How can we accurately assess the functional capacity and work readiness of a 68-year-old homeless male with severe alcohol use disorder, hypertension, atrial fibrillation, and reported blackouts/possible withdrawal, while supporting his motivation to return to a golf‑pro shop and ensuring safety and medical stability?

Assessing Functional Capacity and Work Readiness in Severe Alcohol Use Disorder

This patient is not ready to return to work and requires immediate medical stabilization, structured alcohol treatment, and psychiatric care before any vocational rehabilitation can be safely considered. 1, 2

Immediate Safety and Medical Priorities

Acute Withdrawal Risk Assessment

• The observed tremors and staff-reported blackouts indicate active withdrawal risk requiring urgent medical evaluation. 1, 2 Withdrawal symptoms typically begin 6–24 hours after the last drink and peak at days 3–5, with seizures occurring in up to 15% of patients (usually 12–48 hours post-cessation) and delirium tremens developing in 3–5% of patients 48–72 hours after the last drink with ~50% mortality if untreated. 1
• His atrial fibrillation creates additional concern, as alcohol withdrawal significantly increases the risk of acute atrial fibrillation episodes, particularly in heavy users. 3 Alcohol abstinence has been shown to reduce atrial fibrillation recurrence by 45% (hazard ratio 0.55) in regular drinkers. 4
• Immediate thiamine 100–500 mg IV must be administered before any glucose-containing fluids to prevent Wernicke's encephalopathy, followed by 100–300 mg orally daily for 2–3 months. 1, 2

Inpatient Admission Criteria Met

This patient requires inpatient admission based on multiple high-risk factors: 1, 2

• History of alcohol-related hospitalizations and detox
• Staff-reported blackouts indicating severe current use despite patient minimization
• Observed tremors suggesting withdrawal
• Co-existing serious medical conditions (hypertension, atrial fibrillation)
• High recent alcohol intake (previously two pints vodka daily = ~320g/day for decades)
• Homelessness representing insufficient social support
• Discrepancy between self-report and collateral information

Structured Assessment of Alcohol Use Severity

Quantitative Documentation

• Use the AUDIT (Alcohol Use Disorders Identification Test) questionnaire as the gold-standard screening tool with highest sensitivity and specificity. 5, 1 The AUDIT-C (first 3 consumption questions) can be used for efficient screening if time is limited. 6
• Document consumption in standard drinks per week: at 65+ years, >7 standard drinks/week = heavy drinking; binge drinking = ≥4 drinks within 2 hours. 5
• Calculate "glass-years" (average drinks per day × years of drinking) to capture cumulative exposure—this patient has approximately 51 years × ~20 drinks/day = 1,020 glass-years, indicating severe cumulative damage. 1
• Obtain collateral information from shelter staff, which is critical given the marked discrepancy between patient self-report ("one tall beer daily") and staff observations ("brownouts and blackouts"). 1 Patients commonly under-report due to stigma, impaired recall, or cognitive issues. 1

Withdrawal Severity Monitoring

• Apply the Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) to quantify severity: score ≥8 requires pharmacologic treatment; score ≥15 indicates severe withdrawal requiring aggressive benzodiazepine management. 1, 2
• Monitor vital signs continuously for autonomic instability (tachycardia, hypertension, fever, diaphoresis) before each benzodiazepine dose. 1
• Perform daily assessments for up to 5 days after last drink to confirm symptom improvement. 1

Pharmacologic Management During Stabilization

Benzodiazepine Protocol

Benzodiazepines are mandatory as the only proven agents to prevent seizures and reduce mortality from delirium tremens. 1, 2

• Given his age (68) and atrial fibrillation, use lorazepam 6–12 mg/day (intermediate-acting) rather than long-acting agents to avoid drug accumulation. 1, 2 Long-acting benzodiazepines (diazepam, chlordiazepoxide) would be preferred in younger patients without cardiac/hepatic issues. 1, 2
• Begin taper at ~96 hours after symptom onset, reducing dose by 10–25% every 2–4 days. 1
• Limit total benzodiazepine duration to 10–14 days maximum to prevent iatrogenic dependence; never discontinue abruptly. 1, 2

Post-Acute Relapse Prevention

After withdrawal completion, initiate pharmacologic relapse prevention: 1

• Acamprosate ~2g/day (safe in liver disease, reduces craving) 5, 1
• Baclofen up to 80 mg/day (the only medication proven safe in cirrhosis) 1
• Avoid naltrexone given concern for alcoholic liver disease (25% of heavy drinkers show abnormal liver function tests) 5, 1

