Abstract
Background
The majority of older adults take prescription or over-the-counter medications and about half consume alcohol regularly. Despite high risk for alcohol medication interactions (AMI), few community-level interventions exist to prevent AMI. The current study assessed the acceptability of educational materials created for use in a brief intervention to prevent AMI among older adults.
Methods
Older adults from two senior centers reviewed intervention materials (poster, patient and pharmacist brochures, and public service announcement) and participated in a pre and post-test to provide feedback and to assess changes in AMI-related awareness and intentions.
Results
Post-test data showed positive feedback and an increase in participant understanding of AMI prevention, with statistically significant changes in perceived importance of messaging surrounding risky alcohol use and potential consequences of AMI.
Discussion
The intervention materials were positively received, and participant feedback indicated that the collective presentation of all the materials was the most preferred tool for educating the community. With positive trends in awareness and knowledge, intervention effectiveness needs be further evaluated in future large-scale studies.
Lessons Learned
This study provides health education specialists with information for future interventions to prevent alcohol and medication interactions among older adults.
Keywords: Older adults, alcohol and medication interactions, community intervention
Introduction
Alcohol and medication interaction (AMI) events among older adults are a growing public health issue, both in the United States and abroad. Nine out of every ten U.S. adults aged 60 and older takes at least one prescription medication, and three-fourths take two or more (Gu, Dillon, & Burt, 2010). In addition to a high prevalence of prescription drug use in this population, 42% of U.S. older adults use at least one over-the-counter medication (Qato, Alexander, Conti, Johnson, Schumm, et al., 2008). Risk for AMI among older adults in both the U.S. and Europe is in part due to alcohol consumption rates. Prevalence estimates of adults about 60 years and older conclude 63% consuming alcohol in the past six months (Cousins, Galvin, Flood, Kennedy, Motterlini, et al., 2014), 41% consuming alcohol at least weekly (Qato, Manzoor, & Lee, 2015), and 44% having at least 12 drinks in the past year (Balsa, Homer, Fleming, & French, 2008).
According to a study of older adults in Finland, concomitant use of medications and alcohol in this age group is also widespread (Aira, Hartikainen, & Sulkava, 2005). Simultaneous use is especially risky if a medication is considered alcohol-interactive, and three-fourths of U.S. older adults who take prescription medications take at least one alcohol-interactive medication (Pringle, Ahern, Heller, Gold, & Brown, 2005). Prior research in the U.S. has shown that about half of older adults who drink alcohol take one or more of these medications (Forster, Pollow, & Stoller, 1993; Qato, et al., 2015). Furthermore, between 1983 and 2004 there was a 3000% increase in fatal medication errors related to alcohol and illicit drug use in the U.S. (Phillips, Barker, & Eguchi, 2008), and between 2001 and 2012, a 124% increase in older adult comorbid alcohol and medication poisoning hospitalizations was noted (Zanjani, Smith, Slavova, Charnigo, Schoenberg, et al., 2016).
Alcohol use, even at moderate levels, is associated with increased risk of adverse drug reactions (Onder, Landi, Della Vedova, Atkinson, Pedone, et al., 2002). Older adults are at particular risk for adverse drug reactions involving alcohol due to age-related changes in alcohol and medication absorption and metabolism, and the exacerbation of or interference with the effects of medication when combined with alcohol (Moore, Whiteman, & Ward, 2007). The risk of adverse alcohol events increases after the age of 50 due to decreases in gastric alcohol dehydrogenase, leading to raised blood alcohol concentrations in middle and old age (Hanson, 2011; Seitz, Egerer, Simanowski, Waldherr, Eckey, et al., 1993). Risks to consuming alcohol while taking medications include liver and gastrointestinal disease, sedation, dizziness, falls, hypertension, depression, and diabetes (Moore, et al., 2007). Of particular concern is the combination of alcohol with alcohol-interactive medications among aging adults, as this behavior increases the chance of medication interactions, poisonings, and even death (Onder, et al., 2002; Phillips, et al., 2008).
Despite potential health consequences, a substantial proportion of older adults consume alcohol while taking alcohol-interactive medications (Cousins, et al., 2014) and while having alcohol-sensitive morbidities (Barnes, Moore, Xu, Ang, Tallen, et al., 2010). Pringle et al. (2006) found that older adult decisions to stop consuming alcohol are the same whether they are prescribed alcohol-interactive medications or prescribed non-alcohol interactive medications. Continuing to consume alcohol under risky conditions may be due to a general lack of understanding for prescription drug safety and alcohol medication interactions among older adults and/or an absence of clinical counsel on the issue. Prior research has shown that older adults rarely consult with their doctor or pharmacist about alcohol and medication safety, and they have an inadequate level of drug-interaction literacy (Zanjani, Hoogland, & Downer, 2013).
