Alcohol, Medications, and Older Adults Mailtreyee Mohanty Virginia Commonwealth University

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Case Studies from Age in Action Virginia Center on Aging

2011 Alcohol, Medications, and Older Adults Mailtreyee Mohanty Virginia Commonwealth University

Patricia Slattum Virginia Commonwealth University, [email protected]

Follow this and additional works at: https://scholarscompass.vcu.edu/vcoa_case Part of the Geriatrics Commons

Recommended Citation Mohanty, M., & Slattum, .P (2011). Alcohol, Medications, and Older Adults. Age in Action, 26(3), 1-5.

This Article is brought to you for free and open access by the Virginia Center on Aging at VCU Scholars Compass. It has been accepted for inclusion in Case Studies from Age in Action by an authorized administrator of VCU Scholars Compass. For more information, please contact [email protected]. Case Study Alcohol, Medications, to it. Baby-boomers, those born hol declines with advancing age and Older Adults between 1946 and 1964, tend to and the occurrence of health prob- consume more alcohol compared to lems (Merrick et al., 2008). Some by Maitreyee Mohanty and previous generations, so the preva- 50% of older adults aged 60-64 Patricia W. Slattum lence of alcohol-related problems is years reported alcohol use in the projected to increase as they age. past month, compared to only 39% Educational Objectives An overall understanding of alcohol for those aged 65 and above use by older adults requires atten- (NSDUH, 2010). Merrick et al. 1. Describe patterns of simultane- tion, as well, to patterns of drinking (2008), studying community- ous use of alcohol and Central Ner- and other interacting factors, such dwelling Medicare beneficiaries vous System (CNS) - acting med- as age, gender, marital status, aged 65 years and above, concluded ications among older adults. income, existence of co-morbid that “9% were involved in 2. Understand the mechanisms of conditions, and history of drinking unhealthy drinking (defined as interaction between alcohol and (Merrick et al., 2008). Research monthly use exceeding 30 drinks CNS-acting medications and their studies report varying patterns of per typical month and 'heavy consequences. alcohol use in older adults, in part episodic' drinking of four or more 3. Identify strategies to prevent attributable to their using different drinks in any single day), with alcohol-medication interactions measures of alcohol consumption, higher prevalence in men (16%) among older adults. and different definitions and cut-off than in women (4%).” Alcohol use 4. Recommend resources for older limits for drinking categories. The in older adults is also found to be adults and service providers for National Survey on Drug Use and associated with race, family history identifying and managing problem- Health (NSDUH, 2010) reported of alcohol abuse, educational level, atic alcohol and medication use. that in 2009, 39% of older adults smoking status, and mental illness consumed alcohol in the past (Merrick et al., 2008); the research- Background month; of these, 29% were current ers also noted that alcohol use is drinkers (at least one drink in the often under-reported because of As we grow older, drinking alcohol past 30 days), 8% were involved in some respondents' inability to recall may have unexpected and serious binge drinking (five or more drinks precisely and the desire to present consequences. Demographics, dif- on the same occasion on at least themselves in a favorable way. ferent bodily composition with age, one day in the past 30 days) and 2% and common challenges we experi- reported heavy alcohol use (five or Alcohol use among older adults is ence in later life may trigger more drinks on the same occasion influenced by various social and changes in both the consumption of on each of five or more days in past health related factors. Some may alcohol and how our body responds 30 days). Generally, the use of alco- drink to induce sleep or to uplift a Inside This Issue:

