Hyperactive delirium as a complication of nicotine withdrawal: a case report

Introduction
Many active smokers want to quit and attempt to quit smoking throughout their lifetime of use. As practitioners, it is crucial to understand the difficulty of quitting smoking and offer support through nicotine replacement products as needed. Here we present a case report of a rare side effect of nicotine withdrawal: hyperactive delirium.

Case description
A 61-year-old Caucasian male was voluntarily admitted to the dual diagnosis psychiatric unit for active suicidal ideation and alcohol detoxification. The patient was started on alcohol detoxification protocol with a benzodiazepine taper. The patient exhibited increased agitation, visual hallucinations, irritability and disorientation. Due to the patient’s onset of hyper­active delirium with the absence of any signs or symptoms of alcohol withdrawal, the treatment team reviewed the patient’s substance use history. He reported smoking three packs of cigarettes per day for the past 20 years. The patient was immediately treated with a nico­tine patch and continued to receive a nicotine patch daily. Two days later, the patient denied recurrence of hallucinations, was behaviourally controlled, and was oriented to self, time, place, and situa­tion. The patient was discharged back to his home in stable condition.

Commentary
A study revealed that patients undergoing sudden cessation of smoking were more likely to exhibit hyperactive delirium than non-smokers and that smoking cessation was an independent risk factor for hyperactive delirium. Healthcare providers should be aware of the more rare side effects of nicotine withdrawal especially when admitting patients in the acute condition.