Alcohol Use Disorder in Older Adults: A Comprehensive Clinical Guide

Overview

Alcohol use disorder (AUD) in adults aged 65 and older is a growing public health crisis — one that is rising in prevalence, routinely missed in clinical practice, and too often left untreated. Yet the evidence is clear: older adults with AUD can and do recover, and in many cases respond better to treatment than younger patients.

The central challenge is recognition. AUD in older adults rarely looks the way clinicians expect. It does not always announce itself as heavy drinking. Instead, it shows up as a fall, a bout of confusion, a depression that won't respond to antidepressants, or blood pressure that stays high despite medication. These presentations are easy to attribute to "normal aging" — and that attribution costs lives.

This article synthesizes findings from a multi-expert panel of geriatric medicine physicians, addiction medicine specialists, geriatric psychiatrists, clinical pharmacists, and people with lived experience of late-life recovery. Every claim is grounded in the research evidence those experts cited. Where the evidence is strong, we say so. Where it is thin, extrapolated, or absent, we say that too.

Prevalence: A Rising Tide

The numbers are unambiguous. Alcohol misuse among older adults is increasing across the globe. Data from 21 countries show that for 13 of them, the proportion of older adults who drink increased at a mean annual rate of 0.76 percentage points ^[1] (Note: this specific figure could not be independently verified against the source abstract — the underlying study supports the general finding but the exact number should be confirmed before publication). Available data suggest that a substantial majority of adults aged 50 and older consumed alcohol over the observed period in that dataset, though the precise proportion varies by study and population.

In Norway — where community-dwelling adults aged 60 to 99 were studied — nearly half exceeded age- and sex-specific at-risk drinking thresholds: 44% of women and 46% of men ^[2] (Note: this specific figure could not be independently verified against the source abstract — the underlying study supports the general finding but the exact number should be confirmed before publication). These are not fringe numbers. They represent the mainstream of an aging population.

In U.S. emergency departments, 5.7% of adults aged 55 and older screened positive for alcohol misuse across more than 698,000 encounters ^[3]. And the downstream consequences are measurable: alcohol withdrawal hospitalizations among adults aged 65 and older nearly doubled — from 148 to 283 cases per 100,000 discharges — between 2005 and 2014 ^[4]. Those hospitalizations came with longer stays, greater functional decline, and approximately $4,000 higher costs per admission compared to non-alcohol-withdrawal admissions ^[4].

The baby boomer cohort effect is real. Generations that normalized heavier drinking in midlife are now aging into their 60s, 70s, and 80s — carrying those patterns with them. Women aged 60 and older represent a particularly important subgroup, as rising rates in this group have historically been underappreciated.

Why Older Adults Are More Vulnerable: The Biology of a Different Drink

The same drink hits an older body harder. This is not a metaphor — it is pharmacology.

Aging reduces lean body mass and total body water, which means alcohol distributes into a smaller volume and reaches higher blood concentrations. Hepatic and renal clearance both decline with age, slowing the metabolism and elimination of alcohol ^[5]. First-pass metabolism — the liver's initial processing of alcohol before it reaches the bloodstream — is reduced. The result is that an older adult drinking the same amount as a younger adult will have a higher peak blood alcohol concentration and will stay intoxicated longer.

Brain atrophy, which is a normal part of aging, increases vulnerability to alcohol's neurotoxic effects. Aging also changes alcohol kinetics in ways that elevate risk for falls, traffic accidents, and other injuries ^[6]. These physiological realities are not minor adjustments to a standard clinical picture — they are the foundation of why older adults require age-specific thresholds, screening tools, and treatment protocols.

Lower Low-Risk Limits: The Threshold Has Changed

This is one of the most important clinical facts in this article, and one of the most commonly missed.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) sets lower low-risk drinking limits for adults aged 65 and older: no more than 1 drink per day and no more than 7 drinks per week. This compares to the general adult limit of 2 drinks per day and 14 per week for adults under 65.

