NURS 751 Week 4 Symptom Analysis Evaluation 2 on Nightly Drinking After Bereavement Example

Three Bourbons to Fall Asleep, Fourteen Months After Her Death: A Symptom Analysis Evaluation of Nightly Drinking in a 66-Year-Old Widower That Arrives at Alcohol Use Disorder

Case Presentation

Mr. H., 66, who taught high school chemistry for thirty years, was referred by his primary care nurse practitioner after a second fall at home in three months and a liver panel showing a gamma-glutamyl transferase of 118 units per liter. His wife of 39 years died of ovarian cancer fourteen months ago. He presents with "trouble sleeping since she passed" and says he has "a drink or two to get to sleep." He lives alone in their house, sees his daughter on Sundays and stopped attending his church after the funeral because "everyone looks at me like I'm going to break."

He drank socially before his wife's illness, a beer or two on weekends. During her last months he began having a bourbon at night after she fell asleep. Since her death, the amount has grown. He takes lisinopril and atorvastatin and no other medications, denies opioid or sedative use and has no history of withdrawal seizures. He owns a shotgun, kept from years of hunting with his late brother. He denies suicidal intent but says some nights he "wouldn't mind not waking up."

Symptom Analysis

The chronic symptom under evaluation is nightly drinking used to induce sleep and manage grief.

The analysis shows a symptom with a clear function: alcohol helps him fall asleep and dulls grief in the evening. It also shows escalation, failed attempts to cut down and harm. Those three features shift the question from whether he drinks too much to whether he has lost control over drinking.

Assessment

Interview

Older adults often underreport drinking, partly from shame. Carlat (2017) recommends techniques that make honest disclosure easier, such as normalization ("many people who lose a spouse find themselves drinking more at night") and symptom expectation, asking how much rather than whether, and starting with a high estimate so the patient can correct downward. When I asked whether he drank closer to a fifth a week or more, he said, "Less than that, maybe a bottle every ten days," which suggests about three to four drinks a night, consistent with his estimate.

Screening and Biomarkers

He scored 14 on the AUDIT, a level that points to harmful drinking and may signal dependence. Because self-report can understate drinking, I ordered a phosphatidylethanol level, which reflects drinking over the preceding weeks. In a study of 4,063 psychiatric outpatients who completed both PEth testing and the AUDIT, AUDIT scores correlated strongly with PEth, and an AUDIT score of 5 or more discriminated hazardous use, defined as PEth of 0.3 micromoles per liter or higher, with an area under the curve of 0.80 (Lundholm et al., 2026). His PEth was 0.62 micromoles per liter, confirming sustained heavy drinking.

Medical Assessment

Alcohol-related liver disease is often silent; most patients have no symptoms or only fatigue, and older age and longer drinking increase the risk of progression (Krag et al., 2026). His liver panel showed a gamma-glutamyl transferase of 118 units per liter, an aspartate aminotransferase of 52 and an alanine aminotransferase of 38, with normal bilirubin and albumin; his mean corpuscular volume was 101. I calculated a Fibrosis-4 score, which was below the threshold for advanced fibrosis, and recommended follow-up with his primary care nurse practitioner. A basic metabolic panel showed normal kidney function. I checked vitamin B12 and folate and started thiamine.

Withdrawal Risk, Cognition and Safety

He reports no past seizures or confusion when he stopped drinking, no morning drinking and no tremor after his short abstinent periods, which suggests low risk of complicated withdrawal at his current level. His Montreal Cognitive Assessment score was 26 of 30, with points lost on delayed recall. Because he owns a firearm and has passive death wishes, I asked directly about suicide. He denied plans or intent, but agreed to let his daughter store the shotgun at her house.

Differential Diagnosis

Grief is the context but not the full explanation. The drinking began as a response to loss and now has a life of its own, with tolerance, failed attempts to stop and harm. His pattern also fits research on bereavement. In a national cohort of 25,957 older adults in Japan, spousal loss was associated with higher mortality and dementia risk among men, with men reporting more depression and hopelessness during the first year, and widowed men, unlike widowed women, increased their alcohol consumption and lost social support (Kawaguchi et al., 2026). His drinking began as grief's medicine and has become a second illness that grief alone will not cure.

Diagnosis

Mr. H. meets DSM-5 criteria for alcohol use disorder, moderate (American Psychiatric Association, 2013), with five of eleven criteria in the past twelve months: drinking in larger amounts than intended, persistent desire and unsuccessful efforts to cut down, failure to fulfill obligations, continued use despite physical problems caused or worsened by alcohol, including falls and liver injury, and tolerance. He does not meet criteria for withdrawal. Prolonged grief disorder, which entered the manual with the text revision (American Psychiatric Association, 2022), and major depressive disorder are deferred for reassessment once his drinking has decreased, since alcohol can produce depressive symptoms that resolve with abstinence.

