What is the best course of treatment for an elderly patient with a history of alcohol (ethanol) use disorder, presenting with symptoms of dizziness, nausea, weight loss, and recent falls after alcohol cessation?

Management of Elderly Patient with Alcohol Use History Presenting with Falls, Dizziness, Nausea, and Weight Loss After Cessation

This patient requires immediate benzodiazepine therapy for alcohol withdrawal syndrome (AWS), mandatory thiamine supplementation to prevent Wernicke encephalopathy, and inpatient admission given the elderly age, falls history, and multiple withdrawal symptoms. 1, 2

Immediate Assessment and Risk Stratification

Assess withdrawal severity using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale every 1-2 hours during the first 72 hours when symptoms peak. 2 The presenting symptoms of dizziness, nausea, and falls in an elderly patient after alcohol cessation are consistent with AWS, which typically develops within 6-24 hours after alcohol discontinuation. 3

Critical Red Flags in This Patient:

• Elderly age - increases risk of complications and requires modified benzodiazepine selection 2
• Falls - suggests autonomic instability or neurological compromise 1
• Multiple withdrawal symptoms - indicates at least moderate AWS requiring treatment 2
• Weight loss - suggests chronic malnutrition and increased Wernicke encephalopathy risk 4

First-Line Pharmacological Treatment

Benzodiazepine Selection for Elderly Patient

Use lorazepam (intermediate-acting benzodiazepine) as first-line therapy in this elderly patient, starting with 1-4 mg every 4-8 hours, using symptom-triggered dosing guided by CIWA-Ar scores. 4, 2 Short and intermediate-acting benzodiazepines are safer in elderly patients compared to long-acting agents due to reduced accumulation risk. 1, 2

Benzodiazepines are the gold standard for AWS treatment because they reduce withdrawal symptoms and prevent serious complications including seizures and delirium tremens. 1, 2 While long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior seizure protection in younger patients, the elderly patient's age and fall history necessitate lorazepam to minimize sedation and accumulation. 1, 2

Dosing Strategy:

• Use symptom-triggered dosing rather than fixed-schedule to prevent drug accumulation, which is particularly important in elderly patients 1, 2
• CIWA-Ar score 8-14: moderate withdrawal requiring benzodiazepine treatment 2
• CIWA-Ar score ≥15: severe withdrawal requiring aggressive treatment 2
• Limit benzodiazepine treatment to initial 10-14 days to minimize dependence risk 1

Mandatory Thiamine Supplementation

Administer parenteral thiamine 100-500 mg/day immediately, before any glucose-containing IV fluids. 4, 2 This patient's weight loss, chronic alcohol use, and elderly status place them at high risk for Wernicke encephalopathy. The combination of dizziness and falls could represent early Wernicke's triad (confusion, ataxia, ophthalmoplegia). 4

Continue thiamine 100-300 mg/day for 2-3 months following withdrawal resolution. 4, 2 IV glucose administration before thiamine can precipitate acute thiamine deficiency and Wernicke encephalopathy. 4

Admission Criteria - This Patient Requires Inpatient Management

This patient meets multiple criteria for mandatory inpatient admission: 2

• Elderly age with increased complication risk 2
• Falls suggesting severe withdrawal or neurological compromise 1
• Multiple withdrawal symptoms indicating at least moderate AWS 2
• Likely inadequate social support given presentation pattern 2

Outpatient management is only appropriate for mild-moderate withdrawal (CIWA-Ar <15) with no history of complicated withdrawals, adequate social support, and no concurrent serious conditions - none of which apply to this patient. 2

Additional Supportive Care

Fluid and Electrolyte Management:

Provide IV fluids and correct electrolyte abnormalities, particularly magnesium. 4 Chronic alcohol use commonly causes magnesium depletion, which can worsen withdrawal symptoms and increase seizure risk. 4

Monitoring Requirements:

• Assess vital signs and CIWA-Ar scores every 1-2 hours during first 72 hours 2
• Continue frequent monitoring through days 3-5 post-cessation when withdrawal symptoms are most severe 2
• Monitor closely for worsening mental status or sedation given elderly age 4

Fall Risk Management

The falls in this patient likely represent either: 1

1. Autonomic instability from AWS causing orthostatic hypotension
2. Cerebellar dysfunction from Wernicke encephalopathy
3. Benzodiazepine-related ataxia (if already treated)

Implement fall precautions immediately and reassess gait stability after thiamine administration and AWS symptom control. 4

Medications to Avoid

Do not use antipsychotics as stand-alone treatment - only as adjuncts to benzodiazepines if severe delirium develops unresponsive to adequate benzodiazepine doses. 2 Haloperidol can be used carefully at 0.5-5 mg every 8-12 hours for agitation or hallucinations not controlled by benzodiazepines, but only as adjunctive therapy. 4

Do not use anticonvulsants for seizure prevention following alcohol withdrawal seizures. 2 While carbamazepine is listed as an alternative to benzodiazepines, benzodiazepines remain first-line. 4

Long-Term Abstinence Planning

Request psychiatric consultation for evaluation and long-term abstinence planning. 2 After acute withdrawal resolution, consider pharmacotherapy for alcohol use disorder maintenance:

• Acamprosate 1,998 mg/day (or reduced by one-third if body weight <60 kg) for 3-6 months 4
• Baclofen may be considered, particularly if liver disease is present 4
• Avoid naltrexone given hepatotoxicity concerns in patients with potential alcoholic liver disease 4

Complete abstinence is critical for improved outcomes, especially given the weight loss suggesting possible underlying alcoholic liver disease. 2 Abstinence improves survival, reduces portal pressure, and prevents progression to cirrhosis at all stages of alcoholic liver disease. 4