Title: Challenges in Managing Alcohol Withdrawal Syndrome in Special Populations:

Focus on the Surgical and Elderly Patients.

Joanna Piechniczek-Buczek, MD

Department of Psychiatry Boston University School of Medicine

Alcohol Medical Scholars Program (Slide1)

I.                    INTRODUCTION (Slide 2)

A.     Alcohol misuse is common in the  general  population

1.      80 % lifetime alcohol use[1]

2.      15 % lifetime alcohol abuse

3.      10 % lifetime  alcohol dependence[2]

B.     Alcohol  Use Disorders (AUD) of abuse or dependence  common among

1.      Medical  inpatients  ~ 20%[3]

2.      Surgical Patients:  ~ 43% otorhinolaryngological patients;  50% gastrointestinal tract cancer patients[4]

3.      Trauma patients ~ 40% -50% intoxicated; 94% of those with intoxication have substance abuse or dependence  [5]

4.      Elderly ~ 17%[6]

C.     Alcohol  abuse, dependence, withdrawal:  DSM IV TR definitions [7] (Slide 3)

1.      Abuse: repeated alcohol–related problems in same 12  months with 1+ :

a.       Inability to fulfill role obligations

b.      Use in physically hazardous situations

c.       Legal problems

d.      Social  or interpersonal difficulties

e.       Never dependent

2.      Dependence: repeated alcohol-related problems over 12 months with 3 +:

a.        Tolerance

b.       Withdrawal

c.       Use heavier or longer than intended

d.       Desire and inability to cut down

e.       Activities aborted

f.        Long time spent in alcohol-related activities

g.       On-going use despite consequences

3.         Alcohol Withdrawal Syndrome (AWS) 2 +: (Slide 4)

a.   Autonomic hyperactivity

b.     Tremor

c.      Insomnia

d.     Nausea or vomiting

e.      Hallucinations or illusions

f.       Agitation

g.      Anxiety

h.      Grand mal seizures

D.     Risk factors for  severe alcohol withdrawal:  (Slide 5)

1.      Quantity and frequency of intake (large amounts over long period of time) [8]

2.      Number and severity of prior episodes

3.      Use of other substances[9]

4.      Medical/surgical co-morbidity[10]

5.      Elevated Blood Alcohol Concentration (BAC)[11]

6.      High severity of withdrawal upon presentation[12]

7.      Advanced age[13]

E.       Development of AWS associated with: (Slide 6)

1.      More complicated hospital stay

2.      Longer stay

3.      ↑ need of intensive care[14]

4.      ↑ mortality

F.      This lecture will cover: (Slide 7)

1.      Neurobiology of Alcohol  Withdrawal Syndrome (AWS)

2.      Signs and symptoms of AWS

3.      Evaluation of  patients

4.      Treatment- general principles

5.    Special  considerations in:

a.       Surgical/ trauma patients

l

b.      Geriatric patients

(Slide 8)

II.     NEUROBIOLOGY OF ALCOHOL

A.   Acute effects of alcohol: (Slide 9)

1.       ­ activity at GABA A receptor [15]

2.        ¯ glutamate transmission  at NMDA receptor

3.       ­dopamine

4.       ­ norepinephrine synthesis and release

5.       ↑ effect of serotonin at 5HT3 receptor

6.       ­ beta endorphins levels / µ binding

B.     Chronic  effects of alcohol:

1.      Down- regulation of GABA receptors [16]

2.      Up-regulation of  NMDA receptors

3.      Down-regulation of dopamine receptors

4.      Serotonin depletion

5.      ¯ postsynaptic  receptor norepinephrine sensitivity

6.      ↓ in β-endorphine levels / binding

C.     Withdrawal   (Slide 10)

1.      ↑excitatory effect by: ↓ GABA, ↑ glutamateà tremor, seizures

2.      ­ norepinephrine sensitivity à  autonomic instability

(Slide 11)

III.       ALCOHOL WITHDRAWAL SYMPTOMS

A.               Phase I[17](Slide 12)

1.     Time abstinent or cut down: 6-24 hrs

2.      Signs and symptoms: 

a.       Tremor:  hands most prominent

b.      ↑ autonomic activity:

