Geriatric MedicineTier 2Disease (DEADMAN)

Substance use disorders - withdrawal

Description

Substance withdrawal syndromes (alcohol, benzodiazepine, opioid) present and are managed somewhat differently in older patients, who have reduced physiological reserve to tolerate the autonomic/physiological stress of withdrawal

Undiagnosed alcohol use disorder is likely underrecognised in older adults, partly from lower clinical suspicion in this age group and partly from atypical presentation - it should not be assumed to be a predominantly younger-population problem

Withdrawal is physiologically more dangerous in older patients given reduced cardiovascular/respiratory reserve to tolerate the autonomic surge of alcohol/benzodiazepine withdrawal, and higher rates of comorbidity that can be destabilised by the withdrawal process itself (e.g. withdrawal-related tachycardia/hypertension in a patient with significant cardiac disease)

Withdrawal can present atypically - as delirium, falls, or non-specific deterioration - rather than the classic tremor/agitation picture, and can be misattributed to dementia, an unrelated acute illness, or simply "being unwell" if the substance use history is not actively sought
A history of regular alcohol or benzodiazepine use is easily missed unless specifically asked about - screening should be routine in any older patient with an unexplained acute presentation, delirium, or unexplained autonomic instability, not reserved for those with an obvious history

Standard withdrawal management protocols apply (e.g. symptom-triggered benzodiazepine dosing for alcohol withdrawal) but often require lower starting doses and closer monitoring given altered pharmacokinetics/pharmacodynamics and reduced physiological reserve
Thiamine (for Wernicke's encephalopathy prevention) remains essential in alcohol withdrawal regardless of age, and should not be omitted
Gradual, supervised tapering (rather than abrupt cessation) is generally preferred for long-term benzodiazepine use in older patients, both to manage withdrawal risk and because abrupt cessation itself carries seizure/delirium risk

Alcohol use disorder (often underrecognised in this population), long-term benzodiazepine dependence (frequently iatrogenic, from long-standing prescriptions), delirium tremens

Withdrawal-related delirium in an older patient can be mistaken for a primary dementia presentation or an unrelated medical illness if the substance use history is not actively elicited - a high index of suspicion and direct screening (not just relying on volunteered history) is essential in this population

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