Psych · Old age psychiatry — addiction interface
Late-life substance use
Also known as Geriatric substance use · Substance use disorders in older adults · Late-onset alcohol use disorder · Elderly alcohol misuse · Benzodiazepine dependence older adults · Late-life addiction
Exam-exhaustive fellowship reference on late-life substance use — early- vs late-onset trajectories; alcohol, benzodiazepines/Z-drugs, opioids, cannabis and nicotine; age-related PK/PD vulnerability; AUDIT-C/SMAST-G screening; alcohol withdrawal, thiamine and Wernicke risk; BZD deprescribing (EMPOWER, Beers); pharmacotherapy with older-adult cautions; dual diagnosis, suicide and falls. FRANZCP-primary, globally tagged.
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Red flags
- Alcohol or sedative withdrawal seizures, delirium tremens, or fluctuating confusion — medical emergency; do not discharge unsupervised frail older adults mid-withdrawal
- Suspected Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia — any two Caine-type features) — give high-dose parenteral thiamine immediately; do not wait for the classic triad
- Abrupt inpatient cessation of chronic benzodiazepines or Z-drugs — seizure and delirium risk; reinstate cover then plan taper
- Combined alcohol, benzodiazepine and opioid use — synergistic CNS and respiratory depression and overdose death risk
- Active suicidal ideation with access to alcohol, stockpiled sedatives, or firearms — high lethality in older adults; same-day senior review and means restriction
- Recurrent falls, new cognitive decline, or poorly explained injuries on ongoing sedatives or heavy drinking — do not label as 'just ageing' or 'just dementia'
- Starting naltrexone while opioids are still on board — precipitate opioid withdrawal and block emergency analgesia
Meet the patient
A 78-year-old widow is admitted after a fall. She drinks "two sherry glasses, with dinner" — and has done since her husband died. Her medications include diazepam 5 mg at night, prescribed in 1994 for insomnia, and temazepam 10 mg PRN. Two hours after admission she is nil by mouth for a procedure, and by morning she is tremulous, sweaty, and seeing faces in the curtains.[1][14][16]
The medical team's first note reads "UTI — delirium". Nobody has asked about the last drink or the missed tablets.[5][9]
Two exam questions are now live. What is the tremor and the visual disturbance actually telling you? And why was "two sherry glasses" not reassurance registrar took it for? This topic is the answer to both.[5][16]
Etymology worth one viva line: addiction, from Latin addictus — a person bound over, assigned by decree. The word is older than the illness we attach it to, and the binding is exactly what a thirty-year diazepam script becomes.[9][14]
References16ShowHide
- [1]Kuerbis A, Sacco P, Blazer DG, Moore AA Substance abuse among older adults Clin Geriatr Med, 2014.PMID 25037298
- [2]Barry KL, Blow FC Drinking Over the Lifespan: Focus on Older Adults Alcohol Res, 2016.PMID 27159818
- [3]Moore AA, Blow FC, Hoffing M, Welgreen S, Davis JW, Lin JC, et al. Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial Addiction, 2011.PMID 21143686
- [4]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
- [5]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
- [6]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
- [7]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
- [8]Day E, Bentham PW, Callaghan R, et al. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol Cochrane Database Syst Rev, 2013.PMID 23818100
- [9]Soyka M Treatment of Benzodiazepine Dependence N Engl J Med, 2017.PMID 28614686
- [10]Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial JAMA Intern Med, 2014.PMID 24733354
- [11]Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline Can Fam Physician, 2018.PMID 29760253
- [12]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
- [13]Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
- [14]Markota M, Rummans TA, Bostwick JM, et al. Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies Mayo Clin Proc, 2016.PMID 27814838
- [15]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168
- [16]Mangoni AA, Jackson SHD Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications Br J Clin Pharmacol, 2004.PMID 14678335