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ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 2  |  Page : 86-89

Factors associated with delirium tremens: A retrospective chart study


Department of Psychiatry, Father Muller Medical College , Mangalore, India

Date of Web Publication16-Sep-2013

Correspondence Address:
P John Mathai
Department of Psychiatry, Father Muller Medical College , Mangalore
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.118234

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  Abstract 

Objectives: Delirium tremens is the most severe on the spectrum of alcohol withdrawal syndromes. The mortality rate in this condition has been reported as high as 20%; however, with appropriate diagnosis and prompt treatment, mortality has been reduced to 1%. We studied the sociodemographic, clinical and laboratory data in alcohol dependant patients who developed delirium during the period of abstinence and compared them with patients who had uncomplicated withdrawal states. Materials and Methods: This investigation was done in the deaddiction centre, department of psychiatry, Father Muller Medical College Mangalore. A retrospective chart review spanning a period of 8 months (Jan-Aug 2011) was done to select 60 consecutive patients with alcohol dependence syndrome without medical or other psychiatric co-morbidity (excluding nicotine dependence). Socio demographic, clinical and laboratory data comprising haematological and biochemical parameters at the time of admission were compared between 30 alcohol dependents who developed delirium and 30 alcohol dependents who had uncomplicated withdrawal state. Results: No statistical significance is observed on sociodemographic data between the groups. Early onset dependence were noted to be developing delirium in withdrawal period. Elevated bilirubin levels and SGOT levels are significantly more in delirious patients. Statistically significant higher blood glucose levels were seen in patients with uncomplicated withdrawal. Conclusion: Patients with elevated bilirubin and transaminases, and early onset alcohol dependence are prone to develop delirium during alcohol withdrawal states.

Keywords: Alcohol dependence syndrome, delirium tremens, predisposing factors


How to cite this article:
Chandini S, Sequeira AZ, Mathai P J. Factors associated with delirium tremens: A retrospective chart study. Muller J Med Sci Res 2013;4:86-9

How to cite this URL:
Chandini S, Sequeira AZ, Mathai P J. Factors associated with delirium tremens: A retrospective chart study. Muller J Med Sci Res [serial online] 2013 [cited 2019 Oct 16];4:86-9. Available from: http://www.mjmsr.net/text.asp?2013/4/2/86/118234


  Introduction Top


On the spectrum of alcohol withdrawal syndromes, delirium tremens are the most severe. The mortality rate in this condition has historically been reported as high as 20%; however, with appropriate diagnosis and prompt treatment, mortality has been reduced to 1%. [1] Prevention of alcohol withdrawal delirium will significantly reduce morbidity and mortality. Hence, it is essential to identify the risk factors for its predisposition. Risk factors hypothesized for the development of alcohol withdrawal delirium are electrolyte abnormalities in the form of hypokalemia, hypophosphatemia, hypomagnesemia, high blood urea nitrogen, low nutritional state reflected by hypoalbuminemia, significantly raised levels of biological marker enzymes, such as gamma glutamyl transferase, alanine aminotransferase, and aspartate aminotransferase, raised MCV and carbohydrate deficient transferrin. [2],[3],[4] Researchers have also reported low platelet count as a potential risk factor. [5],[6] In a large cohort of inpatients treated for alcohol withdrawal, a prediction model for withdrawal seizures and delirium tremens during moderate to severe alcohol withdrawal syndrome showed that significant predictors at admission for the occurrence of delirium tremens were lower serum potassium, a lower platelet count and the prevalence of structural brain lesions. [7],[8] Palmstierna concluded that the presence of infectious disease, tachycardia at admission, withdrawal signs accompanied by an alcohol concentration of more than 1 gram per liter of body fluid, a history of epileptic seizures, and a history of delirious episodes can predict outcome for patients seeking acute treatment for alcohol withdrawal. [9] Individuals who began heavy drinking at the age of 20 or below reported significantly greater social role maladaptation, greater severity of alcoholism, more severe alcoholic deterioration, and more frequent psychoperceptual withdrawal symptoms, delirium tremens than later-onset alcoholics. [10],[11],[12] In a cohort study of alcohol withdrawal patients, the clinical, epidemiological, and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of syndrome were recorded. Three variables for the development of delirium tremens were identified: Number of seizures, systolic blood pressure >150 mm Hg and axillary temperature >38 degrees C. [13] Elevated blood pressure, prior complicated alcohol withdrawal and medical comorbidity, alone and in combination, are associated with an increased risk of delirium tremens. [14]


  Aims Top


  • To assess the predisposing factors for delirium in patients with alcohol dependence syndrome.
  • To compare sociodemographic, clinical and laboratory data in alcohol dependant patients who developed delirium during the period of abstinence with patients who had uncomplicated withdrawal states.

  Materials and Methods Top


A retrospective chart review was conducted in deaddiction centre, Department of Psychiatry, Father Muller Medical College, Mangalore. Case files of patients admitted in the deaddiction center satisfying inclusion and exclusion criteria between January 2011 to August 2011 with a clinical diagnosis of alcohol dependence syndrome were retrieved using consecutive sampling technique. They were then divided into 2 groups, the cases and controls depending on whether they developed delirum or not during the course of their hospitalization as recorded in their respective charts. The sociodemographic data and the clinical information pertaining to alcohol use patterns were obtained from these case files. Early onset dependence was used to label those individuals who were dependent on alcohol prior to the age of 25 years. The laboratory parameters comprising hematological and biochemical data at the time of admission were also obtained. All variables were then compared between the cases and controls. The cases for the study included 30 alcohol dependents meeting the inclusion and exclusion criteria, who developed delirium following admission and controls were 30 alcohol dependents who had uncomplicated withdrawal state. The inclusion criteria were inpatients with ICD-10 diagnosis of alcohol dependence syndrome, age group between 20 to 60 years, male patients and with no features to suggest delirium at the time of admission. Patients with other comorbid substance dependence excluding nicotine, the presence of comorbid psychiatric disorders, pre-existing neuropsychiatric, neurodegenerative disorder, and other significant medical disorders which may independently cause delirium were excluded from the study. The study was approved by the institute ethical committee. Collected data were analyzed by frequency, percentage, mean, standard deviations. The data were further analyzed using Chi-square test, t-test (independent and paired), ANOVA and Karl Pearson co-relation co-efficient.