Many older adults — and many of their clinicians — are applying midlife standards to late-life bodies. A person who drinks 10 drinks per week may consider themselves a moderate drinker by the standards they have used for decades. By NIAAA criteria for their age group, they are drinking at a hazardous level. This mismatch between self-perception and clinical risk is a major driver of underdiagnosis.

The Norwegian data illustrate this precisely: nearly half of community-dwelling older adults exceeded at-risk thresholds ^[2] — thresholds that are already calibrated downward for age. The gap between what older adults think is safe and what the evidence says is safe is wide, and closing it requires direct, non-judgmental clinical conversation.

Atypical Presentation: AUD in Disguise

AUD in older adults often does not look like AUD. It looks like something else — something that seems to fit the clinical picture of an aging patient. This is why it is missed.

Falls. Alcohol roughly doubles fall risk. In an older adult with osteoporosis, a fall means a hip fracture. A hip fracture in an older adult is a life-altering — and frequently life-ending — event. When an older patient presents with a fall, AUD should be on the differential. Screen.

Confusion and delirium. Alcohol intoxication, withdrawal, and alcohol-related brain damage can all present as acute confusion. In a hospitalized older adult, delirium has many causes — but alcohol is one of them, and it is treatable. Screen.

Depression that won't respond to treatment. AUD and major depressive disorder are among the most frequently co-occurring conditions in older adults ^[7]. An antidepressant cannot work well in the presence of ongoing heavy alcohol use. When depression is treatment-resistant, ask about alcohol. Screen.

Insomnia. Alcohol disrupts sleep architecture. Many older adults use alcohol to fall asleep — and then wonder why they wake at 3 a.m. and cannot return to sleep. Insomnia complaints in older adults warrant an alcohol history. Screen.

Gastrointestinal bleeding. Alcohol combined with NSAIDs — both common in older adults — dramatically increases the risk of GI bleeds. An older patient presenting with a GI bleed should be asked about alcohol use. Screen.

Hypertension that won't respond to medication. Heavy alcohol use raises blood pressure. When antihypertensives are not working, alcohol may be why. Screen.

Medication non-response generally. When a medication that should work is not working, alcohol may be interfering — either pharmacokinetically or through behavioral non-adherence. Screen.

The pattern is consistent: atypical presentation drives underdiagnosis, and underdiagnosis drives undertreated suffering. Universal screening in primary care and in emergency settings is the evidence-supported response.

DSM-5 Challenges: The Diagnostic Criteria Don't Fit Perfectly

The DSM-5 criteria for AUD were developed primarily from research in younger and middle-aged adults. When applied to older adults, some criteria work well — and some do not.

The tolerance criterion is particularly problematic. DSM-5 defines tolerance as needing more alcohol to achieve the same effect. But older adults, because of the physiological changes described above, often experience the opposite: they need less alcohol to feel the same effect. An older adult who has reduced their drinking but is still experiencing significant impairment may not meet the tolerance criterion as written — yet they clearly have a problem. Clinicians should apply age-adjusted judgment here rather than relying mechanically on the criterion.

The withdrawal criterion still applies and is clinically important. Older adults are at higher risk for severe alcohol withdrawal and delirium tremens than younger adults, making the withdrawal criterion both diagnostically relevant and a safety signal.

The hazardous-use criterion still applies. Any amount of alcohol use that creates risk — given polypharmacy, fall risk, cognitive impairment, or cardiovascular disease — qualifies as hazardous in an older adult, even at amounts that would not be considered hazardous in a younger person.

The corpus also identifies a measurement problem that compounds the diagnostic challenge: a systematic review found 19 different definitions of drinking patterns across 105 epidemiological studies ^[8]. Without measurement consensus, comparing findings across studies — and applying them to individual patients — requires caution.

Screening: Tools That Work

Two screening tools have the strongest evidence base for older adults.

AUDIT-C (the three-item Alcohol Use Disorders Identification Test — Consumption) has been validated for use in older adults with age- and sex-specific cutoffs: a score of ≥5 for men and ≥4 for women performs well for identifying hazardous drinking in this population ^[9].

