low levels of alcohol consumption because of age-related physiological changes, declining health and functional status, and medication use. We have developed and tested a screening measure specifically for older people, the Alcohol-Related Problems Survey (ARPS), to identify older adults with these risks.

DESIGN

Survey.

SETTING

Academic and community primary care clinics.

PARTICIPANTS

Five hundred forty-nine current drinkers aged 65 and older, mostly white with high school or more education.

MEASURES

Alcohol use was classified as harmful, hazardous, or nonhazardous depending upon consumption alone or combined with selected comorbidities and medication use. Harmful drinking (including alcohol abuse or dependence) means the presence of problems (e.g., hypertension, adverse drug events, legal problems) due to drinking. Hazardous drinking means risks for problems are likely. Nonhazardous drinking poses no known risks for problems.

RESULTS

Eleven percent of subjects were harmful drinkers and 35% were hazardous drinkers. Harmful drinking was more common in men than women and in persons younger than 75 than those aged 75 and older. Similar proportions of men and women and younger and older age groups were hazardous drinkers. Most harmful drinkers were identified by their use of alcohol with their comorbidity, whereas most hazardous drinkers were identified by their use of alcohol with medications. Test-retest reliability was substantial (kappa = 0.65).

CONCLUSION

Physicians are urged to screen for alcohol-related problems in older persons. The ARPS reliably identifies harmful, hazardous, and nonhazardous drinking in older adults resulting most often from the interaction between alcohol and disease and medication use.

Knowledge and self-efficacy of community health nurses concerning interactions of prescription medicines with over-the-counter agents and alcohol

Knowledge and self-efficacy concerning interactions of prescription medications with over-the-counter (OTC) agents were assessed in community health nurses. Three convenience samples of community nurses were recruited to complete the instruments. The first was a sample of 20 experienced nurses working for a local visiting nurse agency (VNARNs). The second was a sample of 20 bachelor of science in nursing (BSN) students (graduate nurses [GNs]) completing their final nursing rotation with the VNARNs. The third was a sample of 31 nurses enrolled in a graduate program training nurses for advanced practice (APRNs). There were no significant differences in overall mean self-efficacy scores among the groups of community health nurses. The mean scores indicated moderate self-efficacy about prescription-OTC interactions. Post-hoc analyses determined VNARNs had significantly greater knowledge scores than APRNs. Overall mean self-efficacy was not correlated with mean knowledge scores. Inspection of the knowledge item responses revealed nine general misconceptions about OTC medications held by many community nurses in the sample. The data can guide the development of continuing education programs about prescription-OTC interactions aimed at community health nurses.

Comparing the alcohol-related problems survey (ARPS) to traditional alcohol screening measures in elderly outpatients

Older drinkers may incur alcohol-related risks at low consumption levels, but commonly used screening measures do not address alcohol's effects among persons with declining health and increased medication use. We compared the newly developed Alcohol-Related Problems Survey (ARPS) to three validated alcohol screens: the Cut down, Annoyed, Guilty, Eye-opener (CAGE), Short-Michigan Alcohol Screening Test (SMAST), and Alcohol-Use Identification Test (AUDIT). The ARPS classifies drinking as non-hazardous, hazardous or harmful. Non-hazardous drinking is defined as consumption with no known risks for adverse physical or psychological health events. Hazardous drinking is consumption with such risks. Harmful drinking results in adverse events. The AUDIT screens for hazardous and harmful drinking; the CAGE and SMAST identify abusive (e.g. failure to fulfill social obligations) and dependent (e.g. having withdrawal symptoms) drinkers. In this study of 574 current drinkers 65 years and older who completed the ARPS and AUDIT in primary care clinics, half were randomly assigned to complete the CAGE and half, the SMAST. Drinkers who screened positive on the CAGE, SMAST or AUDIT were correctly classified by the ARPS as hazardous or harmful drinkers 91, 75, and 100% of the time, respectively. The majority of ARPS-identified hazardous or harmful drinkers did not screen positive on the CAGE, SMAST or AUDIT. These drinkers had medical conditions or used medications that placed them at risk for adverse health events, none of which was addressed in these three screens. In this study, the ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers not identified by these measures.

