Aging, abstinence, and medical risk factors in the prediction of neuropsychologic deficit among long-term alcoholics

Visuoperceptive Impairments in Severe Alcohol Use Disorder: A Critical Review of Behavioral Studies

The present literature review is aimed at offering a comprehensive and critical view of behavioral data collected during the past seventy years concerning visuoperception in severe alcohol use disorders (AUD). To pave the way for a renewal of research and clinical approaches in this very little understood field, this paper (1) provides a critical review of previous behavioral studies exploring visuoperceptive processing in severe AUD, (2) identifies the alcohol-related parameters and demographic factors that influence the deficits, and (3) addresses the limitations of this literature and their implications for current clinical strategies. By doing so, this review highlights the presence of visuoperceptive deficits but also shows how the lack of in-depth studies exploring the visual system in this clinical population results in the current absence of integration of these deficits in the dominant models of vision. Given the predominance of vision in everyday life, we stress the need to better delineate the extent, the specificity, and the actual implications of the deficits for severe AUD.

Alcohol use disorders in elderly people: fact or fiction?

The number of older people is increasing in populations throughout the world. Alcohol use disorders in elderly people are a common but underrecognised problem associated with major physical and psychological health problems. Owing to the negative attitudes and inadequate training of healthcare professionals, alcohol misuse is not always being detected or effectively treated. Current diagnostic criteria and common screening instruments for alcohol use disorders may not be appropriate for elderly people. Older people are as likely to benefit from treatment as younger people and the basic principles of treatment are much the same. Better integrated and outreach services are needed. Training of healthcare professionals in this area and pragmatic research should be prioritised to improve detection, treatment and service provision for this vulnerable and neglected population.

Brain derived neurotrophic factor and cognitive status: the delicate balance among people living with HIV, with and without alcohol abuse

INTRODUCTION

The advent of combination antiretroviral therapy(cART) has lead to a significant reduction in morbidity and mortality among people living with HIV(PLWH). However, HIV-associated neurocognitive disorders (HAND) still remain a significant problem. One possible mechanism for the persistence of these disorders is through the effect of HIV on brain-derived neurotrophic factor (BDNF). BDNF is influenced by various factors including hazardous alcohol use (HAU), which is prevalent among PLWH. This study attempts to elucidate the relationships between HAU, BDNF and HAND.

METHODS

Cross-sectional analyses were conducted on a sample of 199 hazardous alcohol users and 198 non-HAU living with HIV. Members of each group were matched according to sociodemographic characteristics and CD4 count. Research procedures included validated questionnaires, neuropsychological assessments and a blood sample to obtain BDNF and immune measurements.

RESULTS

Hazardous alcohol users showed either significantly lower or significantly higher BDNF levels compared to the Non-hazardous (OR=1,4; 95% CI: 1-2.1, p = 0.003). Therefore, for additional analyses, subjects were categorized based on BDNF values in: Group 1 < 4000, Group 2: 4001-7,999 (reference group), and Group 3 for those >8,000 pg/mL. Groups 1 and 3 performed significantly worse than those in Group 2 in the domains of processing speed, auditory-verbal and visuospatial learning and memory. Multivariate analyses confirmed that HAU and BDNF are significant contributors of HAND.

CONCLUSION

Our findings offer novel insights into the relationships between BDNF, and alcohol use among PLWH. Our results also lend support to expanding clinical movement to use BDNF as an intervention target for PLWH, in those with evidence of deficiencies, and highlight the importance of including HAUat the inception of clinical trials.

Greater executive and visual memory dysfunction in comorbid bipolar disorder and substance use disorder

Measures of cognitive dysfunction in Bipolar Disorder (BD) have identified state and trait dependent metrics. An influence of substance abuse (SUD) on BD has been suggested. This study investigates potential differential, additive, or interactive cognitive dysfunction in bipolar patients with or without a history of SUD. Two hundred fifty-six individuals with BD, 98 without SUD and 158 with SUD, and 97 Healthy Controls (HC) completed diagnostic interviews, neuropsychological testing, and symptom severity scales. The BD groups exhibited poorer performance than the HC group on most cognitive factors. The BD with SUD exhibited significantly poorer performance than BD without SUD in visual memory and conceptual reasoning/set-shifting. In addition, a significant interaction effect between substance use and depressive symptoms was found for auditory memory and emotion processing. BD patients with a history of SUD demonstrated worse visual memory and conceptual reasoning skills above and beyond the dysfunction observed in these domains among individuals with BD without SUD, suggesting greater impact on integrative, gestalt-driven processing domains. Future research might address longitudinal outcome as a function of BD, SUD, and combined BD/SUD to evaluate neural systems involved in risk for, and effects of, these illnesses.

Callosal white matter microstructural recovery in abstinent alcoholics: a longitudinal diffusion tensor imaging study

BACKGROUND

Previous neuroimaging studies of recently detoxified alcohol-dependent patients (RDA) have found significant loss of white matter integrity associated with the shrinkage of the frontal lobes and thinning of the corpus callosum, especially the genu. The current study hypothesized that, in addition to exhibiting the most microstructural white matter disruption in RDA, the genu will also evidence the most recovery after abstinence. This microstructural recovery will be associated with improvements in executive functioning measures.