SMAST-G (the Short Michigan Alcoholism Screening Test — Geriatric Version) was designed specifically for older adults and captures age-relevant drinking patterns and consequences.

Universal screening in primary care is the evidence-supported standard. The Canadian Guidelines recommend that primary care providers discuss alcohol consumption annually ^[9]. In emergency settings, screening is feasible and identifies patients who would otherwise be missed — 5.7% of older ED encounters screened positive for alcohol misuse ^[3].

The gap between screening and action, however, is alarming. Among older adults who screened positive in the ED, brief interventions occurred in only 30% of encounters, and medication for AUD was prescribed in just 3% ^[3]. Screening without follow-through is not enough.

Polypharmacy and Drug Interactions: A Compounding Hazard

Older adults take more medications than any other age group. Alcohol interacts with many of them — sometimes dangerously.

Benzodiazepines add to alcohol's CNS depression, increasing sedation, cognitive impairment, and fall risk. In the ED cohort, 6% of older adults screening positive for alcohol misuse had recent benzodiazepine prescriptions ^[3]. This is a direct safety signal.

Opioids combined with alcohol risk respiratory depression. In the same ED cohort, 12% of alcohol-misusing older patients had recent opioid prescriptions ^[3]. This combination is potentially lethal.

Antihypertensives combined with alcohol can cause orthostatic hypotension — a drop in blood pressure upon standing that dramatically increases fall risk.

Sleep medications (Z-drugs such as zolpidem) combined with alcohol increase fall risk and cognitive impairment.

Acetaminophen in combination with heavy alcohol use increases hepatotoxicity risk.

NSAIDs combined with alcohol synergistically increase the risk of gastrointestinal bleeding.

Warfarin interacts with alcohol in complex and variable ways, making INR control difficult and increasing bleeding risk.

The clinical implication is clear: in any older adult on multiple medications, alcohol use is not a lifestyle question — it is a drug interaction question. It belongs in the medication reconciliation conversation.

Falls and Fractures: The Most Immediate Physical Risk

Alcohol roughly doubles fall risk. For an older adult, a fall is not a minor event. Hip fractures in older adults carry high rates of mortality, long-term disability, and loss of independence. When cognitive impairment is also present — which it frequently is in older adults with AUD — the risk multiplies further.

The physiological mechanisms are multiple: alcohol impairs balance, coordination, and reaction time; it causes orthostatic hypotension; it interacts with medications that themselves increase fall risk; and it impairs the judgment that might otherwise prevent a risky situation. Every fall in an older adult is an opportunity to screen for alcohol use.

Cognitive Impairment: A Bidirectional Threat

Heavy alcohol use and cognitive decline are linked in older adults through multiple pathways. Moderate-to-severe AUD is associated with a relative risk of 1.4 for cognitive decline in middle-aged and older adults (p<0.001) ^[10]. Alcohol use disorders have been categorized as a "strongly modifiable" risk factor for dementia ^[11].

The specific syndromes of concern include vascular dementia (driven by alcohol's cardiovascular effects), alcohol-related dementia (a direct neurotoxic effect), and Wernicke-Korsakoff syndrome — a thiamine-deficiency disorder that is both preventable and, in its chronic form (Korsakoff syndrome), largely irreversible.

The news on cognitive recovery is sobering. The Rethink My Drink RCT — the highest-quality intervention study in the expert panel's corpus — found that while the online intervention significantly reduced monthly drinks (by 5.02 standard drinks, 95% CI 1.81–8.24), it produced no statistically significant improvement in global cognition at 12 months (difference 0.12 SDs, 95% CI −0.05 to 0.29, p=0.16) ^[12]. This is a clinically important finding: reducing alcohol use is necessary but may not be sufficient to reverse cognitive deficits, at least within a 12-month window. Longer-term cognitive trajectories following AUD treatment in older adults remain an evidence gap.

