Presentation made by Dr. Patricia Slattum on March 19, 2015 - review details here: http://worldeventsforum.blogspot.com/p/blog-page_28.html

1. REDUCING THE RISK OF
MEDICATION-ALCOHOL
INTERACTIONS IN OLDER ADULTS
Patricia W. Slattum, PharmD, PhD, CGP
Virginia Commonwealth University
pwslattu@vcu.edu

2. Objectives
Identify
medications that
may interact with
alcohol and
potential outcomes
in older adults.
Describe risk
factors for adverse
events from
alcohol and
medication
interactions among
older adults.
Discuss treatment
issues in pain,
falls, depression
and insomnia
when alcohol and
medication
interactions play a
role.
Using case
studies, develop
strategies to
manage alcohol
and medication
interactions in
older adults.

3. Case
Study
BW
BW
no longer drives, but has three sons
living nearby who help with errands such
as grocery shopping and doctor
appointments.
93 year old white
male
lives with his wife
independently in a small
apartment.
married for 71
years
is blind and has
significant
functional
limitations.
requires BW’s
assistance with
activities of daily
living.

4. Case BW
BW suffers
from
CHF
atrial fibrillation
osteoarthritis
recently diagnosed with depression
His current
medications
include:
Furosemide 40 mg BID
Potassium 20 mEq BID
Digoxin 0.125 mg QD
Warfarin 4 mg QD
Sertraline 50 mg QD
Acetaminophen 500 mg QID prn

5. Case BW
His warfarin therapy has been difficult
to manage.
His INR has fluctuated above and
below the target range.
Told his doctor that he wanted to stop
taking all of these medications and
was tired of the monitoring and dosing
changes.
His functional status has begun to
decline and his family hired a
companion service to assist him 3
mornings each week.
Over the past several
months:

6.  After working at the home for 2 weeks, the
companion reported to the son that there were
empty alcohol bottles in the trash.
 BW has a long history of episodes of alcohol
misuse, but had been abstinent for almost 15 years
after falling down the stairs and breaking his arm
while intoxicated.
 The son had purchased a bottle of alcohol for his
father recently because some friends were planning
to visit.
Case BW

7. Case BW
1 week
After the third fall he was
transported to the ER and
was admitted for
heart failure exacerbation.

8. Case BW
The sons called a family
meeting to discuss living
arrangements for BW
They discover that each of
them has been purchasing
alcohol for their father over the
past few months.
Neighbors and grandchildren
have also purchased alcohol
for him. After some investigating it
appears that he may have
been drinking as much as 9 oz
of bourbon daily.

9. • Our bodies experience physical changes as we age.
• These changes can impact:
How well medications get into and out of the body.
How the body responds to medications.
The Aging Body and Medications

10. Body fat increases and body water decreases as
a percent of body weight.
• Example: Alcohol
Delafuente JC. Consult Pharm 2008, 23:324-34.
Changes in Body Composition with
Aging
Alcohol goes into
body water.
With less water,
blood alcohol
concentrations
are higher.

11. Most drugs leave the body through the liver and kidney.
Delafuente JC. Consult Pharm 2008, 23:324-34.
Changes in the Kidney and Liver
with Aging
• Liver and kidney function decline with aging.
• Drugs take longer to get out of the body.
• Older adults may need lower doses or a longer time
between doses.

12. Bowie M, Slattum P. J Geriatr
Pharmacother 2007;5: 263-303
Changes in Drug Response with
Aging
Older adults may
• Have decreased functional ability
before taking the medication.
• Be more sensitive to medications.
• Be less able to compensate for
the effects of medications.
This may result in
unwanted effects of
medications.

13.  Altered mental status/confusion
 Fatigue
 Falling
 Constipation
 Urinary Incontinence
 Depression
 Dizziness
Tangiisuran B, et al. Age and Ageing 2009;38:358-359. Weingart SN, et al. Arch Intern Med 2005;
165:234-240. Schmader KE, et al. Am J Med 2004;116:394-401.
Adverse events often mistaken for normal aging!
Atypical Presentation of Adverse
Drug Events in Older Adults

14. • Prevalence increases as number of prescribed
drugs increases
• 5 to 7 drugs = 4 fold greater risk
• 8 to 10 drugs = 8 fold greater risk
• Cannot prevent all drug interactions!
Mallet L, et al. Lancet 2007;370:185-91.
http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/ucm096391.pdf
Drug Interactions