  Results Top


The 2 groups are comparable on all sociodemographic data [Table 1]. Early onset dependence patients are statistically shown to be at a higher risk to develop withdrawal delirium [Table 2]. Laboratory values of high bilirubin, SGOT, and random blood sugars are also statistically significant among the patients with delirium tremens [Table 3].
Table 1: Sociodemographic Data

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Table 2: Delirium tremens and clinical variables

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Table 3: Delirium tremens and biochemical parameters

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  Discussion Top


This study suggests early onset dependence to be a risk factor for the development of delirium. Early onset of drinking heightens the risk of progression to the development of alcohol disorders. [10],[11],[12] Significantly elevated bilirubin levels and SGOT levels were also predisposing to the development of delirium as found in previous studies. [7],[8] Elevated blood glucose levels were seen in patients with uncomplicated withdrawal which may be explained by undiagnosed medical comorbity highly existent among alcohol dependent patients. High admission respiratory rate and elevated systolic blood pressure have been noted to be risk factors in a previous study. [2] Our study did not support any difference in the physical parameters of the two groups. Serum electrolytes, hemoglobin, WBC counts, and platelets did not differ statistically in the two groups. The clinical data comprising the amount, duration and quantity of alcohol use, past history of withdrawal delirium, withdrawal seizures did not differ statistically in the two groups.

Limitations

This is a retrospective chart review; a prospective study can give more reliable information. The dose of benzodiazepines given after admission were not compared between the groups in the study assuming adequate dose to be administered based on individual requirement. Sample size is inadequate.


  Conclusion Top


A basic history, physical examination, and biochemical parameters can detect patients prone to develop complicated withdrawal during periods of abstinence. Patients with early onset alcohol dependence and deranged LFT are prone to develop delirium during alcohol withdrawal states.

 
  References Top

1.Wright T, Myrick H, Henderson S, Peters H, Malcolm R. Risk factors for delirium tremens: A retrospective chart review. Am J Addict 2006;15:213-9.   Back to cited text no. 1
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2.Ferguson JA, Suelzer CJ, Eckert GJ, Zhou XH, Dittus RS. Risk factors for delirium tremens development. J Gen Intern Med 1996;11:410-4.  Back to cited text no. 2
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3.Dolman JM, Hawkes ND. Combining the audit questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Alcohol Alcohol 2005;40:515-9.  Back to cited text no. 3
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4.Sharpe PC. Biochemical detection and monitoring of alcohol abuse and abstinence. Ann Clin Biochem 2001;38:652-64.  Back to cited text no. 4
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5.Berggren U, Fahlke C, Berglund KJ, Blennow K, Zetterberg H, Balldin J. Thrombocytopenia in early alcohol withdrawal is associated with development of delirium tremens or seizures. Alcohol Alcohol 2009;44:382-6.   Back to cited text no. 5
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6.Cowan DH, Hines JD. Thrombocytopenia of severe alcoholism. Ann Intern Med 1971;74:37-43.  Back to cited text no. 6
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7.Eyer F, Schuster T, Felgenhauer N, Pfab R, Strubel T, Saugel B, et al. Risk assessment of moderate to severe alcohol withdrawal-predictors for seizures and delirium tremens in the course of withdrawal. Alcohol Alcohol 2011;46:427-33.  Back to cited text no. 7
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8.Wetterling T, Kanitz RD, Veltrup C, Driessen M. Clinical predictors of alcohol withdrawal delirium. Alcohol Clin Exp Res 1994;18:1100-2.  Back to cited text no. 8
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9.Palmstierna T. A model for predicting alcohol withdrawal delirium. Psychiatr Serv 2001;52:820-3.  Back to cited text no. 9
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10.DeWit DJ, Adlaf EM, Offord DR, Ogborne AC. Age at first alcohol use: A risk factor for the development of alcohol disorders. Am J Psychiatry 2000;157:745-50.  Back to cited text no. 10
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11.Lee GP, DiClimente CC. Age of onset versus duration of problem drinking on the alcohol use inventory. J Stud Alcohol 1985;46:398-402.  Back to cited text no. 11
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12.Varma VK, Basu D, Malhotra A, Sharma A, Mattoo SK. Correlates of early- and late-onset alcohol dependence. Addict Behav 1994;19:609-19.  Back to cited text no. 12
[PUBMED]    
13.Monte R, Rabuñal R, Casariego E, Bal M, Pértega S. Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting. Eur J Intern Med 2009;20:690-4.  Back to cited text no. 13
    
14.Fiellin DA, O'Connor PG, Holmboe ES, Horwitz RI. Risk for Delirium Tremens in Patients with Alcohol Withdrawal Syndrome. Subst Abus 2002;23:83-94.  Back to cited text no. 14
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
Aims
Materials and Me...
Results
Discussion
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