1. Joanna Piechniczek-Buczek, MD Boston University
Challenges in Managing Alcohol Withdrawal Syndrome in Special Populations: Focus on the Surgical and Elderly Patients
Joanna Piechniczek-Buczek, MD
Boston University
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2. Alcohol Abuse and Dependence
General population
80% lifetime use
15% lifetime abuse
10% lifetime dependence
Special populations
20% medical inpatients
50% trauma and surgical patients
17% elderly
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3. Copyright Alcohol Medical Scholars Program
Definitions I
Substance Abuse ≥ 1
Obligations
Hazardous use
Legal
Interpersonal problems
Substance Dependence ≥ 3
Tolerance
Withdrawal
↑ Amounts/Time
Cut down
↓ Activities
↑ Time
Consequences of use
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4. Definitions II Alcohol withdrawal syndrome (AWS) ≥2
Hallucinations and illusions
Agitation
Anxiety
Seizures
↑ HR and BP
Tremor
Insomnia
Nausea/vomiting
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5. Severe AWS: Risk Factors
Amount/ time
# of prior episodes
Use of other substances
↑ BAC
Severe symptoms on presentation
Medical/surgical comorbidity
↑Age
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6. Copyright Alcohol Medical Scholars Program
Consequences of AWS
Complicated hospital stay
Longer hospitalization
↑ risk of ICU
↑ mortality
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7. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS
Signs and symptoms of AWS
Evaluation of patients
Treatment overall
Special considerations
Surgical patients
Elderly
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8. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS
Signs and symptoms of AWS
Evaluation of patients
Treatment overall
Special considerations
Surgical patients
Elderly
Copyright Alcohol Medical Scholars Program

9. Neurobiology of Alcohol
ACUTE
CHRONIC
↑ GABA
↓ glutamate
↑ NE
↓ GABA
↑ NMDA
↓ NE
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10. Neurobiology of Alcohol
WITHDRAWAL
↑excitatation by: ↓ GABA, ↑ glutamate 
tremor, seizures
 norepinephrine sensitivity 
autonomic instability
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11. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS √
Signs and symptoms of AWS
Evaluation of patients
Treatment overall
Special considerations
Surgical patients
Elderly
Copyright Alcohol Medical Scholars Program

12. Alcohol withdrawal: Phase I
Time abstinent or cut down:
6- 24 hours
Signs and symptoms:
Tremor
↑ autonomic activity:
↑ blood pressure/HR
↑ reflexes
Fever
Insomnia/Anxiety
Sweating
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13. Alcohol withdrawal: Phase II
Time Abstinent: 7-48 hours
Signs and symptoms:
Distractibility
Autonomic instability (↑↓heart rate, ↑↓ blood pressure)
Grand mal seizures
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14. Alcohol withdrawal: Phase III
Time Abstinent:
72-96 hours
Delirium Tremens:
Confusion/disorientation
Severe autonomic instability
Intense tremor
Hallucinations
Agitation
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15. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS √
Signs and symptoms of AWS √
Evaluation of patients
Treatment overall
Special considerations
Surgical patients
Elderly
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16. Evaluation: Interview
Duration of use
Quantity/frequency
Time since last drink
Past withdrawals
Medical/psychiatric problems
Social/domestic/emotional/occupational problems
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17. Evaluation: Screening Tools
AUDIT
10 items scale
Can be self administered
Assesses: frequency, quantity, lack of control, guilt, blackouts etc.
Sensitivity: 90%; Specificity: 85% at score of > 8
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18. Evaluation: Physical Exam
Withdrawal symptoms
Co-occurring medical problems
Cardiac disease (arrhythmia, CHF)
GI bleed
Cancer
Liver/ pancreas disease
Nervous system
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19. Evaluation: Laboratory Tests
CBC/MCV >100
AST > 40, ALT > 40; ratio >2:1
GGT>35
CDT > 20u
Electrolytes
BAC
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20. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS √
Signs and symptoms of AWS √
Evaluation of patients √
Treatment overall
Special considerations
Surgical patients
Elderly
Copyright Alcohol Medical Scholars Program

