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Scalzo SJ, Bowden SC. Over a Century of Study and Still Misunderstood: Recognizing the Spectrum of Acute and Chronic Wernicke-Korsakoff Syndrome. J Clin Med 2023; 12:6880. [PMID: 37959345 PMCID: PMC10649065 DOI: 10.3390/jcm12216880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this study was to objectively evaluate the hypothesis that the neuropsychological presentation of Korsakoff's syndrome, the chronic phase of Wernicke-Korsakoff syndrome (WKS), is invariably a severe, selective amnesia against a background of relatively preserved general intellectual functions in a consecutive clinical sample. An analysis of the neuropsychological profiles of nine cases with a recorded history of WKS was undertaken. All cases were adult males (ages 32 to 70) with a long history of alcohol use disorder. Eight cases were chosen retrospectively on a consecutive basis from patient referrals. One additional case was recruited prospectively. Conventional understanding and some current opinion of Korsakoff's syndrome predicts anterograde memory to be consistently more impaired than other cognitive abilities, but this was not found in this case series. The Mean Wechsler Delayed Memory Index was not significantly different from the Wechsler Full-Scale IQ (FSIQ), p = 0.130. Regression of Delayed Memory on FSIQ produced a non-significant intercept, p = 0.213. The 'hallmark' criterion of anterograde memory score at least 20 points less than intelligence score was observed in four of eight cases with available data, equating to a 'sensitivity' of 50%. Three of eight cases with available data had an FSIQ less than the memory score. Contrary to a common view, general intellectual function was not consistently preserved in Korsakoff's syndrome relative to memory function. This study illustrates one of the specific merits of case series, namely, to critique an established view. Clinicians and researchers should expand their diagnostic criteria for Korsakoff's syndrome to include more variable cognitive phenotypes, including a potentially reversible dementia-like impairment of variable severity, and focus on potential treatment opportunities.
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Affiliation(s)
- Simon J. Scalzo
- Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, Parkville, VIC 3010, Australia;
| | - Stephen C. Bowden
- Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, Parkville, VIC 3010, Australia;
- Centre for Clinical Neuroscience & Neurological Research, St Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia
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2
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Abstract
INTRODUCTION Alwyn Lishman was interested in how memory research could be applied to clinical psychiatry. After a brief review of his major contributions, this paper will focus on his research on the alcoholic Korsakoff syndrome. It will consider how his findings relate to contemporary debates, particularly on how the syndrome should be defined, and its relationship to broader alcohol-induced cognitive impairments. METHODS A review of the contribution of Alwyn Lishman, Robin Jacobson and colleagues to our knowledge of Korsakoff's syndrome, together with a review of the pertinent recent literature. RESULTS Lishman and colleagues followed earlier authors in defining the Korsakoff syndrome in terms of disproportionate memory impairment, but they also noted a variable degree of IQ, frontal-executive, and timed visuo-spatial impairment in their cases. More recent authors have included such features in their definitions of the syndrome. Lishman also argued for a specific "alcoholic dementia". The present paper argues that recent definitions of the Korsakoff syndrome confound its core and associated features, and also fail to recognise the multifactorial basis of alcohol-related brain damage. CONCLUSIONS Korsakoff's syndrome is best defined in terms of disproportionate memory impairment, and more widespread cognitive impairment is best encompassed within "alcohol-related brain damage".
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Affiliation(s)
- Michael D Kopelman
- King's College London, Institute of Psychiatry, Psychology, and Neuroscience, Surrey, UK
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3
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Dingwall KM, Delima JF, Binks P, Batey R, Bowden SC. What is the optimum thiamine dose to treat or prevent Wernicke's encephalopathy or Wernicke-Korsakoff syndrome? Results of a randomized controlled trial. Alcohol Clin Exp Res 2022; 46:1133-1147. [PMID: 35428992 PMCID: PMC9321884 DOI: 10.1111/acer.14843] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 01/14/2023]
Abstract
Background The primary cause of Wernicke–Korsakoff syndrome (WKS) is thiamine deficiency, and more than 90% of cases are reported in alcohol‐dependent patients. While observational studies show parenteral thiamine administration drastically reduced WKS‐related mortality, relevant treatment trials have never been conducted to determine the optimum thiamine dose. Methods Two double‐blind, parallel groups, randomized controlled trials (RCTs) were conducted to determine the optimal thiamine dose required for (1) the prevention of Wernicke's encephalopathy (WE), the acute phase of WKS, in asymptomatic but “at‐risk” alcohol misuse patients (Study 1) and (2) the treatment of WE in symptomatic alcohol misuse patients (Study 2). Each study had a dosage regimen comprising three parenteral thiamine doses that were allocated at a ratio of 1:1:1. Study 1: Asymptomatic At‐Risk patients (N = 393) received either 100 mg daily, 100 mg thrice daily, or 300 mg thrice daily, for 3 days. Study 2: Symptomatic patients (N = 127) received either 100 mg thrice daily, 300 mg thrice daily, or 500 mg thrice daily, for 5 days. Cognitive function was the primary outcome, assessed using the Rowland Universal Dementia Assessment Scale, two Cogstate subtests, and an adapted Story Memory Recall test. Secondary analyses examined differences in neurological function (ataxia, oculomotor abnormalities, and confusion) at follow‐up. Results No significant differences were observed between any of the dosage conditions for either Study 1 or Study 2 on cognition or neurological functioning. This real‐world study found that having a clinically unwell target population with high comorbidity and multiple presentations, coupled with challenges in cross‐cultural assessment is likely to complicate RCT findings. Conclusions The results of this study showed no clear benefit of high dose thiamine over intermediate or lower doses of thiamine, over the time intervals examined, for the treatment and prevention of cognitive and neurological abnormalities related to WKS. Several study limitations temper the interpretation of these findings. Nevertheless, the absence of conclusive evidence for the superiority of high‐dose thiamine supports a recommendation for patient‐specific treatment, while ensuring that the potential impact of other biochemical factors (e.g., magnesium and other B vitamin deficiencies) are considered and corrected if necessary.
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Affiliation(s)
- Kylie M Dingwall
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
| | - Jennifer F Delima
- Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Paula Binks
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Robert Batey
- Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Stephen C Bowden
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia.,Centre for Clinical Neuroscience and Neurological Research, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Araujo I, Henriksen A, Gamsby J, Gulick D. Impact of Alcohol Abuse on Susceptibility to Rare Neurodegenerative Diseases. Front Mol Biosci 2021; 8:643273. [PMID: 34179073 PMCID: PMC8220155 DOI: 10.3389/fmolb.2021.643273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/14/2021] [Indexed: 12/22/2022] Open
Abstract
Despite the prevalence and well-recognized adverse effects of prenatal alcohol exposure and alcohol use disorder in the causation of numerous diseases, their potential roles in the etiology of neurodegenerative diseases remain poorly characterized. This is especially true of the rare neurodegenerative diseases, for which small population sizes make it difficult to conduct broad studies of specific etiological factors. Nonetheless, alcohol has potent and long-lasting effects on neurodegenerative substrates, at both the cellular and systems levels. This review highlights the general effects of alcohol in the brain that contribute to neurodegeneration across diseases, and then focuses on specific diseases in which alcohol exposure is likely to play a major role. These specific diseases include dementias (alcohol-induced, frontotemporal, and Korsakoff syndrome), ataxias (cerebellar and frontal), and Niemann-Pick disease (primarily a Type B variant and Type C). We conclude that there is ample evidence to support a role of alcohol abuse in the etiology of these diseases, but more work is needed to identify the primary mechanisms of alcohol's effects.
