Alcohol & Alcoholism Vol. 36, No. 6, pp.

577–583, 2001

AGE-RELATED DIFFERENCES IN THE COURSE OF ALCOHOL WITHDRAWAL

IN HOSPITALIZED PATIENTS
MARCIN WOJNAR1*, DARIUSZ WASILEWSKI2, IZABELA ŻMIGRODZKA1 and IWONA GROBEL2
1
II and 2I Departments of Psychiatry, The Medical University of Warsaw, Nowowiejska 27, 00-665 Warsaw, Poland

(Received 5 October 2000; in revised form 25 April 2001; accepted 31 May 2001)

Abstract — The aim of this study was to compare the course of alcohol withdrawal (AW) syndromes in different age groups of
hospitalized patients. Medical records of 892 patients treated for AW in Nowowiejski Hospital in Warsaw, Poland from 1973 to 1987
were reviewed using a structured questionnaire; a further 321 patients were observed on a prospective basis in the years 1990–1999.
We compared severity of the symptoms and the course of AW episodes in five age groups: <30, 30–39, 40–49, 50–59 and ≥60 years
old. Although the age groups did not differ in respect of gender, there were significant differences in other demographic variables, such
as marital status, education, employment and number of households. We found a greater prevalence of somatic diseases and hypo-
kalaemia in the older age groups. Older patients were hospitalized longer than the younger patients. The amount of alcohol consumed
was significantly smaller in the older patients. No significant differences were found between age groups in the duration and severity
of AW symptoms. All age groups required comparable doses of medication. The relationship between the duration of AW and the amount
of alcohol consumed during the last drinking bout was significant in patients aged >50 years. There was also a significant positive
correlation between the occurrence of withdrawal seizures or the severity of AW symptoms and the number of previous AW episodes
in patients aged ≥40 years. Although the results did not confirm some previously reported differences in the course of AW between
older and younger patients, they point to some new important differences in the conditions and course of AW in the elderly.

INTRODUCTION
The age of alcohol-dependent persons is increasingly drawing
attention as a factor which enhances the risk of a severe course
of alcohol withdrawal (AW) and which contributes to the
development of delirium tremens or other complications. As
the general population is ageing, medical problems associated
with alcohol use are becoming quite frequent among the
elderly (Atkinson, 1988; Hurt et al., 1988; American Medical
Association, 1996; Kraemer et al., 1999). The AW syndrome
is common in elderly addicted individuals who reduce or stop
their intensive alcohol intake.
Some authors suggest that older persons develop more
severe forms of AW than younger patients (Gross et al., 1972;
Naranjo and Sellers, 1986). The hypothesis was proposed that
withdrawal symptoms’ severity and the likelihood of delirium
or seizures increase with advanced age (Liskow et al., 1989).
Most patients suffering from severe forms of AW are between
40 and 50 years old (Gross et al., 1974), although delirium
tremens was also observed in a 9-year-old child (Sherwin and
Mead, 1975). The patients at the greatest risk of fatal with-
drawal reactions or death during AW are those aged >45 years
(Tavel et al., 1961; Taylor et al., 1983; Feuerlein and Reiser,
1986; Naranjo and Sellers, 1986; Wasilewski et al., 1989).
However, a severe course of AW may also result from a high
level of daily alcohol consumption (Freidman, 1980; Pristach
et al., 1983; Benzer, 1990), a long period of intensive drinking,
the development of a kindling mechanism (Ballenger and Post,
1978; Brown et al., 1988; Lechtenberg and Worner, 1991;
Booth and Blow, 1993; Wojnar et al., 1999a), and/or serious
co-morbid medical or surgical disorders (Thompson et al.,
1975; Thompson, 1978; Taylor et al., 1983; Wojnar et al., 1999b).
Only a few clinical studies have been performed to assess
the impact of age on the course of AW and to evaluate the need
for careful intensive treatment of older alcohol-dependent
*Author to whom correspondence should be addressed.
patients (Liskow et al., 1989; Brower et al., 1994; Foy et al.,
1997; Kraemer et al., 1997). Some of these studies demon-
strated that, compared with young alcohol-dependent persons,
elderly patients undergo more severe AW, for which they
receive more intensive pharmacological treatment (Liskow
et al., 1989; Brower et al., 1994). In the studies by Foy and
Kay (1995) and Foy et al. (1997), it was reported that patients
aged >70 years ran a higher risk of complications in AW,
including delirium and hallucinations. The impact of advanced
age on the severity of AW delirium was also relevant for the
cases of persistent delirium tremens described by Miller
(1994) and Hersch et al. (1997).
Other studies, however, questioned age as a risk factor for
the development of withdrawal delirium or seizures among
in-patients undergoing alcohol detoxifications (Morton et al.,
1994; Schaumann et al., 1994; Mayo-Smith and Bernard,
1995; Ferguson et al., 1996; Kasahara et al., 1996). Kraemer
et al. (1997) reported that AW severity, the amount of benzo-
diazepines used and the duration of pharmacological treatment
did not change significantly with age. Moreover, the authors
of another study observed that, independently of many other
factors, young individuals consuming excessive amounts of
alcohol run an even greater risk of developing severe AW
(delirium tremens) than the elderly (Kramp and Hemmingsen,
1981). A unique study of animals to test the effects of ageing
on the severity of ethanol-withdrawal symptoms revealed
no significant correlation between age and the intensity of
withdrawal symptoms in rats (Riihioja et al., 1999).
This brief overview of clinical research demonstrates that
there is still ambiguity concerning the impact of age on the
severity and course of AW symptoms. Some studies confirm
that age is an important risk factor for severe AW, whereas others
contradict this possible association. The disagreement in find-
ings may have resulted from different methodologies used in
the respective analyses. The patients studied came from differ-
ent settings, not only from detoxification units but also from
medical wards, and therefore the patients’ general somatic

