DELIRIUM TREMENS

Lecture
Jolly Magulu
PCO School, Butabika
 DT IS AN EMERGENCY
• The most serious manifestation and potentially life threatening
consequence of alcohol withdrawal
• Occurs in about 5% to 10% of hospitalized patients with alcohol
problems
• Benzodiazepines are the mainstay of medication-treatment
• Oral or intravenous loading-dose regimens are preferred for
treatment
• Rapidly escalating doses of benzodiazepines titrated to symptom-
severity on structured scales
• Vitamin supplementation, adequate medical, nursing & supportive
care are other essential components
 MANAGING DT IS A LIAISON
PSYCHIATRIST’S JOB
• Liaison psychiatrists are expected to form an integral part of the
multidisciplinary team treating DTin emergency settings

• Only skilled & knowledgeable liaison psychiatrists relying on

standardized treatment-protocols can make certain that patients with
DTreceive adequate care

• The liaison psychiatrist also needs to ensure a safe & humane

withdrawal that protects the patient’s dignity & prepares the patient
for ongoing treatment of dependence
 SIZE OF THE PROBLEM
Gen. Medical Post op ICU Trauma
AUD 22.4% 10% -20% 10% -20% 43%
admissions admissions admissions admissions

AWS 10% 16% 20% 30%

admissions admissions admissions admissions

About 50% of persons with AUD (13 -71%) have symptoms of alcohol withdrawal
Rate of DT varies from 5% to 10% in those with symptoms of alcohol withdrawal
Rate of alcohol-withdrawal seizures is estimated at between 2-9%
30% of untreated patients go on to develop DT
During any stage of the alcohol withdrawal, transient hallucinations either visual or
tactile may occur in 3-10% of patients with severe withdrawal; no prognostic
significance
 RECOGNIZING DELIRIUM TREMENS
Severity Mild withdrawal Moderate withdrawal Severe withdrawal Delirium tremens

Clinical features Mild anxiety, Moderate severity of all Increased severity of all Hyperkinetic delirium
restlessness, insomnia, the symptoms the symptoms with marked confusion,
tremor, sweating, mild mentioned in mild mentioned in moderate disorientation &
headache withdrawal & withdrawal & mild agitation, severe
photosensitivity, pins confusion, autonomic tremors, severe
and needles sensation, symptoms and/or autonomic instability,
sensitivity to sounds withdrawal seizures hyperpyrexia, frank
hallucinations
Time since last drink 6 hours 6-24 hours 24-48 hours 48-72 hours

CIWA-Ar scores < 8-10 11-15 > 15 > 20- 25

Hyperkinetic delirium
Tremors
Autonomic storm
Hallucinations

Mild vs. Severe

Alcohol withdrawal delirium vs. DT
RECOGNIZING DELIRIUM TREMENS

• Mild symptoms appear 6-8 hours after abrupt cessation or reduction of drinking; in
the majority withdrawal syndrome is short-lived & limited to such minor symptoms,
which generally resolve well within 5 days with minimal or no medical treatment
• In others withdrawal symptoms escalate in severity over the first 48 to 72 hours of
the last drink culminating in the DT, or other severe withdrawal states such as
seizures and hallucinations

• Onset of DT is usually between 2-5 days of abstinence, though it might

occasionally take up to 7 days to manifest
• Onset of symptoms after 2 weeks - DT is highly unlikely
• Once fully manifest symptoms of DT last between 2-5 days; duration of is
less than 5 days in 62% of the individuals who develop DT
 SCALES FOR ASSESSMENT OF
ALCOHOL WITHDRAWAL
Instruments Description Severity grading
Clinical Institute 10 items; 8 point < 8-10: mild withdrawal
Withdrawal Likert scale (0-7) > 10 & <15: moderate
Assessment Interviewer withdrawal
Alcohol-revised administered >15: severe withdrawal
(CIWA-Ar) 24, 26
 SCALES FOR ASSESSMENT
OF ALCOHOL WITHDRAWAL
Instruments Description Severity
grading
ShortAlcohol Withdrawal 10 items; 4 point Likert <12: mild withdrawal
Scale (SAWS) 30 scale (0-3) > or = 12: moderate to
5 items each for the severe withdrawal
assessment of
psychological and physical
symptoms
Interviewer administered
Alcohol Withdrawal 11 items; 4 point Likert < or = 5: mild withdrawal
Syndrome (AWS) scale 31 scale (0-3) 6-9: moderate withdrawal
Interviewer administered > or = 10: severe
withdrawal
 RISK FACTORS FOR DT

• Heavy alcohol consumption for long periods

• Past h/o of DT or seizures
• Genetic predisposition
• De-compensated acute/chronic medical conditions
• Autonomic nervous system over-activity
• Blood alcohol levels on admission
• Low potassium level, low platelet count, high serumALT
and GGT
 MANAGING DT
Goals of treatment

• Balance between unnecessarily high doses of medication & doses

sufficient to minimize withdrawal to prevent progression from minor to
major withdrawal

• Initial goal - rapid & adequate control of agitation since this

reduces the incidence of clinically significant adverse events

• Prevention of medical morbidity, injuries and long-term sequelae

(e.g. Wernicke’s encephalopathy or Korsakoff’s syndrome)
 MANAGING DT
Goals of treatment

• Prompt recognition
• Appropriate pharmacotherapy
(Protocol-driven management with monitoring on the
CIWA-Ar or other scales)
• Supportive measures
 MANAGING DT
Goals of treatment

