Alcohol-related brain damage: report from a Medical Council on Alcohol Symposium, June 2010

"I Genuinely Believe This Is the Most Stigmatised Group within the Social Care Sector"-Health and Social Care Professionals' Experiences of Working with People with Alcohol-Related Brain Damage: A Qualitative Interview Study

Appropriate diagnosis, treatment and care contribute to better service engagement, improvements to wellbeing, cost savings and reductions in morbidity and mortality for people with alcohol-related brain damage. In Northeast England, large amounts of alcohol are consumed; this is reflected in the number of alcohol-related deaths in the region. However, the pathway for people with alcohol-related brain damage to receive diagnosis, treatment and care is unknown and could be unwittingly influenced by stigma. Qualitative, in-depth, semi-structured interviews were completed with 25 health and social care professionals from organizations involved with people with alcohol-related brain damage recruited via snowball sampling. Interviews were recorded, transcribed verbatim, coded, and analysed. People with alcohol-related brain damage were found to be stigmatised by both society and professionals, inhibiting their entry into services. Therefore, alcohol-related brain damage remains underdiagnosed and misdiagnosed. There was found to be no dedicated service; silos with revolving doors and underfunded generic care with long waiting lists typically exclude those with alcohol-related or neurological problems. Reducing stigmatising processes associated with alcohol-related brain damage could counteract professionals' reluctance to provide care.

Informing the development of diagnostic criteria for differential diagnosis of alcohol-related cognitive impairment (ARCI) among heavy drinkers: A systematic scoping review

BACKGROUND

Early detection and diagnosis of alcohol-related cognitive impairment (ARCI) among heavy drinkers is crucial to facilitating appropriate referral and treatment. However, there is lack of consensus in defining diagnostic criteria for ARCI. Uncertainty in attributing a diagnosis of suspected ARCI commonly arises in clinical practice and opportunities to intervene are missed. A systematic scoping review approach was taken to (i) summarise evidence relating to screening or diagnostic criteria used in clinical studies to detect ARCI; and (ii) to determine the extent of the research available about cognitive assessment tools used in 'point-of-care' screening or assessment of patients with suspected non-Korsakoff Syndrome forms of ARCI.

METHODS

We searched Medline, PsycINFO, Cinahl and the Web of Science, screened reference lists and carried out forward and backwards citation searching to identify clinical studies about screening, diagnosis or assessment of patients with suspected ARCI.

RESULTS

In total, only 7 studies met our primary objective and reported on modifications to existing definitions or diagnostic criteria for ARCI. These studies revealed a lack of coordinated research and progress towards the development and standardisation of diagnostic criteria for ARCI. Cognitive screening tools are commonly used in practice to support a diagnosis of ARCI, and as a secondary objective we included an additional 12 studies, which covered a range of settings and patient populations relevant to screening, diagnosis or assessment in acute, secondary or community 'point-of-care' settings. Across two studies with a defined ARCI patient sample and a further four studies with an alcohol use disorder patient sample, the accuracy, validity and/or reliability of seven different cognitive assessment tools were examined. The remaining seven studies reported descriptive findings, demonstrating the lack of evidence available to draw conclusions about which tools are most appropriate for screening patients with suspected ARCI.

CONCLUSION

This review confirms the scarcity of evidence available on the screening, diagnosis or assessment of patients with suspected ARCI. The lack of evidence is an important barrier to the development of clear guidelines for diagnosing ARCI, which would ultimately improve the real-world management and treatment of patients with ARCI.

Alcohol-related brain damage: A mixed-method evaluation of an online awareness-raising programme for frontline care and support practitioners

INTRODUCTION

Alcohol-related brain damage (ARBD) is an umbrella term referring to the neurocognitive impairments caused by excessive and prolonged alcohol use and the associated nutritional deficiencies. This study evaluated the outcomes of an online research-informed training program for ARBD which aimed to improve client outcomes by promoting support staff's awareness and confidence in working with clients who may have (or who are at risk of developing) the condition.

