Delirium Tremens Management

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According to the World Health Organization global status report, about 38.3% are drinkers. [1] 

In the UK, alcoholism and alcohol use disorders is a severe problem. It affects approximately 6% of men and 2% of women, an average of 4% for individuals between 16 and 65. 

It's observed that about 31% of men and 16% of women have are drinking heavily. They drink beyond the low risk drinking standard. [2] 

Alcohol withdrawal can be a complex condition to manage for people with a history of alcoholism.

It’s a life-threatening condition that occurs when a person suddenly limits their alcohol intake or suddenly stop drinking alcohol altogether.  

And research indicates that about 20% of the global population has undergone alcohol abuse. Yet approximately 50% of them had experience withdrawal symptoms when trying to stop alcohol use.

And among them, 3% to 5% have exhibited severe withdrawal symptoms like autonomic hyperactivity, profound confusion, and cardiovascular failure called delirium tremens or alcohol withdrawal delirium. [3] 

Delirium tremens can be dangerous but don't fret; there's much more to learn about this condition. Keep reading! 

What Is Delirium Tremens? 

Delirium tremens is a mental health condition that is caused by alcohol abuse.

It results from prolonged alcohol dependence and is where you experience alcohol withdrawal symptoms such as withdrawal seizures, anxiety, and even tactile hallucinations.

Heavy drinking also strikes in as the person has more withdrawal reactions. It’s actually a severe alcohol withdrawal syndrome.  

The American Addiction Centres recommends that alcohol consumption levels be 7 drinks weekly for women and 14 for men. [4] 

Delirium tremens fall under the most severe form of alcohol withdrawal and might result in the death of the alcoholic if not immediately well managed.

It is prevalent with about 2% in people with alcohol dependence, and the general population rate could be below 1%. [5] 

But first; 

What are the signs and symptoms of alcohol withdrawal syndrome? 

Alcohol withdrawal symptoms can be uncomfortable for some people; others may exhibit no symptoms. 

Meanwhile, the distinct symptoms can last from a day to a month, depending on how much alcohol intake or dependence one has. 

They present eight hours after a significant fall in blood alcohol levels. On the second day, the peak, but by day five, the symptoms lessen. 

Minor withdrawal symptoms are observed around 6 to 12 hours after severe dependence. More symptoms are:  

  •  Fatigue  
  • Sleeplessness having withdrawal psychosis, such as anxiety, sleep disturbances, and depression.  
  • The shakes  
  • Fever  
  • Seizures   
  • Blood pressure increase  

So more severe symptoms of alcohol withdrawal and a medical history of withdrawal are the cause of delirium. Well, what are the signs and symptoms of delirium?  

Signs and Symptoms of Delirium Tremens 

Delirium has combined severe alcohol withdrawal symptoms, anxiety, and hallucination. Other signs and symptoms of withdrawal delirium include:  

  • For slight withdrawal, there's tremor, anxiety, nausea, vomiting, and sleeplessness 
  • Significant withdrawal includes auditory hallucinations and visual hallucinations, tremors in the entire body, hypertension, vomiting, and diaphoresis.         
  • Withdrawal seizures      
  • Agitation       
  • Profound confusion orientation 
  • Fever       
  • Hyperactivity 
  • Excessive sweating 

Remember, early diagnosis and intervention is one of the most effective ways to stop the progression of symptoms. It is essential to bring these symptoms to any physician's attention as soon as possible. 

Risk factors of alcohol withdrawal syndrome 

This disorder is dangerous for drinkers and those who are in contact with drinkers who need treatment of alcohol withdrawal. 

Though risk factors for delirium are inconsistent in various research, they however include: 

  • Medical history of delirium tremens      
  • Withdrawal seizures before having simultaneous illnesses and other medical comorbidities like pancreatitis or hepatitis. 
  • Irregular liver function or liver disease 
  • Heavy continuous ethanol intake 
  • Serious withdrawal symptoms on presentation   
  • A significant gap of days from the previous alcohol consumption 
  • Undergone detoxification before     
  • Age. The elderly are most affected 
  • Strong longing for alcohol use 
  • Having structural brain lesions     
  • A high blood level of homocysteine    
  • Hypokalemia  

Some factors that increase the risk for this substance abuse syndrome are: 

  • heavy drinking or binge drinking 10 to 15 units daily  poor physical health        
  • increased levels of anxiety and other mental disorders      
  • concomitant use of other psychotic medication  sleeplessness  
  •   electrolyte disruption 
  • fever 
  • pre-existing medical conditions, and  
  • decreased metabolism.  

How to manage delirium tremens 

There are numerous methods for managing delirium tremens, as discussed below. But ideally, DT needs prompt medical attention in an inpatient facility. And this is to avert its evolution from slight to serious withdrawal symptoms.  