Despite high risk for alcohol medication interactions, few community-level interventions exist to prevent AMI events among older adults. Accordingly, the research team developed educational materials for an intervention aimed at decreasing risk for AMI events in the aging population. In preparation for a larger scale effectiveness trial, the current study had two aims: (1) To examine the acceptability of educational materials aimed to prevent AMI events among older adults, and (2) to assess changes in AMI awareness, intentions, and knowledge among a sample of older adults after viewing the developed educational materials.
Methods
Educational Materials
Using existing literature and preliminary pharmacist surveys and interviews (Zanjani, Crook, Smith, Antimisiaris, Schoenberg, et al., 2016; Zanjani, et al., 2013), educational materials, including a poster, patient brochure, pharmacist brochure, and 60-second public service announcement, were developed by the research team. The materials included the following information: 1) Definition of AMI, 2) risk factors for AMI, 3) behavioral changes that reduce AMI risk, and 4) emergency planning for experiencing an AMI. The messages included in the intervention materials were rooted in the Health Belief Model (Janz & Becker, 1984; Noar, 2005–2006) and the Information-Motivation-Behavioral Skills Model (IMB) (Fisher & Fisher, 2000). The poster included information about AMI symptoms and recognizing and decreasing AMI risk, as well as an emergency plan for when experiencing an AMI. The brochures reinforced the poster information, but also included more detailed steps on how to discuss AMI risk with a health professional and how alcohol consumption can interact with medications to cause serious and long-lasting health effects. The public service announcement, which was a 60-second video of a discussion between two older adults, focused on AMI side effects and was designed to encourage older adults to discuss AMI risk with their clinicians, family, and friends. Highlighting the severity of AMI health consequences, the susceptibility of older adults to experience an AMI, and specific cues to action older adults can take to prevent an AMI are all in concordance with the constructs of the Health Belief Model that contribute to behavior change. In addition, providing general AMI information as well as skills needed to decrease AMI risk are consistent with constructs of the IMB model that are necessary for health behavior change.
Data Collection
This study was approved by the Institutional Review Board (IRB) at the University of Maryland, College Park. In the spring and summer of 2015, a convenience sample was recruited from two senior centers (local, publically funded community centers for older adults) in Virginia. While the intervention materials were designed for delivery in a pharmacy setting in the future, this acceptability evaluation took place in senior centers because of increased access to the target population. After obtaining informed consent, participants were asked to complete a paper and pencil pre-test to assess their self-reported AMI awareness, intentions, and knowledge. Participants then reviewed the educational materials on AMI symptoms, recognizing and decreasing AMI risk, recommendations for responding to AMI events, and communicating with health professionals. There was no time limit, but the materials review was intended to be brief and take less than 15 minutes to complete. Participants then immediately completed a paper and pencil post-test to assess change in AMI awareness, intentions, and knowledge after exposure to the intervention materials. During the post-test, participants were also given the chance to provide written feedback on the poster, brochures, and public service announcement. The pretest, review of the intervention materials, and post-test were all completed during one session.
Measures
Demographics
At pre-test, to characterize the study sample, participants self-reported information on their race/ethnicity, marital status, level of education, employment status, and past-year household income.
Health Status
At pre-test, participants reported the number of current diagnosed health conditions and any physical and/or mental limitations that significantly limited or restricted their life activity. Participants also reported current medications and indicated whether those medications were over the counter only, prescription only, or both over the counter and prescription. Participants reported past-year physician visits and lifetime AMI experience.
Alcohol Consumption
Past three-month alcohol use was measured by participant report of consumption of any beer, wine, or liquor in the past three months (Cacciola, Alterman, DePhilippis, Drapkin, Valadez, et al., 2013). Participants also reported if they had consumed any alcohol in the past 30 days, with response options including (1) no, no alcohol use, (2) yes, typically one drink a day or less (no more than 30 drinks), (3) yes, typically two drinks a day (no more than 60 drinks), and (4) yes, typically three drinks a day or more.
AMI Awareness
On the pre-test, participants reported frequency of talking to a doctor or pharmacist about how alcohol can interact with prescription medications. To assess change from pre to post-test, participants were asked on both assessments about whether they believe alcohol and medications can be used safely together, how much is a safe amount of alcohol to consume when taking prescription medications, what medications they believe are potentially dangerous when taken with alcohol, and possible AMI side effects. These and all AMI instrument questions in this study were designed in consultation with a pharmacist with geriatric expertise and have been used in prior work by the research team (Zanjani, et al., 2013).
AMI Intentions
On both assessments, participants responded yes, no, or maybe to whether they would be willing to talk to their doctor about possible AMI risk, change how much alcohol they consumed to prevent AMI events, talk to friends and family about AMI risk, and be an advocate for safe alcohol and prescription drug use.
AMI Knowledge/Importance
To assess change from pre to post-test, participants were asked on both assessments to rate seven statements on a scale of 1 to 5 for knowledge (1 = Very True to 5 = Very False) and importance (1 = Very Important to 5 = Not Very Important). Statement examples include “Alcohol consumption at any level can be dangerous” and “When consuming alcohol, it is important to be aware of potential minor or severe side effects”. These questions assessed understanding of AMI knowledge, as well as perceived importance and significance of AMI health issues.