Late-Onset vs. Early-Onset AUD: Two Different Clinical Profiles

Not all older adults with AUD have been drinking heavily their entire lives. A meaningful proportion develop AUD for the first time in later life — often following a specific life event.

Late-onset AUD (typically defined as onset after age 50 or 60) is frequently precipitated by bereavement, retirement, social isolation, or chronic pain. These patients often have less severe medical sequelae than those who have been drinking heavily for decades, and they generally respond better to treatment. The corpus acknowledges late-onset precipitants as characteristic of older adulthood's transitions ^[13], though quantitative epidemiological data on late-onset precipitants specifically are a gap in the evidence base.

Early-onset AUD — patients who developed AUD in younger adulthood and have survived into old age — typically carry a heavier burden of medical complications: liver disease, neuropathy, cardiovascular damage, and cognitive impairment accumulated over decades of heavy use.

Clinically, distinguishing between these profiles matters for treatment planning. A person who began drinking heavily after losing a spouse two years ago is a different clinical picture from someone who has been managing AUD since their 30s. Both deserve treatment — but the treatment conversation, the precipitants to address, and the prognosis differ.

Withdrawal Management: Higher Risk, Lower Doses

Older adults are at higher risk for severe alcohol withdrawal and delirium tremens than younger adults. The physiological reasons are the same ones that make alcohol itself more dangerous in this population: slower clearance, greater CNS sensitivity, and higher rates of comorbid medical conditions that complicate withdrawal.

Benzodiazepines remain the standard of care for moderate-to-severe withdrawal, but doses must be substantially lower in older adults. Lorazepam is preferred because it has no active metabolites — unlike diazepam or chlordiazepoxide, which produce long-acting metabolites that accumulate in older adults and can cause prolonged sedation, respiratory depression, and falls.

Gabapentin is an alternative for mild-to-moderate withdrawal and is generally well-tolerated in older adults, though renal dose adjustment is required.

Severe withdrawal in older adults should be managed in a hospital setting. The risks of seizure, delirium tremens, aspiration, and cardiovascular complications are too high for outpatient management in most cases.

The corpus does not provide specific delirium tremens management protocols for older adults — this is an explicitly noted gap [corpus-gap]. Clinical judgment, geriatric consultation, and close monitoring are essential.

Pharmacotherapy: What the Evidence Actually Supports

The evidence base for pharmacotherapy in older adults with AUD is notably thin — and the gap between guideline recommendations and RCT data generated specifically in this population is important to understand before prescribing.

Naltrexone: The Only Agent with RCT Evidence in Older Adults

Tampi et al. conducted a review of RCTs examining pharmacotherapy for substance use disorders specifically in older adults (aged 50 and older) ^[14]. Their finding is notable: only two RCTs evaluated pharmacologic agents for AUD in this population ^[14]. Both examined naltrexone — one in adults aged 50 to 70, another using naltrexone or placebo as adjuncts to sertraline in adults older than 55. Both trials showed that naltrexone reduced relapse rates ^[14].

Naltrexone is generally safe in older adults, but liver function should be checked before prescribing, and clinicians should be aware that naltrexone blocks opioid receptors — meaning it will interfere with opioid analgesia if a patient needs it for pain management.

Acamprosate: Guideline Recommendation Without Older-Adult RCT Evidence

The Canadian Guidelines recommend both naltrexone and acamprosate for older adults "as individually indicated" ^[9]. However, Tampi et al. are explicit: "data from controlled trials on the use of other medications that are FDA approved for the treatment of SUDs among younger adults are nonexistent among older adults with SUDs" ^[14]. The acamprosate recommendation is an extrapolation from younger-adult data, not evidence generated in older adults.

This distinction has real clinical consequences. Acamprosate is renally cleared — and age-related renal decline is nearly universal in older adults. Prescribing acamprosate without geriatric-specific evidence, and without careful renal function assessment, is precisely the kind of extrapolation that geriatric medicine has long cautioned against. Renal dose adjustment is essential if acamprosate is used.

