Delirium tremens is an alcohol withdrawal delirium. It is also called alcohol withdrawal syndrome and belongs to the mental and behavioral disorders caused by alcohol according to ICD-10.
What is delirium tremens?
The term delirium tremens is derived from the Latin words delirium (“insanity”) and tremere (“to tremble”). It is a complication of chronic alcoholism. In most cases, delirium occurs during alcohol withdrawal. However, it can also be triggered by intoxication. The lethality of untreated delirium tremens is 26 percent. That’s why emergency admission to a hospital is necessary if delirium is imminent or beginning.
Causes
Delirium tremens is the result of long-term alcohol dependence. In most cases, it occurs during withdrawal. Delirium usually begins 48 to 72 hours after the last drink of alcohol. Around five percent of all alcohol addicts experience delirium tremens at least once in their lives. The risk of recurrence is high at ten to twenty percent. The risk of suffering delirium tremens during controlled alcohol withdrawal is less than one percent. Delirium is often caused by illnesses triggered by alcohol consumption. Alcoholics often suffer from bleeding in the gastrointestinal tract, liver cirrhosis or pneumonia. If hospitalization occurs as a result of these illnesses and patients are no longer given alcohol there, alcoholic delirium can result. Delirium is triggered by an imbalance of neurotransmitters. Neurotransmitters are messenger substances responsible for signal transmission between nerve cells of the central nervous system (CNS).
Symptoms, complaints, and signs
About half of all deliria begin with an epileptic seizure. However, the seizures tend to be inconspicuous, so they are often misinterpreted as an alcohol-related absence state. At this stage, alcohol delirium is not yet complete. It is therefore also called predelirium. Within a few days, the full picture of the disease develops. The clinical symptoms are divided into psychiatric, neurological and vegetative symptoms. Psychiatric symptoms include visual hallucinations and anxiety. Often these two symptoms occur in combination. Patients are disoriented in time, place, and situation. In addition to hallucinations, illusory misperceptions also occur. In hallucinations, patients perceive something that is not there. In illusionary misperception, reality is misperceived and misinterpreted. A typical neurological symptom is tremor. This is a coarse tremor of the hands. Patients are also confused and not always conscious. The limitation of consciousness may progress to coma. In addition, both tonic and clonic convulsions may occur. Vegetative symptoms of delirium tremens include sweating, increased blood pressure, increased respiratory rate, and increased pulse. Vegetative symptoms can be derailed, particularly in untreated delirium tremens. Such courses can be fatal. Twenty-five percent of all untreated patients die. The prognosis worsens in older patients and in patients who suffer repeated delirium. However, most patients experience a marked improvement in symptoms after three to six days. In individual cases, however, delirium tremens can last up to twenty days. Mild vegetative complaints, sleep disturbances and anxiety may remain. Often, these complaints are the reason why patients turn to alcohol again and relapse.
Diagnosis
The first and sometimes very clear clues for making a diagnosis are provided by the symptoms. The disease must be differentiated from other agitation states, from febrile delirium, from extreme urinary urgency, from an overdose of asthma medication, from hypoglycemia, or from meningitis. The patient’s own and others’ medical histories are also important. However, care must be taken here, as relatives may tend to conceal the patient’s symptoms and complaints out of a sense of shame. Another diagnostic possibility is the administration of alcohol. This can be done orally or venously. If the patient’s complaints are really based on delirium tremens, the symptoms disappear within a few minutes.
Complications
As a rule, delirium tremens results in severe withdrawal symptoms and psychological discomfort. These can also lead to behavioral disturbances, severely reducing the patient’s quality of life and limiting daily activities. In many cases, delirium tremens leads to a relapse and the patient again suffers from alcohol dependence. Not infrequently, an epileptic seizure occurs as a result of the delirium. The affected person suffers from severe anxiety and sweating. In severe cases, hallucinations may also occur, so that the patient can no longer orient himself and also loses the sense of time. The hands shake and cramp. If delirium tremens is not treated properly, death can occur in the worst case. In this case, death occurs due to heart failure, as the heart rate is increased and the blood pressure is also elevated. Sufferers are often unable to sleep at night and therefore suffer from irritability during the day. If there are no complications in the first few days, no particular symptoms continue to occur. As a rule, the withdrawal symptoms disappear after about a week, so that the affected person can wean himself off alcohol.
When should you go to the doctor?
Whether delirium tremens takes on life-threatening features depends on the history and severity of alcohol dependence, as well as the patient’s general condition and symptoms. “Common” and usually harmless withdrawal symptoms such as high blood pressure, palpitations, tremors, sleep disturbances, and restlessness appear soon after alcohol is discontinued, but their intensity decreases after two days. If no worsening of the condition is observed during this phase, it is not necessary to see a doctor. In contrast, delirium tremens, which is additionally characterized by hallucinations, disorientation, and persecutory delusions, does not set in until several days after the onset of abstinence from alcohol. If these symptoms occur, immediate consultation with a physician is advised. Only a specialist in neurology can clearly determine whether delirium tremens is present and whether hospitalization is necessary. Alcohol withdrawal without specific evidence of delirium tremens can also be performed on an outpatient basis, under the supervision of a primary care physician or without medical supervision.