Participant Feedback
In addition to the pre and post-tests, participants were also given a feedback form to provide their opinions on the poster, brochures, and public service announcement (PSA). Questions covered content and preferences about each modality, focusing on aspects such as the graphics, font, colors, actors, and wording. Participants were asked to report what they liked, what they disliked, what was useful, how effective the tool was, and to provide any additional comments. Respondents were also asked what they thought was the most effective tool for educating the community.
Data Analysis
Descriptive statistics were used to calculate the frequencies and means of all variables of interest. Pre and post-test data were compared for each individual item. McNemar’s Test was used to compare dichotomous variables, and tests for marginal homogeneity were used to compare categorical variables with three or more response options. Despite data skewness, parametric tests were used to compare continuous variables due to an adequate sample size (Ghasemi & Zahediasl, 2012). Paired t-tests were used to compare pre and post-test means for each perceived importance and perceived knowledge item, and results were verified using Wilcoxon-Signed Rank tests. For perceived importance and perceived knowledge items, change scores were calculated by subtracting the pre-test mean from the post-test mean. A content analysis of the participant feedback was performed to identify major themes and frequencies.
Results
A total of 36 older adults ages 50 or older (mean age = 76, SD = 8.87) participated in the study. One participant only completed a post-test and was excluded from all analyses, resulting in a total of 35 usable surveys. Two-thirds (69%) of the sample identified as White and 29% identified as Black, and the remaining identified as American Indian. Only one individual identified as Hispanic. Half of participants responded that they were widowed (49%) and 20% were married, with the remaining reporting being divorced, separated, or never married. Approximately 60% of the sample had a high school degree or equivalent. The majority of the sample (63%) reported that they were currently retired and 20% were unable to work. The majority of the sample reported a household income of less than $25,000 in the past year.
Health Status and Alcohol Consumption
Approximately two-thirds of the sample indicated having more than one health condition, with two participants reporting major physical and/or mental limitations that restricted or limited their life activity. The majority reported either having some limitations (46%) or no limitations (49%). The majority of the sample was currently taking medications (91%); over half of these individuals reported taking prescription medications only (52%), only one participant was taking over-the-counter medications only, and 45% were taking both over-the-counter and prescription medications. Only four participants reported consuming alcohol in the past three months, with the majority of drinkers consuming an average of one drink a day or less in the past 30 days. All participants except one had seen a physician in the past year.
AMI Awareness
On the pre-test, as seen in Table 1, about 12% (n = 4) of the sample reported that they had experienced an AMI in the past, 27% reported always talking to their doctor or pharmacist about how alcohol can interact with prescription medications, and over two-thirds of the sample indicated that medications and alcohol can never be used safely together. About one-third of participants responded that no more than one drink a day should be consumed while taking prescription medications, while the majority indicated that no alcohol consumption is ever safe when taking medications. No significant changes in beliefs on safety of consuming alcohol and medication concurrently were found on the post-test.
Table 1.
Alcohol medication interaction (AMI) awareness, before and after the intervention (n = 35).
| Pre-Test n (%) |
Post-Test n (%) |
|
|---|---|---|
| Have you ever experienced an AMI? | ||
| Yes | 4 (11.8) | 4 (13.3) |
| No | 30 (88.2) | 26 (86.7) |
| Do you talk with your doctor or pharmacist about how alcohol can interact with your prescription medication? | ||
| Always | 9 (26.5) | – |
| Occasionally | 2 (5.9) | – |
| Sometimes | 2 (5.9) | – |
| Rarely | 2 (5.9) | – |
| Never | 19 (55.9) | – |
| Do you think alcohol and medications can always be used safely together? | ||
| Always | 0 (0.0) | 1 (3.1) |
| Occasionally | 1 (2.9) | 1 (3.1) |
| Sometimes | 3 (8.6) | 3 (9.4) |
| Rarely | 6 (17.1) | 5 (15.6) |
| Never | 25 (71.4) | 22 (68.8) |
| What do you think is a safe amount of alcohol to consume when taking prescription medications? | ||