It's also for preparing the addict for an extensive treatment of substance abuse minus endangering their autonomy and dignity. 

When the symptoms have progressed to more serious symptoms, treatment will emphasize lessening anxiety and other delirium symptoms with other primary medical illnesses. [6 

And while treating agitation or anxiety, there are many possibilities of reducing the risk of seizures, injuries, and death.

However, it's vital to ensure there's an ongoing treatment of alcohol dependence for easier management of delirium tremens. [7] 

So, suitable and timely treatment of alcohol withdrawal by antipsychotic drugs is the pillar of delirium tremens diagnosis management. Well, the following are the methods of treatment for this disease control: 

Supportive therapy 

Alcohol, while enjoyable in moderation, is not only addicting but also can interfere with the cells in the brain that regulate sleep. This is where supportive therapy comes in.  

Supportive therapy focuses on promoting emotional and social well-being. It aims to reduce severe agitation, depression, and stress. These are all factors that can contribute to delirium tremens. 

Therapy is a more long-term and beneficial method and includes therapy sessions with a mental health worker and a physician.

The sessions are peaceful, in a quiet, well-lit surrounding free from judgment where a person can healthily express themselves. 

They will also take a reasonable amount of time to understand the condition's underlying causes. 

It must also be assured with continuous clinical assessment. Provision of fluids and electrolytes to treat other coexisting addictions is a must for a perfect outcome. 

Thiamine 

A thiamine deficiency can lead to delusions, hallucinations, and eventually death for people with this substance abuse condition. 

It is a common symptom of alcohol withdrawal, and it also occurs in chronic alcoholics with alcohol induced psychotic disorder. Thiamine deficiency can result from a person's diet, alcoholism, or a reaction to a medication.  

This condition is more common in people who abuse alcohol heavily. People who use alcohol over time may not get enough of the body's vitamins to function correctly. This is because alcohol interferes with the absorption of nutrients.  

So thiamine prevents Wernicke encephalopathy, disorder caused by deficiency of thiamine in the body characterized by confusion. Also causes Korsakoff, another advanced manifestation of thiamine deficiency. 

Therefore, parenteral high-potency B complex vitamins are appropriate for patients admitted with thiamine deficiency from alcoholism and under detoxification. 

Also, a pair of ampoules Pabrinex® administered intravenously once daily between three to five days. Ampoules Pabrinex® contains 250mg of thiamine.  

However, in less severe cases of alcohol dependence, where the patient is in perfect health, oral thiamine of 300mg daily is given. It's divided for the duration of detoxification. 

After the detoxification and there’s still chronic deficiency, lower doses of thiamine, about 50mg daily, are recommended by Nice Clinical Knowledge (NICE CKS). [8] 

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Benzodiazepine 

Benzodiazepine medicines are for anxiety relief when undergoing detoxification.

They are slow in action hence less possible to be misused even though there are benzodiazepine refractory cases. There are several types of benzodiazepines.  

For instance, Chlordiazepoxide is used for about 5 to 7 days as a reducing dose. And it’s administered by health practitioners daily.

Diazepam and lorazepam also Ativan are its other variants, and they are both issued via an intravenous method.  

Benzodiazepine is given in a system-triggered routine or a fixed schedule. With a symptom-triggered route, you'll receive treatment once symptoms exist.  

But in a fixed schedule regimen, medication is given at certain fixed intervals. Any other doses are administered based on the withdrawal symptoms. 

While the patient undergoes the substance abuse treatment, use a breathalyzer to ascertain whether they still indulge in alcohol abuse. 

Meanwhile, you can cease using benzodiazepine when the detox is complete or when relapse sets in and the addict go back to heavy drinking. 

And most importantly, the dose depends on the extent of alcohol dependence, sex, weight, and the functionality of the liver.

For mild support, mall doses are appropriate, and large amounts are given for chronic alcohol use disorders. In fact, anyone highly susceptible to delirium tremens require about two weeks of treatment. 

Remember, patients should not drive while undergoing benzodiazepine medication. 

Magnesium 

Magnesium deficiency can come from a number of different causes, and alcohol use is among them. Yet, the effects of this deficiency are widespread, including severe cardiac arrhythmia, constipation, depression, or even muscle breakdown. 

Signs of magnesium deficiency are weakness, tremor, hyperactive reflexes, and weakness, to name a few.  

The detox method for this condition creates a safe environment and limits the patient's access to alcohol and drugs.  

While magnesium deficiency in the body is threatening, eating foods rich in it is the solution.

Foods such as pumpkin seeds, boiled spinach, peanuts, dry roasted cashew, and dry roasted almonds, to name a few, are significant in magnesium. 

