Alcohol related brain damage Dr Louise McCabe Lecturer in Dementia Studies University of Stirling

Today’s presentation What is ARBD? Prognosis Prevalence Individual factors Findings from research Concluding comments Individual factors (age, gender, deprivation)

Alcohol related brain damage A group of conditions where alcohol is determined as the primary reason for brain damage with similar outcomes but different specific causes Wernicke Korsakoff Syndrome ‘Alcohol induced persistent dementia’ Alcohol-related dementia (and so on) Quick definitions of WKS and ARD (and other terms) – more on W/K below Quick discussion on why terminology important (32 terms)

Alcohol and the brain Alcohol damages the brain in a number of ways: Direct toxicity to the brain cells Interference with vitamin absorption Falls and accidents Vascular damage/hypertension Indirect nutritional deficiencies due to poor diet Susceptibility differs between individuals, drinking patterns and different drinks Susceptibility may be genetic – dual susceptibility rare Binge drinking may be more harmful – repeated detoxification leads to more brain damage Type of alcohol drunk may also have an effect Two main types of damage – see next slide

ARBD linked to: Liver cirrhosis (hepatic encephalopathy) Socio-economic factors such as deprivation – multiple factors contribute Patterns of drinking Types of alcohol drunk Genetics – potential link

Wernicke Korsakoff’s Acute phase (Wernicke’s encephalopathy) – delirium type symptoms Vitamin treatment – parenteral thiamine Without treatment 20% die 85% develop long term symptoms (Korsakoff’s syndrome) Most recognised, more clinically defined and so on# But still hugely underdiagnosed – only 20% identified prior to death Symptoms: confusion, ataxia, nystagmus and opthalmoplegia It is a medical emergency – untreated will lead to death in around 20% of cases and Korsakoffs in 85% - up to 25% of Korsakoffs group will require long term institutionalisation

Alcohol related dementia Alcohol use is a risk factor for dementia 9-23% of older people with a history of alcohol abuse have dementia compared with 5% of the general population People with dementia are more likely to have alcohol problems than those who do not have dementia Alcohol related dementia has a higher prevalence than WKS and is likely to have multiple causes – a ‘silent epidemic’ Complex – and not helped by the way it is written about – USA 21-24% of people with dementia have alcohol as a contributory factor Rates for ARBD around 10% 9-23% of older people with history of alcohol misuse have dementia compared with 65% in general population Alcohol also links with other types of dementia but not AD

ARBD prognosis Better prognosis than common types of cognitive impairment with abstinence Continued abstinence allows brain to recover and stability in symptoms is seen, this may be a good indicator that an individual has ARBD Recovery can take up to two years ¼, ¼, ¼, ¼,

¼ recover fully ¼ good recovery ¼ minimal recovery ¼ no recovery – but stability in symptoms

Prevalence of ARBD Not known and not included in recent epidemiological studies (e.g. DementiaUK) Probably rising (fast) Estimates: 10% of dementia cases (Harvey 1998) 21-24% of dementia cases have alcohol as contributing factor (Smith and Atkinson 1995) In Scotland find similarities in levels of ARBD and alcoholic liver disease when looking at hospital discharges

Local prevalence of ARBD Some local authorities have estimated figures Some populations much higher prevalence: e.g. hostel population in Glasgow, 21% Other indicators: Pabrinex prescribing – increasing steadily Not easy to get figures -

10 year increases in ARBD hospital discharges (Ayrshire and Arran report, 2008) Rates per 10,000 96 – 99 Rates per 10,000 03-06 & increases Scotland 3.2 4.3 34% West of Scotland 4.1 5.3 31% East of Scotland 2.8 3.7 33% Rising in line with alcoholic liver disease Rates are about the same West of Scotland – Ayrshire and Arran plus Greater Glasgow

Deprivation and ARBD There is little difference in the amount drunk by different socio-economic groups in Scotland but there is a big difference in the amount of alcohol related morbidity when levels of deprivation are compared ARBD prevalence linked to levels of deprivation WKS directly linked to poor nutrition Complex interactions between poor health, poor mental health, poor housing, poor nutrition, drug and alcohol misuse Ayrshire and Arran report, however, would suggest that levels of ARBD are rising in all parts of the population.

ARBD and age Alcohol related neuropsychiatric conditions are found to increase with age Older brains and bodies more susceptible to damage from alcohol Alcohol misuse common among older men and increasing among older women Alcohol misuse significantly under-diagnosed among older people Frailty and medication Older people have different drinking patterns – alone and at home Older people more likely to under report drinking and less likely to know recommended limits Older people more likely to display stigma concerning alcohol problems

Prevalence: age and gender Still more men than women but increasing in both groups Still more among late middle age and older age groups More older people with ARBD in hospital compared with younger people with ARBD Ayrshire and Arran report found differences in data between hospitals and GPs but didn’t compare to Scotland data – this would be interesting to see Mental welfare commission report – most people were late middle age and older

Stigma Research shows stigma for: Cognitive impairment (dementia) Alcohol as a moral issue Ageing and ageism Stigma evident at all levels of society – individual, institutional and cultural

Stigma evident in specialist services Research in specialist homes/units for people with ARBD found no involvement by alcohol specialists Some staff in specialist homes felt ARBD was self-inflicted – ‘nobody is taking them and pouring the drink down them’ Now will talk about results from research project which focused on ARBD but being up many of the issues for people ageing with alcohol problems/dementia Even in specialist care there is no involvement of alcohol specialist so what hope does someone have in mainstream care in getting help with their alcohol problem??? Staff and professionals share the stigma

Lack of awareness in specialist services Experienced staff didn’t seem to understand link between alcohol and brain damage Importance of abstinence

Awareness among publicans They don’t bring up the link between alcohol use and cognitive impairment or brain damage but do know about it and have experience of it ARBD not included in training or health promotion materials and activities

Barriers to effective support Lack of awareness and stigma Long period of rehabilitation and recovery difficult to deal with Fall between the gaps: Alcohol services not equipped to deal with cognitive impairment Dementia services not equipped to deal with alcohol problems Traditional approached to addressing alcohol addiction assume cognitive intactness

ARBD – policy responses in Scotland Alcohol problems have been and continue to be a key concern of governments Focus is usually on younger people, families and children – not ageing and cognitive impairment But In 2003 two expert groups set up: dual diagnosis and ARBD In 2006 Alcohol and ageing working group convened In 2007 – Commitment 13 Three influential reports A fuller life Mind the gaps Closing the gaps

Concluding comments Need more research on prevalence and epidemiology Need better understanding of prognosis and treatment Need evaluations of successful services and identification of routes for knowledge transfer