Mental Health
Question 21 of 180
A 42 year old man is brought to the Emergency Department by his family. They describe increasing agitation and confusion. Whilst talking to him you note he experiences visual hallucinations. His observations are recorded as:
- Heart rate: 107 beats per minute
- Blood pressure: 145/89 mmHg
- Respiratory rate: 20 breaths per minute
- Oxygen saturations: 96% on air
- Temperature: 37.8°C
His examination is unremarkable. A CT head is performed which is nonspecific. Which diagnosis is most consistent with this patient’s presentation?
Answer:
- In alcohol withdrawal, patients are often confused and agitated and exhibit autonomic instability, resulting in hypertension, tachycardia and, often, fever. Hallucinations are typically visual.
- Schizophrenia typically results in auditory hallucinations and, although patients are delusional, they are not typically confused.
- Patients with anticholinergic poisoning typically present with confusion but also have dry mouth, dry eyes, dry skin, hypoactive bowel sounds, and urinary retention.
- Patients with opioid withdrawal typically have gastrointestinal complaints and, although they may be agitated, they are seldom confused or febrile.
- Thyrotoxicosis is much more common in women, and patients can exhibit lid lag, tremor, and gastrointestinal complaints.
Alcohol Misuse and Withdrawal
Gastroenterology & Hepatology / Mental Health
Last Updated: 12th February 2021
Definitions
- Problem drinking is defined as regular consumption of alcohol above recommended levels (14 units of alcohol per week).
- Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis.
- Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example, liver disease or depression caused by drinking).
- One unit of alcohol in the UK is defined as 10 mL (8 g) of pure ethanol. The number of units in a drink can be calculated by multiplying the total volume of the drink (mL) by its percentage alcohol by volume (ABV) and dividing the result by 1,000. Therefore, A small glass (125 mL) of average strength wine (11% ABV), or a standard pub measure (35 mL) of spirits (40% ABV) each contain 1.4 units of alcohol.
Complications
Specific health complications relating to alcohol misuse include:
- Short term harm:
- Death and illness from accident and injury, drowning, alcohol poisoning, and self-harm related to alcohol.
- Long term harm:
- Cancer (such as mouth, throat, bowel, stomach, liver, and breast cancer).
- Cardiovascular disease - cardiomyopathy, cardiac arrhythmia, hypertensive disease, stroke, CHD.
- Liver disease - fatty liver (steatosis), hepatitis (acute and chronic), and cirrhosis.
- Gastrointestinal bleed.
- Pancreatitis.
- Gout.
- Psychiatric illness.
- Wernicke's encephalopathy.
- Alcohol-use disorder is often associated with a thiamine deficiency which, if severe, may lead to Wernicke's encephalopathy. This is characterised by ocular motility disorders, ataxia, and confusion. When people with Wernicke's encephalopathy are inappropriately treated, mortality rates average about 20% and Korsakoff's psychosis develops in about 85% of survivors. Korsakoff's psychosis is characterised by anterograde and retrograde amnesia, disorientation, and confabulation.
- Alcohol consumption during pregnancy can adversely affect the fetus:
- Fetal alcohol exposure can cause miscarriage, stillbirth, and intrauterine growth restriction.
- Heavy drinking during pregnancy (repeatedly consuming more than around five units per day), can result in fetal alcohol spectrum disorders (FASD). Some of the features of FASD may not be obvious at birth and may only become apparent when the child starts school, or later on in life. Features of FASD include:
- Malformations of the heart, skull, kidneys, limbs, bones, brain, and other organs.
- Dysmorphic facial features (small eyes, thin upper lip, poorly defined philtrum).
- Problems with eyesight and hearing.
- Fetal growth restriction and poor growth throughout life.
- Microcephaly, developmental problems which can range from mild to severe.
- Social complications relating to alcohol misuse include family conflict and domestic violence and abuse.
Screening for alcohol misuse
Screening tools such as the Paddington Alcohol Test (PAT), the Fast Alcohol Screen Test (FAST) and the Audit C are useful in EDs in the UK.
The AUDIT-C questionnaire consists of the first three questions of AUDIT and can be used where time is limited. The full AUDIT questionnaire should be administered to people with an AUDIT-C score of ≥5 as this suggests a high likelihood of drinking at an increasing risk level. The threshold score may be reduced to ≥3 in adults older than 65 years.
