A 62-year-old college professor was admitted to the hospital for elective hip replacement. Surgery was uncomplicated, but on the second postoperative day he was anxious, diaphoretic, and had a low-grade fever. A broad-spectrum antibiotic regimen was begun. That night, he began to hallucinate, insisting that strangers had come into his room. He hardly slept. The next morning he had a generalized convulsive seizure. A neurologic consultant noted agitation, disorientation, impaired recall, visual hallucinations, tremor, and tachycardia. The patient described his alcohol intake as “two per day,” but his wife described his two drinks as tumblers of scotch and estimated his intake at a pint of whiskey daily. He had no history of liver disease, gastrointestinal bleeds, blackouts, withdrawal symptoms, solitary drinking, or occupational impairment.
He was treated with high-dose benzodiazepines, intravenous thiamine, intravenous fluids, and electrolyte replacement. His autonomic signs rapidly stabilized and no further seizures occurred. However he remained confused and agitated during the ensuing 2 weeks. Although he was carefully counseled about his alcohol abuse, and its inherent risks, he rejected the diagnosis of alcoholism, and refused follow-up treatment subsequent to his discharge.
Comment: This is a typical example of the understated abuser of alcoholic beverages. “Two a day” is a classic patient euphemism used to subconsciously or deliberately cover up their daily habit. The physician must always explore the precise meaning of such a statement vis-à-vis the actual amount of wine, beer, or spirits consumed. As in this instance, an observant and often concerned spouse is more frequently able to objectively report the actual degree of alcoholic consumption. A forewarned physician is much better able to critically observe the patient’s in-hospital demeanor. At the slightest hint of cerebral and autonomic decompensation, so classic for early delirium tremens, appropriate therapies can be expeditiously initiated and a potentially fatal outcome prevented.
Delirium is a common, acquired neuropsychiatric disorder frequently encountered in clinical practice. Marked by cognitive and behavioral symptoms and a fluctuating course, delirium presents doctors and families with a host of challenges, from initial diagnosis and management, to ethical dilemmas surrounding informed consent, personal autonomy, and patient safety (Fig. 17.1). There is a lack of consensus regarding the definition and terminology pertaining to delirium. Terms such as “acute confusional state,” “encephalopathy,” and “change in mental status” are often used arbitrarily. As delirium often presents within the context of myriad medical and/or surgical conditions, it is often not appreciated to be a clinically independent entity. Nevertheless, delirium is associated with considerable morbidity and mortality, delaying or interfering with proper care as well as promoting great distress for nursing staff, physicians, and families.
