Neuropsychological impairment and behavioral limitations exhibited within an alcohol treatment program

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.

The use of the mini-mental state examination in recruitment for substance abuse research studies

BACKGROUND

Substance abuse is associated with cognitive impairment. Participation in clinical addiction research can be cognitively demanding. Screening tools can identify cognitively impaired subjects. We examined the use of the mini-mental state examination (MMSE) as an entry criterion in three randomized controlled substance abuse clinical trials.

METHODS

In each of the three studies, we calculated the proportion of subjects excluded due to MMSE scores (<21) suggestive of cognitive impairment. We estimated the potential impact on enrollment based on the number of excluded subjects. Separately, for two of the studies, we assessed the impact of cognitive function on participation in follow-up using multivariable logistic regression.

RESULTS

Of all persons screened for enrollment, 1.6% (171/10,791) were ineligible based solely on a MMSE score of <21. We estimate that 119 of these 171 ineligible persons would have consented and enrolled. These 119 persons would have represented 9.3% of all enrolled subjects across these studies. For subjects in a study in an inpatient detoxification unit, a higher MMSE score was associated with higher odds (adjusted odds ratio 1.15, 95% CI 1.03-1.30) of completing at least one follow-up assessment. A similar impact on subject follow-up was not observed in a study of medical inpatients with unhealthy alcohol use (adjusted odds ratio 1.01, 95% CI 0.86-1.20).

CONCLUSION

Screening for cognitive impairment using the MMSE excludes a small, but substantial, number of persons from addiction research studies. Cognitive ability, as captured by the MMSE may impact follow-up. These data support cognitive screening of substance abuse research subjects.

Educational lectures and films in the clinical treatment of alcoholism: a critique

A recent meta-analysis of alcohol treatment outcome research concluded that educational lectures and films are an ineffective treatment modality in the treatment of persons with alcohol-related problems. This paper suggests several reasons why educational lectures and films are likely to be ineffective with alcohol misusers. Possible explanations include (a) the inability of alcoholics to appreciate and utilize (presented) information because of the cognitive deficits associated with chronic alcohol misuse, (b) the presentation of inaccurate or misleading information about alcoholism through lectures and films (i.e., unitary disease concept, faulty conceptualizations of denial), and (c) conventional alcoholism education which may undermine an individual's belief in her/his ability to make a complete and successful recovery from chemical dependence. Treatment implications and suggestions for further research are briefly discussed.

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.

Utility of a brief cognitive screening instrument in substance abuse patients: initial investigation

The ability of the Cognitive Status Examination (CSE), a brief neuropsychological screening instrument, to detect cognitive impairment in substance abusing patients was evaluated in 200 consecutive admissions to a drug/alcohol rehabilitation unit. While a significant proportion (25%) of patients screened were classified as impaired using the cutoff derived in the original study, agreement with an independent neurological impairment classification was much lower than that reported in the earlier work. Possible reasons for this discrepancy are discussed, including the relatively subtle nature of cognitive impairment in substance abusing patients. Implementation of regular screening did seem to heighten staff sensitivity to cognitive impairment in this sample. Alternate methods of determining the usefulness of cognitive screening tools (e.g., relationship to treatment relevant skills) are also discussed.

Neuropsychodynamics of alcoholism and addiction: personality, psychopathology, and cognitive style

The literature on the neuropsychology, personality, and psychopathology of alcoholism and addiction is reviewed. Neuropsychological studies of substance abusers have found deficits in abstract concept formation, set-maintenance, set-shifting, behavioral control, and cognitive flexibility. However, the evidence that these deficits are the result of direct substance effects on the brain is slim. Both alcoholics and as-yet nondrinking offspring of alcoholics have been found to be deficient in verbal skills and language functioning. Personality studies of alcoholics and addicts have emphasized such characteristics as field dependency, external locus of control, attenuated time extension, poor ego strength, and disturbed object relations. The psychopathology of alcoholics and opiate abusers seems to be dominated by impulsive character disorder, although there may also be a subgroup of anxious, depressed substance abusers. The present review integrates brain-behavioral perspectives with the data on personality and psychopathology, focusing on the relevance of a multidimensional neuropsychological model to psychodynamic concepts of ego functioning and the substance abusers' problems in the regulation of affect and behavior. It is argued that the concept of cognitive style is useful for understanding the relationship of neuropsychological functioning to personality dynamics, and that this approach can be especially productive in understanding the addictions.

Effects of anterior temporal lobectomy on cognitive function

Sixty-three patients with intractable partial complex epilepsy were treated by anterior temporal lobectomy for seizure control. Psychometric studies before and after operation documented cognitive function and evaluated the effects of operation on cognition. The mean follow-up period was 7.7 months. Sixty-two of 63 patients had improved seizure control; 49 (78%) were seizure free. Operation had different effects on cognitive abilities in those with right vs. left temporal lobe excisions. Although both groups maintained summary IQ scores in the average range, after operation the left temporal group was less efficient on language-dependent cognitive tasks, particularly those that involved complex learning and memory. In contrast, persons who had right temporal ablations were either unchanged or slightly better cognitively after operation. Future research and clinical evaluations should focus on the components of the learning and memory processes when the ramifications of temporal lobe ablations on cognitive function are studied.