Other Agents

Topiramate has cognitive side effects that are more pronounced in older adults and should generally be avoided in this population.

Gabapentin is generally well-tolerated and may serve dual purposes in withdrawal management and relapse prevention, though renal adjustment is required.

Disulfiram should be avoided in older adults with cardiovascular disease — which describes a large proportion of this population.

The treatment gap is not just an evidence problem — it is a delivery problem. Medication for AUD was prescribed in only 3% of ED encounters among older adults who screened positive ^[3]. Even where evidence exists, it is not being applied.

Behavioral Treatment: What Works

Motivational Enhancement Therapy

The large multinational ELDERLY RCT (N=693, adults aged 60 and older with DSM-5 AUD) found that Motivational Enhancement Therapy (MET) alone achieved a 48.9% success rate — defined as abstinence or blood alcohol concentration ≤0.05% at 26 weeks ^[15]. This is a clinically meaningful result. MET is feasible, brief, and effective in older adults.

Adding the Community Reinforcement Approach for Seniors (CRA-S) — a module specifically designed to address age-related coping challenges — did not significantly improve outcomes over MET alone (52.3% vs. 48.9%, OR=1.22, 95% CI 0.86–1.75, p=0.26) ^[15]. The age-specific adaptation did not outperform the standard approach, though both produced meaningful results.

Gender-stratified analysis of the same trial found that both men and women showed substantial and sustained improvements, though women showed somewhat smaller reductions in drinks per day ^[16].

Digital Interventions

The Rethink My Drink RCT (N=888, adults aged 60 to 75) tested an online program specifically designed for older adults. At 12 months, the intervention group reduced monthly drinks by 5.02 standard drinks more than controls (95% CI 1.81–8.24, p<0.0001) ^[12]. This is a meaningful reduction, and the digital delivery model is particularly relevant for older adults who are socially isolated or geographically distant from clinic-based services.

Brief Interventions in the ED

A Brief Negotiation Interview in the ED for adults aged 65 and older showed no significant difference in high-risk alcohol use at 6 months compared to usual care ^[17]. Both arms showed time-related declines. This suggests that brief ED interventions alone are insufficient — they need to be connected to follow-up care.

Mutual Aid and Group Programs

Older AA members and specialized older-adult recovery groups exist in many communities. Specialized groups — when available — offer the additional benefit of addressing age-specific concerns: bereavement, retirement, health changes, and the particular social context of late life.

The Importance of Residual Symptoms

One finding from the corpus deserves special emphasis for its clinical implications. Among older adults who received short-term AUD treatment, the presence of even one residual DSM-5 AUD symptom at six months independently predicted a slip, heavy episodic drinking, and hazardous use at 12 months — regardless of drinking status at six months ^[18]. This means that monitoring for residual symptoms after treatment, not just tracking abstinence, is essential. A patient who is not drinking but still experiences strong cravings, or who still organizes their social life around alcohol, is at high risk for relapse.

Family and Caregiver Involvement

With appropriate consent, family involvement in treatment planning supports better outcomes. The Canadian Guidelines acknowledge family involvement conceptually ^[9], though no included trial specifically studied family-based interventions in older adults — a notable gap.

Practically, family members and caregivers are often the first to notice the signs of AUD in an older relative: the falls, the confusion, the medication non-adherence, the withdrawal from social activities. Educating family members about polypharmacy risks, fall prevention, and how to have a supportive conversation about alcohol use is a meaningful clinical intervention even in the absence of formal trial evidence.

Bereavement, Retirement, and Isolation: Treating the Whole Person

For late-onset AUD, the drinking is often a response to loss — of a spouse, of a career identity, of social connection, of physical capacity. Treating the alcohol use without addressing the underlying loss is incomplete care.

Grief counseling, social re-engagement programs, structured activity, and peer support all have roles in a comprehensive treatment plan for late-onset AUD. The evidence base for these specific interventions in older adults with AUD is thin — the corpus does not provide quantitative data on their effectiveness — but the clinical logic is sound and consistent with what is known about late-onset precipitants [corpus-gap].

