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

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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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,

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

10. 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

11. 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 -

12. 10 year increases in ARBD hospital discharges (Ayrshire and Arran report, 2008)
Rates per 10, – 99
Rates per 10,
& 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

13. 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.

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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