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Joanna Piechniczek-Buczek, MD Department of Psychiatry Boston University School of Medicine Alcohol Medical Scholars Program (Slide1) INTRODUCTION (Slide 2) Alcohol misuse is common in the general population 80 % lifetime alcohol use 15 % lifetime alcohol abuse 10 % lifetime alcohol dependence Alcohol Use Disorders (AUD) of abuse or dependence common among Medical inpatients ~ 20% Surgical Patients: ~ 43% otorhinolaryngological patients; 50% gastrointestinal tract cancer patients Trauma patients ~ 40% -50% intoxicated; 94% of those with intoxication have substance abuse or dependence  Elderly ~ 17% Alcohol abuse, dependence, withdrawal: DSM IV TR definitions  (Slide 3) Abuse: repeated alcoholrelated problems in same 12 months with 1+ : Inability to fulfill role obligations Use in physically hazardous situations Legal problems Social or interpersonal difficulties Never dependent Dependence: repeated alcohol-related problems over 12 months with 3 +: Tolerance Withdrawal Use heavier or longer than intended Desire and inability to cut down Activities aborted Long time spent in alcohol-related activities On-going use despite consequences Alcohol Withdrawal Syndrome (AWS) 2 +: (Slide 4) a. Autonomic hyperactivity Tremor Insomnia Nausea or vomiting Hallucinations or illusions Agitation Anxiety Grand mal seizures Risk factors for severe alcohol withdrawal: (Slide 5) Quantity and frequency of intake (large amounts over long period of time)  Number and severity of prior episodes Use of other substances Medical/surgical co-morbidity Elevated Blood Alcohol Concentration (BAC) High severity of withdrawal upon presentation Advanced age Development of AWS associated with: (Slide 6) More complicated hospital stay Longer stay ! need of intensive care ! mortality This lecture will cover: (Slide 7) Neurobiology of Alcohol Withdrawal Syndrome (AWS) Signs and symptoms of AWS Evaluation of patients Treatment- general principles Special considerations in: Surgical/ trauma patients l Geriatric patients (Slide 8) NEUROBIOLOGY OF ALCOHOL Acute effects of alcohol: (Slide 9) ( activity at GABA A receptor  ( glutamate transmission at NMDA receptor (dopamine ( norepinephrine synthesis and release ! effect of serotonin at 5HT3 receptor ( beta endorphins levels / binding Chronic effects of alcohol: Down- regulation of GABA receptors  Up-regulation of NMDA receptors Down-regulation of dopamine receptors Serotonin depletion ( postsynaptic receptor norepinephrine sensitivity ! in -endorphine levels / binding Withdrawal (Slide 10) !excitatory effect by: ! GABA, ! glutamate( tremor, seizures ( norepinephrine sensitivity ( autonomic instability (Slide 11) III. ALCOHOL WITHDRAWAL SYMPTOMS Phase I(Slide 12) Time abstinent or cut down: 6-24 hrs Signs and symptoms: Tremor: hands most prominent ! autonomic activity: ! blood pressure ! reflexes Fever Insomnia Nausea/vomiting Sweating Anxiety Phase II (Slide 13) Time abstinent: 7-48 hrs Signs and symptoms: Distractibility Autonomic instability (!!heart rate, !! blood pressure) Grand mal seizures 5-10% lifetime risk of seizures Phase III (Slide 14) Time abstinent: 72-96 hrs Only in < 5% Symptoms: (Delirium+ severe autonomic instability + tremor = delirium tremens or DT) Confusion/disorientation Severe autonomic instability Auditory/tactile hallucinations Agitation Mortality rate ~ 1 % (Slide 15) IV. ALCOHOL WITHDRAWAL ASSESSMENT A. History/Interview: (Slide 16) Duration of use Chronic use (weeks, months) (! risk of withdrawal Quantity, frequency and drinking pattern > 5-6 drinks/ day Daily or almost daily use Age of first use, periods of heaviest use, periods of abstinence Time since last drink (~6+ hours) Severity of previous withdrawals (e.g. seizures or DTs) Concurrent medical/psychiatric problems Social /domestic/emotional/occupational problems B. History/Screening tools: (Slide 17) Alcohol Use Disorders Identification Test (AUDIT) 10 items scale Can be self administered Assesses: frequency, quantity, lack of control, guilt, blackouts