Alcohol related brain damage

Question 1

1. Which of the following is NOT true of ARBD?
   a) ARBD can be more subtle and less specific than the classical presentation of Korsakoff’s syndrome.
   b) ARBD is a progressive condition, even if there is abstinence from alcohol.
   c) ARBD is characterised by prolonged cognitive impairment, excessive alcohol ingestion and thiamine deficiency.
   d) ARBD refers to a cluster of clinical syndromes.
   e) In up to 25% of cases ARBD is complicated by head injury or disturbances to the blood supply to the brain.

Answer 1

b

Question 2

2. Patients with ARBD commonly present at the age of:
   a) 20–30 years.
   b) 30–40 years.
   c) 40–50 years.
   d) 50–60 years.
   e) 60–70 years.

Answer 2

d

Question 3

3. ARBD is an umbrella term that can describe a wide range of syndromes. Which of the following is NOT one of these syndromes:
   a) Cerebellar atrophy.
   b) Dementia pugilistica (punch drunk syndrome).
   c) Frontal lobe dysfunction.
   d) Korsakoff’s syndrome.
   e) Wernicke’s encephalopathy.

Answer 3

b

Question 4

4. The diagnostic criteria for ARBD define ‘significant alcohol use’ as a minimum average of:
   a) 25 units for women and 40 units for men per week and for a period of more than 3 years.
   b) 25 units for women and 40 units for men per week and for a period of more than 5 years.
   c) 35 units for women and 50 units for men per week and for a period of more than 3 years.
   d) 35 units for women and 50 units for men per week and for a period of more than 5 years.
   e) 45 units for women and 60 units for men per week and for a period of more than 3 years.

Answer 4

d

Question 5

5. Which of the following does NOT support a diagnosis of ARBD?
   a) Alcohol-related hepatic, pancreatic, gastrointestinal, cardiovascular or renal disease, or other end-organ damage.
   b) Ataxia or peripheral polyneuropathy (not attributable to other non-alcohol-related causes).
   c) Improvement in any neurological imaging and evidence of ventricular or sulcal dilatation after 60 days of abstinence.
   d) Neuroimaging evidence of cerebellar atrophy, especially of the vermis.
   e) Worsening of the cognitive deficit beyond 60 days of abstinence.

Answer 5

e

Question 6

6. Regarding the epidemiology of ARBD, which of the following is FALSE?
   a) Health records are a more reliable source of data than post-mortem studies.
   b) Rates of ARBD are highest in areas of socioeconomic deprivation.
   c) Rates of ARBD are increasing.
   d) The British Medical Association (BMA) has confirmed that alcohol consumption among females is increasing in the UK.
   e) Women present with the condition 10-20 years younger than men.

Answer 6

a

Question 7

7. Which of the following cognitive tests would be most appropriate to use in the assessment of a patient with ARBD (assuming they have achieved an adequate period of abstinence)?
   a) Abbreviated Mental Test (AMT).
   b) Addenbrookes Cognitive Examination (ACE-III).
   c) Frontal Assessment Battery (FAB).
   d) Mini Mental State Examination (MMSE).
   e) Six Item Cognitive Impairment Test (6CIT).

Answer 7

b

Question 8

8. If a patient was assessed as requiring specialist ARBD service input, which of the following would be necessary before referral to such a service?
   a) ACE-III testing.
   b) Activity scheduling.
   c) Capacity assessment.
   d) Full alcohol detoxification and thiamine replacement.
   e) Liver ultrasound.

Answer 8

d

Question 9

9. Regarding ARBD patients who require a nursing home placement:
   a) A specialised ARBD unit would optimise recovery.
   b) Controlled drinking should be a priority.
   c) Patients should be given full responsibility for all of their daily living tasks.
   d) Patients should be placed in a care home with patients with dementia.
   e) Patients will remain in that care home indefinitely.

Answer 9

a

Question 10

10. According to Smith and Hillman (1999), what proportion of ARBD patients will have the chance of some recovery if they are identified at an early stage and appropriate intervention is offered?
    a) 10%
    b) 25%
    c) 50%
    d) 75%
    e) 90%

Answer 10

d

Question 11

(1.2) What is ARBD?

ARBD refers to a cluster of clinical syndromes characterised by the following two features:

Answer 11

prolonged cognitive impairment

a causative link to excessive alcohol ingestion and thiamine deficiency.

Question 12

It describes the effects of changes to the structure and function of the brain resulting from a combination of:

Answer 12

the toxic effects of alcohol on brain cells

vitamin and nutritional deficiencies (principally thiamine).

Question 13

In up to 25% of cases ARBD can be complicated by:

Answer 13

head injury (many chronic alcohol-dependent patients experience significant falls and accidents)
 disturbances to the blood supply to the brain.

Question 14

The term alcohol-related dementia introduced in 1989 (Harper et al, 1989) has become problematic, why?

Answer 14

alcohol-related cognitive impairment is not a progressive condition when there is abstinence from alcohol, good nutrition and rehabilitation; it is potentially reversible and therefore cannot be called ‘dementia’.

Question 15

ARBD subtypes

Answer 15

ARBD is an umbrella term that can describe a wide range of syndromes
Korsakoff's
Wernicke's encephalopathy
Cerebellar atrophy
Frontal lobe dysfunction
Central pontine myelinosis
Machiafava-Bignami syndrome

Question 16

Typical presentation and diagnostic difficulties

Answer 16

(1.5) Typical presentation and diagnostic difficulties
ARBD can present in a similar way to dementia, however the patients tend to be younger and can present with significant frontal lobe damage. This in turn may lead to disinhibited and aggressive behaviours.

