Delirium Tremens in the Older Adult.

INTRODUCTION: Caring for patients experiencing alcohol withdrawal syndrome can be challenging. Patients 65 and older are at increased risk for alcohol withdrawal syndrome related complications. The higher prevalence of co-morbidities, including cognitive impairment, longer drinking history and greater sensitivity to alcohol withdrawal syndrome treatment are the result of decreased ability of the brain to adapt to stressors such as illness, trauma, or surgery. DELIRIUM TREMENS: Symptoms may appear earlier from the last drink and present with a wide range of symptoms. The most effective interventions require high-quality nursing care delivery to prevent, decrease the severity and shorten the duration of delirium. NURSING IMPLICATIONS: Strategies that help minimize these challenges starts with obtaining the patient's selfreport of their alcohol use history. Nurses should be diligent in their monitoring for signs of active alcohol withdrawal. Screening and assessment tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised should guide pharmacological management. To support nurses in identifying delirium tremens, this manuscript seek to describe the underlying pathophysiology, key assessment components and nursing management of delirium tremens in the older adult.

Correlation Between mMINDS and CIWA-Ar Scoring Tools in Patients With Alcohol Withdrawal Syndrome.

BACKGROUND: Many alcohol withdrawal scoring tools are used in hospitalized patients to assess the severity of alcohol withdrawal and guide treatment. The revised Clinical Institute Withdrawal Assessment (CIWA-Ar) and the modified Minnesota Detoxification Scale (mMINDS) are commonly used but have never been correlated. OBJECTIVE: To determine the strength of correlation between the CIWA-Ar and mMINDS scoring tools in patients with alcohol withdrawal syndrome. METHODS: A single-center, prospective correlation study conducted at a large academic medical center. Patients treated for alcohol withdrawal syndrome according to the Yale Alcohol Withdrawal Protocol were identified daily, and both the CIWA-Ar and mMINDS were administered at each time point required by the protocol. Clinical data were obtained from the electronic medical records. RESULTS: A total of 185 CIWA-Ar and mMINDS scores were collected in 30 patients. The Pearson correlation coefficient across all scores was 0.82, indicating a strong correlation. The Pearson correlation coefficient was 0.87 for CIWA-Ar scores of 10 or less and 0.52 for CIWA-Ar scores above 10. Strong correlations were also shown for tremor (0.98), agitation (0.84), and orientation (0.87). CONCLUSIONS: The correlation between the CIWA-Ar and mMINDS tools is strong and appears to be most robust in patients with CIWA-Ar scores of 10 or less.

The Addition of Dexmedetomidine as an Adjunctive Therapy to Benzodiazepine Use in Alcohol Withdrawal Syndrome: A Literature Review.

Alcohol withdrawal syndrome (AWS) is commonly encountered in the intensive care unit population. Currently, the mainstay treatment for AWS is the use of benzodiazepines. However, some patients are refractory to benzodiazepine treatment due to heavy alcohol abuse. In addition, escalating doses of benzodiazepines can lead to respiratory depression, requiring intubation and mechanical ventilation. Intubation and mechanical ventilation increase both intensive care unit and hospital length of stay. The addition of pharmacological agents to reduce the amount of benzodiazepine use in AWS has recently been studied. Most recently, the addition of dexmedetomidine, a selective α2 adrenoceptor agonist, has been explored. Dexmedetomidine provides sedation without depressing the respiratory system, making it an ideal pharmacological agent to use. The addition of dexmedetomidine in adjunct to benzodiazepine use has been proven to reduce the amount of benzodiazepine administered, decrease the number of patients requiring intubation and mechanical ventilation, and decrease length of intensive care unit stay and overall length of hospital stay. However, the use of dexmedetomidine has also produced harmful side effects such as hypotension and bradycardia. The use of dexmedetomidine in conjunction with benzodiazepines in the setting of AWS is promising; however, more research needs to be conducted in regard to the safety and efficacy of its use.

The Addition of Dexmedetomidine as an Adjunctive Therapy to Benzodiazepine Use in Alcohol Withdrawal Syndrome: A Literature Review.

