No time to waste: Ageing, alcohol and pharmaceuticals
Forecasts estimate that by 2030 about one in three people living in western nations will be aged 65 years or older. If labour forces around the world are allowed to diminish while health and social needs grow, ageing populations will create complex problems that challenge social and economic stability. The pandemic has highlighted the complexity of meeting the needs of older people, particularly those who are frail or vulnerable, in the context of constrained and pressured health resources (Hubbard et al., 2020).
Ageing populations and the health sector
Agencies such as the OECD and the WHO have proposed that nations should support their workers to remain productive and in paid employment into old age through effective policies that promote good long-term health (Buchan et al., 2017; [OECD], 2020). Many governments and employers will also need to adjust their attitudes and policies towards older workers in ways that encourage employee diversity and retention, especially with regard to women. Women’s paid labour can be a remarkably powerful instrument against poverty and is far more likely to elevate the health status of those around them than male labour (OECD, 2020; Buchan et al., 2017). Yet worldwide, female workforce participation is around 26% lower than for males and when they are employed, women receive lower pay and work more unpaid hours (International Labour Office, 2018).
From a health sector perspective, effective systems that support the health and productivity of women across the entire socioeconomic spectrum will be key. This is because women not only dominate health care and social assistance sectors across Europe and Australia (around 80% of employees), but they also live longer on average and have more illness, doctor visits, hospitalisations and years lived with disability (Ortiz-Ospina & Beltekian, 2018; Ortiz-Ospina & Roser, 2018; Workplace Gender Equality Agency, 2019).
No doubt, dealing with age-related impacts on health sectors is going to challenge many nations, including Australia. Here we propose that the who, what, when, where and why of concurrent alcohol and pharmaceutical use among ageing populations has a significant role to play in how they fare.
Age, alcohol and pharmaceuticals: A dicey three-way intersection
With nearly 80% of men and 74% of women considered current drinkers (Australian Institute of Health & Welfare [AIHW], 2020), alcohol’s status as one of Australia’s most popular psychoactive substances is unlikely to be challenged any time soon. The drinking behaviours of individuals and of populations are nonetheless complex and often change over time. It is commonly the case, for instance, that even though most older people drink less overall than they did in their younger years (Fillmore et al., 2007), they are far more likely to drink regularly. No other age group is more likely to consume alcohol on a daily basis than those in their 70s and beyond (about 13%) (AIHW, 2020).
It seems too that current populations of older drinkers are distinguishing themselves from previous generations. Results from the most recent National Drug Strategy Household Survey (2019) highlighted that over the past decade, proportions of older drinkers (male and female) consuming in excess of national drinking guidelines have been steadily increasing (AIHW, 2020). More people aged in their 50s, 60s and 70s are drinking more than 4 standard drinks on a single occasion compared to those of the same age ten years ago – by as much as 36% for some groups. These trends are all the more striking when contrasted against contemporaneous trends for drinkers in their 40s and young adults, which have either remained stable or declined markedly (AIHW, 2020).
Also typical to older age groups and running parallel to increased daily drinking is the increased likelihood of prescription medication use. Regular use of at least five prescribed medications, otherwise known as ‘polypharmacy’, is especially common among older ages. More than one in three older Australians (70+yrs) take five or more prescribed medications (PMs), and prevalence is slightly higher for women. By age 85, close to one half of the Australian population is affected by continuous polypharmacy (Page et al., 2019). Driven by both increased number of scripts held per individual and increased cost per script, PMs are a key driver of escalating health expenditure (Productivity Commission, 2005).
Although a state of affairs unlikely to set Australia apart from other nations, this three-way intersection, whereby increasing age, increasing regular alcohol use, and increasing use of multiple PMs converge, is foreseeably problematic.
Harms to health from concurrent alcohol and pharmaceutical use
On its own, alcohol is a well-known cause of a wide range of injuries (e.g. falls) and chronic diseases (e.g. hypertension, stroke, cancers) that occur with increasing prevalence in older age (Andreasson et al., 2017; Chikritzhs & Livingston, 2021). Combined use of alcohol and PMs, however, can bring about unique risks that many patients – and their health professionals – may be unaware of (e.g. Zanjani et al., 2018). What’s more, when PMs and alcohol converge, adverse interactions can arise from levels of alcohol use that would generally be considered low or moderate and within low risk drinking guidelines (Holton, Gallagher, Fahey, et al., 2017; Holton, Gallagher, Ryan, et al., 2017; Moore et al., 2007; Weathermon & Crabb, 1999).
