Symptom profile and outcome of delirium associated with alcohol withdrawal syndrome: a study from India

Molecular mechanisms of alcohol's effects on the human body: A review and update

Alcohol consumption has been linked to numerous negative health outcomes although it has some beneficial effects on moderate dosages, the most severe of which being alcohol-induced hepatitis. The number of people dying from this liver illness has been shown to climb steadily over time, and its prevalence has been increasing. Researchers have found that alcohol consumption primarily affects the brain, leading to a wide range of neurological and psychological diseases. High-alcohol-consumption addicts not only experienced seizures, but also ataxia, aggression, social anxiety, and variceal hemorrhage that ultimately resulted in death, ascites, and schizophrenia. Drugs treating this liver condition are limited and can cause serious side effects like depression. Serine-threonine kinases, cAMP protein kinases, protein kinase C, ERK, RACK 1, Homer 2, and more have all been observed to have their signaling pathways disrupted by alcohol, and alcohol has also been linked to epigenetic changes. In addition, alcohol consumption induces dysbiosis by changing the composition of the microbiome found in the gastrointestinal tract. Although more studies are needed, those that have been done suggest that probiotics aid in keeping the various microbiota concentrations stable. It has been argued that reducing one's alcohol intake may seem less harmful because excessive drinking is a lifestyle disorder.

Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease

Alcohol withdrawal syndrome (AWS) is a common condition that is seen in treatment-seeking patients with Alcohol use disorder (AUD) and alcoholic liver disease (ALD). AWS, which typically starts within 4-6 h of the last alcohol use, can range from mild symptoms such as insomnia, tremors, and autonomic hyperactivity to more severe symptoms such as seizures and delirium tremens. Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is the most commonly used scale to assess AWS in clinical practice. The presence of moderate withdrawal as indicated by a score of more than 8 is an indication for pharmacotherapy. Lorazepam and oxazepam are preferred agents for the management of AWS in the setting of ALD. In severe ALD, benzodiazepines should be used cautiously with monitoring due to the risk of excessive sedation or precipitating hepatic encephalopathy.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients

OBJECTIVES

To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology.

DESIGN

Cross-sectional study.

SETTING

International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings.

PARTICIPANTS

1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV).

PRIMARY AND SECONDARY OUTCOME MEASURES

Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory.

RESULTS

Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001).

CONCLUSIONS

This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

Acute inferior ST-elevation myocardial infarction due to delirium tremens: a case report

Background

Delirium tremens is a severe form of alcohol withdrawal syndrome. Literature documenting acute coronary events in the setting of alcohol withdrawal remains scarce. An accepted hypothesis for the underlying process is focused on the hyperadrenergic state that leads to coronary vasospasm and increased myocardial oxygen demand.

Case presentation

A 47-year-old Caucasian man with a past medical history of tobacco and alcohol abuse, hypertension, and anxiety presented to the emergency department for crampy epigastric abdominal pain with intractable nausea and vomiting for the past 2 days. His reported last alcoholic intake was about 10 days prior; however, outpatient records indicated otherwise. He was admitted for electrolyte replacement and fluid resuscitation secondary to gastrointestinal losses from presumed early alcohol withdrawal syndrome. The following night, he developed acute substernal chest pain with elevated cardiac enzymes. Electrocardiography showed an acute inferoposterior infarct with reciprocal changes in leads V1–V4. The patient was taken for emergent catheterization, and a drug-eluting stent was placed in the middle of the left anterior descending artery. Postcatheterization electrocardiography showed sustained inferolateral ST elevations consistent with acute injury pattern. The patient had not required any benzodiazepines until this point. On the morning of catheterization, the patient’s Clinical Institute Withdrawal Assessment for Alcohol–Revised score was 19 with a high of 25, and he was actively hallucinating. He was treated for delirium tremens and an acute coronary event along with an incidental pneumonia. He did not require any benzodiazepines during the last 4 days of admission, and he made a full recovery.

Conclusions

The prevalence of alcohol dependence in hospitalized patients is substantial. Although our patient was being treated with the standard protocols for alcohol withdrawal, he rapidly developed delirium tremens, which led to an acute inferior ST-elevation myocardial infarction in the setting of nonoccluded coronary vessels. This case report adds to the sparse literature documenting acute coronary events in the setting of alcohol withdrawal and suggests that our patient’s ST-elevation myocardial infarction is not fully explained by the current coronary vasospasm hypothesis, but rather was in part the result of direct catecholamine-associated myocardial injury. Further research should be conducted on prophylactic agents such as β-blockers and calcium channel blockers.

Delirium Tremens: Assessment and Management

Delirium Tremens (DT) falls in the most severe spectrum of alcohol withdrawal, which could potentially result in death, unless managed promptly and adequately. The prevalence of DT in general population is <1% and nearly 2% in patients with alcohol dependence. DT presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination. Clinical and laboratory parameters which predict DT have been discussed. Assessment of DT includes assessment of severity of alcohol withdrawal, evaluation of delirium, and screening for underlying medical co-morbidities. Liver disease as a co-morbidity is very common in patients with DT and that could complicate the clinical presentation, determine the treatment choice, and influence the outcome. Benzodiazepines are the mainstay of treatment for DT. Diazepam and lorazepam are preferred benzodiazepine, depending upon the treatment regime and clinical context. In benzodiazepine refractory cases, Phenobarbital, propofol, and dexmedetomidine could be used.

Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version

BACKGROUND

The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain.

OBJECTIVE

To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98).

METHOD

A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98.

RESULTS

The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms.

CONCLUSIONS

Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.

Pattern and correlates of agitation in an acute psychiatry in-patient setting in a teaching hospital

Agitation among psychiatry inpatients can be a distressing and burdensome entity for patients, caregivers and staff. It has been poorly studied in low-middle income countries such as India both within acute care as well as long stay settings. 272 psychiatry admissions had 19.9% prevalence of agitation with the most common form being non goal directed physical agitation (13.6%). Episodes of agitation were most likely to occur on the 3rd or 2nd day of admission. Substance abuse [O.R.=2.51(1.05-5.99)] and the presence of persecutory delusions [O.R.=2.62(1.34-5.15)] were independently associated with agitation. It is difficult to predict violence in acutely ill individuals and there is evidence that the emergence of more serious aggression may be preceded by milder forms of agitation. Therefore, there is a need to identify various forms of agitation and its correlates. An understanding of these factors may assist in planning appropriate interventions that could improve patient outcomes and reduce the burden on caregivers.