[Diagnostics and therapy of alcohol withdrawal syndrome: focus on delirium tremens and withdrawal seizure]. / Diagnostik und Therapie des Alkoholentzugssyndroms: Fokus auf Delirium tremens und Entzugskrampfanfall.

INTRODUCTION: Delirium tremens and withdrawal seizures are serious complications of an alcohol withdrawal syndrome. This review presents the diagnostic procedures required in case of the occurrence of a withdrawal seizure and delirium tremens as well as possible treatment options including prophylactic medication regimen for alcohol withdrawal syndrome. Furthermore non-pharmacological procedures accompanying delirium tremens and a potential integration of viewing videotapes of delirium tremens in the course of alcohol-specific therapy are discussed. METHODS: A systematic literature research using Pubmed has been carried out to find recent studies and review articles dealing with alcohol withdrawal syndrome. RESULTS AND DISCUSSION: Regarding the diagnostic algorithm in case of the occurrence of a withdrawal seizure or a delirium tremens basic diagnostic procedures and special diagnostics including neuro-imaging or cerebrospinal fluid puncture depending on patients' clinical condition have to be considered. Sedatives are important in treatment of alcohol withdrawal seizures and delirium tremens as well as in the prophylaxis of alcohol withdrawal syndrome. A long-lasting prescription of anticonvulsant medication in patients suffering from withdrawal seizure should be considered critically and can be carried out only under certain conditions.

Alcohol withdrawal syndrome: assessment and treatment with the use of the Clinical Institute Withdrawal Assessment for Alcohol-revised.

Alcoholism is a chronic, complex disease and addictive disorder. Sudden cessation of alcohol consumption can lead to alcohol withdrawal, an acute process with devastating and potentially life-threatening consequences. Assessment of alcohol withdrawal is key to a successful outcome. Appropriate assessment of withdrawal symptoms begins with the use of the revised Clinical Institute Withdrawal Assessment for Alcohol, which evaluates the presence and severity of withdrawal symptoms. The higher the patient's score, the greater the risk for experiencing serious withdrawal symptoms. Pharmacotherapy may be gauged to treat the symptoms according the score.

Proposal of a comprehensive clinical typology of alcohol withdrawal--a cluster analysis approach.

AIMS: To characterize the various courses of alcohol withdrawal. METHODS: The Alcohol Withdrawal Scale (AWS) was applied to 217 alcohol-dependent patients every 4 h till the symptoms of withdrawal had passed (until each of four consecutive scores were <3). Patients were medicated by a standardized treatment scheme according to AWS-scores. Hierarchical cluster analysis and discriminant analysis were applied. RESULTS: We found five clusters representing increasing severity of alcohol withdrawal. Each cluster is characterized by a combination of the two maximum subscores (vegetative and psychopathological subscore) and three additional psychopathological symptoms (anxiety, disorientation, and hallucination). In 18.4% of the patients, relevant symptoms were not observed (cluster 1), 18.9% developed mild or moderate vegetative symptoms only (cluster 2), and 40.6% additional anxiety (cluster 3). In cluster 4 (11.1%) the most frequent psychopathological symptoms were disorientation and anxiety but no hallucinations, which could be observed only in cluster 5 (11.1%). Discriminant analysis using the maximum subscores at the first day of treatment as independent variables correctly predicted 89.9% of the five clusters. CONCLUSIONS: Our findings support a model of alcohol withdrawal clustering along the two dimensions of vegetative and psychopathological severity. Furthermore, the AWS may be useful to predict the course of alcohol withdrawal already at the first day of treatment.

Case study of hip fracture in an older person.

PURPOSE: To discuss proximal femoral (hip) fractures as the leading cause of hospitalization for injuries among older persons, using a case example that illustrates not only the orthopedic injury but also how an older person's chronic problems complicate the acute event. DATA SOURCES: Extensive review of scientific literature on the conditions discussed, supplemented by the case study. CONCLUSIONS: Hip fractures in older adults can present multiple challenges to care when complicated by preexisting or coexisting conditions. This case of an older man with a hip fracture emphasizes the resuscitation priorities for the patient found after a "long lie" and the impact of chronic alcoholism and malnutrition, which lead to serious complications. IMPLICATIONS FOR PRACTICE: Careful physical and psychosocial assessment is important for determining the presenting problem and comorbid conditions. Priorities for postoperative management of hip fracture and its complications guide the nurse practitioner through the successful return of the patient to the community.

Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU.

OBJECTIVE: To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients. DESIGN AND SETTING: Prospective randomized, double-blind controlled trial in a surgical ICU. PATIENTS: 44 patients who developed AWS after admission to the ICU. INTERVENTIONS: Patients were randomized to either (a). a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b). the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group). MEASUREMENTS AND RESULTS: The administration of "as-needed" medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%). CONCLUSIONS: We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.

Alcoholic epilepsy: a unified and dynamic classification.

The interactions between alcohol and the CNS are complex and there are experimental data suggesting that chronic and acute effects are different and often opposite. An intriguing hypothesis is that repeated alcohol withdrawal seizures (AWS) may render the brain more excitable, leading to an epileptogenic state reminiscent of the 'kindling' model. To gain insight into this question we compared alcoholic patients with seizures related to episodes of AW (AWS) and patients with seizures unrelated to episodes of AW (UAWS). There were several significant differences between the AWS and UAWS groups. Age at admission for seizure was younger in the AWS groups (p < 0.005), seizure number was higher among patients with a history of seizures before admission in the UAWS group (p < 0.05). Neurologic signs were more frequent in the UAWS group (p < 0.05). Duration of intoxication was longer in the UAWS group and brain atrophy demonstrated by CT scan was more common in the UAWS group than the AWS group. Based on these findings, we propose a dynamic classification in which patients presenting seizures unrelated to any cause other than alcohol are classified in several successive stages of 'alcoholic epilepsy', the first being characterized by AWS and the last by persistent chronic seizures.

The Windsor Clinic Alcohol Withdrawal Assessment Scale (WCAWAS): investigation of factors associated with complicated withdrawals.

A new scale for measuring the severity of the alcohol withdrawal syndrome has been developed. The Windsor Clinic Alcohol Withdrawal Assessment Scale (WCAWAS) has more objective criteria than its parent scales and has high inter-rater reliability and concurrent validity. This article describes the development of the WCAWAS and its use in an investigation of which factors were associated with complicated withdrawals in 142 consecutive patients admitted for detoxification. Multivariate analyses showed that drinking behaviour variables and MCV were successful at predicting complicated withdrawals. The WCAWAS was not successful at predicting which patients developed convulsions. Further studies are required to see if the WCAWAS is more successful at predicting which patients will develop visual hallucinations. The WCAWAS is useful as a teaching aid and in following the clinical course of patients and their response to treatment.

Assessment of the alcohol withdrawal syndrome--validity and reliability of the translated and modified Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A).

The alcohol withdrawal syndrome is a common phenomenon in psychiatric hospital care. Not only treatment strategies, but also the evaluation of the syndrome, are discussed controversially. The most widely used instrument is the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) and the succeeding CIWA-Ar. We modified the CIWA-A and translated it into German. Validity and reliability of the modified and translated scale were analysed by several psychological tests as well as different somatic measures in 31 patients. The German version appears to be a valid and reliable instrument for the assessment of alcohol withdrawal syndrome useful for clinical routine as well as treatment trials.

Consumption indicators of alcohol dependence.

This Data Note evaluates various dichotomous measures of alcohol consumption as screeners for past-year alcohol dependence. The analysis is based on data from 22,102 current drinkers interviewed in the 1988 US National Health Interview Survey. The consumption indicators include measures of average daily intake, frequency of heavy drinking, usual quantity and frequency of drinking and various combinations of these measures. The measures based on frequency of heavy drinking are the most strongly correlated with dependence, but none of the consumption indicators have the sensitivity or specificity of screeners based on alcohol-related problems. Most of the consumption items considered in this analysis screen for dependence more successfully among men than among women.

Pharmacological management of alcohol withdrawal.

Alcohol withdrawal is a common disorder, yet its pharmacological management varies widely. This article outlines the clinical features and complications encountered during alcohol withdrawal. It discusses when and where treatment should be initiated and suggests therapeutic recommendations for pharmacological management.