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Affiliation(s)
- Iskra Araujo
- Gulick Laboratory, Byrd Neuroscience Institute, University of South Florida Health, Tampa, FL, United States
| | - Amy Henriksen
- Gulick Laboratory, Byrd Neuroscience Institute, University of South Florida Health, Tampa, FL, United States
| | - Joshua Gamsby
- Gulick Laboratory, Byrd Neuroscience Institute, University of South Florida Health, Tampa, FL, United States
- Department of Molecular Medicine, Morsani College of Medicine, University of South FL, Tampa, FL, United States
| | - Danielle Gulick
- Gulick Laboratory, Byrd Neuroscience Institute, University of South Florida Health, Tampa, FL, United States
- Department of Molecular Medicine, Morsani College of Medicine, University of South FL, Tampa, FL, United States
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Bowden SC, Crowe SF. Editorial to the Special Issue “Improving the Reliability and Validity of Brief Cognitive Assessments”. AUSTRALIAN PSYCHOLOGIST 2020. [DOI: 10.1111/ap.12253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen C Bowden
- Melbourne School of Psychological Sciences, University of Melbourne,
| | - Simon F Crowe
- School of Psychology and Public Health, La Trobe University,
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Le Daré B, Lagente V, Gicquel T. Ethanol and its metabolites: update on toxicity, benefits, and focus on immunomodulatory effects. Drug Metab Rev 2019; 51:545-561. [PMID: 31646907 DOI: 10.1080/03602532.2019.1679169] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This article summarizes recent experimental and epidemiological data on the toxic and beneficial effects of ethanol and its metabolites (acetaldehyde), and focuses on their immunomodulatory effects. The section dealing with the toxic effects of alcohol focuses on its chronic toxicity (liver disorders, carcinogenic effects, cardiovascular disorders, neuropsychic disorders, addiction and withdrawal syndrome, hematologic disorders, reprotoxicity, osteoporosis) although acute toxicity is considered. The role of oxidative metabolism of ethanol by alcohol dehydrogenase, cytochrome P450 2E1, and aldehyde dehydrogenase, as well as the impact of genetic polymorphism in its physiopathology are also highlighted. The section dealing with the beneficial effects of low to moderate alcohol consumption (on cardiovascular system, diabetes, the nervous system and sensory organs, autoimmune diseases, and rheumatology) highlights the importance of anti-inflammatory and immunomodulatory effects in these observations. This knowledge, enriched by a focus on the immunomodulatory effects of ethanol and its metabolites, in particular on the NLRP3 inflammasome pathway, might facilitate the development of treatments that can reduce ethanol's harmful effects or accentuate its beneficial effects.
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Affiliation(s)
- Brendan Le Daré
- Univ Rennes, INSERM, INRA, Institut NuMeCan (Nutrition, Metabolisms and Cancer), Rennes, France.,Pharmacy Unit, Pontchaillou University Hospital, Rennes, France.,Forensic and Toxicology Laboratory, Pontchaillou University Hospital, Rennes, France
| | - Vincent Lagente
- Univ Rennes, INSERM, INRA, Institut NuMeCan (Nutrition, Metabolisms and Cancer), Rennes, France
| | - Thomas Gicquel
- Univ Rennes, INSERM, INRA, Institut NuMeCan (Nutrition, Metabolisms and Cancer), Rennes, France.,Forensic and Toxicology Laboratory, Pontchaillou University Hospital, Rennes, France
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7
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Rare Dementias. NEURODEGENER DIS 2018. [DOI: 10.1007/978-3-319-72938-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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8
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Nikolakaros G, Kurki T, Paju J, Papageorgiou SG, Vataja R, Ilonen T. Korsakoff Syndrome in Non-alcoholic Psychiatric Patients. Variable Cognitive Presentation and Impaired Frontotemporal Connectivity. Front Psychiatry 2018; 9:204. [PMID: 29910747 PMCID: PMC5992887 DOI: 10.3389/fpsyt.2018.00204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Non-alcoholic Wernicke's encephalopathy and Korsakoff syndrome are greatly underdiagnosed. There are very few reported cases of neuropsychologically documented non-alcoholic Korsakoff syndrome, and diffusion tensor imaging (DTI) data are scarce. Methods: We report clinical characteristics and neuropsychological as well as radiological findings from three psychiatric patients (one woman and two men) with a history of probable undiagnosed non-alcoholic Wernicke's encephalopathy and subsequent chronic memory problems. Results: All patients had abnormal neuropsychological test results, predominantly in memory. Thus, the neuropsychological findings were compatible with Korsakoff syndrome. However, the neuropsychological findings were not uniform. The impairment of delayed verbal memory of the first patient was evident only when the results of the memory tests were compared to her general cognitive level. In addition, the logical memory test and the verbal working memory test were abnormal, but the word list memory test was normal. The second patient had impaired attention and psychomotor speed in addition to impaired memory. In the third patient, the word list memory test was abnormal, but the logical memory test was normal. All patients had intrusions in the neuropsychological examination. Executive functions were preserved, except for planning and foresight, which were impaired in two patients. Conventional MRI examination was normal. DTI showed reduced fractional anisotropy values in the uncinate fasciculus in two patients, and in the corpus callosum and in the subgenual cingulum in one patient. Conclusions: Non-alcoholic Korsakoff syndrome can have diverse neuropsychological findings. This may partly explain its marked underdiagnosis. Therefore, a strong index of suspicion is needed. The presence of intrusions in the neuropsychological examination supports the diagnosis. Damage in frontotemporal white matter tracts, particularly in the uncinate fasciculus, may be a feature of non-alcoholic Korsakoff syndrome in psychiatric patients.