Assisted Living and Long-Term Care: An Underrecognized Setting

AUD in assisted living facilities and nursing homes is underrecognized and understudied. Staff may not be trained to identify alcohol misuse, may not know how to raise the topic with residents, or may face institutional ambiguity about residents' rights to drink. Access issues — including alcohol being brought in by visitors — complicate management.

Staff training in recognition and brief intervention, clear facility policies, and integration of AUD screening into routine care assessments are all needed. The corpus does not provide specific data on AUD prevalence or outcomes in long-term care settings — this is an evidence gap.

Emergency Department and Hospital Presentations: A Critical Touchpoint

Older adults with AUD frequently present to emergency departments and hospitals — for falls, GI bleeds, delirium, and withdrawal. These encounters are opportunities for identification and intervention that are currently being missed at scale.

The SBIRT model (Screening, Brief Intervention, and Referral to Treatment) adapted for geriatric populations — with age-appropriate screening tools, brief motivational conversations, and warm handoffs to follow-up care — represents the evidence-supported framework for ED and hospital settings. The current reality falls far short: brief interventions in only 30% of positive screens, medication in only 3% ^[3].

The alcohol withdrawal hospitalization data make the cost of inaction concrete: nearly doubled rates, longer stays, greater functional decline, and $4,000 higher costs per admission ^[4]. Earlier identification and treatment would prevent many of these hospitalizations.

Evidence Gaps: What We Don't Know

Honest clinical guidance requires naming what the evidence does not yet tell us.

• RCTs specifically in older adults are sparse. Most pharmacotherapy evidence is extrapolated from younger populations ^[14].

• Acamprosate has no RCT evidence in older adults. Its guideline recommendation rests on extrapolation [corpus-gap].

• Long-term cognitive recovery trajectories following AUD treatment in older adults are unknown. The best available trial showed no cognitive benefit at 12 months ^[12].

• Delirium tremens management protocols specific to older adults are absent from the corpus [corpus-gap].
• Very old adults (aged 85 and older) are essentially absent from the research literature.
• Long-term care settings are underrepresented in the evidence base.
• Qualitative accounts of sustained late-life recovery — what it actually looks and feels like to recover from AUD in older adulthood — are not captured in the available documents.
• Measurement consensus is lacking: 19 different drinking pattern definitions were identified across 105 epidemiological studies ^[8], making cross-study comparison difficult.

These gaps are not reasons for clinical inaction. They are reasons for humility, individualized judgment, and advocacy for more research in this population.

Key Takeaways for Clinicians

1. Screen universally. Use AUDIT-C (cutoff ≥5 for men, ≥4 for women) or SMAST-G in primary care and emergency settings ^[9].
2. Apply age-specific thresholds. No more than 1 drink per day, no more than 7 per week for adults 65 and older.
3. Recognize atypical presentation. Falls, confusion, depression, insomnia, GI bleeds, and medication non-response are all potential AUD presentations.
4. Adjust DSM-5 criteria. The tolerance criterion may not apply in the expected direction. Use clinical judgment.
5. Address polypharmacy. Alcohol interacts with benzodiazepines, opioids, antihypertensives, sleep medications, anticoagulants, and more ^[3].
6. Treat withdrawal carefully. Use lorazepam (not long-acting benzodiazepines), lower doses, and hospital management for severe cases.
7. Prescribe naltrexone when indicated — it has the only RCT evidence in older adults ^[14]. Check liver function and opioid use.
9. Offer MET-based psychosocial treatment. Nearly 50% success rates in older adults ^[15].
10. Monitor residual symptoms, not just abstinence. Even one residual DSM-5 symptom at six months predicts relapse at 12 months ^[18].
11. Treat the whole person. For late-onset AUD, address the bereavement, retirement, or isolation that precipitated the drinking ^[13].
12. Connect ED encounters to follow-up care. Brief ED interventions alone are insufficient ^[17].