Treatment and therapy
If delirium tremens is suspected, an emergency physician should be notified immediately. If the illness is full-blown, treatment is usually given in the intensive care unit. Patients are often very agitated and aggressive. Psychotic states also occur regularly. Therefore, treatment with sedatives such as diazepam or clomethiazole is necessary. When administering these drugs, patients must be closely monitored. The substances used have a respiratory depressant effect and can cause respiratory arrest. Depending on the symptoms, other medications, such as haloperidol or clonidine, may be administered. To prevent tonic and clonic withdrawal spasms, carbamazepine is prescribed in some cases. Alcohol delirium can also be interrupted by intravenous administration of alcohol. However, this therapy is usually chosen only if another condition needs to be treated before the delirium. An example of this is bleeding in the gastrointestinal tract. These are only aggravated by the additional delirium. Moreover, the administration of alcohol only has an effect in the predelirium. A fully developed delirium tremens cannot be stopped. Patients’ fluid and mineral balance is monitored concomitantly. Affected persons must be protected from self-injury and from cooling.
Outlook and prognosis
Delirium tremens represents an acute health situation that has an unfavorable prognosis for many patients. Without prompt emergency medical care, the life-threatening condition ends in the patient’s death in 30% of cases. The prognosis worsens with increasing age as well as the duration of delirium tremens. Patients who suffer repeated delirium are also considered to be at risk. If the risk factors can be excluded and prompt medical care is possible, the patient experiences an improvement in health within a few days. Normally, there is relief of symptoms within three to six days. In older patients in particular, the healing process takes up to three weeks.Complete freedom from symptoms is often not achieved in delirium tremens. Many patients experience lifelong impairments that represent a heavy burden in everyday life. Sleep or anxiety disorders occur, which can lead to a relapse of the underlying disease of delirium tremens. The longer the delirium tremens lasts, the worse the prognosis of the underlying disease at the same time. This increases the risks of a relapse into alcohol addiction as well as the recurrence of delirium. Many patients must continue to be cared for in a nursing home after delirium tremens because they do not experience recovery due to the clinical picture.
Prevention
Delirium tremens can usually be prevented by controlled withdrawal. Alcoholic patients who are hospitalized for another condition are usually provided with small amounts of alcohol during treatment so that delirium does not occur.
Aftercare
Because delirium tremens can develop during or after alcohol withdrawal, aftercare is designed according to future addictive behavior. If one is addicted to alcohol, there is usually a lifelong risk of relapse after withdrawal. Those who have had delirium tremens have usually already been severely addicted to alcohol and must change their future lifestyle to avoid relapsing. Particularly after delirium tremens, many sufferers relapse into their alcohol dependence within the first year because they pick up old habits again or are overwhelmed by everyday life. It is therefore not uncommon for inpatient rehabilitation to be prescribed as aftercare following withdrawal. During this rehab, the patient learns to break old habits and to control his or her addictive behavior. Aftercare treatments with psychotherapists are also common. With their help, addicts learn certain rules of behavior to prevent alcohol consumption in the future. Psychotherapy can be done either on an outpatient or inpatient basis with specialists or in a specialized clinic. There are numerous addiction counseling centers, specialized psychotherapists and psychiatrists, and self-help groups. These help to return to a normal life after delirium tremens and support an abstinent lifestyle for the future. Rather rarely, medications are prescribed as an aftercare treatment to curb the craving for alcohol. Regular monitoring and self-care are immensely important after delirium tremens.
Here’s what you can do yourself
At the moment when the affected person suffers delirium tremens, he can do very little for himself. If he is able, he can call an ambulance. However, this will often have to be done by people in the immediate environment. Preventively, the sufferer has several options that he can use to avoid the condition. First and foremost is monitoring the amount of alcohol consumed in everyday life. An alcohol disorder develops over a period of several years. As soon as the affected person notices that he can no longer manage his lifestyle without the consumption of alcohol, he should already seek help. If this does not happen in time, delirium can occur in an intoxication or self-chosen withdrawal. The withdrawal of alcohol must take place in a controlled manner so that delirium tremens can be avoided. If the affected person tries to do it on his own, he takes unnecessary risks that can lead to life-threatening complications. As soon as the first signs of an unexpected course appear, medical help is needed. If an uncontrolled tremor sets in, the best decision for the affected person is to seek medical treatment for his own sake. In advance, if possible, he should obtain comprehensive information about his condition and possible points of contact.