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Schröder S, Westhoff MS, Pfister T, Seifert J, Bleich S, Koop F, Proskynitopoulos PJ, Glahn A, Heck J. Drug safety in older patients with alcohol use disorder: a retrospective cohort study. Ther Adv Psychopharmacol 2024; 14:20451253241232563. [PMID: 38384595 PMCID: PMC10880528 DOI: 10.1177/20451253241232563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/07/2024] [Indexed: 02/23/2024] Open
Abstract
Background Older patients with alcohol use disorder are at particular risk of developing adverse drug reactions due to multimorbidity, polypharmacy, and altered organ function. Objectives In this study, we investigated the frequency and characteristics of potentially serious alcohol-medication interactions, potentially inappropriate medications (PIMs) for older adults, and potential drug-drug interactions (pDDIs) in a population of older patients with alcohol use disorder over a 10-year period. Design Retrospective monocentric cohort study. Methods Prescribed medications were screened for potentially serious alcohol-medication interactions, PIMs, and pDDIs using the POSAMINO (POtentially Serious Alcohol-Medication INteractions in Older adults) criteria, the PRISCUS 2.0 list, the FORTA (Fit fOR The Aged) classification, and the drug interaction program AiDKlinik®. Results We enrolled 114 patients aged ⩾65 years with alcohol use disorder, who were treated in an addiction unit of a university hospital in Germany. About 80.7% of the study population had at least one potentially serious alcohol-medication interaction. Potentially serious alcohol-medication interactions most commonly affected the cardiovascular (57.7%) and the central nervous system (32.3%). A total of 71.1% of the study population received at least one prescription of a FORTA C or D drug, compared with 42.1% who received at least one PIM prescription according to the PRISCUS 2.0 list. A total of 113 moderate and 72 severe pDDIs were identified in the study population. Conclusion Older patients with alcohol use disorders are frequently exposed to potentially serious alcohol-medication interactions, PIMs, and pDDIs. Improvements in the quality of prescribing should primarily target the use of cardiovascular and psychotropic drugs.
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Affiliation(s)
- Sebastian Schröder
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Martin Schulze Westhoff
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Tabea Pfister
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Felix Koop
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Alexander Glahn
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
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White-Ryan L, Heyman JC, Kelly PL, Pardansani M, Caprio TV, Wexler S, Berman J, Abramson T. The invisible gap: Older adults' communication with health care providers about concomitant use of alcohol and medications. GERONTOLOGY & GERIATRICS EDUCATION 2024; 45:26-37. [PMID: 36342337 DOI: 10.1080/02701960.2022.2138866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The purpose of this study was to assess the impact of a new educational intervention, Communicating with your Health Care Providers, which was designed to assist older adults in communicating with their physicians and other health care providers and improving their knowledge about concomitant alcohol and medication risks. A randomized control trial was conducted in older adult centers in an urban community. Participants were assigned to either the intervention group or a control group that received traditional services. The intervention group received educational material about health, physical and other aging changes, medication use and possible adverse interactions between alcohol and medications, as well as strategies to initiate communication with physicians and other health care providers. The outcomes measured were: (1) interest in communicating with physicians and health care providers; (2) perception of the importance of communication; and (3) knowledge about concomitant alcohol and medication use. MANCOVA tests indicated that the intervention group had greater knowledge about the risks of combining alcohol with prescription medications than the control group, as well as greater interest in having health care discussions with their physicians and other health care providers. These findings may be translated into future educational programming for community centers.
