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Delirium Tremens: a Review

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Delirium Tremens: a Review • Delirium tremens: A review RICHARD E. GRIFFIN, DO GEORGE A. GROSS, DO, MPH HOWARD S. TEITELBAUM, DO, PhD, MPH Delirium tremens was first iden­ The biblical comments had to do with the tified as being due to long-term excessive observed behavior of the drinker and the effect of alcohol intake in 1813, but is now known to heavy drinking: 'Who hath woe? .. sorrow? ..con­ be associated with abrupt withdrawal of tentions? .. redness of eyes? .. They that tarry long alcohol in chronically habituated persons. at the wine." (Proverbs 23:20-21). It is not known Recent publications quote an anticipated if the withdrawal syndrome was common or rec­ mortality rate of 15% to 20%. Our experience ognized as a result of excessive drinking; howev­ in the past 20 years has not confirmed that er, the verse in Proverbs 23:32, "At the last it rate. This review reveals that the prevalence biteth like a serpent, and stingeth like an adder," of fatal cases is extremely low, with the true could be a reference to some observed central ner­ mortality close to 0%. We believe that this vous system (CNS) symptoms such as seizures, decrement is due to the increasing use of in withdrawal. benzodiazepines to detoxify alcoholic patients. More recently alcohol is being recognized as It is posstulated that the benzodiazepines a major etiologic factor in the deaths of young peo­ act either to prevent delirium tremens or to ple (motor vehicle accidents), as well as in dis­ reduce the neurotransmitter disruption in eases of various organ systems. Excessive use of alco­ the central nervous system caused by exces­ hol has been implicated in the development of sive alcohol intake, or both. malignancies, particularly of the gastrointestinal (Key words: Electrolytes, mortality rate, tract. 1 Studies of alcoholism revealed that alcohol alcohol withdrawal syndrome, benzodi­ could kill if consumed in too great a quantity, but azepines, cocaine, and alcohol abuse) also seemingly when the drinker decreased or ceased its consumption. Acute treatment of alco­ Alcohol and drinking to excess have been a holism has been directed at detoxification and the part of human culture since the beginnings of civ­ withdrawal syndromes, in particular, the potentially ilization. Comments on drinking appear in the fatal condition delirium tremens. Bible. Morning drinking and drinking through­ According to the National Institute of Drug out the day, 'Woe unto them that rise up early in Abuse's 1990 National Household Survey on Drug the morning, that they may follow strong drink; that Abuse, there are 102.9 million people in the Unit­ continue until night, till wine inflame them" (Isa­ ed States who use alcohol. The lifetime prevalence iah 5:11), was recognized as being different than of alcoholism among all drinkers is 15.4%, of whom social drinking, " ... but use a little wine for thy 2.5% can be expected to experience severe withdrawal. stomach's sake and thine often limitations." (1 The mortality attributed to delirium tremens is Timothy 5:23). usually quoted as being as high as 20%,2 which suggests that we could expect 79,233 deaths per year Drs Griffin, Gross, and Teitelbaum are professors at Michi­ from delirium tremens. This rate would place delir­ gan State University, Department of Community Health ium tremens among the top 10 causes of death in Sciences, East Lansing, Mich. Correspondence to Richard E. Griffin, DO, Department the United States. It is not so listed. Chronic liver of Community Health Sciences, B522 East Lansing, MI disease and cirrhosis accounted for 24,820 deaths 48824-1316. in the 12 months ending November 1991, giving 924 • JAOA • Vol 93 • No 9 · September 1993 Review article • Griffin et al Table 1 Relation of Delirium Tremens to Cessation of Drinking: An Analysis of 101 Cases Related variable Time of Time of onset after onset after last drink hospitalization Indeterminate Interval, No. of No. of No. of h cases cases cases ~24 2 4 ... 25-48 11 15 . .. 49-72 7 4 ... 73-96 17 6 ... > 96 7 2 ... -- -- TOTAL 44 31 26 Adapted from Victor and Adams.6 a rate of 9.8 per 100,000.3 In the United States, Delirium tremens is characterized by the fol­ these diseases were primarily due to alcohol abuse. lowing: (1) elevated temperature (100.2°F); (2) In our own experience in treating alcoholic tachycardia (90 beats per minute); (3) elevated patients (19 years averaging 700 admissions per blood pressure (140/90) mm Hg; (4) tremulous­ year), we have seen two persons in alcohol with­ ness; (5) diaphoresis; (6) hallucinations; (7) dis­ drawal who appeared to be suffering from deliri­ orientation; (8) urinary incontinence (9) agitation; um tremens. Both recovered. The incidence of and (10) inability to feed oneself.6-8 delirium tremens would be 1.5 per 100,000 in this informal