What is Delirium Tremens (Alcohol Withdrawal)?
Alcohol use disorder, which often leads to serious social and health problems, is a common issue affecting up to 20% of people at some point in their lives. Over half of these individuals may experience withdrawal symptoms if they stop or reduce their alcohol consumption. However, only around 3% to 5% experience severe withdrawal symptoms, including extreme confusion, excessive involuntary activity, and potential heart failure. This condition is known as ‘alcohol withdrawal delirium’ or more commonly ‘delirium tremens (DT)’.
Delirium tremens was first identified in 1813, as a disorder linked to heavy alcohol consumption. Generally, it can start as soon as 48 hours after someone with a habit of heavy drinking suddenly stops and can last up to five days. Without proper treatment, it can be fatal, with a potential mortality rate of up to 37%. Therefore, it’s vital to recognize the early signs of withdrawal as it can turn deadly.
What Causes Delirium Tremens (Alcohol Withdrawal)?
Delirium tremens is a condition that happens in people who have been drinking alcohol for a long time and then suddenly stop. It can often start as soon as 48 hours after the last drink.
Risk Factors and Frequency for Delirium Tremens (Alcohol Withdrawal)
Statistics indicate that the chances of experiencing DT, a serious issue often linked to alcohol use disorder, are highest in adult men. Specifically, 17.6% of men may face it within a year and 36% might deal with it at some point in their lives. It’s more common in White, younger groups as well as those who have never been married or who were previously married. People with alcohol use disorder have a 5% to 10% chance of going through DT in their lives.
Here are some factors that could increase your risk of having DT:
- You’ve had DT before.
- You have a history of seizures.
- You have another illness at the same time, especially if it comes with additional health problems.
- You’ve gone through detoxification before.
- It’s been a long time since you last had a drink.
Signs and Symptoms of Delirium Tremens (Alcohol Withdrawal)
When diagnosing and assessing the severity of alcohol withdrawal, it’s crucial to gather a thorough medical history and conduct a complete physical examination. Factors to consider include the amount and duration of alcohol consumption, when the last alcoholic beverage was consumed, previous experiences with alcohol withdrawal and their severity, and any use of other drugs. It’s also important to identify any other medical issues that could complicate the situation, such as heart failure, coronary heart disease, or chronic liver disease.
Since some symptoms might not be reported by the patient, additional investigations are often required. Testing can help identify any underlying medical conditions, electrolyte imbalances, kidney and liver function issues, possible sources of infection, coronary ischemia (decreased blood flow to the heart), rhabdomyolysis (a potentially dangerous condition that can result from muscle injury), and the use of other drugs.
Understanding the timeline since the last alcoholic drink was consumed can be helpful in gauging the severity of withdrawal symptoms. Initial minor symptoms, like anxiety, sleeplessness, heart palpitations, headaches, and stomach issues can appear as soon as 6 hours after stopping alcohol. After 12 hours, these symptoms can escalate to alcohol hallucinosis, which is marked by visual hallucinations. These hallucinations can often resolve within 24 to 48 hours but may also be associated with auditory (sound) and tactile (touch) hallucinations.
Alcohol withdrawal can also induce seizures, which can sometimes appear even before hallucinations start. In some instances, seizures may be the only symptom of withdrawal and usually subside within 24 to 48 hours. It’s very uncommon for these seizures to progress to status epilepticus, a severe seizure condition. Any unusual signs of seizure activity should prompt further examination. If symptoms of withdrawal continue untreated, they can lead to Delirium Tremens (DT). DT is marked by visual hallucinations, severe confusion, a fast heart rate, high blood pressure, an increased body temperature, restlessness, and excessive sweating.
