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Ask the Mental Health Expert Archives 2001-2004

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Inebriated Patient Evaluation

Q. As a member of a Crisis Resolution Team, I am frequently requested to assess patients who have been presented to the Accident & Emergency department with a mental health crisis. There are times when the patient has consumed alcohol, often to excess.

Are there any helpful guidelines you can offer if a patient is intoxicated with alcohol? When should an assessment of their mental state be taken--which would lead to a useful and meaningful assessment of their problems? For example, I think we would agree that the usefulness of the psychiatric assessment decreases as the degree of alcohol/intoxication increases; therefore should I base the 'fitness for assessment' on an alcometer reading of 35 (fit to drive level) or by some other means?

A. The problem of the intoxicated patient used to come up all the time when I was doing ER evaluations--and is often a source of controversy among staff! I generally agree with you that the greater the degree of alcohol (EtOH) intoxication, the less reliable the psychiatric assessment--but that does not mean that an intoxicated patient stating, for example, that he/she is suicidal should not be taken seriously.

Believe it or not, I have heard ER staff say, "He's just drunk. He doesn't really mean he's suicidal!" This is a very dangerous and false assumption, since the acute effects of alcohol intoxication increase the risk of suicidal behavior among the alcoholic and nonalcoholic alike (MR Hufford, Clin Psychol Rev 2001 Jul;21(5):797-811).

On the other hand, Peterson et al (J Stud Alcohol 1990 Mar;51(2):114-22) have documented the adverse effects of EtOH on more subtle neuropsychological performance measures, such as functions associated with the prefrontal and temporal lobes, including planning, verbal fluency, memory and complex motor control. So, there's not much point in trying to get a lot of cognitive data while the patient is intoxicated, except perhaps to see how he/she improves over the course of recovery.

Regarding the timing of psychiatric assessments in EtOH-intoxicated patients, Todd et al (Am J Emerg Med 1992 Jul;10(4):271-3) examined mental status in a group of ethanol-intoxicated patients to determine the interval over which mental status changes could be attributed to uncomplicated intoxication. Study patients were identified by (1) admission breath ethanol greater than or equal to 100 mg/dL; (2) ethanol-related impairment necessitating further observation or treatment; and (3) not critically ill or exhibiting focal neurologic signs.

Mental status scores (sums of specific indices of alertness, orientation, and agitation) were determined initially, 1 hour after arrival, then every 2 hours. Causes of mental status depression other than acute intoxication were diagnosed in 16 patients, while another 18 failed to completely normalize mental status by the time of emergency department discharge or hospital admission. The remaining 71 with uncomplicated ethanol intoxication required (mean +/- SD) 3.2 +/- 3.6 hours to normalize mental status scores.

A large proportion, however, took considerably longer to normalize: 15 (21%) took 7 or more hours, and three (4%) took as long as 11 hours! The authors concluded that there is "?considerable individual variation in the duration of mental status depression caused by uncomplicated ethanol intoxication."

In another study by Brennan et al (Am J Emerg Med 1995 May;13(3):276-80), the rate of ethanol elimination in the ER population was 19.6 mg/dL/h. However, clinical features of intoxication were poorly correlated with ethanol level. Therefore, basing your time of assessment on a blood alcohol level is not really very reliable--much may depend on how tolerant the particular patient is to high ethanol levels. That, in turn, may affect how much the intoxication distorts the patient's psychiatric presentation.

For example, a chronic alcoholic who normally runs a blood alcohol level of 200 mg/dL may show less distortion of his psychiatric presentation than someone with a level of 100 mg/dL who just got drunk for the first time at a fraternity party. So, there are no simple rules that answer your question.

In general, its best to wait as long as the ER will allow you to wait before reaching final conclusions on an intoxicated patient with psychiatric symptoms; and to consult with family or significant others whenever possible, in order to determine what the patient's sober baseline is. In questionable cases with high risk--e.g., someone with suicidal ideation or auditory hallucinations--the best course is often to admit the patient for a period of overnight observation.

August 2003

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