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Affiliation(s)
- Linda White-Ryan
- Graduate School of Social Service, Fordham University, New York, USA
| | - Janna C Heyman
- Graduate School of Social Service, Fordham University, New York, USA
| | - Peggy L Kelly
- Graduate School of Social Service, Fordham University, New York, USA
| | | | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
| | - Sharon Wexler
- College of Health Professions, Pace University, New York, USA
| | | | - Tobi Abramson
- NYC Department for the Aging, Geriatric Mental Initiative, New York, USA
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Jemberie WB, Padyab M, McCarty D, Lundgren LM. Recurrent risk of hospitalization among older people with problematic alcohol use: a multiple failure-time analysis with a discontinuous risk model. Addiction 2022; 117:2415-2430. [PMID: 35470927 PMCID: PMC9543276 DOI: 10.1111/add.15907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Older people with problematic alcohol use vary in psychosocial functioning, age of onset for problem drinking and use of other drugs. The study measured the differential risks of all-cause, alcohol-, polydrug- and psychiatric-related repeated hospitalizations among older people with problematic alcohol use. DESIGN A linked register-based cohort study with discontinuous multiple-failure (time-to-repeated-event) data. Hospitalization and mortality were considered as failure. SETTING Sweden, March 2003-November 2017, using data from the Addiction Severity Index (ASI) register linked to National Inpatient Register and the Swedish cause of death register. PARTICIPANTS Participants aged 50 years and older (n = 1741; 28.2% women), with one or more alcohol problem days in the 30 days before an ASI assessment. MEASUREMENTS Five mutually exclusive latent classes of problematic alcohol use, identified with 11 ASI items, were the independent variables: 'late onset with fewer consequences (LO:FC; reference group)'; 'early onset/prevalent multi-dimensional problems (EO:MD)'; 'late onset with co-occurring anxiety and depression (LO:AD)'; 'early onset with co-occurring psychiatric problems (EO:PP)'; and 'early onset with major alcohol problem (EO:AP)'. Covariates included socio-demographic characteristics, previous hospitalization and Elixhauser comorbidity index. Outcome measurements included recurrent hospitalization and/or mortality due to: (a) all-cause, (b) alcohol-related disorders and diseases (c) polydrug use and (d) other psychiatric disorders. FINDINGS During the study period, more than 75% were hospitalized at least once or died. 57.3% were hospitalized with alcohol-related, 8.5% with polydrug use and 18.5% with psychiatric-related diagnoses. Compared with LO:FC, EO:PP had higher risk for all-cause [adjusted hazard ratio (aHR) = 1.27, 95% confidence interval (CI) = 1.02-1.59] and alcohol-related (aHR = 1.34, 95% CI = 1.02-1.75) hospitalizations. Adjusted risks for polydrug-related hospitalization were 2.55, 95% CI = 1.04-6.27 for EO:MD and 2.62, 95% CI = 1.07-6.40 for EO:PP. Adjusted risk for psychiatric-related hospitalization was higher for LO:AD (aHR = 1.78, 95% CI = 1.16-2.73 and EO:PP (aHR = 2.03, 95% CI = 1.22-3.38). CONCLUSIONS Older addiction service users in Sweden have varying risks of hospitalization due to alcohol use, polydrug use and psychiatric disorders. Older people with problematic alcohol use who have multiple needs and are assessed in social services may benefit from earlier interventions with an integrated focus on substance use and mental health.
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Affiliation(s)
- Wossenseged Birhane Jemberie
- Department of Social WorkUmeå UniversityUmeåSweden,Centre for Demographic and Ageing Research (CEDAR)Umeå UniversityUmeåSweden,The Swedish National Graduate School on Aging and Health (SWEAH), Faculty of MedicineLund UniversityLundSweden
| | - Mojgan Padyab
- Department of Social WorkUmeå UniversityUmeåSweden,Centre for Demographic and Ageing Research (CEDAR)Umeå UniversityUmeåSweden
| | - Dennis McCarty
- Oregon Health and Science University‐ Portland State UniversitySchool of Public HealthPortlandORUSA
| | - Lena M. Lundgren
- Department of Social WorkUmeå UniversityUmeåSweden,Cross‐National Behavioral Health Laboratory, Graduate School of Social WorkUniversity of DenverDenverCOUSA
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Zipperer L, Ryan R, Jones B. Alcoholism and American healthcare: The case for a patient safety approach. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221117952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.
