Evidence-Based Reviews

Who’s at greatest risk for delirium tremens

Current Psychiatry. 2003 January;2(1):14-19

References

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Table 1

RISK FACTORS FOR DELIRIUM TREMENS

Comorbid medical illness (with electrolyte, fluid abnormalities)*
History of delirium tremens*
Blood alcohol level >300 mg/dL on presentation*
Presentation after an alcohol withdrawal seizure*
Older age*
Longer history of alcohol dependence
Intense alcohol craving
Abnormal liver function
* Supported with studies and/or in the medical literature
Source: Saitz R. Introduction to alcohol withdrawal. Alcohol Health Res World 1998;22(1):5-12.

Table 2

STRATEGIES TO PREVENT AND TREAT DELIRIUM TREMENS

Assess risk for DTs with a thorough history, including collaborative family information and medical charts
Admit patients with a history of serious withdrawal symptoms or potential for inpatient detoxification (based on degree of tolerance)
Check complete lab values (chemistry panel, liver function tests including ALT and AST, complete blood count, blood alcohol level, GGT, and others if relevant), and correct any fluid, vitamin, or electrolyte abnormalities
Treat comorbid medical conditions
Differentiate DTs from alcohol hallucinosis, other causes of delirium, and Wernicke’s encephalopathy
Consider giving benzodiazepines along with low-dose neuroleptics, if appropriate, and monitor for disinhibition/ confusion and extrapyramidal symptoms, respectively
Place the patient in a low-stimulation environment with frequent monitoring

Predisposing risk factors

Past withdrawal complicated by seizures or DTs is the single best predictor of future alcohol withdrawal symptoms.¹⁷ Also consider the following patients to be at elevated risk:

any individual who presents with a blood alcohol level >300 mg/dl or after experiencing a withdrawal seizure⁹
patients with comorbid medical conditions, such as electrolyte abnormalities, infection, or poorly treated cardiovascular or respiratory diseases
older persons, who tend to be susceptible to delirium associated with hospitalization, medical illnesses such as urinary tract infections or pneumonia, or use of certain medications.¹⁸

Potential risk factors for developing DTs are summarized in Table 1.¹ Although few studies have been done, clinicians can use these factors as a guide for aggressively preventing DTs in at-risk patients.

Managing and preventing DTs

Management. Drug therapy is considered crucial to quell withdrawal symptoms and reduce the risk of death.¹⁹ Patients usually are treated with one of several benzodiazepines (such as chlordiazepoxide, diazepam, oxazepam, or lorazepam) to decrease autonomic instability and reduce seizure risk during acute alcohol withdrawal. Although dosages of these medications are estimated based on drinking history, some general starting ranges are often used in clinical practice:

chlordiazepoxide, 50 to 100 mg tid
lorazepam, 1 to 2 mg every 4 hours
oxazepam, 15 to 30 mg qid
diazepam, 10 to 20 mg tid/qid.

Treating DTs often requires the use of IV benzodiazepines because of their quick onset of action and benefit for acutely agitated patients who have difficulty taking medications by mouth.

Prevention. Correcting fluid and electrolyte abnormalities may be critical in preventing DTs (Table 2). In one study of patients who died while experiencing DTs, only 25% received adequate fluid replacement, which can be as much as 6 liters per day.²⁰ Ideally, comorbid conditions should be addressed early in presentation and before DTs develop.²¹

High-dose benzodiazepine therapy does not completely protect a patient from DTs or reduce its duration,²² but it may reduce mortality. A meta-analysis of prospective, placebocontrolled trials reported a risk reduction of 4.9 cases of DTs per 100 patients treated with benzodiazepines. Mortality also seems to have been reduced in patients with DTs who were treated with sedative hypnotics.⁹ Benzodiazepines may cause increased confusion and disinhibition, as is frequently seen when patients with dementia are treated with these agents.²³

Neuroleptics such as haloperidol have been used to prevent and treat DTs, but studies of their ability to reduce mortality have produced inconsistent results. What’s more, neuroleptics can reduce the seizure threshold and produce extrapyramidal symptoms.²³ Atypical antipsychotics may offer a safer alternative, although more studies are needed to evaluate whether they decrease the occurrence and severity of DTs.

In summary, a rational approach to preventing and treating DTs is to:

manage comorbid medical illnesses, and correct fluid and electrolyte abnormalities
place the patient in a safe, low-stimulation environment with frequent monitoring
use benzodiazepines judiciously.

Related resources

National Institute on Alcohol Abuse and Alcoholism.
www.niaaa.nih.gov
1995;30(6):765-70 (a thorough review of benzodiazepine use in alcohol withdrawal).

Drug brand names

Chlordiazepoxide • Librium
Diazepam • Valium
Haloperidol • Haldol
Lorazepam • Ativan
Oxazepam • Serax

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.