Late-life substance use — assessment and management (MEQ)

(i) Assessment priorities. Risk first: expand passive death wishes — intent, plan, preparatory acts, access to alcohol stock, surplus temazepam, other medicines, weapons; protective factors; same-day safety planning for an isolated older adult with high late-life suicide lethality framing.[8] Quantify alcohol (standard drinks, last drink, prior seizures/DT), temazepam dose/duration/source, other substances/OTC, multi-prescriber patterns. Collateral from family/GP/pharmacy. Cognitive screen with collateral baseline; do not diagnose irreversible dementia during withdrawal. Medical: fall work-up, electrolytes, LFT, FBC, glucose, nutrition, infection, ECG as indicated. Functional status, driving, home safety, bereavement and social isolation. Capacity for treatment decisions and least-restrictive legal framework if risk escalates (jurisdiction-specific).[1][2]

(ii) Working diagnosis and differentials. Working formulation: late-onset escalation of hazardous/possibly dependent alcohol use in bereavement context, plus long-term prescribed benzodiazepine physiological dependence, presenting with fall and early withdrawal (CIWA-Ar 11), possible dual depression/grief, and cognitive impairment that may be reversible in part after detox. Early-onset ageing-with-addiction is less likely if heavy problems began after widowhood, but take a full lifetime history.[1] Differentials: delirium from medical causes; primary major depression or prolonged grief; Wernicke encephalopathy; progressive dementia/ARBI; sedative intoxication; elder abuse or self-neglect. Discriminators: timeline relative to last use, CIWA trajectory, thiamine risk features, labs, collateral cognition, response after supervised abstinence.[1][4]

(iii) Acute management. Do not leave her without GABA-A cover. Treat alcohol withdrawal with age-adjusted benzodiazepines guided by CIWA-Ar (symptom-triggered where staffing reliable, or cautious fixed schedule with frequent review) — e.g. lorazepam 0.5–1 mg oral/IV per local CIWA band rather than large accumulating diazepam loads if frailty/hepatic concern, with falls precautions and vital-sign monitoring.[2][3] Reinstate a portion of benzodiazepine cover for her chronic temazepam dependence while planning later taper; abrupt stop of both alcohol and BZD is high risk.[5] Give parenteral thiamine early (local high-dose IV regimens, often 200–500 mg IV three times daily initially in high-risk patients) before or with glucose; treat on clinical suspicion rather than awaiting a perfect triad.[4] Correct electrolytes, mobilise carefully, treat fall injuries, monitor for DT/seizure, address suicide means on the ward.[3][8]

(iv) Definitive plan and disposition. After stabilisation: motivational interviewing and elder-adapted psychosocial care for alcohol (brief intervention evidence in older primary-care drinkers supports engagement). Consider naltrexone 50 mg orally daily if opioids not required and LFTs acceptable, or acamprosate with renal dosing (e.g. 666 mg three times daily, reduce in renal impairment) — disulfiram generally avoided in frail multimorbid elderly.[7] Benzodiazepine deprescribing: negotiated gradual taper (often convert then reduce about 10–25% every 1–2 weeks, slower if frail), CBT-I/sleep hygiene, EMPOWER-style education principles, non-drug anxiety strategies; never abrupt outpatient stop.[5][6] Treat depression/grief if criteria met; optimise medical comorbidity; home supports/package; pharmacy reconciliation; early outpatient review; named dual-diagnosis follow-up. Disposition: remains inpatient until withdrawal safe, cognition clearer, and a verified safety plan exists for solitary living — do not discharge mid-withdrawal to an empty house with stockpiled sedatives.[1][8]