Alcohol-related brain damage - diagnosis and treatment

It can be difficult to diagnose alcohol-related brain damage (ARBD) so it's important to know what to look out for.

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Why is ARBD often not properly diagnosed?

Although ARBD has been recognised for a century or more, there is still a real lack of knowledge about it amongst some clinicians as well as amongst the general public. In addition, people with ARBD are often socially isolated, not in touch with healthcare professionals and reluctant to engage with services. This means that many cases of ARBD go undiagnosed right through a person’s life. The tragedy is that the prospects for recovery for someone with ARBD are remarkably positive – provided that they are diagnosed and treated in time.

What are the barriers to getting a clear diagnosis of ARBD?

Diagnosis of ARBD can be difficult for a number of reasons:

  • Many clinicians are not aware of ARBD, and it can be misdiagnosed as a form of dementia (such as Alzheimer’s Disease) or mental illness.
  • There are different types ARBD that may have different symptoms and causes, so a diagnosis needs to be made by someone who is familiar with the various forms of the condition.
  • There’s no single assessment tool that can be used for diagnosis of ARBD, and screening tools intended for other forms of dementia may not give an accurate diagnosis.
  • It can be hard to distinguish between the long-term effects of alcohol on the brain and the short-term effects of intoxication or withdrawal, so diagnosis is easier once a person has been abstinent for a few weeks.
  • The confusion caused by ARBD may make it difficult to get an accurate medical history from a person with the condition.
  • People with ARBD may be alienated from family and friends, and so may not have carers with them who can explain their medical history on their behalf.
  • People with ARBD often have very little insight into their problems and may not seek help for themselves as they don’t think there’s anything wrong. The majority of dependent drinkers don’t access help from alcohol services, and so may continue to drink, thus worsening any ARBD.

How can ARBD be diagnosed?

Whilst the symptoms and severity of impairment vary greatly in different people, there are three broad categories of symptom that professionals can use to help them decide if someone has ARBD:

  1. Problems with long- and short-term memory, with information rarely retained for more than 20 minutes.
  2. Reasoning problems interfering with tasks such as weighing up options, understanding the implications of decisions and learning new information.
  3. Problems with impulse control, including difficulty managing emotions and aggression, tendencies to disclose personal information inappropriately at times and difficulty in coping with even minor stresses.

There are also some other factors in a person’s medical history that can indicate ARBD and prompt clinicians to test for it:

  • A history of drinking at least 35 units of alcohol a week for women, or 50 units a week for men, for a period of at least five years. That’s just less than 3½ bottles of wine or about 14 pints of lager per week for a woman, and 5 bottles of wine or 20 pints of lager in a week for a man.
  • Prolonged cognitive impairment – long-term difficulties with thinking and reasoning.
  • Vitamin B1 (thiamine) deficiency.

Which tests are used?

People with ARBD symptoms should be assessed for their cognitive functioning – how well they respond to tasks that require different brain processes, including memory. There are several tests that can be used, depending on the severity of the impairment. Some of the tests that might be used are:

  • Abbreviated Mental Test Score (AMTS)
    • 10 questions that look at memory and other functions. This might be carried out at a GP surgery or in a care setting.
  • General Practitioner Assessment of Cognition
    • a 4-question test that looks at cognitive functions and is a basic test for dementia conducted by GPs.
  • Addenbrooke’s Cognitive Examination (ACEIII)
    • an interview with a clinician in which the patient is asked a series of questions that look at attention, memory, fluency with words and language ability. This test may be carried out at a memory clinic.
  • Mini Mental State Examination (MMSE)
    • This test comprises 11 questions that look at cognitive functioning. It is likely to be carried out in a memory clinic.
  • Montreal Cognitive Assessment (MoCA)
    • a visual and oral test that looks at a variety of cognitive functions (recall, fluency, orientation, etc.) and is used in memory clinics and care homes.