| No alcohol level is ever safe, so people need to abstain from consuming alcohol when taking medications. | 23 (65.7) | 22 (68.8) |
| No more than one drink a day | 11 (31.4) | 9 (28.1) |
| No more than two drinks a day | 1 (2.9) | 1 (3.1) |
| No more than three drinks a day | 0 (0.0) | 0 (0.0) |
| No more than four drinks a day | 0 (0.0) | 0 (0.0) |
| No more than five drinks a day | 0 (0.0) | 0 (0.0) |
| Alcohol does not need to be limited when taking medications. | 0 (0.0) | 0 (0.0) |
| What medications do you think are potentially dangerous when consuming alcohol? | ||
| Tylenol (acetaminophen) | 10 (28.6) | 14 (41.2) |
| Advil (ibuprofen) | 10 (28.6) | 12 (35.3) |
| Aleve (naproxen) | 11 (31.4) | 14 (41.2) |
| Prescription pain medications | 26 (74.3) | 29 (85.3) |
| Psychotropic or psychiatric treatment medications | 24 (68.6) | 23 (67.6) |
| Indicated that the following was a potential side effect of AMI | ||
| Falling | 24 (68.6) | 29 (85.3) |
| Driving Impairment | 28 (80.0) | 26 (76.5) |
| Memory Loss | 20 (57.1) | 27 (79.4)* |
| Infection | 6 (17.1) | 9 (26.5) |
| Hospitalization | 19 (54.3) | 21 (61.8) |
| Agitation | 16 (45.7) | 19 (55.9) |
| Unable to perform everyday activities | 19 (54.3) | 23 (67.6) |
| Disability or physical/mental decline | 14 (40.0) | 22 (64.7)* |
| Conflicts with friends and family | 19 (54.3) | 21 (61.8) |
| Confusion | 25 (71.4) | 26 (76.5) |
| Vision Loss | 10 (28.6) | 17 (50.0)* |
| Disease | 7 (20.0) | 13 (38.2) |
| Drowsiness | 20 (57.1) | 27 (79.4) |
| Vomiting | 15 (42.9) | 21 (61.8)* |
| Increased blood pressure/heart attack | 17 (48.6) | 24 (70.6) |
| Shortness of breath/difficulty breathing | 17 (48.6) | 23 (67.6) |
| Death | 23 (65.7) | 25 (73.5) |
Indicates significantly different pre and post-test results at the p < 0.05 level.
Note: Frequencies include all available data. Only participants with pre and post-test responses for each individual item were included in comparison analyses.
On the pre-test, the majority of respondents indicated that prescription pain medications are potentially dangerous when consuming alcohol (74%), followed by psychotropic or psychiatric treatment medications (69%). Approximately one-third of all respondents indicated on the pre-test that over-the-counter medications, such as Tylenol (acetaminophen), Advil (ibuprofen), and Aleve (naproxen), are potentially dangerous when consuming alcohol. When asked on the pre-test about harmful AMI effects, the most commonly indicated were driving impairment (80%), confusion (71%), and falling (69%). Relatively few respondents indicated that infection (17%; n = 6), disease (20%), or vision loss (29%) were harmful AMI effects. Significant changes were found from pre to post-test, with more participants reporting that memory loss, disability or physical/mental decline, vision loss, and vomiting were potential AMI side effects.
AMI Intentions
On the pre-test, three-fourths of the sample reported they were willing to talk to their doctor or pharmacist about potential alcohol and medication interactions, and about 86% would change the amount of alcohol they consumed to prevent AMI events (see Table 2). Almost 90% answered that they would be willing to talk to their friends and family about how alcohol can cause harmful drug interactions. Finally, 63% of the sample indicated their willingness to advocate for safe alcohol and prescription drug use. No changes in participant willingness to engage in these prevention-related behaviors were found on the post-test.
Table 2.
Participant intention to engage in alcohol medication interaction (AMI) health behaviors (n = 35).
| Pre-Test n (%) |
Post-Test n (%) |
|
|---|---|---|
| Would you be willing to: | ||
| Talk to your doctor or pharmacist about how alcohol can cause harmful prescription drug interactions? | ||
| Yes | 24 (75.0) | 23 (74.2) |
| No | 2 (6.3) | 2 (6.5) |
| Maybe | 6 (18.8) | 6 (19.4) |
| Change how much alcohol you consume to prevent harmful prescription drug interactions? | ||
| Yes | 24 (85.7) | 19 (79.2) |
| No | 4 (14.3) | 5 (20.8) |
| Maybe | 0 (0.0) | 0 (0.0) |
| Talk to friends and family about how alcohol can cause harmful prescription drug interactions? | ||
| Yes | 27 (87.1) | 25 (86.2) |
| No | 1 (3.2) | 3 (10.3) |
| Maybe | 3 (9.7) | 1 (3.4) |
| Be an advocate for safe alcohol and prescription drug use? | ||
| Yes | 19 (63.3) | 17 (58.6) |
| No | 4 (13.3) | 3 (10.3) |
| Maybe | 7 (23.3) | 9 (31.0) |
Note: Frequencies include all available data. Only participants with pre and post-test responses for each individual item were included in comparison analyses. No statistically significant differences between pre and post-test data were found.