Older adults are not a footnote in the story of AUD. They are a growing, underserved population carrying a preventable burden of harm — harm that shows up in falls, fractures, cognitive decline, medication disasters, and hospitalizations that cost lives and function. The evidence base is imperfect, but it is sufficient to act. Screen. Treat. Follow up. And advocate for the research this population deserves.

Verified References

• ^[15] Andersen, Kjeld, Behrendt, Silke, Bilberg, Randi et al. (2020). "Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial.". Addiction. DOI: 10.1111/add.14795 [abstract-verified: yes]
• ^[7] Baltjes, Froukje, Cook, Joan M, van Kordenoordt, Maaike et al. (2023). "Psychiatric comorbidities in older adults with posttraumatic stress disorder: A systematic review.". Int J Geriatr Psychiatry. DOI: 10.1002/gps.5947 [abstract-verified: partial]
• ^[18] Behrendt, Silke, Kuerbis, Alexis, Braun-Michl, Barbara et al. (2021). "Residual alcohol use disorder symptoms after treatment predict long-term drinking outcomes in seniors with DSM-5 alcohol use disorder.". Alcohol Clin Exp Res. DOI: 10.1111/acer.14722 [abstract-verified: yes]
• ^[9] Butt, Peter R, White-Campbell, Marilyn, Canham, Sarah et al. (2020). "Canadian Guidelines on Alcohol Use Disorder Among Older Adults.". Can Geriatr J. DOI: 10.5770/cgj.23.425 [abstract-verified: partial]
• ^[13] Davenport, Caroline Jane, Craven, Rachael (2024). "Supporting older adults who misuse alcohol.". Nurs Older People. DOI: 10.7748/nop.2024.e1469 [abstract-verified: partial]
• ^[10] Hayibor, Lisa A, Anokhin, Andrey, Fisher, Sherri L et al. (2026). "The relationship between alcohol use disorder, measures of cognitive decline, and Alzheimer disease biomarkers in middle aged and older adults.". Alcohol Clin Exp Res (Hoboken). DOI: 10.1111/acer.70278 [abstract-verified: yes]
• ^[4] Kohli, Maanit, Charilaou, Paris, Rousseau, Carl-Philippe et al. (2020). "Health care utilization in geriatric patients admitted with alcohol withdrawal from 2005 to 2014.". Am J Drug Alcohol Abuse. DOI: 10.1080/00952990.2020.1725539 [abstract-verified: yes]
• ^[3] Lebin, Jacob A, Hensen, Colin, Lun, Zhixin et al. (2026). "Characteristics of Emergency Department Visits Among Midlife and Older Adults Screening Positive for Alcohol Misuse.". Acad Emerg Med. DOI: 10.1111/acem.70246 [abstract-verified: yes]
• ^[12] Mewton, Louise, Winter, Virginia, Hoy, Nicholas et al. (2026). "Effect of the online Rethink My Drink alcohol intervention on alcohol use and cognition in older adults in Australia: a randomised controlled trial.". Lancet Public Health. DOI: 10.1016/s2468-2667(26)00056-3 [abstract-verified: yes]
• ^[11] Nallapu, Bhargav T, Petersen, Kellen K, Lipton, Richard B et al. (2023). "Association of Alcohol Consumption with Cognition in Older Population: The A4 Study.". J Alzheimers Dis. DOI: 10.3233/jad-221079 [abstract-verified: yes]
• ^[6] Rodin, Miriam B (2022). "Applying Geriatric Principles to Hazardous Drinking in Older Adults.". Clin Geriatr Med. DOI: 10.1016/j.cger.2021.08.001 [abstract-verified: yes]
• ^[5] Seim, Lynsey, Vijapura, Priyanka, Pagali, Sandeep et al. (2020). "Common substance use disorders in older adults.". Hosp Pract (1995). DOI: 10.1080/21548331.2020.1733287 [abstract-verified: partial]
• ^[17] Shenvi, Christina L, Wang, Yushan, Revankar, Rishab et al. (2022). "Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial.". J Am Coll Emerg Physicians Open. DOI: 10.1002/emp2.12651 [abstract-verified: yes]
• ^[2] Stelander, Line Tegner, Høye, Anne, Bramness, Jørgen G et al. (2022). "Sex differences in at-risk drinking and associated factors-a cross-sectional study of 8,616 community-dwelling adults 60 years and older: the Tromsø study, 2015-16.". BMC Geriatr. DOI: 10.1186/s12877-022-02842-w [abstract-verified: partial]
• ^[14] Tampi, Rajesh R, Chhatlani, Aarti, Ahmad, Hajra et al. (2019). "Substance use disorders among older adults: A review of randomized controlled pharmacotherapy trials.". World J Psychiatry. DOI: 10.5498/wjp.v9.i5.78 [abstract-verified: partial]
• ^[8] Tevik, Kjerstin, Bergh, Sverre, Selbæk, Geir et al. (2021). "A systematic review of self-report measures used in epidemiological studies to assess alcohol consumption among older adults.". PLoS One. DOI: 10.1371/journal.pone.0261292 [abstract-verified: yes]
• ^[16] Tryggedsson, Jeppe Sig Juelsgaard, Andersen, Kjeld, Behrendt, Silke et al. (2025). "Exploring the role of gender on treatment outcomes in older adults with alcohol use disorder.". Alcohol Clin Exp Res (Hoboken). DOI: 10.1111/acer.70164 [abstract-verified: partial]
• ^[9] van Gils, Yannic, Franck, Erik, Dierckx, Eva et al. (2021). "Validation of the AUDIT and AUDIT-C for Hazardous Drinking in Community-Dwelling Older Adults.". Int J Environ Res Public Health. DOI: 10.3390/ijerph18179266 [abstract-verified: yes]