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Affiliation(s)
- Georgios Nikolakaros
- "Specialists in Psychiatry" Medical Center, Turku, Finland.,Satakunta Hospital District, Psychiatric Care Division, General Psychiatry Outpatient Clinic, Pori, Finland.,Turku University Central Hospital, Salo Psychiatry Outpatient Clinic, Salo, Finland
| | - Timo Kurki
- Terveystalo Pulssi Medical Center, Turku, Finland.,Department of Radiology, University of Turku, Turku, Finland
| | - Janina Paju
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Sokratis G Papageorgiou
- Cognitive Disorders/Dementia Unit, 2nd University Department of Neurology, Medical School, National and Kapodistrian University of Athens, University General Hospital "ATTIKON", Athens, Greece
| | - Risto Vataja
- Division of Neuropsychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Tuula Ilonen
- Department of Psychiatry, University of Turku, Turku, Finland
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9
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Wojtys EM. Concussion Dilemma. Sports Health 2016; 8:17-8. [PMID: 26733589 PMCID: PMC4702161 DOI: 10.1177/1941738115621030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Casson IR, Viano DC, Haacke EM, Kou Z, LeStrange DG. Is There Chronic Brain Damage in Retired NFL Players? Neuroradiology, Neuropsychology, and Neurology Examinations of 45 Retired Players. Sports Health 2014; 6:384-95. [PMID: 25177413 PMCID: PMC4137679 DOI: 10.1177/1941738114540270] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Neuropathology and surveys of retired National Football League (NFL) players suggest that chronic brain damage is a frequent result of a career in football. There is limited information on the neurological statuses of living retired players. This study aimed to fill the gap in knowledge by conducting in-depth neurological examinations of 30- to 60-year-old retired NFL players. HYPOTHESIS In-depth neurological examinations of 30- to 60-year-old retired players are unlikely to detect objective clinical abnormalities in the majority of subjects. STUDY DESIGN A day-long medical examination was conducted on 45 retired NFL players, including state-of-the-art magnetic resonance imaging (MRI; susceptibility weighted imaging [SWI], diffusion tensor imaging [DTI]), comprehensive neuropsychological and neurological examinations, interviews, blood tests, and APOE (apolipoprotein E) genotyping. LEVEL OF EVIDENCE Level 3. METHODS Participants' histories focused on neurological and depression symptoms, exposure to football, and other factors that could affect brain function. The neurological examination included Mini-Mental State Examination (MMSE) evaluation of cognitive function and a comprehensive search for signs of dysarthria, pyramidal system dysfunction, extrapyramidal system dysfunction, and cerebellar dysfunction. The Beck Depression Inventory (BDI) and Patient Health Questionnaire (PHQ) measured depression. Neuropsychological tests included pen-and-paper and ImPACT evaluation of cognitive function. Anatomical examination SWI and DTI MRI searched for brain injuries. The results were statistically analyzed for associations with markers of exposure to football and related factors, such as body mass index (BMI), ethanol use, and APOE4 status. RESULTS The retired players' ages averaged 45.6 ± 8.9 years (range, 30-60 years), and they had 6.8 ± 3.2 years (maximum, 14 years) of NFL play. They reported 6.9 ± 6.2 concussions (maximum, 25) in the NFL. The majority of retired players had normal clinical mental status and central nervous system (CNS) neurological examinations. Four players (9%) had microbleeds in brain parenchyma identified in SWI, and 3 (7%) had a large cavum septum pellucidum with brain atrophy. The number of concussions/dings was associated with abnormal results in SWI and DTI. Neuropsychological testing revealed isolated impairments in 11 players (24%), but none had dementia. Nine players (20%) endorsed symptoms of moderate or severe depression on the BDI and/or met criteria for depression on PHQ; however, none had dementia, dysarthria, parkinsonism, or cerebellar dysfunction. The number of football-related concussions was associated with isolated abnormalities on the clinical neurological examination, suggesting CNS dysfunction. The APOE4 allele was present in 38% of the players, a larger number than would be expected in the general male population (23%-26%). CONCLUSION MRI lesions and neuropsychological impairments were found in some players; however, the majority of retired NFL players had no clinical signs of chronic brain damage. CLINICAL RELEVANCE These results need to be reconciled with the prevailing view that a career in football frequently results in chronic brain damage.
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Affiliation(s)
- Ira R. Casson
- Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York
- Department of Neurology, Hofstra North Shore–LIJ School of Medicine, Hempstead, New York
| | - David C. Viano
- ProBiomechanics LLC, Bloomfield Hills, Michigan
- Department of Biomedical Engineering, Bioengineering Center, Wayne State University, Detroit, Michigan
| | - E. Mark Haacke
- Departments of Radiology and Biomedical Engineering, Wayne State University School of Medicine, Detroit, Michigan
| | - Zhifeng Kou
- Departments of Radiology and Biomedical Engineering, Wayne State University School of Medicine, Detroit, Michigan
| | - Danielle G. LeStrange
- Emergency Nursing and Clinical Outreach, Lawrence Hospital Center, Bronxville, New York
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Abstract
Alcohol abuse and dependence are serious public health problems worldwide, resulting in significant morbidity, mortality, and legal implications. Therefore, sudden unexpected, suspicious, or violent death in alcohol consuming persons are frequently seen in the forensic setting. Alcohol-induced brain damage is predominantly caused by nutritional deficiencies and repeated withdrawal syndrome. Brain lesions associated with heavy alcohol consumption include brain atrophy, hepatic encephalopathy, and central pontine myelinolysis. In addition, the dementing conditions Wernicke-Korsakoff syndrome, acquired hepatocerebral degeneration, Marchiafava-Bignami disease, and pellagrous encephalopathy are closely associated with chronic alcohol consumption. In neuroradiological and autopsy studies, cerebral and cerebellar atrophy has been demonstrated in alcoholics. There is a regional selectivity, with the frontal lobes being particularly affected. Moreover, a disproportionate loss of cerebral white matter relative to cerebral cortex suggests that a major neurotoxic effect of chronic alcohol consumption predominantly affects the white matter.
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Affiliation(s)
- Andreas Büttner
- Forensic Pathology and the Institute of Legal Medicine at the Medical University of Rostock, Germany
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12
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de Fátima Oliveira-Silva I, Pereira SRC, Fernandes PA, Ribeiro AF, Pires RGW, Ribeiro AM. Mild thiamine deficiency and chronic ethanol consumption modulate acetylcholinesterase activity change and spatial memory performance in a water maze task. J Mol Neurosci 2014; 55:217-226. [PMID: 24770900 DOI: 10.1007/s12031-014-0306-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/08/2014] [Indexed: 11/25/2022]
Abstract
Chronic thiamine deficiency may be responsible for pathologic changes in the brains of alcoholics, and subclinical episodes of this vitamin deficiency may cause cumulative brain damage. In the present work, the chronic effects of ethanol and its association to a mild thiamine deficiency episode (subclinical model) on neocortical and hippocampal acetylcholinesterase activity were assessed along with their possible association to spatial cognitive dysfunction. The results indicate that in the beginning of the neurodegenerative process, before the appearance of brain lesions, chronic ethanol consumption reverses the effects of mild thiamine deficiency on both spatial cognitive performance and acetylcholinesterase activity without having significant effects on any morphometric parameter.
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Affiliation(s)
- Ieda de Fátima Oliveira-Silva
- Departamento de Análises Clínicas e Toxicológicas - Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil
| | - Silvia R Castanheira Pereira
- Programa de Pós-graduação em Neurociências, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil
| | - Paula A Fernandes
- Departamento de Análises Clínicas e Toxicológicas - Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil
| | - Andrea F Ribeiro
- Programa de Pós-graduação em Neurociências, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil
| | - Rita G W Pires
- Departamento de Ciências Fisiológicas/Centro Biomédico-Laboratório de Neurobiologia Molecular e Comportamental, Universidade Federal do Espírito Santo, Vitória, 29043-910, Brazil
| | - Angela Maria Ribeiro
- Programa de Pós-graduação em Neurociências, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil.
- Departamento de Bioquímica e Imunologia, Laboratório de Neurociências Comportamental e Molecular, LaNeC, Faculdade de Filosofia e Ciências Humanas, FaFiCH, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-010, Brazil.
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13
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de la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol 2014; 127:71-90. [PMID: 24370929 DOI: 10.1007/s00401-013-1233-3] [Citation(s) in RCA: 253] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 02/08/2023]
Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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14
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Uncommon Dementias. NEURODEGENER DIS 2014. [DOI: 10.1007/978-1-4471-6380-0_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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15
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Patients with Korsakoff syndrome in nursing homes: characteristics, comorbidity, and use of psychotropic drugs. Int Psychogeriatr 2014; 26:115-21. [PMID: 24308344 DOI: 10.1017/s1041610213001543] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Very limited literature exists on the care and course of patients with Korsakoff syndrome (KS) living in long-term care facilities (LTCFs). Even less literature can be found on the pharmacological treatment of behavioral symptoms of KS. The purpose of the present study was to describe baseline characteristics, comorbidity, and the use of psychotropic drugs in institutionalized patients with KS. METHODS In this cross-sectional descriptive study, 556 patients were included living in ten specialized care units in Dutch nursing homes. Data were collected by means of a retrospective chart review. RESULTS The majority of patients were men (75%) and single (78%) with a mean age on admission of 56.7 years (SD 8.9, range 29.8-85.3). Mean length of stay was 6.0 years (SD 5.4, range 0.2-33.3). Sixty-eight percent of patients suffered from at least one somatic disease and 66% from at least one extra psychiatric disorder. One or more psychotropic drugs were prescribed to 71% of patients with a great variation in prescription patterns between the different nursing homes. CONCLUSION Patients with KS depending on long-term care usually have comorbidity in more than one domain (somatic and psychiatric). The indications for prescribing psychotropic drugs are in many cases unclear and it seems probable that they are often given to manage challenging behavior. Longitudinal studies on the evidence for this prescription behavior and possible alternatives are recommended.