AMI Knowledge/Importance
Participants had high baseline knowledge and perceived importance regarding AMI-related messages, as shown in Table 3. On the pre-test, when participants were asked to assess AMI importance, respondents had the highest perceived importance for the statement “It is important to talk to your doctor or pharmacist about alcohol and medication interactions” and the lowest perceived importance for the statement “It is important to consume no more than one drink a day”. After reviewing the intervention materials, the sample rated all seven statements as the same or more important than on the pre-test. Two statements were rated as significantly more important after participants viewed the materials: “It is important to consume no more than one drink a day” and “Alcohol and medication interactions can result in mental and/or physical health consequences”. The remaining questions were rated as more important on the post-test, but not significantly.
Table 3.
Perceived knowledge and importance of alcohol medication interaction (AMI) messages, by mean question score.
| In your opinion, how important is the following statement, from 1 (very important) to 5 (not very important)? | |||
|---|---|---|---|
| Pre-Test | Post-Test | Change Score | |
| Alcohol and medication interactions can be potentially dangerous, and even life threatening. | 1.23 | 1.03 | −0.20 |
| Alcohol consumption at any level can be dangerous. | 1.63 | 1.36 | −0.27 |
| It is important to consume no more than one drink a day. | 1.81 | 1.31 | −0.50** |
| It is important to talk to your doctor or pharmacist about alcohol and medication interactions. | 1.03 | 1.03 | 0.00 |
| Alcohol and medication interactions can result in mental and/or physical health consequences. | 1.29 | 1.19 | −0.10* |
| When consuming any level of alcohol, it is important to be aware of potential minor or severe side effects. | 1.19 | 1.18 | −0.01 |
| During serious alcohol and medication interactions, it is important to visit your local emergency care clinic immediately. | 1.13 | 1.03 | −0.10 |
| In your opinion, how true is the following statement, from 1 (very true) to 5 (very false)? | |||
|---|---|---|---|
| Pre-Test | Post-Test | Change Score | |
| Unexpected physical or mental symptoms and interactions due to medication you are taking can be potentially dangerous, and even life threatening. | 1.21 | 1.06 | −0.15 |
| Alcohol consumption at any level can be very harmful to you. | 1.63 | 1.39 | −0.24 |
| It is important to consume no more than one alcoholic drink a day. | 1.89 | 1.38 | −0.51** |
| It is important to talk to your doctor or pharmacist about how drinking alcohol can change the effect of medications you are taking (such as medication interactions and medication side effects). | 1.19 | 1.03 | −0.16 |
| Alcohol can change the effect of a medication, which can result in unexpected mental and/or physical health symptoms. | 1.27 | 1.21 | −0.06 |
| When consuming any level of alcohol, it is important to be aware of potential minor or severe side effects. | 1.28 | 1.18 | −0.10 |
| During serious alcohol and medication interactions (unexpected physical or mental symptoms, such as mood change, confusion, or dizziness), it is important to visit your local emergency care clinic immediately. | 1.18 | 1.09 | −0.09 |
Note:
p < 0.10;
p < 0.05.
Mean scores include all available data. Only participants with pre and post-test responses for each individual item were included in comparison analyses.
The two statements that had the highest knowledge ratings on the pre-test were “It is important to talk to your doctor or pharmacist about how drinking alcohol can change the effect of medications you are taking” and “During serious AMI events, it is important to visit your local emergency care clinic immediately”. Similar to the findings of the statements’ importance, the two messages regarding alcohol moderation had the lowest knowledge ratings (“It is important to consume no more than one drink a day” and “Alcohol consumption at any level can be very harmful to you”). All statements were rated the same or improved after the intervention. However, the only statement where responses significantly changed from pre to post-test was “It is important to consume no more than one alcoholic drink a day”. Participants believed the other messages to be truer from pre to post-test, but these increases were not significant.
Participant Feedback
Most participants agreed that the collective presentation of all the materials (poster, brochures, and PSA) was the most effective tool. Specifically, most comments about the PSA were positive. The most frequently mentioned positive perceptions focused on the PSA’s content being informative. The sample also responded positively to the actors in the PSA, a male and a female older adult couple, indicating that the portrayal of older adults would encourage other older adults to pay attention. The negative comments included the brevity and lack of detail of the PSA. Several participants felt the actors spoke too quickly and did not enunciate enough for those older adults with hearing impairment. The majority (79%) indicated that the PSA was effective.
Participants were given two brochures – one intended for older adults and one intended for pharmacy staff members. Again, the majority of comments were positive, with the most frequently mentioned comments focusing on the layout, colors, and pictures. However, some suggestions were provided for the brochures. Two individuals reported disliking the color scheme, and several participants mentioned using bolder or larger font to make the brochure easier to read. One participants reported that the brochures “should remark that drinking alcohol with medicine can be dangerous at any age” so that people are aware that this is not just an issue for older adults. Over three-fourths of the participants found the brochures to be very effective or effective for educating the community.
When asked for feedback about the poster, most comments were again positive. The most frequently mentioned positive comments were about the layout and content, and the poster was referred to as “eye-catching” and “a great item for pharmacies”. Respondents mentioned very few negative comments on the poster, less so than the other intervention materials. However, one person did mention that both the poster size and print were too small, and another participant questioned the age parameters, specifically asking why the age of 60 years old and older was presented in the materials. Over 90% of participants rated the poster as very effective or effective, which was more than both the PSA and the brochures, for educating the community.