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Affiliation(s)
- Lorri Zipperer
- Blaisdell Medical Library, University of California Davis, Albuquerque, NM, USA
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Jemberie WB, Padyab M, McCarty D, Lundgren LM. Hospital Admission Rate, Cumulative Hospitalized Days, and Time to Admission Among Older Persons With Substance Use and Psychiatric Conditions. Front Psychiatry 2022; 13:882542. [PMID: 35530023 PMCID: PMC9075517 DOI: 10.3389/fpsyt.2022.882542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/28/2022] [Indexed: 11/15/2022] Open
Abstract
Background Substance use among older persons occurs with medical and psychiatric comorbidities. This study examined the associations of substance use disorder (SUD), psychiatric, and dual diagnoses with 12-month cumulative hospitalized days, hospital admission rate and number of days to first hospitalization. Methods The cohort of 3,624 individuals (28.2% women) aged 50 years or older was assessed for substance use severity in 65 Swedish municipalities during March 2003-May 2017. Addiction Severity Index data were linked to hospital discharge records and crime statistics. The outcomes were (a) 12-month cumulative hospitalized days; (b) Hospital admission rate, and (c) days to first hospitalization. Generalized linear regression techniques investigated associations between outcomes and SUD, psychiatric and dual diagnoses at admission. Results During 2003-2017, 73.5% of the participants were hospitalized. Twelve-month hospitalized days were positively associated with SUD (Incidence rate ratio (IRR) = 1.41, 95%CI: 1.26-1.58), dual diagnosis (IRR = 2.03, 95%CI: 1.74-2.36), and psychiatric diagnoses (IRR = 2.51, 95%CI: 2.09-3.01). Hospital admission rate was positively associated with SUD (IRR = 4.67, 95%CI: 4.28-5.08), dual diagnosis (IRR = 1.83, 95%CI: 1.64-2.04), and psychiatric diagnoses (IRR = 1.73, 95%CI: 1.55-1.92). Days to first hospitalization were negatively associated with SUD (IRR = 0.52, 95%CI: 0.47-0.58), dual diagnosis (IRR = 0.57, 95%CI: 0.50-0.65), and psychiatric diagnoses (IRR = 0.83, 95%CI: 0.73-0.93). The marginal effects of SUD and/or mental disorders increased with age for all outcomes, except for days to first hospitalization. Conclusion Three of four older persons assessed for substance use severity were later hospitalized. Substance use disorders, dual diagnoses and other mental disorders were the primary reasons for hospitalization and were associated with longer stays, earlier hospitalization, and repeated admissions. Sensitizing service providers to old age substance use and sharing data across the care continuum could provide multiple points of contact to reduce the risk of hospitalizations among older persons with problematic substance use.
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Affiliation(s)
- Wossenseged Birhane Jemberie
- Department of Social Work, Umeå University, Umeå, Sweden
- Centre for Demographic and Ageing Research (CEDAR), Umeå University, Umeå, Sweden
- The Swedish National Graduate School on Aging and Health (SWEAH), Faculty of Medicine, Lund University, Lund, Sweden
| | - Mojgan Padyab
- Department of Social Work, Umeå University, Umeå, Sweden
- Centre for Demographic and Ageing Research (CEDAR), Umeå University, Umeå, Sweden
| | - Dennis McCarty
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, United States
| | - Lena M. Lundgren
- Department of Social Work, Umeå University, Umeå, Sweden
- Cross-National Behavioral Health Laboratory, Graduate School of Social Work, University of Denver, Denver, CO, United States
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Tevik K, Bergh S, Selbæk G, Johannessen A, Helvik AS. A systematic review of self-report measures used in epidemiological studies to assess alcohol consumption among older adults. PLoS One 2021; 16:e0261292. [PMID: 34914759 PMCID: PMC8675766 DOI: 10.1371/journal.pone.0261292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022] Open
Abstract
Background There is a lack of standardization regarding how to assess and categorize alcohol intake in older adults. The aim of this study was to systematically review methods used in epidemiological studies to define drinking patterns and measure alcohol consumption among older adults. Methods A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, EMBASE, and CINAHL databases for studies published from January 2009 to April 2021. Studies were included if they were observational studies with a quantitative design; the mean age of the participants was ≥ 65 years; questionnaires, screening tools, or diagnostic tools were used to define alcohol consumption; and alcohol consumption was self-reported. Results Of 492 studies considered, 105 were included. Among the 105 studies, we detected 19 different drinking patterns, and each drinking pattern had a wide range of definitions. The drinking patterns abstaining from alcohol, current drinking, and risk drinking had seven, 12 and 21 diverse definitions, respectively. The most used questionnaire and screening tools were the quantity-frequency questionnaire, with a recall period of 12 months, and the full and short versions of the Alcohol Use Disorders Identification Test, respectively. Conclusion No consensus was found regarding methods used to assess, define, and measure alcohol consumption in older adults. Identical assessments and definitions must be developed to make valid comparisons of alcohol consumption in older adults. We recommend that alcohol surveys for older adults define the following drinking patterns: lifetime abstainers, former drinkers, current drinkers, risk drinking, and heavy episodic drinking. Standardized and valid definitions of risk drinking, and heavy episodic drinking should be developed. The expanded quantity-frequency questionnaire including three questions focused on drinking frequency, drinking volume, and heavy episodic drinking, with a recall period of 12 months, could be used.