                                                                                                               i.     ↑ blood pressure

                                                                                                             ii.      ↑ reflexes

                                                                                                            iii.      Fever

c.       Insomnia

d.      Nausea/vomiting

e.       Sweating

f.        Anxiety

B.            Phase II (Slide 13)

1.      Time abstinent: 7-48 hrs

2.      Signs and symptoms:

a.        Distractibility

b.      Autonomic instability (↑↓heart rate, ↑↓ blood pressure)

c.       Grand mal seizures

3.      5-10% lifetime risk of seizures

C.           Phase III (Slide 14)

1.      Time abstinent: 72-96 hrs

2.      Only in < 5%

3.      Symptoms: (Delirium+ severe autonomic instability + tremor = delirium tremens or DT)

a.          Confusion/disorientation

b.         Severe autonomic instability

c.          Auditory/tactile hallucinations

d.         Agitation

4.      Mortality rate ~ 1 %[18]

(Slide 15)

IV.      ALCOHOL WITHDRAWAL ASSESSMENT

A.       History/Interview: (Slide 16)

1.      Duration of use

Chronic use (weeks, months) à↑ risk of withdrawal

2.      Quantity, frequency and drinking pattern

a.                   > 5-6 drinks/ day

b.                  Daily or almost daily use

c.                   Age of first use, periods of heaviest use,  periods of abstinence

3.      Time since last drink (~6+ hours)

4.      Severity of previous withdrawals (e.g. seizures  or DTs)

5.      Concurrent medical/psychiatric problems

6.      Social /domestic/emotional/occupational problems

B.       History/Screening tools: (Slide 17)

1.      Alcohol Use Disorders Identification Test (AUDIT)

a.   10 items scale

b.     Can be self administered

c.       Assesses: frequency, quantity, lack of control, guilt, blackouts etc.

d.      Sensitivity: 90%;  Specificity: 85% at score of > 8

2.      CAGE  Cut down,  Annoyed,  Guilty, Eye opener

a.          Very brief

b.         2 or > + responsesà high likelihood of alcoholism

c.          Sensitivity 85%; Specificity 90%

d.         Not gender sensitive; does not identify recent or episodic use

3.      Michigan Alcohol Screening Test (MAST)

a.          Structured interview

b.         25 questions

c.           Positive answers to 4 + questions suggest alcohol “problem”

C.       Physical exam: (Slide 18)

1.      Focused on identifying withdrawal symptoms (e.g. sweating, tremors, etc.)

2.      Chronic alcohol exposure stigmata:

a. Spider angiomata-superficial spider-like cluster of capillaries,

b.   Palmar erythema- reddening of the palms

c. . Hepatosplenomegaly-↑ liver and spleen

3.      Assessment of  possible complicating medical conditions:

a.  Cardiac arrhythmias (irregular heart rate)

b. Congestive heart failure (secondary to hypertension or cardiomyopathy)

c.  Gastrointestinal bleeding (blood in vomit or stool),

d.   Cancer (esophagus, stomach, head and neck, lungs)

e.  Liver disease (fatty liver, hepatitis, cirrhosis)

f.   Pancreatitis[19] (abdominal pain, ↑ pancreas enzymes  e.g. amylase)

g.  Nervous system impairment:

                                                                                    i.         Central  (confusion, cerebellar damage)

                                                                                  ii.         Peripheral (neuropathy e.g. “pins+ needles” in hands/feet)

D.               Laboratory investigations:[20] (Slide 19)

1.      Blood count:↑ red blood cells size; mean corpuscular volume (MCV) > 100

2.       Liver functions tests (LFTs)

a.       ↑ Aspartate aminotransferase (AST); > 40 u/l

b.       ↑ Alanine aminotransferase (ALT); > 40 u/l

c.        AST/ALT  ratio > 2 e.g. à suggestive of alcoholic liver disease;

3.      ↑ Carbohydrate deficient transferrin (CDT) : high sensitivity and specificity/ good indicator of early relapse: 20U or 2.6 %

4.       ↑ Gamma-glutamyl transferase (GGT):  levels↑ after 70 drinks/week for several weeks; > 35 u/l

