In which time interval do the most serious life-threatening effects of alcohol withdrawal occur

Excessive alcohol use among community-dwelling elders is prevalent, has serious consequences, and is often underrecognized. Age-related physiological changes in alcohol metabolism, greater risks of alcohol interaction with prescription medications, and the presence of comorbid medical and psychosocial conditions, such as depression and bereavement, make older persons more susceptible to adverse outcomes related to alcohol consumption. Therefore, according to the proposed recommendations of the Royal College of Psychiatrists, London, United Kingdom, the upper limit for alcohol consumption in adults older than 65 years of age should be no more than 1.5 units per day (a unit is defined as a small glass of wine or a half-pint [approximately 568 mL] of beer) or half the recommended limit for younger adults.1

Alcohol abuse is defined as continued excessive use of the substance despite social, economic, or legal pressures to the contrary.2 Alcohol dependence is defined as alcohol abuse in conjunction with physiological manifestations, such as tolerance, or the requirement of greater amounts of a substance to achieve the same desired effects. Tolerance to alcohol may be defined using any of the following three definitions: (1) at least a 50% increase in the amount of alcohol required to achieve a desired effect2; (2) a blood alcohol level of 150 mg without intoxication3; or (3) the equivalent consumption of one-fifth of a gallon or 750 mg or more of liquor in a day by a 180-lb person.3 It has been estimated that more than $200 billion, or 2.7%, of the gross domestic product of the United States is attributable to the social and healthcare costs of alcohol and alcohol use disorders.4 Among individuals aged 65 years and older, the prevalence of reported alcohol abuse and dependence in the general US population is 1.45%, equivalent to more than 490,000 people.5 Given the known underreporting of this problem, the true prevalence is likely even higher. Furthermore, despite a slight decrease of 0.39% to 0.24% in the rate of reported alcohol dependence among elders during the last decade, the prevalence of alcohol abuse rose from 0.25% to 1.21%—an almost five-fold increase—during the same period.5 With the burgeoning size of this demographic group as the baby-boom population reaches the age of 65 years, the number of elders who abuse alcohol can be expected to increase, making it imperative for clinicians to recognize and appropriately manage this important problem. This review article discusses some of the most reliable tools for screening and managing alcohol abuse problems in older adults.

Screening for Heavy Alcohol Consumption

One of the most important and challenging principles of alcohol abuse and withdrawal management is the early identification of patients at greatest risk. Alcohol-related problems are often overlooked by healthcare providers, as  the constellation of presenting symptoms may not be attributed to prior alcohol consumption and recent cessation, especially in elders. Obtaining a thorough alcohol history of every patient is essential, especially among those suspected of alcohol abuse.6

Information about the amount of alcohol consumed, the type of beverage and volume, the frequency of intake, and the pattern of consumption can alert providers to high-risk patients. A history of social, financial, or legal problems related to alcohol; recent changes in drinking patterns leading to an escalation in the amount of alcohol consumed; a family history of abusive behavior; or the use of illicit substances may suggest alcohol abuse or dependence.7 Providers also need to clarify whether the patient has a history of alcohol withdrawal or delirium tremens, as these are independent risk factors for withdrawal. Asking patients about previous medical interventions and their effectiveness can both confirm a history of withdrawal and guide management and selection of the most appropriate pharmacological and nonpharmacological interventions. Identification of at-risk patients should be part of all preoperative assessments.

A number of screening instruments have been developed to help identify problematic drinking. These instruments assess the quantity and frequency of drinking, social and legal problems resulting from alcohol abuse, health problems related to excessive alcohol use, symptoms of addictive drinking, and self-recognition of alcohol-related problems. A few of these tools are relevant in elders.

The CAGE questionnaire, which is an acronym of its four questions, is commonly used by primary care physicians to screen for alcohol abuse8 and has been validated for use in elders.9 The questionnaire consists of the following four questions regarding alcohol consumption: (1) Have you ever felt that you should cut down on your drinking?; (2) Have people annoyed you by criticizing your drinking?; (3) Have you ever felt guilty about your drinking?; and (4) Have you ever had a drink first thing in the morning as an eye–opener to steady your nerves or to get rid of a hangover? In elderly patients, the sensitivity and specificity of this screening instrument are 86% and 78%, respectively, for a cut-off score of one positive response and 70% and 91%, respectively, for a cut-off score of two positive responses.9 Although other screening tests, such as the Alcohol Use Disorders Identification Test (AUDIT) or the Alcohol-Related Problems Survey (ARPS), may perform better than the CAGE questionnaire in elderly patients with multiple comorbidities, CAGE continues to be widely used in the primary care setting because of the short time required for its administration and the ease of incorporating it into a standard clinical interview.10 The 10-item AUDIT and the 60-item ARPS questionnaires are time-consuming to complete and therefore less feasible for general screening among geriatric patients.