At any age, the range of potential harms from concurrent use is very wide and can include higher than expected blood alcohol levels, increased or decreased drug metabolism and unexpected increased (e.g. overdose) or decreased (e.g. therapeutic failure) PM effects. Concurrent users are also at increased risk of: liver damage and gastrointestinal bleeding; sedation and insomnia; hypotension and hypertension; dizziness, cognitive and psychomotor impairment (e.g. visuo-motor control, attention, reaction time, response inhibition, working memory); and, a range of injuries (e.g. falls, road traffic crashes) (Andreasson et al., 2017; Bright et al., 2020; Burge et al., 1999; Chikritzhs & Livingston, 2021; Holton, Gallagher, Fahey, et al., 2017; Holton, Gallagher, Ryan, et al., 2017; Lynskey et al., 2003; Moore et al., 2007; Onder et al., 2002; Swift et al., 2007; Weathermon & Crabb, 1999). Concurrent use effects can be mediated by type and dose of medication, frequency and quantity of alcohol use and even drinking setting. For older age groups, age-related physical changes including absorption, metabolism and tolerance will complicate matters further (Bright et al., 2020; Burge et al., 1999; Holton, Gallagher, Fahey, et al., 2017; Holton, Gallagher, Ryan, et al., 2017; Lynskey et al., 2003; Onder et al., 2002; Swift et al., 2007; Weathermon & Crabb, 1999).
A relatively recent review of international research evidence suggested older people who use PMs have a particularly high propensity for experiencing adverse outcomes due to concurrent moderate alcohol intake (generally a maximum of 70-140g pure alcohol per week) (Holton, Gallagher, Fahey, et al., 2017). Taking study quality into account, Holton, Gallagher, Fahey et al. (2017) concluded that 21% to 35% of older people used ‘alcohol-interactive’ (variously defined) PMs and alcohol concurrently. A 2005 Australian survey found one in three 65+ year olds engaged in concurrent use (Swift et al., 2007), although a critical appraisal of the study’s methods concluded under-estimation was likely (Holton, Gallagher, Fahey, et al., 2017). A small but more recent retrospective Australian study of older aged patients who received treatment for alcohol use disorders found nine out of ten were taking at least one PM that would place them at high risk of adverse outcomes if consumed with alcohol (Bright et al., 2020).
As Holton et al have noted, few if any longitudinal studies have ever been conducted on concurrent use effects among older people and research on actual adverse outcomes rather than propensity for harm is scant, mostly confined to fall-related injuries (Holton, Gallagher, Fahey, et al., 2017). An exception to the latter was a large Italian study of older aged moderate wine drinkers. The study found a 30% increase in the risk adverse outcomes for women and a 14% increase for men from concurrent wine and PM use; gastrointestinal, metabolic/endocrine, dermatological/allergic and arrhythmic complications were most frequently reported (Onder et al., 2002).
Frequently prescribed medications for common conditions
Crucially, many PMs implicated in alcohol-related adverse outcomes are frequently prescribed to treat conditions that are highly prevalent among ageing populations e.g. depression, heart disease, hypertension, type 2 diabetes, GI problems. Developed based on expert opinions of geriatricians, general practitioners and pharmacists, POSAMINO (POtentially Serious Alcohol–Medication INteractions in Older adults) criteria lists 38 drugs where risk of an adverse outcome is increased with concurrent alcohol use including: antidepressants, antipsychotics, anxiolytics, benzodiazepines, antihypertensives, diuretics, digoxin, anticoagulants, opioids, antihistamines, H2 blockers and, anti-diabetic drugs, antibiotics and even over-the-counter pain medications (Holton, Gallagher, Fahey, et al., 2017). Notably, some 40% of POSAMINO listed PMs affect the central nervous system; an estimated 41% of Australians in residential aged care use prescribed antidepressants (Harrison et al., 2020).
Most wanted: Evidence-informed forward planners
The problem of ageing populations is a mammoth challenge but mitigatable with forward planning that integrates evidence-informed policy and practice. Key priority areas outlined in the National Alcohol Strategy 2019-2028 (National Drug Strategy Committee, 2016) and Draft National Preventive Health Strategy (Department of Health, 2020) include supporting individuals to obtain help and systems to minimise harm, and reducing alcohol and other drug-related harm. At the very least, more work is needed to advance both health professional knowledge in this area and training in appropriate screening practices for identifying drinking behaviours among older people.
In terms of sustainability, few sectors could be more at risk from the ill-effects of half-hearted responses and systemic inaction than Health. If keeping older people healthy for longer, especially women, is a key part of the solution, then the public health sector could do worse than insist on urgent investment into understanding concurrent alcohol and pharmaceutical use with a view to identifying cost-effective and rapidly deployable intervention strategies. There is no time to waste.
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