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Authors

  1. Keys, Vicky A. MSN, RN-BC

Abstract

Overview: For a chronic drinker, sudden alcohol withdrawal because of an unexpected hospitalization can lead to escalating withdrawal symptoms and even death if unrecognized and untreated. Nurses need to be aware of the prevalence of alcohol abuse in the United States and consider the possibility of unplanned alcohol withdrawal in their patients. This article discusses the effects on the body of chronic alcohol intake, the potential symptoms of alcohol withdrawal, and ways to recognize and treat these symptoms through early assessment and consistent intervention.

 

Keywords: alcohol abuse, alcoholism, alcohol withdrawal, alcohol withdrawal delirium, alcohol withdrawal syndrome, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, hospitalization, substance withdrawal syndrome

 

Article Content

Lorraine Wilson, 74 years of age, is admitted to the hospital at noon for a hip fracture sustained after a fall at her home. (This case is a composite based on my experience.) After several hours in the ED, she's transferred to the surgical unit. Around 8 PM the nurse notices that Ms. Wilson is a bit confused and anxious. Assuming the patient is experiencing "sundown syndrome," the nurse reorients her to time and place, ensures adequate lighting, and continues with her patient assessments. By 11 PM Ms. Wilson is extremely anxious, shaky, and nauseated. The nurse puts in a call to the physician for antiemetic and sleep medication. What she doesn't realize is that Ms. Wilson is exhibiting symptoms of alcohol withdrawal.

  
Figure. Early screen... - Click to enlarge in new windowFigure. Early screening for alcohol use can help nurses prevent and treat alcohol withdrawal in hospitalized patients more effectively.

Unfortunately for the nurse, guessing which patient may be abusing alcohol is a futile exercise at best and a dangerous practice at worst, as there's simply no way to tell the heavy drinker from the moderate one.

 

Chronic alcohol consumption is prevalent in the United States, and for many heavy drinkers hospitalization forces at least a temporary abstinence. According to the Behavioral Risk Factor Surveillance System (BRFSS), 15% of surveyed adults reported binge drinking (defined as "five or more drinks during a single occasion for men or four or more drinks during a single occasion for women"), and 5% reported heavy drinking (defined as "more than two drinks per day on average for men or more than one drink per day on average for women").1

 

Managing the potentially severe symptoms associated with a sudden and unplanned alcohol withdrawal can be challenging. Nurses need to be aware of the pervasiveness of alcohol use and consider the possibility of alcohol withdrawal in their patients.

 

ALCOHOL IN THE BODY

Alcohol affects every system of the body. Absorbed from the stomach and upper intestine, it quickly passes into the bloodstream and within minutes permeates the brain, liver, heart, pancreas, lungs, and kidneys.

 

While chronic drinking affects all of these organs, the abrupt withdrawal of alcohol most immediately affects the brain. The brain balances and directs the activity of neurotransmitters, which carry signals to the peripheral nervous system and direct nearly every bodily function. For every neurotransmitter moving along a neuron carrying a signal, there must be a receptor in the receiving cell ready to accept that signal. The interaction between a neurotransmitter and its receptor initiates a series of biochemical events in the receiving cell. Neurotransmitters either excite or inhibit the signal-receiving cell.

 

Alcohol depresses the central nervous system in two ways. First, it inhibits the N-methyl-D-aspartate (NMDA) neuroreceptors, which are designed to receive glutamate, one of the major excitatory neurotransmitters. In addition, it enhances the main inhibitory neurotransmitter, [gamma]-aminobutyric acid (GABA), which acts via the GABA-A receptor to inhibit or slow certain brain activity.2,3

 

Chronic drinking consistently depresses the central nervous system. The brain compensates by increasing the response of NMDA receptors and decreasing that of GABA-A receptors, which is why tolerance to alcohol increases along with intake.2

 

Yo-Yo drinking. Repeated cycles of intoxication followed by abstinence lead to long-term changes in neurotransmitters. This is known as the "kindling" phenomenon (see Figure 13).2,3 After repeated episodes of drinking and withdrawal, chemical imbalances in the brain become more pronounced.3 The more frequent the episodes of intoxication and abstinence, the greater the severity of withdrawal symptoms and the sooner they appear.

  
Figure 1 - Click to enlarge in new windowFigure 1. The Kindling Phenomenon

SYMPTOMS OF WITHDRAWAL

The brain regulates various mechanisms in the body, including blood pressure, heart rate, mood, perception, movement, temperature, and balance. In the chronic drinker, these mechanisms are continually depressed. Once the depressant effect of alcohol is removed, every mechanism will overreact within hours of the last drink, resulting in alcohol withdrawal syndrome (AWS). Symptoms of AWS range from mild to life threatening, and include anxiety, irritability, agitation, tremors, seizures, hallucinations, and delirium tremens. Mild symptoms can manifest within six to eight hours of the last drink, while more serious complications typically present 12 to 72 hours afterward (see Table 12).2,3

  
Table 1 - Click to enlarge in new windowTable 1. Symptoms of Alcohol Withdrawal Syndrome

ASSESSING AND SCREENING FOR ALCOHOL WITHDRAWAL

Because minor alcohol withdrawal symptoms such as tremor and anxiety are common in hospitalized patients, they can be easily overlooked. However, if symptoms accurately reflect alcohol withdrawal and intervention doesn't take place early on, they will most likely become more severe and gradually progress to hallucinations, seizures, and delirium tremens. They may even eventually lead to life-threatening conditions such as arrhythmia, pneumonia, central nervous system injury or infection, or to an exacerbation of underlying conditions such as pancreatitis or hepatitis. (In addition, chronic drinkers tend to have a lowered immune response; a recent study of patients who are heavy drinkers revealed a lowered ratio of T helper 1 to T helper 2 cells prior to surgery, which may have accounted for the increased rate of infection in these patients following surgery.4)

 

It's important for nurses to assess their patients' alcohol intake upon admission. If patients indicate that they drink, ask for how many years, when they had their last drink, and what they typically drink and how much. Some patients may resist disclosing information regarding their drinking habits. Let them know that your queries are only meant to ensure their well-being; because certain medications may interact negatively with alcohol, it's essential that they candidly discuss their alcohol intake.

