Late-life substance use — structured clinical viva

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]