VCoA Editorial, 6 VCoA Focus: Thelma Watson, 13 Downside of Medicare, 16 VDA Editorial, 7 Bert Waters Award, 14 Elder Rights Award, 17 USDA Guidelines, 9 GTE Funding Applications, 14 Calendar of Events, 18 ARDRAF Recipients, 10 Preventing Falls, 15 Walk to End Alzheimer’s, 20 depressed mood (Ferreira & aged 50 and above reported co- that consists of the brain and spinal Weems, 2008). Moderate drinking occurrence of alcohol dependence/ cord. Several medications, includ- has been associated with improved abuse and mental illness. A German ing antidepressants to treat depres- social interactions and self-reported study (Du, Scheidt-Nave & Knopf, sion, sedatives to induce sleep, and health status among older adults 2008) found that approximately 8% antipsychotics to control psychosis, (Ferreira & Weems, 2008). Bene- of the non-institutionalized older act on the CNS. Importantly, some fits of moderate drinking in dimin- adults reported combined use of of these CNS-acting medications ishing the risk of cardiovascular psychotropic drugs and alcohol. show exaggerated response in older events and mortality, touted by sev- adults for two fundamental reasons: eral studies, promote the daily Generally, there is little control or 1) there are age-related changes in intake of alcohol (Ferreira & monitoring of what alcoholic bever- CNS functions, like altered neuro- Weems, 2008). Moreover, late-life ages older adults consume, and transmitters or number of receptors, related changes such as retirement, drinking is an individual decision. and 2) there is increased sensitivity loss of loved ones, and disease con- However, as the quick review with age to some drugs, such as ditions, might induce an older adult above suggests, a lack of awareness benzodiazepines, opioids, and into habitual drinking (Ferreira & or guidance about alcohol use in anaesthetics (Bowie & Slattum, Weems, 2008). However, health older adults might have serious 2007). Significantly, most of the conditions like diabetes, gout, consequences, given aging-related CNS medications, from antidepres- upper gastrointestinal conditions, physiologic changes affecting the sants to anti-anxiety medications, insomnia, depression, and cancer response to alcohol, the presence of sedatives, opioid analgesics, actually worsen with alcohol con- co-morbid health conditions, and antipsychotics, certain anticonvul- sumption (Moore, Whiteman & numerous interactions between sant and certain antitussive agents, Ward, 2007). Alcohol may, initially, alcohol and medications in older are CNS depressant, as is alcohol. help an older adult fall asleep, but it adults. So, when an older adult consumes interferes with staying asleep and CNS medications with alcohol, it may induce or worsen the sleep dis- Alcohol and CNS-acting could lead to exaggerated sedation, order (Moore, Whiteman & Ward, Medication Interactions impairment of motor skills, and 2007). impaired judgement, any of which Aging related changes in physiolo- could increase the risk of injury Several studies have found an asso- gy affect the distribution and (Moore, Whiteman & Ward, 2007). ciation between alcohol use disor- metabolism of alcohol. Alcohol dis- Apart from CNS-acting medica- ders and depressive symptoms tribution in the body depends on tions, several other medications (Choi & DiNitto, 2010; Moore, age and gender, as older people and also have the potential to interact Whiteman & Ward, 2007). Older females have less body water and with alcohol and cause adverse adults who indulge in heavy/binge more body fat as a percent of body events. For instance, nonsteroidal drinking to cope with depressive weight, and alcohol distributes in anti-inflammatory drugs (NSAIDs) symptoms have higher risk of hav- body water. Thus, for a given are associated with increased risk of ing alcohol problems (Choi & amount of alcohol consumption, the gastrointestinal bleeding; and anti- DiNitto, 2010). blood alcohol level is higher in hypertensive medications to lower older adults than in their younger blood pressure (such as hydralazine Alcohol-related disorders can co- counterparts. In addition, older and α-blockers) are associated with occur with psychiatric illness, such adults and females have lower lev- incidences of orthostatic hypoten- as depressive symptoms, anxiety or els of alcohol-metabolizing sion, when consumed with alcohol major depressive disorder (Choi & enzymes, which results in reduced (Moore, Whiteman & Ward, 2007). DiNitto, 2010). In 2009, the alcohol metabolism (Moore, White- NSUDH report stated that 11% of man & Ward, 2007). Consequences of Concurrent Use older adults (ages 65 and above) of Alcohol and CNS-Medications reported some kind of mental ill- The central nervous system (CNS) ness, while 7% of the population is the part of the nervous system Simultaneous use of alcohol and