5.      Urine/serum toxicology screen: to exclude other drug use

6.      Electrolytes: ↓ Na, ↓Mg à ↑ risk of seizures

7.      Blood alcohol concentration (BAC):

BAC ~ 150 w/o intoxication or ~ 300 w/o somnolenceà  evidence of tolerance à ↑ risk of withdrawal

(Slide 20)

 V. ALCOHOL WITHDRAWAL TREATMENT[21]

A.     General care: (Slide 21)

1.      Multivitamins (MVI): 1 tablet daily

2.      Thiamine: 100 mg daily

3.      Folic acid: 1 mg daily

4.      Fluid repletion if  dehydration evident

B.     Medication regimen- benzodiazepines (BZDs) [22](Slide 22)

1.      First line treatment

2.      BZD are effective to decrease:

a.       Severity of withdrawal

b.      Incidence of delirium

c.       Incidence of seizures

3.      Are 2 types:

a.       Longer acting ( ½ life  ~ 30 hours)

       E.g. diazepam (Valium)

b.      Shorter acting ( ½ life ~15 hours)

      e.g.  lorazepam (Ativan)

4.      Longer acting better at preventing seizures, but  ­ sedation

5.      Two main strategies:

a.       “ Fixed schedule” (Slide 23)

                                                                                       i.      Description:

ü      Specific doses administered  at specific intervals

ü       Additional doses used as needed  based on the severity of symptoms

                                                                                     ii.      Examples:

ü       Lorazepam 2 mg  every 4 hours; 

ü      Diazepam 10-20 mg every 6 hours;

ü      Chlordiazepoxide (Librium) 25-50 mg  every 6 hours

                                                                                    iii.      Tapered gradually over several days

                                                                                   iv.      Problems: over / under- medication ( too difficult to control symptoms)

b.   “Symptom–triggered” (Slide 24)

                                                                                 i.            Description:

ü    Medication given when CIWA-AR >8

ü      Clinical Institute Withdrawal Assessment, Revised (CIWA- Ar) - severity scale 0-7 on the following items: (Slide 25)

·        Nausea, vomiting

·        Tremor

·        Diaphoresis (sweating)

·        Anxiety

·        Agitation

·        Tactile hallucinations (touch)

·        Auditory hallucinations

·        Visual hallucinations

·        Headache

·        Orientation and clouding of sensorium (confusion)

                                                                                     ii.      Examples:

ü      Lorazepam 2 mg q 1 hour  for  CIWA 8-13

ü      Lorazepam  3 mg q 1 hour for CIWA 14-20

ü      Lorazepam 4 mg q 1 hour for CIWA >20

                  iii.   Problems: ­ cost/ staff time

 

C.     Non-pharmacological treatments: (Slide 26)

1.      Reassurance

2.      Reality-orientation techniques (time, place, situation)

3.      Rest/sleep

4.      Adequate nutrition.

                                                            (Slide 27)

VI. ALCOHOL WITHDRAWAL IN SURGICAL AND TRAUMA PATIENTS

A.      Epidemiology (Slide 28)

1.      50-60% prevalence of alcohol abuse/dependence in trauma patients

2.      16% incident of AWS post-surgery vs. 8% in general population[23]

3.      Pre-operative assessment/prophylaxis prevents post-operative AWS complications in 75% of patients

4.      Highest risk of DTs: in 40+ year olds and  s/p fall or burn

B.     Risks

1.      ­ operative and post operative morbidity and mortality[24]

2.      Postoperative morbidity 2-3 X ↑ if  21+ drinks/week[25]

3.      50%  longer hospital stay

4.      Poorer 3 month outcomes: infections, bleeding, cardiopulmonary

C.     Challenges (Slide 29)

1.      During surgery:

a.       Alcohol can ­or ¯sensitivity to anesthesia[26]

b.      Alcohol ↓ coagulation

c.       ↑ risk of  hypoxia and poor BP control

2.      After surgery:

a.       Alcohol ¯ immune functions; surgery ­ immunosuppressionà ­ risk of inflammation/ infection

b.      Alcohol ↑ metabolic acidosis and ↑ surgery stress response[27]

c.       DTs often  confused with[28]