One of the few alcoholism screening tools that has been specifically validated in elders is the Michigan Alcoholism Screening Test–Geriatric Version (MAST-G). It has been shown to have test characteristics that are comparable to or an improvement over those of the CAGE questionnaire. In a population of outpatient geriatric patients, MAST-G had a sensitivity and specificity of 91% and 84%, respectively,11 and in a study of elderly outpatients at a Veterans Affairs hospital, it had a sensitivity and specificity of 70% and 81%, respectively.12 The MAST-G is a 24-item questionnaire, however, and thus requires significantly more time to administer than the 4-item CAGE questionnaire.

Challenges in Identifying and Treating Elders With Alcohol Use Disorders

Obtaining a history of alcohol use in an elderly patient can be difficult, as these individuals often have multiple comorbidities and may not be able to provide an accurate history if they have communication impairments due to cognitive, behavioral, or physical constraints.13 They may also feel compelled to provide a false history because of feelings of guilt or shame regarding alcohol consumption. Reluctance to speak about alcohol use may be more pronounced among women than men, as women may perceive greater social stigma associated with alcoholism.14 Because alcohol abuse and dependence are systemic illnesses that create a ripple effect that also affects the patient’s family and friends, it can be useful to obtain collateral information from those who know the patient well. Family and community involvement is essential in every stage of care for the patient who misuses alcohol, from identification to management to relapse prevention.7

Recognition of alcohol use disorders in elders is especially challenging because the presentation often differs from the more typical symptoms present in younger individuals. Compared with younger patients, elders with alcohol use problems are more likely to present with nonspecific conditions, such as cognitive impairment, daytime sleepiness, weakness, and hypertension. Elderly patients who abuse alcohol may also present with depression, lability of mood, abnormal behavior or personality changes, physical trauma, myopathy, or hypothermia. Headaches, which are common in younger adults withdrawing from alcohol, occur less frequently in elderly alcoholics.15 Elders may also display classic symptoms of alcohol withdrawal (eg, insomnia, nausea/vomiting, hallucinations) later in the course of the syndrome compared with younger individuals. Because of increased frailty and compromised physiological reserves, the older alcoholic is at risk of accelerated decline when withdrawing from alcohol. Early identification and intervention for alcohol withdrawal in elders is critical for good clinical outcomes.

Clinicians should counsel all elderly patients regarding the perils of excessive alcohol consumption, including liver and pancreatic damage, falls, confusion, and depression.16 Awareness of studies that promote the heart healthy aspects of moderate drinking may lead some patients to ask whether they should consume alcohol. It is not advisable to counsel patients to start drinking for cardiovascular benefits. Instead, it is reasonable for clinicians to point out that although some studies have shown that a moderate amount of alcohol may have beneficial cardiovascular effects, the study population in these investigations often underrepresented elders or excluded those with a high intake of alcohol. For instance, in a prospective study of 490,000 subjects, Thun and colleagues17 found that those who consumed one or two drinks of alcohol per day had lower mortality rates than nondrinkers (one drink was defined as 12 g of alcohol). However, the mean age of the study population was 56 years, and those who consumed three or more drinks of alcohol per day showed an increasing trend in all-cause mortality. Based on these findings and the prevalence of comorbidities and polypharmacy in elders, it would be appropriate for clinicians to recommend complete abstinence from alcohol for all elderly individuals.

Identification of Alcohol Withdrawal in Elders

Alcohol withdrawal is a clinical diagnosis; there is no single laboratory value or imaging study that can be used to diagnose alcohol withdrawal in a patient. The Diagnostic and Statistical Manual of Mental Disorders-IV-TR lists four criteria for the diagnosis of alcohol withdrawal: (1) cessation of or reduction in heavy and prolonged use of alcohol; (2) two or more clinical symptoms of alcohol withdrawal within several hours or days of cessation of alcohol use; (3) significant distress or impairment in functioning caused by the clinical symptoms of alcohol discontinuation; and (4) patient’s condition is not secondary to another medical or psychiatric condition.2 Clinical symptoms of alcohol withdrawal include autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, hallucinations or illusions, psychomotor agitation, anxiety, and grand mal seizures.

