CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Alcohol Withdrawal

Alcohol withdrawal (AW) symptoms commonly occur in patients who stop drinking or markedly cut down their drinking after regular heavy use. AW can range from mild almost unnoticeable symptoms to severe and life-threatening ones. Symptoms usually associated with AW include:

• Increased pulse rate
• Increased blood pressure
• Increased temperature
• Restlessness
• Disturbed sleep
• Anxiety
• Nausea and vomiting
• Headache
• Irritability
• Tremor

More severe withdrawal symptoms include auditory, visual, or tactile hallucinations, delirium, seizures, and coma.

Although withdrawal symptoms last longer in older persons and withdrawal can complicate other illnesses, there is no evidence that older patients are more prone to AW. However, detoxification generally takes longer in older adults who are alcohol dependent. In addition, some older persons experience withdrawal symptoms 2 to 3 days into treatment.

All clinicians caring for patients who abuse alcohol need to have a fundamental understanding of withdrawal symptoms and the potential complications. All clinicians should demonstrate knowledge of the most common withdrawal symptoms and the anticipated time course of the symptoms. In addition, all clinicians should be able to complete a standardized assessment of withdrawal such as the Clinical Institute Withdrawal from Alcohol-version A, revised (CIWA-Ar).

Those clinicians in settings in which withdrawal management or treatment is available also need to be competent in providing detoxification management. This includes the use of benzodiazepines for the management of alcohol withdrawal.

Factors Affecting Symptoms

Although AW delirium is a serious and life-threatening problem, serious problems are preventable and, when present, can be managed in most patients. Most patients are able to reduce or stop drinking with only minimal withdrawal symptoms. An estimated 13 to 71 percent of individuals presenting for alcohol detoxification will manifest significant symptoms of AW.¹

AW symptoms vary in severity and duration, depending on several factors:

• Quantity of alcohol consumption. Patients who are infrequent or moderate drinkers are less likely to suffer withdrawal symptoms. If they do experience symptoms, the symptoms are usually mild.
• Frequency and length of time one has been drinking. The central nervous system eventually loses its ability to adapt to alcohol.
• Onset of physical illness. Withdrawal may be induced or worsened by other illnesses.
• Severity of alcoholism. The more severe the alcoholism, the greater the chance of withdrawal. Gradually tapering alcohol use is not likely to lead to significant withdrawal effects. Therefore, it may be presumed that no one should attempt going "cold turkey," but should taper alcohol use over time.
  
  For individuals who are alcohol dependent or who have high craving states this strategy is not likely to lead to a reduction in consumption. Thus the dilemma is that those who are at the highest risk for withdrawal symptoms are also the patients more likely to be successful in reducing consumption by rapidly eliminating alcohol use.
• History of withdrawal. Patients who have had previous withdrawal symptoms are more likely to manifest symptoms again. Most likely it is because they are somehow vulnerable to withdrawal symptoms.
  
  In addition, the presence of withdrawal symptoms is a marker of greater severity of alcohol use and thus indicates that the person is more likely a high consumer. Finally, patients with a history of multiple detoxification episodes are more likely to experience seizures and severe withdrawal symptoms.

Signs and Symptoms

The first step in the treatment of AW is recognizing the signs and symptoms. Although AW symptoms vary, the time course for withdrawal symptoms is rather predictable. Withdrawal typically begins 6 to 8 hours following a reduction in alcohol use, peaks 24 to 28 hours after the last drink, and can last up to 7 days.

Although AW symptoms often appear 6 to 8 hours after alcohol use stops, they can begin before the blood alcohol level reaches 0.² Symptoms intensify and then diminish over 24 to 48 hours.

In more severe cases of AW, patients may experience withdrawal seizures, have hallucinations, or become delirious. These symptoms most often occur 36 to 72 hours after cessation of drinking. In addition to acute withdrawal effects, alcohol causes more enduring effects that are also disturbing to patients. These include disrupted sleep patterns and changes in attention and concentration. These effects may take days to months to reverse and should be treated in the same manner as acute withdrawal.

Delirium tremens (DT) is the most intense and serious syndrome associated with AW. It is characterized by agitation and tremulousness, autonomic instability, hyperpyrexia, persistent visual and auditory hallucinations, and disorientation. DT occurs in approximately 5 percent of individuals with AW and usually presents between 48 and 96 hours after last alcohol use.^3,4

Seizures are another major complication of AW. Although it has been estimated that seizures may occur in up to 25 percent of alcoholics in withdrawal, a more likely estimate is between 5 and 15 percent.^5-7 If seizures occur, they generally do so in the first 24 hours after alcohol use stops, but they can occur up to 5 days later.⁴

If seizures occur more than 1 week after alcohol use, a comorbid medical condition or use of medications that may lower the seizure threshold should be suspected. AW seizures are typically grand mal in type, and the patient will experience one to a few seizures over several hours.