2 CNS medications may result in en and aspirin, can also interact and five "as needed" medications. such adverse events as a fall, fall- with alcohol (Moore, Whiteman & Her scheduled prescriptions includ- related fracture, or traffic accident. Ward, 2007). So, easy access to an ed: lisinopril, nadolol, and amlodip- These may lead to emergency OTC medicine does not mean that ine for hypertension; furosemide department visits or hospitalization it is totally safe and without precau- for edema; levothyroxine for thy- and increased use of healthcare tions. Limit alcohol consumption. roid replacement; albuterol for asth- resources. A Swedish study (Sten- According to recommendations by ma; pantoprazole for gastroe- backa, 2002) showed that high the National Institute of Alcohol sophageal reflux disease (GERD); alcohol intake and use of sedatives/ Abuse and Alcoholism (NIAAA), solifenacin for urinary inconti- hypnotics were significantly associ- older males should not consume nence; citalopram, bupropion, and ated with injurious falls among more than one alcoholic drink a day quetiapine for depression; tra- older women, defined as aged 60 (a standard drink is 15 grams zodone for insomnia and depres- and above. A very recent study ethanol, meaning 12 ounces of reg- sion; tramadol for pain; and supple- reports that, out of 524,050 emer- ular beer, five ounces of wine, or ments of potassium and Vitamin D. gency department (ED) visits 1.5 ounces of 80–proof distilled Additionally, trazodone (sleep- involving drugs (including illicit spirits); and for older females, the inducer), promethazine (for nausea substances and pharmaceutical limit is “somewhat less” than that and vomiting), docusate (for consti- agents) and alcohol taken together, recommended for males (Blow & pation), acetaminophen, and 8,600 visits (2%) were documented Barry, 2003). Older adults should cholestyramine (for loose stool) in older adults (Drug Abuse Warn- be encouraged to drink within the were prescribed as needed. Evalua- ing Network [DAWN], 2011); this recommended limits if they choose tion of her medication regimen study identifies drugs for insomnia, to consume alcohol and to use cau- indicated that bupropion, quetiap- anxiety (primarily benzodi- tion when mixing alcohol with ine, trazodone, and tramadol have azepines), and narcotic pain reliev- medications. the potential to interact with alco- ers as the major drug categories hol, increasing her CNS depression involved in emergency visits. Case Study # 1 and her risk for falling. The phar- Clearly, older adults are vulnerable macist recommended to the physi- to harmful effects when taking Mrs. O is an 80-year-old white cian to change trazodone to use alcohol and CNS-medications at the woman who lives in an assisted liv- only when needed, and to discon- same time and need to be alert to ing community. At the time of her tinue quetiapine, if possible. Mrs. prevent harmful results. medication review by a pharmacist, O's physician educated her about her family expressed concerns that the potential risk of mixing alcohol Managing Alcohol and she had been “loopy and out of it” and her medications, and her physi- CNS-Medication Intake recently. She also experienced a fall cian, pharmacist, and family each in the evening but was not injured. advised her to stop her drinking. Prudent practice suggests the fol- There hadn’t been any recent Mrs. O did, in fact, stop her alcohol lowing: Avoid drinking alcohol and changes in her medications; but consumption and some changes in taking CNS-medications whenever during the pharmacist’s interview, her drug regimen were instituted, possible. Read the labels on med- Mrs. O mentioned drinking wine in after which her functional and cog- ications, which can help identify the evening. The medication techni- nitive status improved noticeably. which medications should be avoid- cian, who often works on Mrs. O's ed with alcohol. Healthcare profes- floor, stated that she “stays up all Case Study #2 sionals can increase awareness night drinking wine and watching about alcohol and medication inter- TV then sleeps throughout the day.” Ms. SP is an 82-year-old white action in older adults. Some over The medication technician was not female who suffers from chronic the counter (OTC) products like sure how much she drinks nightly obstructive pulmonary disorder sedating antihistamines and com- or whether she was drinking more (COPD). She had a medical history mon non-steroidal anti-inflammato- than usual. Mrs. O was taking 16 of aortic aneurysm, which was ry drugs, such as ibuprofen, naprox- scheduled prescription medications treated surgically, and was diag-