METHODS

Fifteen RDA were examined approximately 2 weeks after abstinence and again after 1 year of abstinence and compared to 15 age- and education-matched nonalcoholic controls using diffusion tensor imaging (DTI). The effects of group, time, and their interactions on fractional anisotropy, radial diffusivity, and axial diffusivity were evaluated with repeated measures MANOVA; in addition, 2 × 2 ANOVA was used to test changes in measures of executive functioning in the 2 groups.

RESULTS

At 2 weeks of abstinence, DTI of RDA showed significantly lower fractional anisotropy and greater radial diffusivity compared to controls in the genu and body of the corpus callosum. Reexamination after 1 year showed significant time by group interaction with fractional anisotropy increasing and radial diffusivity decreasing in RDA but not controls in these 2 regions. A smaller relapsed group did not show improvements between the 2 time points. Abstinent RDA also showed improvement on Digit Span Backward, a measure of working memory, but did not benefit from practice effects on the Halstead Category Test compared to controls.

CONCLUSIONS

The results suggest susceptibility of the genu and body of the corpus callosum to the effects of alcohol, and the potential for recovery of both these regions after abstinence, perhaps via mechanisms involving myelin reconstitution.

Cognitive changes in topiramate-treated patients with alcoholism: a 12-week prospective study in patients recently detoxified

AIMS

The aim of this study was to determine the 12-week cognitive changes in topiramate-treated patients recently detoxified from alcohol.

METHODS

Participants were inpatients with DSM-IV alcohol dependence. All of them were discharged within 14 days after the initiation of topiramate treatment. The topiramate dose range was 50-300 mg/day. The Montreal Cognitive Assessment (MoCA) was used on day 0, day 29, day 57, and day 85. Differences of the MoCA total and seven subtest scores among four time-points were compared.

RESULTS

Thirty-eight participants (36 men and two women) had a mean ± SD age of 43.1 ± 8.6 years old. At enrollment, they were abstinent for a mean ± SD of 11.5 ± 5.3 days. Five, one, and three patients dropped out of the study on day 29, day 57, and day 85, respectively. On day 85, the mean ± SD dose of topiramate was 253.1 ± 60.8 mg/day. Alcohol consumption decreased drastically during follow up. At each time-point, 75%-80% of the participants were continuous abstainers. The mean ± SD MoCA total, language subtest, and delayed recall subtest scores increased significantly from day 0 to day 85, from 22.0 ± 4.7 to 24.7 ± 3.4 (P < 0.01), from 1.1 ± 1.0 to 1.3 ± 1.0 (P = 0.03), and from 2.7 ± 1.7 to 4.1 ± 1.0 (P < 0.01), respectively.

CONCLUSION

Topiramate-treated patients recently detoxified from alcohol usually have an improvement of their cognitive function, especially in the language and delayed recall domains. This phenomenon may be caused by the greater influence of cognitive recovery associated with decreased drinking as compared with topiramate-induced cognitive impairment.

Widespread and sustained cognitive deficits in alcoholism: a meta-analysis

The cognitive repercussions of alcohol dependence are well documented. However, the literature remains somewhat ambiguous with respect to which distinct cognitive functions are more susceptible to impairment in alcoholism and to how duration of abstinence affects cognitive recovery. Some theories claim alcohol negatively affects specific cognitive functions, while others assert that deficits are more diffuse in nature. This is the first meta-analysis to examine cognition in alcohol abuse/dependence and the duration of abstinence necessary to achieve cognitive recovery. A literature search yielded 62 studies that assessed cognitive dysfunction among alcoholics. Effect size estimates were calculated using the Comprehensive Meta-Analysis V2, for the following 12 cognitive domains: intelligence quotient, verbal fluency/language, speed of processing, working memory, attention, problem solving/executive functions, inhibition/impulsivity, verbal learning, verbal memory, visual learning, visual memory and visuospatial abilities. Within these 12 domains, three effect size estimates were calculated based on abstinence duration. The three groups were partitioned into short- (< 1 month), intermediate- (2 to 12 months) and long- (> 1 year) term abstinence. Findings revealed moderate impairment across 11 cognitive domains during short-term abstinence, with moderate impairment across 10 domains during intermediate term abstinence. Small effect size estimates were found for long-term abstinence. These results suggest significant impairment across multiple cognitive functions remains stable during the first year of abstinence from alcohol. Generally, dysfunction abates by 1 year of sobriety. These findings support the diffuse brain hypothesis and suggest that cognitive dysfunction may linger for up to an average of 1 year post-detoxification from alcohol.

Similar profile of cognitive impairment and recovery for Aboriginal Australians in treatment for episodic or chronic alcohol use

AIMS

The cognitive impairment and recovery associated with chronic alcohol abuse and subsequent abstinence is well understood. However, the recovery profile following heavy episodic or 'binge' use, which is common among some Australian Aboriginal users, has not been investigated thoroughly and no empirical studies have examined chronic use in this population. The aim of this study was to identify and compare cognitive impairment and recovery associated with chronic and episodic alcohol use among Aboriginal Australians.

DESIGN

Longitudinal case-control design.

SETTING

Residential alcohol treatment programmes in northern Australia.

PARTICIPANTS

Forty chronic alcohol users, 24 episodic users and 41 healthy controls [mean age = 34.24; standard deviation (SD) = 9.73].

MEASUREMENTS

Cognitive assessments of visual motor, attention, memory, learning and executive functions at baseline (start of treatment), then 4 weeks and 8 weeks later. Reassessment of 31% of participants an average of 11 months later (SD = 4.4) comparing those who remained abstinent (n = 5), those who relapsed (n = 11) and healthy controls (n = 19).