Alcohol withdrawal syndrome (AWS) is commonly encountered in the intensive care unit population. Currently, the mainstay treatment for AWS is the use of benzodiazepines. However, some patients are refractory to benzodiazepine treatment due to heavy alcohol abuse. In addition, escalating doses of benzodiazepines can lead to respiratory depression, requiring intubation and mechanical ventilation. Intubation and mechanical ventilation increase both intensive care unit and hospital length of stay. The addition of pharmacological agents to reduce the amount of benzodiazepine use in AWS has recently been studied. Most recently, the addition of dexmedetomidine, a selective α2 adrenoceptor agonist, has been explored. Dexmedetomidine provides sedation without depressing the respiratory system, making it an ideal pharmacological agent to use. The addition of dexmedetomidine in adjunct to benzodiazepine use has been proven to reduce the amount of benzodiazepine administered, decrease the number of patients requiring intubation and mechanical ventilation, and decrease length of intensive care unit stay and overall length of hospital stay. However, the use of dexmedetomidine has also produced harmful side effects such as hypotension and bradycardia. The use of dexmedetomidine in conjunction with benzodiazepines in the setting of AWS is promising; however, more research needs to be conducted in regard to the safety and efficacy of its use.

Observing nurses has improved my alcohol dependency care.

My first placement in my first year of nursing training was on a gastrointestinal/hepatology ward. Alongside my mentor, I was caring for a patient who had been withdrawing from alcohol since admission to hospital the previous evening.

The Clinical Nurse as an Agent of Change.

The physiologic risk is great for patients undergoing alcohol withdrawal without appropriate medication apd monitoring support. An interprofessional team adapted several alcohol withdrawal protocols for this project using evidence-based practice principles.

Alcohol-related liver disease.

Alcohol is one of the three leading causes of liver disease in the developed world. Patients with alcohol-related liver disease are often cared for in general wards and hospitals, rather than specialist centres. This may be a result of the number of patients being admitted or a lack of referral to specialist services by healthcare professionals. The financial cost of caring for patients with alcohol-related injuries is continuing to rise. This article explores the mechanisms of liver injury caused by alcohol; the risk factors associated with alcohol-related liver disease; assessment tools used to identify patients with alcohol use disorders; withdrawal from alcohol; chronic liver disease; and issues surrounding transplantation. The importance of the nursing role in assessing and monitoring patients undergoing withdrawal from alcohol, information giving and advice on the prevention of alcohol-related liver injury, and supporting patients with alcohol-related liver injury is highlighted.

A 'symptom-triggered' approach to alcohol withdrawal management.

In acute hospital settings, alcohol withdrawal often causes significant management problems and complicates a wide variety of concurrent conditions, placing a huge burden on the NHS. A significant number of critical incidents around patients who were undergoing detoxification in a general hospital setting led to the need for a project to implement and evaluate an evidence-based approach to the management of alcohol detoxification-a project that included a pre-intervention case note audit, the implementation of an evidence-based symptom-triggered detoxification protocol, and a post-intervention case note audit. This change in practice resulted in an average reduction of almost 60% in length of hospital stay and a 66% reduction in the amount of chlordiazepoxide used in detoxification, as well as highlighting that 10% of the sample group did not display any signs of withdrawal and did not require any medication. Even with these reductions, no patient post-intervention developed any severe signs of withdrawal phenomena, such as seizures or delirium tremens. The savings to the trust (The Pennine Acute Hospital Trust) are obvious,but the development of a consistent, quality service will lead to fewer long-term negative effects for patients that can be caused by detoxification. This work is a project evaluation of a locally implemented strategy, which, it was hypothesised,would improve care by providing an individualised treatment plan for the management of alcohol withdrawal symptoms.

Symptom-Triggered vs. Fixed-Dosing Management of Alcohol Withdrawal Syndrome.

A literature review was conducted with the objective of creating evidence-based recommendations for use of symptom-triggered therapy (STT) or fixed-schedule dosing in treating alcohol withdrawal syndrome in inpatients. Use of STT reduced duration of therapy as well as the number of patients requiring treatment or medication, potentially reducing costs and risk of adverse medication reactions.

Fusion of psychiatric and medical high fidelity patient simulation scenarios: effect on nursing student knowledge, retention of knowledge, and perception.

