Alcohol Withdrawal in Older People - The Management of

Publication: 17/02/2010  --
Last review: 20/07/2020  
Next review: 20/07/2023  
Clinical Guideline
CURRENT 
ID: 1948 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The Management of Alcohol Withdrawal in Older People

  1. Detection of misuse
  2. Presentation of alcohol withdrawal syndrome
  3. Treatment of alcohol withdrawal symptoms
  4. Wernicke’s encephalopathy (WE) or alcoholic encephalopathy
  5. Management of hypoglycaemia
  6. Discharge and Outpatient management
        Appendix 1: Rockwood Clinical Frailty Score
        Appendix 2: Shorter Michigan alcohol Screening Test for Older People
        Appendix 3: CAGE Questionnaire
        Appendix 4: Clinical algorithm for the pharmacological management of alcohol withdrawal in older people

1. Detection of misuse

An alcohol history should be taken in all patients admitted to hospital, this is especially important in older people presenting with a delirium, where there needs to be a high index of suspicion.

It may be necessary to gain information from additional sources e.g. relatives, carers, or General Practitioner. This should be done as soon as possible in the admission. Studies show a prevalence of 14-18 % for alcohol use disorders in older patients in emergency departments and medical wards.

If alcohol dependence or misuse is identified the plan of care must include following this protocol with close observation for symptoms of alcohol withdrawal and prompt intervention if it occurs.

As well as determining the quantity of alcohol drunk, the following issues should be identified:

  • Duration of alcohol misuse and whether others/ self have concerns
  • Dependence (e.g. crave a morning drink)
  • Physical problems (unexplained collapse, falls, seizures)
  • Social issues
  • Assessment of comorbidities that may increase the risks associated with alcohol excess
  • Review of medications that may increase risk of harm (for example bleeding, drowsiness, hypoglycaemia)

A number of questionnaires are available to aid detection of alcohol misuse. The most validated in older people is the Short Michigan Alcohol Screening Test for Older Adults (S-MAST-G, see appendix 2). The CAGE questionnaire also has good sensitivity and specificity for detecting dependence with score> 1(see appendix 3).

Supporting evidence may come from examination, e.g. bruising, and signs of chronic liver disease. Laboratory markers can provide corroboratory evidence; however, none are sensitive or specific enough to be used in isolation.

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2. Presentation of alcohol withdrawal syndrome

Alcohol withdrawal is dangerous in any age group, but older people potentially have greater risk of complications due to medical co-morbidity, baseline cognitive problems and sensitivity to treatment. The manifestations of withdrawal can vary greatly among individuals, but it may be more severe and last longer in this age group.

It is important to note that many acute medical conditions in elderly patients can resemble the signs and symptoms of alcohol withdrawal. A careful assessment of all possible contributing factors is essential.

The risk of withdrawal is not directly related to intake.

Elderly patients with a history of alcohol dependence or misuse are at risk of acute alcohol withdrawal when they are hospitalised. The following are characteristics of patients at highest risk:

  • History of long duration and large volumes of alcohol intake
  • Coexisting acute illness
  • Previous episodes of acute withdrawal or seizures
  • Previous history of detoxification
  • Intense craving for alcohol

The signs and symptoms of mild-moderate, and severe alcohol withdrawal are detailed below. Delirium tremens and or seizures represent severe alcohol withdrawal and this is a medical emergency. Older patients presenting with a delirium related to alcohol withdrawal must be managed as severe alcohol withdrawal, as detailed below.

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3. Treatment of alcohol withdrawal symptoms

See appendix 4 for summary flow chart.

Close physical monitoring, including vital signs (pulse, BP, oxygen saturations, respiratory rate) and mental assessment by medical and nursing staff is essential in elderly patients at risk of alcohol withdrawal. A baseline capillary glucose level should be checked.

a) Non- Pharmacological treatment:

  • A supportive, non-threatening, calm, and well-lit environment is essential to help minimise the psychological distress associated with withdrawal.
  • Hydration and nutritional status must be assessed. Intravenous fluids* may be required to correct electrolyte disturbances and insensible losses from increased autonomic activity.  All patients should undergo nutritional screening and appropriate nutritional support initiated. Nutritional supplementation must include replacing deficiencies of magnesium, calcium and potassium, to reduce the risk of re-feeding syndrome. Guidelines on oral nutritional support of adults are available via LTHT intranet, Leeds Health Pathways. *Vitamin replacement is discussed below (section 4), but high potency intravenous vitamins B and C must be administered if giving intravenous glucose due to the risk of precipitation of encephalopathy.
  • All patients identified with alcohol misuse should have an osteoporosis risk assessment.

b) Use of benzodiazepines:

Pharmacological sedation is not routinely required for patients in whom a severe withdrawal syndrome is unlikely to occur.

