As clinicians know all too well, the legality of a drug does not mitigate its potential health consequences. And while alcohol has a historic seat as a widely used and accepted substance, legally speaking, it can cause both short- and long-term physical and mental health damage. One of those long-term effects seldomly discussed or correctly diagnosed is alcohol-related brain damage (ARBD), which may be further divided into alcohol-related dementia (ARD) and Wernicke-Korsakoff syndrome (WKS).

COVID-19 has placed a greater spotlight on substance use and abuse, including alcohol use disorder (AUD), which is often left undiagnosed and can lead to ARBD. And while ARBD presents with both structural changes and clinical symptoms, the condition is often under- and misdiagnosed. Understanding the early signs of both AUD and ARBD may enable clinicians to help struggling patients sooner rather than later.

As of March 2020, Nielsen reported a 54% increase in alcohol sales from the same time in 2019.1 In an October 2020 commentary for the Journal of General Internal Medicine, experts at McLean Hospital cautioned that COVID could instigate a greater spike in alcohol consumption than previous crises, such as terrorist attacks and natural disasters. Needless to say, the combined – and ongoing – social disruption, isolation, limited social support, decreased and disproportionate access to medical care, and negative domestic and economic environments are all risk factors for substance abuse.2

Standard Screening May Miss Alcohol-Related Dementia

While standard screening of current patients may alert clinicians to alcohol-related assaults on the hepatic and cardiovascular system, the cognitive implications of excessive alcohol use are not always considered – especially when seeing new patients via teletherapy. The rate of people affected by ARBD is debatable, especially as large organizations such as the CDC do not categorize ARBD as a distinct condition, however, several studies and systematic reviews have indicated heavy alcohol use as an influential factor in dementia, particularly in early-onset dementia.3-5 Perhaps more important, early intervention may be able to reverse many structural changes and clinical symptoms of alcohol-related dementia and brain damage.

There are two main theories behind ARBD:

  • The neurotoxicity hypothesis suggests that the direct physiological effects of chronic alcohol exposure can cause structural damage and neuronal loss through glutamate excitotoxicity, oxidative stress, and the disruption of neurogenesis.3 Support for this hypothesis is based on animal models that show dose-related, ethanol-induced damage to the hippocampus, hypothalamus, and cerebellum. Damage presents as impairments in learning, memory, and executive tasks. Following these animal studies, imaging studies of uncomplicated alcoholics (ie, patients with no history of nutrition deficiency, brain injury, or hepatic failure) showed structural changes to the corpus callosum, pons, and cerebellum,4 however it is unclear whether this damage was related solely to neurotoxicity, or if there were confounding factors.
  • Wernicke-Korsakoff syndrome (WKS) refers to a degenerative brain disorder caused by thiamine (B1) deficiency that damages areas of the brain involved with memory. The acute phase of WKS is known as Wernicke encephalopathy (WE), which can produce symptoms similar to dementia, such as memory loss and confusion. In developed countries, excessive alcohol consumption is considered to be a primary cause of WKS and WE. According to the NIH, dietary deficiencies, prolonged vomiting, eating disorders, or chemotherapy can also lead to WE. With early intervention, however, most symptoms will subside.

Symptoms of WE include jerky eye movements, paralysis of eye muscles, double-vision, poor balance, staggering, an inability to walk, and confusion. If this syndrome is suspected, immediate treatment with thiamine supplementation and alcohol abstinence is recommended.5 Not all WKS first presents as acute WE, however; as seen by autopsy investigation in one study, WKS was correctly diagnosed in only 20% of patients.5

Diagnosing Alcohol-Related Dementia in Patients with Alcohol Use Disorder

Like many disorders, ARD seems to be a heterogenous condition that is likely modulated by both neurotoxicity and thiamine deficiency.6

“They are separate pathological processes (ARD & WKS) but many people have a mixture of the two, so it is often not a clear cut situation,” explains Brian Draper, MD, MBBS, FRANZCP, professor of psychiatry at the University of NSW in Sydney, Australia, who specializes in Old Age Psychiatry, as well as ARBD.