Discussion
This study is the first step in examining the acceptability of an educational intervention to prevent alcohol and medication interactions among older adults. The majority of participants in the current study were taking prescription medications, which is consistent with findings in previous studies of older adults (Gu, et al., 2010). However, only a few participants reported past-month alcohol consumption, which is below national averages (Qato, et al., 2015). Results also indicate that the sample reported understanding the potential danger of consuming alcohol while taking medications, but participants needed more information on the specific types of medications that are potentially dangerous when consumed with alcohol, including over-the-counter and prescription pain medications and psychiatric treatment medications. Even after exposure to the educational materials, less than half of the sample indicated that taking over-the-counter pain medications, including Tylenol (acetaminophen), Advil (ibuprofen), and Aleve (naproxen), was potentially dangerous when also consuming alcohol. Given the potential dangers of concurrent use of alcohol and this class of medications, which may cause upset stomach, liver damage, ulcers and bleeding, and increased heartbeat (National Institute on Alcohol Abuse and Alcoholism, 2003), increased focus on over-the-counter medications in the intervention materials is warranted. Though results were consistent with the notion that individuals are less likely to recognize the dangers of over-the-counter medications when compared to prescription medications (Bower, Grau, & Taylor, 2013), future versions of the intervention materials should work to counter such misbeliefs among older adults.
While the majority of the sample reported willingness to talk to their doctor about AMI prevention, change their alcohol consumption to prevent AMI events, and discuss AMI prevention with family and friends, more emphasis is needed on encouraging older adults to act as advocates for AMI prevention within their communities. Low levels of willingness to act as an advocate may be due to the need for further explanation and details about the role of a community advocate in this instance, which may have caused misunderstanding. There is great potential for older adults to be an integral part of spreading AMI prevention messages given their strong community presence, such as in senior centers, retirement communities, and nursing homes, so their advocacy role needs to be better understood.
The study sample had a high baseline understanding of the importance of discussing AMI risks with their doctor, recognizing potential AMI side effects, and seeking medical attention in the case of an AMI. Comparing pre and post-intervention outcomes, the intervention materials increased participant perceived importance and knowledge for AMI messages, with significant changes on understanding risky alcohol use and knowledge of physical and mental AMI consequences. These significant findings are consistent with the Health Belief Model and the Information-Motivation-Behavioral Skills Model, which posit the benefits of messages regarding knowledge of the severity of a health behavior as well as the steps to take to avoid consequences. The significant change in both perceived importance and knowledge of consuming no more than one alcoholic drink a day was expected, given that this specific message was a highlight of all of the educational materials viewed by participants.
Although participant feedback on the intervention materials was overwhelmingly positive, revisions to the educational materials prior to future trials may be beneficial in increasing the impact of the intervention. Many participants noted that the public service announcement was brief and lacked detail, which could be offset by increased information being presented in the written materials. The addition of subtitles to the video would assist older adults with hearing impairment in understanding the messages being portrayed. In addition, the written materials should also be revised to make the text larger for those older adults with visual or reading impairments.
The results of this study should be considered in context of its limitations. The number of participants who reported consuming alcohol in the past month was much lower than the national average for older adults (Substance Abuse and Mental Health Services Adminstration, 2014), which may have influenced participants’ attitudes, knowledge, and beliefs regarding alcohol and alcohol medication interactions. The low level of alcohol consumption is in stark contrast with the approximately forty percent who consulted with clinicians on their AMI risk, perhaps indicating the successful effect of clinical counsel for AMI prevention. This low level of alcohol use may explain why half of participants reported never talking to their doctor about alcohol medication interactions, as they may believe they are not at risk as a non-drinker. A solid baseline understanding of the severity of mixing alcohol and medications may explain non-significant differences between pre and post-test data on health attitudes and beliefs. Self-report data on health behaviors and attitudes are subject to social desirability bias, and may have led to an underreporting of alcohol use (van de Mortel, 2008). Furthermore, while limited change in AMI beliefs would be expected for non-drinkers, the community advocacy and material acceptability still applies to the non-drinking sample.
In addition, participants were from a single state and the sample size was small, which may affect generalizability of the results to other older adult populations. The small sample size should also be taken into consideration when interpreting any statistically significant change, highlighting the need for replication in larger studies. The research team did not ensure that research participants had no cognitive impairment symptoms that may have affected their ability to participate in this study, which is a concern given that about half the sample reported at least some physical or mental limitations. However, these results are promising and an important starting point in the evaluation of this AMI prevention intervention. Future studies should employ a larger sample with an increased proportion of drinkers and participants from geographically diverse environments.