FINDINGS

At baseline, chronic and episodic alcohol users showed impaired visual motor, learning, memory and executive functions. With the exception of visual motor impairment, all deficits had improved to normal levels within 4 weeks. Visual motor deficits had normalized within 11 months. Performances did not differ at any time between chronic and episodic alcohol groups.

CONCLUSIONS

In Aboriginal Australians, episodic drinking is associated with similar patterns of impairment and recovery as chronic alcohol use. Most cognitive deficits appear to recover within the first month of abstinence, while persisting visual motor problems recover within 1 year.

Effects of alcoholism severity and smoking on executive neurocognitive function

AIMS

Neurocognitive deficits in chronic alcoholic men are well documented. Impairments include memory, visual-spatial processing, problem solving and executive function. The cause of impairment could include direct effects of alcohol toxicity, pre-existing cognitive deficits that predispose towards substance abuse, comorbid psychiatric disorders and abuse of substances other than alcohol. Cigarette smoking occurs at higher rates in alcoholism and has been linked to poor cognitive performance, yet the effects of smoking on cognitive function in alcoholism are often ignored. We examined whether chronic alcoholism and chronic smoking have effects on executive function.

METHODS

Alcoholism and smoking were examined in a community-recruited sample of alcoholic and non-alcoholic men (n = 240) using standard neuropsychological and reaction-time measures of executive function. Alcoholism was measured as the average level of alcoholism diagnoses across the study duration (12 years). Smoking was measured in pack-years.

RESULTS

Both alcoholism and smoking were correlated negatively with a composite executive function score. For component measures, alcoholism was correlated negatively with a broad range of measures, whereas smoking was correlated negatively with measures that emphasize response speed. In regression analyses, both smoking and alcoholism were significant predictors of executive function composite. However, when IQ is included in the regression analyses, alcoholism severity is no longer significant.

CONCLUSIONS

Both smoking and alcoholism were related to executive function. However, the effect of alcoholism was not independent of IQ, suggesting a generalized effect, perhaps affecting a wide range of cognitive abilities of which executive function is a component. On the other hand, the effect of smoking on measures relying on response speed were independent of IQ, suggesting a more specific processing speed deficit associated with chronic smoking.

The effect of 12-week open-label memantine treatment on cognitive function improvement in patients with alcohol-related dementia

There is compelling evidence that alcohol-induced neurotoxicity is related to glutamate excitotoxicity. It was hypothesized that the low-affinity NMDA receptor antagonist memantine would improve the cognitive function of patients with alcoholic dementia. The aim of this study was to test this hypothesis and to evaluate the effect of memantine on the cognitive improvement of patients with alcohol-related dementia (ARD). The study was designed as a 12-wk open-label study investigating the efficacy of 20 mg memantine, a low-affinity NMDA receptor antagonist, as a treatment for cognitive and behavioural problems in 19 patients with probable ARD according to the criteria for ARD proposed by Oslin and colleagues. The CERAD-K (Consortium to Establish a Registry for Alzheimer's Disease - Korean version) and several clinical assessment scales were completed before and after the 12-wk memantine treatment period. Significant improvements in the mean scores from baseline to final assessment were observed in the Global Deterioration Scale (p<0.05), Brief Psychiatric Rating Scale (p<0.01), Geriatric Quality of Life - Dementia scale (p<0.01) and Neuropsychiatric Inventory (p<0.01) at the end of week 12. The CERAD-K subscales of word list recall (p<0.05), word list recognition (p<0.05), time orientation (p<0.01), drawing an interlocking pentagon (p<0.05), and the total MMSE-K (Mini Mental State Examination - Korean version) scores (p<0.01) of the patients all showed significant improvement following the memantine trial. In this open-label study, patients with ARD treated with 20 mg/d memantine for 12 wk showed improvement on global cognition, quality of life and behavioural symptoms. The result of this study suggests the possible usefulness of memantine for the treatment of ARD. As this was an open-label study, the possibility that participants improved cognitively on their own due to protracted abstinence from alcohol cannot be discounted.

The relationships of sociodemographic factors, medical, psychiatric, and substance-misuse co-morbidities to neurocognition in short-term abstinent alcohol-dependent individuals

Co-morbidities that commonly accompany those afflicted with an alcohol use disorder (AUD) may promote variability in the pattern and magnitude of neurocognitive abnormalities demonstrated. The goal of this study was to investigate the influence of several common co-morbid medical conditions (primarily hypertension and hepatitis C), psychiatric (primarily unipolar mood and anxiety disorders), and substance use (primarily psychostimulant and cannabis) disorders, and chronic cigarette smoking on the neurocognitive functioning in short-term abstinent, treatment-seeking individuals with AUD. Seventy-five alcohol-dependent participants (ALC; 51+/-9 years of age; three females) completed comprehensive neurocognitive testing after approximately 1 month of abstinence. Multivariate multiple linear regression evaluated the relationships among neurocognitive variables and medical conditions, psychiatric, and substance-use disorders, controlling for sociodemographic factors. Sixty-four percent of ALC had at least one medical, psychiatric, or substance-abuse co-morbidity (excluding smoking). Smoking status (smoker or nonsmoker) and age were significant independent predictors of cognitive efficiency, general intelligence, postural stability, processing speed, and visuospatial memory after age-normed adjustment and control for estimated pre-morbid verbal intelligence, education, alcohol consumption, and medical, psychiatric, and substance-misuse co-morbidities. Results indicated that chronic smoking accounted for a significant portion of the variance in the neurocognitive performance of this middle-aged AUD cohort. The age-related findings for ALC suggest that alcohol dependence, per se, was associated with diminished neurocognitive functioning with increasing age. The study of participants who demonstrate common co-morbidities observed in AUD is necessary to fully understand how AUD, as a clinical syndrome, affects neurocognition, brain neurobiology, and their changes with extended abstinence.