3 nosed previously with depression, for which she was treated with anti- Some commonly used CNS-acting medications depressants. She was a smoker for Sedatives/hypnotics/anti-anxiety Antipsychotics the last 40 years and a moderate drugs alcohol-drinker. After moving to a Risperidone ( Risperdal) senior congregate living center, she Alprazolam (Xanax) Ziprasidone (Zeldox, Geodon) started drinking more heavily, Zolpidem (Ambien) Olanzapine (Zyprexa) which led to incidences of falls and Temazepam (Restoril) Clozapine ( Clorazil) Hydroxyzine (Vistaril) Aripiprazole (Abilify) a fractured arm. Her prescriptions Doxepin (Sinequan) Quetiapine (Seroquel) consisted of 11 medications: Advair Buspirone (Buspar) Haloperidol (Haldol) (combination of fluticasone and sal- Chlordiazepoxide (Librium) Chlorpromazine (Thorazine) meterol), tiotropium, albuterol, Clorazepate (Tranxene) Perphenazine (Trilafon) montelukast, and Mucinex (guaife- Eszopiclone (Lunesta) Fluphenazine (Permitil) nesin and pseudoephedrine) for COPD; paroxetine for depression; Antidepressants Opioid analgesics simvastatin for cholesterol; and Citalopram (Celexa) Codeine supplements (iron and calcium). Ecitalopram (Lexapro) Hydrocodone (Vicodin) She was also taking digoxin for Sertraline (Zoloft) Oxycodone (Percocet) congestive heart failure and primo- Paroxetine ( Paxil, Pexeva) Morphine (Avinza) dine for tremor. However, during Duloxetine (Cymbalta) Meperidine (Demerol) the interview she did not mention a Fluoxetine (Prozac) Fentanyl (Actiq) history of tremor or heart failure. Venlafaxine (Effexor) After checking for potential drug Amitriptyline (Amitriptyline) Anticonvulsants interactions, it was found that prim- Mirtazepine (Remeron) Bupropion (Wellbutrin) Phenytoin (Dilantin) idone and ethanol have a moderate Pregabalin (Lyrica) interaction, while paroxetine and Antihistaminics/antiemetics Lorazepam (Ativan) ethanol have a minor level of drug Clonazepam (Klonopin) interaction. After the fall incident, Fexofenadine (Allegra) Diazepam (Valium) her physician advised her to quit Cetrizine (Zyrtec) Phenobarbital (Luminal) drinking. Ms. SP underwent three Chlorpheniramine (Chlor-Trimeton) Topiramate (Topamax) sessions of counselling with her Meclizine (Antivert) Primidone (Mysoline) physician and then decided to Diphenhydramine (Benadryl) Gabapentin (Neurontin) Promethazine (Phenergan) abstain from drinking and smoking. Subsequently, she has not reported Note: The above list of medications is not exhaustive. any incidence of fall or other forms Note: Some medications listed above are used for more than one health condi- of injury. This case illustrates co- tion (such as clonazepam is used in controlling seizures and panic attacks and occurrence of depression and alco- lorazepam is used in anxiety and insomnia) hol intake, resulting in simultaneous use of alcohol and antidepres- adults, because of age-related awareness about alcohol and med- sants. As noted, the concurrent use changes in physiology, existing ication interactions among older of alcohol with some prescription health conditions, and complex adults. drugs increases the risk of falls and medication use, can be vulnerable injury. to harmful effects of alcohol and Study Questions medication interactions. These, in Conclusion turn, may diminish quality of life 1. Discuss at least two likely conse- and may result in costly healthcare quences of consuming alcohol and These cases demonstrate the dan- expenses. Importantly, these effects CNS-medications concurrently. gers associated with mixing alcohol are avoidable, so steps should to be 2. Why are older adults more vul- and CNS-acting medications. Older taken to educate and increase nerable to alcohol and CNS-med-

