Alcohol-related brain damage: a 21st-century management conundrum

Alcohol and cognitive impairment

The relationship between alcohol use and cognitive impairment has been notoriously difficult to disentangle. We present what is known about cognitive impairment associated with alcohol use/misuse, covering the spectrum from mild and subtle cognitive change through to severe alcohol-related brain damage, including Wernicke-Korsakoff syndrome. We highlight aids to the diagnosis and management of these conditions, and emphasise the benefits of prompt treatment on outcome. We also review progress in understanding their neurobiology. Suggestions for possible service configuration based on both our clinical practice and national guidelines are given.

Learning Objectives

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Comprehensive assessment of alcohol-related brain damage (ARBD): gap or chasm in the evidence?

Alcohol-related brain damage (ARBD) causes a broad range of both neurological and neurocognitive impairment. Mental health nurses are required to provide programmes designed to facilitate individuals with chronic alcohol dependency to radically change their drinking behaviour, invariably with an abstinence focus. No evidence that related to the nutritional and physical intervention needs of this group was found. Most instruments used to access domains relevant to ARBD in terms of providing a comprehensive assessment have not been validated in this group. Alcohol-related brain damage (ARBD) is primarily caused by chronic alcohol misuse and thiamine deficiency, and results in a broad range of impairments. Despite the increasing incidence of ARBD in the UK in recent decades, it is currently underdiagnosed, managed inappropriately and treated inadequately. Moreover, information about assessments for individuals with ARBD is currently absent from clinical guidelines and policy documents. The aim of this paper was to review the evidence relating to the neurological, neuropsychological, psychosocial, physical and nutritional assessment of individuals with ARBD to identify appropriate assessment tools that could be used to measure and monitor the impact of ARBD over time. A systematic online database search revealed a total of 160 separate references, 133 of which were rejected and two of which could not be accessed. Twenty-five papers were included in the review, including six neuroimaging studies, 17 neuropsychological studies and two studies using psychosocial methods of assessment. A lack of evidence for nutritional and physical assessment of individuals with ARBD was found. The review findings are inconclusive; most instruments currently used in ARBD research have not specifically been validated for use within an ARBD context. Further research is required to identify comprehensive methods of ARBD assessment.

Alcohol related brain damage – a case of neglect?

Purpose

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

Design/methodology/approach

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

Findings

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

Originality/value

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

Assessment of Alcohol-related Memory Deficits: A Comparison between the Rivermead Behavioural Memory Test and the California Verbal Learning Test

Objectives: Neuropsychological assessment of memory disorders is an important prerequisite in the treatment of patients with alcohol-related cognitive disorders. Although many memory tests are available in clinical practice, a question remains regarding which test is most appropriate for this purpose. Our study's goal was to evaluate the discriminative power of indices of a standard memory test (the California Verbal Learning Test; CVLT) versus the subtests of an ecologically valid everyday memory test (the Rivermead Behavioural Memory Test; RBMT) in patients with alcohol-use disorder.

Method: The patients included 136 with Korsakoff's syndrome (KS), 73 alcoholics with cognitive impairment (CI) not fulfilling the criteria for KS, and 24 cognitively unimpaired alcoholics (ALC).

Results: KS patients performed significantly lower on all RBMT and CVLT variables than CI patients. ALC patients performed significantly better than CI patients on only one RBMT subtest, and had a significantly lower rate of forgetting and higher scores on free recall on CVLT. A combination of RBMT subtests and CVLT indices was able to discriminate KS patients from CI and ALC patients. The RBMT subtests could not significantly distinguish ALC from CI patients. Both rate of forgetting and a comparison between free and cued recall testing on the CVLT showed the largest between-group differences.

Conclusion: Although the RBMT provides information about everyday memory performance, the CVLT indices are better able to distinguish between uncomplicated alcoholics and those with cognitive impairment or KS.

Mental Health is Central to Good Neurorehabilitation after TBI

Those after traumatic brain injury (TBI) who suffer mental health problems, by which I mean problems that a psychiatrist might understand as falling within their remit, suffer a double whammy. Not only do they suffer the stigma of the disabled, but even within this group they may be stigmatised. It has often been my experience that while families will allow for their injured loved one to be under the care of rehabilitation services, including a psychologist, they baulk at the possibility that their loved one may need psychiatric care. This comes to a head when it comes to detaining a patient, in England and Wales, under the Mental Health Act; this may be vigorously resisted by family because of what they infer this says about their loved one's sanity.

Alcohol-Related Cognitive and Affective Impairments in a Sample of Long-Term Care Residents

We provide a detailed exploration of cognitive and affective impairments in a small group (N = 8) of detoxified chronic alcohol abusers living in a long-term care facility. The findings of our cognitive test battery suggest impairment in executive functions with reduced mental flexibility, deficits in cognitive estimation, and deteriorated memory performances. The results of our affective tests demonstrate a reduced capability to correctly recognize emotional facial expressions and an impaired processing of affective verbal material included in our sample. Given the present findings, we conclude the necessity of developing local clinical pathways for the management of severely deteriorated alcohol-related brain damaged individuals by elaborating specific lifelong 24 h care programs focusing on sociotherapeutic support.