METHODS

Staff working within a large non-governmental non-profit housing organisation (n = 883) enrolled in the training program. Questionnaires were used pre- and post-training to collect self-reported awareness of ARBD and confidence in supporting individuals with the condition. Semi-structured interviews were conducted with 27 staff members approximately 10 weeks post-completion of the program. Interviews were audio-recorded, transcribed verbatim and analysed by employing qualitative content analysis.

RESULTS

Findings from the questionnaires indicated a significant increase in all measures after completing the training program. Three main themes were developed based on the interview data: changes to awareness and understanding; professional practice; and training-specific characteristics. Participants reported changes in their ability to identify potential service users with ARBD and confidence in doing so.

DISCUSSION AND CONCLUSION

Our findings demonstrate that online training programs can be effective in improving support staff's ability to identify ARBD, potentially leading an increase in signposting service users to relevant services. The research-informed nature of the training demonstrates that translating research findings directly to frontline workers can have a substantial impact and may improve outcomes for this client group.

Age differences in brain structural and metabolic responses to binge ethanol exposure in fisher 344 rats

An overarching goal of our research has been to develop a valid animal model of alcoholism with similar imaging phenotypes as those observed in humans with the ultimate objective of assessing the effectiveness of pharmacological agents. In contrast to our findings in humans with alcohol use disorders (AUD), our animal model experiments have not demonstrated enduring brain pathology despite chronic, high ethanol (EtOH) exposure protocols. Relative to healthy controls, older individuals with AUD demonstrate accelerating brain tissue loss with advanced age. Thus, this longitudinally controlled study was conducted in 4-month old (equivalent to ~16-year-old humans) and 17-month old (equivalent to ~45-year-old humans) male and female Fisher 344 rats to test the hypothesis that following equivalent alcohol exposure protocols, older relative to younger animals would exhibit more brain changes as evaluated using in vivo structural magnetic resonance imaging (MRI) and MR spectroscopy (MRS). At baseline, total brain volume as well as the volumes of each of the three constituent tissue types (i.e., cerebral spinal fluid (CSF), gray matter, white matter) were greater in old relative to young rats. Baseline metabolite levels (except for glutathione) were higher in older than younger animals. Effects of binge EtOH exposure on brain volumes and neurometabolites replicated our previous findings in Wistar rats and included ventricular enlargement and reduced MRS-derived creatine levels. Brain changes in response to binge EtOH treatment were more pronounced in young relative to older animals, negating our hypothesis. Higher baseline glutathione levels in female than male rats suggest that female rats are perhaps protected against the more pronounced changes in CSF and gray matter volumes observed in male rats due to superior metabolic homeostasis mechanisms. Additional metabolite changes including low inositol levels in response to high blood alcohol levels support a mechanism of reversible osmolarity disturbances due to temporarily altered brain energy metabolism.

A Case of Wernicke Encephalopathy Developing After Ileal Bypass Surgery

Wernicke encephalopathy is an acute neurological problem resulting from thiamine deficiency and manifesting with mental confusion, oculomotor dysfunction, and ataxia. It is associated with alcohol dependence in adults. Preparatory factors include hyperemesis gravidarum, prolonged diarrhea, prolonged parental nutrition without vitamin support, absorption disorders, anorexia, cancer, and chemotherapy. Failure to consider the clinical findings and preparatory factors of this disease, which is rare in children, can delay diagnosis. This report describes a case of Wernicke encephalopathy developing in a patient with brid ileus and receiving total parenteral nutrition after partial ileal bypass surgery. The patient's clinical and cranial magnetic resonance findings were compatible with Wernicke encephalopathy. Although these are not widespread, typical ocular findings for Wernicke encephalopathy were present. Dramatic improvements were observed in clinical, ocular, and cranial magnetic resonance findings after treatment.

The Role of Aging, Drug Dependence, and Hepatitis C Comorbidity in Alcoholism Cortical Compromise

Importance

The prevalence of alcohol misuse increased substantially over a decade in adults, particularly in those aged 65 years or older. Ramifications for brain structural integrity are significant, especially in older adults.

Objectives

To combine cross-sectional, longitudinal data to test age-alcoholism interactions and examine the association between prevalent comorbidities (drug dependence and hepatitis C virus [HCV] infection) and cortical volume deficits in alcohol dependence.