Lessons Learned
The results of this study can be used to inform the work of health education specialists in regards to testing the acceptability of educational materials to decrease risk for alcohol and medication interactions among older adults. This study provided needed information on understanding prescription drug safety knowledge and attitudes in this population. Findings highlighted acceptability of the intervention materials and the presence of a potential ceiling effect in regards to the utility of the assessments in monitoring change.
When planning health education and promotion programs for AMI prevention, a partnership with community stakeholders is essential. For example, the intervention materials in this study were developed with the input of local pharmacists, due to the nature of the content and because the intervention has an intended distribution in the local pharmacy setting. Health specialists can also use this study as a model when including potential stakeholders and partners in the program planning stages. Theoretical models were used in the development of these materials, which proved effective as messages of perceived severity, a construct of the Health Belief Model, led to improvement after review of the materials. Health education specialists in the field of prescription drug safety should continue to use messages that increase knowledge on potential health consequences. In addition, feedback was elicited from the participants, as this study was intended to assess the acceptability of the intervention materials. Revisions and modifications will be made based on assessment findings and this participant feedback, which is a crucial step when implementing health education and promotion programs. The research team and other health specialists can use this information to plan and implement AMI prevention efforts in communities on a larger scale in the future, focusing on promoting responsible alcohol and medication use among older adults.
Conclusion
In summary, this research indicates that the intervention materials were positively received. In the future, it may be important to consider more emphasis on educating older adults on specific medications that are potentially dangerous when consuming alcohol, as well as the importance of understanding the dangers of risky alcohol consumption and the potential severity of alcohol medication interactions. The intervention materials demonstrated trends for improving older adult knowledge and awareness of alcohol and medication interaction issues. This intervention shows potential impact as a health promotion program to decrease the risk for alcohol medication interactions among older adults.
Highlights.
Tested alcohol and medication interaction (AMI) prevention material acceptability
Results show an increase in participant understanding of AMI risk and consequences
Intervention materials, developed by the research team, were positively received
Program effectiveness should be tested in future large-scale studies
Acknowledgments
Funding: This work was supported by the National Institutes of Health [grant number 1K01DA031764]. The National Institutes of Health had no further role in the study design, the collection, management, analysis, and interpretation of the data, in the writing of the manuscript, or in the decision to submit the paper for publication.
Biographies
Dr. Faika Zanjani is an Associate Professor in the Department of Gerontology at the Virginia Commonwealth University School of Allied Health Professions. Her research focuses on adult development, health promotion, and preventing mental health and substance use problems in later life.
Hannah Allen is a PhD Candidate and research assistant in the Department of Behavioral and Community Health at the University of Maryland School of Public Health. Her main interests include mental health and substance use in a developmental context.
Dr. Nancy Schoenberg is the Associate Dean for Research in the College of Public Health at the University of Kentucky as well as a Marion Pearsall Professor in the Behavioral Science Department at the University of Kentucky College of Medicine. Her research involves addressing health inequities, particularly among rural residents, using community-based participatory research strategies, intervention trials, and mixed method designs.
Dr. Catherine Martin is the Director of the Division of Child and Adolescent Psychiatry and a Professor of Psychiatry at the University of Kentucky College of Medicine. Her clinical interests include adult, child, and adolescent psychiatry, anxiety, depression, high-risk behaviors, and substance abuse.
Dr. Richard Clayton is a Professor Emeritus in the Health, Behavior, and Society Department in the College of Public Health at the University of Kentucky. His work has focused mainly on tobacco control, drug abuse, and health disparities.
Footnotes
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Conflict of interest: The authors declare that they have no conflict of interest.
