Internal Medicine Internal Medicine Residency Noon LectureResidency Noon Lecture
October 30, 2007October 30, 2007
Rebecca J. Beyth, MD, Rebecca J. Beyth, MD, MScMScAssociate ProfessorAssociate ProfessorGRECC, NF/SGVHSGRECC, NF/SGVHS
UF COM, Dept of Aging & GeriatricsUF COM, Dept of Aging & Geriatrics
Case Case
82 year old man with history of DJD, 82 year old man with history of DJD, and HTN admitted for right total hip and HTN admitted for right total hip replacement. replacement. Routine postRoutine post--op medications for pain, op medications for pain, and DVT prophylaxisand DVT prophylaxisOne day after surgery he begins to One day after surgery he begins to hallucinatehallucinateWhat do we do?What do we do?
Case Case
Usually drinks 3Usually drinks 3-- 4 mixed drinks daily4 mixed drinks daily
BackgroundBackground
Alcohol abuse affects 9% populationAlcohol abuse affects 9% population1111--15 million Americans report 15 million Americans report ““heavy heavy alcohol intakealcohol intake””Costs of associated medical Costs of associated medical complications $100 billion/yearcomplications $100 billion/year
BackgroundBackground
National Institute on Alcohol Abuse National Institute on Alcohol Abuse and Alcoholism (NIAAA):and Alcoholism (NIAAA):–– Heavy use (at risk for Heavy use (at risk for withdrawlwithdrawl))
Women: > 4 drinks/dayWomen: > 4 drinks/dayMen: >5 drinks/dayMen: >5 drinks/day
–– At risk for alcoholismAt risk for alcoholismWomen: > 1 drink/day Women: > 1 drink/day Men: > 2 drinks/dayMen: > 2 drinks/day
BackgroundBackground
Standard DrinkStandard Drink–– 12 oz. beer12 oz. beer–– 5 oz. wine5 oz. wine–– 1.5 oz. liquor1.5 oz. liquor
PrevalencePrevalence
2020--25% of hospitalized general 25% of hospitalized general medicine medicine 2525--47% of trauma patients47% of trauma patientsMore than half of those > 65 donMore than half of those > 65 don’’t t drink at alldrink at all66--9% are 9% are ““at riskat risk”” drinkersdrinkers
~17% of those > 60 years misuse ~17% of those > 60 years misuse alcohol or prescription drugsalcohol or prescription drugs
PrevalencePrevalence
1/3 men, 20% women in retirement 1/3 men, 20% women in retirement communities report > 3 drinks/daycommunities report > 3 drinks/day33--25% are 25% are ““heavy useheavy use””15% men/12% women are 15% men/12% women are ““alcohol alcohol abuseabuse””-- drinking in excess of drinking in excess of recommended limits/guidelines, rapid recommended limits/guidelines, rapid progression to alcoholprogression to alcohol--related related illness/complicationsillness/complications
BackgroundBackground
Incidence of alcohol withdrawal Incidence of alcohol withdrawal syndromesyndrome–– ~ 2 million/year~ 2 million/year–– ~ 500,000/year require pharmacologic ~ 500,000/year require pharmacologic txtx
BackgroundBackground
Alcohol use disorders in elderlyAlcohol use disorders in elderly–– 2/3 early onset (< 60 years)2/3 early onset (< 60 years)
Greater financial, legal and social problemsGreater financial, legal and social problemsHeaver drinkersHeaver drinkers
–– 1/3 late onset (> 60 years) 1/3 late onset (> 60 years) Aging social drinkerAging social drinker
–– More intoxicated with same dose More intoxicated with same dose –– Increase in drinking after Increase in drinking after ““lossloss””
Cognitive disorderCognitive disorder
BackgroundBackground
Increased blood alcohol concentration in Increased blood alcohol concentration in elderlyelderlyDecreased lean body massDecreased lean body massDecreased total body waterDecreased total body waterDecreased gastric alcohol Decreased gastric alcohol dehydrogenasedehydrogenase
Medical Complications of Medical Complications of Alcohol Use Disorder Alcohol Use Disorder
