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Delirium is a reversible form of cognitive impairment characterised by its **acute** onset, **fluctuating** course and propensity to cause **inattention**. PINCH ME is a helpful acronym to remember common causes of delirium - Pain, Infection, Nutrition, Constipation, Hydration, Medication and Environment (unfamiliar). In this patient, there is a clearly identifiable trigger preceding the onset of the confusion - constipation
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Delirium
QuestionChoice
Hypoglycaemia in this patient is a valid concern - with her confusion, constipation and vomiting, she may be having very minimal oral intake. Hypoglycaemia can cause confusion and vomiting; however, it would not be in keeping with this patients 5-day history of agitation and disorientation - it would present much more acutely, coming on over minutes to hours, not days
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Hypoglycaemia
QuestionChoice
Though bowel cancer can present for the first time with bowel obstruction, which may be the case here with the patients marked constipation and subsequent vomiting, it would not explain the rapid onset of the confusion. You may also experience other associated red flag symptoms to be present such as a change in bowel habit for more than 6 weeks, blood in the stool or weight loss
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Malignancy
QuestionChoice
In the elderly, depression can often manifest with cognitive impairment. Additionally, depression and dementia are common co-existing conditions. However, the very acute nature of this confusion and the lack of any affective symptoms points away from depression as the cause
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Depression
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Cognitive impairment in dementia is gradual in onset, over many months to years. It would not progress suddenly over the course of 5 days. Additionally, the clear trigger of constipation here makes a primary neurological cause much less likely
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Dementia
QuestionComment
Is this really DTs? or just ordinary Delirium?
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Kawasaki Serotonin
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# Summary

Delirium tremens (DT) is a severe form of alcohol withdrawal that presents with acute confusion, hallucinations, autonomic hyperactivity, and, in rare cases, seizures. Typically occurring around 72 hours after the cessation of alcohol intake, DT necessitates immediate medical attention and management. The first-line treatment is lorazepam, administered either orally or parenterally, followed by maintenance management strategies.

# Definition

Delirium tremens is a life-threatening condition characterized by a rapid onset of confusion often precipitated by alcohol withdrawal. It generally develops around 72 hours after the cessation of alcohol intake and can persist for several days. This condition is marked by extreme autonomic hyperactivity and neuropsychiatric symptoms.

# Aetiology

The primary cause of delirium tremens is abrupt withdrawal or a significant reduction in alcohol intake in a person with prolonged, heavy alcohol use. Other factors that can precipitate DT include infection, trauma, or illness in a person with a history of chronic alcoholism.

# Signs and Symptoms

Symptoms typically peak between the 4th and 5th day post-withdrawal. The clinical features of delirium tremens include:

- Confusion and disorientation
- Hallucinations, which can be visual or tactile (e.g., formication – the sensation of crawling insects on or under the skin)
- Autonomic hyperactivity, manifesting as sweating and hypertension
- Rarely, seizures


# Differential Diagnosis

Delirium tremens must be distinguished from other conditions that can present with similar symptoms:

- **Alcohol withdrawal syndrome:** Features include anxiety, insomnia, anorexia, tremor, and autonomic hyperactivity, but without the severe confusion or hallucinations seen in DT.
- **Wernicke-Korsakoff syndrome:** This condition is characterized by ataxia, ophthalmoplegia, and confusion but lacks the autonomic instability of DT.
- **Encephalitis:** Features include fever, headache, altered mental status, and focal neurological signs which are not typically observed in DT.
- **Meningitis:** This presents with fever, neck stiffness, and altered mental status but without the characteristic hallucinations seen in DT.



# Investigations

Investigations largely aim to rule out other conditions. These include:

- Routine Blood panel including B12, Folate, Thyroid Function
- Infection screen: Chest Xray, Urine dip, Blood Cultures
- CT Head to assess for evidence of a structural brain lesion e.g. subdural haemorrhage in patients presenting with an unwitnessed fall while intoxicated
- Lumbar Puncture if meningitis or encephalitis are suspected


# Management

NICE guidelines suggest offering oral lorazepam as the first-line treatment. 

If symptoms persist, or oral medication is declined, offer parenteral lorazepam or haloperidol.

For maintenance management of alcohol withdrawal, the following steps are recommended:

- Administer Chlordiazepoxide. Eventually this can be tapered according to **Clinical Institute Withdrawal Assessment for Alcohol (CIWA)** scoring
- Ensure adequate hydration with fluids
- Provide anti-emetics to manage nausea
- Pabrinex to replenish vitamins
- Refer the patient to local drug and alcohol liaison teams for further support and management

When patients present with seizures, sometimes they remain in hospital for inpatient detoxification. This is however rare and the evidence shows that community detoxification is more effective.

# NICE Guidelines

[NICE CKS - Alcohol-use disorders](https://www.nice.org.uk/guidance/cg100/chapter/Recommendations)
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Delirium tremens
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Neurology
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A 71-year-old female patient is brought into the Emergency Department from a care home with worsening confusion and vomiting. She has not opened her bowels in 7 days and has been increasingly agitated, disorientated and difficult to engage in conversation for the past 5 days.

What is the most likely cause of this patients confusion?
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