MEDICATION USE IN THE OLDER POPULATION
Concurrent Use of Alcohol and Medications.
Because of age-related physiological changes, declining health and functional status, and medication use, older adults can incur problems at low levels of alcohol consumption (Fink et al., 2002). Memmott (2003) states that estimates of alcohol dependence in the population over age 65 range from 1 to 5 percent, while the prevalence of problem drinking in the elderly varies from 10 to 15 percent. Lazow (2001) reports that within the high percentage of adults 65 and older who are admitted to a hospital at least once a year (20% of the population of this age), 20 to 50 percent who entered the hospital for nonalcohol or other drug-related problems were identified as having such problems.
The prevalence of alcohol use in geriatric trauma patients may be understated as indicated by the results of a study by Zautcke et al. (2002), who found that only a small percentage of older trauma patients are tested for alcohol use. Of the 32,382 patients 65 or older who entered a Level I or Level 2 trauma center in Illinois between 1994 and 1996, only 5.2 percent were tested for the presence of alcohol. Of those tested, 49.7 percent tested positive for alcohol and 71.8 percent of those were considered intoxicated (blood alcohol concentration [BAC] level = .08 or higher). Zautcke et al. (2002) note that the decision whether to test a patient for alcohol use was likely skewed and determined by clinical signs of intoxication. Clinical signs of intoxication are often difficult to detect, especially at lower concentrations.
Inappropriate Prescription Drug Use by Older Subjects |
||||
|---|---|---|---|---|
Study |
Number, age, and sex of subjects |
Incidence of inappropriate medication use |
Inappropriate medications most commonly identified |
Reference |
| National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey | 22,031 subjects; 25% 65–69 years old, 24.9% 70–74 years old, 23.8% 75–79 years old, 26.2% ≥ 80 years old; 59% female and 41 % male. | Ranged from 6.01% in 1996 to 7.82% in 2000 | Propoxyphene, hydroxyzine, diazepam, amitriptyline, and oxybutynin | Goulding (2004) |
| Outpatient prescription claims database of AdvancePCS (pharmaceutical benefit manager) | 765,423 subjects; 73.7 ± 6.5 (mean ± SD) years old; 58.3% female and 41.7% male | 21% of the subjects filled a prescription for one or more drugs of concern | Amitriptyline and doxepin accounted for approximately 23% of the total claims for Beers list drugs | Curtis et al., (2004) |
| 1996 Medical Expenditure Panel Survey | Sampling weights used to derive National Estimates for the population of 32.29 million community-dwelling older people age 65+ | 19% use psychotropic medications (64% are female). 7.14% of all older people and 37.86% of those using psychotropic medications received potentially inappropriate psychotropic medications. 32.9% of those taking psychotropic drugs received agents that were generally inappropriate and 10.2% received agents that were inappropriate in the presence of specific conditions. | Study focused on psychotropic medications that should generally be avoided, and those that should be avoided in patients with specific medical conditions. Amitriptyline, doxepin, diazepam, chlordiazepoxide, long-acting benzodiazepines w/falls, meprobamate, flurazepam, barbiturates | Aparasu and Mort (2004) |
| 1998 Medicare Current Beneficiary Survey | 9,851 age 65+ | 6.8% annual prevalence of propoxyphene use | Study focused only on propoxyphene | Kamal-Bahl et al. (2003) |
| Mexican-Americans Living in the Southwestern U.S. | 3,050 age 65+ | 12% of the sample within 2 weeks of the home interviews assessing medication use | Four drugs accounted for 54% of the inappropriate prescribing: chlorpropamide, propoxyphene, amitriptyline, dipridamole. | Raji et al. (2003) |
| Duke Established Populations for Epidemiological Studies of the Elderly (fourth wave, 1989/90, seventh wave, 1992/93) | 3,234 (fourth wave) and 2,508 (seventh wave); 49.1% <75 years old, 41.1% 75–84 years old, 9.8% 85+ years old; 64.8% female and 35.2% male | 21.0% of the fourth wave study population and 19.2% of the seventh wave study population used one or more inappropriate medications | Benzodiazepines and NSAIDs | (Hanlon et al., 2002) |
In a survey by Adams (1995) 38 percent of the elderly community dwellers reported concurrent use of alcohol and high-risk medications (e.g., antidepressants, antihypertensives, sedative-hypnotics). Six percent reported consuming seven or more drinks per week while taking a high-risk medication.
