Alcohol Related Disorders

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ALCOHOL INTOXICATION

Clinical Description

Behavioral change with disinhibition, potentially agitated and aggressive behavior after recent ingestion of alcohol

Clinical Features

SIGNS AND SYMPTOMS

  • Argumentativeness
  • Lability of mood
  • Impaired attention and judgment, and interference with personal functioning
  • Unsteady gait
  • Difficulty standing
  • Slurred speech
  • Decreased conscious level
  • Flushed face
  • Conjunctival injection

INVESTIGATIONS

  • Blood or breath alcohol (if available)

Treatment

NON-PHARMACOLOGICAL

  • Management is primarily supportive until the effects of the alcohol have worn off
    • If very aggressive then follow treatment guidelines for Violence and Aggression management
  • Admission

Note: Diazepam should be avoided due to increased risk of respiratory depression

FOLLOW-UP

  • If underlying condition and behavioral disturbance cannot be managed at home or health facility
  • Give advice about safe levels of alcohol intake and screen for alcohol use disorders (CAGE questionnaire) and provide alcohol brief interventions

 

ALCOHOL WITHDRAWAL SYNDROMES

Clinical Description

These occur following sudden withdrawal from alcohol. They are often seen 12 to 18 hours after the last drink, but may be earlier and are worst between 24 to 48 hours after onset. This commonly occurs in patients admitted to hospital for other problems e.g. arising from accidents or physical illnesses, which keeps them from drinking. The presentation varies from minimal tremors to states of full-blown agitation and confusion, which are potentially fatal. Caused by abrupt cessation or significant reduction in alcohol intake in an individual with heavy drinking over many months or years.

Clinical Features

SIGNS AND SYMPTOMS

Minor Withdrawal Alcoholic Hallucinosis Alcoholic Seizures Onset 12 to 18 hours after last drink, but may be earlier. Peaks between 24-48 hours 12-24 hrs after cessation of drinking and generally stops within 48 hours 7-36 hours after the last drink but may be earlier. 

  • Headache
  • Nausea
  • Anxiety
  • Fevers
  • Shaking
  • Tremor
  • Sweating
  • Vomiting
  • Increased pulse and blood pressure
  • Agitation
  • In severe cases will progress to Delirium Tremens which presents with: confusion, marked agitation, aggression, hallucinations (frequently visual), delusions, seizure and autonomic instability

INVESTIGATIONS

  • Full physical examination including vital signs (to exclude other causes of delirium if present)
  • Consider FBC, LFT
  • Random blood sugar

Treatment 

  • The aim of treatment is to reduce the symptoms associated with alcohol withdrawal, which can result in seizures and potentially be fatal
    • A reducing course of oral Diazepam should be given four times a day, over five to seven days, titrated according to symptom resolution: for example:  
      • Diazepam 20mg 6 hourly for 1 day 
      • Diazepam 15mg 6 hourly for 1 day
      • Diazepam 10mg 6 hourly for 1 day
      • Diazepam 5mg 6 hourly for 1 day
      • Diazepam 5mg 12 hourly for 1 day
      • Diazepam 5 mg 24 hourly 1 day, It should be accompanied by oral Thiamine supplements
      • Thiamine 100mg 24 hourly orally for 1 month

Secondary /alternative treatment

  • If markedly agitated and unable to comply with oral medication IV Diazepam 5-10mg can be used up to 4 times per day until able to comply with oral treatment

Red Flags 

  • High dose IM / IV thiamine can be given if available
  • IV fluids may be required if evidence of dehydration (low BP, tachycardic)

For admission:

  • Delirium tremens should be treated as an inpatient {medical emergency)
  • People with a high risk of seizures e.g., previous seizures, known epilepsy,
  • People with co-morbid physical illnesses e.g., HIV, jaundice

Note: The dose of Diazepam should be reduced in the physically frail or those with liver impairment or alternatively use lorazepam. 

FOLLOW-UP

  • Once detoxification complete offer advice regarding safe levels of alcohol intake and counseling support if planning to stop drinking.  Refer to alcoholic anonymous 

REFERRAL CRITERIA

  • Refer all patients with alcohol withdrawal syndromes to a psychologist or psychiatrist. Also refer all children to a paediatrician.
  • Acute confusional state that occurs within hours to days of cessation, or reduction of alcohol intake after prolonged {weeks to months) / heavy consumption
  • The peak onset is at 24-48 hours post last ingestion and it can last for 7 - 10 days if untreated

 

WERNICKE-KORSAKOFF SYNDROME

Clinical Description

Is characterized by confusion, ataxia and ocular disturbances (usually due to weakness or paralysis of 6th cranial nerve) including nystagmus

  • May have acute onset or develop slowly over 1 week or so
  • Korsakoff's psychosis is a state of amnesia that usually follows Wernicke’s syndrome
  • This is due to thiamine (vitamin B1) deficiency in alcoholics and malnourished non-alcoholics

Clinical Features

SIGNS AND SYMPTOMS

  • Mostly anterograde amnesia (inability to retain new memories) and possibly retrograde amnesia (inability to recall the past)
  • Fabricating answers or confabulating to cover their memory problems, and
  • Oculomotor disturbances - nystagmus
  • Patient is alert but can be confused if having Wernicke’s disease, responsive and normal

INVESTIGATIONS

  • Substance use history
  • String test to diagnose Korsakoff's psychosis (clinician asks the patient to take an imaginary string in his or her hands, and the patient complies, as though the string were real)
  • Do a physical examination to rule out medical complications or comorbid illnesses
  • Laboratory tests include FBC, offer PITC for HIV, LFTs, Urine/ Blood glucose test

Treatment 

NON-PHARMACOLOGICAL

Management of Physical and Neurological

Complications of Alcohol Dependence 

  • Conduct a comprehensive physical examination of the patient
  • Counsel the patient
  • Institute a brief intervention or motivational interview
  • Abstinence is essential
  • Refer to Alcoholic Anonymous groups if available or link with other agencies such as religious organizations, social welfare services
  • Encourage a healthy diet   with   high protein and vitamin content {give thiamine or Vitamin B Complex)
  • Treat specific disorders symptomatically (e.g., gastro-intestinal disorders, cirrhosis, neuropathy) as per guidelines

PHARMACOLOGICAL 

The aim is to rapidly treat Wernicke's syndrome in order to prevent onset of Korsakoff's psychosis 

  • Immediately give Thiamine {Vitamin B1) 500 mg IV over 30 minutes 8 hourly for 2 consecutive days followed by 250mg IV/IM 24 hourly for 5 days follow with one month of oral thiamine 100mg OD 
  • Glucose without Vitamin B1 can worsen Wernicke's encephalopathy
  • Advise the patient to abstain from alcohol use or consider alcohol detoxification to prevent alcohol withdrawal
  • Always treat medical complications of chronic alcohol use such as GIT, neurologic, cardiovascular, pulmonary, hematologic and endocrine.
  • To treat delirium tremens: see alcohol withdrawal section

Red Flags

For Admission

  • If delirium tremens or wernickes encephalopathy
  • Severe medical complications of chronic alcohol use such as vomiting blood
  • Continued high risk alcohol use or multiple substance use

FOLLOW UP

  • Assess for continued alcohol use and offer brief intervention to promote change in alcohol use on each visit
  • Assess for and treat the medical complications
  • Counsel the patient using problem solving technique
  • Educate and support the family