US Pharm. 2007;32(6):HS20-HS30.
Prescription medication and alcohol misuse affect
up to 17% of Americans ages 65 and older.1 Pharmacists are in a
powerful position to help older adults prevent and identify problems with
medication and alcohol interactions, misuse, or abuse. Many older adults may
not realize they are taking medications that can have dangerous interactions
with alcohol or other drugs. Medication and alcohol misuse and/or abuse are
not typically at the forefront of issues associated with older adults;
however, pharmacists must be aware of factors that put the older population at
risk, since they have a unique opportunity to recognize, prevent, and treat
The population of older adults in America is
growing due, in large part, to longer life expectancies and the aging
"baby-boomer" generation. Statistics from 2002 show that people who have
survived to age 65 show a total average life expectancy of about 84 years.2
Between 2011 and 2030, the baby boomers, born between 1946 and 1964, will
reach age 65 and comprise approximately 20% of the total population.3
Currently, people older than 65 represent only 13%
of the American population; however, they use about 30% of all prescription
drugs,4 and 40% of them take five or more different medications per
week.5 Older adults are more likely to suffer from chronic
illnesses and are therefore more likely to use medications long-term and to
use more of them.6 This is a concern, since up to 50% of
prescription medications are not used according to physician directions.7
This issue is complicated further by a lack of knowledge and awareness about
medication misuse in older adults. As many as 20 years ago, the National
Council on Patient Information and Education (NCPIE) described medication
misuse as "America's Other Drug Problem," because incorrectly or
inappropriately taking prescription medications is a largely underreported
topic and is detrimental to those individuals who are at risk.8
Older adults are at greater risk for medication misuse for many reasons,
including but not limited to polypharmacy, socioeconomic changes, and
physiologic and psychologic changes. These factors may affect the patient's
attitude toward health care, as well as the pharmacokinetic drug disposition
of medications, leading to the potential for direct health consequences.
According to the American Society on Aging and the
American Society of Consultant Pharmacists, medications may be the "single
most important health care technology to prevent illness, disability, and
death in the older population. Older persons with chronic conditions and
diseases benefit the most from taking medications, and risk the most from
failing to take them properly" and/or combining them with
Patients misuse medications or alcohol for a
variety of reasons, including personal attitudes, ethnic beliefs, social and
economic circumstances, and communication barriers between themselves and
health care professionals.10 These factors are not easily changed,
but they provide opportunities for pharmacist interventions. Perceptions
regarding alcohol, medication, and health care in general may significantly
affect how medications and alcohol are used. The recommended maximum intake of
alcohol for older adults is widely misunderstood or unknown. Men ages 65 and
older should limit alcohol consumption to no more than one drink per day,
while their female counterparts should limit alcohol intake to less than one
drink per day. These recommendations may vary based on the body mass of the
patient. Standard drink sizes vary according to the type of alcoholic
beverage: one drink amounts to one can of beer or ale (12 oz.), one glass of
table wine (5 oz.), one glass of fortified wine (3-4 oz.), one shot of hard
liquor (80 proof; 1.5 oz.), or one small glass of a cordial, liqueur, or
aperitif (2-3 oz.). Serving sizes can be misinterpreted, leading to
overindulgence and potential detrimental health effects. Although older people
do not usually exhibit high rates of heavy drinking, many engage in patterns
of alcohol consumption that exceed current guidelines.11 Past
research looking at older persons living in the community and in retirement
settings reported that 25% and 38%, respectively, consumed alcohol and took
alcohol-interactive medications and thus were at risk for alcohol-medication
interactions.12 Another source of misconceptions regarding alcohol
consumption are the many studies that have been conducted during the past
decade indicating that wine and other alcoholic beverages may be beneficial in
preventing heart disease. Despite these claims, the American Heart Association
does not endorse the use of alcohol for this purpose, since alcohol causes
many other negative health effects.13
Risk Factors for Misuse or Abuse
Physiologic Changes: Older patients may not understand the effect of
aging on the ability to tolerate medications and alcohol. Decreases in liver
and kidney function have a direct effect on drug metabolism and elimination,
resulting in a slower onset of action or increased duration of action.