DSM-III-R and proposed DSM-IV alcohol abuse and dependence, United States 1988: a nosological comparison.

The purpose of the present study was to compare DSM-III-R and the proposed DSM-IV (options 1 and 2) diagnostic criteria for alcohol abuse and dependence in a representative sample of the United States general population. Alcohol abuse and dependence diagnostic categories were contrasted in terms of prevalence and overlap. The prevalences of DSM-III-R and DSM-IV diagnoses of alcohol abuse and dependence combined were remarkably similar. However, disaggregation of abuse and dependence diagnoses showed that there were major discrepancies between the classification systems. Reasons for these discrepancies are discussed in terms of differences in the number of diagnostic criteria and the content of the DSM-III-R and DSM-IV abuse and dependence categories, the requirement for physiological dependence in DSM-IV classifications, the relationship between the abuse and dependence categories, and the impact of the duration criteria.

DSM-III-R and the proposed DSM-IV alcohol use disorders, United States 1988: a nosological comparison.

The purpose of the present study was to compare DSM-III-R and the proposed DSM-IV diagnostic criteria for alcohol abuse and dependence in a representative sample of the United States general population. Alcohol abuse and dependence diagnostic categories were contrasted in terms of prevalence and overlap. The prevalence of DSM-III-R diagnoses of alcohol abuse and dependence combined (8.63%) was greater than the corresponding DSM-IV diagnoses (6.00%). Disaggregation of abuse and dependence diagnoses showed that the major discrepancy between the classification systems resided between the abuse categories. Reasons for the discrepancies are discussed in terms of differences in the content of the DSM-III-R and DSM-IV abuse categories, in the relationship that each abuse category shares with its respective dependence category, and the impact of the DSM-III-R duration criterion.

[Clinical and laboratory differentiation of alcohol withdrawal syndrome ("predelirium") and alcoholic delirium]. / Zur klinischen und labortechnischen Differenzierung des Alkoholentzugssyndroms ("Prädelir") und des Alkoholdelirs.

In a retrospective study, data from 99 male and female inpatients with alcohol withdrawal syndrome or alcohol withdrawal delirium, treated between 1977 and 1987, were analyzed. DSM-III criteria were used to assign the diagnosis of either withdrawal delirium (with obligatory clouding of consciousness) or alcohol withdrawal syndrome (without disturbances of consciousness and/or perception). No statistically significant differences between the two groups were found with respect to the red and white blood count, liver enzymes, and electrolytes. Significant differences were found in calcium levels, lymphocyte counts, and in electrophoresis. However, these differences are of no use for diagnostic purpose. Moreover, they are unspecific with respect to etiology. Hence, the distinction between alcohol withdrawal syndrome and alcohol withdrawal delirium can only be made clinically, i.e., it is dependent on the presence or absence of a clouded consciousness. This is in line with the findings published by other investigators. In the light of our metabolic findings, alcohol withdrawal syndrome and alcohol withdrawal delirium represent the two extremes of a continuum rather than two separate nosological entities.

Characterization of DSM-III-R criteria for uncomplicated alcohol withdrawal provides an empirical basis for DSM-IV.

The DSM-III-R criteria for uncomplicated alcohol withdrawal require the presence of coarse tremor of the hands, tongue, or eyelids plus one of a number of other clinical features. We examined the validity and other characteristics of these items in 137 patients in pure alcohol withdrawal using the reliable and valid Clinical Institute Withdrawal Assessment for Alcohol. The DSM-III-R items of hand tremor amplitude, nausea or vomiting, headache, transient hallucinations, autonomic hyperactivity (increased pulse or sweating), and anxiety correlated significantly with total score and significantly indicated clinical severity. Addition of an "agitation" item improved the correlation. The diagnostic accuracy is greater than 95% if any two or more items are present. The number of positive items, of which tremor can be one, to grade clinical severity shows that a score of 2 indicates "very mild"; 3, "mild"; 4, "moderate"; and 5, "severe.". We propose that an Alcohol Withdrawal Diagnostic Inventory and a DSM-III-R-compatible brief Clinical Institute Withdrawal Assessment for Alcohol are useful for clinical research, where graded symptom characterization is needed. Our data may be helpful in the development of criteria for DSM-IV.