Delirium in alcohol withdrawal

Most delirium in hospitalised patients is multifactorial; see Risk factors for delirium in adults. In patients with alcohol dependence, common risk factors for delirium are acquired brain injury, cognitive impairment including dementia, and acute medical or surgical illness. Intoxication should be excluded. Delirium tremens is rarely seen, probably because of the widespread use of benzodiazepine treatment to manage alcohol withdrawal.

In assessing delirium in alcohol withdrawal, consider precipitating factors particularly infection, anaemia, head injury, electrolyte disturbances and metabolic disturbances such as hypoglycaemia, Hepatic encephalopathy and Wernicke encephalopathy. Some of these disturbances may be part of refeeding syndrome; refer patients to a dietitian to assist with refeeding.

Hyperactive delirium can complicate delirium of any cause; it poses a serious risk for falls, absconding, or harm from the use of physical restraints. Use local hospital guidelines and seek specialist advice for all patients with delirium during alcohol withdrawal, because they are at high risk of complications. For general advice on managing delirium, see Principles of managing delirium. Drug therapy is preferred to physical restraint. Benzodiazepines are not a treatment for delirium (other than for delirium tremens) and will only exacerbate it. Antipsychotics are the drugs of choice in managing hyperactive delirium.

Evaluate bleeding risk before giving any intramuscular injection; haemorrhage has occurred after intramuscular injection in patients with unrecognised severe thrombocytopenia or coagulopathy associated with liver disease.