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Alcohol related brain damage on the rise

Scotland is experiencing an increase in rates of alcohol related brain damage. It has some of the highest rates of this condition in the United Kingdom. The diagnosis is associated with deprivation and is occurring in younger people.

The Scottish Executive makes a brief mention of services for this group in the Plan for Action on Alcohol Problems (1) to the extent of commissioning an Expert Group to report on the condition. No commitment to resources has been made.

What is alcohol related brain damage (ARBD)?

Long-term excessive consumption of alcohol has a harmful effect on almost all organs of the body. Those particularly affected include the brain and the gastro-intestinal system (gut and liver). The effect of protracted excessive consumption on the brain varies from person to person for reasons, which are not yet clear. Theories include the style of alcohol consumption, for example, binge versus chronic consumption, and differences in an individual's susceptibility, usually thought to be genetic.

ARBD incorporates a range of diagnoses and refers to the effects of changes to the structure and function of the brain resulting from long term consumption of alcohol.

There is no single cause of ARBD, which usually results from a combination of factors. These include the direct toxic effects of alcohol on brain cells, the effects of dehydration on the brain, vitamin and nutritional deficiencies, head injury and disturbances to the blood supply of the brain usually incurred whilst intoxicated.

A patient with alcohol related brain damage can present in a variety of ways. These include Wernicke's Encephalopathy which is an extremely acute and reversible condition, difficult to recognise and treat as most people experience this at home and receive no treatment. Sufferers reach a catastrophically low level of the vitamin Thiamine in their system and as a result begin to have small bleeds into the areas of the brain most related to memory. They present with the classic signs of ataxia (staggering gait), nystagmus (paralysis of eye movments) and confusion (lack of orientation in time, place and person). The emergency treatment of this is immediate Thiamine administration by injection. This is a rare presentation as most individuals do not have all the clinical signs. If untreated this can lead on to Korsakoff's Psychosis/amnestic syndrome. This is the more permanent deficit state seen either following untreated Wernicke's Encephalopathy or presenting to services. The individual has sparing of most of their cognitive functions but a very dramatic deficit in their short-term memory. The main treatment for this is intensive neuro-psychological rehabilitation and total avoidance of alcohol. The individual may be so incapacitated by their short-term memory that they are unable to live outside an institution and may, for example, forget crucial new information such as the death of a spouse. This condition can be permanent or can slowly recover with some recovery occurring in up to 75 per cent of sufferers (2).

Alcohol Dementia presents as a more global deterioration in intellectual function with memory not being specifically affected. Sufferers can present in their early thirties although the more common age for presentation is in the fifth, sixth and seventh decades. This condition is not, as suggested, a true dementia, in that recovery is possible. This seems to be more common in women and the recovery rates are better than for Korsakoff's Psychosis, provided correct support and alcohol abstinence is ensured.

Most presentations are somewhere along the spectrum between Korsakoff's Psychosis and a global dementia. Others can present with damage to the frontal lobes to their brain which causes disinhibition, loss of planning, and executive functions and a blithe disregard for the consequences of their behaviour.

Treatment of ARBD.

This is a complex area particularly as knowledge of the conditions and their management needs to be improved amongst care providers.

Clear diagnosis rests on the assessments of a range of professionals, including social work, occupational therapy, medical and psychology services. In particular neuro-psychological assessment is crucial to making an accurate diagnosis and guiding rehabilitative efforts. Rehabilitation can be provided in a range of settings including the patient's home if they are actively motivated and capable of making the judgement to abstain from alcohol.

Unfortunately, what happens in most cases at present is that either the case goes undiagnosed or patients spend long periods of time after diagnosis inappropriately placed. This includes patients remaining in an acute medical bed for several months while suitable placements are found.

Repeat neuro-psychological testing to measure progress is a requirement as a clear impression of the patient's recovery is not obtainable until two years after they have stopped drinking.

Increasing Rates – True or False?

The impression of many clinicians is that there has been a true increase in the rate of this condition. While there has been some recent interest in understanding and treating this condition, perhaps resulting in increased rates of diagnosis, there is also clear evidence from hospital discharge rates and the numbers of patients with this diagnosis occupying a long-term psychiatric bed in Scotland, that there is a true increase in prevalence (3).

There are several potential causes of this, which include:

  • advice from the Committee on Safety of Medicines that injectable vitamins cannot be given in settings where resuscitation facilities are not available. This means that alcohol dependent patients are no longer likely to be given top ups of vitamins by their GPs or by nurses undertaking home detoxification. This and the withdrawal of this product for a period of time in the late eighties did seem to exacerbate an already increasing problem (4). Oral vitamin supplementation in active drinkers is largely ineffective.
  • While the Scottish Executive claim that the national levels of alcohol consumption remain static for the last twenty years, it is clear to those working in the addiction field feel that there is increased consumption of illicitly acquired alcohol imported from the continent. This is not recorded on Customs and Excise figures.
  • The relative cost of alcohol has fallen making it possible for those even on the lowest incomes to maintain enormous levels of consumption. A recent survey carried out by nurses in my service found that alcohol could be obtained for 5p per unit in local supermarkets.
  • Changing social trends and the increased number of single people in the population may have worsened the nutritional state in many alcohol dependent and alcohol abusing individuals making them more vulnerable to alcohol brain damage.

The Government's Response

The services part of the Plan for Action on Alcohol Problems makes reference to commissioning an expert group to investigate this condition. Unfortunately, at no point in the Alcohol Action Plan is there any mention of increased resources for sufferers.

At the time of writing, the Report from the Expert group is in draft and its main recommendations are (5):

  • to provide health promotion and prevention by increasing public awareness and to provide health promotion literature for young people, adults and older people. (There is no evidence that health promotion or information makes much impact on any aspect of people's drinking behaviour other than drink driving.)
  • to challenge stigma by increasing awareness and changing attitudes to ARBD.
  • to carry out more research and evaluation into service design and delivery
  • to provide information and training for front line staff.
  • to develop agreed care pathways between addiction services, psychiatry, older people's services, primary care, and local authority partners.
  • Alcohol Action Teams/Alcohol Drug Action Teams agree arrangements for local integrated care pathways and identify local co-ordinators.
  • the needs of people with ARBD must be included in the review of the new Mental Health Act and also within Adults with Incapacity legislation especially emphasising the need for review of these cases.
  • raise awareness with organisations responsible for quality standards of the needs of this group.

Disappointingly the document makes no recommendations whatsoever about funding or training and employing more specialist front line staff to manage this extremely disadvantaged group nor about tackling the prime causes of the problem which are the very low price of a unit of alcohol in the United Kingdom.

Dr Audrey Hillman 

Dr Audrey Hillman is a consultant psychiatrist at Ravenscraig Hospital, Greenock

REFERENCES:

(1) Scottish Executive.
Plan for Action on Alcohol Problems

(2) Victor, M., Adams, R.D. and Collins, G.H. The Wernicke-Korsakoff
Syndrome and related neurobiological disorders due to alcoholism and malnutrition (1st Ed) Philadelphia, PA. F.A. Davis

(3) Smith, I.S. and Flanigan, C. Parenteral Thiamine and Korsakoff's Psychosis.
Alcohol and Alcoholism. Vol. 33. No. 5, pp. 549-553, 1998.

(4) Jauhar, P. and Ramayya, A.
Increasing incidence of Korsakoff's Psychosis in the East End of Glasgow. Alcohol and Alcoholism. Vol. 33. No. 5, 1998.

(5) Report of the Expert Group on Alcohol Related Brain Damage.
Consultation Draft. Dementia Services Development Centre, University of Stirling.