ACCORDING TO ONE ESTIMATE, one in five patients admitted to a hospital suffers from an alcohol use disorder (AUD) such as alcohol abuse or dependence.1 Other data indicate that one in four medical-surgical patients admitted to a hospital has an AUD.2 Consequently, hospital nurses care for many complex patients who experience alcohol withdrawal in the ED or a nursing unit. Yet patients at risk for alcohol withdrawal aren't always obvious, and signs of alcohol abuse can be obscure.3 Patients who drink heavily may not recognize that they have a problem, or be embarrassed and minimize their drinking pattern, not realizing that alcohol withdrawal can be life-threatening.
A focused nursing assessment is critical in identifying the potential for alcohol withdrawal symptoms in all hospitalized patients. This article discusses how to assess patients at risk and how to use these assessment findings as a basis for nursing interventions.
Coming to terms
Terminology describing alcohol use and misuse is variable and confusing, but these broad categories help guide assessment: at-risk drinking, abuse, and dependence. Patients at risk consume quantities of alcohol that put them at risk of dependence but don't meet the criteria for abuse or dependence, such as experiencing withdrawal symptoms after cessation of drinking.4 Alcohol abuse can be described as a pattern of drinking resulting in “significant and recurrent adverse consequences.”5 The World Health Organization (WHO) describes harmful drinking as “a pattern of alcohol consumption carrying with it a risk of harmful consequences to the drinker.”6
Alcohol dependence (also called alcoholism) is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as a disease with four symptoms:7
- craving: a strong need or urge to drink alcohol
- loss of control: inability to stop drinking once drinking has begun
- physical dependence: appearance of withdrawal signs and symptoms after stopping drinking
- tolerance: the need to drink greater amounts of alcohol to get “high.”
The clinical signs and symptoms associated with cessation of alcohol consumption are known collectively as alcohol withdrawal syndrome (AWS).4 Signs and symptoms indicating or consistent with alcohol withdrawal include anorexia, chills, craving for alcohol, muscle cramps, irritability, palpitations, disorientation, tachycardia, hypertension, low-grade fever, mood changes, slurred speech, impaired gait, poor dexterity, fatigue, and abdominal pain.
The potential for AWS can easily be overlooked. For example, alcohol abuse among older adults is a national epidemic, and those who underreport their use of alcohol may fail to get appropriate treatment.8
To complicate matters, signs and symptoms of AWS may be confused with or masked by those of many other medical conditions, such as pneumonia, postoperative delirium, septicemia, uremia, pancreatitis, and adverse drug reactions. Be aware that complex critically ill patients may falsely present with symptoms of alcohol withdrawal. In addition, many patients with AUD have comorbid psychiatric disorders, such as mood, anxiety, and personality disorders.9
Because patient assessment completed at admission is unlikely to identify all patients with an AUD, Schuckit (2009) recommends routinely screening all patients for unhealthy drinking behaviors (such as three or four standard drinks per day) as part of both the initial and ongoing patient assessment.10 In the United States, a standard drink contains about 14 g of pure alcohol (about 1.2 tablespoons).11
The CAGE (cut-annoyed-guilty-eye) questionnaire is a simple, internationally recognized assessment instrument for identifying problems with alcohol. You can easily include this quick, effective tool in routine assessments. Two out of four positive answers to the following questions indicates AUD.12
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Also ask patients when they had their last drink, how much they drank, and what type of drink. Find out how long (months or years) they've been drinking heavily. Patients who develop AWS more than 2 days after their last drink are more likely to experience severe symptoms than patients who develop AWS in a shorter time.4 In addition, patients who have a long history of intoxication and withdrawals will experience more severe withdrawal. A history of seizures, delirium, and tachycardia, and blood alcohol levels greater than 100 mg/dL further increase the risk of more severe withdrawal symptoms.13
Two additional tools that are being increasingly used to identify AUD are the AUDIT (Alcohol Use Disorders Identification Test) published by the WHO, and Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide published by the National Institutes of Health (NIH)/NIAAA.14,15
Although a skillful clinical assessment may successfully identify patients with obvious alcohol-related problems, those with covert problems may remain undetected until signs and symptoms develop.3
Signs of trouble
In patients who are physically dependent on alcohol, the central nervous system adapts to the presence of alcohol and loses the ability to function normally in its absence. Signs and symptoms of AWS reflect declining blood alcohol levels. These usually appear within a few hours to a few days after cessation of alcohol consumption, although in some patients symptoms may develop up to 10 days after the last drink.16 (See A matter of timing: When withdrawal symptoms may appear.)