Other treatment options include: 

  • Anaesthetic agents such as ketamine, dexmedetomidine, and propofol.         

  • Barbiturates such as phenobarbital and pentobarbital. 

Something to note about medication and detoxification is that you may not need medication for detoxification in the following instances: 

  •  Male patients having 15 units of alcohol and less while ten units and less in females and they have no withdrawal symptoms. 

To make it easy, a scale is used to ascertain the severity of the syndrome. The Clinical Institute Withdrawal Assessment for Alcohol scale (CIA-Ar) primarily provides the assessment. 

Follow up for acute alcohol withdrawal

As the body starts to recover after acute alcohol withdrawal, some people still feel ill. Health practitioners provide medical advice on the guidelines on how to get back on track during the recovery process.    

  • Get plenty of rest.        
  • Avoid intense physical activity.       
  • Stay hydrated with plenty of water; eight glasses per day is recommended.      
  • Eat healthy, nutritious foods        
  • Take vitamins to avoid nutritional deficiencies       
  • Eat enough calories to maintain a healthy weight       
  • Be sure to speak with a doctor or mental health professional for people with co-occurring alcohol use disorder.  
  • Talk with a doctor or mental health professional to provide medical advice about getting back to work. 
  • Counselling and self-help support groups like Alcoholics Anonymous keep them busy while undergoing treatment.        
  • Administering of medications to avert relapse       
  • Addressing any underlying medical and mental status issues 

A person recovering from alcohol use disorder through acute alcohol withdrawal may not think about anything else they need for recovery. Still, they must call the doctor's office with any questions or concerns.

Prevention of acute alcohol withdrawal and delirium tremens 

There is no quick and effective treatment for delirium tremens. However, there are some things you can do to get things moving again.

Besides, if alcohol abuse is identified early such complications as delirium tremens cannot occur. 

One of the most important things is alcohol dependent patients to be screened in the hospital for alcohol dependence.  

Moreover, get the person's body fluids back in balance. Your doctor will probably prescribe IV fluids for the person to drink each day.

Also, the doctor may prescribe certain drugs to be taken to prevent alcohol withdrawal seizures.  

Since someone with delirium tremens may not eat, your doctor will need to oversee the person's nutrition. A special diet like ketogenic can be a good remedy for alcohol withdrawal symptoms. [9] 

Outcomes 

DTs are not fatal if treated properly. The root cause of DTs occurs when alcoholism is left untreated for too long. Not drinking or stopping to drink alcohol will help prevent severe alcohol withdrawal.  

When dependent drinkers stop to drink heavily, the withdrawal will last only a few days to two weeks. Symptoms of withdrawal are weakness, nausea, vomiting, shaking, insomnia, seizures, fever, and hallucinations. 

And though there's management of alcohol withdrawal delirium, mortality rates range from approximately 5 to 15%.

And the only means to reduce mortality is aggressive resuscitation and managing any simultaneous sicknesses. Remember, any delay in diagnosis or failure to treat results in high morbidity and death. [10] 

Conclusion

Delirium tremens are a potentially fatal medical emergency. There are distinct frightening and life-threatening delirium tremens symptoms that make delirium tremens treatment a more serious topic than any other illness.

It is characterised by confusion, hyperactivity, hallucinations, tremors, and elevated blood pressure. The condition is acute and extremely dangerous if not treated immediately.  

Alcohol withdrawal management still present many challenges to mental health and addiction even though mental health services administration field is improving every year to diagnose and treat alcohol use disorders.  

However, as you can see from the research above, withdrawal often requires a multidisciplinary approach to ensure patient safety.

The treatment regime of delirium tremens can involve pharmacotherapy, administration of benzodiazepines, alcohol withdrawal medication, supportive care, and preventing seizures.

Benzodiazepines are fast-acting medications that can relieve symptoms related to intoxication in the nervous system. 

But managing the psychological and physiological effects of delirium tremens ultimately comes down to one thing: the support of loved ones and with health and care excellence from a mental health services administration. 

Abbeycare Pricing Bot

Last Updated: February 23, 2022

About the author

Peter Szczepanski

Peter has been on the GPhC register for 29 years. He holds a Clinical Diploma in Advanced Clinical Practice and he is a Clinical Lead in Alcohol and Substance Misuse for Abbeycare Gloucester and works as the Clinical Lead in Alcohol and Substance Use in Worcestershire. Peter also co-authored the new 6th edition of Drugs In Use by Linda Dodds, writing Chapter 15 on Alcohol Related Liver Disease. Find Peter on Respiratory Academy, Aston University graduates, University of Birmingham, Q, Pharmaceutical Journal, the Dudley Pharmaceutical Committee, Dudley Council, Twitter, and LinkedIn.