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Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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Tan JE, Springate BA, Tremont G. Neuropsychologists’ Beliefs About Alcohol and Dementia. Clin Neuropsychol 2012; 26:879-93. [DOI: 10.1080/13854046.2012.699102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Oscar-Berman M. Function and dysfunction of prefrontal brain circuitry in alcoholic Korsakoff's syndrome. Neuropsychol Rev 2012; 22:154-69. [PMID: 22538385 PMCID: PMC3681949 DOI: 10.1007/s11065-012-9198-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
The signature symptom of alcohol-induced persisting amnestic disorder, more commonly referred to as alcoholic Korsakoff's syndrome (KS), is anterograde amnesia, or memory loss for recent events, and until the mid 20th Century, the putative brain damage was considered to be in diencephalic and medial temporal lobe structures. Overall intelligence, as measured by standardized IQ tests, usually remains intact. Preservation of IQ occurs because memories formed before the onset of prolonged heavy drinking--the types of information and abilities tapped by intelligence tests--remain relatively well preserved compared with memories recently acquired. However, clinical and experimental evidence has shown that neurobehavioral dysfunction in alcoholic patients with KS does include nonmnemonic abilities, and further brain damage involves extensive frontal and limbic circuitries. Among the abnormalities are confabulation, disruption of elements of executive functioning and cognitive control, and emotional impairments. Here, we discuss the relationship between neurobehavioral impairments in KS and alcoholism-related brain damage. More specifically, we examine the role of damage to prefrontal brain systems in the neuropsychological profile of alcoholic KS.
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Affiliation(s)
- Marlene Oscar-Berman
- Department of Neurology and Division of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
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Rao R, Shanks A. Development and implementation of a dual diagnosis strategy for older people in south east London. ADVANCES IN DUAL DIAGNOSIS 2011. [DOI: 10.1108/17570971111155595] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Aho L, Karkola K, Juusela J, Alafuzoff I. Heavy alcohol consumption and neuropathological lesions: a post-mortem human study. J Neurosci Res 2010; 87:2786-92. [PMID: 19382227 DOI: 10.1002/jnr.22091] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Epidemiological studies have indicated that excessive alcohol consumption leads to cognitive impairment, but the specific pathological mechanism involved remains unknown. The present study evaluated the association between heavy alcohol intake and the neuropathological hallmark lesions of the three most common neurodegenerative disorders, i.e., Alzheimer's disease (AD), dementia with Lewy bodies (DLB), and vascular cognitive impairment (VCI), in post-mortem human brains. The study cohort was sampled from the subjects who underwent a medicolegal autopsy during a 6-month period in 1999 and it included 54 heavy alcohol consumers and 54 age- and gender-matched control subjects. Immunohistochemical methodology was used to visualize the aggregation of beta-amyloid, hyperphosphorylated tau, and alpha-synuclein and the extent of infarcts. In the present study, no statistically significant influence was observed for alcohol consumption on the extent of neuropathological lesions encountered in the three most common degenerative disorders. Our results indicate that alcohol-related dementia differs from VCI, AD, and DLB; i.e., it has a different etiology and pathogenesis.
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Affiliation(s)
- Leena Aho
- Department of Clinical Medicine, Unit of Neurology, Kuopio University, Kuopio, Finland
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FEENEY GERALDFX, CONNOR JASONP. Wernicke-Korsakoff syndrome (WKS) in Australia: no room for complacency. Drug Alcohol Rev 2009; 27:388-92. [DOI: 10.1080/09595230802090048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fujiwara E, Brand M, Borsutzky S, Steingass HP, Markowitsch HJ. Cognitive performance of detoxified alcoholic Korsakoff syndrome patients remains stable over two years. J Clin Exp Neuropsychol 2008; 30:576-87. [PMID: 17852615 DOI: 10.1080/13803390701557271] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Excessive alcohol consumption is assumed to promote cognitive decline, eventually increasing the risk of dementia. However, little is known about the time course of cognitive functions in patients with chronic alcoholic Korsakoff syndrome (KS). Therefore, we assessed neuropsychological performance in 20 detoxified chronic KS inpatients at time 1 (T1) with a follow-up after two years (T2). The neuropsychological tests assessed verbal and visual short- and long-term memory, working memory, basic executive functions, language, general knowledge, and visual-spatial abilities. Surveys with caregivers and medical records provided information about current and previous disease-related parameters, drinking history, additional pathologies, as well as psychosocial and cognitive therapy within the two-year period. At both sessions, the majority of the KS patients' results were inferior to those of normal subjects. Comparing T1 and T2 revealed no significant decline in any of the investigated functions. Instead, general knowledge, visual long-term memory, and verbal fluency improved slightly after two years, though they still remained within pathological range. Comparing most improved and most deteriorated patients, better outcome occurred more frequently in men than women and was associated with higher premorbid education and fewer detoxifications in the past. In this sample of detoxified KS patients there was no indication of accelerated cognitive decline or onset of dementia-like symptoms over two years.
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Affiliation(s)
- Esther Fujiwara
- Physiological Psychology, University of Bielefeld, Bielefeld, Germany.
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Abstract
BACKGROUND To date, there is a wealth of literature describing the deleterious effects of active alcoholism on cognitive function. There is also a growing body of literature on the extent of cognitive recovery that can occur with abstinence. However, there is still a dearth of published findings on cognitive functioning in very long-term abstinence alcoholics, especially in the elderly population. METHODS The current study examines 91 elderly abstinent alcoholics (EAA) (49 men and 42 women) with an average age of 67.3 years, abstinent for an average of 14.8 years (range 0.5 to 45 years), and age and gender comparable light/nondrinking controls. The EAA group was divided into 3 subgroups: individuals that attained abstinence before age 50 years, between the ages 50 and 60 years, and after age 60 years. Attention, verbal fluency, abstraction/cognitive flexibility, psychomotor, immediate memory, delayed memory, reaction time, spatial processing, and auditory working memory were assessed. The AMNART and cranium size were used as estimates of brain reserve capacity, and the association of all variables with alcohol use measures was examined. RESULTS Overall, the EAA groups performed comparably to controls on the assessments of cognitive function. Only the abstinent in group before 50 years of age performed worse than controls, and this was only in the domain of auditory working memory. EAAs had larger craniums than their controls. This effect was strongest for those who drank the longest and had the shortest abstinence. Such individuals also performed better cognitively. CONCLUSIONS Our data showed that elderly alcoholics that drank late into life, but with at least 6 months abstinence can exhibit normal cognitive functioning. Selective survivorship and selection bias probably play a part in these findings. Cognitively healthier alcoholics, with more brain reserve capacity, may be more likely to live into their 60s, 70s, or 80s of age with relatively intact cognition, and to volunteer for studies such as this. Our results do not imply that all elderly alcoholics with long-term abstinence will attain normal cognition.
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Affiliation(s)
- George Fein
- Neurobehavioral Research, Inc., Corte Madera, California 94925, and Honolulu, Hawaii, USA.
