QuestionSBA
QuestionChoice
Paranoid schizophrenia is a psychiatric disorder associated with paranoid delusions and auditory hallucinations. It is more common in patients between 20-30 years old (some female patients may also present in their 40s). This condition does not develop overnight, so there would likely be some mention of these symptoms when initially presenting to the emergency department. Although they have paranoid delusions, there is no evidence of any auditory hallucinations
33702
e
Paranoid schizophrenia
QuestionChoice
Delirium tremens is a condition associated with acute withdrawal from alcohol in an alcohol-dependent person. This typically occurs 72 hours after alcohol cessation and presents with confusion, agitation, cravings, visual hallucinations and tremor. This patient is presenting too early for this (assuming their last drink would be just before admission), and they do not have any tremor or visual hallucinations
33701
d
Delirium tremens
QuestionChoice
Alzheimer's disease generally presents with a long history of cognitive decline. This patient presents with an acute onset of disorientation, behavioural change and delusions after a hip fracture. This is not typical for dementia, making delirium the more appropriate diagnosis. Dementia is, however, a risk factor for delirium and having delirium in the past increases a patient's risk of developing dementia
33699
b
Alzheimer's disease
QuestionChoice
Delirium is an acute confusional state with a variety of causes. The two most significant risk factors are trauma/severe illness and being elderly, both present in this case. This woman is presenting with hypoactive delirium, as she is withdrawn. In addition, she is presenting with distractibility and disorientation, which are other characteristic features of delirium. Patients with delirium may also present with persecutory delusions, as in this case. This patient should be managed conservatively initially by reorientating them to the environment and addressing reversible causes, e.g. pain management, eating and drinking, urinary retention and constipation, managing infection and reviewing medications
33698
a
Delirium
QuestionChoice
Vascular dementia generally presents with a long history of stepwise cognitive decline. This patient presents with an acute onset of disorientation, behavioural change and delusions after a hip fracture. This is not typical for dementia, making delirium the more appropriate diagnosis. Dementia is, however, a risk factor for developing delirium
33700
c
Vascular dementia
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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2680
Delirium tremens
Topic
34
Neurology
6740
An 88-year-old female presents to the emergency department, where she is diagnosed and treated for a neck of femur fracture and admitted to the orthopaedic ward. The next day, she does not engage with the medical staff and seems withdrawn and distractible. She does not know where she is and has not eaten her food as she thinks it has been poisoned.

What is the most likely diagnosis?
a