“In my view, from a consumer/clinician perspective, it doesn’t really matter much between ARD/WKS – we often just lump it together as Alcohol-Related Brain Damage (ARBD). Another factor to consider is that other conditions – such as traumatic brain injury, strokes, and intellectual disability – are more common in this population (people with ARBD) and add their bit to the mix. There is much debate as to whether ARD is a specific disorder … not many people have the ‘pure’ condition, which refers to physical signs of ARD without compounding factors such as trauma and disability.”

People diagnosed with ARBD are typically between ages 40 and 50 but younger drinkers are more susceptible to brain damage that can contribute to dementia. In other words, the cognitive consequences that we see later in life are typically caused by excessive drinking earlier in life.

Dr. Draper tells Psycom Pro, “The issue of alcohol consumption and risk for developing other types of dementia has not been resolved. There is likely to be an age effect in that most damage appears to occur in early to mid-life excess and express itself from the ages of 40 to 70 in conditions such as vascular dementia. In later life, the evidence for alcohol consumption to increase dementia risk is meager and if anything might be protective,” he says.

Thus, catching the early warning signs of alcohol excess can be difficult, particularly in the emerging world of telemedicine. The collective symptoms of ARBD may include:7-9

  • impaired learning ability
  • personality changes
  • difficulty with clear and logical thinking on tasks, which require planning, organizing, common sense, judgment and social skills.
  • balance problems
  • decreased initiative and spontaneity

In older patients, it may be especially difficult to distinguish between Alzheimer’s Disease and ARBD, but there are some signs (see next section).

How to Differentiate Alcohol-Related Dementia from Alzheimer’s Disease

 In addition to the earlier onset of ARD (40s, 50s), there are some key differences between alcohol-related dementia and Alzheimer’s. Knowing these differences can help clinicians to differentiate between ARD and early onset Alzheimer’s Disease, which is the diagnosis given to anyone who is under 65 at diagnosis. Young Alzheimer’s or Early- onset Alzehimer’s is thought to affect 5 to 6% percent of people with Alzheimer’s disease.10 The most notable and crucial differences are:

  • ARD can be prevented with early intervention. Indeed, even in patients diagnosed later in life, abstinence from alcohol has been shown to reverse some of the structural damage caused by excessive alcohol use, namely the white matter shrinkage, accompanied by clinical improvements in cognitive and motor abilities. The mechanism behind improvement is thought to involve restoration of myelination and axonal integrity, but is vulnerable to renewed damage, if alcohol consumption if resumed.3
  • Patients with suspected ARD:
    • are more often socially isolated
    • may exhibit poor balance at a young age (in their 40s or 50s)
    • have a history of drinking or substance abuse
    • are unlikely to show language impairment
    • generally, perform better on verbal memory recognition that patients with Alzheimer’s disease
    • generally, have poorer performance on visuospatial measures that include clock drawing and copying tasks
  • Those with WKS commonly present with the tendency to confabulate (ie, make up stories to cover for a failing memory). Patients may often be disoriented and have vision problems.5
  • Other distinguishing characteristics may include:3
    • profound anterograde amnesia and impaired recall of past events.
    • implicit memory and procedural memory are comparatively spared
    • may also exhibit impaired executive functions, difficulties with working memory and have visuoperceptual difficulties.

Overall, patients with alcohol dependence, or AUD, often lack insight into their condition, are ashamed, isolated, and, in many cases, lack access to proper healthcare.

In addition to regularly monitoring alcohol levels in new patients, and at annual visits, Dr. Draper highlights some additional red flags clinicians can look for in assessments:

  • Younger patients in mid-life who have non-resolving depression, subjective cognitive complaints (raised by patient or partner), behavioral change, and/or problems in performing tasks at work should undergo a cognitive screen in addition to an alcohol screen using a tool such as the Montreal Cognitive Assessment. Dr. Draper recommends this test over the Folstein Mini-Mental Status Examination (MMSE) – he feels that this diagnostic tool is more sensitive to the type of cognitive change related to alcohol.
  • In older patients, the same assessment may be used but, generally, cognitive screening is standard in this patient population.