survey. Colleagues have reported similar Historical perspective expenences. Delirium tremens was first described in the med­ icalliterature in 1813 by Thomas Sutton.9 He CUlTent diagnostic criteria identified excessive intake of alcohol for a long The criteria for alcohol withdrawal delirium, accord­ period as the etiologic agent. He differentiated ing to the Diagnostic and Statistical Manual ofMen­ delirium tremens from "phrenitis" (inflammation tal Disorders (DSM-III-R), 4 are as follows: (1) Delir­ of the brain) by noting that delirium tremens had ium. .,developing after cessation of heavy alcohol a prodrome of tremor, fever, and diaphoresis. Sut­ ingestion or a reduction in the amount of alcohol ton described a syndrome of malaise, headache, ingested (usually within 1 week); (2) marked auto­ fever, tremor, general agitation, anxiety, forget­ nomic hyperactivity, such as tachycardia, sweating; fulness, tetany, and diaphoresis. He treated delir­ (3) not due to any other physical or mental disorder. ium tremens with opioids with good results. He These foregoing criteria reflect a psychiatric noted 2 deaths in 16 cases so treated (12.5% mor­ bias. The consensus of people working in the field tality rate). of addiction medicine reflects the results of phys­ According to Romano,lO Ware described the ical examination of the alcoholic in addition to a psy­ clinical manifestations of delirium tremens in chiatric evaluation. A consensus definition of delir­ 1831, his diagnosis resting on the presence of ium tremens is a syndrome that follows a long "... delirium, watchfulness, and tremor." He thought period of heavy drinking, occurring within 3 to 5 that these manifestations were due to drinking, days following the cessation of alcohol ingestion and dismissed sudden abstinence as a cause. Ware (Tables 1 and 2). Delirium tremens is usually pre­ did not think that any treatment was necessary in ceded by a prodromal syndrome.5 the person who was in good health; in others, he (Continued on page 929) Review article • Griffin et al JAOA • Vol 93 • No 9 • September 1993 • 925 Table 2 Mortality in Delirium Tremens: Review of the Literature Prevalence No. of of cases No. of cases with deaths No. of with delirium from Mortality alcoholic delirium tremens delirium rate Authority Year cases tremens (%) tremens (%) I Sutton9 1813 16 16 100.0 2 12.5 Bostonll 1908 Not cited 140 Undetermined 1-13 0-70.0 Ranson and ScoW4 1911 Not cited 934 Undetermined 206 37.0 Hoppe15 1918 375 59 15.7 2 3.4 Cline and Coleman16 1936 Not cited 157 Undetermined 6 3.8 Piker and Cohn 17 1937 Not cited 300 Undetermined Not cited 5.3 Moore and 1915- 38,376 2,375 6.2 560 24.0 Gray 18 1936 Victor7 1953 Not cited 101 Undetermined 15 6.7 Isbell et a}19 1955 10 2 20.0 0 0 Mendelson 1959 Not cited 30 Undetermined 0 0 et al20 Tavel et al21 1961 Not cited 162 Undetermined 30 18.5 Tavel et aP1 1961 Not cited 168 Undetermined 9 5.4 Cheshmedjiev 1972 1,156 1 0.1 0 0 and Atanassov22 Wadstein and 1978 Not cited 26 Undetermined 0 0 Skude23 Cushman24 1987 7,084 92 1.3 3 3.3 thought that bleeding would be appropriate. the cause of delirium tremens was not universal­ By 1905, there seemed to be general agree­ ly accepted. Early reports imply that the cause ment about the diagnosis of delirium tremens.ll The was the intake of alcohol. 18 As time went on, disease had been divided into two phases, with attempts were made to correlate the amounts the first, the incipient stage, characterized by ingested and the duration of the drinking with "insomnia, restlessness, tremor, and occasionally the likelihood of delirium tremens. No consistently by hallucinations."12 The second stage was char­ strong association was found. From a review of acterized by visual hallucinations, fear, boister­ the earlier literature, one might conclude that ousness, uncoordinated movements, delirium, delirium tremens was caused by chronic heavy fever, leukocytosis, and diaphoresis. drinking. Around the turn ofthe century, the Euro­ From the turn of the century until about the peans postulated that a toxin formed in the gas­ time of Prohibition, 13 the incidence and prevalence trointestinal tract, kidneys, eNS, or spinal fluid (or of delirium tremens reported in the literature a combination) led to delirium tremens. 25 increased.7,9,14-24 There was no uniform definition Withdrawal of alcohol as a cause of delirium of delirium tremens during this period. tremens was met with skepticism. Bleuler,26 in Abrupt cessation of alcohol consumption as his Textbook on Psychiatry in 1924 said, "The Review article • Griffin et al JAOA • Vol 93 • No 9 • September 1993 • 929 omission of alcohol kills nobody, it is only the use the ability to suppress antidiuretic hormone, so of it that does." A number of reports in the 1920s levels rise and an isosmotic retention of water and and early 1930s that examined persons who had electrolytes results.
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