Benzodiazepines are given in alcohol withdrawal to prevent and treat seizures, not primarily as a measure to control agitation or other withdrawal symptoms.

By following the guidelines below an individualised approach can be developed for each patient with frequent reassessment being the key to safe use of benzodiazepines in this age group.

In hospital regular monitoring for alcohol withdrawal is recommended in at risk patients and it is best to assess the need and adjust the frequency of benzodiazepine intake to the severity of the withdrawal.

In older patients at risk of withdrawal the need for drug sedation needs to be clinically assessed regularly, specifically every 6 hours in the first 72 hours.

i) None or minimal symptoms of alcohol withdrawal:
None or minimal symptoms requires no pharmacological treatment.

ii) Moderate alcohol withdrawal:
If symptoms of moderate withdrawal are present (suggested by several marked autonomic features described below) pharmacological treatment may be necessary, particularly if complicated by an acute medical illness. Due to the favourable pharmacokinetic profile, short acting benzodiazepines such as lorazepam are preferred to chlordiazepoxide for elderly patients.

Alcohol withdrawal results from increased autonomic activity, symptoms begin 6 to 12 hours after the last drink. The symptoms and signs include:

  • tremor
  • anxiety
  • nausea,
  • sweating
  • hypervigilance
  • insomnia,
  • tachycardia and increased blood pressure.

           They may vary in severity, but usually peak 24-36 hours after last drink.

  • If benzodiazepines are required a small stat oral dose can be given, with a recommended initial dose of 0.5mg lorazepam PO.
  • 1 hour after benzodiazepines have been given (and after every subsequent dose) the patient must be re-evaluated to: reassess symptoms and signs of over sedation; this should include the measurement of oxygen saturations and respiratory rate.
  • If symptoms require, repeated doses can be given and the patient reassessed within 1 hour. In this situation lorazepam 0.5mg can be written on the “as required section” of the drug chart, with clear directions “DO NOT GIVE IF DROWSY”, and detailing the maximum dosage in 24 hours. The majority of patients will not need more than 0.5-1mg lorazepam/24 hours. Do not exceed 2mg lorazepam/24 hours.
  • If benzodiazepines are not required and the clinical situation remains stable, the patient should be re-evaluated after 6 hours

This symptom triggered therapy allows for medication adjustment according to symptoms and signs observed, leading to less overall benzodiazepine requirement than using fixed regular dosing regimes.

iii) Severe alcohol withdrawal (delirium tremens):
Severe alcohol withdrawal occurs in approximately 5% of patients undergoing alcohol withdrawal, but accounts for the highest morbidity and mortality.

Onset is usually 12 to 72 hours (but can be up to 10 days later) following cessation of alcohol and represents a medical emergency. If untreated death may result from respiratory and cardiovascular collapse or cardiac arrhythmias.

The clinical features include:

  • hallucinations (often visual, or tactile) clouding of consciousness
  • delusions, confusion and disorientation
  • severe tremor, fever, tachycardia >100/min
  • seizures

If symptoms and signs of severe alcohol withdrawal are present a small dose of lorazepam should be given immediately (0.5mg initially) to prevent seizures. The patient must be carefully monitored and re-assessed within1 hour, including the measurement of oxygen saturations. Repeated doses may be needed if symptoms require, oxygen saturations are maintained and the patient is not over sedated. With regular assessment of the effect, the dose of lorazepam, can be carefully titrated and tailored to each patient dependent upon severity of withdrawal. Patients with severe alcohol withdrawal after the initial titration are likely to require regular small doses of benzodiazepine, in this circumstance regular lorazepam 0.5mg can be prescribed bd on the drug chart, for a maximum 2-3 days with clear instructions “DO NOT GIVE IF DROWSY”. Additional PRN doses may still be required, do not exceed 2mg lorazepam in 24 hours. This strategy avoids over-treatment associated with excessive sedation and under-treatment associated with patient discomfort and higher incidence of complications such as seizures.

