QuestionSBA
QuestionChoice
This is a likely case of delirium precipitated by recent orthopaedic surgery. Despite the previous injury to staff earlier in the day, it would be most appropriate for you to try and de-escalate the situation using verbal reassurance and orientation before you consider pharmacological management. This is since it recognised that some of the drugs to treat delirium, for example, benzodiazepines, can worsen it and nonpharmacological measures if used appropriately can be quite effective. Interventions, such as reducing noise by nursing in a side room if safe, using familiar nurses, orientating with a clock and calendar, using photographs and inviting in the family, can often have a positive effect on these patients in their transient delirium.
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Verbal reassurance and orientation
QuestionChoice
Haloperidol is a recognised treatment for delirium. However, nonpharmacological interventions should be trialled in the first instance in this case. On occasion, pharmacological interventions may be tried as first-line treatment if necessary and proportionate, that is, if the patient poses an immediate risk to themselves or others. There is no evidence in this case that the patient is currently posing an immediate risk to herself or anyone around her. Haloperidol is a butyrophenone antipsychotic and antagonises the dopamine (D2) receptor. Therefore, it is avoided in patients with Parkinson's disease or Lewy body dementia, due to the risk of precipitating rigidity. The QTc should be checked before providing haloperidol wherever possible due to the risk of causing prolongation. Haloperidol may also worsen delirium in some patients.
52888
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Haloperidol
QuestionChoice
Lorazepam is a benzodiazepine given intravenously or orally. It can be used in the treatment of delirium alongside other types of benzodiazepines. However, it should not be used before nonpharmacological interventions in this case. Side effects include drowsiness and worsening of delirium. It is a suitable alternative to haloperidol in patients with Parkinson's disease or Lewy body dementia.
52889
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Lorazepam
QuestionChoice
Olanzapine is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological treatments first. In the elderly, olanzapine has also been associated with increased episodes of venous thromboembolism and may also worsen delirium. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity.
52890
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Olanzapine
QuestionChoice
Risperidone is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological interventions first. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity. It can also cause worsening of delirium in some patients.
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Risperidone
QuestionComment
Do you still try verbal reassurance if the patient is manic?
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subscriber
Myotonia Malignant
Concept
Chapter
# 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
Topic
34
Neurology
10638
Delirium in elderly patients post-surgery can often be managed effectively with verbal reassurance and orientation before considering pharmacological interventions.
An 82-year-old woman is agitated after a total knee replacement 1d ago. The nurse in the bay has asked for help from the on call team as the patient is trying to leave her bed unattended and is shouting out non-specifically. The nurse reports that the patient settles if asked to remain in bed. The patient is often sleeping during the day but awake and eating throughout the night. She pushed over one of the physiotherapists earlier in the morning but there have been no further instances of aggression. The patient has no significant past medical or social history.

What is the first step in the management of this patient?
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