Alcohol withdrawal is a potentially life-threatening condition that requires prompt recognition and management. Alcohol exerts its effects through multiple mechanisms, including an increase in the function of inhibitory gamma-aminobutyric acid receptors and a decrease in the function of excitatory
N-methyl-d-aspartate glutamate receptors. The resulting increase in inhibition and decrease in excitation causes the central nervous system (CNS) depressant effects of alcohol.18 Abrupt cessation of alcohol leads to alcohol withdrawal syndrome, marked by overexcitation of the CNS. Alcohol withdrawal syndrome is characterized by four distinct conditions on a spectrum of severity (Figure).19 

Minor alcohol withdrawal symptoms typically appear between 6 and 12 hours after a rapid decrease in blood alcohol level and include anxiety, sleep disturbances, and mild tremors. Alcoholic hallucinosis, with an onset from 12 to 24 hours after cessation of alcohol, is characterized primarily by visual disturbances but can also involve auditory or tactile senses. These hallucinations usually resolve within 48 hours in patients whose orientation is relatively unimpaired. Next on the spectrum of severity are withdrawal seizures, which most often occur as generalized tonic-clonic convulsions between 24 and 48 hours after alcohol cessation, although they can occur as early as 2 hours afterward. Delirium tremens, a severe complication of abrupt alcohol cessation and a medical emergency, is characterized by tachycardia, agitation, disorientation, hypertension, fever, diaphoresis, and hallucinations in a patient whose sensorium is clouded. Delirium tremens most commonly occurs between 48 and 72 hours after alcohol cessation, and symptoms may last up to 1 week. Because this condition has a high mortality rate of up to 5% and elderly patients are often less able than their younger peers to withstand its adverse effects, preventing delirium tremens is one of the most important management principles of alcohol withdrawal.20,21 Of note, among patients who develop delirium tremens, the most common conditions resulting in death within 1 month of onset include cardiac arrhythmias, pneumonia, and hepatic or pancreatic dysfunction secondary to large amounts of alcohol consumption.22 Thus, clinicians should be aware of these lethal complications and routinely monitor patients’ cardiac, pulmonary, and gastrointestinal functions.

Management of Alcohol Withdrawal Syndrome in Elders

Before initiating treatment for alcohol withdrawal syndrome, the clinician needs to consider other possible conditions that may simulate or coexist with alcohol withdrawal. It is important to obtain all necessary medical history, physical examination findings, and laboratory data as efficiently as possible because after expeditious treatment of alcohol withdrawal syndrome is started with sedative agents (eg, benzodiazepines), it may be more difficult to elicit a reliable medical history from the patient, resulting in greater difficulty in determining the diagnosis.23

Basic laboratory and radiological studies can help the clinician evaluate concurrent conditions or those that simulate alcohol withdrawal syndrome. Blood work, including a complete blood count, liver function tests, and chemistry panel, can detect associated anemia and allow evaluation of metabolic derangements from hepatic or renal failure resulting from extensive alcohol use. When clinically indicated, a urinalysis with urine culture and radiographic imaging may help rule out common causes of infection in elders, including urinary tract infections and pneumonias. This is important because the presentation of these infections can simulate alcohol withdrawal syndrome in some cases. If the patient has a history of falls, the physical examination suggests head trauma, or the neurological examination reveals abnormalities, a noncontrast computed tomography scan of the head should be obtained to evaluate potential intracranial hemorrhage or other abnormalities. Because iatrogenic effects from prescription and over-the-counter medications can simulate the presentation of alcohol withdrawal syndrome, a thorough medication review should be undertaken. A urine toxicology panel should be obtained if illicit substance abuse is suspected. Because alcohol withdrawal syndrome stems from CNS hyperactivity, use of stimulants (eg, amphetamines, cocaine) or withdrawal from depressants (eg, opioids) may simulate this syndrome. Any recent changes in medications should also alert the clinician to possible iatrogenic causes for the presenting symptoms.

A serum alcohol level may be useful to document consumption, but a level of zero does not rule out alcohol withdrawal syndrome, as it can indicate either no alcohol consumption or that the patient is late in the course of alcohol withdrawal and is in a high-risk window for developing withdrawal seizures or delirium tremens.

Supportive therapy is a cornerstone of managing alcohol withdrawal syndrome in all patients, but is particularly important among elders, who are more likely to be hypovolemic, nutritionally deficient, or malnourished at a time when the autonomic nervous system is overactive and the metabolic rate is high.24 Use of normal saline intravenous fluids can help prevent or treat dehydration, a common finding among patients with alcohol withdrawal. Because elderly patients may be less tolerant of fluid overload and the resulting potential cardiac diastolic dysfunction and respiratory compromise, volume status should be carefully monitored. The confused elderly patient is at high risk for aspiration.25 Strict aspiration precautions, including no food by mouth and elevation of the head of the bed, can help prevent this potentially fatal complication. A “banana bag,” consisting of thiamine, dextrose, folate, and multivitamins, will provide nutritional supplementation for a patient who is unable to receive adequate nutrients by mouth and may help prevent Wernicke’s encephalopathy and the damaging effects of excessive alcohol consumption.26 Finally, electrolyte derangements, such as abnormalities of potassium, magnesium, and phosphate, are extremely common among patients with alcohol withdrawal. All electrolytes should be monitored closely and promptly repleted as necessary.25 