Moderate alcohol consumption and adverse drug reactions among older adults

PURPOSE

To assess the effect of moderate alcohol consumption on Adverse Drug Reactions (ADRs) among older adults admitted to acute care hospitals and to examine the consistency of this effect across gender and age groups.

METHODS

We used the GIFA (Italian Group of Pharmacoepidemiology in the Elderly) database, which includes information on patients admitted to 81 medical centers in Italy. For this study we examined exclusively the ADRs detected at hospital admission that were classified as definite or probable based on the Naranjo algorithm.

RESULTS

Among 22,778 participants, 894 were found to have one or more ADRs (3.9%). Gastrointestinal complications (n = 210; 0.9% of the population) were the most frequent ADRs, followed by metabolic/endocrine (n = 156; 0.7%), dermatological/allergic (n = 102; 0.4%) and arrhythmic (n = 78; 0.3%) complications. Diuretics were the most frequent culprit drugs, followed by NSAIDs and digoxin. An ADR was recorded in 383/10,427 (3.7%) non-drinkers and in 511/12,351 (4.1%) moderate drinkers. After adjusting for potential confounders, moderate alcohol consumption was associated with a 24% increased risk of ADRs (OR 1.24; 95%CI: 1.08-1.43). This effect seemed more evident among women (OR 1.30; 95%CI: 1.09-1.55), than men (OR 1.14; 95%CI: 0.90-1.43), while it was similar across different age groups (< 65 years OR 1.28; 95%CI: 0.99-1.66; 65-79 years OR 1.22; 95%CI: 0.98-1.52; > or = 80 years OR 1.20; 95%CI: 0.93-1.56). Considering the most common ADRs, moderate alcohol users presented a significantly higher risk of drug-related headache (OR 3.89; 95%CI: 1.43-10.61) and metabolic/endocrine complications (OR 1.67; 95%CI: 1.19-2.33).

CONCLUSIONS

Moderate alcohol intake is associated with an increased risk of ADRs; this effect seems more evident among women than men, and it does not differ across age groups.

Delivering health information about self-medication to older adults: use of touchscreen-equipped notebook computers

Preventing Drug Interactions in Active Older Adults is an educational intervention to prevent prescription and over-the-counter (OTC) drug and alcohol interactions in active, community-living older adults. The objectives of the program are to increase older adults' knowledge of potential interactions of prescription medications with OTC drugs and alcohol and to increase their confidence (self-efficacy) about how to avoid such interactions. An interactive multimedia computer software program (Personal Education Program or PEP) was designed for the learning styles and psychomotor skills of older adults. Focus groups of older adults evaluated PEP components in a formative manner during development. The program content dealing with antacids, calcium supplements, and acid reducers was pilot tested with 60 older adults recruited from local senior centers. Participants used the PEP on notebook computers equipped with infrared-sensitive touchscreens. Users of PEP had greater knowledge and self-efficacy scores than controls. Participants indicated a high degree of satisfaction with the PEP and reported their intent to make specific changes in self-medication behaviors.

Informing older adults about non-hazardous, hazardous, and harmful alcohol use

Low levels of alcohol may be hazardous in the elderly, but available education focuses on younger, abusive, and dependent drinkers. A total of 209 older persons participated in various components of the development and evaluation of 'A Toast To Health In Later Life!' health promotion materials for the elderly. Patient focus groups, physicians, educators, and alcohol-use researchers contributed to all materials and measures. An education model for older adults guided the instructional format. Knowledge and self-efficacy scores increased significantly from pre- to post-test. Over 45% of persons in selected senior centers reviewed the materials without prompting by the study team. Older adults are willing to read extensively about the relationships among drinking, health, and medication use. Patient educators should include consumers in the design of health promotion materials and measures. Practitioners who rely on written educational materials for patient education and counseling should be provided with evidence of appropriateness, effectiveness, and feasibility.

