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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

Definitions II Alcohol withdrawal syndrome (AWS) ≥2 Hallucinations and illusions Agitation Anxiety Seizures ↑ HR and BP Tremor Insomnia Nausea/vomiting Copyright Alcohol Medical Scholars Program

Severe AWS: Risk Factors Amount/ time # of prior episodes Use of other substances ↑ BAC Severe symptoms on presentation Medical/surgical comorbidity ↑Age Copyright Alcohol Medical Scholars Program

Copyright Alcohol Medical Scholars Program Consequences of AWS Complicated hospital stay Longer hospitalization ↑ risk of ICU ↑ mortality Copyright Alcohol Medical Scholars Program

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

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

Neurobiology of Alcohol ACUTE CHRONIC ↑ GABA ↓ glutamate ↑ NE ↓ GABA ↑ NMDA ↓ NE Copyright Alcohol Medical Scholars Program

Neurobiology of Alcohol WITHDRAWAL ↑excitatation by: ↓ GABA, ↑ glutamate  tremor, seizures  norepinephrine sensitivity  autonomic instability Copyright Alcohol Medical Scholars Program

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

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 Copyright Alcohol Medical Scholars Program

Alcohol withdrawal: Phase II Time Abstinent: 7-48 hours Signs and symptoms: Distractibility Autonomic instability (↑↓heart rate, ↑↓ blood pressure) Grand mal seizures Copyright Alcohol Medical Scholars Program

Alcohol withdrawal: Phase III Time Abstinent: 72-96 hours Delirium Tremens: Confusion/disorientation Severe autonomic instability Intense tremor Hallucinations Agitation Copyright Alcohol Medical Scholars Program

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

Evaluation: Interview Duration of use Quantity/frequency Time since last drink Past withdrawals Medical/psychiatric problems Social/domestic/emotional/occupational problems Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

Evaluation: Physical Exam Withdrawal symptoms Co-occurring medical problems Cardiac disease (arrhythmia, CHF) GI bleed Cancer Liver/ pancreas disease Nervous system Copyright Alcohol Medical Scholars Program

Evaluation: Laboratory Tests CBC/MCV >100 AST > 40, ALT > 40; ratio >2:1 GGT>35 CDT > 20u Electrolytes BAC Copyright Alcohol Medical Scholars Program

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

Treatment: General Care Multivitamins (MVI): 1 tablet daily Thiamine: 100 mg daily Folic acid: 1 mg daily Fluid repletion if dehydrated Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 10-20 mg q6h Chlordiazepoxide 25-50 mg q6h Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

Treatment: Supportive Non-pharmacological treatment Reassurance Reality-orientation techniques (time, place, situation) Rest/sleep Adequate nutrition Copyright Alcohol Medical Scholars Program

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

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

AWS in Surgical Patients: Assessment II Differential diagnosis/common surgical causes of agitation: Bleeding Metabolic/electrolyte abnormalities Infection Pain Copyright Alcohol Medical Scholars Program

AWS in Surgical Patients: Treatment Supportive care Pain management Pulmonary toileting Eliminate catheters Early mobility Pharmacological treatment BZD Symptom-triggered Dosages generally larger Copyright Alcohol Medical Scholars Program

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

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

AWS in Elderly Patients: Assessment II Differential diagnosis: Other substances Delirium of other causes Psychiatric conditions Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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 Copyright Alcohol Medical Scholars Program

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