Delirium tremens

Introduction

Delirium is a transient disorder of brain function. It manifests as a global cognitive impairment and behavioural disturbance. It is more common at the extremes of life though it can occur at any age.
Incidence up to 15% has been reported
among general medical inpatients; up to 40% among acutely ill geriatric patients.
Poor detection and misdiagnosis are common
The most common causes are:

  • Trauma
  • Infections
  • Metabolic derangements
  • Side effects of drugs

Clinical features

  • Disturbance of consciousness
  • Disorientation
  • Memory deficits
  • Language disturbances
  • Perceptual disturbances
  • Rapid fluctuations
  • Disruption of sleep-wake cycle
  • Psychomotor hyperactivity
  • Mood alterations

Differential diagnoses

  • Dementia
  • Acute (idiopathic) psychotic disorders

Complications

  • Usually transient but may be associated with increased morbidity (e.g. from falls) and
    mortality

Investigations

  • Determined by any causal or contributing medical conditions

Treatment objectives

  • Identify and ameliorate any causal or contributing medical conditions
  • Normalize behaviour
  • Improve cognition

Non-drug treatment

  • Nurse in a quiet, well-lit environment
  • Support physical care, including food and fluid intake
  • Provide orienting cues
  • Physical restraint judiciously used when indicated

Drug treatment

High-potency antipsychotics in low dosages for sedation
Haloperidol

  • Adult: 0.5-1 mg orally or parenterally every 6 – 8 hours
  • Child
    • 2 – 12 years: initially 12.5 – 25 micrograms/kg orally twice daily, adjusted according to response to maximum 10 mg daily;
    • 12 – 18 years: initially 0.5 – 3 mg daily, adjusted according to response to lowest effective maintenance dose (as low as 5-10 mg daily)

Benzodiazepines

  • For severe agitation (i.e. life-threatening features) or patient seriously disrupting management

Supportive measures

  • Give reassurance to patient and
    relatives/caregivers

    • The transient nature of condition
    • No risk of “madness”.

Caution

  • Close nursing care is required to prevent injuries and falls
  • Avoid over-medication, especially as antipsychotics and sedatives used may worsen delirium

Prevention

  • Early treatment of infective and metabolic conditions
  • Care with the use of drugs (especially anticholinergic medications) in the elderly