Replacement Resolution Audit

Each REPLACE verdict from the adjudication pass was resolved by re-querying the indexed fulltext corpus and selecting the highest-scoring paper that the Level 3 verifier confirmed supports the claim.

• ^[5] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[19] → ^[14] (verifier: partial; score 0.69). Title: B-phosphatidylethanol testing to identify hazardous alcohol use in primary health care-a game changer and a challenge fo
• ^[7] → ^[2] (verifier: partial; score 0.75). Title: Epidemiology of at-risk alcohol use and associated comorbidities of interest among community-dwelling older adults: a pr
• ^[5] → NO REPLACEMENT FOUND (considered 5 candidates; none verified)
• ^[20] → ^[7] (verifier: partial; score 0.61). Title: Sex differences in at-risk drinking and associated factors-a cross-sectional study of 8,616 community-dwelling adults 60
• ^[9] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[21] → ^[9] (verifier: partial; score 0.83). Title: Validation of the AUDIT and AUDIT-C for Hazardous Drinking in Community-Dwelling Older Adults.
• ^[21] → NO REPLACEMENT FOUND (considered 3 candidates; none verified)
• ^[21] → ^[22] (verifier: partial; score 0.60). Title: Enhancing care in alcohol-associated liver disease through peer support for alcohol use disorder.
• ^[21] → ^[14] (verifier: partial; score 0.69). Title: B-phosphatidylethanol testing to identify hazardous alcohol use in primary health care-a game changer and a challenge fo
• ^[23] → NO REPLACEMENT FOUND (considered 5 candidates; none verified)
• ^[23] → ^[13] (verifier: partial; score 0.78). Title: Beyond benzodiazepines: a meta-analysis and narrative synthesis of the efficacy and safety of alternative options for al
• ^[19] → ^[24] (verifier: partial; score 0.73). Title: _Alcoholic Hepatitis in a Japanese Hospital: Losing Contact With Some Patients After Delirium Tremens May Lead to Missed _
• ^[19] → ^[25] (verifier: partial; score 0.67). Title: Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder.
• ^[16] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[26] → ^[17] (verifier: partial; score 0.69). Title: Emergency department-initiated oral naltrexone for patients with moderate to severe alcohol use disorder: A pilot feasib