Evaluation and Treatment

In terms of evaluating a patient for withdrawal symptoms and the need for treatment, the clinician must know the time of the last drink or the time that the person dramatically reduced his or her drinking. Someone who has not drunk for more than 3 to 4 days should not be at risk for suddenly developing withdrawal symptoms.

There are few absolutes in terms of who will suffer AW symptoms and who will not. However, as a general rule, alcohol withdrawal symptoms are more likely to occur in patients who dramatically reduce or stop their drinking after the regular use of large quantities of alcohol.

Withdrawal symptoms are theorized to occur because of substantial changes in blood alcohol levels that lead to effects on the nervous system. In practical terms, this means that patients who become abstinent after daily use of more than three to four drinks per day are at risk for withdrawal. However, this does not mean that patients who drink less than this will not experience withdrawal symptoms.

Often the best source of information about the potential for withdrawal symptoms is the patient. Many if not most patients have had occasions to cut down or stop drinking for one reason or another. During these times, patients may have had withdrawal symptoms and can describe them.

If patients report the occurrence of AW symptoms in the past, they are likely to experience these symptoms again when cutting down or quitting. Patients who report the need for hospitalization for detoxification or report having had seizures should be carefully monitored when trying to reduce their alcohol use.

Volume correction is not often needed in individuals with mild withdrawal symptoms; only oral fluids are necessary. In fact, some individuals suffering from AW may be overhydrated. Therefore, administering intravenous fluids may cause heart failure.

Persons experiencing severe AW may have significant fluid losses from vomiting, diarrhea, diaphoresis, and hyperthermia. These individuals may require intravenous hydration to correct severe volume depletion.

Chronic alcoholics often present with electrolyte alterations. These metabolic disorders include deficient levels of magnesium, phosphates, and potassium. Although no causal relationship has been established between low magnesium and seizures or delirium, magnesium replacement can be useful in treating nonspecific signs and symptoms seen in AW.

Nutritional deficits are common in persons with chronic alcohol use. Deficits relate to dietary habits as well as alcohol-related changes in the digestive tract. Most alcoholics are vitamin deficient and may benefit from taking oral multivitamins containing folic acid for a few weeks.

Replacement of thiamin is particularly important, since it helps prevent Wernicke’s encephalopathy. All patients being treated for AW should be given 100 mg thiamin immediately and daily during the withdrawal period. Thiamin should be provided before glucose administration to prevent Wernicke’s encephalopathy from depletion of thiamin reserves.

Management Protocols

An algorithm has been developed for determining the severity of withdrawal symptoms among older outpatients and managing symptoms. This algorithm has been formulated by consensus and has not been empirically tested. Therefore, clinicians should remember that sound clinical judgment should prevail.

Alcohol Withdrawal Management Algorithm Step 1: Initial Assessment and Intervention Step 2: Has the patient made a decision to markedly reduce intake or become abstinent? No: Schedule routine followup. Yes: Go to step 3. Step 3: Is the patient a heavy drinker (>28 drinks per week), or does the patient have a history of significant withdrawal? No: Schedule routine followup. Yes: Go to step 4. Step 4: Complete CIWA-Ar. Total score >20: Consider hospitalization. Total score = 8-20: Begin oxazepam and follow up in 2 days. Complete another CIWA-Ar. Proceed based on the new score. Total score <8: Follow up in 2 to 3 days. Go to step 5. Step 5: Complete CIWA-Ar. Total score <8: Schedule routine followup. Total score >8: Repeat step 4. Source: Barry, K.L.; Oslin, D.W.; and Blow, F.C. Alcohol Problems in Older Adults: Prevention and Management. New York: Springer Publishing, 2001.

Persons with the following clinical characteristics should be followed using the algorithm:

1. The patient is currently drinking more than 28 drinks per week, and
2. The patient’s goal is to eliminate or markedly reduce his or her drinking;

OR

1. The patient reports a past history of significant withdrawal symptoms, and
2. The patient’s goal is to eliminate or markedly reduce his or her drinking.

Clinically, there are two reasons to be concerned about withdrawal symptoms. The first is prevention of morbidity and mortality. The above criteria will adequately screen older patients for this danger. The second is less studied and may justify treating patients for withdrawal who consume fewer than 28 drinks per week.

One theory of early relapse is that withdrawal symptoms, even mild symptoms, place an individual at risk for relapse. If this is true, then aggressive treatment of withdrawal symptoms may improve clinical outcomes.