AUDIT-C questions:
- How often do you have a drink that contains alcohol?
- How many standard alcoholic drinks do you have on a typical day when you are drinking?
- How often do you have 6 or more standard drinks on one occasion?
Remaining AUDIT questions:
- How often in the last year have you found you were not able to stop drinking once you had started?
- How often in the last year have you failed to do what was expected of you because of drinking?
- How often in the last year have you needed an alcoholic drink in the morning to get you going?
- How often in the last year have you had a feeling of guilt or regret after drinking?
- How often in the last year have you not been able to remember what happened when drinking the night before?
- Have you or someone else been injured as a result of your drinking?
- Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down?
AUDIT scores are interpreted as:
- Low-risk drinking: score of 1–7.
- Hazardous drinking: score of 8–15.
- Harmful drinking: score of 16–19.
- Possible alcohol dependence: score of 20 or more.
Recognising alcohol withdrawal
The symptoms of alcohol withdrawal can vary in severity and include:
- Mild — hypertension and tachycardia, anorexia, anxiety, emotional lability, insomnia, irritability, diaphoresis, headache, and fine tremor.
- Moderate — worsening mild symptoms plus agitation and coarse tremor.
- Severe/delirium tremens — worsening moderate symptoms plus confusion/delirium, generalised tonic-clonic seizures (this may be the first manifestation of alcohol withdrawal for some people), auditory, visual, or tactile hallucinations, hyperthermia subsequent to psychomotor agitation.
Note: Mild to moderate withdrawal may start as early as 4 to 6 hours after the last drink, and peak at 24 to 36 hours. Severe withdrawal symptoms occur after 24 hours and usually peak at day 2. Delirium tremens generally occurs after 3 days of abstinence or decreased drinking.
Managing alcohol withdrawal
- Who to admit:
- Offer admission to hospital for immediate (unplanned) medically assisted alcohol withdrawal for people in acute alcohol withdrawal with, or who are likely to be at high risk of developing, alcohol withdrawal seizures or delirium tremens. Consider a lower threshold for admission for people who are frail, have cognitive impairment or multiple comorbidities, lack social support, or have a learning disability.
- Urgently admit people with clinical features of Wernicke's encephalopathy (such as confusion, ataxia, ophthalmoplegia, nystagmus, memory disturbance, hypothermia, hypotension, and coma) for treatment with parenteral thiamine.
- Offer referral to specialist alcohol services for people showing moderate or severe signs of alcohol dependence so that they can enter a programme of planned withdrawal. People in whom medically-assisted withdrawal is planned should be advised to avoid a sudden, unsupervised reduction in alcohol intake, and offered information about how to contact local alcohol support services.
- Treatment:
- Choice of agent
- A long-acting benzodiazepine, such as chlordiazepoxide or diazepam, is recommended to attenuate alcohol withdrawal symptoms; local clinical protocols should be followed.
- Carbamazepine [unlicensed indication] can be used as an alternative treatment in acute alcohol withdrawal.
- Clomethiazole may be considered as an alternative to a benzodiazepine or carbamazepine. It should only be used in an inpatient setting and should not be prescribed if the patient is liable to continue drinking alcohol.
- Regimen
- Follow a symptom-triggered regimen for drug treatment for people in acute alcohol withdrawal who are in hospital or in other settings where 24-hour assessment and monitoring are available.
- The patient is regularly assessed and monitored, either using clinical experience and questioning alone or with the help of a designated questionnaire such as the CIWA–Ar. Drug treatment is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal.
- Withdrawal seizures
- In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures. If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen.
- Delirium tremens
- In people with delirium tremens (characterised by agitation, confusion, paranoia, and visual and auditory hallucinations), offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol. If delirium tremens develops during treatment for acute alcohol withdrawal, the withdrawal drug regimen should also be reviewed.
- Wernicke’s encephalopathy
- Parenteral thiamine, followed by oral thiamine, should be given to patients with suspected Wernicke’s encephalopathy, those who are malnourished or at risk of malnourishment, those who have decompensated liver disease or who are attending hospital for acute treatment.
- Prophylactic oral thiamine should also be given to harmful or dependent drinkers if they are in acute withdrawal, or before and during assisted alcohol withdrawal.
- Parenteral thiamine is available as part of a vitamin B substances with ascorbic acid preparation.
- Choice of agent
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
