Elderly hospital inpatients who have intact cognitive function on admission to hospital have a low risk of developing cognitive impairment and delirium during their hospital stay. In this population, however, benzodiazepine use accounted for 29% of cases of cognitive impairment which did occur. The data also suggest that dehydration, urinary retention, and an admission diagnosis of CNS disease may be important risk factors for delirium.
A modified version of the Clinical Institute Withdrawal Assessment Scale (CIWA) was used in the management of alcohol withdrawal in a general hospital. Patients who developed seizures or confusion were noted to score higher on the scale, even before these complications, than patients who remained uncomplicated (21.7 +/- 1.2 compared to 15.6 +/- 0.55). When the score was used as a guide for treatment, it was found that patients scoring greater than 15 were at significantly increased risk of severe alcohol withdrawal if they remained untreated (RR, 3.72; 95% confidence interval, 2.85-4.85). The higher the score the greater this relative risk. Some patients however, still suffered complicated withdrawals although their scores were low or they were apparently adequately treated. It is concluded that the use of an objective clinical scale of alcohol withdrawal is valuable in a general hospital to identify those patients in early withdrawal who need sedation to avoid complication. There will however, be a small group of patients whose clinical course will be difficult to predict and further work is needed to determine the reasons for this.
We conducted an observational study of 539 episodes of alcohol withdrawal in a general hospital, to determine the natural history, the incidences of seizures, hallucinations and delirium, and the risk factors for these events. The reaction began soon after arrival, at a median time of 5 h, and resolved at a median time of 22 h. Patients with a blood alcohol level of zero were in withdrawal on arrival, and only four patients had reactions lasting 120 h or longer. Complications were observed in 113 patients (21%) during the admission. Seizures occurred on arrival, hallucinations usually in the first 24 h and delirium in the first 48 h. No mortality was associated with alcohol withdrawal itself, but complications did extend length of stay by a median of 4 days, with delirium contributing most to the increase. Patients over 70 years of age or admitted with seizures had an increased risk of complication, but the greatest risk was associated with a delay in assessment of > 24 h. We conclude that in general hospitals, the alcohol withdrawal reaction becomes established very early, and detection and monitoring of patients within the first 24 h is the most important element in management.
A survey was carried out using the Canterbury Alcohol Screening Test (CAST) and clinical criteria for risk of alcohol withdrawal of 2000 randomly selected hospital in-patients in order to determine the prevalence of alcohol-related problems, the work-load for a specialist alcohol withdrawal service and the target group for early intervention. Patients at risk of alcohol withdrawal were followed prospectively.The major findings were: 14.3% of patients had a positive CAST and 8% were at risk of alcohol withdrawal; the prevalence of positive clinical criteria was greatest in men under the age of 30 years (OR 3.6) and very low (OR 0.34) in women over 60 years. In addition, patients who were too sick or refused to complete the questionnaire had high rates of being at risk for alcohol withdrawal. The prevalence of CAST positivity was greatest in men under the age of 40 years (OR 3.7) and lowest in women over 70 years (OR 0.2). It is concluded that 15-20% of in-patients have alcohol problems and 8% are at risk of withdrawal; questionnaires will produce underestimates of the order of 25%; and female in-patients over the age of 60 years are extremely unlikely to have problems with alcohol.
The objective of this study was to conduct a pilot study of naltrexone in opiate-dependent patients in order to determine the sample size for a double-blind controlled trial, to identify possible confounders and to obtain experience with the drug's side effects and acceptability to patients. Opiate-dependent patients presenting to a public hospital for treatment for their dependence were invited to participate. Patients with major organic illness, another Axis I diagnosis, or who were pregnant were excluded. Naltrexone was prescribed at a dose of 50 mg daily for 6 months. Data were collected on drug use, social stability, physical and mental health before during and after the treatment programme. Patients were seen weekly for 6 months then monthly for a further 6 months. Forty-four patients were enrolled, but three stopped naltrexone early because of possible side effects. Of the remainder, 32 were followed for at least 12 months. Eight (25%) ceased opiate use from the start, and another two were no longer using at the end of 12 months giving an abstinence rate of 31% at 12 months. Retention in treatment was 34%. Of the abstinent patients however, only two took naltrexone for the whole 6 months. Naltrexone was well tolerated and associated with a significant abstinence rate, but most patients do not feel they need to take the drug for 6 months. A double-blind controlled trial would be justified.
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