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Bruns MB, Miller MW. Neurotrophin ligand-receptor systems in somatosensory cortex of adult rat are affected by repeated episodes of ethanol. Exp Neurol 2007; 204:680-92. [PMID: 17320080 PMCID: PMC1995597 DOI: 10.1016/j.expneurol.2006.12.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 12/19/2006] [Accepted: 12/28/2006] [Indexed: 12/24/2022]
Abstract
Ethanol exposure profoundly affects learning and memory and neural plasticity. Key players underlying these functions are neurotrophins. The present study explored the effects of ethanol on the distribution of neurotrophins in the cerebral cortex of the adult rat. Age- and weight-matched pairs of adult male, Long-Evans rats were fed a liquid, ethanol-containing (6.7% v/v) diet or pair-fed an isocaloric control diet three consecutive days per week for 6, 12, 18, or 24 weeks. Brains were processed immunohistochemically for nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) expression and for the expression of three neurotrophin receptors, p75, trkA, and trkB. Total numbers of immunolabeled neurons in specific layers of somatosensory cortex of ethanol- and control-fed animals were determined stereologically. Ethanol exposure induced an increase in the numbers of NGF- or BDNF-expressing neurons and in neurotrophin content per somata. These changes were (a) time and (b) laminar dependent. In contrast, the number of receptor-expressing neurons did not change due to ethanol exposure or to length of time on the ethanol diet. Thus, ethanol induces the recruitment of cortical neurons to express neurotrophins and an increase in the amount of neurotrophin expression per neuron.
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Affiliation(s)
- Marla B. Bruns
- Department of Neuroscience and Physiology, State University of New York- Upstate Medical University, Syracuse NY 13210 USA
- Developmental Exposure Alcohol Research Center, State University of New York, Binghamton NY 13902 USA and Syracuse NY 13210 USA
| | - Michael W. Miller
- Department of Neuroscience and Physiology, State University of New York- Upstate Medical University, Syracuse NY 13210 USA
- Developmental Exposure Alcohol Research Center, State University of New York, Binghamton NY 13902 USA and Syracuse NY 13210 USA
- Research Service, Veterans Affairs Medical Center, Syracuse NY 13210 USA
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Bruns MB, Miller MW. THIS ARTICLE HAS BEEN RETRACTED: Functional nerve growth factor and trkA autocrine/paracrine circuits in adult rat cortex are revealed by episodic ethanol exposure and withdrawal. J Neurochem 2006; 100:1155-68. [PMID: 17316397 DOI: 10.1111/j.1471-4159.2006.04301.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The hypothesis tested is that cortical neurotrophins communicate through an inducible autocrine/paracrine mechanism. As ethanol (Et) can induce cortical nerve growth factor (NGF) expression, adult rats were challenged with Et on three consecutive days per week for 6 weeks. The focus of the study was layer V, the chief repository of receptor-expressing neuronal cell bodies. Brains were collected immediately after the sixth Et exposure or 72 h later [i.e., following withdrawal (WD)]. Double-label in situ hybridization-immunohistochemistry studies showed that many neuronal somata co-expressed NGF mRNA with NGF, trkA, or phosphorylated trk (p-trk), essential components of an inducible autocrine system. The frequencies of co-labeling were affected by neither Et nor WD. On the contrary, Et increased the number of NGF mRNA-expressing neurons and the amount of NGF mRNA expressed per cell. Et also increased total cortical concentration of NGF protein, the number of layer V neurons expressing trkA transcript, the amount of trkA mRNA expressed per neuron, and trkA phosphorylation. Following WD, the frequency of NGF-mRNA-expressing cells increased, although transcript and protein content fell. WD induced an increase in trkA mRNA and protein expression, however, p-trk expression was unaffected. Thus, Et treatment reveals that layer V has inducible autocrine/paracrine and anterograde neurotrophin systems. WD unveils the dynamism and recruitability of these systems.
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Affiliation(s)
- Marla B Bruns
- Department of Neuroscience and Physiology, State University of New York-Upstate Medical University, Syracuse, New York 13210, USA
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Kapaki E, Liappas I, Paraskevas GP, Theotoka I, Rabavilas A. The diagnostic value of tau protein, beta-amyloid (1-42) and their ratio for the discrimination of alcohol-related cognitive disorders from Alzheimer's disease in the early stages. Int J Geriatr Psychiatry 2005; 20:722-9. [PMID: 16035118 DOI: 10.1002/gps.1351] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chronic and heavy alcohol abuse or dependence may result in impaired cognition and dementia. The increased risk of Alzheimer's disease (AD) in older individuals interferes with the differential diagnosis, especially when dealing with elderly patients with a long history of alcohol abuse. The aim of the present study was to evaluate the diagnostic value of the putative cerebrospinal fluid (CSF) biomarkers tau, beta-amyloid 1-42 (Abeta42) and their ratio in differentiating alcohol related cognitive disorder (ARCD) from AD. METHODS Double-sandwich ELISA (Innotest htau antigen and beta-Amyloid (1-42), Innogenetics) were used to quantify the above markers in a total of 20 patients with ARCD, 33 AD patients with mild to moderate dementia and 50 mentally intact subjects. RESULTS Tau protein successfully differentiated AD from normal ageing with 96% specificity and 93.9% sensitivity and from ARCD with 95% specificity, and 87.9% sensitivity. Abeta42 alone had a specificity of 88% and a sensitivity of 69.7% in differentiating AD from normal ageing, while the corresponding values for differentiating AD from ARCD were 80% and 84.8% respectively. The tau/Abeta42 ratio was better than tau alone for differentiating AD from normal ageing (specificity 94%, sensitivity 97%) and better than any of the candidate markers alone, for differentiating AD from ARCD (specificity 100%, sensitivity 97%). CONCLUSIONS The combined use of CSF tau and Abeta42 may be a useful tool in the differential diagnosis of ARCD from AD, especially in the early stages, where diagnostic uncertainty is greater.
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Affiliation(s)
- Elisabeth Kapaki
- Department of Neurology, Athens National University, School of Medicine, Eginition Hospital, Athens, Greece.
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Miller MW. Repeated episodic exposure to ethanol affects neurotrophin content in the forebrain of the mature rat. Exp Neurol 2004; 189:173-81. [PMID: 15296847 DOI: 10.1016/j.expneurol.2004.05.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2004] [Revised: 04/16/2004] [Accepted: 05/20/2004] [Indexed: 11/26/2022]
Abstract
Chronic exposure to ethanol can cause deficits in learning and memory. It has been suggested that withdrawal is potentially more damaging than the ethanol exposure per se. Therefore, we explored the effect of repeated episodic exposure to ethanol on key regulators of cortical activity, the neurotrophins. Rats were exposed to ethanol via a liquid diet for 3 days per week for 6-24 weeks. Control rats were pair-fed an isocaloric liquid diet or ad libitum fed chow and water. The concentrations of nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and neurotrophin-3 (NT-3) were determined using enzyme-linked immunosorbant assays (ELISAs). Five telencephalic structures were examined: parietal cortex, entorhinal cortex, hippocampus, the basal nucleus, and the septal nuclei. All five areas expressed each of the three neurotrophins; BDNF was most abundant and NGF the least. The parietal cortex was susceptible to ethanol exposure, NGF and BDNF content increased, and NT-3 content fell, whereas no changes were detectable in the entorhinal cortex. In the hippocampus, the amount all three neurotrophins increased following episodic ethanol exposure. Neurotrophin content in the two segments of the basal forebrain was affected; NGF and NT-3 content in the basal forebrain was reduced and NGF and BDNF content in the septal nuclei was increased by ethanol exposure. In many cases where ethanol had an effect, the change was transient so that by 24 weeks of episodic exposure, no significant changes were evident. Thus, the effects of ethanol are site- and time-dependent. This pattern differs from changes caused by chronic ethanol exposure, hence, neurotrophins must be vulnerable to the effects of withdrawal. Furthermore, the ethanol-induced changes do not appear to fit a model consistent with retrograde regulation, rather they suggest that neurotrophins act through autocrine/paracrine systems.