Decreases in lean body mass and total body water reduce the distribution of
medications and alcohol, resulting in higher concentrations in the blood,
compared with younger adults who consume the same amounts. The enzyme alcohol
dehydrogenase, which metabolizes alcohol, is markedly decreased in older
adults. This contributes to higher blood-alcohol levels that remain raised for
a longer period of time, producing an increased effect. In addition, the
elderly have a greater likelihood of health problems that can be adversely
affected by alcohol, such as diabetes, cardiac disease, or gastrointestinal or
Medical Risks:Polypharmacy refers to
the concomitant use of multiple prescription and/or OTC medications. This
definition may be extended to include other variables, such as quantification
of medications (i.e., more than four prescriptions), utilization of one
medication to treat the adverse effects of another, or utilization of multiple
health care providers and pharmacies.14-16 Two studies found that
adverse drug effects were the most common cause of emergency department visits
and hospitalization in an older adult population taking an average of six
prescriptions per day.17,18 Harmful reactions and interactions may
occur from using many prescription, OTC, and/or herbal products, especially
when combined with alcohol. Interactions resulting in increased efficacy are
equally problematic as those resulting in reduced efficacy.16 Pain,
discomfort, and sleep problems from various physical and mental health
conditions may lead to self-medication with alcohol or drugs, which in turn
may lead to adverse drug reactions (ADRs) or exaggerated therapeutic
Mental status changes (e.g., Alzheimer's disease,
depression, dementia) in older patients can often lead to medication misuse.
Misunderstanding directions or the inability to remember to take prescribed
doses leads to incorrect use of medications. Memory deficiency is a difficult
barrier to overcome, requiring frequent follow-up and the involvement of
family members or caregivers.
Psychologic and Social Issues: In
addition to mental status changes, older adults are predisposed to many
different types of psychological issues, such as the loss of family members or
friends, decreased social status and/or professional identity, loss of
mobility, problems with self-care, poor eyesight/hearing, lack of
transportation, and financial problems. These situations have the potential to
reduce self-esteem; induce a sense of hopelessness, isolation, loneliness, or
boredom; and potentially lead to depression. Many studies have identified a
link between depression and poor overall medication adherence.9,18-22
This may be due to symptoms associated with depression, such as poor
concentration and focus, poor motivation and hopelessness, and lack of energy
and attention.20,22 To relieve such feelings of dismay, many
patients resort to self-treatment with alcohol or OTC medications. It is
important for pharmacists to recognize the prevalence of depression in the
older population, as well as the impact that this illness can have on
adherence to medication regimens.
Cultural differences among older adults is another
concern, since about 10% of older Americans are born outside of the U.S., and
almost 13% do not speak English as their primary language.23 Many
cultures have their own unique beliefs regarding medication, alcohol, and even
health care professionals. A study of older Chinese-American adults found that
medication misuse may have been due to a number of cultural factors, including
reliance on Chinese medications and herbs, cultural views on authority that
affect the patient-provider relationship, and language barriers.24
Language barriers are especially challenging when trying to properly counsel a
patient. It is difficult for older adults to make appropriate health care
choices if they cannot understand instructions, drug interactions, or even the
necessity for the medication.
Social and economic circumstances, such as
education, income, and minority status, can affect access to health care. Over
34% of older adults do not have a high school diploma.23 About 16%
of older adults are minorities.25 Although the poverty rate is
lower among older adults than among the total population, it is estimated that
about 10% of people ages 65 and older live in poverty.23 Economic
situations may lead to intentional nonadherence, another form of medication
misuse, which occurs when patients knowingly and purposefully do not take
their medications due to the inability to pay high prescription drug costs.17,21,26
However, it is important for patients to understand that the
ramifications of nonadherence will be more expensive in the long-term in the
form of overall health care costs.27
Vision and hearing problems are also associated
with poor adherence in patients ages 65 and older. Up to 34% of older adults
have trouble seeing, and over 80% have trouble hearing.28 Patients
with visual impairment may have difficulty reading the small print on labels,
may not be able to differentiate between pills, and may even have difficulty
locating prescription bottles. Patients with auditory deficits are prone to
misunderstanding verbal instructions, such as how to take the medication, and
important precautions and warnings.28 Many studies have found an
association between visual and auditory impairment and nonadherence.9,14,29
Role of the Pharmacist
is important for health care professionals to be aware of the issues involved
with medication and alcohol misuse among older adults. There are many
opportunities for pharmacists to affect the outcomes of treatment in older
adults, as they are easily accessible and trusted by patients.
Screening patients for alcohol use can be a
personal and uncomfortable situation for both patient and pharmacist. Patients
may feel that their privacy has been invaded and become defensive. Using less
direct questioning techniques and asking questions such as "How do you use
alcohol?" may help to identify problematic misuse of alcohol.1
When filling prescriptions for benzodiazepines, sedatives, or any narcotic
analgesics, pharmacists should recommend that patients not drink alcohol when
using these medications. Acetaminophen can damage the liver, particularly when
combined with alcohol. Patients who regularly consume three or more servings
of alcohol per day should avoid taking acetaminophen unless recommended by
their primary care provider. Pharmacists should warn patients about
acetaminophen-containing products, both prescription and OTC, especially if
they are already taking an acetaminophen-containing medication (e.g., Vicodin
or Percocet). Patients should be advised to carefully check the labels of all
of their medications for acetaminophen. The maximum daily amount of
acetaminophen for young, healthy, nondrinking adults is 4 g/day (equivalent to
eight extra-strength acetaminophen or Vicodin 5/500 tablets). However, for
individuals who are chronic alcohol users, no more than 2 g/day of
acetaminophen is recommended if administration of this drug cannot be avoided.30
In addition, patients should be advised to avoid alcohol use with cough and
cold preparations that contain antihistamines and alcohol. Patients must also
be counseled to avoid alcohol use with the antimicrobial metronidazole.