Gender and alcohol use: the roles of social support, chronic illness, and psychological well-being

Men and women differ in their use of alcohol, in their rates of chronic illnesses and psychological symptoms, and in the social support they receive. In this paper, we assess how the latter three factors are associated with alcohol use, and how these associations differ by gender. Respondents were 3,074 male and 3,947 female randomly selected Health Maintenance Organization members who responded to a mail survey in 1990. Hierarchical multiple regression analyses indicate that social support is associated with alcohol consumption in similar ways for both genders, yet the associations between some demographic, physical health/functioning, and psychological well-being measures are different for men and women. Men with fewer role limits due to physical health drank more, while women with better psychological well-being drank less. Poor psychological well-being may be a modifiable risk factor for increased alcohol use among women; practitioners should be alert for greater consumption among men with few functional limitations and good health.

Alcohol consumption in a community sample of older people

OBJECTIVE

To examine the prevalence and pattern of alcohol use among community-living elderly Australians.

METHODS

A survey was conducted of randomly selected non-institutionalised people aged 75 years and older living in the inner western suburbs of Sydney. Personal interviews by trained interviewers covered background demographic information and self-reported alcohol use.

RESULTS

72% of men and 54% of women drank alcohol. The median usual daily volume of ethanol consumed by drinkers was 10 grams for men and 1.3 grams for women. However 11% of male drinkers and 6% of female drinkers consumed at defined hazardous or harmful levels.

CONCLUSIONS AND IMPLICATIONS

Although a sizeable majority of these older people were either non-drinkers or very light drinkers, a small but important proportion drank in the hazardous to harmful range. Despite increasing evidence of the health benefits of alcohol consumption it remains important to be alert for potentially harmful alcohol use among older people.

Investigations of the effects of ethanol on warfarin binding to human serum albumin

Ethanol effects on warfarin binding to human serum albumin (HSA) have been studied by equilibrium dialysis and fluorescence methods at pH 7.4 in phosphate-buffered saline at 37 degrees C. In the presence of various amounts of ethanol fluorescence intensity of bound warfarin decreased significantly but this intensity reduction was not solely from displacement of bound warfarin from HSA. By comparing fluorescence and equilibrium dialysis data we concluded that fluorescence intensity reduction of warfarin was mainly the result of changes in the surrounding environment of the warfarin binding site by ethanol interaction with HSA and that displacement of bound warfarin was not significant compared to the fluorescence intensity changes. The dissociation constant of warfarin binding to HSA decreased with an increasing amount of ethanol. From the changes in fluorescence intensity upon warfarin binding to HSA with the presence of ethanol ranging from 0 to 5.0% the following dissociation constants (Kd) were determined: 0% ethanol 5.39 +/- 0.2 microM, 0.1% ethanol 5.86 +/- 0.1 microM, 0.3% ethanol 5.83 +/- 0.2 microM, 0.5% ethanol 6.76 +/- 0.1 microM, 1% ethanol 7.01 +/- 0.1 microM, 3% ethanol 9.9 +/- 0.7 microM, 5% ethanol 13.01 +/- 0.1 microM. From the equilibrium dialysis with the same ranges of ethanol presence the following Kd values were obtained: 0% ethanol 6. 62 +/- 1.6 microM, 0.1% ethanol 6.81 +/- 1.1 microM, 0.3% ethanol 8. 26 +/- 2.5 microM, 0.5% ethanol 8.86 +/- 1.9 microM, 1% ethanol 11. 01 +/- 4.2 microM, 3% ethanol 20.75 +/- 2.4 microM, 5% ethanol 21.67 +/- 2.2 microM. The results suggest that warfarin bound to HSA was displaced by ethanol. These data indicate that ethanol influence on warfarin binding to HSA may alter the pharmacokinetics of warfarin.

[Improper use of medications with alcohol at a rural office]

OBJECTIVES

To determine the prevalence of the joint use of alcohol and medication with the risk of interaction with alcohol, the social and personal features of patients most likely to use the two combined, and the extent of anti-alcohol medical counselling of these patients.

DESIGN

Prevalence study.

SETTING

Primary care. Rural local clinic at Trigueros (Huelva).

PARTICIPANTS

581 histories of patients over 14, started between October 1993 and December 1996.