Design, Setting, and Participants

During 14 years, 826 structural magnetic resonance images were acquired in 222 individuals with alcohol dependence and 199 age-matched control participants (aged 25-75 years at initial study), parcellated with a common atlas, and adjusted for brain volume. Longitudinal data were available on 116 participants with alcoholism and 96 control participants. DSM-IV criteria determined alcohol and drug diagnoses; serology testing determined HCV status. The study was conducted at SRI International and Stanford University School of Medicine from April 11, 2003, to March 3, 2017.

Main Outcomes and Measures

Magnetic resonance imaging-derived regional cortical volumes corrected for supratentorial volume and sex.

Results

Of the 222 participants with alcoholism, 156 (70.3%) were men; mean (SD) age was 48.0 (10.0) years; the mean age for the 199 control participants was 47.6 (14.0) years. Participants with alcohol dependence had volume deficits in frontal (t = -5.732, P < .001), temporal (t = -3.151, P = .002), parietal (t = -5.063, P < .001), cingulate (t = -3.170, P = .002), and insular (t = -4.920, P < .001) cortices; deficits were prominent in frontal subregions and were not sex dependent. Accelerated aging occurred in frontal cortex (t = -3.019, P < .02) and precentral (t = -2.691, P < .05) and superior gyri (t = -2.763, P < .05) and could not be attributed to the amount of alcohol consumed, which was greater in younger-onset than older-onset participants with alcoholism (t = 6.1191, P < .001). Given the high drug-dependence incidence (54.5%) in the alcoholism group, analysis examined drug subgroups (cocaine, cannabis, amphetamines, opiates) compared with drug-dependence-free alcoholism and control groups. Although the alcohol plus cocaine (t = -2.310, P = .04) and alcohol plus opiate (t = -2.424, P = .04) groups had smaller frontal volumes than the drug-dependence-free alcoholism group, deficits in precentral (t = -2.575, P = .01), supplementary motor (t = -2.532, P = .01), and medial (t = -2.800, P = .01) volumes endured in drug-dependence-free participants with alcoholism compared with control participants. Those with HCV infection had greater deficits than those without HCV infection in frontal (t = 3.468, P = .01), precentral (t = 2.513, P = .03), superior (t = 2.533, P = .03), and orbital (t = 2.506, P = .03) volumes, yet total frontal (t = 2.660, P = .02), insular (t = 3.526, P = .003), parietal (t = 2.414, P = .03), temporal (t = 3.221, P = .005), and precentral (t = 3.180, P = .01) volume deficits persisted in the uninfected participants with alcoholism compared with control participants with known HCV status.

Conclusions and Relevance

Drug dependence and HCV infection compounded deleterious effects of alcohol dependence on frontal cortical volumes but could not account for the frontally distributed volume deficits in the drug-free participants with alcoholism. We speculate that age-alcohol interactions notable in frontal cortex put older adults at heightened risk for age-associated neurocompromise even if alcohol misuse is initiated later in life.

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Zusammenfassung. Erwachsene in der Schweiz trinken durchschnittlich zwei Gläser Wein pro Tag. Alkoholmissbrauch und kognitive Störungen sind eng verknüpft, vor allem bei älteren Personen. Die klinische Untersuchung muss nach Anzeichen von Unterernährung suchen und eine neuropsychologische Untersuchung einschliessen, wenn der Mini-Mental-Status pathologisch ist. Bei Anzeichen einer Gayet-Wernicke-Krankheit muss eine intravenöse B1-Vitamin-Therapie zur prophylaktischen oder therapeutischen Behandlung eingeleitet werden. Kognitive Beeinträchtigung ist eine schlechte Prognose für die Behandlung von Alkoholabhängigkeit, sollte aber nicht dazu führen, die Behandlungsbemühungen aufzugeben.

Alcohol-related cognitive impairment: current trends and future perspectives

Excessive alcohol use is associated with a wide range of physical, psychological and social consequences, and is responsible for a significant proportion of the burden of disease globally. An area which has received increasing interest is alcohol-related brain damage, not just because of the cost to the individual and society through resource utilization, but also because of the potential for prevention and reversibility. This paper aims to review the current literature on this subject and seeks to explore issues around diagnosis and treatment of alcohol-related brain damage.

