Alcohol Dependence

Question 1

Features of alcohol dependence

Answer 1

• Physiological withdrawal symptoms
• Increasing tolerance
• Salience- progressive neglect of alternative pleasures or interests
• Starts drinking at previous levels after periods of abstinence
• Difficulty to control levels of drinking
• Evidence of harmful effects but persists drinking
• A strong desire or compulsion to drink
• Drinking patterns narrow progressively

Question 2

Alcohol withdrawal delirium (DTs)

Answer 2

• Onset 1-7 days after last drink
• Peak incidence at 48 hours
• Symptoms include:
  
  • Confusion
  • Agitation
  • Hallucinations (esp. visual)
  • Delusions
  • Autonomic arousal
  • Often dehydration and pyrexia (risk factors for increased mortality)
  • Seizures
• Risk
  
  • Severe dependence
  • Comorbid infection
  • Pre-existing liver disease
• Mortality around 10%

Question 3

Management of alcohol withdrawal delirium

Answer 3

• Fluid replacement
• Correct electrolytes (commonly low K+ and Mg)
• Start benzodiazepines
• Pabrinex/Thiamine supplementation
• Post-withdrawal management (i.e. support)

Question 4

Wernicke’s Encephalopathy

Answer 4

• Classic triad (only occur in 16%) of:
  
  • Confusion
  • Ataxia
  • Opthalmoplegia
• Acute onset
• Global confusional state
• Drowsiness
• Ataxia
• Double vision
• Abnormal eye movements or paralysis of eye muscles
• Can develop suddenly and symptoms can be mistaken for intoication

Question 5

When to treat in Wernicke’s Encephalopathy

Answer 5

• Evidence of chronic alcohol misuse plus:
  
  • Acute confusion
  • Decreased conscious level
  • Opthalmoplegia
  • Memory disturbance
• Hypothermia
• Hypotension
• Alcohol Withdrawl Delirium
• Hypoglycaemia in those with chronic alcohol ingestion

Question 6

Treatment of Wernicke’s Encephalopathy

Answer 6

• Give 2 paits of vials of Pabrinex in A&E
• If admitted five 2 pairs of visls 3 times a day for 3 days
• If improvement give 1 pair of vials per day for 5 days or until clinical improvement ceases
• Remember magnesium
• 84% of Wernicke’s go on to develop Korsakoff’s amnestic syndrome
• Wernicke’s = acute organic reaction
• Korsakoff’s = residual and sometimes permanent deficit

Question 7

Korsakoff’s psychosis - alcohol related brain damage

Answer 7

• Preservation of immediate recall
• Deficit in ability to acquire and retain new knowledge (recent memory)
• Disorientation to time
• Retrograde amnesia
• Remote memory much better preserved
• High dosage parenteral thiamine replacement must be attempted
• In cases with enduring memory disturbance, high potency vitamin injections “should be pursued for as long as improvement is occurring”