577

© 2001 Medical Council on Alcohol

578 M. WOJNAR et al.
condition might have influenced the course of AW. Some
studies analysed small-sized samples (Liskow et al., 1989;
Brower et al., 1994). In a few studies, researchers compared
patients of only two distant age groups, and such a comparison
might have influenced results. Moreover, in assessing with-
drawal symptoms, some authors lacked a validated rating scale,
and others failed to take into consideration the possible influence
of other important factors, e.g. parameters of drinking history or
the patients’ somatic state.
The aim of our study was to determine the impact of age
on the severity of the AW syndrome and on the development
of related complications. In order to overcome a number of
limitations of the above-mentioned studies, we decided to study
the course of AW in a large population of hospitalized patients
of several age groups and representing most of the adult with-
drawal population.
PATIENTS AND METHODS
The study included a group of 1500 in-patients hospitalized
at the Nowowiejski Hospital (general psychiatric hospital)
in Warsaw, Poland from 1973 to 1999 who were diagnosed
with alcohol withdrawal (AW) or alcohol withdrawal delirium
according to the DSM-IV classification criteria (American
Psychiatric Association, 1994).
Patients with any other concomitant substance dependence
were excluded from the analysis to avoid the influence of
other factors on the course of AW. The retrospective analysis
relied on medical records of 892 patients hospitalized in the
years 1973–1987 and a further 321 patients were observed on
a prospective basis in the years 1990–1999. The final analysis
included each patient’s most recent available record in order to
evaluate the effect of the number of prior detoxifications on
the course of the studied AW episode.
The retrospective data (from records) were entered in a
structured questionnaire (Szelenberger et al., 1989) by a group
of psychiatrists with at least 5 years of experience in treating
patients. They received detailed training in using the question-
naire for the purpose of assessing the documentation. Inter-
rater reliability of the group was r = 0.838. Data gathered
during prospective observation was entered into the same
questionnaire.
The questionnaire included five major domains of variables:
(1) demographics (sex, age, education, family and professional
status); (2) drinking history (age of onset of intensive drinking,
duration of harmful drinking, length of the last drinking bout,
daily intake of alcohol during the last period, number of
prior detoxifications); (3) injuries, somatic disorders in the
past and somatic condition during hospitalization [concomitant
somatic disorders, heart rate, blood pressure, body tempera-
ture, deviations in results of laboratory tests (haemoglobin, red
blood cells count, alanine aminotransferase, potassium, urea)
and for patients hospitalized from 1990 also mean corpuscular
volume, gamma-glutamyltransferase (GGT), glucose and plate-
let count]; (4) severity of AW symptomatology (according to
the scale described below) and the course of AW (duration of
symptoms, complications, occurrence of withdrawal seizures,
length of hospitalization); (5) pharmacological treatment
(pharmacological agents and daily dose; benzodiazepine
doses were reported in equivalent milligrams of diazepam).
Depending on their clinical state at the time of admission,
patients were classified as being at one or another stage of AW
as follows: stage 1, uncomplicated AW (symptoms according
