The Discovery of Acute Alcohol Withdrawal as a Cause of Delirium

By Eelco F. M. Wijdicks
First Online: 02 March 2021

For heavy drinkers to come into a hospital carries risks, and worryingly, signs associated with imposed abstinence appear soon after admission. A considerable number could be transferred to intensive care units including neurointensive care units when the primary diagnosis was neurological. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol to recognize and treat alcohol withdrawal is, in fact, one of the most common order sets (and so is IV thiamine). When we know a just admitted patient drinks excessively and for years—taking into account a continuously changing definition of ‘excessive’ over the last decades and cultural differences—we anticipate a delirium with or without seizures already within 24 h of admission.

A forgotten medical history is that for decades (and into 1950s), delirium was attributed to the direct effect of alcohol. The possibility that alcohol withdrawal plays an important role in the initiation of delirium was considered common knowledge in some circles around the turn of the century and by prominent psychiatrists Adolf Elholz, Wagner von Jauregg, and Hare [1]. Sudden distaste for alcohol had been recognized as an early sign, and much had been made of this statement in Kinnier Wilson's leading textbook of Neurology in the 1940s, which also noted that abstinence was not a factor [2]. This surprised the Europeans, who had no difficulties linking delirium to sudden alcohol abstinence. In the USA, it remained a controversy due to contrasting observations. Bellevue Hospital’s psychiatric ward in New York (with ward designations of “quiet,” “semi-disturbed,” and "disturbed”) reviewed data in thousands of patients and found little related to sobriety [3]. Boston City Hospital, however, confirmed alcohol withdrawal in their series of 101 cases with delirium and, in all, with falling blood alcohol levels [4]. Proof delirium tremens was due to abstinence would come from a prospective study. Isler and colleagues embarked on a controversial study in which prisoners were given as much whiskey as they wanted for a defined interval, after which it was suddenly stopped. This study with "informed" consent found alcohol did not cause delirium but rather the lack thereof.


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