INTRODUCTION: Alcohol withdrawal in older adults, despite being prevalent, is an understudied and thus poorly understood syndrome. The lack of evidence-based studies regarding presentation, diagnosis, treatment, and outcomes has led to poor recognition and often inadequate treatment of this syndrome in older adults. MANUSCRIPT 1: Alcohol Withdrawal in the Elderly: A Systematic Review OBJECTIVES: To identify the current evidence about alcohol withdrawal syndrome and treatment in older adults. METHODS: Using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, we conducted a systematic review of articles from 1/1/1980-6/1/2012. The search included several databases and used plain language key words such as alcohol withdrawal, alcohol withdrawal syndrome, alcohol withdrawal seizures, alcohol withdrawal delirium, ethanol withdrawal, and alcoholism. Studies that included and/or focused on older adults were included. The details of the study design, participant characteristics, study setting, assessment, and outcome data were extracted from each of the included studies. RESULTS: Seven studies were identified and all were descriptive cohort studies; 3 prospective, 2 retrospective, and 3 retrospective and prospective. All studies included both younger and older adults. More severe withdrawal was reported in several, but not all, studies. Similar findings were seen with respect to duration of hospitalization, frequency of delirium tremens, and dosages of benzodiazepines. CONCLUSIONS: The literature regarding older adults and alcohol withdrawal is limited with only seven studies to date. The small pool of existing literature provides no consensus on how older adults manifest with and are treated for alcohol withdrawal. MANUSCRIPT II: Alcohol Withdrawal in the Elderly: A Descriptive Study OBJECTIVES: To describe the population of older adults with alcohol withdrawal who present to the Emergency Department (ED) and are admitted to the hospital. METHODS: We conducted a retrospective chart review of patients aged ? 65 years who presented to the ED and were admitted and treated for alcohol withdrawal syndrome (AWS). Potential patients were identified using ICD-9 codes for alcohol-induced mental disorders. Patients were excluded if no alcohol withdrawal treatment was administered or the subject was directly admitted to the psychiatry service. Data regarding demographics, symptoms, treatments, and outcomes were collected. RESULTS: A total of 211 patients were screened and 90 (mean age 73 years, 59% men) were given a diagnosis of AWS and are included in this analysis. The most common physical comorbidity reported was hypertension (16%) and coronary artery disease (19%); 16% had multiple (? 3) major physical comorbidity. The chief complaint was alcohol-related (48%), trauma (30%), followed by psychiatric conditions (13%); 13% were suicidal at presentation. Tremors were documented in 42% of cases, and were present for 32%. Hyperreflexia was not documented in 99% of cases. Tongue fasciculations were documented in 13% and were present in 10%. In total, 59% received at least one dose of a benzodiazepine in the ED; specifically lorazepam (12%), diazepam (21%) or chlordizepoxide (4%); an additional 22% received a combination of these. For 41%, no benzodiazepine was ordered in the ED. The standard Clinical Institute Withdrawal Assessment protocol was followed in 41%. Based on post-discharge surveillance, 36 patients (25%) presented to the ED again within 30 days; of these 18 had alcohol-related conditions, 10 had trauma, 3 had psychiatric conditions, and 14 had other diagnoses. CONCLUSIONS: Commonly held notions that elderly patients with AWS are more likely to have multiple comorbidities, live alone, and present with a traumatic or infectious complaints, are not universally correct. ED physicians likely need to re-assess how they approach older adults, to raise their index of suspicion for alcohol withdrawal in this population, and to be more systematic and efficient in identifying older adults with AWS.