iv) Treatment of Seizures:
An “ABC” (Airway, Breathing and Circulation) assessment must be made, and senior help called on if required. In the acute phase intravenous lorazepam may be required to terminate seizure activity (1mg initially, titrated to a maximum of 4mg) The patient’s airway must be protected and they should be nursed in the recovery position, on a low mattress. If seizures are ongoing anaesthetic support should be obtained. If intravenous access is a problem lorazepam can be given intramuscularly (although absorption is slower and can be erratic when given by this route). Rectal diazepam (as solution not suppositories, maximum 250micrograms/kg) is an alternative if lorazepam is not immediately available.

There is little evidence to support the use of conventional anti-epileptics in the prophylaxis or treatment of alcohol withdrawal related seizures.

v) Severely confused/agitated patients unable to take oral treatment:
In this circumstance intramuscular (or intravenous if access available) lorazepam may be required (0.5mg initially) and repeated according to assessment of symptoms, as detailed above.

vi) Other situations:
Lorazepam is also the benzodiazepine of choice in patients with cirrhosis and/or liver failure, but cautious dosing is required.

The efficacy and safety of prescribing alcohol to prevent or treat withdrawal has not been established in the medical literature and should not be prescribed in this setting.

Further advice is available from your ward pharmacist and input may be required from old age psychiatry

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4. Wernicke’s encephalopathy (WE) or alcoholic encephalopathy

This is a reversible biochemical problem within the central nervous system, caused by overwhelming metabolic demands being made upon depleted B-vitamin reserves, in particular thiamine. It occurs in 12.5% of alcohol misusers, and usually develops over a number of days. If inappropriately managed it is the primary or a contributory cause of death in 17% of patients and results in permanent brain damage (Korsakoff’s psychosis) in 85% of survivors. Wernicke’s encephalopathy is classically described as a triad of signs, however all 3 only occur in 10% of patients:

  • acute confusion
  • ataxia
  • ophthalmoplegia

High Risk patients are:

Anyone with known/suspected history of alcohol misuse and any of the following:

  • Intercurrent illness
  • Delirium tremens
  • Alcohol related seizures
  • IV glucose administration or requirement for IV glucose*
  • Significant weight loss
  • Poor diet
  • Signs of malnutrition
  • Recent diarrhoea or vomiting
  • Drinking greater than 20 units/day
  • Peripheral neuropathy

*high potency intravenous vitamins B and C must be administered if giving intravenous glucose due to the risk of precipitation of encephalopathy

Wernicke’s encephalopathy is initially reversible with intravenous high potency vitamins B and C (e.g Pabrinex®), so treatment should be initiated immediately a diagnosis is suspected, or prophylaxis commenced in all patients with alcohol abuse or dependence.

Pabrinex® administration is associated with a small risk of anaphylaxis. It should be given by infusion over 30min in 50-100ml 0.9% sodium chloride or 5% glucose. Facilities for treating anaphylactic reactions should be available.

a. Prophylaxis in low risk patients:
Oral thiamine 100mg three times a day should be given during detoxification (i.e. during hospital stay)

All patients admitted with any intercurrent illness are defined as high risk (and therefore includes the majority of older patients with alcohol misuse admitted to hospital).

b. Prophylaxis in high risk patients:
Pabrinex® intravenous 1 ampoule PAIR daily for 3 to 5 days. The need for ongoing intravenous replacement should be reviewed after 72 hours.

It is only necessary to prescribe oral B vitamins when intravenous vitamins are discontinued.

c. Treatment of Wernicke’s encephalopathy:
Recommended if one or more signs of encephalopathy present

Pabrinex® intravenous 2 ampoule PAIRS three times a day for 2 days, followed by 1 PAIR once a day until improvement ceases.

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5. Management of hypoglycaemia

Hypoglycaemia can occur in the withdrawal period as both malnutrition and liver disease impair the storage of glycogen. Hypoglycaemia should be treated with an oral glucose load if possible (if patient conscious and able to swallow safely), e.g. Lucozade, Polycal or any sugary drink immediately available. If oral route not possible use 25-50mls of 50% glucose intravenously. Refer to the LTHT hypoglycaemia guideline (available on LTHT intranet). Parental vitamins must also be administered owing to the risk of precipitation of
encephalopathy.