Wernicke's encephalopathy in a child with high dose thiamine therapy

Wernicke's encephalopathy is an acute neurological disorder characterized by mental confusion, oculomotor dysfunction, and ataxia. It has been reported in individuals with alcohol dependence, hyperemesis gravidarum, and prolonged parenteral nutrition without vitamin supplementation. Here we present the case of a 13-year-old male patient with neuroblastoma and a history of poor oral intake and nausea for 3 months. After admission, he showed gait disturbances, nystagmus, and excessive dizziness; his mental state, however, indicated he was alert, which did not fit the classical triad of Wernicke's encephalopathy. A diagnosis of Wernicke's encephalopathy was made only after brain magnetic resonance imaging and serum thiamine level analyses were performed. The patient's symptoms remained after 5 days of treatment with 100-mg thiamine once daily; thus, we increased the dosage to 500 mg 3 times daily, 1,500 mg per day. His symptoms then improved after 20 days of replacement therapy. This case report describes a pediatric patient who was promptly diagnosed with Wernicke's encephalopathy, despite only 2 suspicious symptoms, and who completely recovered after high doses of thiamine were given intravenously.

Alcohol related brain damage – a case of neglect?

Purpose

– The purpose of this paper is to argue that alcohol-related brain damage (ARBD) is a neglected problem. ARBD is a term that has begun to be used over the past decade to describe prolonged cognitive impairment caused by alcohol use, including Wernicke's encephalopathy and Korsakoff syndrome, alcohol dementia and alcohol-related brain injury.

Design/methodology/approach

– The paper provides an overview of ARBD describing the research around its prevalence and prognosis. There is a consensus in the literature that there is little research and a lack of awareness of this condition. The author uses case studies from his own experience working with people with ARBD to describe the difficulties in accessing appropriate assessment and care for this group, and suggests that they are often excluded in a way that is familiar from the experience of the person with “dual diagnosis”.

Findings

– Recommendations are made including raising awareness, improving screening for cognitive impairment and developing specialist services.

Originality/value

– ARBD appears to have been neglected in the “dual diagnosis” world and this paper attempts to address this, and so should be of interest to a wide range of professionals working with substance use, mental health, homelessness and social work.

Alcohol-related brain damage in humans

Chronic excessive alcohol intoxications evoke cumulative damage to tissues and organs. We examined prefrontal cortex (Brodmann’s area (BA) 9) from 20 human alcoholics and 20 age, gender, and postmortem delay matched control subjects. H & E staining and light microscopy of prefrontal cortex tissue revealed a reduction in the levels of cytoskeleton surrounding the nuclei of cortical and subcortical neurons, and a disruption of subcortical neuron patterning in alcoholic subjects. BA 9 tissue homogenisation and one dimensional polyacrylamide gel electrophoresis (PAGE) proteomics of cytosolic proteins identified dramatic reductions in the protein levels of spectrin β II, and α- and β-tubulins in alcoholics, and these were validated and quantitated by Western blotting. We detected a significant increase in α-tubulin acetylation in alcoholics, a non-significant increase in isoaspartate protein damage, but a significant increase in protein isoaspartyl methyltransferase protein levels, the enzyme that triggers isoaspartate damage repair in vivo. There was also a significant reduction in proteasome activity in alcoholics. One dimensional PAGE of membrane-enriched fractions detected a reduction in β-spectrin protein levels, and a significant increase in transmembranous α3 (catalytic) subunit of the Na⁺,K⁺-ATPase in alcoholic subjects. However, control subjects retained stable oligomeric forms of α-subunit that were diminished in alcoholics. In alcoholics, significant loss of cytosolic α- and β-tubulins were also seen in caudate nucleus, hippocampus and cerebellum, but to different levels, indicative of brain regional susceptibility to alcohol-related damage. Collectively, these protein changes provide a molecular basis for some of the neuronal and behavioural abnormalities attributed to alcoholics.

