It’s a common quandary. A patient comes in to hospital and denies recent use of alcohol but a relative might say he’s been drinking
heavily for decades. Or he may say that
he’s been drinking heavily and has a history of delirium tremens and seizures
when withdrawing from alcohol in the past. The patient may be admitted to the
trauma service after an accident or to a general medical unit for some other
Abruptly, he starts to act confused and tries to leave the hospital. He may be disoriented or hallucinating. Despite normal or near normal vital signs and little to no subjective symptoms of alcohol withdrawal, the physician assumes that alcohol withdrawal is the cause and immediately starts giving the patient benzodiazepines such as Librium or Ativan. The patient doesn’t improve and the confusion worsens. The physician’s response is to increase the dose of
benzodiazepine, sometimes to the point of a continuous intravenous infusion. The
patient must then be intubated and transferred to the intensive care unit to
protect his airway.
His agitation gets worse. Every time an attempt is made to dial down the
benzodiazepine infusion rate, the patient becomes more combative as the heavy
sedation lifts. A vicious cycle ensues with alternating higher doses of
benzodiazepine, periodic attempts to taper the drug with worse agitation
followed by putting the patient back to sleep with more benzodiazepine
sometimes adding other agents such as anesthetics. At that point a psychiatric
consultant is called. Depending on the level of experience the psychiatrist has
with withdrawal syndromes and with the management of delirium in general, the
recommendation may be to add another benzodiazepine, perhaps with one or more
Finally, the decision must be made to simply sharply limit
the doses of sedatives or even stop them and weather the combativeness as
safely as possible while the patient awakens. In the aftermath, after careful
review of the objective vital sign records and checking for other medical
causes of delirium—the conclusion is that alcohol withdrawal was not the cause
of the delirium. In fact, in retrospect the conclusion may also be that
well-intentioned aggressive efforts to treat presumed alcohol withdrawal with
sedatives actually caused or worsened delirium.
Scenarios similar to this are played out in hospitals
everywhere and speak to the critical importance of being alert for other
possible medical causes of delirium in patients with alcohol use disorders. Not
every patient (or relative, friend, spouse, acquaintance of the patient, etc.)
who gives a history of complicated alcohol withdrawal (alcohol withdrawal
seizures or delirium tremens) is a reliable reporter. And not every patient who
has a genuine history of complicated alcohol withdrawal will have the syndrome
each and every time he comes to hospital requesting detoxification.
There is a need for reliance on measurable objective signs
such as elevated blood pressure and heart rate, observable sweating, and visible
tremors in addition to subjective reports of distress in the diagnosis of
alcohol withdrawal. Inappropriate use of
alcohol withdrawal assessment scales such as the Clinical Institute Withdrawal
Assessment-Revised (CIWA-Ar) in some hospital settings can lead to misdiagnosis
of alcohol withdrawal and adverse outcomes [1, 2].
It may be helpful to screen patients admitted to hospital
using validated scales such as the AUDIT-C though not all potential cases can
be captured in this way. The AUDIT-C is a 3-item alcohol screen that can help
identify patients who are hazardous drinkers or who have active alcohol use
disorders including alcohol abuse or dependence.
Using an alcohol withdrawal rating scale that emphasizes
objective signs of withdrawal could be another way to more reliably identify
those who are in withdrawal. And either symptom-triggered or fixed dose, scheduled
benzodiazepine tapers should be considered for those requiring medically
supervised detoxification in the hospital.
Finally—think about delirium from other medical causes in
patients who have alcohol use disorders. Many of these patients have a variety
of other medical problems that put them at risk for delirium.
1. Bostwick, J.M. and M.I. Lapid, False positives on the clinical institute
withdrawal assessment for alcohol-revised: is this scale appropriate for use in
the medically ill? Psychosomatics, 2004. 45(3): p. 256-61.
2. Hecksel, K.A., et al., Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc, 2008. 83(3): p. 274-9.