Clinical Case 12 of 15 · ~624 words
Clinical Case No. 12. Severe Alcohol Use Disorder with Psychotic Symptoms and Persistent Memory Impairment
History and condition on admission
Tom is 58. He worked for many years as a mechanic in Kamloops. As work gradually declined, alcohol came to structure his day: mainly vodka, often 250 to 375 mL daily, with variable periods of lower consumption. He eats irregularly. His daughter lives nearby, brings groceries, and stays in touch, but does not always know how much he actually drinks.
Over recent months, Tom has several times heard voices accusing him of theft. During these periods, he generally knew where he was and could give a coherent account of events. The voices appeared during heavy drinking or abrupt reductions. No prior history of prolonged independent psychosis emerges, although the timeline is initially incomplete.
His daughter brings him to hospital after a fall without significant injury. He is exhausted, walks unsteadily, and struggles to remember what has just been said. There is tremor and autonomic evidence of withdrawal after reducing alcohol. At this stage, he needs a general medical admission to assess injury, metabolic status, nutrition, and the risk of complicated withdrawal.
The emergency physician and consultation psychiatrist assess three processes: alcohol withdrawal, hallucinatory experiences, and cognitive-neurological deterioration. The timing of voices, clarity of consciousness, and fluctuations in attention help distinguish alcohol-induced psychosis from delirium.
Withdrawal and suspected thiamine deficiency
The physician prescribes lorazepam under the inpatient withdrawal protocol. Nursing staff regularly assess symptom severity, sedation, breathing, and haemodynamic status; these observations guide dose adjustments and reductions once the acute syndrome has resolved. [81]
Poor nutrition, ataxia, and memory impairment raise concern for Wernicke encephalopathy. The full classical triad may be absent; parenteral thiamine is given immediately without waiting for laboratory confirmation. The team corrects electrolytes, including magnesium, and plans nutritional restoration. If hypoglycaemia is present, glucose is given immediately, with thiamine administered as soon as possible. [144, 145, 146]
Liver tests are abnormal in the context of longstanding use. The differential assessment of cognitive and motor impairment includes hepatic encephalopathy, injuries, vascular changes, and other deficiencies; further investigations depend on clinical findings.
What remains after the acute phase
Withdrawal resolves, and gait improves. With abstinence, psychotic symptoms fade. After stabilization, the team reviews the need for further antipsychotic treatment.
Several weeks later, Tom can sustain a conversation but forgets his daughter's morning visit and fills gaps with confabulations. Serial assessments after the acute phase support a persistent amnestic syndrome in the context of probable Wernicke-Korsakoff syndrome.
Repeated assessment focuses on learning new information, daily activities, and the ability to use prompts. Over the following months, recovery and the required level of support will be monitored.
Tom makes tea using a familiar sequence but loses track of the next step in a new task. The occupational therapist introduces simple external cues, a repeated schedule, and training for those close to him.
Long-term addiction treatment and supported living
With acceptable renal function and abstinence as the goal, acamprosate is selected. Several daily doses are coordinated with support workers who will help because of his memory impairment. [81]
His daughter continues working and visits regularly. Meals, medication, and rehabilitation of skills are organized in a supported setting. Decision-making capacity is assessed separately for treatment, accommodation, and finances.
He chooses music, clothes, and activities, recognizes those close to him, and enjoys talking about his former work. Some longstanding skills are better preserved than his ability to learn new information. This helps shape a day that contains more than memory checks and medication administration.
After several months, everyday functioning improves; help with new tasks and medication remains necessary. Tom abstains from alcohol, eats regularly, and maintains activities connected to longstanding skills.