References
- Aira M, Hartikainen S, Sulkava R. Community prevalence of alcohol use and concomitant use of medication- A source of possible risk in the elderly aged 75 and older? International Journal of Geriatric Psychiatry. 2005;20(7):680–685. doi: 10.1002/gps.1340. [DOI] [PubMed] [Google Scholar]
- Balsa AI, Homer JF, Fleming MF, French MT. Alcohol consumption and health among elders. Gerontologist. 2008;48(5):622–636. doi: 10.1093/geront/48.5.622. [DOI] [PubMed] [Google Scholar]
- Barnes AJ, Moore AA, Xu HY, Ang A, Tallen L, Mirkin M, et al. Prevalence and correlates of at-risk drinking among older adults: The Project SHARE Study. Journal of General Internal Medicine. 2010;25(8):840–846. doi: 10.1007/s11606-010-1341-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bower AB, Grau SL, Taylor VA. Over-the-counter vs. prescription medications: Are consumer perceptions of the consequences of drug instruction non-compliance different? International Journal of Consumer Studies. 2013;37(2):228–233. [Google Scholar]
- Cacciola JS, Alterman AI, DePhilippis D, Drapkin ML, Valadez C, Fala NC, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM) Journal of Substance Abuse Treatment. 2013;44(3):256–263. doi: 10.1016/j.jsat.2012.07.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cousins G, Galvin R, Flood M, Kennedy MC, Motterlini N, Henman MC, et al. Potential for alcohol and drug interactions in older adults: Evidence from the Irish longitudinal study on ageing. BMC Geriatrics. 2014;14(1):57–67. doi: 10.1186/1471-2318-14-57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fisher J, Fisher W. Theoretical approaches to individual-level change. New York, NY: Kluwer Academic Plenum Press; 2000. [Google Scholar]
- Forster LE, Pollow R, Stoller EP. Alcohol use and potential risk for alcohol-related adverse drug reactions among community-based elderly. Journal of Community Health. 1993;18(4):225–239. doi: 10.1007/BF01324433. [DOI] [PubMed] [Google Scholar]
- Ghasemi A, Zahediasl S. Normality tests for statistical analysis: A guide for non-statisticians. International Journal of Endocrinology and Metabolism. 2012;10(2):486–489. doi: 10.5812/ijem.3505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007–2008. NCHS Data Brief. 2010;42(1):1–8. [PubMed] [Google Scholar]
- Hanson V. Technology skill and age: What will be the same 20 years from now? Universal Access in the Information Society. 2011;10(4):443–452. [Google Scholar]
- Janz N, Becker M. The Health Belief Model: A decade later. Health Education Quarterly. 1984;11(1):1–47. doi: 10.1177/109019818401100101. [DOI] [PubMed] [Google Scholar]
- Moore AA, Whiteman EJ, Ward KT. Risks of combined alcohol/medication use in older adults. American Journal of Geriatric Pharmacotherapy. 2007;5(1):64–74. doi: 10.1016/j.amjopharm.2007.03.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 13-5329. 2003. Harmful interactions: Mixing alcohol with medicines. [Google Scholar]
- Noar S. A health educator’s guide to theories of health behavior. International Quarterly of Community Health Education. 2005–2006;24(1):75–92. doi: 10.2190/DALP-3F95-GCT3-M922. [DOI] [PubMed] [Google Scholar]
- Onder G, Landi F, Della Vedova C, Atkinson H, Pedone C, Cesari M, et al. Moderate alcohol consumption and adverse drug reactions among older adults. Pharmacoepidemiology and Drug Safety. 2002;11(5):385–392. doi: 10.1002/pds.721. [DOI] [PubMed] [Google Scholar]
- Phillips DP, Barker GEC, Eguchi MM. A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs. Archives of Internal Medicine. 2008;168(14):1561–1566. doi: 10.1001/archinte.168.14.1561. [DOI] [PubMed] [Google Scholar]
- Pringle KE, Ahern FM, Heller DA, Gold CH, Brown TV. Potential for alcohol and prescription drug interactions in older people. Journal of the American Geriatrics Society. 2005;53(11):1930–1936. doi: 10.1111/j.1532-5415.2005.00474.x. [DOI] [PubMed] [Google Scholar]
- Pringle KE, Heller DA, Ahern FM, Gold CH, Brown TV. The role of medication use and health on the decision to quit drinking among older adults. Journal of Aging and Health. 2006;18(6):837–851. doi: 10.1177/0898264306293583. [DOI] [PubMed] [Google Scholar]
- Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300(24):2867–2878. doi: 10.1001/jama.2008.892. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Qato DM, Manzoor BS, Lee TA. Drug-alcohol interactions in older U.S. adults. Journal of the American Geriatrics Society. 2015;63(11):2324–2331. doi: 10.1111/jgs.13787. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Seitz H, Egerer G, Simanowski U, Waldherr R, Eckey R, Agarwal D, et al. Human gastric alcohol dehydrogenase activity: Effect of age, sex, and alcoholism. Gut. 1993;34(10):1433–1437. doi: 10.1136/gut.34.10.1433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Substance Abuse and Mental Health Services Adminstration. Results from the 2013 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863 2014 [Google Scholar]
- van de Mortel TF. Faking it: Social desirability response bias in self-report research. Australian Journal of Advanced Nursing. 2008;25(4):40–48. [Google Scholar]
- Zanjani F, Crook L, Smith R, Antimisiaris D, Schoenberg N, Martin C, et al. Community pharmacy staff perspectives on programming to prevent alcohol and medication interactions in older adults. Journal of the American Pharmacists Association. 2016;56(5):544–548. doi: 10.1016/j.japh.2016.04.561. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zanjani F, Hoogland AI, Downer BG. Alcohol and prescription drug safety in older adults. Drug, Healthcare and Patient Safety. 2013;5:13–27. doi: 10.2147/DHPS.S38666. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zanjani F, Smith R, Slavova S, Charnigo R, Schoenberg N, Martin C, et al. Concurrent alcohol and medication poisoning hospital admissions among older rural and urban residents. American Journal of Drug and Alcohol Abuse. 2016;42(4):422–430. doi: 10.3109/00952990.2016.1154966. [DOI] [PMC free article] [PubMed] [Google Scholar]