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Affiliation(s)
- Michael W Miller
- Department of Neuroscience and Physiology, State University of New York-Upstate Medical University, Syracuse, NY 13210, USA.
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Abstract
Young onset dementia is a challenging clinical problem with potentially devastating medical and social consequences. The differential diagnosis is wide, and includes a number of rare sporadic and hereditary diseases. However, accurate diagnosis is often possible, and all patients should be thoroughly investigated to identify treatable processes. This review presents an approach to the diagnosis, investigation, and management of patients with young onset dementia, with particular reference to common and treatable causes.
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Affiliation(s)
- E L Sampson
- Dementia Research Group, Institute of Neurology, University College London, London, UK
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Casos en imagen 2. — Enfermedad de marchiafava-bignami. presentación clínica. RADIOLOGIA 2004. [DOI: 10.1016/s0033-8338(04)77963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hazelton LD, Sterns GL, Chisholm T. Decision-making capacity and alcohol abuse: clinical and ethical considerations in personal care choices. Gen Hosp Psychiatry 2003; 25:130-5. [PMID: 12676427 DOI: 10.1016/s0163-8343(03)00005-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Requests for competency assessment of elderly patients are among the more common referrals that medical and surgical units make to consultation-liaison psychiatrists. Special considerations arise when impairment in cognition, judgment and function arise in the context of substance abuse. At what point during the admission should the evaluation be made? What if the person does well on the cognitive exam but has shown repeated evidence of self-neglect and need for medical care? What role should the medical profession play in mandating that patients give up harmful addictions? In this paper, we describe a case that illustrates these problems, and discuss some of the clinical and ethical considerations involved in the assessment of personal care competence of patients with alcohol abuse, and provide guidelines for these assessments.
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Affiliation(s)
- Lara D Hazelton
- Department of Psychiatry, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
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Reid MC, Maciejewski PK, Hawkins KA, Bogardus ST. Relationship between alcohol consumption and Folstein mini-mental status examination scores among older cognitively impaired adults. J Geriatr Psychiatry Neurol 2002; 15:31-7. [PMID: 11936241 DOI: 10.1177/089198870201500107] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to determine whether older cognitively impaired adults with significant current or past alcohol histories manifest distinctive cognitive profiles as determined by a widely used cognitive screen, the Folstein Mini-Mental Status Examination (MMSE) test, when compared with older persons without significant alcohol histories. Study participants included 801 consecutive patients, ages 65 years or above, who underwent comprehensive geriatric assessments. Proxy-reported current alcohol intake was classified as none, former, light (<1 drink/week), moderate (> or = 1 but < 14 drinks/week), and heavy (> or = 14 drinks/week), and the presence of an alcohol abuse/dependence disorder was determined by medical record review. Potential exposure-outcome associations were assessed for patients (n = 470) with established cognitive impairment, defined as an MMSE score < 24, and for individuals with MMSE scores > or = 24 (n = 331). Among participants with established cognitive impairment, mean (total) MMSE scores were not significantly different (17.2 vs 16.4 vs 18.5 vs 18.5 vs 17.4) across the categories of current alcohol exposure (none, former, light, moderate, and heavy). Mini-Mental State Examination subscores also did not vary as a function of current alcohol consumption, and a history of alcohol abuse/dependence was not associated with differences in total scores or individual MMSE subscores in this patient group. Among participants with MMSE scores > 24, increased current use of alcohol or a history of alcohol abuse/dependence was not associated with lower total MMSE scores or individual MMSE subscores. Despite these negative findings, prospective investigations of older populations that incorporate more comprehensive cognitive measures are warranted because (1) the Folstein is a brief cognitive screen that does not assess all cognitive domains, and (2) alcohol is a demonstrated risk factor for adverse cognitive outcomes in middle-aged adults and is potentially modifiable.
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Affiliation(s)
- M Carrington Reid
- Clinical Epidemiology Unit, VA Connecticut Healthcare System, West Haven, Connecticut 06515, USA
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Bates ME, Bowden SC, Barry D. Neurocognitive impairment associated with alcohol use disorders: implications for treatment. Exp Clin Psychopharmacol 2002; 10:193-212. [PMID: 12233981 DOI: 10.1037/1064-1297.10.3.193] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Between 50% and 80% of individuals with alcohol use disorders experience mild to severe neurocognitive impairment. There is a strong clinical rationale that neurocognitive impairment is an important source of individual difference affecting many aspects of addiction treatment, but empirical tests of the direct influence of impairment on treatment outcome have yielded weak and inconsistent results. The authors address the schism between applied-theoretical perspectives and research evidence by suggesting alternative conceptual models of the relationship between neurocognitive impairment and addiction treatment outcome. Methods to promote neurocognitive recovery and ways in which addiction treatments may be modified to improve psychosocial adaptation are suggested. Specific suggestions for future research that may help clarify the complex relations between neurocognitive impairment and addiction treatment are outlined.
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Affiliation(s)
- Marsha E Bates
- Center of Alcohol Studies, Rutgers University, Piscataway, New Jersey 08854-8001, USA.
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Fiala JC, Spacek J, Harris KM. Dendritic spine pathology: cause or consequence of neurological disorders? BRAIN RESEARCH. BRAIN RESEARCH REVIEWS 2002; 39:29-54. [PMID: 12086707 DOI: 10.1016/s0165-0173(02)00158-3] [Citation(s) in RCA: 613] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Altered dendritic spines are characteristic of traumatized or diseased brain. Two general categories of spine pathology can be distinguished: pathologies of distribution and pathologies of ultrastructure. Pathologies of spine distribution affect many spines along the dendrites of a neuron and include altered spine numbers, distorted spine shapes, and abnormal loci of spine origin on the neuron. Pathologies of spine ultrastructure involve distortion of subcellular organelles within dendritic spines. Spine distributions are altered on mature neurons following traumatic lesions, and in progressive neurodegeneration involving substantial neuronal loss such as in Alzheimer's disease and in Creutzfeldt-Jakob disease. Similarly, spine distributions are altered in the developing brain following malnutrition, alcohol or toxin exposure, infection, and in a large number of genetic disorders that result in mental retardation, such as Down's and fragile-X syndromes. An important question is whether altered dendritic spines are the intrinsic cause of the accompanying neurological disturbances. The data suggest that many categories of spine pathology may result not from intrinsic pathologies of the spiny neurons, but from a compensatory response of these neurons to the loss of excitatory input to dendritic spines. More detailed studies are needed to determine the cause of spine pathology in most disorders and relationship between spine pathology and cognitive deficits.
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Affiliation(s)
- John C Fiala
- Department of Biology, Boston University, 5 Cummington Street, MA 02215, USA.
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Abstract
The initial approach to the patient with memory complaints should consist of a focused history, mental status examination, and functional assessment. Patients with MCI should be monitored every 6 to 12 months for conversion to dementia. Delirium, depression, amnestic disorders, and aphasias should be considered in the differential diagnosis of memory impairment. Once a diagnosis of dementia is made, patients should have a brain CT or MRI scan and laboratory tests to assist with determining the cause. It is crucial that dementia be recognized and evaluated at the earliest stage so as to begin appropriate therapy and allow the patient to have a role in management decisions. In the future, therapies for MCI may prevent conversion to dementia. The need for early recognition makes the development of diagnostic tools, such as quantitative or functional neuroimaging, and genetic or clinical biologic markers essential.
