1. Liaison and Emergency Psychiatry Moray 1 Alcohol dependence and Safe Withdrawal In-patient detox in Dr Grays

2. Liaison and Emergency Psychiatry Moray 2 Moray

3. Liaison and Emergency Psychiatry Moray 3 Statistics Alcohol sales data suggests that consumption has increased by 11% since 1994. In 2010, 23% more alcohol was sold in Scotland than in England & Wales, the widest gap to date. Impact of this excessive consumption is estimated to cost Scots £3.6 billion each year, equivalent to £900 for each & every adult in Scotland. Alcohol cost Scotland’s health service £405 million (2008 figures).

4. Liaison and Emergency Psychiatry Moray 4 High % of patients admitted to hospitals may experience some symptoms of withdrawal from alcohol. Detox can be inconsistent and dependence is not always recognised until there is an episode of violence where the patient at a later time is identified as suffering from psychosis due delirium tremens. Cost to the NHS in Scotland is rising

5. Liaison and Emergency Psychiatry Moray 5 How do you know if someone is withdrawing from alcohol? Not always this obvious!

6. Liaison and Emergency Psychiatry Moray 6 Mild Withdrawal Symptoms – 4 Hourly observations for 24 hours Slight tachycardia (80-99) Tremor Sweating Anxiety Restlessness Insomnia Poor concentration and memory Low mood.

7. Liaison and Emergency Psychiatry Moray 7 Moderate to severe withdrawal – hourly observations Rapid pulse (100+) Systolic hypertension Constant tremor of arms & body Profuse sweating Panic Autonomic hyperactivity Formed & vivid hallucinations Disorientation to time; place & person

8. Liaison and Emergency Psychiatry Moray 8 Complications of moderate to severe withdrawal. Wernicke’s Encephalopathy (a neurological disorder caused by thiamine deficiency) seizure (history) delirium tremens hypoglycaemia hypokalaemia hypocalcaemia respiratory alkalosis.

9. Liaison and Emergency Psychiatry Moray 9 Symptoms of Wernicke’s Encephalopathy acute confusion altered consciousness memory disturbance Ataxia Opthalmoplegia Nystagmus unexplained hypotension with hypothermia.

10. Liaison and Emergency Psychiatry Moray 10 Delirium Tremons

11. Liaison and Emergency Psychiatry Moray 11 Definition of Delirium Tremons An acute & sometimes fatal episode of delirium caused by withdrawal or absence from alcohol. Characterized by hallucinations & delusions; anxiety; confusion; sweating & trembling

12. Liaison and Emergency Psychiatry Moray 12 Prompt identification of patients likely to experience withdrawal symptoms following admission Known history of excessive alcohol use? Routine bloods to include U & E’s, FBC, LFT’s and blood alcohol concentration (BAC). Regulate fluid balance. Monitor physical observations up to 4 hourly in first 24hrs. Check blood sugar is within normal ranges

13. Liaison and Emergency Psychiatry Moray 13 “ Prevention is better than cure” The aim is to provide a safe and consistent approach to hospital in-patients withdrawing from the affects of alcohol. Ultimately the reduction or prevention of in- patients developing the delirium tremens will improve patient and staff safety.

14. Liaison and Emergency Psychiatry Moray 14 Two heads or specialities are better than one! Approved regime for detox in Dr Grays Hospital has not been agreed. Previously Psychiatry and the General Hospital were two separate entities and neither were keen to accept responsibility for the alcohol dependent patient. Patients dependent on alcohol come from all walks of life, these include nurses, doctors, bankers, politicians etc there are no exceptions.

15. Liaison and Emergency Psychiatry Moray 15 Withdrawal from alcohol can result in socially unacceptable or dangerous behaviours. Advantages of prompt and effective detox are; 1. Reduction in length of admission. 2. Reduction of costs for care of each patient. 3. Reduction in the episodes of violent or aggressive incidents. 4. Reduction in episodes of serious illness or death. 5. Improved staff knowledge. 6. Happier staff and patients.

16. Liaison and Emergency Psychiatry Moray 16 Treatment of Withdrawals

17. Liaison and Emergency Psychiatry Moray 17 Detoxification regime Medication used in Moray is Chlordiazepoxide at regular intervals (4- 6hrs) dose depending on severity of dependence maximum dose 210mgs daily. If this is not sufficient Consultant advice is recommended. Diazepam is also used in alcohol withdrawal

18. Liaison and Emergency Psychiatry Moray 18 Considerations in Prescribing Level of alcohol dependence Age i.e. elderly patients at increased risk of side effects from benzodiazepines therefore start low & go slow Metabolism of Chlordiazepoxide is impaired by liver failure. Can be used cautiously in small doses. For severe liver failure Lorazepam may by used as Lorazepam metabolism is not impaired in liver disease. Chlordiazepoxide 25mg=Lorazepam 1mg=Diazepam10mg

19. Liaison and Emergency Psychiatry Moray 19 Vitamins Thiamine 100mgs three times daily Pabrinex is an option for the malnourished patient or patients who are unable to accept an oral diet. Pabrinex must be given prior to IV glucose therapy.

20. Liaison and Emergency Psychiatry Moray 20 Reducing regime Calculate the total amount of Chlordizepoxide taken in the last 24 hours, deduct one dose,total remaining is divided by four or five depending on frequency of drug administration times. Continue in this way until detox has been completed. Maximum dose including PRN should not exceed previous days total. Learn to recognise the signs and symptoms of withdrawal

21. Liaison and Emergency Psychiatry Moray 21 Alcohol Withdrawal Prompt treatment in A&E can minimise complications Obtain an accurate drinking history Prompt use of Chlordiazepoxide Remember vitamins – Thiamine, Pabrinex ?Alcohol Liaison Nurse

22. Liaison and Emergency Psychiatry Moray 22 Emergency Sedation Policy Emergency sedation as per policy may be required in the event that a patient withdraws from alcohol in an unsafe or uncontrolled way. Uncontrolled or unrecognised withdrawal may result in episodes of aggression or violence.

23. Liaison and Emergency Psychiatry Moray 23 Discussion