4 ication interactions? Choi, N. G. & DiNitto, D. M. (2011). Substance Abuse and Mental Health 3. How can a potential alcohol and Heavy/binge drinking and depressive Services Administration. (2009). CNS-medication interaction be pre- symptoms in older adults: gender dif- Results from the 2009 National Survey vented? ferences. International Journal of Geri- on Drug Use and Health: Mental atric Psychiatry, 26: n/a. doi: 10.1002/ Health Detailed Tables. Retrieved from gps.2616. On-line pre-publication. http://oas.samhsa.gov/NSDUH/2k9NS Useful Links for More DUH/MH/tabs/Sect1peMHtabs.htm#Ta Information Du, K., Scheidt-Nave, C., & Knopf, H. b1.8B (2008). Use of psychotropic drugs and 1) Alcohol and Aging Awareness alcohol among non-institutionalised Substance Abuse and Mental Health Group (AAAG) is a state level group elderly adults in Germany. Pharma- Services Administration. Drug Abuse consisting of public and private organi- copsychiatry, 41, 242-251. and Warning Network (2011). National zations that are collaboratively educat- Estimates of Drug-Related Emergency ing and training older adults and their Ferreira, M. P. & Weems M. K. S. Department Visits:2008. Retrieved service providers about alcohol and (2008). Alcohol consumption by aging from: https://dawninfo.samhsa.gov/ medication misuse. AAAG’s upcoming adults in United States: Health benefits pubs/edpubs/default.asp. projects include screening, brief inter- and detriments. Journal of American vention, referral to treatment, web- Dietetic Association, 108(10), 1668- About the Authors based training for service providers. 1676. For more information, please contact: Maitreyee Mohanty is (804) 213-4688 or Merrick, E. L., Horgan, C. M., a graduate student in (www.abc.virginia.gov/Education/ Hodgkin, D., Garnick, D. W., the Department of olderadults/aaagroup.html) Houghton, S.F., Panas, L., Saitz, R., & 2) Alcohol use in older adults. National Blow, F.C. (2007). Unhealthy drinking Pharmacotherapy and Institute of Aging (NIA). patterns in older adults: prevalence and Outcomes Science at (www.nia.nih.gov/healthinformation/ associated characteristics. Journal of the VCU School of publications/alcohol.htm) the American Geriatrics Society, 56(2), Pharmacy. She earned her Masters 3) Harmful interactions: mixing alco- 214-23. of Pharmacy Practice degree from hol with medicines. NIAAA publica- National Institute of Pharmaceutical tion. (http://pubs.niaaa.nih.gov/ Moore, A. A, Whiteman, E. J., & Ward, Education and Research (NIPER, publications/Medicine/medicine.htm) K.T. (2007). Risks of combined alco- Mohali), in India. Her research 4) Alcoholism and alcohol abuse: hol/medication use in older adults. interest is medication related issues signs, symptoms, and help for drinking American Journal of Geriatric Phar- in older adults. problems. (http://helpguide.org/ macotherapy, 5, 64-74. mental/alcohol_abuse_alcoholism_ signs_effects_treatment.htm) Stenbacka, M. (2002). Association Patricia Slattum, 5) How to talk to an older person who between use of sedatives or hypnotics, PharmD, PhD is has a problem with alcohol or medica- alcohol consumption, or other risk fac- Director of the Geri- tions. (www.hazelden.org/ web/pub- tors and a single injurious fall or multi- atric Pharmacothera- lic/hff10730.page) ple injurious falls: A longitudinal gen- py Program, Depart- eral population study. Alcohol, 28(1), ment of Pharma- References 9-16. cotherapy and Outcomes Science, at the Virginia Commonwealth Substance Abuse and Mental Health Bowie, M. W. & Slattum, P. W. (2007). University School of Pharmacy. Pharmacodynamics in older adults: A Services Administration. (2010). Her interests include improving review. American Journal of Geriatric Results from the 2009 National Survey Pharmacotherapy, 5, 263-303. on Drug Use and Health: Volume I. pharmacotherapy for older adults Summary of National Findings (Office residing in the community and Blow, F. C. & Barry, K. L. (2003). Use of Applied Studies, NSDUH Series H- assisted-living facilities and the and misuse of alcohol among older 38A, HHS Publication No. SMA 10- effects of medications on cognition. women. NIAAA publications. 4856Findings). Retrieved from: She is a member of the Alcohol and Retrieved from: http://pubs.niaaa.nih. http://www.oas.samhsa.gov/NSDUH/2 Aging Awareness Group. gov/publications/arh26-4/308-315.htm k9NSDUH/2k9Results.htm#3.1