Fink et al. (2002) cite a study by Adams, Yuan, Barboriak, and Rimm (1993) who conducted a national study using 1989 Medicare claims data, and found that alcohol-related hospitalizations were more common among elderly people than hospitalizations for myocardial infarction. Fink et al. (2002) developed the Alcohol-Related Problems Survey to detect older people who are at risk for or are experiencing problems because of their use of alcohol alone or in conjunction with their comorbidities, medication use, and functional status. The Alcohol-Related Problems Survey9 (ARPS) was administered by Fink et al. (2002) to 549 current drinkers 65 and older who were mostly Caucasian (87%) with high school or higher education (94%). Eligible participants reported drinking at least one alcoholic beverage in the past 12 months. Based on the ARPS score, drinkers were classified into three categories: harmful drinkers (alcohol abuse or dependence, or the presence of problems such as hypertension, adverse drug events, or legal problems due to drinking); hazardous drinkers (drinking poses a likely risk for problems); or nonhazardous drinkers (drinking poses no known risks for problems). Eleven percent of subjects were harmful drinkers, and 35 percent were hazardous drinkers. Most harmful drinkers were identified by their use of alcohol with their comorbidity (e.g., three or more drinks, two to three times per week and having hypertension, depression or other psychiatric condition, or gout; or, any amount of alcohol plus having had hepatitis in the past 12 months, cirrhosis or other liver condition, or gastritis in the past 12 months). More men than women were classified as harmful drinkers, and more women than men were classified as nonhazardous drinkers. Most hazardous drinkers were identified by their use of alcohol with medications. Similar proportions of men and women, and older (age 75+) and younger (age 65 to 74) age groups were hazardous drinkers.
Looking at the number of medications used with potential alcohol interaction by the study sample, Fink et al. (2002) report that:
- 12 percent used no such medications;
- 46 percent used 1 to 3 such medications;
- 32 percent used 4 to 6 such medications; and
- 9 percent used 7 or more such medications.
The most common combination of alcohol use and medications was one or more drinks per day with the following medications (in hierarchical order from most common to least common): arthritis and pain medications, cimetidine10 or ranitidine,11 antidepressants, warfarin,12 nitrates, diphenhydramine,13 or antiseizure medication. The second most common combination of medications and alcohol use for hazardous drinkers was two or more drinks per day, and the use of aspirin (two or more) or hypertensives.
9 The ARPS is a self-administered questionnaire with 60 items about the presence of medical and psychiatric conditions, symptoms of disease, smoking behavior, medication use, physical function and health status, quantity and frequency of alcohol use, episodic heavy drinking, symptoms of alcohol abuse and dependence, driving after drinking, and gender.
10 Cimetidine (brand names: Tagamet; Tagamet HB 200; Tagamet Tiltab) is used to treat ulcers, gastroesophageal reflux disease, and conditions where the stomach produces too much acid. OTC cimetidine is used to prevent and treat symptoms of heartburn associated with acid indigestion and sour stomach. Cimetidine is in a class of medications called histamine 2 receptor antagonists (H2RA).
11 Ranitidine (brand names: Zantac; Zantac AR) is used to treat ulcers, gastroesophageal reflux disease, and conditions where the stomach produces too much acid. OTC ranitidine is used to prevent and treat symptoms of heartburn associated with acid indigestion and sour stomach. Ranitidine is in a class of medications called histamine 2 receptor antagonists (H2RA).
12 Warfarin (brand name: Coumadin) is used to prevent blood clots from forming or growing larger. It is often prescribed for patients with certain types of irregular heartbeat and after a heart attack or heart valve replacement surgery.
13 Diphenhydramine (brand names: Benadryl; Benylin) is an antihistamine that relieves red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, and the common cold. It also may relieve the itching of insect bites, sunburns, bee stings, poison ivy, poison oak, and minor skin irritation. Diphenhydramine is also used to prevent and treat motion sickness, induce sleep, treat Parkinson's disease, and relieve cough caused by minor throat or airway irritation.