Functional Capacity Assessment Framework

Cognitive and Physical Evaluation

• Screen for alcohol-related neurocognitive disorder given 51-year history of heavy use and reported blackouts. 1 Prolonged heavy alcohol use causes brain atrophy and increased vulnerability to cognitive impairment. 5
• Assess for hepatic encephalopathy, which can impair recall and judgment (25% of heavy Korean drinkers showed abnormal liver function). 5
• Evaluate cardiovascular stability given atrial fibrillation—uncontrolled arrhythmia would preclude safe work return. 3, 4
• Document hygiene deficits and environmental instability (bed bugs, street sleeping) as objective functional impairments. 1

Psychiatric Stability Requirements

Mandatory psychiatric consultation is required after medical stabilization to assess AUD severity and devise long-term treatment plans. 2

• His Major Depressive Disorder (recurrent, unspecified) requires treatment—consider antidepressant therapy once alcohol use is controlled, as ongoing alcohol exacerbates depressive symptoms. 5
• Poor appetite, low energy, and sleep disturbance indicate inadequate psychiatric control that would impair work performance. 5
• Psychosocial support should be routinely offered, with structured psychological interventions (motivational techniques) when provider capacity allows. 5

Work Readiness Decision Algorithm

Phase 1: Medical Stabilization (Weeks 1–4)

1. Complete inpatient alcohol withdrawal management with benzodiazepines and thiamine 1, 2
2. Stabilize atrial fibrillation and hypertension with cardiology input 3, 4
3. Initiate psychiatric treatment for depression 5
4. Secure stable housing (homelessness is a significant psychosocial stressor contributing to psychiatric instability) 1

Phase 2: Sustained Sobriety (Months 2–6)

1. Achieve minimum 3–6 months documented abstinence with objective verification (random breathalyzers, collateral reports). 5 His previous longest sobriety was only 3 months, indicating high relapse risk. 5
2. Start relapse-prevention medication (acamprosate or baclofen) 5, 1
3. Engage in mutual-help groups (Alcoholics Anonymous)—familiarize with locally available groups and encourage participation, monitoring impact on recovery. 5
4. Demonstrate consistent medication adherence for cardiac and psychiatric conditions 5
5. Establish stable housing and daily routine 1

Phase 3: Vocational Rehabilitation (Month 6+)

Only after completing Phases 1–2 should vocational rehabilitation be considered: 5

• Refer to supported employment program specializing in individuals with substance use disorders 5
• Begin with volunteer work or part-time hours at golf pro shop to assess tolerance 5
• Maintain weekly check-ins with addiction counselor and monthly psychiatric follow-up 5
• Monitor for relapse triggers (work stress, access to alcohol at golf clubs) 5

Critical Pitfalls to Avoid

Minimization of Current Use

The 87% discrepancy between patient self-report and collateral information is typical in severe AUD and must be weighted heavily in decision-making. 1 Staff reports of "brownouts and blackouts" indicate blood alcohol levels >200 mg/dL, incompatible with his claim of "one tall beer daily." 5

Premature Work Return

Returning to work before achieving medical/psychiatric stability and sustained sobriety will result in: 5, 1

• Increased relapse risk due to unmanaged stressors
• Safety hazards (operating golf carts, handling equipment during withdrawal or intoxication)
• Job loss reinforcing cycle of homelessness and drinking
• Potential harm to customers if cognitive impairment present

Inadequate Monitoring

Daily physician visits for 3–5 days are required even for outpatient withdrawal management—this patient requires inpatient care given multiple high-risk factors. 1 Outpatient management would be inappropriate and dangerous. 1, 2

Supporting Motivation While Prioritizing Safety

Therapeutic Approach

• Acknowledge his strong occupational identity and pride in golf pro work as a powerful motivator for recovery. 5 Use motivational enhancement techniques to frame sobriety as the pathway to reclaiming this identity. 5
• Set concrete, time-based goals: "To return to the pro shop safely, we need to first stabilize your heart condition and achieve 6 months of sobriety with treatment support." 5
• Involve him in treatment planning to maintain autonomy while establishing non-negotiable safety requirements. 5

Harm Reduction vs. Abstinence

Complete abstinence is mandatory given his severe AUD (DSM-5 criteria met), cardiac disease, and work safety requirements. 5, 1 Persistent consumption >2 standard drinks/day raises mortality in patients with underlying conditions (relative risk ~2.6 in males). 1 Harm reduction approaches are inappropriate for this severity level and vocational goal. 5