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6. Discharge and Outpatient management

Age should not deter from helping the patient achieve long term successful alcohol treatment, and all older patients should be offered Forward Leeds support prior to discharge.

Oral vitamins should only be given at discharge if there are concerns over the patient’s diet or there is evidence of cognitive impairment. The TTO should state whether the GP is to continue oral vitamins or not. If required recommended doses are Thiamine 300mg daily (as split dose100mg three times a day) .Benzodiazepines should not be prescribed on discharge from hospital for alcohol withdrawal in older patients.

In general elderly patients require inpatient management of alcohol withdrawal, because of the increased risk of complications. However, there maybe a few instances where patients with mild alcohol withdrawal may be suitable for outpatient treatment, if other acute medical problems have been diagnosed and treated effectively. This decision must be made by a senior doctor and follow the guidelines detailed in the LTHT alcohol withdrawal policy.

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Appendix 1 - Rockwood clinical frailty score

The Clinical Frailty Scale (CFS) is validated for people aged 65 yrs or more and MUST BE scored as the person was before their current illness- usually estimated as “about two weeks ago, did you need help with…”'

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Appendix 2 - Shorter Michigan alcohol Screening Test for Older People

If you are concerned that one of your patients may be drinking too much, the short screening questionnaire below will help you determine whether or not this is the case.

In the past year:

  1. When talking with others, do you ever underestimate how much you actually drink?
  2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you do not feel hungry?
  3. Does having a few drinks help decrease your shakiness or tremors?
  4. Does alcohol sometimes make it hard for you to remember parts of the day or night?
  5. Do you usually take a drink to relax or calm your nerves?
  6. Do you drink to take your mind off your problems?
  7. Have you ever increased your drinking after experiencing a loss in your life?
  8. Has a doctor or a nurse ever said that they worried about your drinking?
  9. Have you ever made rules to manage your drinking?
  10. When you feel lonely, does having a drink help?

Scoring:
A total of two or more “yes” responses indicate a probable alcohol problem.

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Appendix 3 - CAGE Questionnaire

  • Have you ever felt the need  to Cut down on your drinking?
  • Have you ever felt Annoyed by criticism of your drinking?
  • Have you ever felt Guilty about your drinking?
  • Have you ever felt the need to drink as morning Eye -opener?

With score > 1 having good sensitivity and specificity for alcohol dependence.

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Appendix 4 - Clinical algorithm for the pharmacological management of alcohol withdrawal in older people

LTHT Pharmacological management of alcohol withdrawal in older people

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Links

The management of alcohol withdrawal in adults
Guidelines for oral nutritional support of adults

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Provenance

Record: 1948
Objective:

This guideline is intended to provide guidance to LTHT practitioners in managing alcohol withdrawal in older people and to provide consistency in management across the trust.

It covers the following areas:

  1. Detection of misuse
  2. Presentation of alcohol withdrawal syndrome
  3. Treatment of alcohol withdrawal symptoms
  4. Wernicke’s encephalopathy or alcoholic encephalopathy
  5. Management of hypoglycaemia
  6. Discharge and outpatient management
  • Recognition of alcohol misuse and dependence in older hospital patients
  • Prompt initiation of appropriate medical and nursing management
  • Develop an individualised approach to each patient with frequent reassessment of signs and symptoms
  • Minimise morbidity and mortality and maximise patient comfort
Clinical condition:

Alcohol Withdrawal in Older People

Target patient group:

Any patient aged ≥80 years, admitted to hospital where clinical staff have identified or suspect excess alcohol intake.