CirrhosisCirrhosis–– 1 year death rate: 60% for those > age 60 1 year death rate: 60% for those > age 60
compared to 7% in younger patientscompared to 7% in younger patients
Cardiovascular EffectsCardiovascular Effects–– Women: 4Women: 4--fold cardiac risk CAD fold cardiac risk CAD –– Increased risk of AF (holiday heart)Increased risk of AF (holiday heart)–– Increased stroke riskIncreased stroke risk
CancerCancer–– Increased incidence of liver, esophageal, Increased incidence of liver, esophageal,
head/neck and colon cancershead/neck and colon cancers
Medical Complications of Medical Complications of Alcohol Use Disorder Alcohol Use Disorder
HemeHeme–– Thrombocytopenia, bleeding, Thrombocytopenia, bleeding,
macrocytosismacrocytosis
NeuroNeuro PsychPsych–– Increased dementia, Increased dementia, WernickeWernicke’’ss
encephalopathy, encephalopathy, KorsakoffKorsakoff’’ss psychosis psychosis –– Mood disorders, Mood disorders, pseudodementiapseudodementia–– suicidesuicide
DSMDSM--IV Criteria for IV Criteria for Substance DependenceSubstance DependenceMaladaptive pattern and 1 of the following in Maladaptive pattern and 1 of the following in
12 months:12 months:Failure to fulfill obligations at work, school, Failure to fulfill obligations at work, school, or homeor homeRecurrent use when physically hazardousRecurrent use when physically hazardousRecurrent related legal problemsRecurrent related legal problemsContinued use despite recurrent social or Continued use despite recurrent social or legal problemslegal problems
DSMDSM--IV Criteria for IV Criteria for Substance DependenceSubstance DependenceMaladaptive pattern and 3 or more of the following in Maladaptive pattern and 3 or more of the following in
12 months:12 months:Tolerance (often reduced in elderly)Tolerance (often reduced in elderly)Withdrawal (often delayed, with mental status Withdrawal (often delayed, with mental status changes in elderly)changes in elderly)Greater amount of use or longer duration than Greater amount of use or longer duration than expectedexpectedUnsuccessful efforts to reduce useUnsuccessful efforts to reduce useImportant activities reduced or given upImportant activities reduced or given upContinued use despite its aggravation or physical or Continued use despite its aggravation or physical or psychological problemspsychological problems
BiomarkersBiomarkers
Elevated GammaElevated Gamma--glutamylglutamyl transferasetransferase(GGT): Sensitivity of 70(GGT): Sensitivity of 70--80% if 680% if 6--8 8 drinks/daydrinks/dayMean corpuscular volume (MCV) > 90 Mean corpuscular volume (MCV) > 90 consistent with alcohol dependenceconsistent with alcohol dependenceCarbohydrate deficient Carbohydrate deficient transferrintransferrin (CDT): > (CDT): > 14 units/L consistent with social drinker; > 14 units/L consistent with social drinker; > 2020--30 units/liter consistent with alcohol 30 units/liter consistent with alcohol dependence dependence
QuestionnairesQuestionnaires
MASTMAST--G is specific to geriatric alcohol G is specific to geriatric alcohol use disordersuse disordersAUDIT most comprehensiveAUDIT most comprehensiveCAGE and TWEAK are quick, limited CAGE and TWEAK are quick, limited sensitivtysensitivty and sensitivityand sensitivity
CAGECAGE
Have you ever felt the need to Have you ever felt the need to CCut ut down on drinking?down on drinking?Have your ever felt Have your ever felt AAnnoyed by nnoyed by criticism of your drinking?criticism of your drinking?Have you ever felt Have you ever felt GGuilty about your uilty about your drinking?drinking?Have you ever taken a morning Have you ever taken a morning EEye ye opener?opener?
