Heavy drinking can result in significant harm. A member of the NICE guideline development group discuses the main issues from the latest alcohol misuse guide
For the past two years the National Institute for Health and Clinical Excellence (NICE) has worked with an independent group of clinical experts to develop a clinical guideline for the NHS on how to diagnose and treat a range of physical complications caused by alcohol misuse. Of particular relevance to nurses are the recommendations on how to assess patients for their risk of developing acute alcohol withdrawal (AAW), as well as how then to ensure that their symptoms are treated in the best way possible. The guideline also details how healthcare professionals should assess heavy drinkers for their risk of thiamine deficiency, and includes advice on ways to prevent this from progressing to Wernicke-Korsakoff syndrome.
Risks of acute alcohol withdrawal
People who are alcohol dependent are at risk of developing acute alcohol withdrawal (AAW) and have complex needs. The guideline is therefore a welcome addition to the tools available to nurses encountering such patients.
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Early detection and prompt initiation of treatment is crucial - untreated AAW may progress to delirium tremens, which can be fatal if untreated. Nurses have a key role in ensuring patients receive accurate assessment and optimal treatment, as this can result in reduced mortality, complications and the course and duration of AAW, which subsequently reduces the length of stay in hospital.
The dedicated alcohol specialist nurse has an important role in enhancing patient concordance, augmenting medical treatments and coordinating aftercare and follow up. Indeed, the guideline states: “People in acute alcohol withdrawal should be assessed immediately on admission to hospital.” All nurses can therefore ensure they have the skills to accurately assess the risk of AAW as well as monitor progression of withdrawal symptoms and signs.
The guideline recommends that all hospitals develop locally specified protocols to assess and monitor patients in AAW. A useful tool to aid this assessment; is the revised Clinical Institute Withdrawal Assessment for Alcohol (Sullivan et al, 1989). However, as with all clinical tools this should be used in conjunction with clinical judgement.
A further risk to heavy drinkers is Wernicke-Korsakoffsyndrome (WKS), which can develop in thiamine deficient patients and is often difficult to detect. In the early stages it presents as Wernicke’s encephalopathy, which has a triad of symptoms: confusion; eye signs; and ataxia. This condition is reversible if it is detected early enough.
The cause of WKS is most likely linked to inadequate dietary intake and poor thiamine absorption. Oral thiamine absorption is limited and appears to be independently affected by both alcohol and malnutrition. Factors commonly seen in people who misuse alcohol, such as poor diet, diarrhoea and vomiting, may affect thiamine absorption. Since thiamine requirements are linked to carbohydrate intake, it is vital that intravenous dextrose is not given to a thiamine deficient patient without concomitant thiamine.
The optimal dose and route for thiamine replacement is yet to be determined; however the guideline recommends that oral thiamine should be given in doses toward the upper end of the British National Formulary range.
Most importantly, the guideline asserts that nurses and other healthcare professionals should maintain a high level of suspicion for the possibility of Wernicke’s encephalopathy, particularly if the person is intoxicated. Parenteral treatment to provide thiamine should be given for a minimum of five days in suspected Wernicke’s. Oral thiamine treatment should follow parenteral therapy.
This guideline will help to improve the quality of care given to patients whose drinking has resulted in significant harm and increased risk to their physical health.
The guideline is available by clicking here.
AUTHOR Lynn Owens, PhD, BA, Dip HE, Cert Ed, RN, is nurse consultant - clinical lead for alcohol services, Liverpool PCT, and honorary research fellow, The University of Liverpool
Sullivan JT et al (1989) Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction; 84: 1353-1357.