to alcohol withdrawal DSM-IV criteria); stage 2, predelirium
state (fleeting illusions or hallucinations, slight disorientation,
mild difficulties in contact, sleep disorder); stage 3, developing
delirium (vivid hallucinations, delusions, psychotic anxiety,
but still in contact with reality); stage 4, developed delirium
tremens (false psychotic orientation, lost contact with sur-
rounding, disorganized thought, marked agitation, disordered
sleep/wake cycle); stage 5, deep consciousness disturbances,
without any contact.
The maximum stage of withdrawal syndrome severity was
subsequently assessed during hospitalization.
In the group of patients hospitalized from 1990 (n = 321)
the maximum severity of AW symptoms during their stay in
hospital was evaluated also with the CIWA-A scale (Shaw
et al., 1981). The score analysed was that recorded at the onset
of the pharmacological treatment administered in hospital. In
order to examine the accuracy of the above list of stages of
AW severity, we calculated the correlation between the stage
of the withdrawal symptoms’ severity and the CIWA-A score
in this group of patients. The correlation was positive and
statistically significant (r = 0.641, P < 0.0001).
In order to assess the possible impact of age on the course
of AW, we compared the variables studied across several age
groups. For this purpose, we used the interval of 10 years to
divide the population of our study into five age groups: <30
years, 30–39 years, 40–49 years, 50–59 years and ≥60 years.
Assessing the course of AW in relation to the age of patients,
we considered age as the independent variable, while severity
and duration of AW symptoms, complications, occurrence
of withdrawal seizures, length of treatment and daily dose of
medication were the major dependent variables. Other groups
of variables (demographics, drinking and medical history,
somatic state) were studied for their possible influence on the
AW course and, additionally, for assessment of other differ-
ences between age groups of alcohol-dependent patients. We
also compared the correlation in all age groups between the
severity of AW symptoms, the duration of AW symptoms, and
the occurrence of withdrawal seizures on the one hand with
the duration of harmful drinking, the number of prior detoxi-
fications, the length of the preceding drinking bout, and daily
alcohol intake during the last bout on the other.
In a statistical analysis of the results, the χ2-test for categorical
data, analysis of variance (ANOVA) for continuous variables,
Kruskal–Wallis ANOVA and non-parametric correlation
analysis (Kendall’s Tau) were performed where appropriate,
with the significance level for probability of the null hypo-
thesis set to 0.05. SPSS statistical software was used (Norusis,
1993).
RESULTS
Of the 1213 patients included in the study, 82.9% were men,
and 17.1% were women. The age of patients ranged from 18
to 78 years with a mean ± SD of 41.04 ± 10.13 years. Patients
<30 years of age made up 11.5% of the total population,
patients of 30–39 years 36%, patients of 40–49 years 32.5%,
patients of 50–59 years 15.9%, and patients of ≥60 years 4.1%.
 AGE AND ALCOHOL WITHDRAWAL 579
Table 1. Demographic characteristics of patients diagnosed with alcohol withdrawal hospitalized at the Nowowiejski Hospital in the years
1973–1999 by age group

Age (years)

<30 30–39 40–49 50–59 ≥60

Demographic n = 140 n = 437 n = 394 n = 192 n = 50 P
variable (11.5%) (36.0%) (32.5%) (15.9%) (4.1%) (χ2-test)

Gender (% male) 81.8 84.5 81.7 83.4 80.8 n.s.