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Affiliation(s)
- G Webster Ross
- Honolulu Department of Veterans Affairs, John A. Burns School of Medicine, University of Hawaii, Pacific Health Research Institute, 846 South Hotel Street, Suite 307, Honolulu, HI 96813, USA.
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Abstract
Calpain, a calcium-activated cysteine protease, has been implicated in neuronal degeneration and death. In this study, we have characterized calpain activation in adult rat cerebral cortex and cerebellum, using an experimental paradigm of in vivo chronic ethanol exposure. Ethanol treatment increased the calpain activity in cortex and cerebellum, but to a higher extent in the cortex. Western blot analysis revealed a significant decrease in m-calpain levels while calpastatin levels were unaltered. Calpain activation was further monitored by the proteolysis of alpha-spectrin (fodrin) and protein kinase C-alpha (PKC-alpha). Protease specific spectrin breakdown products revealed calpain generated 150- and 145-kDa fragments. In addition, we also observed a 120-kDa fragment characteristic of caspase-3 activation in the cerebellum. PKC-alpha levels were decreased in the cortex and cerebellum by ethanol. Calpain activation, cleavage of alpha-spectrin into calpain specific signature fragments and decreased PKC-alpha protein levels after ethanol treatment provide the evidence of calpain involvement besides caspase-3-mediated cell death in the cortex and cerebellum. Given the role of calpains in cell death, increased calpain activity followed by alpha-spectrin cleavage in this study suggests that calpains are important effectors in ethanol-mediated cell injury and alcoholic neurodegeneration.
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Abstract
The psychotic manifestations of alcohol physical and psychiatric disorders have been documented for many centuries; however, the distinction of the various disorders remains less well defined. Individuals often have comorbid elements of several disorders, and the psychotic phenomenon are often diverse. The psychotic manifestations of alcohol withdrawal, delirium tremens, alcohol hallucinosis, Wernicke's-Korsakoff's psychosis, alcohol pellagra and hepatic encephalopathy, Marchiafava-Bignami, central pontine myelinosis, and alcohol dementia are discussed in this article.
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Affiliation(s)
- D M Greenberg
- Department of Psychiatry, University of Western Australia, & State Forensic Mental Health Service, Graylands Hospital, Locked Bag 1, Claremont, WA 6010, Australia.
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Abstract
Chronic alcohol abuse has deleterious effects on several organs in the body including the brain. Neuroradiological studies have demonstrated that the brains of chronic alcoholics undergo loss of both gray and white matter volumes. Neuropathological studies using unbiased stereological methods have provided evidence for loss of neurons in specific parts of the brain in chronic alcoholics. The purpose of this paper is to propose a mechanism for this alcohol related neuronal loss. The hypothesis is based on the neurodegeneration observed in patients with the genetic disorder xeroderma pigmentosum (XP), who lack the capacity to carry out a specific type of DNA repair called nucleotide excision repair (NER). Some XP patients develop a progressive atrophic neurodegeneration, termed XP neurological disease, indicating that endogenous DNA damage that is normally repaired by NER has the capacity to cause neuronal death. Accumulating evidence indicates that the neurodegenerative DNA damage that is responsible for neuronal loss in XP patients results from reactive oxygen species (ROS) and lipid peroxidation products, and has the capacity to inhibit gene expression by RNA polymerase II. Therefore, the following model is proposed: chronic alcohol abuse results in increased levels of ROS and lipid peroxidation products in neurons, which results in an overwhelming burden on the NER pathway, and increased steady state levels of DNA lesions that inhibit gene expression. This results in neuronal death either by reduction in the levels of essential gene products or by apoptosis. The implications of this model for future studies are discussed.
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Affiliation(s)
- P J Brooks
- Section on Molecular Neurobiology, Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, NIH, 12420 Parklawn Drive, MSC 8110, MD 20892-8110, Bethesda, USA.
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Abstract
Cognitive impairment is common in patients with advanced liver disease. It has been suggested that patients with alcoholic liver disease (ALD) have more impaired cognition than nonalcoholics. The objective of this study was to characterize any differences in cognitive functions between alcoholic cirrhotic patients and non-alcoholic cirrhotic patients of similar age, education, and severity of liver disease. We assessed cognitive functions in 117 patients with alcoholic cirrhosis and 163 patients with nonalcoholic cirrhosis using a brief battery of neuropsychological tests. In addition, all patients had standard psychiatric examinations to assess the effect of the disease severity, alcoholism, anxiety, and depression on the test scores. The study showed a higher proportion of patients with cognitive impairment in the alcoholic group. Alcoholics performed poorly in tests of memory and motor speed compared with nonalcoholics, despite similar premorbid IQ and education. Because patients with alcoholic cirrhosis had more severe liver disease (Child-Pugh score 8.5 +/- 2.2 vs. 7.6 +/- 2.2, P =.03) than nonalcoholics, the results were reanalyzed after adjusting for the linear effects of Child-Pugh score on cognitive test scores. We also used two-way analysis of variance to examine the interaction between Child class and alcoholism. Finally, the test scores were compared within each Child class. These analyses revealed no primary or interaction effect of alcoholism and confirmed that the differences in the test scores observed in alcoholics reflect the greater severity of their liver disease. The severity of cognitive impairment is similar in both alcoholic and non-alcoholic cirrhotic patients when adjusted for the severity of liver disease.
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Affiliation(s)
- D Edwin
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21287-7218, USA.
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Abstract
The human hypothalamus is subdivided into some 20 well-defined nuclei that have a multitude of specific functions from the time of birth to the moment we die. Hypothalamic nuclei show structural and functional differences not only in relation to classic neuroendocrine disorders, such as diabetes insipidus, climacteric flushes and Kallman's syndrome, but also in relation to gender and sexual orientation, to adaptive processes such as non-thyroidal illness and in psychiatric disorders such as depression.
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Affiliation(s)
- DF Swaab
- Netherlands Institute for Brain Research, Graduate School of Neurosciences Amsterdam, Meibergdreef 33, 1105 AZ Amsterdam, The Netherlands
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42
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Lukoyanov NV, Madeira MD, Paula-Barbosa MM. Behavioral and neuroanatomical consequences of chronic ethanol intake and withdrawal. Physiol Behav 1999; 66:337-46. [PMID: 10336163 DOI: 10.1016/s0031-9384(98)00301-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We have examined if long-term (13 months) alcohol consumption and the same treatment followed by a 6-week withdrawal period cause different neuropathological changes in rats. Spatial reference and working memory of alcohol-consuming and withdrawn rats were evaluated by comparison of their performance with age-matched controls in the Morris water maze. In the reference memory task we did not observe significant cognitive deficits in rats continuously exposed to ethanol, whereas withdrawn animals showed an obvious impairment of their overall performance. The reference memory deficit in withdrawn rats was evident in the spatial probe trial; these animals required significantly longer swimming distances to approach the former position of the platform when compared with controls and alcohol-consuming animals. In contrast, working memory was not significantly altered in either experimental group. Stereological methods were applied to compare the neurodegenerative changes produced by alcohol intake and withdrawal in the hippocampal formation. In the alcohol-consuming animals there was a significant cell loss in CA1 (18%) and CA3 (19%) hippocampal regions. Moreover, in withdrawn rats there was a further decay in the total number of pyramidal neurons, which amounted to 15% relative to nonwithdrawn animals. In the granular layer of the dentate gyrus there was a trend in the same direction, but it did not reach significance. Thus, our findings indicate that withdrawn rats are cognitively impaired relative to animals submitted to continuous alcohol consumption and to age-matched controls, which fits the morphological data showing that withdrawal aggravates ethanol-induced degenerative processes in the hippocampal formation.