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Affiliation(s)
- Kjerstin Tevik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- * E-mail:
| | - Sverre Bergh
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Aud Johannessen
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Vestfold, Norway
| | - Anne-S. Helvik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
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Abstract
Older adults continue to drink as they age. Aging changes alcohol kinetics just as with any other drug. Older adults have increased sensitivity to acute alcohol intake that accounts for the increased risk of falls, traffic accidents, and other injury. The Annual Medicare Wellness Exam is an excellent opportunity to introduce screening for unsafe drinking along with accumulated risks and deficits of aging. Older adults have responded well to brief interventions for unhealthy drinking. In the presence of alcohol use disorder or serious comorbidity including psychiatric illness, referral to specialized multidisciplinary care can be lifesaving.
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Anfinogenova ND, Trubacheva IA, Popov SV, Efimova EV, Ussov WY. Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases. Expert Opin Drug Saf 2021; 20:1191-1206. [PMID: 33970732 DOI: 10.1080/14740338.2021.1928632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.
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Affiliation(s)
- Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Irina A Trubacheva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Elena V Efimova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Wladimir Y Ussov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
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Holton AE, Keeney C, Ryan B, Cousins G. Prevalence of potentially serious alcohol-medication interactions in older adults in a community pharmacy setting: a cross-sectional study. BMJ Open 2020; 10:e035212. [PMID: 32868351 PMCID: PMC7462154 DOI: 10.1136/bmjopen-2019-035212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Previous prevalence estimates of POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) are based on in-home inventories of medications; however, this method is associated with under-reporting of medications when compared with dispensing records. This study aims to estimate the prevalence of POSAMINO among community-dwelling older adults using drug dispensing data from the community pharmacy setting. DESIGN Cross-sectional study. SETTING Irish Community Pharmacy. PARTICIPANTS 1599 consecutive older adults presenting with a prescription to 1 of 120 community pharmacies nationwide; community-dwelling, aged ≥65 years, able to speak and understand English, with no evidence of cognitive impairment. The mean age of sample was 75.5 years (SD 6.5); 55% (n=884) female. MEASURES 38 POSAMINO criteria were identified using participants' pharmacy dispensing records linked to self-reported alcohol consumption (beverage-specific quantity and frequency measures) over the last 12 months. RESULTS The overall prevalence of POSAMINO in the study population was 28%, with 10% at risk of at least one POSAMINO criteria and 18% at risk of two or more. Exposure to POSAMINO most commonly involved cardiovascular agents (19%) and central nervous system agents (15%). Exposure to a higher number of POSAMINO criteria was associated with younger age (adjusted incident rate ratio (AIRR): 0.97; 95% CI: 0.95 to 0.98), male sex (AIRR: 0.55; 95% CI: 0.45 to 0.67) and a higher number of comorbidities (AIRR: 1.05; 95% CI: 1.01 to 1.13). CONCLUSION This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol-medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.
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Affiliation(s)
- Alice E Holton
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Cora Keeney
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Benedict Ryan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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