Under diagnostic criteria specified by the Diagnostic Statistical Manual of Mental Disorders, alcohol withdrawal has these components:
A. Cessation or reduction of heavy and prolonged alcohol use.
B. Two or more of the following, developing within several hours to a few days after criterion A:
- autonomic hyperactivity
- increased hand tremor
- nausea or vomiting
- transient hallucinations or illusions
- psychomotor agitation
- grand mal seizures.
C./D. The diagnostic criteria also specify that signs and symptoms cause “clinically significant” distress or impairment, that they aren't due to another medical condition, and that they “are not better accounted for by another mental disorder.”17
DTs: A medical emergency
The most severe form of alcohol withdrawal is delirium tremens (DTs), characterized by altered mental status and severe autonomic hyperactivity that may lead to cardiovascular collapse.16,18 Only about 5% of patients with alcohol withdrawal progress to DTs, but about 5% of these patients die.18,19
Because of its high mortality, DTs is a medical emergency. Signs and symptoms, which may worsen abruptly, include body tremors, diaphoresis, tachycardia, hypertension, fever, delirium, severe anxiety or agitation, disorientation, hallucinations, and seizures.16,18
DTs are most common in patients with a history of prolonged AUD and in those who've experienced previous withdrawal episodes. Neuronal changes related to repeated alcohol withdrawal increase the risk for more frequent and severe withdrawal episodes, a phenomenon known as kindling.18
Treatment for AWS is individualized according to symptom severity. Some patients require supportive care only; others require medication and other interventions. Supportive care includes fluid and electrolyte replacement; nutritional support; and supplemental thiamine, glucose, and multivitamins.
If medication is indicated to manage moderate or severe AWS, benzodiazepines are the drugs of choice. Their safety and efficacy in easing the discomfort of withdrawal, especially for preventing or treating seizures and delirium, is well documented.20
Traditionally, the treatment approach has been fixed-schedule dosing in which the healthcare provider prescribes a routine benzodiazepine regimen. Fixed dosing prevents individualized treatment based on close monitoring of symptoms. In contrast, symptom-triggered dosing is based on administration of medication as needed depending on symptom severity.
As direct caregivers, nurses are ideally positioned to improve patient outcomes by using the symptom-triggered approach. Based on an objective withdrawal severity scale, a symptom-triggered approach provokes faster and more effective relief of withdrawal symptoms than treatment based on clinicians' subjective judgment alone.21
The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is the gold standard withdrawal assessment rating scale in both hospital and outpatient settings. (See Table 1.) This evidence-based, validated objective observer-rated assessment tool is designed to maintain consistency in patient assessment and treatment.22
Clinicians use the CIWA-Ar tool to rate 10 signs/symptoms on numeric scales to determine the severity of signs and symptoms. The total score can range from 0 (no symptoms) to a maximum of 67. Any score over 18 indicates severe withdrawal.13 The tool takes approximately 5 minutes to administer.
The CIWA-Ar provides a measure of withdrawal severity and helps to guide treatment, enabling clinicians to intervene early in withdrawal to prevent poor patient outcomes. Signs and symptoms of severe AWS include withdrawal seizures (generalized clonic-tonic convulsions), alcoholic hallucinosis, and DTs. Although withdrawal seizures are usually singular or present only in short bursts, they may progress to DTs in one-third of patients if untreated.21
Individualized drug therapy based on symptom assessment is guided by a sliding benzodiazepine scale per institution and unit protocol. Generally, when the CIWA-Ar score is >9, a benzodiazepine is indicated.20
In a typical protocol, the CIWA-Ar scale is repeated hourly until the score is <10. Benzodiazepine is continued until the score is <9 for four consecutive assessments.20 Then, the CIWA-Ar can be done every 8 hours until the score is <6 for four consecutive assessments.