• Management of withdrawal only be a transitional step

towards long-term abstinence
• Asafe withdrawal which enables the patient to become
alcohol-free; a withdrawal that is humane & protects the
patient’s dignity & one which prepares the patient for on-
going treatment of dependence
PHARMACOLOGICAL MANAGEMENT

• Benzodiazepines drugs of choice

Although the efficacy of benzodiazepine and some non-
benzodiazepine alternatives in controlling withdrawal is probably
similar, benzodiazepines are the preferred alternatives mainly
because of their greater margin of safety

• Principal alternatives include anticonvulsants (mainly

carbamazepine), chlormethiazole, antipsychotics, barbiturates, beta-
blockers, alpha-2 adrenergic agonists and baclofen
• As efficacious as benzos. in mild to moderate withdrawal butefficacy
in preventing DTand withdrawal seizures is questionable
used as adjuncts
 BENZODIAZEPINE REGIMENS

• Fixed-schedule dosing
• Symptom-triggered
• Loading

• Loading-dose regimens (also referred to as “front-loading”) rely on

rapid administration high doses of medications in the early stages of
alcohol withdrawal till the patient is sedated, but can be aroused
• Commonly utilize diazepam because of its rapid onset of action and
long half-life, which allow for better titration, better titration and slow
taper of the medications to avoid breakthrough symptoms
 LORAZEPAM

• Longer onset may lead to iatrogenic over-sedation if titrated

to rapidly
• Preferred over diazepam in the presence of COPD, hepatic
dysfunction, renal dysfunction, age >65 years
• Lorazepam infusions carry risk of propylene glycol toxicity with
metabolic acidosis and renal failure, and have numerous drip
incompatibilities
1 mgof lorazepam = 5 mgof diazepam
 FRONT LOADING

• Loading-dose protocols are best suited for patients with a prior

history or current presentation of severe withdrawal complications
such as seizures or DT
• Rapid control of withdrawal symptoms leading to a five-fold
shortening of duration of symptoms and lesser requirement for
medications subsequently
• The most suitable regimens for treatment of DT are oral or
intravenous loading or rapid-loading regimens
 FRONT LOADING

• Rapidly escalating doses are driven by protocols using frequent

monitoring by structured scales (resembling symptom-triggered
treatment), with the options to intensify or de-escalate treatment
depending on the patient’s response

• Adjunctive treatment with phenobarbitone, antipsychotics or other

alternative medications is often needed in patients with severe DT
 FRONT LOADING
CIWA-Ar scores > 15 & clinical features of DT

• Oral or intravenous diazepam or lorazepam

• Bolus dose of 10-30 mgs diazepam equivalent every 5-10 minutes

until light sedation (drowsy but verbally responsive) is achieved or CIWA-
Ar scores are < 8
• Then 5 -20 mg every hour as maintenance; monitoring with CIWA-Ar every
10 minutes for first hour & every 2 hrs once stable along with monitoring of
vitals
• Initial treatment-duration 1-2 hours following which medications are tapered
over 72 hours & a less intensive medication regimen substituted
FRONT LOADING
 REFRACTORY DT

• In about 10% of the patients with DT are more difficult to manage

• Benzodiazepine resistant or refractory DTis present when patients

need greater > 40-50 mgs of diazepam in the first hour or > 200
mgs of diazepam in the first 3-4 hours to control their withdrawal
symptoms.

• Other definitions include non-response to 400 mg of diazepam in 8

hours, requirement of bolus doses of > 40 mgs of diazepam, or
persistence of CIWA-Ar scores of >25 despite adequate treatment.
 REFRACTORY DT
• Massive doses of medications, continuous infusions of alternative
sedative-hypnotics or antipsychotics , intubation &mechanical
ventilation
• Only possible in intensive care units
• Options include the use of loading with escalating doses of
benzodiazepines titrated to severity of withdrawal and the use of
adjunctive medications such as phenobarbitone, beta-blockers,
alpha-2 agonists and antipsychotics
• In patients who do not respond to the above medications, propofol
infusions are an alternative
 THIAMINE
• Wernicke's encephalopathy - confusion, ataxia & ophthalmoplegia -
often missed
• Mortality of 20%, with 75% developing a permanent severe
amnesticsyndrome (Korsokoff ’s psychosis)
• All patients in alcohol withdrawal should receive at least 250 mg
thiamine by the parenteral route once a day for the first 3-5 days,
whereas for those with suspected WE, thiamine 500 mg/day for 3-5
days is advised; total duration 2 weeks
• Concurrent administration of parenteral thiamine with glucose is
advised traditionally
• Multivitamin supplements on long-term basis
 MEDICAL, NURSING &
SUPPORTIVE CARE

• Treatment of possible medical or surgical complications

• Nursing in quiet & well-lit surroundings
• Frequent reassurance and reorientation
• Careful monitoring of vital signs, hydration & nutrition
• Temporary application of mechanical restraints if
required
 ROLE OF THE
(LIAISON) PSYCHIATRIST
• Key member of the multi-disciplinary team managing DT;
coordinate the various aspects of the patient’s care
• Should have knowledge of all aspects treatment of
alcohol withdrawal
• Should possess the skills required for adequate
management of patients with alcohol withdrawal
including DT
• Only skilled and knowledgeable liaison psychiatrists
relying on standardized treatment-protocols can make
certain that patients with alcohol withdrawal receive
adequate care
 ROLE OF THE
(LIAISON) PSYCHIATRIST

• After completion of withdrawal treatment, the liaison

psychiatrist needs to ensure that patients can
seamlessly transit from acute to long-term provided by
specialized substance-use services

• The psychiatrist has to make sure that the whole process

occurs in a safe and humane way, which preserves the
dignity of the patient suffering from alcohol withdrawal.