Poisoning the mind

Question 1

What are the physiological harms that are related to regular heavy drinking?

Answer 1

 Insomnia  Depression  Anxiety  Attempted suicide/Suicide  Changes in personality  Amnestic syndrome (formerly Korsakoff Syndrome)  Dementia  Delirium tremens  Alcohol hallucinosis  Association with other addictions

Question 2

What has korsakoffs syndrome now called?

Answer 2

alcoholic amnestic syndrome

Question 3

What cognitive features are affected in 50% of alcoholic adults?

Answer 3

 Spatial skills  Planning  Learning and memory

Question 4

Is IQ or language affected in alcholics?

Answer 4

no, usually ok

Question 5

What is the recovery prospects of cognition and alcohol abuse?

Answer 5

 Much in 1st month  More in 1st year if sober

Question 6

What are the major effects of chronic heavy drinking and associated malnutrition?

Answer 6

Alcohol Related Brain Damage: - neuropathies - cerebellar degeneration - dementia - Wernicke-korsakoff syndrome/amnestic syndrome

Question 7

What are the predisposing factors to alochol induced brain damage?

Answer 7

`Neurotoxicity  Genetic predisposition to alcohol induced neurotoxicity  Quantity / frequency of alcohol use  Severity of dependence  Frequent episodes of acute intoxication  Withdrawal syndromes (cytotoxic damage)  Other drugs use  Concurrent liver damage Nutritional/Thiamine Deficiency  Weight loss in the past year  Reduced Body Mass Index  High carbohydrate intake  Recurrent episodes of vomiting

Question 8

What are the daily requirements of thiamine?

Answer 8

1-2mg men 1.4; women 1.0

Question 9

What are the stores of thiamine?

Answer 9

Liver: 3-4 mg. Total body ?30 mg

Question 10

What are the symptoms of Wernicke-Korsakoff syndrome?

Answer 10

* Confusion * Eye symptoms - gaze paralysis (diencephalon implicated) - nystagmus * Gait ataxia (unable to stand) Neuropathological lesions: Lesions along the neural axis, particularly close to the ventricle walls - e.g. mamillary bodies and mediodorsal thalamic nucleus

Question 11

Why are the mamillary bodies and mediodorsal thalamic nucleus areas of the brain affected by thiamine deficiency?

Answer 11

Require thiamine for glucose metabolism. In absence, area is starved of energy = neuronal damage

Question 12

What is confabulation?

Answer 12

lying - may be marked but is not invariably present in amnesic syndrome

Question 13

What is agnosia?

Answer 13

nability to interpret sensations and hence to recognize things

Question 14

What is aphasia?

Answer 14

impairment of language, affecting the production or comprehension of speech and the ability to read or write

Question 15

what is apraxia?

Answer 15

individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and he/she is willing to perform the task

Question 16

What are the structural changes in amnestic syndrome?

Answer 16

shrinking of ventricles and cerebellum

Question 17

What are functional changes in amnestic syndrome?

Answer 17

hypofunction within the parietal region of the brain = spatial organisation difficulties

Question 18

What is the difference between alcohol and non-alcohol related forms of Wernicke-Korsakoff syndrome?

Answer 18

thiamine depletion alone usually show full recovery with time.(If underlying medical condition allows for this). Alcohol neurotoxicity on its own leads to a slowly reversible form of global cognitive impairment/dementia provided abstinence from alcohol is achieved The combination of susceptibility to alcohol neurotoxicity and thiamine depletion can lead to irreversible cognitive impairment involving damage to cortical (alcohol-induced) and sub-cortical (alcohol and thiamine depletion induced) structures.This forms a spectrum of disorders from a classic amnestic syndrome to dementia.

Question 19

What is fetal alcohol syndrome?

Answer 19

FAS is a serious developmental disorder caused by prenatal alcohol exposure of the fetus and characterized by: - Prenatal and/or postnatal growth retardation - Central nervous system dysfunction - Characteristic craniofacial abnormalities

Question 20

What are the facial features of FAS?

Answer 20

Question 21

What is hepatic encephalopathy?

Answer 21

a decline in brain function that occurs as a result of severe liver disease. In this condition, the liver cannot adequately remove toxins from the blood. This causes a buildup of toxins in the bloodstream, which can lead to brain damage

Question 22

Describe the pathogenesis of hepatic encephalopathy

Answer 22

Ammonia and the glutamate-glutamine cycle are important in the pathogenesis of hepatic encephalopathy {Blood-brain barrier more permeable to ammonia with down regulation of glutamate receptors and uptake ->increase in astrocyte glutamine and osmotic stress etc}

Question 23

What is the differential diagnosis of hepatic encephalopathy?

Answer 23

• METABOLIC ENCEPHALOPATHIES
• Drugs/Toxins
• INTRACRANIAL STRUCTURAL DISORDERS
• Infection
• SEIZURES
• Wernicke’s encephalopathy
• HEAD INJURY

Question 24

What are precipitating factorrs of hepatic encephalopathy?

Answer 24

 Increased protein load e.g. upper GI haemorrhage

 Decreased excretion of ammonia e.g. renal failure

 Others : electrolyte disturbance,

 dehydration, paracentesis, creation of portacaval shunts ,infection, drugs (e.g. sedatives), superimposed acute liver injury

Question 25

How is hepatic encephalopathy assessed?

Answer 25

West Haven criteria for grading mental state in hepatic encephalopathy

Question 26

What is the treatment for hepatic encephalopathy?

Answer 26

LACTULOSE AND DIETARY MEASURES TO REDUCE NITROGEN LOAD , removal of precipitants , GENERAL SUPPORTIVE MEASURES, reduction or closure of shunts

Question 27

What is the effects of alcohol use with ageing

Answer 27

 Decreased lean body mass and total body water increase blood alcohol concentration  Age-related decrease in gastric alcohol dehydrogenase increases BAC  Liver oxidation decreases with age, increases BAC  Sensitivity of brain to alcohol increases with age

Question 28

What is the prognosis in alcohol related brain damage?

Answer 28

 Poorer in sudden-onset than in insidious-onset cases

 Better with more global cognitive impairment than in purer amnestic syndrome (provided there is abstinence from alcohol)

 Improved if abstinence from alcohol is maintained in milder cases

Question 29

What are the rehabilitative principles in ARBD?

Answer 29

 Regular review in first year after diagnosis

 Eventual placement determined by careful multidisciplinary assessment

 If patient not capable of independent living then provisions of Mental Health Act,guardianship and Adults with Incapacity act can be used to ensure safety

 Design of environment and use of memory rehabilitation techniques important