Delirium Tremens

What Is Delirium Tremens?

Delirium tremens (DTs) is the most severe form of alcohol withdrawal and is characterized by altered mental status and elevated blood pressure and heart rate that can lead to cardiac collapse. Alcohol withdrawal occurs when people who are physically dependent on alcohol stop drinking or reduce their amount of drinking.

How Common Is This Condition? 

Delirium tremens is an extremely dangerous condition that affects those who have long-term histories of alcohol misuse or severe alcohol use disorders (AUDs). Of that population, more than 50% exhibit alcohol withdrawal symptoms after discontinuing or decreasing their alcohol use. The lifetime risk for developing DTs in this population is approximately 5-10%.

How Long Does Delirium Tremens Last?

Delirium tremens typically occur 3-10 days following a person’s last drink. However, for those with severe AUD, DTs can occur as early as 48 hours after abrupt cessation of alcohol and can last up to 5 days.

What Causes Delirium Tremens?

Alcohol acts on chemicals in the brain called neurotransmitters, specifically GABA. GABA is an inhibitory neurotransmitter, meaning that it slows down excitatory functions in the brain and body, which is one of the reasons why alcohol can temporarily result in a calming effect and decrease anxiety.

When alcohol is withdrawn from the body, functional loss of GABA occurs. The nervous system goes into overdrive, causing the body to experience states of excitation, resulting in the clinical signs of alcohol withdrawal:

• Tremors
• Agitation
• Hallucinations
• Increased heart rate, blood pressure, and body temperature
• Seizures

What Are The Risk Factors For Delirium Tremens?

Delirium tremens occurs when an individual who drinks heavily and has alcohol dependence suddenly stops or reduces their amount of alcohol and experiences alcohol withdrawal; therefore, the most significant risk factor is being dependent on alcohol.

Alcohol dependence is defined as a physiological adaptation of the body to alcohol to the point that the body becomes so used to alcohol being present in the system that when the person cuts back on their use or quits, withdrawal symptoms emerge. In other words, if you feel like you need alcohol to feel and function normally, you’re at an increased risk for DTs. Other factors that increase your risk of developing DTs include the following:

• Previous alcohol withdrawal
• History of delirium tremens
• Heavy drinking
• Co-occurring mental health disorder or substance use disorder
• Having an underlying medical disorder that affects metabolism
• Having nutritional deficiencies
• Currently in severe alcohol withdrawal
• Prolonged time before last drink with a recent history of heavy drinking
• Previous treatment for alcohol detoxification
• Older age
• Low potassium
• Low platelets

Delirium Tremens Symptoms

Symptoms of DTs include two categories: profound global confusion and autonomic hyperactivity.

Profound global confusion is the hallmark of delirium tremens and consists of disorientation, confusion, agitation, and sensory disruption. People with DTs often talk nonsensically and are unaware of where they are or what is happening.

Autonomic hyperactivity includes high blood pressure, fast heart rate, fevers, sweating, high body temperature, nausea and vomiting, tremors, headaches, and seizures.

Delirium Tremens Hallucinations

Hallucinations caused by delirium tremens are unique “immersion” hallucinations, meaning that the person believes they are in a different environment than in reality. For example, a person may be fiddling with the wall at the back of their room, and when asked what they’re doing, they will say, “I’m trying to get this stove to work.” In their mind, they are at home in the kitchen. People experiencing DTs are immersed in another time and place and interact with that environment.

DT hallucinations differ dramatically from alcoholic hallucinosis. Alcoholic hallucinosis occurs during the beginning stages of alcohol withdrawal and is characterized by auditory hallucinations, paranoid symptoms, and fear. Alcoholic hallucinosis usually begins around 12-24 hours after the last drink and can last for 1-2 days. People with alcoholic hallucinosis are generally not disoriented and usually have normal vital signs, which differ drastically from people with delirium tremens.

How Is Delirium Tremens Diagnosed?

Delirium tremens are diagnosed based on history and physical examination. History is based on past drinking patterns, and common questions include:

• Do you have a history of alcohol misuse?
• When was your last drink?
• Have you experienced alcohol withdrawals or delirium tremens in the past?

It is helpful to have family members or loved ones present during the assessment as they can often provide more information in terms of the individual’s alcohol history.

Vital signs are strictly monitored, particularly blood pressure and heart rate, as these are often the signifying vital signs that are increased during severe alcohol withdrawal and delirium tremens. People experiencing minor alcohol withdrawal often have average heart rates. As the severity of withdrawal symptoms worsens, so does the heart rate, and people with DTs have markedly elevated heart rates, usually well over 150. Other physical examination signs that are used to diagnose delirium tremens are:

• Fever
• Increased blood pressure
• Agitation
• Disorientation
• High body temperature
• Sweating
• Tremors
• Seizures

What Tests Will Be Done To Diagnose Delirium Tremens?

The most widely used tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), which is a survey that consists of ten items and can be rapidly administered at the bedside. However, the person must be coherent enough to answer the questions logically. This survey is only intended for people who have been drinking recently, as it measures the severity of alcohol withdrawal and the potential risk of developing DTs. The ten items in the survey include questions about experiencing nausea and vomiting, anxiety, tremors, sweating, auditory and visual disturbances, and agitation. A score of greater than 15 is seen in people with severe alcohol withdrawal and should be treated with medication. They should be carefully monitored for the development of delirium tremens.

Aside from the assessment, laboratory tests are often ordered to help the medical team evaluate the person’s organ function and nutritional status. Blood and urine tests include blood alcohol level, serum chemistry test to determine electrolyte status and kidney function, liver enzymes, ketones, and urine drug test to determine if any other drugs are involved that can interact with alcohol withdrawal.

Delirium Tremens Treatment

Delirium tremens are treatable if proper medical care is sought immediately and no comorbid medical conditions or complications exist. The mainstay of treatment is medications used to lower the overactive nervous system in order to control heart rate and blood pressure and prevent seizures. Sedating medications such as benzodiazepines are the mainstay treatment for delirium tremens as benzodiazepines act on the same GABA receptors as alcohol and are known to induce a calming nervous system. The type, amount, and frequency of benzodiazepines administered depends on the severity of symptoms and the person’s past history. In general, for DTs, high doses of diazepam are given intravenously until the person is calm but alert, and then dosages are gradually tapered.

Anesthetic agents such as ketamine, propofol, and barbiturates have also been used to treat DTs and are used if the person requires sedation and intubation.

Individuals who have a history of alcohol abuse are often dehydrated and malnourished; therefore, hydration and nutrition are usually prioritized upon admission to prevent organ damage. Thiamine, folate, dextrose, and electrolytes are often administered in an intravenous bag of fluids to help replenish the chemical balance and hydration status.

Complications Of Delirium Tremens

Despite modern treatment for delirium tremens, mortality rates are still 5-15%. The most common causes of death in people with delirium tremens are cardiac arrhythmias and respiratory failure. People who have the highest mortality risk are those with severe electrolyte and fluid imbalance, high fevers, Wernicke-Korsakoff syndrome, pneumonia, alcohol ketoacidosis, hepatitis, and pancreatitis. If any of these medical conditions are present, treating them immediately while also treating DTs is essential.

Get Help For An Alcohol Use Disorder

If you or a loved one struggles with alcohol misuse, it’s important to seek treatment so you don’t develop dangerous complications associated with an alcohol use disorder (such as DTs). Contact a treatment provider today to discuss your treatment options and take the first step towards a healthier, addiction-free life.