Diagnostic Criteria for Delirium Tremens
Delirium tremens (DT) is diagnosed when severe alcohol withdrawal symptoms (tremor, sweating, tachycardia, hypertension) occur together with delirium features including altered mental status, disorientation to person/place/time, and fluctuating symptoms that typically peak 3-5 days after alcohol cessation. 1
Core Diagnostic Features
DT represents the most severe manifestation of alcohol withdrawal syndrome and requires the presence of both components:
Alcohol Withdrawal Symptoms
- Autonomic hyperactivity: tachycardia, hypertension, high fever, profuse sweating 1
- Tremor (particularly hand tremor) 1
- Gastrointestinal symptoms including nausea and vomiting 1
Delirium Component
- Acute onset and fluctuating course - symptoms vary substantially throughout the day with the cardinal feature of inattention 2
- Altered level of consciousness - ranging from hypervigilance to reduced arousal 2
- Disorganization of thought and disorientation to person, place, or time 1
- Cognitive and perceptual disturbances including hallucinations (often visual) 3, 4
Temporal Pattern
- Symptoms typically begin 6-24 hours after abrupt cessation of alcohol in chronic heavy drinkers 1
- Peak severity occurs at 3-5 days following alcohol cessation 1
- The condition represents a medical emergency with potential for fatal outcomes if untreated 3, 4
Clinical Assessment Tools
While the Confusion Assessment Method (CAM) is validated for general delirium diagnosis with 82-100% sensitivity and 89-99% specificity 2, the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol is NOT recommended for diagnosing DT because high scores can occur in other conditions like sepsis, hepatic encephalopathy, and anxiety disorders 1
Key Distinguishing Features from Other Conditions
- Unlike general delirium: DT specifically follows alcohol cessation in dependent individuals and includes prominent autonomic hyperactivity 1
- Unlike alcohol withdrawal seizures: DT includes altered mental status and delirium, whereas withdrawal seizures are isolated events not requiring anticonvulsants 1
- Unlike primary psychosis: DT features altered consciousness and fluctuating symptoms, whereas psychosis typically maintains intact awareness 1
Risk Factors Predicting DT Development
- Chronic heavy alcohol consumption (often >20 standard drinks daily for many years) 5, 6
- History of previous delirium tremens episodes 7
- History of alcohol withdrawal seizures 7
- Concurrent medical comorbidities including liver disease, infection, dehydration, electrolyte imbalances 1
Essential Concurrent Evaluation
While confirming DT diagnosis, immediately evaluate for life-threatening complications:
- Vital signs monitoring for fever, tachycardia, hypertension 1
- Dehydration and electrolyte disturbances 1
- Renal failure 1
- Infection (particularly pneumonia and urinary tract infections) 1
- Gastrointestinal bleeding 1
- Pancreatitis 1
- Hepatic failure 1
- Head trauma 1
Critical Clinical Pitfall
DT carries significant mortality risk (historically up to 15%, currently <3% with appropriate treatment) and requires immediate intensive care unit admission with continuous vital signs monitoring. 4 The condition should never be managed in outpatient settings given the risk of malignant arrhythmias, respiratory arrest, severe seizures, and sepsis 4
Treatment Approach
- Long-acting benzodiazepines (diazepam or chlordiazepoxide) are first-line treatment for preventing seizures and managing symptoms through GABA activation 1
- Lorazepam is preferred for patients with severe DT, advanced age, or recent head trauma 1
- Very high doses of diazepam (260-480 mg/day IV) may be required in severe cases following prolonged heavy alcohol use 5
- Psychiatric consultation is recommended for acute management and long-term abstinence planning 1