Alcohol withdrawal/Delirium

Question 1

A 64 year old legal secretary who lives alone is admitted to hospital with a urinary infection. You are asked to see her because of confusion and hallucinations. She states that she consumes 1⁄2 bottle of wine daily. How would you manage this?

Answer 1

Impression:
- likely delirium secondary to UTI
- Very common in elderly patients admitted to hospital. Is fluctuating derangement in attention and cognition.
Consider/ rule out
- Alcohol withdrawal: Wernicke’s/ Korsakoffs
- Psychiatric presentation
- Other substance use disorder

Goals:

• assess and identify cause of confusion
• treat underlying cause
• reduce risk of complications

Question 2

Delirium - History

Answer 2

History:

• Sx: confusion, agitation,
• UTI: dysuria, frequency, fevers, night sweats
• Sexual history
• PMHx, previous delirium, underlying neurological degeneration
• Current medications, any recent changes
• Alcohol history, substance use history

Question 3

Delirium - Examination

Answer 3

Exam:

• Vital signs
• cognitive assessment/mental state exam
• Abdominal exam (flank pain, peritonitis, etc)
• External genitalia if indicated

Question 4

Delirium - Investigations

Answer 4

Investigations
Delirium is predominantly a clinical diagnosis, however would consider some further investigations in setting of ?UTI and other reversible triggers for delirium in hospital setting:
- Bedside: UA + MCS, BSL, VBG
- Bloods: FBC, UEC, LFT, CRP/ESR
- Imaging: Neuroimaging if indicated

Question 5

Delirium - Management

Answer 5

Management:
Supportive
- One-on-one nursing support
- AGEM transfer
- Encourage family visitation, have some home comforts in room
- Room with windows

Definitive
Is treatment of underlying triggers and pathology, no specific treatment for delirium.
- UTI: pharmacological (Trimethorpim 1st line)
- Alcohol withdrawal: thiamine, AWS
- Consider the use of anti-psychotics if patient is a risk to themselves/others (haloperidol/droperidol)