CAGECAGE
Overall sensitivity of 85%, specificity Overall sensitivity of 85%, specificity of 89%; with three positives it is of 89%; with three positives it is 100% sensitive100% sensitiveDoes not distinguish between past and Does not distinguish between past and present alcohol use, not helpful in present alcohol use, not helpful in acute acute withdrawlwithdrawl
QuestionnairesQuestionnaires
Clinical Institute Withdrawal Clinical Institute Withdrawal Assessment for Alcohol, revised Assessment for Alcohol, revised (CIWA(CIWA--r)r)–– Reliable, validated toolReliable, validated tool–– Brief, easy to useBrief, easy to use–– Score correlates with severity of Score correlates with severity of
withdrawalwithdrawal–– Not diagnostic, used in conjunction with Not diagnostic, used in conjunction with
clinical contextclinical context
CIWACIWA--rr
Mild, score 8Mild, score 8--1515Moderate, score 16Moderate, score 16--2525Severe, score > 25Severe, score > 25Score < 10 can observe patientScore < 10 can observe patientScore > 10 should admitScore > 10 should admitScore > 15 will need treatmentScore > 15 will need treatment
Alcohol Withdrawal Alcohol Withdrawal SyndromeSyndrome
3 distinct phases3 distinct phases–– Autonomic instabilityAutonomic instability–– Alcohol withdrawal seizuresAlcohol withdrawal seizures–– Delirium TremensDelirium Tremens
Continuous or sporadic presentationContinuous or sporadic presentationInpatient or outpatientInpatient or outpatient
Autonomic Instability Autonomic Instability
Starts soon, last 48Starts soon, last 48--72 hours72 hoursClinically:Clinically:–– Tremulousness, anorexia, tachycardiaTremulousness, anorexia, tachycardia–– Irritability, nausea, hypertension, hallucinationsIrritability, nausea, hypertension, hallucinations
Remember:Remember:–– Quiet, well lit roomQuiet, well lit room–– Thiamine, MVI with Thiamine, MVI with folatefolate–– Diet, social support (family/friends)Diet, social support (family/friends)
Alcohol Withdrawal Alcohol Withdrawal SeizuresSeizures
1212--72 hours after stop/ cut back72 hours after stop/ cut backGeneralized tonicGeneralized tonic--clonicclonic seizures, last seizures, last minutesminutesExclude other causes of seizuresExclude other causes of seizuresTreat underlying causeTreat underlying causeKeep patient safeKeep patient safe
Delirium TremensDelirium Tremens
7272--96 hours after stop/ cut back96 hours after stop/ cut backUsually resolves 3Usually resolves 3--5d 5d aysays after startingafter startingComplicates 5Complicates 5--10% of 10% of withdrawlswithdrawls15% mortality15% mortalityClinically:Clinically:–– Tremulousness, agitation, disorientation,Tremulousness, agitation, disorientation,–– Hallucinations, confusions, feverHallucinations, confusions, fever
Remember: Fluids and electrolytesRemember: Fluids and electrolytes
Treat WithdrawalTreat Withdrawal
Inpatient Inpatient vsvs outpatientoutpatientBenzodiazepines remain cornerstoneBenzodiazepines remain cornerstone–– Short acting: Short acting: lorazepamlorazepam
Peaks and valleysPeaks and valleysIdeal for elderly/impaired drug clearanceIdeal for elderly/impaired drug clearance
–– Medium/long acting: diazepam/Medium/long acting: diazepam/chlordiazepoxidechlordiazepoxideLong slow tapersLong slow tapersIdeal for outpatientsIdeal for outpatients
–– Severe hepatic dysfunction: Severe hepatic dysfunction: oxazepamoxazepam
No efficacy:No efficacy:–– MgSO4, MgSO4, clonidineclonidine, , atenololatenolol, , neurolepticsneuroleptics, anti, anti--pyschoticspyschotics, ,
antianti--emeticsemetics
Treat WithdrawalTreat Withdrawal