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Benzodiazepine sedative-hypnotics serve as the basis of therapy for alcohol withdrawal syndrome because they effectively treat the symptoms of CNS hyperactivity and prevent late complications, such as seizures and delirium tremens. With their decreased physiological reserves, frail elders are less able to tolerate the adverse effects of withdrawal. Treatment with benzodiazepines in these patients must, however, be carefully monitored to balance the risk of oversedation with that of insufficient treatment, which could lead to full-blown alcohol withdrawal. Because treatment of elders with alcohol withdrawal requires frequent observation, monitoring, nourishment, and assessment, it has been recommended that all patients older than 40 years who have alcohol withdrawal syndrome be admitted to the intensive care unit.27

The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) measures the severity of alcohol withdrawal and is commonly used for guiding the administration of pharmacological agents. The scale comprises 10 categories: nausea and vomiting; sweats; anxiety; agitation; tremors; headache; auditory disturbance; visual disturbance; tactile disturbance; and orientation.28 The maximum score is 67 (10-15 indicates mild withdrawal; 16-20 suggests moderate withdrawal; and >20 indicates severe withdrawal). However, use of a symptom-based treatment tool such as the CIWA-Ar can be challenging when applied to the elderly because most published studies on the management of alcohol withdrawal syndrome focus on relatively young and otherwise healthy middle-aged men. In fact, in the original published studies of the CIWA-Ar, the recruitment population consisted of patients whose ages ranged between 18 and 65 years.29 As stated previously, alcohol withdrawal syndrome can present differently in elders compared with younger individuals because of increased comorbidities and use of medications that affect or mask the syndrome’s presentation in this population. Therefore, the weighting of CIWA-Ar categories may need to shift, depending on the age of the patient.15 Furthermore, many elderly patients have a decreased ability to communicate, which may limit the reporting of important symptoms, such as headaches and hallucinations.

The CIWA-Ar is based on the principle of symptom-based treatment, which can be problematic in elders with alcohol withdrawal syndrome; however, in studies comparing a symptom-based approach with a prophylactic treatment approach to alcohol withdrawal management, the use of severity scales such as the CIWA-Ar was shown to decrease the amount of pharmacological agents needed.23 Clinical acumen is essential for titrating medications to achieve only minor sedation, the level at which pharmacological detoxification can start. In the assessment of the elderly patient’s status, frequent monitoring of vital signs has been shown to be critical because the results of the CIWA-Ar may be confounded by dementia or communication impairments.7 Compared with subjective symptom reporting, objective findings such as heart rate and blood pressure may serve as more reliable markers of balance between adequate sedation and overtreatment in elders.

Pharmacological Agents for Prevention of Alcohol Withdrawal Complications

Benzodiazepines are considered the foundation of alcohol withdrawal management. They act both by treating agitation and by preventing progression of withdrawal to seizures and delirium tremens. Six prospective trials between 1961 and 1983 have conclusively shown that benzodiazepines are more efficacious than placebo in reducing withdrawal symptoms and the development of seizures.30 No single agent within the benzodiazepine family has been proven to be significantly more efficacious than another agent, but diazepam, chlordiazepoxide, and lorazepam have been most extensively studied and are most commonly used in the clinical setting.30

The selection of an optimal pharmacological agent for managing alcohol withdrawal in elderly patients presents a number of challenges. Elders are prone to oversedation and development of delirium with the use of sedative-hypnotics, such as benzodiazepines. On the basis of the Beers Criteria of inappropriate medication use in the elderly,31 all benzodiazepines, including short- and long-acting agents, are considered to have serious adverse outcomes, such as falls, delirium, memory loss, and sleep disturbances.32 Because of the high morbidity and mortality associated with benzodiazepines, alcohol withdrawal remains one of the few widely accepted indications for these agents in elders.

