Alcohol Related Brain
Damage
Charlie Place York Street Health Practice Sep 2014
What is ARBD?
 Alcohol Related Brain Damage (ARBD) is
a relatively new term that has begun to
be used in practice and the literature to
describe cognitive impairment related to
alcohol use
ARBD umbrella
‘umbrella’ term to describe a range of
conditions including:
 Wernicke’s encephalopathy
 Korsakoff’s syndrome
 Alcohol dementia
 Alcohol related brain injury
Wernicke’s encephalopathy
 Wernicke’s encephalopathy is the acute
neuropsychiatric reaction to thiamine
deficiency
 Characterised by problems with walking,
balance, coordination, confusion, eye
movement
 Wernicke’s is a medical emergency – untreated
can lead to death in 20% of cases or
Korsakoff’s syndrome in 85% of survivors
(Kopelman et
al, 2009)
Korsakoff syndrome
 Memory disorder associated with chronic
alcohol abuse and thiamine deficiency
 Associated with Wernicke’s
 Characteristically patient gives
impression of being unimpaired and often
use ‘confabulation’ to cover gaps
 Chronic condition
Why is ARBD preferable?
 There is rarely a clear clinical picture
 For example, Wernicke’s encephalopathy
is well-known amongst clinicians but
rarely seen in practice
 Drinker (or ex-drinker) with cognitive
impairment will often have multiple
possible factors that are likely to have
contributed to cognitive impairment
ARBD advantages cont…
 Almost impossible to ‘unpick’ story
 Multiple factors in play: unassisted withdrawal,
nutritional defiencies, toxic effects of alcohol on
brain, brain injuries
 25% presenting with ARBD evidence of
vascular dementia and/or head trauma (Wilson et al,
2012)
 ARBD is useful umbrella to describe condition
– currently no appropriate term in DSM and
ICD (RCP 2014)
Why not call it Alcohol Related
Dementia?
Fundamental difference from dementia:
 Evidence suggests that some degree of
recovery is possible for most people with
ARBD. Prognosis estimated:
 25% full recovery
 25% significant recovery
 25% slight recovery
 25% no recovery (Smith and Hillman 1999)
 First three months of abstinence
associated with significant improvement
(RCP 2014)
Prevalence
 Surprisingly little data
 Due to diagnositc problems, patients not being
aware, variability of presentation, poor levels of
awareness amongst clinicians, and stigma
related to ‘self inflicted’ alcohol problems (RCP 2014)
 Most robust evidence is from post-mortems:
between .5% and 1.5% of general adult
population have changes to brain from alcohol
misuse and most do not have this recorded (Cook
et al, 1998)
Prevalence cont..
 The ARBD service in Greater Glasgow
serves a population of around 900,000
and estimates three to four new cases
each week and over 500 established
cases with long-term care needs
identified over a five year period. Average
age at referral to the Glasgow service is
55 years with 74% of the referrals being
male (Smith in Thomson et al 2012).
Prevalence cont…
 Screening of 266 homeless hostel
residents in Glasgow found 82% had
degree of cognitive impairment
 21% could be said to have ARBD (Gilchrist and
Morrison 2005)
 Prevalence appears very high – drinking
at time?
 But functionally impaired – ultra high risk
group?
ARBD often overlooked…why?
