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SponsoredAccording to 2024 data, 57.9 million Americans aged 12 and older engaged in binge drinking in the past month, 14.5 million reported heavy alcohol use and 27.9 million met the diagnostic criteria for alcohol use disorder (AUD). This is a medical condition characterized by an inability to stop or control drinking despite negative consequences.
In 2020-2021, roughly 178,000 people died from excessive alcohol use, which represented a 29% increase from 2016-2017 when 138,000 died. As noted in the 2018 Journal of Clinical and Experimental Hepatology, one potential alcohol-related cause of death is symptoms of delirium tremens when they are not properly managed and treated.
What Is Delirium Tremens?
Delirium tremens (DTs) is the most severe form of alcohol withdrawal and is sometimes referred to as alcohol withdrawal delirium. DTs features sudden and severe nervous system changes that can occur any time after a prolonged period of heavy alcohol abuse.
Delirium tremens was first recognized as a condition attributed to excessive alcohol misuse in 1813. Without appropriate treatment, in 2023, experts estimated a mortality rate of 37%.
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However, while DTs are highly dangerous, it is also rare. Research indicates that DTs occurs in roughly 2% of people who are dependent on alcohol.
Diagnostic criteria include having delirium and being in severe alcohol withdrawal. Delirium is characterized by a rapid onset of symptoms, including disturbances in consciousness, motor activity, cognition, thinking, and sleep-wake cycles.
As noted in 2018, delirium tremens is usually a short-lived condition with a typical duration of 3-4 days. However, it can last up to 10 days in severe cases. It usually starts with cognitive disturbances and confusion and ends with prolonged sleep.
What Are Delirium Tremens Symptoms?
Delirium tremens (DTs) is a severe and potentially life-threatening condition that can occur during alcohol withdrawal. It represents a medical emergency that requires prompt treatment and professional supervision to ensure safety and recovery.
Alcohol Withdrawal
The first symptom of alcohol withdrawal is typically tremors—or uncontrollable shaking—which can show up as soon as 6 hours after your last drink.
Severe Alcohol Withdrawal
While rare, hallucinations can occur and usually show up in the first 12-24 hours. The third symptom of severe alcohol withdrawal is seizure, which may happen anytime after the first 24 hours.
Delirium Tremens
Delirium tremens symptoms are considered the fourth and final major symptom of severe alcohol withdrawal. Because symptoms of DTs do not appear suddenly, early intervention in the first 48 hours of alcohol withdrawal can prevent delirium tremens.
Common delirium tremens symptoms include:
- Changes in mental function
- Brain fog
- Severe confusion
- Hallucinations (i.e., seeing, hearing, or feeling sensations that do not match reality)
- Body tremors
- Irritability or agitation
- Sudden changes in mood
- Sensitivity to sound, light, and touch
- Severe agitation
- Autonomic instability with rapid heartbeat and high blood pressure
- Fever and excessive sweating
- Nausea and vomiting
- Disturbed sleep
- Severe insomnia
- Seizures
While seizures are a common symptom of DTs, they are also a manifestation of less severe alcohol withdrawal. Alcohol-related seizures are usually generalized tonic-clonic (also called grand mal) seizures and occur within 12-48 hours of the last drink. Tonic-clonic seizures involve loss of consciousness and muscle convulsions. Alcohol-related seizure activity is more common in people with past complications from alcohol withdrawal.
What Are Delirium Tremens Risks?
Delirium tremens risks can be serious. Some possible complications include:
- Seizures
- Injuries from falls that occur during seizures
- Injuries to self or others caused by delirium, confusion, or hallucinations
- Irregular heartbeat that may become life-threatening
- High blood pressure
- Altered mental status
- Profound confusion
- Aspiration pneumonitis (i.e., lung injury caused by inhaled vomit or gastric contents)
- Respiratory failure
DT-related deaths most often occur from:
- Cardiac arrhythmia (i.e., an abnormal heartbeat, including too fast, too slow, or irregular)
- Hyperthermia (i.e., abnormally high body temperature)
- Seizure complications
- Medical conditions related to chronic alcohol abuse, such as alcohol-related liver disease
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Who Is at Risk for Delirium Tremens?
Delirium tremens symptoms are rare, even in people with alcohol dependence. Only about half of the people diagnosed with alcohol use disorder experience alcohol withdrawal symptoms.