Testing for Delirium Tremens (Alcohol Withdrawal)
Doctors use the CIWA-Ar questionnaire to assess the severity of alcohol withdrawal symptoms. Scores from the questionnaire determine if symptoms are mild, moderate, or severe. Severe symptoms can lead to seizures and delirium tremens (DT). The CIWA-Ar is not used for patients with withdrawal delirium. Patients with DT require evaluation of electrolyte levels, nutrition, and hydration. They are often dehydrated and have electrolyte imbalances. Multivitamins and thiamine are given to prevent brain disorders. Certain factors increase the risk of DT, such as a history of DT, concurrent illness, older age, low potassium levels, and previous withdrawal or detox experiences.
Treatment Options for Delirium Tremens (Alcohol Withdrawal)
The goal of alcohol withdrawal treatment is to control restlessness, prevent seizures, and reduce the risk of death or complications. Benzodiazepines, such as lorazepam, diazepam, and chlordiazepoxide, are commonly used for treatment. They can be given through an IV either when symptoms appear or on a regular schedule. Symptom-triggered treatment is often more efficient, but the amount of benzodiazepine needed varies. If severe symptoms persist, other drugs like phenobarbital or propofol can be used, but propofol requires a ventilator. Drugs like clonidine and dexmedetomidine may be helpful in combination with benzodiazepines, but should not be used alone. It is recommended to avoid using certain drugs for treatment due to limited research on their safety during alcohol withdrawal.
What else can Delirium Tremens (Alcohol Withdrawal) be?
When a doctor is trying to diagnose DT, they need to consider many other conditions that might be causing the symptoms. These other conditions could include:
- Severe infection throughout the body (sepsis)
- A condition where the kidneys can’t filter waste (uremia)
- Stroke
- A brain infection (meningitis or encephalitis)
- A brain condition linked to severe alcohol withdrawal (Wernicke encephalopathy)
- A serious reaction to certain psychiatric drugs (neuroleptic malignant syndrome)
- An adrenal gland tumor that can release high levels of adrenaline (pheochromocytoma)
- Drug toxicity from substances like amphetamines, hallucinogens, cocaine, heroin, or phencyclidine
- Imbalances of body salts, such as low calcium or low magnesium
- An overactive thyroid (thyrotoxicosis)
- A brain bleed (cerebral hemorrhage)
- A blockage in the brain’s blood supply (cerebral embolism)
- Toxic ingestion or exposure, such as ethylene glycol (found in antifreeze)
- Sudden liver failure
- A serious diabetes complication (diabetic ketoacidosis)
- Brain abscess
- Low blood sugar (hypoglycemia)
It’s important for the doctor to consider all of these possibilities when diagnosing, in order to make sure the right treatment is given.
What to expect with Delirium Tremens (Alcohol Withdrawal)
The death rate from Delirium Tremens (DT), a severe form of alcohol withdrawal, has significantly reduced due to early detection and treatment. With prompt care, the death rate has dropped to below 5%. However, complications such as serious muscle damage (rhabdomyolysis), irregular heart rhythms (arrhythmia), and other existing medical conditions can occur alongside DTs.
Furthermore, factors such as pneumonia, pancreatitis, being older in age, and having a history of other health issues can increase the chances of death.
Possible Complications When Diagnosed with Delirium Tremens (Alcohol Withdrawal)
Here are some adverse effects that a person may experience:
- Seizures
- Confusion or disorientation
- High blood pressure (Hypertension)
- High body temperature (Hyperthermia)
- Changes in mental state or thinking
- Widespread confusion
- Irregular heart rhythms (Arrhythmias)
- Inflammation in the lungs caused by inhaling vomit (Aspiration pneumonitis)
- Failure of the respiratory system
- Potentially, death
Recovery from Delirium Tremens (Alcohol Withdrawal)
To avoid falling back into old habits, it may be beneficial for the patient to join support groups like Alcoholics Anonymous. Undergoing cognitive behavior therapy might also be useful in preventing a relapse for some patients. If needed, a consultation with a psychiatrist to evaluate potential depression and anxiety could assist in maintaining abstinence from alcohol.