Selecting the appropriate benzodiazepine in elderly patients with alcohol withdrawal syndrome requires consideration of agents’ medication pharmacokinetics and pharmacodynamics. Traditionally, long-acting agents such as diazepam (half-life, 20-100 hours) and chlordiazepoxide (half-life, 5-30 hours) have been recommended because they require less frequent administration, which may reduce the risk of with-
drawal seizures caused by decreased serum levels between doses.30 In addition, long-acting agents may have a decreased risk of rebound symptoms; however, drug distribution, metabolism, and excretion are altered with increasing age, such that administration of the same dose of medication in older patients may result in significantly higher levels than those expected in a younger population.33 Elders have a higher percentage of body fat, a smaller water compartment, and decreased muscle mass, thus increasing the volume of distribution for alcohol, which is miscible in lipophilic and aqueous substrates. Metabolism via the hepatic oxidation pathway may be decreased in the elderly population. In addition, renally excreted medications are highly dependent on the glomerular filtration rate, which usually decreases with age.

Given the pharmacokinetic changes of aging, lorazepam (half-life, 9-16 hours) is currently the benzodiazepine of choice for use among elders, as it is cleared by glucuronidation and age-related changes minimally affect older adults’ ability to metabolize it. In contrast, both diazepam and chlordiazepoxide have long half-lives and are biotransformed in the liver via the oxidation pathway, the efficiency of which is significantly reduced with aging.33 Although longer-acting benzodiazepines may be appropriate in patients with a history of withdrawal seizures or delirium tremens, the risk of oversedation from these medications is increased in elders and in those with concurrent hepatic dysfunction. Since elderly individuals often take multiple medications, it is important to consider possible drug-drug interactions when administering benzodiazepines to treat alcohol withdrawal syndrome.34 In accordance with the general principles of medication use in elders, the clinician should use the minimum number and dosage of benzodiazepines required for adequate treatment of alcohol withdrawal syndrome.

Other pharmacological agents that have been studied for alcohol withdrawal include barbiturates, anticonvulsants, beta-blockers, antipsychotics, and ethanol. A summary of these agents is given in the Table. All barbiturates are on the Beers Criteria list and are used for refractory delirium tremens that has failed to resolve with benzodiazepine therapy. These agents should be administered with extreme caution because they are lipid soluble, leading to an increased volume of distribution in elders.31,33 Patients being given barbiturates should be closely monitored for any signs of potentially fatal respiratory depression and sedation.

Anticonvulsants such as carbamazepine have been widely used in Europe and have been shown to be efficacious in the management of alcohol withdrawal syndrome when compared with placebo.30 However, because of the current lack of large prospective trials, further investigation is needed before their use can be recommended over benzodiazepines.

Beta-blockers decrease signs of autonomic hyperactivity but have no anticonvulsant activity. Therefore, such agents may be dangerous, as they mask the progression of signs and symptoms of alcohol withdrawal syndrome, but do not treat its most serious consequences. Beta-blockers can also significantly increase the risk of delirium in the elderly patient; thus, their use is not a recommended withdrawal treatment.35

Antipsychotics have been used for the treatment of agitation, delusions, and hallucinations in patients withdrawing from alcohol. However, these agents, especially first-generation or typical agents (eg, haloperidol) should be avoided because they lower the seizure threshold at a time when patients are already susceptible to withdrawal seizures. In addition, QTc abnormalities have been reported in persons with alcohol withdrawal syndrome, which increases the risk of cardiac arrhythmias when QTc-prolonging antipsychotics are used.36 

In the past, ethanol was commonly used to treat patients withdrawing from alcohol, but ethanol has not been shown to be more effective than benzodiazepines and is associated with significantly more side effects, including hepatic and pancreatic disorders, hematological disturbances, and central and peripheral nervous system damage. For these reasons, it is not recommended in the treatment of alcohol withdrawal.30

Conclusion

Alcohol abuse is a prevalent condition that is on the rise among elders. Alcohol withdrawal syndrome is a serious and potentially fatal condition that is often overlooked in the elderly population as a result of difficulties in communication, stigma associated with alcohol misuse, concurrent comorbidities, or variability of presenting symptoms. Obtaining a thorough alcohol and medical history is essential for early identification of patients at risk for alcohol withdrawal syndrome. Although the patient should be the primary historian, it is often necessary to obtain collateral information from family members or friends, as there may be communication impairments or the patient may have feelings of shame and guilt regarding his or her excessive alcohol consumption. After other potential causes of the presenting symptoms and the presence of concurrent diagnoses are ruled out, aggressive supportive therapy that includes nutritional and fluid/electrolyte supplementation is critical in any alcohol withdrawal patient, but especially in the frail elderly population. Further studies are needed to determine the optimal management of alcohol withdrawal syndrome in elders, but at present, the judicious use of benzodiazepines remains the cornerstone of pharmacological management.

The authors report no relevant financial relationships.

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How long does AWS last?

How long does it take to go into DTs?

What is the most severe form of withdrawal?

What happens as soon as you stop drinking?