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 these problems.

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 alcohol.9

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
Aging-Related 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 neurologic disorders.

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 reactions.

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
It 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.

It 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.

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