etc. Sensitivity: 90%; Specificity: 85% at score of > 8 CAGE Cut down, Annoyed, Guilty, Eye opener Very brief 2 or > + responses( high likelihood of alcoholism Sensitivity 85%; Specificity 90% Not gender sensitive; does not identify recent or episodic use Michigan Alcohol Screening Test (MAST) Structured interview 25 questions Positive answers to 4 + questions suggest alcohol problem C. Physical exam: (Slide 18) Focused on identifying withdrawal symptoms (e.g. sweating, tremors, etc.) Chronic alcohol exposure stigmata: Spider angiomata-superficial spider-like cluster of capillaries, Palmar erythema- reddening of the palms . Hepatosplenomegaly-! liver and spleen Assessment of possible complicating medical conditions: Cardiac arrhythmias (irregular heart rate) Congestive heart failure (secondary to hypertension or cardiomyopathy) Gastrointestinal bleeding (blood in vomit or stool), Cancer (esophagus, stomach, head and neck, lungs) Liver disease (fatty liver, hepatitis, cirrhosis) Pancreatitis (abdominal pain, ! pancreas enzymes e.g. amylase) Nervous system impairment: Central (confusion, cerebellar damage) Peripheral (neuropathy e.g.  pins+ needles in hands/feet) Laboratory investigations: (Slide 19) Blood count:! red blood cells size; mean corpuscular volume (MCV) > 100 Liver functions tests (LFTs) ! Aspartate aminotransferase (AST); > 40 u/l ! Alanine aminotransferase (ALT); > 40 u/l AST/ALT ratio > 2 e.g. ( suggestive of alcoholic liver disease; ! Carbohydrate deficient transferrin (CDT) : high sensitivity and specificity/ good indicator of early relapse: 20U or 2.6 % ! Gamma-glutamyl transferase (GGT): levels! after 70 drinks/week for several weeks; > 35 u/l Urine/serum toxicology screen: to exclude other drug use Electrolytes: ! Na, !Mg ( ! risk of seizures Blood alcohol concentration (BAC): BAC ~ 150 w/o intoxication or ~ 300 w/o somnolence( evidence of tolerance ( ! risk of withdrawal (Slide 20) V. ALCOHOL WITHDRAWAL TREATMENT General care: (Slide 21) Multivitamins (MVI): 1 tablet daily Thiamine: 100 mg daily Folic acid: 1 mg daily Fluid repletion if dehydration evident Medication regimen- benzodiazepines (BZDs) (Slide 22) First line treatment BZD are effective to decrease: Severity of withdrawal Incidence of delirium Incidence of seizures Are 2 types: Longer acting ( life ~ 30 hours) E.g. diazepam (Valium) Shorter acting ( life ~15 hours) e.g. lorazepam (Ativan) Longer acting better at preventing seizures, but ( sedation Two main strategies: Fixed schedule (Slide 23) Description: Specific doses administered at specific intervals Additional doses used as needed based on the severity of symptoms Examples: Lorazepam 2 mg every 4 hours; Diazepam 10-20 mg every 6 hours; Chlordiazepoxide (Librium) 25-50 mg every 6 hours Tapered gradually over several days Problems: over / under- medication ( too difficult to control symptoms) Symptomtriggered (Slide 24) Description: Medication given when CIWA-AR >8 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) Examples: Lorazepam 2 mg q 1 hour for CIWA 8-13 Lorazepam 3 mg q 1 hour for CIWA 14-20 Lorazepam 4 mg q 1 hour for CIWA >20 iii. Problems: ( cost/ staff time Non-pharmacological treatments: (Slide 26) Reassurance Reality-orientation techniques (time, place, situation) Rest/sleep Adequate nutrition. (Slide 27) VI. ALCOHOL WITHDRAWAL IN SURGICAL AND TRAUMA PATIENTS Epidemiology (Slide 28) 50-60% prevalence of alcohol abuse/dependence in trauma patients 16% incident of AWS post-surgery vs. 8% in general population Pre-operative assessment/prophylaxis prevents post-operative AWS complications in 75% of patients Highest risk of DTs: in 40+ year olds and s/p fall or burn Risks ( operative and post operative morbidity and mortality Postoperative morbidity 2-3 X ! if 21+ drinks/week 50% longer hospital stay Poorer 3 month outcomes: infections, bleeding, cardiopulmonary Challenges (Slide 29) During surgery: Alcohol can (or (sensitivity to anesthesia Alcohol ! coagulation ! risk of hypoxia and poor BP control After surgery: Alcohol ( immune