Diagnosing Alcohol Use Disorder (AUD)

In comparison, the DSM-5 provides clinicians with guidelines for diagnosing AUD, however most of these criteria are self-diagnostic and depend on the patient’s own awareness and observations.7 According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA),  AUD signs may include:

  • drinking more, or longer, than planned
  • trying to cut back or stop more than once without success
  • spending a lot of time drinking, being sick, or hungover
  • wanting alcohol so badly you can’t think of anything else
  • Having problems with work, school, or family because of your habit (or because you’re sick after having alcohol)
  • continuing to drink even though it has caused problems for you or your relationships
  • quitting or cutting back on other activities that were important to you in order to drink
  • finding yourself in situations while drinking or afterward that made you more likely to get hurt
  • continuing to drink alcohol even though it made you depressed or anxious, hurt your health, or led to a memory blackout
  • having to drink more than you used to for the effect you want
  • finding that you had withdrawal symptoms when the buzz wore off, like trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, a seizure, or seeing, hearing, or feeling things that aren’t there.

If the patient confirms two or three of those symptoms in the past year, they are likely to have mild AUD. If the patient confirms four or five, the AUD is likely mild; six or more confirmations signals severe AUD.7

According to American Addiction Centers, additional signs of alcohol abuse may include:11

  • mood swings
  • headaches
  • tremors
  • repeated blackouts
  • gastrointestinal problems
  • appetite changes
  • erectile dysfunction
  • falls, dizziness, and poor balance
  • burning, tingling, or numbness in the hands and feet
  • faculty concentrating
  • memory loss
  • itching (related to alcohol-induced liver damage)

When Patients Ask, How Much is Too Much Alcohol?

Patients always seem to ask this question. The answer is … it depends. There’s no conclusive consensus on the amount or duration of alcohol consumption that leads to ARBD. For starters, countries lack a standard measure of what a “standard” drink is. A person’s weight, gender, metabolism, and genetic predisposition are also factors.

NIAAA defines low-risk drinking as no more than three drinks on any single day and no more than seven drinks per week, for women.  For men, it is defined as no more than four drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits meet the criteria for AUD, however, even within these limits, people can have problems if they drink too quickly or if they have other health issues.12

Treatment Options for Excessive Alcohol Use and Abuse

Psycom Pro talked to Alyssa Peckham, PharmD, BCPP, a clinical addiction specialist at Massachusetts General Hospital and a clinical assistant professor of pharmacy at Northeastern University, about treatment approaches and access to alcohol addiction rehabilitation programs.

Whether or not they have signs of dementia, “all individuals with AUD should be offered treatment,” says Dr. Peckham. “It is possible that those with mild AUD (per DSM-5 criteria) can receive non-medication treatment alone such as psychosocial treatment but those with moderate to severe AUD will likely need treatment involving medication, as many chronic illnesses do.”

The three FDA approved agents for medication-assisted treatment (MAT) are naltrexone, acamprosate, and disulfiram. Additionally, there are two agents that are not FDA approved but have displayed positive results on alcohol-related outcomes, notes Dr. Peckham – gabapentin and topiramate. Medications should be selected based on patient preference (shared decision-making), comorbid disease states, drug-drug interactions, and other pertinent factors that may preclude or prefer a certain medication.

Says Dr. Peckham, “Offering medication, in addition to other treatment such as therapy, peer support programs is critical. However, these treatment options should be offered and not forced, as patients should be engaged in their own treatment planning and decision-making process.”

See also, our primer on MAT for AUD and a Q&A on short-term addiction treatment with NIAAA Director George F. Koob.

 

The Role of the Health Professional in Identifying Risks of AUD

There are many obstacles to helping patients with ARBD. The disorder itself if not clearly defined and diagnosis often depends on self-reported data of lifestyle and personal history. An awareness of ARBD is a start and there are many ways mental health and addiction experts can be vigilant about working with this vulnerable population.

“There are many screening tools available that can assist clinicians in identifying risky alcohol consumption. These screening tools can be delivered via telemedicine just as easily as they can be administered in the office. Some are as brief as three to four questions while others have 10 questions. They are not diagnostic tools but a positive screen should warrant evaluation for alcohol use disorder,” says Dr. Peckham. She also emphasizes that many people do not have access to treatment or to telehealth, making support outreach crucial.

Professional Takeaways

  • With current patients, pay attention to cognitive changes, such as depression and mood, and any problems with balance or organization.
  • With new patients, perform screens when necessary and have open, upfront conversations about alcohol use.
References
Last Updated: Jan 14, 2021