Improvement in memory and static balance with abstinence in alcoholic men and women: selective relations with change in brain structure

We investigated whether changes in memory or static balance in chronic alcoholics, occurring with abstinence or relapse, are associated with changes in lateral and fourth ventricular volume. Alcoholics meeting DSM-IV criteria for Alcohol Dependence (n=15) and non-alcoholic controls (n=26) were examined twice at a mean interval of 2 years with standard Wechsler Abbreviated Scale of Intelligence (WASI), Wechsler Memory Scale-Revised (WMS-R) tests, an ataxia battery, and structural MRI. At study entry, alcoholics had been abstinent on average for over 4 months and achieved lower scores than controls on WASI General IQ Index, WMS-R General Memory Index, and the ataxia battery. The 10 alcoholics who maintained sobriety at retest did not differ at study entry in socio-demographic measures, alcohol use, or WASI and WMS-R summary scores from the five relapsers. At follow-up, abstainers improved more than controls on the WMS-R General Memory Index. Ataxia tended to improve in abstainers relative to controls. Associations were observed between memory and lateral ventricular volume change and between ataxia and fourth ventricular volume change in alcoholics but not in the controls. Both memory and ataxia can improve with sustained sobriety, and brain-behavior associations suggest selective brain structural substrates for the changes observed.

Neuropsychological and sensory gating deficits related to remote alcohol abuse history in schizophrenia

Recent evidence suggests that changes in brain structure associated with alcohol abuse are compounded in individuals dually diagnosed with alcohol abuse and schizophrenia. To investigate the separate, and possibly interacting, effects of these diagnoses, an event-related brain potential (ERP) measure of auditory information processing (P50 sensory gating paradigm) and neuropsychological measures were administered to healthy control participants with either (1a) no history of alcohol abuse/dependence, or (1b) a remote history of alcohol abuse/dependence, and patients with schizophrenia with either (2a) no history of alcohol abuse/dependence, or (2b) a remote history of alcohol abuse/dependence. Schizophrenia was associated with impaired P50 sensory gating and poorer performance across neuropsychological scores compared to measurements in healthy control participants. Those with a positive alcohol history had impaired gating ratios in contrast to those with a negative alcohol history. There were additive effects of schizophrenia diagnosis and alcohol history for P50 sensory gating and for neuropsychological scores: attention, working memory, and behavioral inhibition. For executive attention and general memory there was an interaction, suggesting that the combination of schizophrenia and history of alcohol abuse results in greater impairment than that predicted by the presence of either diagnosis alone.

Consistency of retrospective reports of DSM-IV criterion A traumatic stressors among substance use disorder patients

Posttraumatic stress disorder (PTSD) is prevalent among substance use disorder (SUD) patients. Although Criterion A trauma is critical to the formulation of a PTSD diagnosis, little research has examined the reliability of retrospective reports of such stressors and factors that affect reporting among these patients. This study examined these issues among SUD patients. Participants (N = 120) were assessed by interviews and questionnaires after entering inpatient SUD treatment and at a 6-month follow-up. About 40% of participants met criteria for a current PTSD diagnosis. Results revealed moderate stability of Criterion A trauma reports, which improved when Criterion A requirements were relaxed (i.e., participants were required to report the stressor but not the Criteria A1 and A2). Intrusive symptoms were associated with increased stressor reporting over time, whereas numbing symptoms and SUD abstinence were associated with decreased stressor reporting over time. Dissociative symptoms were associated with changes in reporting in either direction.

Binge drinking and sex: effects on mood and cognitive function in healthy young volunteers

This study compared the mood and cognitive performance of male and female teetotal and binge drinking students. The binge drinkers had significantly lower self-ratings of trait anxiety and depression and of state alertness at the time of testing than did the teetotallers. The females had significantly higher ratings of trait and state anxiety, but there were no Sex x Bingeing interactions on mood. The binge drinkers made significantly fewer correct responses in a test of sustained attention and recalled fewer line drawings. There was a significant Sex x Binge interaction in a spatial recognition task because the male, but not the female, binge drinkers were slower to make correct responses. Males performed better than females in both the spatial and pattern recognition memory tasks. There were three tests of executive function. In a spatial working memory task, males performed better than females, but there were no effects of binge drinking. There were no effects in a test of mental flexibility. However, in a test of planning, the binge drinkers were significantly slower than the teetotallers were. Thus, compared with a group of teetotallers, the binge drinkers had lower trait anxiety and depression and poorer performance in tests of sustained attention, episodic memory and planning ability.

