How To Treat Alcohol Withdrawal In The Elderly

Transcription

1 ALCOHOL ABUSE AND WITHDRAWAL SYNDROME IN THE ELDERLY Colin Muscat Family Medicine

2 Case 90 year old Female Lives with son on vacation Admitted for FTT Consult -? GARP Develops increasing confusion during hospital stay Tremulous, tachycardic, anxious

3 Case Collateral Hx from daughter reveals at least 2 known drinks daily Closet Alcoholic years of drinking behind closed doors, with bottles hidden around the house Takes Xanax TID (and PRN...) since 1980 s

4 Questions How does alcohol abuse affect the Elderly? How is alcohol withdrawal syndrome different in the Elderly? How is alcohol withdrawal treated in the Elderly? Special considerations?

5 Patterns of Alcohol Consumption in the Elderly Early onset lifelong pattern of drinking and are now elderly 2/3 of elderly alcoholics More likely to have chronic health problems due to alcohol liver disease, organic brain syndrome, comorbid psychiatric disorders

6 Patterns of Alcohol Consumption in the Elderly Late Onset Became alcoholic in their drinking pattern for first time later in life 1/3 of elderly drinkers Often triggered by stressful life event Generally milder cases of alcoholism Fewer accompanying medical problems

7 Special Considerations in the Elderly Decreased body water reach higher blood alcohol concentration quicker, with lower doses Slower metabolism of ETOH in gut and liver Polypharmacy and drug interactions More prone to alcoholic gastritis Increased risk of delirium, falls Self medication

8 Acute ETOH Intoxication Inhibits neuro-excitatory NMDA receptors and reduces release of their NT Glutamate Activates neuro-inhibitory GABA receptors Leads to anxiolysis, sedation, motor incoordination

9 Chronic ETOH use Down-regulates GABA receptors Up-regulates NMDA receptors Leads to phenomenon of tolerance

10 ETOH Withdrawal NMDA function increases GABA function decreases Increased excitation and decreased inhibition Leads to psychomotor agitation and autonomic excitability *Worse in patients with chronic ETOH neural changes

11 Diagnosis of ETOH Withdrawal

12 Diagnosis

13 Clinical Manifestations The 4 clinical states of ETOH withdrawal

14 Autonomic Hyperactivity Sx typically develop between 6-24 hrs after the last drink Due to increased levels of circulating catecholamines HTN, tachycardia, palpitations, diaphoresis, GI tract upset, tremors, hyper-reflexia, irritability, agitation, anxiety Clear sensorium

15 Alcoholic Hallucinosis 30% Develops within hrs of abstinence Resolve within hrs Usually visual and tactile (formication) Auditory uncommon Clear sensorium

16 Withdrawal Seizures 10% hrs after last drink Generalized tonic-clonic convulsions Usually in patients with long history of alcoholism Usually singular episode or a brief flurry over a short period Prolonged/recurrent/status epilepticus should prompt investigation into other etiology

17 Delerium Tremens 5% hrs after last drink Lasts 1-5 days Delerium combined with autonomic hyperactivity and alcoholic hallucinosis Clouded sensorium, hallucinations, disorientation, tachycardia, HTN, fever, diaphoresis, agitation Metabolic and electrolyte disturbances due to hypermetabolic state Mortality rate of around 5% when treated

18 Management of ETOH withdrawal

19 Goals of Management 1) Prevent Seizures and DT 2) Decrease severity of withdrawal sx 3) Prevention of concurrent complications 4) Facilitate entry into a treatment program

20 Supportive Therapy Fluids Correction of electrolyte and metabolic disturbances Prevention of Wernicke s Encephalopathy with thiamine Correction of nutritional deficiencies

21 Benzodiazepines Cornerstone of therapy for Alcohol Withdrawal Counter neurologic hyperexcitation by stimulating inhibitory GABA receptors Treat psychomotor agitation and progression to seizures and delirium No one benzodiazepine has been proven superior for the treatment of ETOH withdrawal 2010 Cochrane review: benzodiazepines are effective against alcohol withdrawal seizures, when compared to placebo Not studied well against other agents

22 Lorazepam vs Diazepam Diazepam - longer acting (T 1/2: h) with active metabolites. Theoretically smoother course with less chance of recurrent withdrawal or seizures Lorazepam shorter half life (T 1/2: 12.9 h). Prevents prolonged effects if over-sedation occurs. Better for patients with cirrhosis Moldonado et al - no evidence of clinical advantage for choosing benzodiazepines based on their half lives

23 CIWA-Ar Protocol Clinical institute withdrawal assessment for alcohol Gold standard observer rated measure of withdrawal severity Provides a guide for Symptom Triggered Therapy Symptom Triggered Therapy vs. Scheduled Dosing regimens - less time to symptom control and less medication used

24 Beta Blockers and A2 Agonists Shown to be effective for symptomatic treatment through reductions in autonomic hyperactivity Helpful in reducing hemodynamic stresses in patients with underlying cardiac disease Do not prevent seizures or delirium May mask the severity of the withdrawal syndrome and subsequently lead to under-medicating with benzodiazepines Do not use as monotherapy

25 Neuroleptics Halperidol has been shown to be useful as an adjunctive therapy Reduces agitation and hallucinations Decreases seizure threshold, hypotension, QT prolongation Must be used sparingly and with caution

26 Alcohol Withdrawal in the Elderly Data is lacking about the optimal management of alcohol withdrawal in the elderly Confusion may be the predominant sign Benzodiazpines are still the mainstay of treatment

27 Alcohol Withdrawal in the Elderly Short acting (lorazepam, oxazepam) are preferred as long acting benzodiazepines will have an increased risk of excess sedation Particular attention to titrating benzodiazepine dose to relieve withdrawal symptoms while causing the smallest amount of sedation May still use antipsychotic medications judiciously for hallucinations

28 References 1) Substance abuse and withdrawal in the critical care setting. Tetrault JM. O'Connor PG. Critical Care Clinics. 24(4):767-88, viii, 2008 Oct. 2) Alcohol withdrawal syndromes in the intensive care unit. Sarff M, Gold JA. Crit Care Med Sep;38(9 Suppl):S ) Anticonvulsants for alcohol withdrawal. Minozzi, Silvia; Amato, Laura; Vecchi, Simona; Davoli, Marina. The Cochrane Database of Systematic Reviews. Issue: Volume (3), ) Benzodiazepines for alcohol withdrawal. Amato, Laura; Minozzi, Silvia; Vecchi, Simona; Davoli, Marina. The Cochrane Database of Systematic Reviews. Issue: Volume (3), ) Management of moderate and severe alcohol withdrawal syndromes. Hoffman R, Weinhouse G. Uptodate.com May ) Assessment and treatment of alcoholism and substance-related disorders in the elderly. Menninger J. Bulletin of the Menninger Clinic. 66(2):166-83, ) Rigler, S K K. "Alcoholism in the elderly." American family physician 61.6 (2000):