From the Guidelines
Delirium tremens is diagnosed when a person with alcohol dependence develops a severe form of alcohol withdrawal characterized by altered mental status, disorientation to person, place, or time, and intra- and inter-daily variations of symptoms, typically worst at 3-5 days following the abrupt cessation of alcohol consumption 1. The diagnostic criteria for delirium tremens (DTs) include:
- Altered mental status
- Disorientation to person, place, or time
- Intra- and inter-daily variations of symptoms
- Autonomic instability, such as high fever, tachycardia, hypertension, and sweating
- Comorbidities, such as dehydration, electrolyte imbalance, renal failure, head trauma, infection, gastrointestinal bleeding, pancreatitis, and liver failure These symptoms must occur in the context of alcohol cessation or reduction after prolonged heavy use, and other medical conditions must be ruled out. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is known to be helpful for evaluating the severity of AWS, but high scores may be seen in psychiatric conditions that are similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions such as sepsis, hepatic encephalopathy, and severe pain 1. Treatment typically involves benzodiazepines, such as lorazepam, which is recommended for patients with severe AWS, advanced age, recent head trauma, liver failure, respiratory failure, or other serious medical comorbidities, started at a dosage of 6-12 mg/day and tapered off following resolution of the withdrawal symptoms 1. Additionally, thiamine supplementation is recommended for all patients with AWS, at a dose of 100-300 mg/day, and maintained for 2-3 months following resolution of their withdrawal symptoms 1.
From the Research
Criteria for Delirium Tremens
The criteria for delirium tremens (DT) include a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination 2.
Clinical Presentation
DT presents with:
- Severe alcohol withdrawal symptoms
- Symptoms of delirium
- Agitation
- Hallucination (sometimes) 2
Assessment
Assessment of DT includes:
- Assessment of severity of alcohol withdrawal
- Evaluation of delirium
- Screening for underlying medical co-morbidities 2
Predictive Factors
Clinical and laboratory parameters can predict DT, although the specific factors are not detailed in the provided studies 2. Liver disease is a common co-morbidity in patients with DT, which can complicate the clinical presentation, determine the treatment choice, and influence the outcome 2.
Treatment
Benzodiazepines are the mainstay of treatment for DT, with diazepam and lorazepam being preferred options depending on the treatment regime and clinical context 2, 3, 4. In benzodiazepine refractory cases, other medications such as phenobarbital, propofol, and dexmedetomidine may be used 2.