Heavy alcohol consumption in individuals with HIV infection: effects on neuropsychological performance

Higher rates of alcohol use have been reported in HIV+ individuals compared to the general population. Both heavy alcohol use and HIV infection are associated with increased risk of neuropsychological (NP) impairment. We examined effects of heavy active alcohol use and HIV on NP functioning in a large sample of community-residing HIV+ individuals and HIV- controls. The four main study groups included 72 HIV- light/non-drinkers, 70 HIV- heavy drinkers (>100 drinks per month), 70 HIV+ light/non-drinkers, and 56 HIV+ heavy drinkers. The heavy drinking group was further subdivided to assess effects of the heaviest levels of active alcohol use (>6 drinks per day) on NP functioning. A comprehensive NP battery was administered. Multivariate analysis of covariance was employed to examine the effect of HIV and alcohol on NP functioning after adjusting for group differences in age and estimated premorbid verbal intellectual functioning. The analyses identified main effects of heavy drinking and HIV on NP function, with greatest effects involving the contrast of HIV+ heavy drinkers and the HIV- light drinkers. Synergistic effects of heaviest current drinking and HIV infection were identified in analyses of motor and visuomotor speed. Supplementary analyses also revealed better NP function in the HIV+ group with antiretroviral treatment (ART) and lower level of viral burden, a finding that was consistent across levels of alcohol consumption. Finally, heavy alcohol use and executive functioning difficulties were associated with lower levels of self-reported medication adherence in the HIV+ group. The findings suggest that active heavy alcohol use and HIV infection have additive adverse effects on NP function, that they may show synergistic effects in circumstances of very heavy active alcohol use, and that heavy drinking and executive functioning may mediate health-related behaviors in HIV disease.

Recovery of Short-Term Memory and Psychomotor Speed but Not Postural Stability With Long-Term Sobriety in Alcoholic Women

The authors assessed effects of extended abstinence on cognitive and motor function deficits previously observed in a group of alcoholic women (n = 43) initially tested after 15 weeks of sobriety. Alcoholic women were retested 1 and 4 years later, and control women were retested 3 years later. At Year 1, 14 of 23 returners had maintained sobriety, but they did not perform significantly better than relapsers; the group as a whole continued to show deficits relative to age norms. By Year 4, 13 of 14 returners had maintained sobriety for more than 30 months; as a group, these women had returned to normal levels on tests of memory and psychomotor speed but remained impaired in standing balance.

A profile of neuropsychological deficits in alcoholic women

Neuropsychological deficits, most notable in executive, visuospatial, and functions of gait and balance, are detectable in alcoholic men even after a month of sobriety. Less well established are the severity and profile of persisting deficits in alcoholic women. The authors used an extensive test battery to examine cognitive and motor functions in 43 alcoholic women who were sober, on average, for 3.6 months. Functions most severely affected in alcoholic women involved visuospatial and verbal and nonverbal working memory processes as well as gait and balance. Areas of relative sparing were executive functions, declarative memory, and upper-limb strength and speed. The authors found that lifetime alcohol consumption was related to impairment severity on Block Design (Wechsler Adult Intelligence Scale-Revised, D. Wechsler, 1981) and verbal and nonverbal working memory, suggesting a dose effect of alcohol abuse. The alcohol-related deficits in working memory, visuospatial, and balance implicate disruption of prefrontal, superior parietal, and cerebellar brain systems.

Alcohol related dementia: proposed clinical criteria

Current diagnostic criteria for Alcohol Related Dementia (ARD) are based almost exclusively on clinical judgment. Moreover, there are no guidelines available to assist the clinician or the researcher in distinguishing Alcohol Related Dementia from other causes of dementia such as Alzheimer's Disease (AD). However, this distinction may have implications for the prognosis and treatment of patients. In this article, provisional diagnostic criteria for establishing a diagnosis of Alcohol Related Dementia are proposed for further study. The criteria are based on the available literature on the relationship between alcohol consumption and dementia and were modeled after existing diagnostic criteria for AD and Vascular Dementia. Validity of these criteria for distinguishing AD from ARD will require further study.

Screening Cognitive Impairment in Alcohol Abusers

1. Studies have reported various neuropsychological abnormalities in people with excessive drinking patterns and associated problems with the assessment and treatment of this group. 2. The aim of this study was to assess the potential of a screening instrument to help detect the presence of cognitive impairment in excessive alcohol users undergoing detoxification. 3. The Memory Screening Test has potential as a screening instrument to assess clients' cognitive ability to benefit from psychoeducational material.

Effects of abstinence and relapse upon neuropsychological function and cerebral glucose metabolism in severe chronic alcoholism

Prolonged excessive consumption of alcohol has been associated with a variety of cognitive disorders accompanied by neuropathological and neurochemical abnormalities of the brain, particularly in the frontal lobes. Studies with positron emission tomography (PET) have shown decreased local cerebral metabolic rates for glucose (lCMRglc) in frontal regions, with correlated abnormalities on neuropsychological tests sensitive to executive functioning. This investigation was designed as a pilot study to examine the effects of abstinence and relapse in patients with severe chronic alcoholism studied longitudinally with PET and with neuropsychological evaluation to assess both general and executive functioning. Six patients, including 4 who remained relatively abstinent and 2 who relapsed following their initial evaluation, were studied twice, with inter-evaluation intervals ranging from 10 to 32 months. The patients who remained abstinent or who had minimal alcohol use showed partial recovery of lCMRglc in two of three divisions of the frontal lobes and improvement on neuropsychological tests of general cognitive and executive functioning, whereas the patients who relapsed had further declines in these areas. These results, although based upon a relatively small number of subjects, provide preliminary support for at least partial recovery of metabolic and cognitive functioning in individual patients who abstain from alcohol.

