Alcohol Dependence and Withdrawal Flashcards
What is the approach used to tackle harmful drug use or dependence with a patient?
FRAMES
Describe FRAMES
1) Feedback → discuss risks and listen
2) Responsibility → up to them to change
3) Advice → change, harm minimisation
4) Menu → give people options e.g. AA, CBT
5) Empathy → non-judgemental
6) Self-efficacy → project optimism for change
What condition can result from alcohol withdrawal?
Delirium tremens (delirium in the setting of alcohol withdrawal)
What is the typical presentation of someone with delirium tremens?
1) Agitation
2) Sweating
3) Tremor
4) High BP
5) High pulse
6) High temperature
7) Seeing small animals
What are other symptoms sometimes present in someone with alcohol withdrawal?
1) Sensitivity to light and sound
2) Confusion → disorientated to time and place
3) Hallucination (visual)
4) Seizures
When do visual hallucinations usually occur?
In delirium or from medication, not really schizophrenia
What will someone’s BAC be if they are in alcohol withdrawal?
Might be 0 but might be high/over drink drive limit → if drinking excessive alcohol, can go into alcohol withdrawal after an hour of not drinking
How should you assess someone with alcohol withdrawal?
1) Use a structured tool e.g. CIWA → breaks down abnormalities into spectrums and gives score according to how deranged each spectrum is
2) Decide whether to give medication based on score
When is treatment critical in alcohol withdrawal?
First 2 days when there are early symptoms
Describe the time scale of delirium tremens
- Tends to hit on day 3 and peak and day 4
- Most of it calms down by at 7 but if complicated then it can carry on for a couple of weeks
What causes people to die of alcohol overload?
Acute increasing GABA activation and high chloride flow
What happens in chronic alcohol dependence to GABA receptors?
Makes GABA receptors less sensitive to excess alcohol
What is LTP (long term potentiation)?
The process where your brain converts short term to long term memory
Acutely, what does alcohol inhibit?
NMDA-mediated transmission and therefore LTP
What is the chronic alcohol on NMDA receptors?
Leads to receptor up-regulation (adaptation to mitigate against effects on memory)
What happens when you remove alcohol to NMDA and GABA receptors?
- NMDA-mediated transmission is increased
- Glutamate transmission potentiation (bc GABA usually modulates it and there are more receptors)
- Bc GABA modulates NA transmission → sweating tachycardia
- Dopamine → hallucinations
What is the mortality of delirium tremens?
10-25%
How do you treat delirium tremens differently from delirium?
- Need much bigger doses of benzodiazepines (much higher than BNF limits)
- Anti-psychotics don’t work as well + risk of causing arrhythmic arrest
What are risk factors for DT?
- Metabolic disturbances
- Sepsis
What is a cause of sepsis v common in people with alcohol dependence?
Aspiration pneumonia
How is the immune system different in alcohol dependence?
1) Macrophage activation and inflammation in the liver → innate immune system activation
2) Depression in adaptive immune response → so pneumococcal vaccine doesn’t work as well
3) Alveolar macrophages don’t work that well
What is Wernicke’s encephalopathy?
Acute confusional state secondary to thiamine (B1) deficiency
How does alcohol dependence/withdrawal lead to WE?
1) People who are alcohol dependent often struggle to eat bc nausea and vomiting are major side effects of alcohol withdrawal
2) Alcohol is toxic to the gut where thiamine is absorbed
3) Alcohol interferes with thiamine transport and conversion to its active form bc this is done in the liver
How does thiamine deficiency lead to WE?
1) Causes brain to malfunction bc thiamine is important in the Kreb’s cycle and brain needs glucose
2) Thin layered parts of the brain are more sensitive → problems in cerebellum and hippocampus
3) Leads to confusion and internuclear ophthalmoplegia (double vision and paralysis of lateral gaze)