Marital status (%) <0.0001
Single 53.5 22.4 10.3 7.7 7.4
Married 34.5 47.8 47.6 48.6 39.0
Widowed 0.2 1.6 4.4 9.0 31.7
Divorced/separated 11.8 28.2 37.7 34.7 21.9
Education (%) <0.01
Primary 43.0 34.8 42.7 41.6 59.5
High 50.5 56.6 46.1 42.3 29.7
University 6.5 8.6 11.2 16.1 10.8
Employment (%) <0.0001
Employed 70.6 71.8 68.5 53.5 24.8
Unemployed 23.9 23.1 16.3 9.0 5.2
Pension/retired 5.5 5.1 15.2 37.5 70.0
Number in household (%) <0.0001
0 10.0 18.2 26.5 27.1 42.5
≥1 90.0 81.8 73.5 72.9 57.5

n.s. denotes not significant.

Demographic characteristics are presented in Table 1. The
age groups did not differ in respect of gender. There were
significant differences in other demographic variables: marital
status, education, employment, and number in households. As
expected, we observed significant trends for more widowed,
pensioned, and living-alone persons as age increased.
Differences in drinking histories, past somatic and with-
drawal histories are shown in Table 2. The elderly patients
(≥60 years) started intensive drinking ~11 years later than
young patients (<30 years), but had drunk alcohol harmfully
for a much longer time (18 years on average) until the index
hospitalization. The amount of alcohol consumed during the
drinking bout preceding admission was significantly lower as
patients’ age advanced. Young patients reported past with-
drawal seizures more frequently than patients aged >60 years;
the age groups did not differ significantly in respect of the
number of prior admissions for detoxification. There was also
a significant trend for more somatic diseases in the past as age
increased. Patients aged >60 years seemed to have longer
drinking bouts but the difference was not significant.
The course of AW, the complications and the treatment
administered are shown in Table 3. The severity of symptoms
and the duration of AW episode were similar in all age groups.
We observed a similar incidence of DTs across the age groups;
there were no significant differences in CIWA-A scoring of
maximum AW severity in patients hospitalized from 1990.
Concomitant somatic disorders, elevated blood pressure, hypo-
kalaemia and somatic complications of AW recorded during
hospitalization were more frequent as patients’ age advanced;
patients aged >60 years were also hospitalized longer than

Table 2. Drinking and medical history by age group

Age (years)

<30 30–39 40–49 50–59 ≥60

Variable n = 140 n = 437 n = 394 n = 192 n = 50 Pa

Age of onset of intensive 18.8 22.6 27.8 33.0 39.7 <0.001

drinking (years) (mean ± SD) ± 3.3 ± 5.5 ± 7.7 ± 10.0 ± 12.7
Duration of harmful alcohol 7.6 12.4 16.3 20.5 25.2 <0.001
drinking (years) (mean ± SD) ± 3.4 ± 5.4 ± 7.6 ± 9.6 ± 11.5
Average alcohol intake 301.6 304.1 278.9 268.6 204.1 <0.05
during the last drinking bout ± 173.3 ± 178.7 ± 149.2 ± 154.9 ± 103.6
(g pure ethanol/day) (mean ± SD)
Average length of the last 14 14 14 9 21 n.s.
drinking bout (days)b [median (IQR)] (8–60) (8–35) (7–30) (5–20) (12–70)
No. of prior in-patient 2 2 2 3 2 n.s.
detoxificationsb [median (IQR)] (2–4) (2–3.5) (2–4) (2–5) (2–3)
Withdrawal seizures in the past (%) 18.4 11.5 17.7 12.9 6.5 <0.05
Somatic diseases in the past (%) 50.4 53.7 61.8 74.8 80.5 <0.001
a
Continuous variables were analysed by ANOVA, categorical variables by χ2-tests.
b
Kruskal–Wallis ANOVA was applied.
n.s. denotes not significant. IQR indicates interquartile range (25th–75th percentile).
580 M. WOJNAR et al.
Table 3. The course of alcohol withdrawal (AW) episode and treatment administered by age group

Age (years)

<30 30–39 40–49 50–59 ≥60

Variable n = 140 n = 437 n = 394 n = 192 n = 50 Pa

Duration of AW (h) 74.0 71.2 70.8 71.5 67.6 n.s.