Patients should wait one to three days after stopping metronidazole therapy
before resuming consumption of alcohol.31 Pharmacists should also
advise patients to avoid using herbal and natural products without consulting
a pharmacist or primary care provider, since many of these products have
interactions with prescription medications and alcohol.
When prescription misuse (i.e., taking too much or
too little medication) is suspected, prescription directions should be
confirmed with the prescriber and reinforced with the patient. Pharmacists
should consider the following questions when reviewing the medication profiles
of older patients:
• Do any of the medications interact with each
other or with alcohol?
• Is more than one health care
provider prescribing medications or involved with the care of this patient?
• Does the patient use more than
one pharmacy and/or mail order?
• Does the patient follow the
directions for all medications?
In addition to drug interactions, it is imperative
to consider hearing/visual impairment and language barriers when counseling
older adults. Visual cues should be employed whenever possible. Patience and
persistence are also key components to effective communication with older
adults. Be sure to speak slowly and use clear language without being
patronizing. Breaking up the information being given into small, clear
segments or "chunks" aids in audience comprehension and retention. Asking
open-ended questions--those that begin with the words who, what
, where, when, how, and why--will help engage the
patient in a dialogue and encourage disclosure of valuable information as well
as the patient's involvement in his or her own health care. Barriers to
communicating with older adults present a real challenge. It is important to
employ various communication techniques (e.g., visual, verbal) to ensure that
the information disseminated was received and understood by the patient.
Language barriers can be overcome by asking the patient to bring in a friend
or family member to translate the counseling information.
Patient perception about medications is a
significant indicator of how well older adults will adhere to regimens.32
Older adults who perceive their medications as necessary, useful, and less
harmful are more likely to take medications as prescribed.14 For
these reasons, it is vital for health care professionals to properly explain
the reason for and effects of the medications they prescribe and dispense.
Having knowledge and confidence is powerful, especially since adults who are
more self-assured in their ability to adhere to prescribed medication regimens
are also more likely to do so.33
Older patients who see more than one primary care
provider or who use more than one pharmacy are at a significantly greater risk
for nonadherence, hospitalization, adverse drug events, and increased costs.15-17,34-36
Patients using more than one doctor may assume that the different providers
communicate with each other when infact one may not even be aware of the other.15,35
Patients may also assume that the databases of different pharmacies are linked
or that they include information about the patient's OTC and herbal
medications. Use of multiple pharmacies does not allow the pharmacist to keep
track of a patient's entire medication profile. Additional information for
pharmacists and patients regarding medication and alcohol misuse can be found
in Tables 1 and2.
is important for health care providers to be aware of the potential for
medication and alcohol misuse/abuse in the older population. It is recommended
that every adult age 60 or older should be screened for alcohol and
prescription drug use as part of a regular physical examination. Counseling
older patients on the risks associated with the concurrent use of medications
and alcohol is imperative to avoid preventable lapses or breakdowns in the
patient's care. Effective communication through patient counseling is the key
to the continuity of care of our older population. Pharmacists are in the
perfect position to bridge the gap between primary care provider and the
patient by regularly interviewing and educating the patient.
Center for Substance Abuse Treatment. Substance Abuse Among Older Adults
. Treatment Improvement Protocol (TIP) Series, Number 26. DHHS pub. No. (SMA)
02-3688. Washington, DC: U.S. Government Printing Office, 1998, 2002.
National Center for Health Statistics: Fast Stats A-Z. Older persons' health.
Centers for Disease Control and Prevention Web site. Available at:
www.cdc.gov/nchs/fastats/older_americans.htm. Accessed April 4, 2007.
The State of Aging and Health in America 2004. Centers for Disease Control and
Prevention Web site. Available at:
April 2, 2007.
AOD - Alcohol, medication and other drugs: abuse and misuse among older
adults. The facts. American Society on Aging Web site. Available at:
www.asaging.org/asav2/aod/facts.cfm. Accessed March 30, 2007.
Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in
the ambulatory adult population of the United States: the Slone survey. JAMA.
Beers MH, Baran RW, Frenia K. Drugs and the elderly, Part 1: The problems
facing managed care. Am J Manag Care. 2000;6:1313-1320.