functions; surgery ( immunosuppression( ( risk of inflammation/ infection Alcohol ! metabolic acidosis and ! surgery stress response DTs often confused with Sepsis ! Circulation to brain Worsening of closed head injury Autonomic instability ( e.g. ! or! blood pressure) due to alcohol withdrawal ( incorrectly attributed to traumatic injury Agitation due to withdrawal Challenges nursing care Risks displacement of monitors and dressings Hallucinations (difficult to assess in intubated patients Assessment and treatment History (Slide 30) Scheduled surgeries: Good pre-operative assessment to screen for AUDs Advise abstinence if not at risk of AWS Pre-surgical detoxification should be considered if needed Trauma and emergency surgeries History taking difficult Collateral informants (family, friends, witnesses) important Physical exam/ laboratory findings important Differential diagnosis/common surgical causes of agitation: (Slide 31) Bleeding, Metabolic/electrolyte abnormalities Infection Pain Supportive care (Slide 32) Pain management Pulmonary toileting Eliminate unnecessary catheters Early mobility Pharmacological treatment BZDs Symptom-triggered approach most effective Dosages generally larger (Slide 33) A VII. ALCOHOL WITHDRAWAL IN THE ELDERLY: Epidemiology (Slide 34) 11% of elderly in acute medical settings have alcohol abuse or dependence 20% in psychiatric settings 14% in emergency departments Risks Even moderate drinking in the elderly : ! disease burden and ! risk of complicated withdrawal Aging affects alcohol levels: ! body water (! volume of distribution(! alcohol concentration ! gastric alcohol dehydrogenase (! alcohol concentration Alcohol ! risk of falls leading to hip fractures/ subdural hematomas ( bleed under skull) Alcohol interacts with many common medications Challenges (Slide 35) Age alone( predictor of ! withdrawal severity Early onset drinkers( long use( ! probability of prior withdrawals( ! severity of AWS  Functional reserve and tolerance of physiological stressors ! with age ! risk of adverse effects from use of BZDs  Cognitive impairment Daytime sedation Falls Assessment and treatment (Slide 36) History: Difficult because: Patient ashamed to admit Family reluctant to share Physicians not likely to suspect Clues that should ! suspicion of AUD in the elderly: Frequent falls Bruises Many ED visits ! blood pressure Depressed mood and suicidal thoughts Insomnia 2. Differential diagnosis (Slide 37) Withdrawal from other substances (e.g. BZDs, Barbiturates) Delirium of other causes ( see DTs differential diagnosis described above) Psychiatric conditions (anxiety, dementia, psychosis) 3. Supportive treatment (Slide 38) Safe/ well lit environment Gentle/empathic/ non-judgmental approach Hearing aids/glasses as individually indicated Extremes of sensory input- to be avoided Sleep/rest/nutrition 4. Pharmacological interventions (Slide 39) Shorter acting agents (lorazepam, oxazepam) preferred because: No active metabolites ! rate of side effects  Symptom-triggered approach preferred For some patients (with history of sz and DTs) (fixed schedule preferred Medication held for sedation Medication dosages typically lower. (Slide 40)      PAGE \* MERGEFORMAT 1 REFERENCES:  Foster SE, Vaughan RD, Foster WH, Califano JA, Jr. Alcohol Consumption and expenditures for underage drinking and adult excessive drinking. JAMA 2003;289:989-995  Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability and co morbidity of DSM IV alcohol abuse and dependence in the Unites States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 2007; 64: 830-842  Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL. Management of Alcohol Withdrawal Delirium Archives of Internal Medicine 2004;164:1505-1412  Spies CD, Rommelspacher H Alcohol Withdrawal in surgical patients: prevention and treatment; Anesthesia Analg 1999;88:946-54  Gantillelo L, Donovan D, Dunn C, Rivara F. Alcohol interventions in trauma centers: current practice and future directions. 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