 Ignorance of ARBD amongst clinicians leading
to misdiagnosis of other forms of dementia or
mental illness
 Stigma
 Commonly used assessments not well suited
(eg MMSE)
 Difficulty differentiating between prolonged /
permanent effects and short term intoxication
 People with ARBD often socially isolated (Alcohol
Concern 2014)
Screening tools
 Mini-Mental State Examination (MMSE)
is widely used in clinical practice
 Concerned that it may not be
sophisticated enough to pick up ARBD
type cognitive impairment
Two tools recommended by RCP:
 Montreal Cognitive Assessment (MoCA)
 ACE-R
Montreal Cognitive Assessment
 Montreal Cognitive Assessment (MoCA) is a
brief (10 minute approx) cognitive screening
instrument
 Developed to be sensitive to mild cognitive
impairment (MCI)
 More sensitive to cognitive decline than MiniMental State Examination (MMSE)
 Validated for use with substance use (Copersino et al
2009)
 Recommended by RCP report on ARBD
Summary (nationally)
 Drinkers, professionals and the public
lack awareness of ARBD
 ARBD is underdiagnosd
 There is a lack of research
 There are a lack of services
 There is a lack of training
Summary (locally)
 Local situation reflects national picture
 There is no service for this group
 Specialist CMHT for younger people with
dementia excludes drinkers
 Memory services exclude younger
people
 Nothing vs. care home?
Recommendations (RCP 2014)
 All new patients referred for alcohol treatment
should have a cognitive assessment (should
be all addiction services??)
 Specialisation in recognition and management
of mild/moderate ARBD should be built within
alcohol services
 Specialist services for ARBD should be
commissioned
Local developments
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Over past 18 months
Effort made to raise problem in city
Commissioners and public health aware
Ceryl Harwood (public health registrar)
lead with project for public health Leeds
 Can’t find people in the data!
 No extra money
Possible plan for Leeds
 With no extra resources, build pathway
for ARBD into health and social care
 Recommissioning of drug and alcohol
service provides opportunity to build into
new structure?
 Raise awareness
 Screening
Possible pathways?
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Improve access to specialist assessment
Improve ASC awareness / skills
Provide rehabilitation pathway
Have ARBD route within detox / rehab?
Have ARBD route within supported
housing? THUs?
 Rely on interest from organisations?
 Avoid nothing vs. care home
Anyone interested?
 Over coming months, recommendations
will be made
 If you as an individual or your
organisation are interested, please get in
touch
References:
 Alcohol Concern (2014) All in the Mind, Alcohol Concern Cymru, Cardiff.
(available at www.alcoholconcern.org.uk/cymru)
 Royal College of Psychiatrists (2014) Alcohol and Brain Damage in Adults, College
Report 185, RCP London.
 Cook C, Hallwood P, and Thomson A (1998) ‘B vitamin deficiency and
neuropsychiatric syndromes in alcohol misuse’ Alcohol and Alcoholism, 33, pp.31736.
 Copersino et al (2009) ‘Rapid Cognitive Screening of Patients with Substance Use
Disorders’, Experimental and Clinical Psychopharmacology, 17, pp.337-344.
 Gilchrist, G, Morrison, D (2005) ‘Prevalence of alcohol related brain damage
among homeless hostel dwellers in Glasgow’ European Journal of Public Health,
15, p.587-588.
 Kopelman et al (2009) ‘The Korsakoff Syndrome: Clinical Aspects, Psychology and
Treatment’, Alcohol and Alcoholism, 44, pp.148-154.
 Smith, I and Hillman, A (1999) ‘Management of Alcohol Korsakoff Syndrome’,
Advances in Psychiatric Treatment, 5, pp. 271-278.
 Wilson et al (2012)
Local case study

AB is a 56 year old man with a history of homelessness, alcohol
dependence and mental health problems. He took an overdose in
response to voices and was admitted to acute community mental health
services. Whilst under their care, AB attended the primary care practice
and was seen by the alcohol nurse. AB said he had spent over £1200 in
a two week period and could not recall doing this – he had a bank
statement confirming these withdrawals. There was no evidence of fraud
and it appeared AB had withdrawn the money himself but was not able to
remember doing so. AB identified his memory as very poor. He was not
drinking at this time. He completed the Montreal Cognitive Assessment
(MoCA) scoring 4 out of 30 (26 and above is normal range). The acute
mental health services had not been aware of his cognitive impairment
until this point. The Community Mental Health Nurse allocated as care
coordinator referred AB to a specialist Community Mental Health Team
(CMHT) for working age people with dementia who would not agree to
assess AB due to his history of problem drinking. He was discharged
from the CMHT to primary care and currently has no specialist support.