Tommasello AC. Substance abuse and pharmacy practice: what the community
pharmacist needs to know about drug abuse and dependence. Harm Reduct J
National Council on Patient Information and Education. Public Policy and
Compliance. Available at: www.talkaboutrx.org/med_compliance.jsp. Accessed
April 5, 2007.
Vik SA, Hogan DB, Patten SB, et al. Medication nonadherence and subsequent
risk of hospitalisation and mortality among older adults. Drugs Aging.
Alcohol Alert. No. 40. National Institute of Alcohol Abuse and Alcoholism Web
site. April 1998. Available at: pubs.niaaa.nih.gov/publications/aa40.htm.
Accessed April 2, 2007.
Liberto JG, Oslin DW, Ruskin PE. Alcoholism in older persons: a review of the
literature. Hosp Community Psychiatry. 1992;43:975-984.
Pringle KE, Ahern FM, Heller DA, et al. Potential for alcohol and prescription
drug interactions in older people. J Am Geriatr Soc. 2005;53:1930-1936.
Alcohol, Wine and Cardiovascular Disease. American Heart Association Web site.
Available at: www.americanheart.org/presenter.jhtml?identifier=4422. Accessed
April 12, 2007.
Cramer JA. Enhancing patient compliance in the elderly. Role of packaging aids
and monitoring. Drugs Aging. 1998;12:7-15.
Monane M, Monane S, Semla T. Optimal medication use in elders. Key to
successful aging. West J Med. 1997;167:233-237.
Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic
review of the role of the pharmacist. Drugs Aging. 2003;20:817-832.
Malhotra S, Karan RS, Pandhi P, Jain S. Drug related medical emergencies in
the elderly: role of adverse drug reactions and non-compliance. Postgrad
Med J. 2001;77:703-707.
Yee JL, Hasson NK, Schreiber DH. Drug-related emergency department visits in
an elderly veteran population. Ann Pharmacother. 2005;39:1990-1995.
Spiers MV, Kutzik DM. Self-reported memory of medication use by the elderly. Am
J Health Syst Pharm. 1995;52:985-990.
Wang PS, Bohn RL, Knight E, et al. Noncompliance with antihypertensive
medications: the impact of depressive symptoms and psychosocial factors. J
Gen Intern Med. 2002;17:504-511.
Benner JS, Glynn RJ, Mogun H, et al. Long-term persistence in use of statin
therapy in elderly patients. JAMA. 2002;288:455-461.
Gehi A, Haas D, Pipkin S, Whooley MA. Depression and medication adherence in
outpatients with coronary heart disease: findings from the Heart and Soul
Study. Arch Intern Med. 2005;165:2508-2513.
Gist YJ, Hetzel LI. We the People: Aging in the United States. Census 2000
Special Reports. December 2004. Available at:
www.census.gov/prod/2004pubs/censr-19.pdf. Accessed April 10, 2007.
Zhan L, Chen J. Medication practices among Chinese American older adults
influences: A study of cultural. J Gerontol Nurs. 2004;30:24-33.
Demographic Trends in the 20th century. Census 2000 Special Reports. November
2002. Available at: www.census.gov/prod/2002pubs/censr-4.pdf. Accessed April
Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among
Medicare beneficiaries. Health Aff (Millwood). 2003;22:220-229.
Balkrishnan R, Rajagopalan R, Camacho FT, et al. Predictors of medication
adherence and associated health care costs in an older population with type 2
diabetes mellitus: a longitudinal cohort study. Clin Ther.
Summary health statistics for U.S. adults: National Health Interview Survey,
2004. Centers for Disease Control and Prevention. May 2006. Available at:
www.cdc.gov/nchs/data/series/sr_10/sr10_228.pdf. Accessed April 10, 2007.
Botelho RJ, Dudrak R 2nd. Home assessment of adherence to long-term medication
in the elderly. J Fam Pract. 1992;35:61-65.
Facts and Comparisons, efacts. Acetominophen drug monograph. Available at:
www.factsandcomparisons.com. Accessed April 24, 2007.
Facts and Comparisons, efacts. Metronidazole drug monograph. Available at:
www.factsandcomparisons.com. Accessed April 24, 2007.
Horne R, Weinman J. Patients' beliefs about prescribed medicines and their
role in adherence to treatment in chronic physical illness. J Psychosom Res
Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs
on medication adherence in the elderly. Drugs Aging. 2006;23:191-202.
Kaiser RM, Schmader KE, Pieper CF, et al. Therapeutic failure-related
hospitalisations in the frail elderly. Drugs Aging. 2006;23:579-586.
Monane M, Bohn RL, Gurwitz JH, et al. The effects of initial drug choice and
comorbidity on antihypertensive therapy compliance: results from a
population-based study in the elderly. Am J Hypertens. 1997;10:697-704.
Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of
medication adherence among seniors. Ann Pharmacother. 2004;38:303-312.
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