Frontal lobe volume loss observed with magnetic resonance imaging in older chronic alcoholics

This study used magnetic resonance imaging to quantify the extent and pattern of tissue volume deficit and cerebrospinal fluid volume enlargement in younger versus older chronic alcoholics relative to normal controls. In the present analysis, we divided our previously reported group of 62 alcoholic men into a younger group (n = 33, age mean = 37.5 +/- 4.5, and range = 26 to 44 years) and an older group (n = 29, age mean = 52.7 +/- 6.0, and range = 45 to 63 years) to examine whether, in addition to extent, the two age groups differed in pattern of tissue type and regional brain volume abnormalities quantified with magnetic resonance imaging. Brain volumes were adjusted for normal variation in head size and age established from a group of healthy controls and were expressed as Z-scores. The younger group had significant cortical gray, but not white, matter volume deficits and sulcal and ventricular enlargement relative to age-matched controls. The older group had volume deficits in both cortical gray and white matter and sulcal and ventricular enlargement that significantly exceeded the younger alcoholic group. An analysis of six cortical regions revealed that, although both age groups had gray matter volume deficits throughout the cortex, the older alcoholic group had a selectively more severe deficit in prefrontal gray matter relative to the younger alcoholic group. Similarly, the cortical white matter volume deficit in the older alcoholics was especially severe in the prefrontal and frontal regions. The differences in brain dysmorphology between the two alcoholic groups cannot easily be attributed to potential alcohol history differences typically related to age because the two groups had similar disease durations and amounts of lifetime alcohol consumption. These results provide in vivo evidence that the frontal lobes are especially vulnerable to chronic alcoholism in older men.

Intermanual differences on motor and psychomotor tests in alcoholics: no evidence for selective right-hemisphere dysfunction

Some previous studies have suggested that alcoholics exhibit selective right-hemisphere dysfunction, based on alcoholics' poor performance on tests believed to subserve the right hemisphere. However, some of these experiments did not account adequately for differences in difficulty or novelty in putative right hemisphere tasks. This experiment was designed to evaluate and compare intermanual differences in grip strength, motor speed, fine-motor dexterity, and nonverbal problem-solving ability in 93 recently detoxified alcoholics, 54 long-term abstinent alcoholics, and 73 nonalcoholic controls. All subjects were right-handed men, matched for age and education, and both alcoholic groups had similar drinking histories. Using percent difference scores to assess intermanual differences, adjusted for demographics where appropriate, we found that, although recently detoxified alcoholics demonstrate some motor and psychomotor impairments, there is no evidence using these tests to suggest the right hemisphere is selectively more vulnerable to the effects of chronic alcohol abuse.

Single photon emission computed tomography with iodoamphetamine-123 and neuropsychological studies in long-term abstinent alcoholics

Ten long-term abstinent alcoholics (mean abstinence = 7.7 years) were compared with 13 recently detoxified substance-dependent inpatients (mean abstinence = 25 days) and 8 nonalcoholic control subjects on global end regional measures of cortical cerebral blood flow (CBF), and on neuropsychological measures. CBF was assessed using 123iodoamphetamine (IMP) single photon emission computed tomography (SPECT) under conditions of behavioral challenge (Raven's Progressive Matrices). CBF and neuropsychological test performance were worse in the recently detoxified inpatients. Of greater interest, there was a dissociation in the long-term abstinent group, which, while neuropsychologically indistinguishable from controls, showed significantly decreased mean cortical IMP uptake. We conclude that there may be persistent physiologic abnormalities in long-term abstinent alcoholics who have achieved full behavioral recovery. Smoking on the day of SPECT scanning was also identified to be a significant confound to understanding CBF changes in alcoholism.

Brain atrophy and cognitive function in older abstinent alcoholic men

We used computer-aided magnetic resonance image analysis and an age-normed battery of neuropsychological tests to measure brain atrophy and cognitive function in 14 older abstinent alcoholic men and 11 older controls in the expectation that these subject groups would show the greatest and most persistent cerebral effects consequent to chronic alcoholism. The abstinent alcoholics exhibited cognitive impairments (primarily in memory and visual-spatial-motor skills) compared with the controls. In contrast, we found no difference in global cerebral atrophy between the groups, although two alcoholics had extensive atrophy compared with all other subjects. However, there was a stronger association between age and ventricular dilation in the alcoholic sample compared with controls. We conclude that a substrate other than magnetic resonance imaging-detectable global atrophy must underlie the persistent cognitive impairments evident in the sampled alcoholics. Furthermore, if there are global atrophic changes in the brain associated with chronic alcoholism, these effects are not ubiquitous and/or may be reversible in most patients with sufficient abstinence.

Alcoholic dementia

At least four distinct cerebral diseases--Wernicke-Korsakoff, Marchiafava-Bignami, pellagrous encephalopathy, and acquired hepatocerebral degeneration--have a close association with chronic alcoholism. Each is characterized by a distinctive pathologic change and a reasonably well-established pathogenesis; in each the role of alcohol in the causation is secondary. The question posed in this review is whether there is, in addition to the established types of dementia associated with alcoholism, a persistent dementia attributable to the direct toxic effects of alcohol on the brain--i.e., a primary alcoholic dementia. The clinical, psychologic, radiologic, and pathologic evidence bearing on this question is critically reviewed. None of the evidence permits the clear delineation of such an entity. The most serious flaw in the argument for a primary alcoholic dementia is that it lacks a distinctive, well-defined pathology, and it must remain ambiguous until such time as its morphologic basis is established.

