Delirium tremens (DT) is a serious condition that occurs when someone suddenly stops consuming alcohol after prolonged and excessive intake. DT can cause physical and psychological symptoms, including severe confusion and shaking, and can be life-threatening if not diagnosed and treated quickly.
- Delirium tremens (DT) is caused by suddenly stopping chronic and excessive alcohol consumption.
- DT is a serious condition that can cause severe and life-threatening consequences.
- Early intervention and treatment are necessary and can include medications, careful monitoring, and treatment for alcohol dependence.
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Understanding delirium tremens
Delirium tremens (DT), sometimes synonymously referred to as alcohol withdrawal delirium, is a severe and potentially life-threatening condition that occurs during alcohol withdrawal. [1]
Alcohol causes central nervous system (CNS) depression by activating GABA receptors that inhibit neuronal activity. With heavy and chronic alcohol consumption, the body attempts to balance ongoing CNS depression by adapting levels of neurotransmission. Increasing amounts of glutamate are produced to help stimulate neurons that are inhibited by alcohol. [1][2]
If someone with heavy alcohol use, alcohol dependence, or alcohol use disorder (AUD) suddenly stops drinking alcohol, the same level of CNS depression and inhibition no longer occurs. However, the body cannot suddenly adapt its neurotransmitter activity, causing excessive and unmatched glutamate activity that damages cells, known as excitotoxicity. Once this occurs, the signs and symptoms of DT emerge. [1][2]
Prevalence
According to the World Health Organization (WHO), 7% of the world’s population has AUD. [3] Reports show that DT affects between 3% and 15% of people with AUD, with a greater prevalence among those with more severe alcohol dependence. [4]
Reportedly, around half of people with alcohol use disorder will experience alcohol withdrawal syndrome (AWS), and only a small number of these individuals will experience severe symptoms requiring medical attention. Among those with AWS, approximately 3% to 5% will develop DT. [1][5]
Delirium tremens symptoms
Symptoms of DT can vary, although cognitive disturbances such as extreme confusion and disturbing tremors are distinct characteristics of the condition. Symptoms can include: [1][2]
- Shaking
- Extreme confusion
- Agitation
- Fear
- Disorientation
- Fever
- Hallucinations
- Headache
- Sweating
- Increased heart rate
- Hyperthermia
- Nausea and vomiting
- Heart irregularities
DT occurs within the context of alcohol withdrawal and is considered a severe form of AWS. As such, it typically occurs alongside other alcohol withdrawal symptoms, such as seizures, heart issues, mood changes, insomnia, and fatigue. [1][5]
Causes and risk factors
DT occurs due to severe alcohol withdrawal, although not all who experience alcohol withdrawal will develop DT. As such, certain other factors can be responsible for the development of DT symptoms or increased risks during alcohol withdrawal, including: [1][2][4][5]
- Sudden alcohol cessation: DT only occurs when heavy and chronic alcohol use is stopped suddenly. People who gradually reduce their intake or have consumed moderate amounts will not experience severe withdrawal or DT symptoms.
- Severity of alcohol dependence: A greater duration and amount of alcohol consumption is likely to result in an increased severity of alcohol dependence. The more severe the dependence, the greater the likelihood of DT onset in withdrawal.
- Severe alcohol withdrawal: DT is unlikely to occur in instances of mild alcohol withdrawal. Those who experience severe alcohol withdrawal symptoms are most likely to go on to develop DT within the following days.
- History of DT or withdrawal seizures: People with a history of DT or severe withdrawal symptoms, such as seizures, are more likely to develop DT in future alcohol withdrawal situations.
- Electrolyte imbalances: Electrolyte imbalances, particularly low magnesium and potassium levels, contribute to the likelihood and risks of DT.
- Head injury: People with head injury may be more likely to experience delirium in alcohol withdrawal. This can make the diagnosis of DT more challenging and can mask or confuse the recognition of DT symptoms.