The prevalence of DT increases with the severity of alcohol dependence. Those with severe cases of alcohol use disorder and longer histories of chronic heavy alcohol abuse are at highest risk of developing delirium tremens symptoms.
While the cause is not well understood based on current research, adult men are more likely to develop DTs. 2023 data reveal the prevalence is highest in young, Caucasian men who have never married. The lifetime risk of developing delirium tremens in this population is 5-10%.
Liver disease is a common comorbidity with delirium tremens. However, it appears there is a bidirectional component. Comorbidity may suggest that people with liver conditions are at higher risk of DTs. However, liver disease may not increase your risk since it is often caused by long-term alcohol use, which is a known risk factor for delirium tremens.
Older age is also a risk factor, with elderly persons with AUD more at risk of experiencing delirium tremens symptoms during withdrawal.
Research indicates that the following are also risk factors:
- History of delirium tremens
- Prior history of seizures
- Prior history of alcohol detox or withdrawal
- More than 10 years of heavy alcohol use
- Concurrent illness
- Electrolyte imbalance
- Head injury
- Infection
- Low platelet count
- Low levels of certain vitamins and minerals
These risk factors can also increase the mortality of delirium tremens. According to research reported in the Journal of Clinical and Experimental Hepatology, those with head injuries have an 11% mortality rate from DT compared to the average 1-4% mortality rate.
How Is Delirium Tremens Treated?
Delirium tremens is a medical emergency that requires immediate treatment. Treatment aims to relieve symptoms, prevent complications, and reduce the risk of permanent side effects or death.
Physical Exams and Testing
When you seek medical care for DTs, your health care provider performs a physical exam, monitoring for the following symptoms:
- Irregular or rapid heartbeat
- Rapid muscle tremors
- Increased startle reflex
- Heavy sweating
- Problems with eye muscle movement
- Dehydration
Your provider may also perform the following tests:
- Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar)
- Comprehensive metabolic panel
- Electrocardiogram (ECG)
- Electroencephalogram (EEG)
- Blood phosphate and magnesium levels
- Renal and liver function tests
- Toxicology screen
- Urinalysis/drug screening
To diagnose and treat delirium tremens, your doctor may also ask questions about your medical history, including:
- How much alcohol you drink, how often, and how long you have abused alcohol in that amount
- How long has it been since your last alcoholic drink
- Have gone into alcohol withdrawal before, and what your symptoms were, including if you needed treatment
- If you use other substances, including legal, over-the-counter, or recreational, like anxiety medication (e.g., Xanax), Tylenol, or marijuana
- If you have any complicating medical problems, such as:
- Coronary heart disease
- Diabetes
- Chronic liver disease
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Hospital Stay
Treatment for delirium tremens requires a hospital stay, so your healthcare provider can routinely check your electrolytes, blood serum levels, body fluids, and vital signs.
Medications may be prescribed to treat your symptoms, relieve tremors or seizures, keep you calm and treat co-occurring medical conditions.
Medications
Benzodiazepines such as diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are typically used, which can drastically reduce mortality rates.
Treatment can be administered at the same time every day or a symptom-triggered regimen, such as when you experience a specific symptom. The medications are typically given intravenously. Symptom-triggered regimens usually require the least amount of medication and have the shortest duration of treatment. There is no standard dosage requirement as it can vary from person to person.
Some patients with severe delirium tremens symptoms may not respond to benzodiazepines. In these cases, barbiturates, such as phenobarbital, may be prescribed. Propofol is also sometimes used with benzodiazepines, but only during mechanical ventilation.
Aftercare and Long-Term Treatment
Long-term treatment is recommended after you recover from delirium tremens and are released from the hospital. Some post-withdrawal symptoms, such as mood swings, drowsiness, and insomnia, can last for a year or longer. You may benefit from counseling or medications to help ease these symptoms.
Addiction treatment can help you maintain abstinence and prevent relapse. Some treatment options you may consider include:
- Inpatient rehabilitation
- Outpatient programs
- Individual counseling and psychotherapy
- Family therapy
- Peer support groups, such as Alcoholics Anonymous, HAMS, SOS, and SMART Recovery
If you are struggling with alcohol misuse or dependence, call
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