21. Treatment: General Care
Multivitamins (MVI): 1 tablet daily
Thiamine: 100 mg daily
Folic acid: 1 mg daily
Fluid repletion if dehydrated
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22. Treatment: Benzodiazepines
First line
Effective to ↓:
Severity of withdrawal
Incidence of delirium
Incidence of seizures
2 types:
Longer acting ( ½ life ~ 30 hours)
e.g. diazepam, chlordiazepoxide
Shorter acting ( ½ life ~15 hours)
e.g. lorazepam, oxazepam
Longer acting better for ↓ seizures, but  sedation
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23. BZD Dosing Strategies “Fixed schedule” Set doses at fixed intervals
PRNs for breakthrough symptoms
Tapered over 3-5 days
Problems: over/under- medication
Examples:
Lorazepam 2 mg q4h
Diazepam mg q6h
Chlordiazepoxide mg q6h
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24. Copyright Alcohol Medical Scholars Program
BZD Dosing Strategies
“Symptom- triggered”
Medication given when CIWA >8
↓ Dose, side effects, tx time
Problems:  cost/staff time
Examples
Lorazepam 2 mg q1h CIWA 8-13
Lorazepam 3 mg q1h CIWA 14-20
Lorazepam 4 mg q1h CIWA >20
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25. Copyright Alcohol Medical Scholars Program
CIWA-Ar Score 0→7 on:
Nausea, vomiting
Tremor
Sweating
Anxiety
Agitation
Tactile hallucinations
Auditory hallucinations
Visual hallucinations
Headache
Disorientation
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26. Treatment: Supportive
Non-pharmacological treatment
Reassurance
Reality-orientation techniques (time, place, situation)
Rest/sleep
Adequate nutrition
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27. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS √
Signs and symptoms of AWS √
Evaluation of patients √
Treatment overall √
Special considerations
Surgical patients
Elderly
Copyright Alcohol Medical Scholars Program

28. AWS in Surgical Patients
Epidemiology
50% of trauma patients have AUD
16% incident of AWS post-surgery
Pre-operative tx prevents AWS in 75% of patients
AWS in surgical patients ↑ risk:
Intra/post operative morbidity/mortality
Postoperative morbidity 2-3 X ↑ if 21+ drinks/week
50% ↑ LOS
Poor 3 month outcomes
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29. AWS in Surgical Patients: Challenges
After surgery
During surgery
 immune functions
↑ metabolic acidosis and ↑ stress response
DTs missed
Autonomic instability incorrectly attributed
Agitation
Hallucinations
Alcohol or sensitivity to anesthesia
Alcohol ↓ coagulation
↑ risk of hypoxia and poor BP control
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30. AWS in Surgical Patients: Assessment I
History
Scheduled surgeries:
Good screening
Advise abstinence if not at risk of AWS
Pre-surgical detoxification
Trauma and emergency surgeries:
May not be available
Collateral informants
Physical exam/ laboratory findings
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31. AWS in Surgical Patients: Assessment II
Differential diagnosis/common surgical causes of agitation:
Bleeding
Metabolic/electrolyte abnormalities
Infection
Pain
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32. AWS in Surgical Patients: Treatment
Supportive care
Pain management
Pulmonary toileting
Eliminate catheters
Early mobility
Pharmacological treatment
BZD
Symptom-triggered
Dosages generally larger
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33. Copyright Alcohol Medical Scholars Program
This Lecture Reviews
Neurobiology of AWS √
Signs and symptoms of AWS √
Evaluation of patients √
Treatment overall √
Special considerations
Surgical patients √
Elderly
Copyright Alcohol Medical Scholars Program

34. Copyright Alcohol Medical Scholars Program
AWS in the Elderly
Epidemiology
11% of elderly medical inpatients have AUD
20% in psychiatric settings
14% in emergency departments
Risks
Age: ↑ disease burden;↑ risk of withdrawal
Age ∆ alcohol concentration
Interactions with medications
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35. AWS in Elderly Patients: Challenges
Age  predictor of ↑ withdrawal severity
Early onset drinkers↑ severity of AWS
Functional reserve and tolerance of physiological stressors ↓
↑ risk of adverse effects from use of BZDs
Cognitive impairment
Daytime sedation
Falls
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36. AWS in Elderly Patients: Assessment I
History:
Patient ashamed to admit
Family reluctant to share
Physicians not likely to suspect
Clues ↑ suspicion of AUD:
Frequent falls/ bruises
ED visits
↑ blood pressure
Depressed mood and suicidal thoughts
Insomnia
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37. AWS in Elderly Patients: Assessment II
Differential diagnosis:
Other substances
Delirium of other causes
Psychiatric conditions
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38. AWS in Elderly Patients: Treatment I
Supportive treatment:
Safe/well lit environment
Gentle/empathic/non-judgmental approach
Hearing aids/glasses
Avoid extremes of sensory input
Sleep/rest/nutrition
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39. AWS in Elderly Patients: Treatment II
Shorter acting BZDs preferred
No active metabolites
↓ rate of side effects
Symptom-triggered
History of sz and DTs fixed schedule. Hold for sedation
Medication dosages typically lower
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40. Copyright Alcohol Medical Scholars Program
This Lecture Reviewed
Neurobiology of AWS √
Signs and symptoms of AWS √
Evaluation of patients √
Treatment overall √
Special considerations
Surgical patients √
Elderly √
Copyright Alcohol Medical Scholars Program