15. • Patient groups at increased risk:
– Older adults taking multiple medications
– Those seeing more than one doctor
– Those being infrequently or inadequately monitored
– Those with impaired liver or kidney function
• Dietary supplements, herbal products and over-the –
counter medications and alcohol must also be
considered.
• Pharmacists look for drug interactions when filling
prescriptions.
Mallet L, et al. Lancet 2007;370:185-91.
Drug-Drug Interactions

16. Harmful interactions: Mixing alcohol with Medicines Brochure
https://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm
Drug-Alcohol Interactions
Mixing certain medications
with alcohol can cause
adverse events
Mixing alcohol with
sedatives, pain
medications or other
drugs acting on the
brain can result in
increased sedation,
unsteadiness or falls.
Mixing alcohol with
aspirin, ibuprofen,
naproxen or similar
drugs can increase
risk of
gastrointestinal
bleeding.
Mixing alcohol with
blood pressure
lowering medications
can cause blood
pressure to go too
low.
OTHER

17. http://www.rochester.edu/uhs/healthtopics/Alcohol/interactions.html
https://webapps.ou.edu/alcohol/docs/13EtohandMedicationInteractions40-54.pdf
Alcohol and AcetaminophenAcetaminophen
found in many combination pain products.
recommendations for maximum dose/day recently
decreased to 3,000 mg/day.
when taken during or right after drinking increases the risk of
liver damage.
chronic drinking may increase the production of toxic metabolites of
acetaminophen.

18.  Pain
 Depression
 Insomnia
 Other
Treatment Issues

19. • Many medications recommended to manage
pain in older adults interact with alcohol:
– Acetaminophen
– Nonsteroidal Anti-inflammatory Drugs
– Opiate analgesics
• Some patients may be using alcohol to
self-treat pain.
Pain

20. CASE
STUDY
LR
LR
When her daughter tries to discuss this
with her, she claims that this is “normal” for
someone her age and to stop worrying her.
LR brings up the issue of dry mouth with each of her
three doctors, but the only recommendations she
has received is to suck on hard candy and drink
more fluids.
LR doesn’t feel that these
measures really help.
LR’s daughter requests a medication
assessment to determine if her medications
may be contributing to her dry mouth.
PRIMARY COMPLAINT:
DRY MOUTH
lives alone in her own home
has difficulty with instrumental activities
of daily living such as paying her bills
and shopping for groceries.
dozes off frequently during the day and seems
unsteady on her feet.

21. Her current medication regimen:
CASE: LR
TIME MEDICATION WHEN STARTED
MORNING 1 Gabapentin (Neurontin®) 800 mg 2 years ago
1 Potassium chloride 20mEq 4 years ago
1 Furosemide (Lasix®) 20mg 4 years ago
½ Metoprolol 25mg 8 years ago
NOON 1 Duloxetine (Cymbalta®) 60mg 3 weeks ago
1 Gabapentin (Neurontin®) 800 mg 2 years ago
2 Oxaprozin (Daypro®) 600 mg 1.5 years
NIGHT 2 Quetiapine (Seroquel®) 25mg 1 year ago
1 Amitriptyline 50mg 3 months ago
1 Temazepam (Restoril®) 15 mg 10 years ago
1 Gabapentin (Neurontin®) 800mg 2 years ago
½ Metoprolol 25mg 8 years ago
1 Duloxetine (Cymbalta®) 60mg 3 weeks ago

22. • During an interview, LR admitted to
changing the administration times of some
of her medications and to consuming
“some” alcohol most days of the week.
• She also takes 1000 mg of acetaminophen
in the morning and before going to bed in
the evening each day.
CASE: LR

23. What are the signs that LR may be
experiencing medication-related problems?
1. New complaint of dry mouth
2. Difficulty with instrumental activities of daily living
3. Dozing off during the day
4. Unsteady on her feet
5. Living alone
What strategies may be used to help LR?
CASE: LR

24. • Alcohol interacts with all classes of
antidepressants.
• Major depression and alcohol use disorder:
either doubles the chance of having the other.
• There appears to be a causal link between
alcohol use disorder and major depression.
• Best treatment approaches for the older adult
are still unknown.
Boden and Fergussen. Addiction 2011;106:906-914.
Depression

25. Mohanty M, Slattum PW. Age in Action 2011; Summer
CASE
STUDY
SP
SP
After moving to a senior living center, she started
drinking more heavily leading to several falls and a
fractured arm.
82 year old female
Diagnosed with depression and
treated with antidepressants in the
past
Has Chronic Obstructive
Pulmonary Disorder
(COPD)
Was a smoker for the
last 40 years and a
moderate alcohol drinker