(mean ± SD) ± 1.3 ± 46.5 ± 46.9 ± 40.9 ± 42.6
Severity of AW symptoms 23.6 21.9 24.4 26.8 34.0 n.s.
(% of fully developed DTs)
CIWA-A scoreb [median (IQR)] 29 (16–49) 30 (19–38) 24 (16–33) 23 (14–31) 27 (3–51) n.s.
(n = 27) (n = 120) (n = 123) (n = 43) (n = 8)
Average duration of hospitalization 8.6 8.9 10.0 10.3 11.5 <0.05
(days) (mean ± SD) ± 5.5 ± 7.5 ± 7.8 ± 7.8 ± 9.1
Withdrawal seizures (%) 6.1 2.9 3.5 5.0 2.1 n.s.
Concomitant somatic disease (%) 34.2 31.8 40.7 46.3 48.8 <0.01
Elevated blood pressure 23.0 20.3 31.1 32.4 27.7 <0.01
>160/95 mmHg (%)
Gamma-glutamyltransferase 405.5 121.8 205.9 354.6 142.0 <0.05
(IU/l) (mean ± SD) ± 514.6 ± 89.1 ± 291.4 ± 468.2 ± 131.7
Hypokalaemia (%) 12.9 14.2 20.5 16.6 34.0 <0.01
Somatic complications of AW (%) 12.4 10.1 17.9 22.8 28.9 <0.001
Diazepam in dose >30 mg/day (%) 8.9 6.6 14.0 10.8 15.0 n.s.
Mean daily dose of benzodiazepines 55.7 55.2 52.0 51.2 42.5 n.s.
(equivalent mg of diazepam) ± SD ± 27.3 ± 34.6 ± 37.5 ± 37.0 ± 36.6
(n = 27) (n = 120) (n = 123) (n = 43) (n = 8)
a
Continuous variables were analysed by ANOVA or Kruskal–Wallis ANOVA; categorical variables by χ2-tests.
b
Pertains to AW in patients hospitalized from 1990 to 1999.
n.s. denotes not significant. IQR indicates interquartile range (25th–75th percentile). DTs, delirium tremens.

younger groups. Patients from all age groups were treated with
high doses of diazepam (>30 mg daily) with similar frequency;
the mean daily dose of benzodiazepines was also comparable.
There were no significant differences between the groups in
frequency of withdrawal seizures or in results of the majority
of blood tests. Patients aged <30 years demonstrated highest
serum concentrations of GGT.
With age as a continuous variable we performed correla-
tions for the following variables: with severity of symptoms
(r = –0.028, P = 0.346), CIWA-A score (r = –0.116, P = 0.117),
benzodiazepine dosage (r = –0.066, P = 0.295) and duration of
AW (r = –0.018, P = 0.535). Since ANOVA had not revealed
significant differences between the five age groups analysed
in Table 3, we performed t-tests to compare patients aged <60
with those aged ≥60 years. Differences were once again not
statistically significant (for the above variables, t = –1.91,
P = 0.056; t = 0.01, P = 0.98; t = 0.74, P = 0.455; and t = 0.55,
P = 0.576, respectively). Thus, using age as a continuous
variable in parametric tests, we obtained comparable results to
those given in Table 3 for age categories.
The associations of the severity of AW, its duration, and the
occurrence of withdrawal seizures with some parameters of
drinking history differed significantly between the age groups,
as shown in Table 4. Even though no significant differences
were found between age groups in the duration or severity of
the AW symptoms, the correlation between the duration of
AW and the level of alcohol intake during the last drinking
bout was meaningful in patients aged >50 years. On the other
hand, the duration of AW symptoms correlated highly with the
length of the last drinking bout only in young patients (those
aged <30 years).
Severity of symptoms correlated significantly with the
duration of harmful drinking and the amount of daily alcohol
consumption in patients aged between 30 and 50 years.
The highest positive correlation between the severity of AW
symptoms and the number of previous AW episodes was
found in patients aged >60 years.
Occurrence of withdrawal seizures was positively associated
with the length of the preceding bout in patients >50 years,
and with the number of prior episodes in patients >40 but <60
years old.
DISCUSSION
We found no significant relationship between the age groups
of hospitalized alcohol-dependent patients and the severity or
the duration of withdrawal symptoms. Among the patients
who were rated with the CIWA-A scale, all age groups experi-
enced similar degrees of severity. We did not corroborate
several prior studies (Liskow et al., 1989; Brower et al., 1994;
Foy and Kay, 1995; Foy et al., 1997). The study of Liskow et al.
(1989) showed that elderly alcohol-dependent individuals
underwent more severe withdrawal and received higher doses
of benzodiazepines than young alcoholic patients. In that
study, aged persons seemed to be more sensitive to alcohol in
that the relationship between the severity of withdrawal symp-
toms and the amount of alcohol consumed was significant only
in patients >58 years of age. However, the limitation of that
study was its small-sized sample (n = 26 for >58 years old and
n = 24 for 21–33 years old). Brower et al. (1994) also demon-
strated that elderly patients suffered from significantly more
severe AW symptoms which lasted longer than in younger
patients. In addition, the elderly group had a higher incidence
of cognitive impairment, daytime sleepiness, weakness, and ele-
vated blood pressure. However, these latter authors did not find
significant differences between age groups with regard to the
dosage and the number of days when detoxification medication
 AGE AND ALCOHOL WITHDRAWAL 581
Table 4. Correlations between severity, duration of alcohol withdrawal (AW) symptoms, occurrence of withdrawal seizures and selected variables
by age group