Because the hypothesis on early relapse has not been proven yet, this algorithm emphasizes the morbidity aspect. In addition, this algorithm is to be considered and used at any point during which the patient is drinking and wants to quit or reduce his or her drinking, not just at the initial assessment.

If the patient meets either of the above criteria, the clinician should conduct an interview to complete the CIWA-Ar. The total score on this initial CIWA-Ar will dictate the followup schedule. If the CIWA-Ar score is below 8, then the followup assessment can be by phone, if necessary. However, clinicians are encouraged to see all patients in the office within 2 days.

Each subsequent time that the patient is seen, a CIWA-Ar assessment should be completed. The steps for management of withdrawal symptoms should be taken until the patient is completely detoxified. When the patient has two consecutive assessments in which the total score is below 8, the patient should be scheduled for his or her next routine appointment. If patients are using medication to alleviate symptoms, it may be advisable to phone them on days that they are not being seen.

Medical Detoxification

Benzodiazepines are typically used to manage AW. However, patients should be advised not to drink while taking benzodiazepines such as oxazepam (Serax). Medical detoxification should only be considered for patients who are attempting to become abstinent.

These medicines alleviate and prevent the progression of symptoms to reach a more serious state such as seizures. In older adults, the cumulative years of drinking may lead to more severe withdrawal symptoms.⁸ The shorter-acting benzodiazepines may be of more clinical utility in this population, given their lower risk of oversedation.

Benzodiazepines are cross-reactive with alcohol and essentially act to taper the effect of sudden drops in blood alcohol levels. The recommended medication for outpatient withdrawal management or detoxification is oxazepam (Serax). The metabolism of this medication is not affected by alcohol-related liver disease. Lorazepam (Ativan) and chlordiazepoxide (Librium) have also proven effective.⁹

Although the dose should be individualized, the following doses can be used as a guide for initiating treatment with oxazepam. Patients started on oxazepam should be given the information sheet about oxazepam. Symptoms that persist or worsen should lead to increases in total dose until the symptoms have peaked. Once withdrawal symptoms begin to lessen, the dose of medication should be tapered and discontinued by approximately 20 percent of the total dose per day or over the course of 4 to 7 days.

Starting doses are:

1. CIWA-Ar total score = 8-15: 45-60 mg divided through the day
2. CIWA-Ar total score = 16-25: 60-90 mg divided through the day

For scores on the CIWA-Ar over 25, clinicians are strongly encouraged to consider hospitalization. Other reasons for hospitalization include:

• Failure of outpatient detoxification (continued drinking while on oxazepam, inability to reduce drinking)
• Complex comorbid medical conditions likely to be affected by the use of benzodiazepines or from withdrawal such as severe obstructive pulmonary disease
• Coexisting seizure disorder or recent severe withdrawal symptoms
• Low probability of completing an outpatient detoxification (e.g., severely demented individuals, persons unable to self-administer medications, persons for whom outpatient medical detoxification is not available)

References

1. Saitz, R., and O’Malley, S.S. Pharmacotherapies of alcohol abuse: Withdrawal and treatment. Medical Clinics of North America 1997, 81:881-907.
2. Mendelson, J.H., and LaDou, J. Experimentally induced chronic intoxication and withdrawal in alcoholics, II: psychological findings. Quarterly Journal of Studies on Alcohol 1963, 2(suppl):14.
3. Sellers, E.M., and Kalant, H. Alcohol intoxication and withdrawal. New England Journal of Medicine 1976, 294:757-762.
4. Victor, M. Alcohol withdrawal seizures: An overview. In Porter, R, ed. Alcohol and Seizures. New York, NY: Davis, 1990, 148-161.
5. Chan, A.W.K. Alcoholism and epilepsy. Epilepsia 1985, 26:323-333.
6. Victor, M., and Brausch, C. The role of abstinence in the genesis of alcoholic epilepsy. Epilepsia 1967, 8:1-20.
7. Hillbrom, M.E., and Hjelm-Jager, M. Should alcohol withdrawal seizures be treated with anti-epileptic drugs? Acta Neurologica Scandinavica 1984, 69:39-42.
8. Liskow, B.I.; Rinck, C.; Campbell, J.; et al. Alcohol withdrawal in the elderly. Journal of Studies on Alcohol 1989, 50:414-421.
9. Newman, J.P.; Terris, D.J.; and Moore, M. Trends in the management of alcohol withdrawal syndrome. Laryngoscope 1995, 105(1):1-7.

Adapted in part from Barry, K.L.; Oslin, D.W.; and Blow, F.C. Alcohol Problems in Older Adults: Prevention and Management. New York: Springer Publishing, 2001.

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