26. Her prescriptions consisted of 11 medications:
• advair (combination of fluticasone & salmeterol),
tiotropium, albuterol, montelukast, and Mucinex
(guaifenesin and pseudoephedrine) for COPD
• paroxetine for depression
• simvastatin for cholesterol
• supplements (iron and calcium)
• also taking digoxin for congestive heart failure and
primodine for tremor.
However, during the interview she did not mention a history
of tremor or heart failure.
Mohanty M, Slattum PW. Age in Action 2011; Summer
CASE: SP

27. • What were the signs that SP might be
experiencing a medication-related problem?
1. Falls
2. Fracture
3. Living in a senior living center
4. Smoking
5. Depression
• What recommendations do you have for SP?
CASE: SP

28. • Alcohol interacts significantly with sedatives
used to treat insomnia.
• Alcohol worsens sleep disorders.
• Options:
– Treat underlying health conditions
– Evaluate medications as a contributor
– Sleep hygiene: daytime exercise, limit caffeine,
exposure to natural light during day, limit napping
during the day, etc.
Insomnia

29. Mohanty M, Slattum PW. Age in Action 2011; Summer
CASE
STUDY
OP
OP
80 year old female
Lives in an assisted
living community.
At the time of her
medication review by a
pharmacist, her family
expressed concerns that
she had been “loopy and
out of it” recently.
Experienced a fall in the
evening but was not injured.
There hadn’t been any recent
changes in her medications, but
during the pharmacist’s interview, OP
mentioned drinking wine in the
evening.
The medication technician,
who often works on OP’s
floor, stated that OP “stays
up all night drinking wine
and watching TV then
sleeps throughout the day.”
The medication technician was not
sure how much she drinks nightly or
whether she was drinking more than
usual.
OP was taking 16
scheduled prescription
medications and 5 as
needed medications.

30. Her scheduled prescriptions included:
– lisinopril, nadolol, and amlodipine for hypertension
– furosemide for edema
– levothyroxine for thyroid replacement
– albuterol for asthma
– pantoprazole for gastroesophageal reflux disease (GERD)
– solifenacin for urinary incontinence
– citalopram, bupropion, and quetiapine for depression
– trazodone for insomnia and depression
– tramadol for pain
– supplements of potassium and Vitamin D
Mohanty M, Slattum PW. Age in Action 2011; Summer
CASE: OP

31. What are the signs that OP may be experiencing
a medication-related problem?
1. Falls
2. Living in an assisted living facility
3. Being "loopy and out of it"
4. Excessive daytime sleepiness
5. Watching TV all night
What recommendations do you have?
CASE: OP

32. Improving the Quality of Medication Use in
Elderly Patients: A Not-So-Simple Prescription
“Putting the pieces of the puzzle together to
create a solution remains a formidable, but not
insurmountable task….All the pieces of the
puzzle lie before us; it remains for us to find a
way to fit them together”
Jerry H. Gurwitz, M.D.
Gurwitz JH, Arch Intern Med 2002; 162:1670-3

33. During his hospitalization, BW abstained from
alcohol and his medications were adjusted.
After returning home
• His CHF symptoms and mood improved.
• His gait, balance and functional status
improved.
• His family support and companion services
were expanded to assist with medication
adherence and to monitor for alcohol use.
REVISITING CASE: BW

34. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Drinking Guidelines for Older Adults (over 65 y/o) recommends:
Responsible Drinking
Consider concurrent
medications
No more than 7 drinks per week
(one drink per day)
Maximum of 2 drinks on
special occasions
Somewhat lower
limits for women

35. • Stay engaged
• Exercise the body
• Eat well
• Read warning labels
• Don’t mix alcohol and medications before
seeking advice
Wellness Promotion for the Adult

36. Take-away Message for
Family Caregivers
If you are an
adult child,
friend or
caregiver of an
older adult who
is in need of
assistance:
Face the problem
Be direct with the individual
Be supportive without enabling
Offer encouragement and praise
Encourage them to seek help from
community resources

37. Take-away Message for
Professionals
If you are a
professional in
the field:
Discuss alcohol use with clients/patients
Refer to pharmacist or prescriber for advice on
mixing alcohol with specific medications
Learn and use Screening, Brief Intervention,
and Referral to Treatment (SBIRT)
Know your community resources