Discriminating neuropsychological sequelae of head injury from alcohol-abuse-induced deficits: a review and analysis

Alcohol abuse is linked strongly with neuropsychological deficits that may resemble deficits seen in head-injured individuals. Heavy daily drinking appears more damaging than episodic abusive consumption. Cognitive deficits associated with alcohol include abstraction, perceptuospatial, and problem-solving skills. Verbal abilities are spared. For alcoholics younger than 40, abstinence is associated with improved functioning. For those over 40, deficits may be permanent. Intelligence tests are unlikely to pick up alcohol-induced deficits. Points for neuropsychologists to consider in differentiating between head injury and alcohol-induced deficits include abstinence from drinking prior to testing, intactness of remote memory and verbal functions, and changes in tolerance for alcohol.

Neuropsychological deficits are correlated with frontal hypometabolism in positron emission tomography studies of older alcoholic patients

In an extension of previous work, we studied the behavioral correlates of medial frontal lobe glucose hypometabolism in chronically alcohol-dependent patients. Thirty-one male patients who were detoxified, medically stable, and free of other central nervous system risk factors for neuropsychological impairment were examined with (1) anatomic imaging (CT or MR), (2) functional imaging with [18F] fluorodeoxyglucose (18F-FDG) and positron emission tomography (PET), and (3) a battery of neuropsychological tests, including two measures of abstraction known to be generally sensitive to frontal lobe disease or dysfunction [the Wisconsin Card Sorting Test (WCST) and the Halstead Category Test (HCT)]. 18F-FDG PET data from 18 age- and sex-matched normal control subjects were used for comparison. All patients met criteria for severe alcohol dependence and for at least a mild degree of alcoholic-induced cognitive impairment. Although the mean IQ level of the alcoholic patients was in the average range, the concepts attained and the error scores on the WCST and HCT were significantly impaired in comparison with established norms. Local cerebral metabolic rate for glucose (LCMRglc) was significantly decreased in a sagittal strip of the medial frontal cortex in the alcoholic patients as compared with the normal controls. Comparison of data from PET scans and anatomic images indicated that the reduced LCMRglc could not be attributed to reduced amounts of tissue alone. A statistically significant relationship was found between LCMRglc in the medial frontal region of the cerebral cortex and performance on the WCST, but not the HCT. These findings suggest that chronic alcohol intake results in impaired function of cerebral tissue in the medial frontal region.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol and the elderly: an overlooked phenomenon in the literature in developing countries-the Israeli case

This paper provides a review and critique of research on Israeli older people's drinking. On the basis of a review of all published Israeli alcohol research, in Hebrew and English, it summarizes the findings concerned with alcohol and ageing in Israel. Research findings on this population are as inadequate in Israeli literature as is the case in other developing countries: this is a reflection of the common lack of interest in the problems of the elderly. In Israel and other developing countries, gerontologists are not interested in alcohol problems, alcohol researchers are not interested in the elderly, and alcohol abuse is not perceived as a problem of ageing. It is suggested that, with the increasing proportion of the population living past 65 years of age, the connections between ageing and alcohol abuse should be explored. Various directions for future research in Israel and other developing countries are suggested.

Alcohol, head injury, and neuropsychological function

Evidence is reviewed indicating that the extent of alcohol abuse alone cannot account for the neuropsychological deficits observed in alcoholics, and that alcohol abuse and head injury may interact in some patients to influence neuropsychological status. Alcohol abuse both increases the risk for head trauma and potentiates the resulting brain injury, which can lead to negative neuropsychological consequences. Clinicians involved in the treatment of addiction should assess patients for history of head injury, and neuropsychological deficits consequent to both head injury and ethanol. These deficits may limit patient ability to comply with addiction rehabilitation programs. Conversely, clinicians in acute care and rehabilitation of the sequelae of head trauma should routinely assess their patients for substance abuse, because such abuse can have a significant impact on recovery from brain injury.

Long-term abstinent alcoholics have normal memory

It is generally believed that many non-Korsakoff alcoholics have subtle defects in memory. To determine whether such defects vary as a function of length of abstinence (LOA), we performed extensive memory testing with: (1) recently detoxified (n = 31; LOA-29 days); (2) intermediate-term abstinent (n = 28; LOA = 1.9 years); (3) long-term abstinent (n = 32; LOA-7.0 years) alcoholics; and (4) nonalcoholic controls (n = 37). All subjects were matched on age and education. Alcoholics were matched on years of alcoholic drinking. Memory measures were divided into the following domains: verbal learning, verbal recall, visual learning, visual recall, and paired associate learning. A series of MANOVAs were conducted that revealed a significant relationship between visual learning and length of abstinence, and a significant interaction between age and length of abstinence on visual recall. Long-term abstinent subjects were not significantly different from controls on any test. We conclude that memory disturbance demonstrable among recently detoxified alcoholics in the early weeks of their abstinence is not evident in demographically matched long-term abstinent alcoholics with similar drinking histories.

