Delirium Tremens (DTs)

What happens in delirium tremens

Alcohol slows the brain by boosting the calming chemical GABA and blocking the excitatory chemical glutamate. With months or years of heavy drinking, the brain adapts: it makes less GABA activity and more glutamate activity to stay awake and alert despite the alcohol.

When drinking suddenly stops, that adaptation is left unopposed. The nervous system becomes over-excited. Mild withdrawal causes shakes and anxiety. In DTs the over-excitement reaches the point where the brain cannot keep attention and awareness steady (delirium), and the body's automatic systems run out of control, with high heart rate, blood pressure and temperature.

DTs are the far end of alcohol withdrawal, which is often described in stages.

Alcohol withdrawal timeline

The timeline varies. Someone who cuts down rather than stopping completely can still develop DTs.

Symptoms of delirium tremens

• Delirium: confusion that comes on over hours, fluctuates through the day and is often worse at night. The person may not know where they are, the date, or who people are.
• Hallucinations: often vivid visual ones, such as insects or small animals, or the feeling of bugs crawling on the skin.
• Severe agitation, fear and paranoia.
• Coarse tremor of the hands and body.
• Autonomic overactivity: a heart rate often over 100 beats a minute, high blood pressure, fever, drenching sweats and fast breathing.
• Dehydration, from sweating, vomiting and not drinking fluids.

Some people become very sleepy or stuporous instead of agitated.

Who is at risk

• Daily heavy drinking for many years
• Previous DTs or withdrawal seizures, the strongest predictors
• Age over 65
• Other illness at the same time, such as pneumonia, a head injury, pancreatitis or liver disease
• Low platelet count, low potassium or low sodium on blood tests
• Withdrawal symptoms that start while there is still alcohol in the blood
• Long gaps since the last drink before being seen, for example after a hospital admission for another reason

How DTs are diagnosed

DTs are diagnosed clinically: a history of heavy drinking that has recently stopped, plus delirium and signs of withdrawal. Doctors use a scoring tool such as CIWA-Ar to rate tremor, sweating, anxiety, agitation, hallucinations and orientation, and to guide treatment.

Tests look for other causes of confusion and for complications:

• blood sugar, salts (sodium, potassium, magnesium, phosphate), kidney and liver function, blood count
• blood alcohol level and a drug screen
• tests for infection, including a chest X-ray
• a CT scan of the head if there has been a fall, a first seizure or confusion that does not fit
• sometimes a lumbar puncture to rule out meningitis or encephalitis

Treatment

DTs are treated in hospital, usually in an intensive care or high-dependency unit.

• Benzodiazepines (such as diazepam, lorazepam or chlordiazepoxide) are the main treatment. They calm the over-excited brain and prevent seizures. Doses are often large and are given according to symptom scores.
• Other sedatives such as phenobarbital or, in intensive care, dexmedetomidine or propofol, are used when benzodiazepines are not enough.
• Thiamine (vitamin B1) is given by injection before any glucose, to prevent or treat Wernicke encephalopathy.
• Fluids and salts: IV fluids and replacement of magnesium, potassium and phosphate.
• Cooling for high temperature, and treatment of any infection or injury.
• A calm, well-lit room with frequent reassurance helps with disorientation.

Antipsychotics are used only alongside benzodiazepines for severe hallucinations, because on their own they can lower the seizure threshold.

Complications

• Seizures and falls
• Aspiration pneumonia from inhaling vomit
• Heart rhythm problems
• Severe dehydration and kidney injury, including muscle breakdown (rhabdomyolysis)
• Injuries from agitation

Outlook and recovery

With treatment, most people recover over 3 to 7 days, though some confusion, poor sleep and anxiety can last weeks. Memory problems that persist may point to Wernicke-Korsakoff syndrome. Anyone who has had DTs is at higher risk of DTs again in future withdrawals, so any future attempt to stop should be medically supervised.

The hospital stay is a chance to start treatment for alcohol use disorder. Medicines such as naltrexone, acamprosate or disulfiram, counseling and mutual-support groups reduce relapse.

Preventing DTs

• Do not stop heavy daily drinking abruptly on your own. Talk to a doctor first.
• A medically supervised detox, at home with close follow-up for low-risk people or in a hospital or detox unit for higher-risk people, uses a short, tapering course of medicine to keep withdrawal mild.
• Tell hospital staff about your drinking if you are admitted for anything, so they can prevent withdrawal.

Frequently asked questions

How long after stopping drinking do DTs start?

Delirium tremens usually begins 48 to 96 hours after the last drink, and occasionally up to 7 to 10 days later. Milder withdrawal symptoms such as shaking and sweating come first, often within 6 to 24 hours.

How long do DTs last?

With treatment, delirium tremens typically lasts 3 to 7 days. Some people have milder confusion, sleep problems and anxiety for several weeks afterward. Older people and those with other illnesses may take longer to recover.

Can you die from delirium tremens?

Yes. Without treatment, DTs can kill through seizures, heart rhythm problems, high fever, dehydration and infection. With prompt hospital treatment the death rate is low, typically quoted at under 5%. This is why anyone showing signs needs emergency care.

What is the difference between DTs and alcohol withdrawal?

Alcohol withdrawal covers the whole range of symptoms after stopping heavy drinking, from mild shakes to seizures. Delirium tremens is the most severe stage, defined by delirium (confusion and disturbed awareness) plus a racing heart, fever and sweating.

Who gets delirium tremens?

Mostly people who have drunk heavily every day for years, especially those who have had DTs or withdrawal seizures before. Older age, other illnesses, and abnormal blood salt levels raise the risk. Fewer than 5% of people who go through alcohol withdrawal develop DTs.