Age (years)

Correlations between <30 30–39 40–49 50–59 ≥60

variables (n = 140) (n = 437) (n = 394) (n = 192) (n = 50)

Severity of AW symptoms and:

Duration of harmful drinking 0.07 0.14 0.09 0.03 –0.05
P = 0.88 P = 0.0005 P = 0.01 P = 0.54 P = 0.66
No. of prior detoxifications 0.18 0.06 0.11 0.16 0.31
P = 0.001 P = 0.016 P = 0.007 P = 0.001 P = 0.002
Length of preceding drinking bout 0.49 0.31 0.26 0.25 0.33
P = 0.037 P = 0.0002 P = 0.0009 P = 0.06 P = 0.14
Daily alcohol intake during last bout 0.02 0.24 0.34 0.23 0.33
P = 0.85 P = 0.0036 P = 0.0000 P = 0.098 P = 0.26
Duration of AW symptoms and:
Duration of harmful drinking –0.04 0.05 0.13 0.02 0.01
P = 0.56 P = 0.15 P = 0.01 P = 0.77 P = 0.88
No. of prior detoxifications –0.05 –0.11 –0.01 –0.06 0.04
P = 0.021 P = 0.061 P = 0.78 P = 0.11 P = 0.67
Length of preceding drinking bout 0.45 0.16 0.16 0.04 0.20
P = 0.006 P = 0.025 P = 0.022 P = 0.76 P = 0.25
Daily alcohol intake during last bout 0.04 0.09 0.064 0.38 0.36
P = 0.67 P = 0.094 P = 0.24 P = 0.0001 P = 0.038
Occurrence of withdrawal seizures and:
Duration of harmful drinking –0.01 0.03 –0.12 –0.06 0.19
P = 0.79 P = 0.43 P = 0.001 P = 0.23 P = 0.089
No. of prior detoxifications 0.06 0.01 0.12 0.12 0.10
P = 0.29 P = 0.56 P = 0.002 P = 0.035 P = 0.32
Length of preceding drinking bout 0.07 0.05 0.07 0.31 0.32
P = 0.66 P = 0.48 P = 0.28 P = 0.01 P = 0.023
Daily alcohol intake during last bout –0.11 0.08 –0.09 0.13 –0.27
P = 0.15 P = 0.06 P = 0.04 P = 0.035 P = 0.07

In the statistical analysis, non-parametric correlation analysis (Kendall’s Tau) was applied.

