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Clinical Atlas Prestige · Evidence-first

Psych VivasAddiction psychiatry

Psych Vivas · Addiction psychiatry

Addiction in older adults — structured clinical viva

Fellowship viva on older-adult alcohol withdrawal presenting as post-operative delirium, screening, pharmacotherapy, and dual diagnosis.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. A medical team admits a 76-year-old man with confusion two days after hip-fracture surgery. His alcohol history was not taken pre-op. The drug chart shows no benzodiazepines. He is tremulous, hypertensive, and picking at the sheets. Junior staff suggest 'UTI delirium only', 'haloperidol 5 mg IM now', or 'he is too old for detox — just fluids'. Cross-examine on withdrawal vs other delirium, thiamine, geriatric dosing, screening tools for future admissions, naltrexone candidacy later, and late-life suicide risk if depression emerges.

Interpretation

Reveal interpretation

Reject the junior plan. Post-operative day 2–3 confusion with autonomic arousal after unrecorded heavy alcohol use is classic alcohol withdrawal until proven otherwise — not "UTI only." High-dose haloperidol alone without GABA-A cover risks worsening the picture; ageist refusal of detox is unsafe.[1][3]

Immediate management. ABC, concurrent delirium work-up (infection, electrolytes, hypoxia, pain, constipation, medications), benzodiazepine protocol with geriatric sedation and falls monitoring, parenteral thiamine, magnesium/electrolytes, close nursing, and collateral alcohol/sedative history (including pre-admission BZD that may have been omitted).[1][2]

Later care. Screen systematically (AUDIT-C/SMAST-G culture), brief intervention/SBIRT (BRITE logic), dual diagnosis for depression and suicide risk, and after detox consider naltrexone 50 mg daily if opioid-free with monitoring (Oslin older-adult adjunct evidence).[6][4][5]

Escalating viva probes

  1. Why might blood alcohol be higher after fewer drinks in this man than in a younger adult?
  2. Name geriatric-sensitive alcohol screening tools.
  3. What is the risk of starting naltrexone if he is still on post-op opioids?
  4. How do you discuss EMPOWER/Beers if long-term night sedatives are discovered on collateral?
  5. Why is late-life suicide assessment mandatory even if he denies active plans today?
[1] [2] [4] [5]

Key points

Withdrawal is medical

Not a behavioural nuisance — protocolised care plus medical differential.

Thiamine early

Do not wait for a perfect triad or MRI.

Naltrexone 50 mg

Only when opioid-free; older adults can benefit.
[1] [4]

References

  1. [1]Lehmann SW, Fingerhood M. Substance-Use Disorders in Later Life N Engl J Med, 2018.PMID 30575463
  2. [2]Kuerbis A, Sacco P, Blazer DG, et al. Substance abuse among older adults Clin Geriatr Med, 2014.PMID 25037298
  3. [3]Barry KL, Blow FC. Drinking Over the Lifespan: Focus on Older Adults Alcohol Res, 2016.PMID 27159818
  4. [4]Oslin D, Liberto JG, O'Brien J, et al. Naltrexone as an adjunctive treatment for older patients with alcohol dependence Am J Geriatr Psychiatry, 1997.PMID 9363289
  5. [5]Blow FC, Brockmann LM, Barry KL. Role of alcohol in late-life suicide Alcohol Clin Exp Res, 2004.PMID 15166636
  6. [6]Schonfeld L, King-Kallimanis BL, Duchene DM, et al. Screening and brief intervention for substance misuse among older adults: the Florida BRITE project Am J Public Health, 2010.PMID 19443821