For patients <80 years, please follow the current standard LTHT policy on the management of alcohol withdrawal symptoms (LTHT intranet, Leeds Health Pathways)

It may however still be appropriate in patients <80 years with moderate to severe frailty to consider using this guideline for management of alcohol withdrawal in older people (See clinical frailty score Appendix 1)

Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. O Connell H; Alcohol use disorders in elderly people–redefining an age old problem in old age. BMJ 2003; 327
  2. Dhalla S,Kopec J: The CAGE Questionnaire for alcohol misuse:A review of reliability and validity study. Clin Invest Med 2007; 30 (1): 33-41.
  3. V Rawlani, S Vekaria: The CAGE, MAST, and sMAST are the most widely used, with
    the MAST being more sensitive than CAGE, except in elderly patients, where CAGE may be   more  effective. Overall the CAGE, MAST, and sMAST perform comparably . The Internet Journal of Internal Medicine. 2008 Volume 8 Number 1.
  4. Kraemer KL, Conigliaro J, Saitz R. Managing alcohol withdrawal in the elderly. Drugs and Aging 1999: 14(6);409-425.
  5. Pepper MP. Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease. Pharmacotherapy 1996:16(1); 49-53
  6. Letizia M, Reinbolz M. Identifying and managing acute alcohol withdrawal in the elderly. Geriatric Nursing 2005: 26(3); 176-183.
  7. Deblinger L, Adams W, Atkinson R, Ganz SB, O’Connor PG. Topics in geriatrics: alcohol problems in the elderly. Patient Care for the Nurse Practitioner 2000: 3(10);68-79.
  8. Alcohol withdrawal syndrome: how to predict, prevent, diagnose and treat it. Prescrire International 2007:16(87);24-31.
  9. McKeon A, Frye M, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry 2008;79:854-862.
  10. Fitzgerald FT. As the occasion arises: PRN sedative orders in alcohol withdrawal treatment. Arch Inter Med 2002;162:1093-4.
  11. Rey E, Treluyer JM, Pons G. Pharmacokinetics of benzodiazepine therapy for acute seizures: focus on delivery routes. Clinical Pharmacokinetics 1999: 36(6);409-24.
  12. The World Health Organisation. Screening and brief intervention for alcohol problems. www.who.int/entity/substance_abuse/activities/sbi/en/index.html
  13. A report of a Working Party of the Royal College of physicians.Alcohol - can the NHS afford it? Recommendations for a coherent alcohol strategy for hospitals. February 2001.
  14. Nursing Council on Alcohol. The detection of alcohol misusers attending hospital and the management of alcohol withdrawal syndrome and Wernicke’s encephalopathy. An evidence based protocol.
  15. Cook C et al. B vitamin deficiency and Neuropsychiatric syndromes in alcohol misuse. Alcohol and Alcoholism; 33:317-336
  16. Rix KJB. Alcohol withdrawal States
  17. Mehta DK (Executive editor). British National Formulary. No. 52 September 2006. The British Medical Association and the Royal Pharmaceutical Society of Great Britain.
  18. Working Group on Mental Illness. The management of alcohol withdrawal and delirium tremens; a good practice statement. June 2004
  19. Hall W & Zador D. The alcohol withdrawal syndrome. Lancet 1997;349:1897-1900.
  20. Taylor D, Paton C, Kerwin R. The South London & Maudsley NHS Trust Prescribing Guidelines 7th edition. (2003). Martin Dunitz Ltd, London.
  21. Thomson A. Mechanisms of vitamin deficiency in chronic alcohol misuers and the development of the Wericke-Korsakoff Syndrome. Alcohol & Alcoholism 2000 : 35, suppl. 1 ;2-7.
  22. Hutchinson TA, Shahn DR & Anderson ML (eds) Drugdex System Internet version Micromedex Inc. Greenwood Village, Colorado. Drug Therapy of ethanol withdrawal.
  23. Electronic Medicines Compendium. Datapharm Communication Ltd. http://emc.medicines.org.uk
  24. Sullivan JT et al. ‘Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWAAr)’. British Journal of Addiction 1989:84;1353-1357.
  25. Rubino F. Neurologic Complications of Alcoholism. The Interface of Psychiatry and Neurology 1992:15:2;359-371.
  26. Cook C. Prevention and Treatment of Wernicke-Korsakoff Syndrome. Alcohol and Alcoholism. 2000:35;19-20.
  27. Raistrick D. Management of alcohol detoxification. Advances in psychiatric treatment. 2000:6;348-355.
  28. Holbrook A et al. Diagnosis and management of acute alcoholwithdrawal. CMAJ 1999;160 (5).
  29. BAP Guidelines. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and co morbidity; recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2004:18(3).

Evidence levels: C

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

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