 

Screening. Historically, alcohol screening and intervention have been reserved for people whose behavior suggests chronic alcohol abuse. In an effort to intervene earlier, the Substance Abuse and Mental Health Services Administration (SAMHSA) has funded the Screening, Brief Intervention, and Referral to Treatment (SBIRT) initiative to increase alcohol abuse screening, intervention, and treatment in all health care settings.5 Three screening tools are typically used: the Alcohol Use Disorders Identification Test (AUDIT); the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST); and the Drug Abuse Screening Test (DAST). (These tools can be found on the SAMHSA Web site, at http://sbirt.samhsa.gov/core_comp/screening.htm.)

 

The CIWA-Ar scale. If screening indicates the potential for AWS, ongoing assessment and management of symptoms become necessary. A widely used standardized assessment tool is the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), which assesses the presence of 10 symptoms: anxiety; tremor; sweating; auditory, visual, and tactile disturbances; agitation; nausea and vomiting; headache; and orientation. The higher the score, the more severe the withdrawal symptoms.6 (See Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised [CIWA-Ar].)

 

Studies have shown that the use of the CIWA-Ar in the inpatient setting can shorten detoxification time, avoid the administration of unnecessary medications, help decrease the incidence of delirium tremens, and generally improve patient outcomes.7-9 The CIWA-Ar can help the nurse identify and assess the severity of symptoms in order to intervene appropriately. It also directs the timing of reassessments.

 

MANAGEMENT

The goal of AWS management is to preserve respiratory and cardiovascular function and to alleviate symptoms until alcohol levels are sufficiently reduced. Timely intervention is critical; the greater the time elapsed between the patient's last drink and appropriate treatment, the more severe the symptoms. It's also essential to watch for subtle shifts in the patient's status.

 

Medications. The medications most widely used to manage AWS are the benzodiazepines (most commonly diazepam [Valium], lorazepam [Ativan], and chlordiazepoxide [Librium]),8 which act upon the GABA system and mimic the effects of alcohol.10 Because it takes several days for the neurotransmitters' equilibrium to be readjusted, patients must be medicated consistently during the entire withdrawal period, as directed by the CIWA-Ar score. Although benzodiazepines carry a risk of dependency, the benefit of their short-term use during AWS outweighs that risk. Furthermore, when used in response to a CIWA-Ar score, they can be tapered off as the patient's condition improves, thereby decreasing the risk of dependency.

 

Other management measures. Continued vigilance is essential: watch the patient carefully and consistently reevaluate her or his condition. It's also important to implement precautions against falling, frequently monitor the patient's vital signs, and provide a one-on-one sitter if possible.

 

Upon discharge. The nurse, hospital discharge planner, and primary care provider should talk about the patient's withdrawal experience to identify the level of postdischarge follow-up required. The patient may need outpatient counseling or a referral to a rehabilitation center. Follow-up appointments should be discussed, and arranged if possible, to increase the chances for successful abstinence. Referrals to community resources may also be helpful.

 

REVISITING MS. WILSON

A quick alcohol intake assessment by the nurse upon Ms. Wilson's arrival on the surgical unit, followed by the use of the CIWA-Ar, would have prevented the aggravation of her alcohol withdrawal symptoms. Follow-up assessments with the CIWA-Ar would have helped the physician to properly manage her symptoms by using benzodiazepines.

  
Box. CLINICAL INSTIT... - Click to enlarge in new windowBox. CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE, REVISED (CIWA-AR)

REFERENCES

 

1. Centers for Disease Control and Prevention. Alcohol and Public Health. 2010. http://www.cdc.gov/alcohol. [Context Link]

 

2. Bayard M, et al. Alcohol withdrawal syndrome. Am Fam Physician 2004;69(6):1443-50. [Context Link]

 

3. Becker HC. Kindling in alcohol withdrawal. Alcohol Health Res World 1998;22(1):25-33. [Context Link]

 

4. Spies CD, et al. Altered cell-mediated immunity and increased postoperative infection rate in long-term alcoholic patients. Anesthesiology 2004;100(5):1088-100. [Context Link]

 

5. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Screening, brief intervention, and referral to treatment (SBIRT). n.d. http://sbirt.samhsa.gov. [Context Link]

 

6. Sullivan JT, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84(11):1353-7. [Context Link]

 

7. Daeppen JB, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002;162(10):1117-21. [Context Link]

 

8. Jaeger TM, et al. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001;76(7):695-701. [Context Link]

 

9. Weaver MF, et al. Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity. J Addict Dis 2006;25(2):17-24. [Context Link]

 

10. Fleming RL, et al. The effects of acute and chronic ethanol exposure on presynaptic and postsynaptic gamma-aminobutyric acid (GABA) neurotransmission in cultured cortical and hippocampal neurons. Alcohol 2009;43(8):603-18. [Context Link]

 

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