Patients with ARBD commonly present at the age of 50–60 years. Typically the rates are higher among males, although rates are rising in females. If females develop the condition they tend to present a decade younger. Rates are also rising in the elderly population.

Most cases of ARBD tend to become apparent when a patient encounters a time of crisis, either physically, mentally or socially.

Diagnosing ARBD can be problematic as the term is not mentioned in ICD-10 or DSM-5. Diagnoses such as ‘mental and behavioural disorders due to use of alcohol - amnesic syndrome’, ‘alcoholic dementia’ and ‘substance/medication-induced major or mild neurocognitive disorder’ describe classical presentations that are rare in clinical practice. The plans for ICD-11 are yet to be revealed (as at December 2014).

The concept of the wider term ARBD provides a more pragmatic and clinical approach to diagnosis and has the advantages of:
facilitating differentiation from dementia
making diagnosis more accessible for patients with cognitive impairment
providing access to treatment for more people.

Question 17

Making the diagnosis of ARBD

Answer 17

Criteria for the clinical diagnosis of probable ARBD include:
evidence of cognitive impairment (as demonstrated by clinical examination or use of appropriate instruments)
significant alcohol use, defined by the minimum average of 35 units for women and 50 units for men per week and for a period of more than 5 years (modified from Oslin’s criteria which employ ‘standard alcoholic drinks’). The period of significant alcohol use must occur within three years of clinical onset of the cognitive deficits.

The diagnosis of ARBD is supported by the presence of:
alcohol-related hepatic, pancreatic, gastrointestinal, cardiovascular or renal disease, or other end-organ damage ataxia or peripheral polyneuropathy (not attributable to other non-alcohol-related causes)
stabilisation or improvement in the cognitive deficit beyond 60 days of abstinence
improvement in any neurological imaging and evidence of ventricular or sulcal dilatation after 60 days of abstinence
neuroimaging evidence of cerebellar atrophy, especially of the vermis.

The following clinical presentations indicate that there may be complicating conditions:
the presence of language impairment, especially dysnomia or anomia
the presence of focal neurological signs or symptoms
neuroimaging evidence of infarction, subdural haematoma or other focal brain pathology
elevated Hachinski Ischemia Scale score (Hachinski et al, 1975).

Question 18

Epidemiology

Answer 18

Much of the epidemiological data relating to ARBD is from post-mortem studies, which suggests that the condition is under-diagnosed. It is also important to note that much of the literature available relates specifically to Korsakoff’s syndrome.
It has been estimated that up to 1.5% of brains from 39,704 post-mortems of the general population in the USA and Europe showed lesions caused by prolonged alcohol exposure (Cook et al, 1998). It has also been calculated that approximately 35% of alcohol dependents examined at post-mortem have classical lesions of Wernicke’s encephalopathy and/or cerebellar atrophy (Torvik et al, 1982).

Some epidemiological studies have generated data from health records. For example, Chiang (2002) estimated a prevalence of 7 per 10,000 for Wernicke’s encephalopathy/Korsakoff’s psychosis in the Argyle and Clyde area of Scotland (McRae & Cox, 2003).

With regard to the prevalence of ARBD, the following trends have been found:
Rates of ARBD are highest in areas of socio-economic deprivation.
Rates are increasing, which may reflect rising alcohol misuse and/or improving diagnostic expertise.
The highest prevalence is found between the ages of 50 and 60, although a higher number of younger people are developing the condition.
Women present with the condition 10–20 years younger than men; the Australian ARBD service Arbias has reported that over half of its patients are between the ages of 35 and 54.
The British Medical Association (BMA) has confirmed that alcohol consumption among females is increasing in the UK.

Question 19

Value of having specialised ARBD facilities

Answer 19

A greater number of specialised ARBD services would have a hugely positive effect on these areas. This is highlighted in a paper by Wilson et al (2012), which reports that the existence of a specific ARBD service in the Wirral, England, resulted in an 85% reduction in acute hospital bed days per year occupied by patients with severe ARBD. This allowed for 75% of ARBD patients to be settled in non-institutional settings.

Question 20

Cognitive testing in ARBD

Answer 20

3.2) Detection and cognitive testing
ARBD frequently presents with frontal lobe abnormalities (Tuck & Jackson, 1991). Consequently, the commonly used assessment tool Mini Mental State Examination (MMSE) is unlikely to identify early cases.

Consideration should be given to using the Addenbrookes Cognitive Examination (ACE-III) or Montreal Cognitive Assessment (MOCA) tools, both of which cater for elements of frontal lobe testing. Other options include combinations of generic tests, such as the Six Item Cognitive Impairment Test (6CIT), with more specific tests such as the Frontal Assessment Battery (FAB) or Trail Making Test. However, a clinical judgement should be based on the entire picture of a patient’s function, and clinicians should not rely upon cognitive tests alone.

It is important to note that when assessing capacity, immediate recall is usually preserved, with little evidence of short-term memory loss obvious during an interview. Delayed recall should be tested sometime later (at least 45 minutes), often requiring a second interview (Wilson, 2013).

Question 21

Outcome for recovery

Answer 21

Recovery is measured in terms of improved cognitive functioning, physical ability and quality of life. It is important to emphasise, therefore, that 75% of this group of people will have the chance of some recovery if they are identified at an early stage and appropriate intervention is offered.
25%- none
25%- minimal, slight, complete