was administered, with only a slight trend for more days on
medication among the elderly. They concluded that AW might
be more severe and longer-treated among elderly, than younger,
individuals. Here again the compared groups were small
(≥60 years old: n = 48; 21–35 years old: n = 36). Moreover, in
assessing withdrawal symptoms the authors did not use a
rating scale (e.g. CIWA-A or another), which was used in most
studies, e.g. Liskow et al. (1989) and Kraemer et al. (1997).
The studies of Liskow et al. (1989) and Brower et al.
(1994) compared patients from distant age groups: ≥58–60
and ≤33–35 years. It has been suggested that the results of
studies designed in such a way might reflect differences in the
course of AW specific to the younger groups rather than to the
elderly (Kraemer et al., 1997). Most patients hospitalized for
detoxification are 30–50 years of age (68.5% of the patients in
our study). We selected patients of several age groups, divided
by the interval of 10 years, in order to include a representative
group of the adult withdrawal population.
There are other studies which, like ours, failed to find
greater severity of AW symptoms in the elderly. For example,
Kraemer et al. (1997) found that AW severity, as measured by
CIWA-Ar scores and benzodiazepine requirement, did not vary
significantly with age. As in our study, older patients required
longer hospital stays. The study supported recommendations
of the American Medical Association (1996) that older patients
with AW require close supportive care in well-monitored
settings. Kraemer et al. (1997) reported also that older patients
(≥60 years) were at higher risk for transient cognitive impair-
ment (i.e. delirium) during AW. We also found a higher frequency
of delirium tremens in patients ≥60 years (34%), but, compared
with other age groups, the difference was not statistically signifi-
cant. The observed rate of delirium in the study of Kraemer
et al. was 14%, but most of those cases were states of delirium
due to a general medical condition. Only 1% of the total study
sample was considered AW delirium, which is a very low
value, compared with our result. These authors suggested that
most cases of delirium during AW in studied older populations
were not classic delirium tremens (for Kraemer et al., delirium
tremens signifies only the most severe cases of delirium occur-
ring with confusion, agitation and extreme autonomic hyper-
activity). In our study, we assumed delirium tremens to be
synonymous with alcohol withdrawal delirium (according to
DSM-IV criteria) and we did not distinguish a state of general
delirium when the patient was simultaneously undergoing
AW. Moreover, it is surprising that withdrawal severity scores
(CIWA-Ar) in the study of Kraemer et al. (1997) were com-
parable across different age groups, while the delirium rate
was higher in older patients. The CIWA-Ar score also reflects
cognitive disturbances during AW and, in our opinion, with-
drawal severity scores should increase with growing delirium
incidence. It is, however, probable that younger patients of
Kraemer et al.’s population experienced, for example, particu-
larly elevated autonomic hyperactivity, and that is why the
CIWA-A score was comparable in the studied groups. In the
Polish sample of alcohol-dependent patients, we observed also
similar withdrawal severity across all age groups.
In our study, we found a higher frequency of hypertension,
hypokalaemia, coexisting somatic diseases and somatic
582 M. WOJNAR et al.
complications of AW, as age increased, which is consistent
with the general observation that older patients are at a higher
risk of somatic morbidity, especially if they drink alcohol
intensively (Hurt et al., 1988; Schuckit et al., 1995). However, a
comparable delirium rate in all groups is slightly confusing,
because of the difference in somatic state between age groups.
It is well known that concomitant somatic disorders make the
course of AW more severe (Thompson et al., 1975; Ferguson
et al., 1996; Wojnar et al., 1999b). In our study, older patients
were hospitalized for a longer period of time, despite having
similar profiles of withdrawal severity and requiring similar
amounts of benzodiazepines. Their longer hospitalizations
could obviously be due to the above-mentioned differences in
the somatic condition between older and younger patients.
Furthermore, the medical staff might have been more caring
towards the older patients, which might have led to their longer
hospitalization. This result is consistent with the findings in
Kraemer et al. (1997).
Kraemer et al. (1997) suggested that cognitive complications
of AW in older patients may be attributable to the adverse
effects of medication used, rather than to being a direct effect
of AW. Benzodiazepines are known to be more slowly meta-
bolized, to achieve higher blood concentrations and increased
clinical effects in the elderly (Ozdemir et al., 1996; Peppers,
1996). Some studies reported that older patients were treated
with higher doses of benzodiazepines for AW than younger
adults (Liskow et al., 1989), which, according to the hypo-
thesis put forth by Kraemer et al. (1997), might consequently
lead to more frequent occurrence of delirium tremens in older
patients. Our study, like the studies of Kraemer et al. (1997)
and Brower et al. (1994), showed that hospitalized patients of
all age groups needed comparable amounts of benzodiazepines
during the treatment of withdrawal symptoms. This finding