High fidelity patient simulation (HFPS) has become an increasingly popular teaching methodology in nursing education. To date, there have not been any published studies investigating HFPS scenarios incorporating medical and psychiatric nursing content. This study utilized a quasi-experimental design to assess if HFPS improved student knowledge and retention of knowledge utilizing three parallel 30-item Elsevier HESI(TM) Custom Exams. A convenience sample of 37 senior level nursing students participated in the study. The results of the study revealed the mean HESI test scores decreased following the simulation intervention although an analysis of variance (ANOVA) determined the difference was not statistically significant (p = .297). Although this study did not reveal improved student knowledge following the HFPS experiences, the findings did provide preliminary evidence that HFPS may improve knowledge in students who are identified as "at-risk." Additionally, students responded favorably to the simulations and viewed them as a positive learning experience.

An alcohol withdrawal tool for use in hospitals.

An estimated 40% of patients admitted with alcohol-related problems to Glasgow hospitals are at risk of alcohol withdrawal syndrome (AWS). Not managing them effectively can affect the physical and psychological wellbeing of staff and other patients. This article describes the development and implementation of a tool, the Glasgow Modified Alcohol Withdrawal Scale, to manage patients with AWS. It is part of a more comprehensive assessment and management protocol and incorporates a protocol to help nurses decide whether to administer fixed-dose or symptom-triggered benzodiazepine to these patients.

Alcohol withdrawal in the critical care unit.

Managing acute alcohol withdrawal in critical care presents a unique challenge to the critical care nurse. The prominence of alcohol use within the Australian community means that many critical care admissions involve acute alcohol withdrawal, an alcohol induced illness, or indeed an unrelated admission with underlying heavy alcohol intake. Current statistics suggest 1 in 5 Australians drink to 'risky' levels each month. This suggests that most critical care nurses will encounter a patient who is experiencing active withdrawal from alcohol, often without clear physiological symptomatology. Acute alcohol withdrawal delirium can be difficult to distinguish from other forms of delirium and in the absence of a comprehensive history, alcohol withdrawal and its sequelae may go untreated. Contemporary management guidelines for alcohol withdrawal suggest a common framework of first line benzodiazepine usage, with emerging research focusing on adjunctive therapy aimed at reducing benzodiazepine doses, and therefore reducing length of stay in the critical care unit. The controversial therapy of ethanol infusion and common assessment and withdrawal scales are examined in relation to their usefulness in critical care. Alcohol withdrawal management in critical care necessitates careful nursing assessment, including alcohol usage history, delirium management, withdrawal assessment and symptomatic relief using an evidence-based protocol.

Changes in general nurses' knowledge of alcohol and substance use and misuse after education.

PURPOSE: This study aims to assess the impact of an education program on Australian general nurses' knowledge and competence in identifying and managing patients with alcohol and substance use and misuse, and compare findings with existing literature on mental health nurses. DESIGN AND METHODS: Pre- and posttest design without a control group. FINDINGS: The nurses' knowledge of safe drinking limits and alcohol withdrawal management improved following the education. Nevertheless, overall the nurses reported a lack of adequate knowledge and competence. Compared to mental health nurses, the nurses in this study had lower levels of knowledge and competence. PRACTICE IMPLICATIONS: We suggest several opportunities for general nurses to strengthen their knowledge and skills and the need for a comprehensive and regular education program.

Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity.

Studies show that symptom-triggered dosing is best for treatment of alcohol withdrawal in patients on chemical dependence wards without other illness. On general medical hospital wards, withdrawal may be affected by comorbid medical illness. A clinical trial was undertaken to determine whether there is a difference between symptom-triggered (ST) and fixed-schedule (FS) dosing of lorazepam in patients hospitalized on general medical wards at a university medical center. One hundred eighty-three subjects were assessed by their nurses with the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Subjects in the ST arm received lorazepam doses based on CIWA-Ar score. Subjects in the FS arm received scheduled lorazepam with tapering over 4 days. Symptom-triggered dosing for alcohol withdrawal for general medicine inpatients results in less lorazepam given with similar reduction in CIWA-Ar scores for the first 2 days, but a higher proportion of protocol errors.