A model for predicting alcohol withdrawal delirium

OBJECTIVE: The aim of this study was to develop a model for identifying patients with a high risk of developing alcohol withdrawal delirium after assessment in the emergency department. METHODS: Patients seeking acute treatment for alcohol withdrawal at St. G?ran's hospital in Stockholm were evaluated for known risk factors for alcohol withdrawal delirium. All patients with any risk factor were admitted to the hospital and received standard treatment with benzodiazepines. All patients were evaluated at admission by the physician in charge at the psychiatric and dependency emergency unit at the hospital. Treatment and final assessment were conducted at the unit's inpatient acute-treatment facility. Correlations were determined between risk factors noted at admission and development of alcohol withdrawal delirium, as defined in DSM-IV, after admission. A total of 334 alcohol-dependent patients were included in the study. RESULTS: Twenty-three patients, or 6.9 percent, developed alcohol withdrawal delirium after admission despite benzodiazepine treatment. In a stepwise multiple regression model, five risk factors were significantly correlated with the development of alcohol withdrawal delirium: current infectious disease; tachycardia, defined as a heart rate above 120 beats per minute at admission; signs of alcohol withdrawal accompanied by an alcohol concentration of more than 1 gram per liter of body fluid; a history of epileptic seizures; and a history of delirious episodes. No patient without these five risk factors developed delirium. CONCLUSION: Assessment for five easily detectable risk factors can enable the clinician to make an accurate and quantitative assessment of a patient's risk of developing alcohol withdrawal delirium.     

Ethylene oxide polyneuropathy

Sensorimotor polyneuropathy developed in two workers who had been exposed to ethylene oxide gas repeatedly for several months. Sural nerve biopsies revealed axonal degeneration with mild changes of the myelin sheath. Unmyelinated fibers were also involved. Muscle biopsies showed typical denervation atrophy. Symptoms improved after exposure to ethylene oxide terminated.     

Pathobiochemistry and pharmacotherapy of alcohol withdrawal delirium]

The spectrum and time course of different symptoms during alcohol withdrawal may be caused by the involvement of various neurotransmitter systems that are differentially vulnerable to the effects of ethanol. Withdrawal symptomatology results from increased activity of excitatory mechanisms (NMDA-receptor, catecholamines among others) and from reduced functioning of inhibitory receptors (GABAA-, alpha 2-adreno-receptor among others). The neuronal mechanisms are subject to different dynamics of restitution following intoxication. Some of these probably contribute to long-lasting changes in CNS functions by "kindling" processes. Therapeutic guidelines are deduced from results of basic research and clinical trials. It is concluded that clomethiazole and benzodiazepines are superior in treating delirium tremens and certain risk-patients, whereas carbamazepine and clonidine may be helpful in moderate withdrawal syndromes or as adjunctive agents. However, the need for improved methodological standards of method in clinical research is evident.     

Alprazolam withdrawal delirium unresponsive to diazepam: case report

A case is presented in which a 68-year-old man became delirious after being withdrawn from a low dosage of alprazolam. The delirium was not affected by administration of alprazolam. The authors suggest that alprazolam may have enhanced specificity for a subpopulation of benzodiazepine receptors.     

A case of psychosis and delirium following withdrawal from triazolam

A 53-year-old man with a 3-month addiction to approximately 5 mg/day of triazolam experienced psychosis and delirium following relatively abrupt withdrawal from the drug. In contrast to a previous report suggesting that triazolobenzodiazepine withdrawal may not respond to replacement doses of other benzodiazepines, this patient's withdrawal syndrome was effectively treated with lorazepam.     

Alcohol withdrawal delirium manifested by manic symptoms in an elderly patient

Alcohol withdrawal syndrome is a commonly seen problem in psychiatric practice. Alcohol withdrawal delirium is associated with significant morbidity and mortality. Withdrawal symptoms usually include tremulousness, psychotic and perceptual symptoms, seizures, and consciousness disturbance. Herein, we report a case involving a 63‐year‐old man who had alcohol withdrawal delirium that was manifested mainly by manic symptoms.     

Diagnostic and prognostic value of additional neurologic diagnosis in alcohol withdrawal delirium

A severe course of alcohol withdrawal has been observed in 28% of patients in a neurological intensive care unit due to complicating central nerve system (CNS) diseases. In any atypical alcoholic delirium, especially with focal neurological signs, partial seizures, or decreased level of consciousness, CNS diseases like meningoencephalitis, intracranial hemorrhage, or central pontine myelinolysis must be diagnosed by computed tomography (CT) scan and cerebral spinal fluid (CSF) tap. The diagnostic and prognostic value of CT scan and CSF analysis was examined in 32 persons with alcohol withdrawal syndrome or delirium tremens. Neurological complications and cerebral convulsions at the beginning of delirium tremens appear to predispose the patient to a protracted clinical course and necessary mechanical ventilation. Blood-CSF barrier permeability is increased in 70% of alcohol withdrawal patients and that also seems to be a marker of a prolonged clinical course. Cerebral atrophy as shown in CT scan does not play a role in predicting clinical course. In our experience, CT examination or lumbar puncture is not necessarily recommended if clinical signs are typical for alcohol delirium.     

Benzodiazepine withdrawal delirium with catatonic features. Occurrence in patients with partial seizure disorders

We report the cases of 3 patients with medically intractable seizures in whom withdrawal of treatment with a long-acting benzodiazepine (clorazepate dipotassium, 2 patients; clonazepam, 1 patient) was followed by delirium with catatoniclike features. While an increase in seizure frequency occurred during withdrawal and prior to the onset of behavioral changes, electroencephalograms did not show epileptiform activity during the delirium. We compared these 3 patients with 10 others with intractable seizures in whom antiepileptic therapy was withdrawn without subsequent behavior changes. High-dose benzodiazepine therapy and a history of viral encephalitis may be risk factors for withdrawal delirium.