Late-life substance use — structured clinical viva · Psych Vivas

Prompt

You are the old-age psychiatry registrar. A 79-year-old man with COPD and chronic pain is admitted with confusion two days after a hip-fracture operation. Family say he has 'always liked a drink' and takes oxycodone plus lorazepam at home. Neither was charted postoperatively. He is sweaty, tremulous, CIWA-Ar 16, and asking for 'my sleeping tablets'. Discuss formulation (alcohol and sedative/opioid interfaces), acute management including thiamine and withdrawal pharmacology with older-adult dosing philosophy, deprescribing and pain strategy after stabilisation, suicide and falls risk, and how you would explain a long-term plan to the orthogeriatric team.

Interpretation

Reveal interpretation

Formulate as missed postoperative alcohol withdrawal plus abrupt interruption of home benzodiazepine (and possible opioid physical dependence) in a medically frail older adult — not "sundowning only" or primary dementia until detox and medical drivers are addressed.[1][2]

Acute priorities: airway/oxygenation given COPD, CIWA-guided benzodiazepine treatment for alcohol withdrawal, reinstate appropriate GABA-A cover for chronic lorazepam rather than cold turkey, assess opioid withdrawal and multimodal analgesia, give parenteral thiamine early on Wernicke-risk suspicion, correct metabolic issues, falls and delirium care, and screen suicide risk.[2][3][4][5][8]

After stabilisation, plan alcohol aftercare (MI, supports, consider naltrexone/acamprosate with cautions), gradual BZD deprescribing (Beers PIM logic), and opioid stewardship without abandoning pain control. Explain to orthogeriatrics that prevention is a pre-op substance history and charted withdrawal plan.[5][6][7]

Key points

[1] [3] [5]

References

[1]Kuerbis A, Sacco P, Blazer DG, Moore AA Substance abuse among older adults Clin Geriatr Med, 2014.PMID 25037298
[2]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.PMID 2597811
[3]Mayo-Smith MF Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal JAMA, 1997.PMID 9214531
[4]Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy J Neurol Neurosurg Psychiatry, 1997.PMID 9010400
[5]Soyka M Treatment of Benzodiazepine Dependence N Engl J Med, 2017.PMID 28614686
[6]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder Am J Psychiatry, 2018.PMID 29301420
[7]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[8]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168

Interpretation

Reveal interpretation

Key points

[1]

[3]

[5]

References

[1]Kuerbis A, Sacco P, Blazer DG, Moore AA Substance abuse among older adults Clin Geriatr Med, 2014.PMID 25037298
[2]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.PMID 2597811
[3]Mayo-Smith MF Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal JAMA, 1997.PMID 9214531
[4]Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy J Neurol Neurosurg Psychiatry, 1997.PMID 9010400
[5]Soyka M Treatment of Benzodiazepine Dependence N Engl J Med, 2017.PMID 28614686
[6]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder Am J Psychiatry, 2018.PMID 29301420
[7]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[8]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168