                                                                                 i.            Sepsis

                                                                               ii.            ↓ Circulation to brain

                                                                              iii.            Worsening of closed head injury

d.      Autonomic instability  ( e.g. ↑ or↓ blood pressure) due to alcohol withdrawal à incorrectly attributed  to traumatic injury

e.       Agitation due to withdrawal

                                                                                 i.  Challenges nursing care

                                                                               ii.  Risks displacement of monitors and dressings

f.        Hallucinations àdifficult to assess in intubated patients

D.      Assessment and treatment

1.      History  (Slide 30)

a.    Scheduled surgeries:[29]

                                                                              i.     Good pre-operative assessment to screen for AUDs

                                                                            ii.     Advise abstinence if not at risk of AWS  

                                                                           iii.     Pre-surgical detoxification should be considered if needed

b.   Trauma and emergency surgeries

                                                                              i.      History taking difficult

                                                                            ii.      Collateral informants (family, friends, witnesses) important

                                                                           iii.      Physical exam/ laboratory findings important

2.      Differential diagnosis/common surgical causes of agitation[30]: (Slide 31)

a.          Bleeding,

b.         Metabolic/electrolyte abnormalities

c.          Infection

d.         Pain

3.      Supportive care (Slide 32)

a.          Pain management

b.         Pulmonary toileting

c.          Eliminate unnecessary catheters

d.         Early mobility

4.      Pharmacological treatment[31]

a.       BZDs

b.      Symptom-triggered approach most effective

c.       Dosages generally larger

 

(Slide 33)

iii.                        A

VII.   ALCOHOL WITHDRAWAL IN THE ELDERLY:

A.     Epidemiology    (Slide 34)

1.      11% of elderly in acute medical settings have alcohol abuse or dependence

2.      20% in psychiatric settings

3.      14%  in emergency departments

B.     Risks[32]

1.      Even moderate drinking in the elderly : ↑ disease burden and ↑ risk of complicated withdrawal

2.      Aging affects alcohol levels:[33]

a.                 ↓ body water à↓ volume of distributionà↑ alcohol concentration

b.               ↓ gastric alcohol dehydrogenase à↑ alcohol concentration

3.      Alcohol ↑ risk of  falls leading to  hip fractures/ subdural  hematomas ( bleed under skull) 

4.      Alcohol interacts with many common medications

 

C.     Challenges (Slide 35)

1.      Age aloneà predictor of ↑ withdrawal severity[34]

2.       Early onset drinkersà long useà ↑ probability of prior withdrawalsà ↑ severity of AWS [35]

3.      Functional reserve and tolerance of physiological stressors ↓ with age[36]

4.      ↑ risk  of adverse effects from use of BZDs [37]

a.       Cognitive impairment[38]

b.      Daytime sedation

c.       Falls

D.      Assessment and treatment (Slide 36)

1.       History:

a.       Difficult because:

                                                                                 i.             Patient  ashamed to admit

                                                                               ii.             Family reluctant to share

                                                                              iii.             Physicians not likely to suspect[39]

b.      Clues that should ↑ suspicion of AUD in the elderly:

                                                                              i.               Frequent falls

                                                                            ii.               Bruises

                                                                           iii.               Many ED visits

                                                                          iv.               ↑ blood pressure

                                                                            v.               Depressed mood and suicidal thoughts

                                                                          vi.               Insomnia

2.  Differential diagnosis[40] (Slide 37)

a.       Withdrawal from other substances (e.g.  BZDs, Barbiturates)

b.      Delirium of other causes ( see DTs differential diagnosis described above)

c.       Psychiatric  conditions (anxiety, dementia, psychosis)

3. Supportive treatment (Slide 38)

a.       Safe/ well lit environment

b.      Gentle/empathic/ non-judgmental approach

c.       Hearing aids/glasses as individually indicated

d.      Extremes of sensory input- to be avoided

e.       Sleep/rest/nutrition

4. Pharmacological interventions (Slide 39)

a.     Shorter acting agents (lorazepam, oxazepam)  preferred because:

a.     No active metabolites

b.     ↓ rate of side effects [41]

b.     Symptom-triggered  approach preferred

c.     For some patients (with history of sz and DTs) àfixed schedule preferred Medication  held for sedation

d.     Medication dosages typically lower.

 

(Slide 40)

 

 

 

 

 

 

 

 

 

 

 

 

 

 



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