Local case study

AF is a 48 year old male who was referred to York St alcohol service by
Leeds Addiction Unit when inpatient in LTHT. Identified problems with
memory which were creating problems at home with leaving on cooker,
for example. Discussed with friend / carer who confirmed AF’s account
and suggested social care needed. Requested social work referral in
LTHT but ward would not agree to refer as did not feel AF had significant
cognitive impairment – ‘he can go out for a cigarette and come back’ was
the comment of one nurse. MoCA score when sober = 8 out of 30.
Assessment at home confirmed problems and suggested problems with
vulnerability as living in shared home with other male who had assaulted
him. AF no longer staying in tenancy but ‘sofa surfing’ with others in local
area. Referred to Leeds Adult Social Care by York St who accepted
referral and assessed. Regular LTHT admissions due to liver failure.
Continues to drink when out of hospital – approx 2 to 4 x cans 5%. Adult
social care looking at options – possible temporary placement in Bradford
care home?
Local case study

AC is a 60 year old man who was referred to the primary care alcohol service by
the hospital addictions team. AC was drinking dependently but in a controlled way
(approx 8 x cans of 5% lager daily) and living in sheltered housing. AC was
referred to hospital addictions team during admission and they had continued to
support him after discharge home, including becoming involved in helping him to
get money and shopping as due to cognitive impairment he was not able to do so
himself. A referral to adult social care was made and a social worker appointed as
case manager. AC did not want to change his drinking habits and felt his drinking
was under control. He scored 11 out of 30 when scored on the Montreal Cognitive
Assessment (26 and above = normal range). AC appeared stable with home care
helping with meals and medication however his behaviour deteriorated as he
became increasingly agitated, causing serious problems in the housing complex
(such as going into other’s rooms) and showing persecutory beliefs. He was
admitted twice in a week into an acute medical bed and settled in hospital but his
behaviour again became a problem on discharge and he was eventually admitted
informally to an acute mental health bed. He was detained whilst an inpatient
under Section 2 of the Mental Health Act and his level of cognitive impairment
improved significantly over the period of admission as he was abstinent from
alcohol and eating well. Discharged back to sheltered housing, AC was referred to
the dementia service whilst an inpatient but not accepted so has generic CMHT
support at present.
Local case study

AE is a 60 year old man who has been sleeping rough for many years. He was
recently registered with the homeless primary care service when the Street
Outreach Team brought him to the practice after they found him wandering in town.
AE has been drinking dependently for many years and has been known to the
Street Outreach Team for a long time. He was brought to see the alcohol nurse in
primary care several months ago but was not registered, however he presented as
so cognitively impaired at this point (unable to say where he was, what was
happening) that he was sent to the emergency department due to concerns of
Wernicke’s encephalopathy. Following admission to a medical bed and treatment
with parental thiamine, there was some recovery and AE was discharged from
hospital then returned to sleeping rough. Supported housing was arranged but he
did not appear to stay there. He presents currently as seriously impaired although
he was orientated to place and time, but does not appear aware of housing, health,
dietary or financial arrangements. He would not engage in formal cognitive
assessment. There is only ad hoc contact with AE when found by professionals
and so the city Street Outreach Team arranged assessment under mental health
act. AE was detained due to vulnerability and cognitive impairment and admitted
to the Becklin centre. No significant recovery during admission.
Case studies highlight problems:
 Cognitive impairment had not been identified for some time
despite repeated contact with a range of health
professionals.
 ‘ad hoc’ support often put in place by agencies (such as
community drug and alcohol services) as no more
appropriate service was available.
 More intensive support only became available in a crisis
situation, sometimes leading to admission to acute medical
or mental health care.
 Even when engaged with secondary mental health care,
individuals with ARBD did not have access to specialist
support from memory services or staff skilled in the
assessment of cognitive impairment.
 None of the individuals currently has support from services
with expertise in cognitive impairment.