MEASUREMENTS AND MAIN RESULTS

From the clinical histories we obtained the social and personal features, toxic habits, type and number of medicines prescribed, and whether or not there was medical counselling on alcohol consumption. Potential interactions were looked for through the list provided by Mengual Sandra and Gila Azañedo. 10.15% (95% CI, 7.8-12.9) of the subjects consumed at the same time medication with risk of interaction and alcohol. Males (OR = 7.1), over-65s (OR = 4.9), married people (OR = 3.1) and smokers (OR = 2.3) were more likely to combine alcohol and at-risk medication. 6.8% of the patients with potential risk of interaction were counselled against alcohol.

CONCLUSIONS

The simultaneous use of alcohol (as drinks or a component of medicine) and at-risk drugs is a common reality in primary care. Men, the over-65s, smokers and married people are at greater risk. Medical counselling of patients at potential risk of interaction is quite rare, although it is greater than of drinkers who do not take at-risk medicines.

A new paradigm for alcohol use in older persons

BACKGROUND

Current paradigms for conceptualizing alcohol-related problems typically focus on persons who are abusing or dependent on alcohol. These paradigms may not apply to older drinkers whose alcohol use, regardless of consumption-level, can cause problems because of age-related changes in physiology and interactions with increased morbidity, medication use, and functional limitations.

OBJECTIVE

We convened an expert panel# to develop clinical indications of harmful, hazardous, and nonhazardous drinking in persons 65 years of age and older.

RESEARCH DESIGN AND SUBJECTS

Nine panelists with expertise in psychiatry, geriatrics, internal medicine, and alcohol research were provided with epidemiological data and a published explicit literature review of alcohol use in the elderly. The RAND/UCLA two-round panel method was used to develop the indications. After the second round, the authors wrote a draft statement that was circulated to the panelists whose comments were incorporated into a final document.

RESULTS

Panelists agreed on 215 scenarios in which older peoples' use of alcohol either alone or in the presence of chronic medical conditions, medication use, symptoms, smoking, and functional limitations are hazardous or harmful. Panelists' ratings of risk did not differ significantly between persons aged 65 to 74 years and those aged 75 years and older.

CONCLUSION

Alcohol use may be hazardous or harmful for older persons, particularly in conjunction with physical or emotional illnesses, medication use, functional limitations, smoking, and driving after drinking. When asking about alcohol use in older persons, clinicians need to be aware of these factors to assist in identifying and managing potential or actual alcohol-related problems.

Physician awareness of alcohol use disorders among older patients

OBJECTIVES

To determine primary care physicians' awareness of, and screening practices for, alcohol use disorders (AUDs) among older patients.

DESIGN

Cross-sectional telephone survey of a national sample of primary care physicians.

PARTICIPANTS

Physicians randomly sampled from the Masterfile database of the American Medical Association and stratified by specialty as family practice physicians, internal medicine physicians, and either family practice or internal medicine physicians with geriatric certification.

MAIN RESULTS

A total of 171 physicians were contacted: 155 (91%) agreed to participate, and responses were analyzed from 150 (50 family practice, 50 internal medicine, 50 with geriatric certification). The median prevalence estimate of AUDs among older patients was 5% for each group of physicians. In contrast to published prevalence rates of AUDs ranging from 5% to 23%, 38% of physicians reported prevalence estimates of less than 5%, and 5% cited estimates of at least 25%. Compared with the other groups, the physicians with geriatric certification were more likely to report no regular screening (42% vs 20% for family practice vs 18% for internal medicine, p = .01), while younger (<40 years) and middle-aged physicians (40-55 years) reported higher annual screening rates relative to older physicians (>55 years) (77% vs 60% vs 44% respectively, p = .03). Among physicians who regularly screened (n = 110), 100% asked quantity-frequency questions, 39% also used the CAGE questions, and 15% also cited use of biochemical markers.

CONCLUSIONS

Primary care physicians may "underdetect" AUDs among older patients. The development of age-specific screening methods and physician education may facilitate detection of older patients with (or at risk for) these disorders.