was consistent with the similarities in the severity of AW course
in all the groups we studied. However, it is probable that,
despite similar doses of medication, older patients achieved
higher blood concentrations of benzodiazepines, which could
potentially alleviate the risk of more severe AW symptoms.
Therefore, older alcoholics might actually undergo more intense
AW episodes, but these would be hidden by pharmacological
treatment.
An analysis of the relationships of AW severity, duration
of symptoms, and occurrence of seizures with variables of
drinking history yielded some ambiguous results. The only
clear association was that of longer duration of AW with a
high level of alcohol consumption in patients aged >50 years,
which confirms previous findings (Freidman, 1980; Pristach
et al., 1983; Benzer, 1990). Severity of symptoms correlated
with daily alcohol intake and duration of harmful drinking in
those aged 30–49 years. These diverse relationships between
AW course and patients’ age could explain, to some extent, the
variation of results in other studies. Some studies have found
that drinking history is a predictor of withdrawal severity (e.g.
Ballenger and Post, 1978; Lechtenberg and Worner, 1992),
while others have not (e.g. Brown et al., 1988; Wojnar et al.,
1999a). It is possible that studied populations of patients
suffering from AW differed in respect of age and, presumably,
in other factors. Our findings suggest that certain variables of
drinking history can be predictors of withdrawal severity only
in patients >50 years old. Younger age can therefore be con-
sidered a mitigating factor.
Some authors suggested that the occurrence of more
severe forms of AW in the elderly may result from a kindling
phenomenon (Ballenger and Post, 1978; Brown et al., 1988;
Lechtenberg and Worner, 1991; Booth and Blow, 1993). Both
in our previous study (Wojnar et al., 1999a), and in the present
study (performed on the more extended population), we observed
that the relationship between the severity of AW symptoms
(i.e. occurrence of delirium tremens) and the number of previous
AW episodes (as a manifestation of the kindling mechanism)
was most significant in patients >60 years. On the other hand,
a correlation between the occurrence of withdrawal seizures
and the number of prior detoxifications was significant for
younger groups of patients (>40 but <60 years). Our findings
did not result from a different number of previous AW episodes
in age groups. The number of prior admissions for detoxification
did not differ between age groups, although older alcoholics
had been problem drinkers for significantly longer periods
than younger persons. More apparent manifestations of kind-
ling in older alcoholics may be due to the more pronounced
CNS sensitivity of this group of patients; they may be more
susceptible to the neurophysiological, psychopathological and
somatic consequences of prolonged alcohol drinking and
repeated episodes of withdrawal. Consistent with our other
findings, the correlation between the duration of treated AW
syndrome and the recent daily amount of alcohol consumed
was only prominent in elderly patients, despite the fact that
they drank smaller quantities than the younger patients.
The main limitation of our study is the fact that our analysis
relied to a large extent on medical records. Retrospective
search of records might not yield reliable data, despite the use
of standardized procedures (structured questionnaire, trained
study team). We therefore supplemented our retrospective find-
ings using a prospectively studied sample (patients hospitalized
since 1990). Moreover, we attempted to standardize measures
of AW severity assessment and to confirm retrospective find-
ings using a validated CIWA-A scale during admissions from
1990 onwards.
Although we gathered data for a large population of in-
patients in AW, this included a relatively small number aged
≥60 years. Unfortunately, in the prospective part of the study,
we only had eight patients of that age, a small number which
could have influenced the statistical significance and thus the
validity of our results. The differences in numbers of patients
between age groups reflect typical age distribution of alcohol-
dependent patients hospitalized at the Nowowiejski Hospital:
elderly patients are relatively infrequent. Moreover, our studied
population consisted of in-patients admitted for detoxification
to a city general psychiatric hospital; many of these patients
suffered from delirium tremens. This fact probably accounts
for the difference in delirium rate between our findings and
that of other studies. Most other studies were conducted in
detoxification units and focused on uncomplicated AW, with
only sporadic incidence of delirium of the order of a few per
cent (Brown et al., 1988; Lechtenberg and Worner, 1991;
Booth and Blow, 1993; Kraemer et al., 1997).
In conclusion, our study does not support several earlier
reports that AW may be more severe in older alcoholics.
However, it is worth remembering that the population of
alcohol-dependent persons aged >40 years is more susceptible
to serious somatic disorders and the somatic complications of
AW. Moreover, those older patients who experience repeated
 AGE AND ALCOHOL WITHDRAWAL
withdrawal episodes are more prone to develop withdrawal
seizures or delirium tremens. Therefore, they need careful
medical assessment, monitoring and treatment in closely
supervised detoxification settings.
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