Symptom-triggered treatment is safe and effective, and generally manages signs and symptoms with lower medication doses compared to a fixed-schedule dosing approach.23
This tool documents withdrawal trends
The Withdrawal Trend Profile (WTP) was developed by nursing staff at the NIAAA, a part of the U.S. NIH. Like the CIWA-Ar, this tool isn't copyrighted and may be freely used and modified as needed. (See Table 2.)
The WTP provides an ongoing record of the patient's condition, and can be used as an adjunct to the CIWA-Ar to assess withdrawal trends and the patient's response to treatment. The nurse takes the breath alcohol concentration (BrAC), which measures the alcohol content of air in the patient's lungs and reflects the blood alcohol level (BAL). The nurse reviews the BAL value. The higher the value, the greater the potential for withdrawal symptoms.
The nurse also documents the patient's vital signs, looking for an upward trend indicating increased withdrawal symptoms. On a scale of 0 (none) to 3 (severe), the nurse then rates key signs and symptoms, such as nausea/vomiting; tremors; diaphoresis; anxiety; agitation; tactile, auditory, and visual disturbances; headache; and orientation. For example, a patient whose arms or body are visibly shaking while in bed rates a score of 3 for tremor symptoms. A patient who has tremors only when extending the arms would rate a score of 2. A patient who has fingertip tremors that aren't visible but can be felt by the nurse rates a score of 1.
Combined with the CIWA-AR score, the WTP identifies trends in the patient's condition and helps the nurse determine whether or not withdrawal symptoms require the p.r.n. use of medication. For example, a noncompromised patient with a CIWA-Ar of 7 and normal vital signs would require standard nursing support and reassurance with no medication intervention. However, an hour later the same patient might be tachycardic and hypertensive, indicating an upward trend in withdrawal symptoms and the need for medication.
Using benzodiazepines to manage withdrawal
The individualized, symptom-triggered approach to benzodiazepines use satisfies the need to use medication only when needed and may also reduce inpatient hospital stays. In fact, many patients can be safely managed with supportive care only, avoiding the risks and costs of unnecessary medication.23
When indicated, the most commonly used benzodiazepines are diazepam, lorazepam, chlordiazepoxide, and oxazepam. These drugs mimic the effects of alcohol in the central nervous system.24
Although all benzodiazepines have similar properties, certain agents may be recommended over others based on their pharmacokinetics. For example, long-acting drugs such as diazepam and chlordiazepoxide help prevent recurrent withdrawal signs and symptoms. Intermediate-acting drugs such as lorazepam or oxazepam may be indicated for older adults, critically ill patients, or those with hepatic dysfunction to minimize the risk of oversedation.25
Older adults have more difficulty metabolizing and excreting alcohol than younger patients, and eliminate benzodiazepines at a slower rate. Carefully assess and monitor withdrawal signs and symptoms in these patients, and administer lower doses of intermediate-acting benzodiazepines as prescribed to prevent medication accumulation and oversedation, which could lead to respiratory depression.
Patients experiencing seizures or DTs require I.V. benzodiazepine administration, so maintain venous access for any patient at risk of severe AWS. Avoid giving I.M. injections because they're painful and drug absorption is unpredictable.
In some institutions, AWS is treated with I.V. ethanol replacement therapy. Current research supports the use of benzodiazepines as the gold standard; ethanol replacement therapy is outmoded and not recommended. Therapy with benzodiazepines is safer and more effective, and is well supported by the evidence.4,21,26
Nursing care for patients in withdrawal
Frequently reassess the patient as indicated throughout the withdrawal process using the CIWA-Ar. Initiate fall and seizure precautions as indicated. Elevate the head of the bed to reduce the risk of aspiration. Provide nonjudgmental, supportive, empathetic, and comprehensive emotional care.