Delayed discharge in alcohol-related dementia: consequences and possibilities for improvement

Individuals with alcohol-related dementia (ARD) are over-represented among 'difficult to discharge' patients. ARD is associated with prolonged hospital stay and high rates of discharge at own risk. Risk factors for delayed discharge in patients with ARD include: a lack of appropriate medical and social support; multiple and complex needs; psychiatric symptoms; challenging behaviours; and an unmet need for appropriate residential care. Integration into present services is problematic and aged care is not an acceptable option for these patients. The present paper identifies three key possibilities to reduce the burden of prolonged hospitalisation of patients with ARD. These are: improved availability of specialised, multidisciplinary care pathways for patients with ARD, many of which could be developed out of existing services; the development of flexible supported-accommodation options, including harm minimisation, for the subset of patients who are not able to live independently; and improved practice in the emergency department (ED) to ensure timely administration of parenteral thiamine to all patients at risk of developing ARD.

How does ethanol induce apoptotic cell death of SK-N-SH neuroblastoma cells

A body of evidence suggests that ethanol can lead to damage of neuronal cells. However, the mechanism underlying the ethanol-induced damage of neuronal cells remains unclear. The role of mitogen-activated protein kinases in ethanol-induced damage was investigated in SK-N-SH neuroblastoma cells. 3-[4,5-Dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide cell viability assay, DNA fragmentation detection, and flow cytometric analysis showed that ethanol induced apoptotic cell death and cell cycle arrest, characterized by increased caspase-3 activity, DNA fragmentation, nuclear disruption, and G₁ arrest of cell cycle of the SK-N-SH neuroblastoma cells. In addition, western blot analysis indicated that ethanol induced a lasting increase in c-Jun N-terminal protein kinase activity and a transient increase in p38 kinase activity of the neuroblastoma cells. c-Jun N-terminal protein kinase or p38 kinase inhibitors significantly reduced the ethanol-induced cell death. Ethanol also increased p53 phosphorylation, followed by an increase in p21 tumor suppressor protein and a decrease in phospho-Rb (retinoblastoma) protein, leading to alterations in the expressions and activity of cyclin dependent protein kinases. Our results suggest that ethanol mediates apoptosis of SK-N-SH neuroblastoma cells by activating p53-related cell cycle arrest possibly through activation of the c-Jun N-terminal protein kinase-related cell death pathway.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

The evolution and treatment of Korsakoff's syndrome: out of sight, out of mind?

Wernicke's Encephalopathy is an acute neuro-psychiatric condition caused by an insufficient supply of thiamine (Vitamin B1) to the brain. If undiagnosed or inadequately treated, it is likely to proceed to Korsakoff's Syndrome. Wernicke's Encephalopathy can result from dietary deficiency alone and this form is usually successfully treated, with little chance of Korsakoff's Syndrome supervening. On the other hand, thiamine deficiency associated with alcohol misuse/dependence may require up to 1 gram of thiamine IV in the first 24 hours to be treated successfully. The reasons for this difference in treatment will be discussed. Thiamine diphosphate acts as a co-factor for a number of thiamine-dependent enzymes. Thiamine deficiency leads to a reduction in the activity of these enzymes, and this leads to alterations in mitochondrial activity, impairment of oxidative metabolism, decreased energy status and eventually selective neuronal death. The damage caused by the combination of thiamine deficiency and alcohol metabolism probably interferes with adequate thiamine transport at a number of sites in the body, including the blood-brain barrier, as well as causing damage to the apoenzymes which then require higher concentrations of thiamine to work normally. The accumulated damage is likely to render the use of oral thiamine therapeutically inadequate since the body is unable to produce high enough concentrations of thiamine in the blood to traverse the blood-brain barrier. Some individuals are probably genetically predisposed to develop Wernicke's. Long before individuals with alcohol misuse or dependence develop Wernicke's Encephalopathy the neurons and other cells of the body are functioning sub-optimally because of the inadequate supply of thiamine and the neurotoxic effect of alcohol. This relative deficiency initiates a series of pathological changes which accumulate and further interfere with the supply of thiamine and its utilisation at a time when the requirements are increased. The best treatment for Korsakoff's Syndrome is timely recognition of Wernicke's Encephalopathy and appropriate intervention and prevention.