Hand movement speed and accuracy in detoxified alcoholics

Detoxified alcoholics (n = 192) were found to be 9.3% slower than age-matched controls (n = 112) with regard to the composite speed (movement time, MT) with which they were able to strike targets of various sizes and distances with a hand-held stylus at onset of a light stimulus (Fitts's Task). Females (n = 102) were 8% slower than males (n = 202), and blacks (n = 103) about 15.6% slower than whites (n = 201). Gender was the only significant factor with regard to errors (target misses), with women committing 28% fewer errors than men. Women, in contrast to men, appear to trade speed for accuracy in this task. Favorable socioeconomic/medical status and target misses were directly related to movement speed. Thus, when the MT data were corrected for lifestyle variables, the significance of the alcohol effects on MT disappeared, but gender differences persisted. The alcohol effect became statistically significant, the ethnic group differences remained statistically significant, and the gender effect became insignificant when MT scores were corrected for accuracy of performance (target misses). The slope of the linear function relating MT to target difficulty was similar for all subgroups. Prior knowledge of the direction of movement was found to affect MT performance more in white than in black subjects. With regard to reaction times, ethnic group and alcohol use effects remained statistically significant after corrections for lifestyle and errors were made, with values for blacks about 5% slower than values for whites, and values for alcoholics about 4.6% slower than those for controls. Prior knowledge of the direction of movement significantly improved (shortened) reaction time in all subgroups (14%-19%).

Cognitive performance of alcoholics: a longitudinal evaluation of the role of drinking history, depression, liver function, nutrition, and family history

To assess the role of drinking history, depression, liver function, nutrition, and family history on cognitive performance, 171 detoxified male alcoholics were administered a brief neuropsychological examination at admission and discharge from an inpatient treatment program and at a 3-month follow-up evaluation. Regression analyses showed that at admission, depression and liver function were significant predictors of neuropsychological performance, whereas at discharge 3 to 4 weeks later only age and an estimate of premorbid intelligence were significant predictors. At the 3-month follow-up, estimates of drinking following discharge and severity of depressive symptoms were major significant predictors of neuropsychological performance. Indices of drinking prior to admission to the treatment program, nutrition, and family history for alcoholism did not predict performance on any of the three test occasions. These findings indicate that in addition to the chronic neurotoxic effect of alcohol a number of different medical and psychiatric factors, as well as the acute effects of alcohol, contribute to the cognitive scores of patients at various points in the clinical course.

Cognitive impairments in early sobriety: nursing interventions

In the United States, more than 100,000 people are treated in inpatient treatment centers for alcoholism and other forms of mind-altering drug addictions. One of the most important elements of this treatment is education about the disease process, recovery, and the effects of the drugs on the body, mind, and spirit. Unfortunately, many alcoholics experience cognitive impairment that may impede their learning in the early weeks of recovery. After briefly describing how cognitive impairment may manifest itself in many alcoholic patients in early recovery, and listing some of the possible causes of this impairment, the authors provide several nursing interventions designed to enhance the learning process in early alcoholic recovery.

Assessment of olfactory deficits in detoxified alcoholics

Olfactory functioning was evaluated in 37 male detoxified alcoholics and in 21 age-matched nonalcoholic controls using the University of Pennsylvania Smell Identification Test (UPSIT). Of the original subjects, 23 alcoholics and 14 controls returned for reevaluation 3-4 months following initial testing. The results showed that alcoholics had significantly lower UPSIT scores than did the controls, both at baseline and follow-up testing. Thirty-two percent of the alcoholics' UPSIT scores, in comparison to five percent of the controls' scores, fell into the clinically impaired range. Although current smoking patterns correlated significantly with UPSIT indices, comparisons limited to nonsmokers still indicated that the alcoholics were significantly impaired on this olfactory task. Correlational analyses indicated that olfactory performance was unrelated to alcoholics' scores on visuoconceptual and language tasks. Correlations with MR-derived indices of CSF volume showed a highly significant relationship between UPSIT scores and cortical sulcal volumes. Additionally, alcoholics (N = 15) who remained abstinent had significantly higher scores at follow-up than those who were not abstinent (N = 8). These findings demonstrate that alcoholism is associated with basic olfactory impairments which are only partially reversible with abstinence and that cortical structures play an important role in this sensory loss.

Videotape versus computer interactive education in alcoholic and nonalcoholic controls

Few studies have evaluated the ability of the alcoholic patient to learn treatment-related information and all have involved conventional educational modalities such as videotape or lecture. Since computer interactive (CI) programs allow for individualization, feedback, and active learning, we were interested in determining whether CI would prove to be a more effective educational/treatment modality for male alcoholic patients than the conventional videotape (V) modality. The current study compared the relative effectiveness of the CI and V educational interventions for VA alcoholic patients and a cognitively and sociodemographically matched sample of nonalcoholic VA patients. The 91 male alcoholic subjects (46 V, 45 CI) were lower socioeconomic outpatients in a VA Alcoholism Treatment program. Control subjects were 35 nonalcoholic men (18 V, 17 CI) attending an outpatient medical clinic at the same facility. All subjects were individually exposed in a single session to a 1 hr intervention on the Medical Effects of Alcohol. Baseline knowledge was measured prior to the intervention using a 21-item multiple choice test, while learning and retention were assessed with the same instrument 24 hr after the intervention. All four subgroups (two types of subjects x two types of intervention) identified approximately three more items correctly at the post-test than at baseline. Thus, neither alcoholics for nonalcoholics acquired more information when exposed to the CI intervention. Further, no differences were found overall in the learning of the alcoholic and nonalcoholic subjects. The implications of these findings and their limitations are discussed.