Even though alcohol abuse is not nearly as prevalent in the elderly population as it is in the younger population, it remains one of the most underdiagnosed and undertreated condition in elderly patients. Recent literature shows a consensus that screening and identifying alcohol abuse and withdrawal in elderly patients is extremely difficult 1. From a pharmacist perspective, it is concerning that alcohol abuse is prevalent yet underdiagnosed because alcohol abuse is a risk factor for several other illnesses as well as an obstacle to therapeutic goals in certain conditions.
Another study of alcohol use in the elderly population which used three representative cross-sectional surveys (the National Household Survey on Drug Abuse, National Household Survey on Drug Abuse and the Behavioral Risk Factor Surveillance system) showed that a significant number of elderly patients consume alcohol on a regular bases2. In a study group of patients between the ages of 65-84, the prevalence of moderate and heavy drinking amongst men was estimated to be, respectively, 37.6% and 10.1% 2. Patients who had less than one drink were considered moderate drinkers whereas patients who had more than one drink daily were classified as heavy drinkers. In women, the prevalence of moderate drinking was 32.3% and heavier drinking was 2.2 % 2. These findings show that a significant number of elderly Americans consume alcohol.
Furthermore, elderly patient who are diagnosed with alcohol abuse and withdrawal symptoms experience much severe alcohol withdrawal symptoms than their younger population due. A different cross-sectional prevalence study of alcohol use in elderly emergency department patients in a mixed urban and rural population was done. Using cage questionnaires in 209 patients aged 65 years and older, the study found the lifetime prevalence of alcohol abuse to be 24% and alcohol use within the past year to be 14% 3. Additionally, 22% of those patients also presented with gastrointestinal issues and 7% presented with falls or other trauma3. This study demonstrates that alcohol abuse and withdrawal is a prevalent problem in elderly ED patients which leads to other health condition if not properly managed. As a result, treating alcohol abuse and withdrawal is imperative in managing other health conditions in elderly patients.
There are several proposed etiologies that explain alcohol abuse and withdrawal, but most point to the influence of alcohol on the central nervous system. Alcohol acts on the inhibitory neurotransmitter ?-amino-butyric acid (GABA) receptors. Alcohol increases the inhibitory effect of GABA-A neuroreceptors4. This action leads to decrease in the overall excitability of the brain. As a person is exposed to alcohol over a long period of time, the number of GABA receptors decreases to compensate and offset for the increased inhibitory effect of alcohol on the GABA neuroreceptors4. This explains why a person develops tolerance which leads to further abuse to get the same effect and potential addiction and withdrawal symptoms.
When a person suddenly stops drinking, the absence of alcohol leads to hyperexcitation in the form of acute CNS alcohol withdrawal symptoms such as irritability, tremor, nausea, and anxiety4. Another part of alcoholism and alcohol withdrawal is the inhibition of the excitatory N-methyl-D aspartate (NMDA) receptors which leads to upregulated of NMDA in patients who have been exposed to alcohol for a long time5. When a person is no longer under the influence of alcohol, it results in hyperexcitability of the NMDA receptor causing withdrawal. Other possible pathophysiology offered for alcohol withdrawal is the concept of ‘kindling’ which leads to super sensitivity of the brain. ‘Kindling’ causes long-term change in the neurons which predisposes patient to increase risk of seizure and severe withdrawal when patient when detoxification occurs in patients.
Alcohol withdrawal occurs when a person who consume alcohol in large quantities that would be considered outside of healthy indulgence experience distressful impairment hours to days after6. Most heavy drinkers will present with minor withdrawal symptoms a few hours to days after alcohol use such as hyperactivity, anxiety, retching, tachycardia, hypertension and various others. The more serious symptoms of withdrawal include delirium and seizures. These are rare, but they do occur in severe alcohol withdrawal. According to the DSM-IV, alcohol withdrawal must include cessation or reduction of alcohol consumption in someone who has been a heavy drinker as well as two more symptoms of withdrawal: sweating, increased tremor, insomnia, nausea or vomiting and a few others such as anxiety, seizures4. These symptoms must lead to distress and impairment to the patient.
To determine the severity of alcohol withdrawal symptoms, it is important to assess amount of alcohol intake, frequency, duration, previous history of withdrawals and other medical history4. Within 6-12 hrs. of cessation of alcohol use, some potential minor symptoms to be monitor would be insomnia, gastrointestinal issues, sweating4. Within 12-24 hrs., we would monitor for auditory and visual hallucinations4. In severe cases, we would monitor hallucinations, sweating, disorientation and others more serious symptoms4. When deciding whether a patient is suffering from alcohol withdrawal should be admitted in the hospital or treated in the outpatient setting, depending on the initial and expected severity of the withdrawal symptoms. Generally, outpatient is preferred only in patient with have mild or slightly moderate alcohol withdrawal and no other illness and strong support at home.
There are several goals for the treatment of alcohol withdrawal. The most common and important goals include the safe withdrawal of patients from alcohol, reduction in the severity of withdrawal signs and symptoms, reduction of delirium, prevention of seizure, assisting patients with transition to alcohol treatment4,5. Some of the other goals that are specific to elderly include prevention of comorbidities, especially in patient with other health care problems.