Scheduled dosingScheduled dosing–– ChlordiazepoxideChlordiazepoxide 100mg q 6 hours100mg q 6 hours
Convenient, adapt to outpatientConvenient, adapt to outpatientHigher medication use, less nurse interactionHigher medication use, less nurse interaction
Load and TaperLoad and Taper–– Diazepam 10mg every 2 hours until asleepDiazepam 10mg every 2 hours until asleep
Patient comfort, easy for physicianPatient comfort, easy for physicianUnnecessary medication, over sedationUnnecessary medication, over sedation
Individualized treatment (Individualized treatment (sxsx triggered)triggered)–– LorazepamLorazepam 2 mg q 12 mg q 1-- 2 hrs for 2 hrs for ““agitationagitation””
Less medication used, shorter hospital staysLess medication used, shorter hospital staysHigher nursing involvement, ? SeizureHigher nursing involvement, ? Seizure
ReferencesReferences
1.1. Administration on Aging. Statistics on the Aging Population, Administration on Aging. Statistics on the Aging Population, Rockville, MD; US Dept of Health and Human Services; Rockville, MD; US Dept of Health and Human Services; 2003; US Bureau of the Census.2003; US Bureau of the Census.
2.2. J. J. GeriatrGeriatr. Psychiatry . Psychiatry NeuroNeuro. 2000:13;106. 2000:13;106--14.14.3.3. Brower, K. J., Brower, K. J., MuddMudd, S., Blow, F.C., Young, J.P. & Hill, E.M. , S., Blow, F.C., Young, J.P. & Hill, E.M.
(Jan./Feb., 1994). Severity of alcohol withdrawal in elderly (Jan./Feb., 1994). Severity of alcohol withdrawal in elderly versus younger patients Alcoholism: Clinical and versus younger patients Alcoholism: Clinical and Experimental Research, 18 (1), 196Experimental Research, 18 (1), 196--201. 201.
4.4. Holbrook, A.M., Holbrook, A.M., CrowtherCrowther, R., , R., LotterLotter, A., & Cheng, C. , A., & Cheng, C. (March 9, 1999). Diagnosis and management of acute (March 9, 1999). Diagnosis and management of acute alcohol withdrawal. Canadian Medical Association Journal, alcohol withdrawal. Canadian Medical Association Journal, 160 (5),: 675160 (5),: 675--680. Online at: 680. Online at: www.cmaj.ca/cgi/reprint/160/5/675.pdf (Retrieved August www.cmaj.ca/cgi/reprint/160/5/675.pdf (Retrieved August 8, 2003). 8, 2003).
5.5. Peppers, M.P. (1996). Benzodiazepines for alcohol Peppers, M.P. (1996). Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease. withdrawal in the elderly and in patients with liver disease. Pharmacotherapy, 16(1), 49Pharmacotherapy, 16(1), 49--58. 58.
ReferencesReferences
6. Wojnar, M., Wasilewski, D., Zmigrodzka, I. & Grobel, I. (2001). Age-related differences in the course of alcohol withdrawal in hospitalized patients. Alcohol and Alcoholism, 36 (6), 577-583.
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behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation and statement. Ann Intern Med. 2004; 140(7):554-556.
9. Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69(6):1443-1454.
10. Ferguson JA, Suelzer CJ, Eckert GJ, et al. Risk factors for delirium tremens development. J Gen Intern Med. 1996;11:410-414.
ReferencesReferences
11. Ferguson JA, Suelzer CJ, Eckert GJ, et al. Risk factors for delirium tremens development. J Gen Intern Med. 1996;11:410-414.
12. Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict. 1989;84:1353-1357.
13. Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and intervention for alcohol problems: a national survey of primary care physicians and psychiatrists. J Gen Intern Med. 2000;15(2):84-91.
14. Daeppen J-B, Gache P, Landry U, et al. Symptom-triggered vs. fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162:1117-1121
