Clinical Presentation and Prevalence

The features of alcohol withdrawal delirium are disturbance of consciousness and changes in cognition or perceptual disturbance (see Table 8.6). A number of medical conditions, including metabolic, infectious, toxic and traumatic causes, may cause delirium.

TABLE 8.6: DSM-5 diagnostic criteria for delirium

A	A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B	The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
C	An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
D	The disturbances in Criteria A and C are not explained by another pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
E	There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Source: American Psychiatric Association 2013, Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revised, American Psychiatric Association.

Alcohol withdrawal delirium typically commences 2 to 3 days after drinking, and usually lasts for a further 2 to 3 days, although in severe cases can persist for several weeks. The incidence of alcohol withdrawal delirium in placebo-treated alcohol dependent patients entered into inpatient clinical trials averages 5 per cent, although with effective treatment the incidence is much lower. Early studies reported mortality rates as high as 15 per cent; however, the rate has fallen with advances in management to less than 1 per cent. Accompanying clinical features often include autonomic hyperactivity, such as hyperpyrexia, tachycardia, hypertension and diaphoresis.

Concomitant medical conditions are common and may not be obvious or self-reported. These may include dehydration, electrolyte abnormalities, renal failure, unrecognised head trauma, infections (including meningitis), gastrointestinal haemorrhage, pancreatitis and liver failure.