As with most therapy, it is important to explore the non-pharmacological option available to manage alcohol withdrawal. There aren’t too many studies that show evidence that supportive care treats withdrawal, but it is recommended to provide supportive care to optimize patient experience on pharmacological treatment7. Some supportive care that help manage alcohol withdrawal include ensuring that patient is oriented to time, place and people and ensuring that patient is in a quiet and low deemed setting. Patients should receive adequate fluid to replenish for fluid loss caused by sweating and vomiting4. Additionally, it is important to ensure patient is receiving adequate nutrition. In cases of agitation, it is not recommended to restrain the patient, but rather work with the patient to ensure they feel respected and heard. Lastly, offering social support in the form of engaged family members and friends in the patient’s therapy helps as well.
In terms of pharmacological management of alcohol withdrawal, benzodiazepines are the most common drug class for the reduction of alcohol withdrawal symptoms including seizure and delirium. Long-acting benzodiazepines such as diazepam are higher risk than short-acting ones because they do not require as much metabolism5. With long-acting benzos, the pharmacokinetic profile requires both phase I and Phase II glucuronidation whereas the shorter acting-acting benzodiazepine such as lorazepam, oxazepam and alprazolam undergo only phase II5. Although the data is being debated about how long-acting benzodiazepine presents higher risk, it is generally safer to use short acting as their toxic effect can be reversed much faster than longer-acting benzodiazepine 4. It requires constant evaluation and monitoring for appropriateness since elderly patient experience much more sedation than younger patient at the same dose of benzodiazepine5. Additionally, it is important to monitor for adherence as abrupt discontinuation cause withdrawal symptoms and seizure.
There are several ways to deliver benzodiazepines in treating alcohol withdrawal to protect patient. These include fixed schedule, front-loading and symptom-triggered regiment5. In fixed schedule regimen, we would administer the benzodiazepine in amounts that are fixed by tampering it over 3 to 5 days. A fixed schedule has been found to be effective in reducing delirium and seizure, but it presents risk of over sedation5. Both front-loading and symptom-triggered approaches provide medication on a as needed basis over 1 to 2 hours until symptoms are managed. The difference between symptoms triggered and front loading is that symptom triggered requires that patient reaches a specific threshold before receiving medication8.
The pharmacist plays an important role in determining how appropriate the approach is depending on patient. With individualized care approach, the pharmacist on the health care would be making decision about the effectiveness in controlling symptoms while also shortening duration of treatment and preventing risk for seizure10. The last approach which is the symptom-triggered therapy uses assessment scale to administer medication only when the symptoms reach a certain threshold. The fixed schedule approach presents the most risk, so pharmacist must determine its appropriate in most likely use as last resort in severe withdrawal symptoms. It also present risk for under dosing the patient. The pharmacist would need to constantly evaluate the patient because individualizing the therapy is best5. Furthermore, the pharmacist would need to monitor for sedating, especially in fixed regimen. It is recommended to monitor patient within 1-hour after each benzodiazepine dose for continuation appropriateness in terms of sedation and observe the patient for 24-hours after last benzodiazepine dose5.
Beta-blockers such as propranolol and alpha-2 agonists such as clonidine have shown efficacious in reducing signs and symptoms associated with alcohol withdrawal5. Specifically, adjunctive treatment of beta blocker helps in patients with artery disease4. Although they improved sign and symptoms of withdrawal, they were not found to be effective in reducing incidence of seizure and delirium. In patients with underlying seizure, it is appropriate to use Phenytoin (Dilantin) as an adjunctive therapy. As a result, it is normally allowed to use them as adjunctive therapy while monitoring for their risk in elderly.
Because Barbiturates are a non-selective central nervous system depressant, they are not accepted as treatment due to risk of adverse effects, drug abuse and possible respiratory depression5. Chronic alcohol use seems to cause deficiency in magnesium because it increases the excretion of manegium5. It is recommended to implement magnesium replacement or supplement. Thiamine supplement is also recommended because it does help with Wernicke’s encephalopathy and jorsakoff’s syndrome5. It does not have any direct effect on alcohol withdrawal.
The use of antipsychotics in treating alcohol withdrawal is not recommended. The exception is low dose haloperidol which is effective in treating agitation and sleep disturbances. The use of Carbamazepine to help with symptoms of alcohol withdrawal is not well established5, but barbiturates are appropriate alternative of benzodiazepam in outpatient setting9. There are couple of other agents that have not received much study include paraldehyde and clomethiazole.
As pharmacist, it will be important to ensure that the treatment of alcohol withdrawal in patient is followed with treatment for alcohol dependence4. Educating the patient on the underlying condition of addiction is important. One particularly promising treatment that decrease alcohol consumption and increase abstinence in alcohol-dependent patients is the anticonvulsant topiramate (Topamax). Additionally, informing patient about 12-step groups such as Alcohol Anonymous is important.
In conclusion, alcohol abuse can lead to alcohol withdrawal symptoms which must be properly managed in elderly patient as they are more vulnerable and susceptible to complication of pre-existing condition. As pharmacist, we have an opportunity to play a huge role in the management of alcohol withdrawal symptoms. Using clinical judgement and taking into account the severity of an elderly patient, we would be the best trained professionals on the team to recommend medications and monitor them in a way that maximize therapy for a given patient. Additionally, we are able to provide resources to help patient their independence from their withdrawal symptoms and live out a life free of withdrawal
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