Treatment Plan

Motivational Interviewing

He is ambivalent rather than resistant: he wants to sleep and does not want to fall again, but he fears the nights without a drink. Using motivational interviewing, I reflected his own reasons for change, his grandson's game and his fear of a broken hip, and asked what he would like to do. He chose to aim for no more than one drink a night for two weeks, then to try alcohol-free nights, with a goal he set himself of abstinence for three months.

Medication

After discussing options, we started naltrexone, which reduces heavy drinking and craving and can be taken once daily. His liver enzymes are only mildly elevated and his bilirubin normal, he takes no opioids, and I will repeat liver tests in four to six weeks. Acamprosate was the alternative if naltrexone was not tolerated, since his kidney function is normal. Adherence matters: in a national claims study of 51,915 adults starting medication for alcohol use disorder, the median time to discontinuation was 30 days, although older age was associated with staying on medication longer (Busch et al., 2026). I scheduled follow-up in two weeks to support adherence.

Grief, Sleep and Connection

I referred him to a bereavement group through a local hospice and to cognitive behavioral therapy for insomnia, which treats sleep without sedatives and gives him something to do at 8 p.m. other than sit in his wife's chair. We discussed returning to church, and he agreed to call his former Sunday school teacher. Woodworking in the evening, rather than television in her chair, became part of his plan.

Lapses and Relapse Prevention

We talked about what will happen if he drinks heavily again, which is likely at some point, especially around her birthday in March. A lapse will be treated as information rather than failure: we will look at what led to it and adjust the plan. He identified his two highest-risk times, the first evening after Sunday dinner with his daughter, when the house feels emptiest, and the week of their anniversary. For each he wrote a plan: calling his daughter or a friend from the bereavement group, working in the garage and keeping no bourbon in the house. He agreed that if he drinks more than three drinks on any night, he will tell me at the next visit, and that two such nights in a week would prompt an earlier appointment. Because naltrexone works best when taken consistently, he will keep it beside his coffee maker and use a weekly pill box.

Strengths

Mr. H. brings real strengths to treatment. He sought no excuses when the drinking was named, he is close to his daughter and grandchildren, he has a lifelong habit of careful work and he still has a church community that remembers him and his wife. His grief reflects a long and loving marriage, and in time it can become a source of meaning rather than a reason to drink. These strengths make outpatient treatment appropriate.

Safety and Follow-Up

His daughter now keeps the shotgun. We completed a safety plan, and he will use a night light and grab bar in the bathroom. He will return in two weeks, then monthly, with a repeat PEth at three months to measure progress objectively, a repeat PHQ-9 and MoCA after a month of reduced drinking, and coordination with his primary care nurse practitioner on liver follow-up.

Conclusion

Mr. H.'s nightly drinking, analyzed by onset, amount, pattern, triggers and consequences and confirmed with the AUDIT and a phosphatidylethanol level, meets DSM-5 criteria for moderate alcohol use disorder in the setting of grief. The plan treats both: motivational interviewing and naltrexone for the drinking, bereavement support and insomnia therapy for what the drinking was treating, firearm and fall safety for the risks, and reassessment of depression and cognition once he is drinking less.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Busch, A. B., Hodgkin, D., Kennedy-Hendricks, A., Ritter, G. A., Uscher-Pines, L., Horgan, C. M., & Huskamp, H. A. (2026). Discontinuation of medications for alcohol use disorder in the United States: Patient, prescriber and medication predictors. Addiction, 121(10), 2691-2700. https://doi.org/10.1111/add.70498

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Kawaguchi, K., Nakagomi, A., Ide, K., Shirai, K., Koga, C., Chen, Y. R., Kondo, K., & Shiba, K. (2026). Health and well-being after spousal loss among older men and women. Journal of Affective Disorders, 403, Article 121391. https://doi.org/10.1016/j.jad.2026.121391

Krag, A., Åberg, F., Mellinger, J., Lee, B. P., & Israelsen, M. (2026). Alcohol-related liver disease: A review. JAMA, 336(5), 413-425. https://doi.org/10.1001/jama.2026.12038

Lundholm, L., Skånberg, J., Wallhed-Finn, S., & Lenhard, F. (2026). Identification of hazardous alcohol use in outpatient psychiatric care: A comparison of biomarker phosphatidylethanol (PEth) and self-report. Drug and Alcohol Dependence, 279, Article 113047. https://doi.org/10.1016/j.drugalcdep.2026.113047