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Affiliation(s)
- N V Lukoyanov
- Department of Anatomy, Porto Medical School, Portugal.
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Parsons OA. Comments on tau protein levels in alcoholics. Alcohol Clin Exp Res 1999; 23:573-4. [PMID: 10235289 DOI: 10.1111/j.1530-0277.1999.tb04155.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Castaneda R, Sussman N, Levy R, O'Malley M, Westreich L. A review of the effects of moderate alcohol intake on psychiatric and sleep disorders. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 1998; 14:197-226. [PMID: 9751947 DOI: 10.1007/0-306-47148-5_9] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In this chapter we discuss the effects of moderate ethanol consumption on the treatment of psychiatric and sleep disorders. A review of the literature on the interactions of ethanol with neurotransmitters and psychotropic medications suggests that although ethanol affects the clinical course of psychiatric and sleep disorders by different mechanisms, it does so principally through perturbations it causes in the balance of central nervous system neurotransmitter systems, which may modify the clinical course of primary psychiatric and sleep disorders and undermine the therapeutic response to psychotropic medications. Neurotransmitter responses may also be manifested clinically by rebound phenomena, akin to a subsyndromal withdrawal, which affect sleep and precipitate anxiety and mood symptoms. In addition, ethanol also modifies the clearance and disposition of a variety of psychotropic metabolites and interferes with their clinical effectiveness. We recommend that most psychiatric patients, and all patients with sleep disorders, should abstain from even moderate ethanol use, as this may adversely affect their clinical course and response to treatment.
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Affiliation(s)
- R Castaneda
- Department of Psychiatry, New York University School of Medicine, Bellevue Hospital Medical Center, New York 10016, USA
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Estruch R, Bono G, Laine P, Antunez E, Petrucci A, Morocutti C, Hillbom M. Brain imaging in alcoholism. Eur J Neurol 1998; 5:119-135. [PMID: 10210823 DOI: 10.1046/j.1468-1331.1998.520119.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Copyright Rapid Science Ltd
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Affiliation(s)
- R Estruch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
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46
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Abstract
The ever greater emphasis on the application of a standard work-up in the clinical diagnosis of dementia -- and Alzheimer's Disease (AD) in particular -- has made it easier to identify potentially treatable and/or reversible cases. The aim of this paper is to update the issue of treatable and reversible dementias.
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Affiliation(s)
- C Piccini
- Department of Neurological and Psychiatric Sciences, University of Florence, Policlinico di Careggi, Italy
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Cullen KM, Halliday GM, Caine D, Kril JJ. The nucleus basalis (Ch4) in the alcoholic Wernicke-Korsakoff syndrome: reduced cell number in both amnesic and non-amnesic patients. J Neurol Neurosurg Psychiatry 1997; 63:315-20. [PMID: 9328247 PMCID: PMC2169687 DOI: 10.1136/jnnp.63.3.315] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The cholinergic nucleus basalis (Ch4) is an exclusive site of neurofibrillary degeneration in alcoholic patients with Wernicke's encephalopathy. AIM To test the hypothesis that the loss of Ch4 neurons contributes to the memory disorder, Korsakoff's psychosis, commonly seen in Wernicke's encephalopathy. METHODS Magnocellular basal forebrain neurons were quantified in alcoholic patients with Wernicke's encephalopathy, both with and without Korsakoff's psychosis, and neurologically asymptomatic alcoholic and non-alcoholic controls. Because amnesic and non-amnesic patients with Wernicke's encephalopathy share common periventricular lesions, both thiamine deficient groups as well as alcoholic patients with no neurological complications were included to determine the lesion specific to memory impairment. RESULTS Ch4 cell number did not differ significantly between alcoholic and non-alcoholic controls and there was no correlation between cell number and lifetime alcohol intake. However, Ch4 cell number in all groups was significantly correlated with the volume of its major projection target, the cerebral cortex. Ch4 cell number in the non-amnesic Wernicke's encephalopathy group was significantly below controls (24%), with cell number in patients with Korsakoff's psychosis 21% below controls. There was considerable overlap in cell number between groups. On discriminant analysis, there was significantly greater cell loss in three non-amnesic patients with Wernicke's encephalopathy than in some patients with Korsakoff's psychosis. The nonamnesic patient with the greatest cell loss was impaired on attentional tasks. CONCLUSION Whereas neurons in the nucleus basalis are at risk in thiamine deficient alcoholic patients, cell loss is minor and does not account for the profound memory disorder.
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Affiliation(s)
- K M Cullen
- Department of Pathology, The University of Sydney, NSW, Australia
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Tobita M, Mochizuki H, Takahashi S, Onodera H, Itoyama Y, Iwasaki Y. A case of Marchiafava-Bignami disease with complete recovery: sequential imaging documenting improvement of callosal lesions. TOHOKU J EXP MED 1997; 182:175-9. [PMID: 9261936 DOI: 10.1620/tjem.182.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Serial CT and MR imaging findings in a 44-year-old woman with Marchiafava-Bignami disease (MBD) are reported. In the acute stage, CT studies disclosed subtle hypodensity in the splenium, and T2-weighted MR images revealed apparent high signal intensity of the splenium and the central portion of the corpus callosum. Treatment with vitamin B complex resulted in complete recovery. T2-weighted MR images obtained three weeks after admission revealed dramatic resolution of imaging abnormalities, with only faint high signal intensity remaining in the splenium. The sequential changes observed on CT and MR images provided early diagnosis of MBD and the resolution of the lesion considered as brain edema, which suggested that edema might, in addition to demyelination or necrosis, be involved in the acute progression of MBD.
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Affiliation(s)
- M Tobita
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan
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Caine D, Halliday GM, Kril JJ, Harper CG. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. J Neurol Neurosurg Psychiatry 1997; 62:51-60. [PMID: 9010400 PMCID: PMC486695 DOI: 10.1136/jnnp.62.1.51] [Citation(s) in RCA: 286] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To establish better operational criteria for the diagnosis of Wernicke's encephalopathy. Current criteria for diagnosing Wernicke's encephalopathy require the presence of three clinical signs (oculomotor abnormalities, cerebellar dysfunction, and an altered mental state), although it has often been reported that most patients do not fulfil all these criteria. METHODS The clinical histories of 28 alcoholics with neurological and neuropsychological assessments and definitive neuropathological diagnoses were examined to determine clinical signs for use in a screening schedule. Operational criteria were then proposed for differentiating patients with Wernicke's encephalopathy alone or in combination with Korsakoff's psychosis or hepatic encephalopathy. The new criteria for Wernicke's encephalopathy require two of the following four signs; (1) dietary deficiencies, (2) oculomotor abnormalities, (3) cerebellar dysfunction, and (4) either an altered mental state or mild memory impairment. Reproducibility and validity testing of these criteria were performed on 106 alcoholics screened from a large necropsy sample. RESULTS Despite rater variability with regard to specific symptoms, within and between rater reliability for diagnostic classification using the criteria retrospectively on patient records was 100% for three independent raters. Validity testing showed that Wernicke's encephalopathy was underrecognized only when occurring with hepatic encephalopathy (50% sensitivity). CONCLUSIONS By contrast with current criteria, the proposed operational criteria show that the antemortem identification of Wernicke's encephalopathy can be achieved with a high degree of specificity.
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Affiliation(s)
- D Caine
- Neuropsychology Unit, Royal Prince Alfred Hospital, Camperdown, Australia
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