Current recommendations for evidence-based nursing interventions during alcohol withdrawal include the following:26
- Ensure a patent airway; suction as needed. Frequently monitor vital signs, observing for respiratory distress.
- Assess skin for abnormalities such as jaundice, pressure ulcers, rashes, signs of dehydration, and ecchymoses; inspect for needle tracks from I.V. drug use.
- Use the CIWA-Ar tool to guide medication with benzodiazepines.
- Encourage the patient to rest by organizing and prioritizing nursing interventions. Decrease environmental stimuli with controlled lighting.
- Provide adequate nutrition. Obtain a dietary consult as indicated to treat malnutrition. Administer thiamine to prevent Wernicke-Korsakoff syndrome and Wernicke encephalopathy, and additional vitamins as prescribed.
- Measure and document intake and output. Maintain I.V. access, and administer I.V. fluids as prescribed.
- Review all lab results and closely monitor for electrolyte imbalances, including hypomagnesemia, hypokalemia, and hypophosphatemia. Also watch for liver biochemical test abnormalities, including serum aspartate aminotransferase, alanine aminotransferases, and gamma-glutamyl transferase. A serum carbohydrate-deficient transferrin level can identify chronic heavy alcohol consumption.21
- Assess mental status and sleep pattern, and provide emotional support to reduce anxiety. Reassure the patient that depressive symptoms and sleep disturbances during withdrawal are common but temporary.
The rate of alcohol metabolism varies depending on various factors, such as the patient's health status, age, gender, liver function, and ethnicity. On average, however, patients eliminate the equivalent of one standard drink or 0.6 oz (14 g) of pure alcohol per hour. When caring for older adults, keep in mind that the speed of alcohol metabolism diminishes with age, resulting in higher blood levels.27
In addition, assess dental hygiene and document recent weight loss. Assess for bladder distension or incontinence of urine and feces. Use therapeutic management techniques and medications to prevent the use of physical restraints. Be prepared to initiate cardiac monitoring and emergency life support depending on the severity of AWS.
When you interact with the patient, be matter-of-fact and respectful, and maintain a positive, supportive environment.28 Communicate with short, simple statements in a calm manner, using a low tone of voice. Use concrete language and statements beginning with “I” rather than “you.”
If the patient is hallucinating, don't agree or disagree with the patient's statements. For example, using an “I” statement, you might respond, “I see the curtain moving next to you” instead of “You're hallucinating.”
Present reality without challenging or escalating the patient's anxiety and thought disturbances. Build a therapeutic rapport with the patient by providing relief from his or her symptoms and meeting physiologic and safety needs. Meet the patient's needs promptly to reduce the risk of violence or aggression. Don't approach the patient with loose items that the patient could grab if he or she becomes agitated, such as a clipboard or dangling identification badge.
It's imperative to examine your own feelings and beliefs about working with patients who have alcohol problems to provide nonbiased care. You want to remain objective so you can provide nonjudgmental support to the patient and family. If needed, discuss with a healthcare professional your own feelings, thoughts, and biases, especially if you have a personal or family history of alcohol abuse, or close friends who have alcohol abuse issues.28
Alcoholism is a chronic and relapsing disease requiring complex treatment strategies to improve patient outcomes. Many patients with AUD have other psychiatric conditions, such as anxiety, bipolar disorder, post-traumatic stress disorder, and mood or personality disorders, so involve the social worker or designee immediately in discharge planning. Referrals for short-term and/or long-term rehabilitation centers, counselors who specialize in addiction, cognitive behavioral therapy, motivational enhancement therapy, medical and medication management, sober housing, and Twelve Step modalities are important for patient recovery.
Intervene early to improve outcomes
AWS is a frequently encountered medical consequence of AUDs. Closely monitor your patient during your shift to identify subtle changes and intervene appropriately. The consistent use of the CIWA-Ar in all hospital units can help clinicians accurately identify patients at high risk for alcohol withdrawal and meet the same standard of care throughout the facility.