- Infection: Similarly, infection can cause or worsen delirium, thus also contributing to the development of DT and making diagnosis more challenging.
- Older age: Older people are more likely to develop DT symptoms in alcohol withdrawal.
- Comorbid health conditions: Other health conditions, including Wernicke encephalopathy, liver disease, or heart issues, can increase the risks and severity of DT and alcohol withdrawal symptoms and may increase mortality risks.
Can delirium tremens be fatal?
Yes, DT can be fatal. DT is more likely to result in death if it is not recognized and treated effectively. The likelihood of death due to DT is between 1% and 20%, although early recognition and intervention can reduce the risk significantly. [1][2]
Often, DT results in death due to medical issues such as hyperthermia, heart arrhythmias, or complications from seizures. Additionally, death is more likely among people with DT who have head injuries or comorbid conditions. [1]
Alcohol withdrawal and DT
After abruptly stopping alcohol consumption, symptoms of DT typically emerge within 48-72 hours. However, other withdrawal symptoms will emerge before symptoms of DT. The timeline of DT onset may be the following: [1][2]
- Six hours after cessation, tremors begin
- After 12-24 hours, people may experience hallucinations, although this does not always occur
- After 24 hours or more, seizures occur
- After 48 hours or more, DT develops
Treatment for delirium tremens
Treatment for AWS can be implemented before the symptoms of DT emerge, which may help to prevent the development of DT. Once DT symptoms begin, intervention should be implemented urgently to avoid complications and severe outcomes. It is often necessary to provide this care within an inpatient or ICU setting, within a calm and comfortable environment. [1]
If treatment is commenced early, it will involve the management of withdrawal symptoms to prevent a worsening of the condition. If DT symptoms have begun, treatment will focus on managing agitation, delirium, and underlying conditions. This can help reduce the risk of seizures and fatality. [4]
Throughout treatment, it will be necessary for the individual and their vitals to be closely monitored, along with various blood tests and laboratory investigations. Ensuring adequate fluids and electrolytes is also imperative during this time, particularly in the case of excessive sweating or vomiting. [1][2]
During or closely following this treatment, the individual should also be prepared for the implementation of treatment for alcohol use disorder or dependence, which may involve additional services and rehabilitation programs.
Delirium tremens medication
Benzodiazepines are a key medication in the treatment of DT and alcohol withdrawal, particularly long-acting benzodiazepines such as diazepam. These medications can be used for consistent and prolonged management of withdrawal symptoms, including agitation, delirium, and seizures. [1][5]
In some cases, benzodiazepines may not be effective or adequate, in which case additional or alternative medications are necessary, such as haloperidol, phenobarbital, or dexmedetomidine. However, these medications can cause additional risks and are not as well-evidenced as benzodiazepine treatments. [1][2]
Safely managing delirium tremens during withdrawal
People stopping or significantly reducing alcohol intake, particularly after prolonged and chronic use, may require professional support to safely manage withdrawal. This can include various types of treatment programs, either through inpatient or outpatient service options, where therapies and medications can be provided to support detox and withdrawal.
People who are quitting drinking without professional support may benefit from understanding the symptoms of alcohol withdrawal. Being aware of dangerous withdrawal symptoms can allow for early intervention from professionals, which can prevent or reduce the impact of AWS or DT. [5]
Any signs of DT should be immediately reported to a doctor for appropriate treatment or referral, as life-saving care may be required. [1]
Final thoughts
Delirium tremens is a potentially life-threatening condition that occurs when people with heavy and chronic alcohol use abruptly stop or rapidly reduce their alcohol consumption. To help avoid DT, drink sensibly or make gradual reductions in alcohol intake when trying to stop drinking. DT can be safely managed if it is recognized and treated early, but without effective or quick treatment, it can be severe or fatal.
People who have difficulty managing their alcohol intake may require professional support. Various options are available.
The Recovered directory provides information about local rehab centers.
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