Pharmacokinetic interactions between alcohol and other drugs

The frequent use of alcohol (ethanol) together with prescription drugs gives any described pharmacokinetic interaction significant clinical implications. The issue is both the effect of alcohol on the pharmacokinetics of various drugs and also the effect of those drugs on the pharmacokinetics of alcohol. This review discusses these pharmacokinetic interactions but also briefly describes some other effects of alcohol that are clinically relevant to drug prescribing. The use of several different study designs may be required before we can confidently state the presence or absence of any alcohol-drug interaction. Short term administration of alcohol in volunteers is the most common study design but studies of social drinking and prolonged moderate alcohol intake can be important in some situations. Community-based studies may illustrate the clinical relevance of any interaction. Alcohol can affect the pharmacokinetics of drugs by altering gastric emptying or liver metabolism (by inducing cytochrome P450 2E1). Drugs may affect the pharmacokinetics of alcohol by altering gastric emptying and inhibiting gastric alcohol dehydrogenase. The role of gastric alcohol dehydrogenase in the first-pass metabolism of alcohol is reviewed in this article and the arguments for and against any potential interaction between alcohol and H2 receptor antagonists are also discussed. The inhibition of the metabolism of acetaldehyde may cause disulfiram-like reactions. Pharmacodynamic interactions between alcohol and prescription drugs are common, particularly the additive sedative effects with benzodiazepines and also with some of the antihistamine drugs; other interactions may occur with tricyclic antidepressants. Alcohol intake may be a contributing factor to the disease state which is being treated and may complicate treatment because of various pathophysiological effects (e.g. impairment of gluconeogenesis and the risk of hypoglycaemia with oral hypoglycaemic agents). The combination of nonsteroidal anti-inflammatory drugs and alcohol intake increases the risk of gastrointestinal haemorrhage.

Geriatric substance use disorders

AUDs are increasingly recognized as common problems among older adults. The magnitude of this problem is likely to increase over ensuing decades as baby boomers reach retirement age with drinking habits that are significantly different from current cohorts of older adults. Barriers to detection are numerous and include nonspecificity of alcohol-related presentations, patient denial, and clinicians' unwillingness to recognize that patients can and do develop alcohol problems in later life. Despite the limitations of current screening and diagnostic instruments, the authors recommend use of the CAGE as a formal screening tool for older patients because of its brevity, demonstrated efficacy, and convenience. In patients who answer affirmatively to any CAGE question, diagnostic certainty can be increased by use of follow-up questions or referral to an alcohol treatment specialist. Referral of patients with established alcohol abuse or dependence is essential for definitive treatment, and successful outcomes can be expected and are gratifying once achieved. In patients with less severe AUDs, brief interventions with frequent follow-up are recommended. Age-specific screening and diagnostic instruments for older AUD patients, once fully developed and validated, will facilitate identification. Much less is known about other substance use disorders in older adults. Psychoactive drug use is not uncommon in this patient population and may result in adverse health outcomes. Treatment interventions proposed for AUDs are advocated for older adults found to have other substance use disorders as well and are likely to yield improved outcomes. Future investigations that better define the epidemiology, detection, and treatment of other substance use disorders in older populations are clearly warranted at this time.

Alcohol use in retirement communities

OBJECTIVES

Anecdotal reports and two previous studies suggest that retirement communities have a particularly high prevalence of heavy drinking. The objective of this study was to verify or refute this finding and to identify characteristics associated with heavy drinking in retirement communities.

METHODS

This cross-sectional study used a mailed survey to gather information from three retirement communities in suburban Milwaukee, Wisconsin. The questionnaire included alcohol use questions adapted from the Khavari questionnaire and the CAGE questionnaire to screen for alcohol abuse.

RESULTS

Three hundred seventeen of 454 independent residents of the retirement communities completed and returned surveys for a response rate of 70%. Mean age of respondents was 83 +/- 6 years, 100% were white, 77% were female. Forty-seven percent used some alcohol, 15% had one to six drinks per week, 8% had seven or more drinks per week. Only two people screened positive on the CAGE questionnaire for abusive drinking. The majority of drinkers had decreased alcohol use since moving to the community. Male sex, socialization, lack of religious affiliation, and smoking were factors whose percentages increased significantly with increasing alcohol use. Although drinkers were more likely to smoke cigarettes, no indicators suggested that they were less healthy than abstainers.

CONCLUSIONS

Despite the advanced age of this population, regular alcohol use was prevalent. In contrast to previous reports from retirement communities, heavy and abusive drinking were uncommon by our measures, perhaps because of the older age and female predominance of the sample. Drinking appears to be associated with more social contacts and, possibly, better health status.