None of these is a specific diagnostic tool for ARBD, but can help determine the level and type of damage. The tests can then be repeated as part of ongoing care, to see whether there have been improvements in brain function. Scans such as MRIs can help confirm diagnosis of specific elements of ARBD by showing changes in the shape and size of parts of the brain.

Alongside cognitive problems, people with ARBD may experience physical illnesses as a result of heavy drinking, including liver and other organ damage, heart problems, high blood pressure and malnutrition. For this reason, there should always be a thorough physical assessment at the time of diagnosis.

Can someone recover from ARBD?

The positive news is that ARBD is not like other types of dementia, such as Alzheimer’s Disease, in that it does not inevitably worsen over time. Its progress can be halted and even reversed. No treatment is guaranteed 100% effective, but around 75% of people with ARBD who receive treatment do make some recovery.

  • 25% make a complete recovery
  • 25% make a significant recovery
  • 25% make a slight recovery
  • 25% make no recovery

What is the treatment for ARBD?

Since ARBD is really a cluster of different conditions caused by heavy drinking, it’s not surprising that different treatments have been found to help different people, depending on the type of brain damage they have. It’s important to get the right diagnosis so that the treatment can be tailored to the person’s needs.

Usually, treatment will involve abstaining from alcohol, or at the very least cutting back. Stopping drinking altogether gives the best chance of improvements in memory and other brain functions. For heavy and dependent drinkers this can be a difficult thing to hear; but the good news is that there are many options and lots of support available for people who want to drink less or stop altogether. High doses of vitamin B1 (thiamine) will be needed, plus there will be exercises to improve brain function. Support from family and/or friends is also very important in improving the outcomes for people with ARBD.

The treatment for ARBD can be broken down into five phases – from first dealing with acute symptoms, right through to long-term rehabilitation:

Phase 1: Physical stabilisation and withdrawal. This involves stabilising any health problems and starting detoxification (‘detox’) from alcohol. At this stage, the person with ARBD should also receive high-doses of vitamin B1 (thiamine) via a drip (intravenous) or injection (intramuscular). This is sometimes known by its commercial name ‘Pabrinex’ or the slang term ‘banana bag’ (as the liquid vitamin drip is very yellow). This all needs to be done under medical supervision in hospital.

Phase 2: Psycho-social Assessment. The purpose of this phase is to make a thorough assessment of the person with ARBD in a safe environment (which could be their own home, in hospital or in a care home), after they have stopped drinking. Quite often, a person’s cognitive function improves during this 2- to 3-month phase as the effects of alcohol begin to wear off.

Phase 3: Therapeutic Rehabilitation. During this phase, which can last for up to 3 years, the person with ARBD is taken through a planned rehabilitation programme. This includes support to remain abstinent from alcohol. In most cases, gradual improvement can be seen during this time. In milder cases of ARBD, people may be cared for at home or in supported accommodation, e.g. a housing cluster with a warden. In more severe or complex cases, the ARBD patient may need to live in a care home or specialist residential unit. There are currently very few specialist homes for people with ARBD, but more are planned. Find out more about the types of treatment and services that are available.

Phase 4: Adaptive Rehabilitation. At this stage, the person with ARBD is helped to find the right level of support and an appropriate place to live in order to move on with their life. The aim is to enable them regain a good quality of life. By this stage, many people with ARBD are able to live in their local community with some level of support.

Phase 5
: Social Integration and Relapse Prevention. This final stage aims to help people with ARBD to build relationships and social networks. This can be particularly important if their old social networks were based on drinking and they want to make new non-drinking friends, so as not to undermine their recovery. They will need some amount of ongoing care to support continued improvement.

Living with ARBD

People with ARBD all have their own experience of what it’s like to live with the condition. With the help of carers and support workers, they often find their own particular ways to dealing with it, as this example shows:

I struggle with loose change. Staff will help, but I find it embarrassing to struggle with coins if there’s a queue so I just hand over a note. Reading is difficult unless the book is very exciting. I have to watch films over and over as I can’t remember what happens! I take a notebook everywhere with me and make lists for everything. I leave things in exactly the same place in the house and I mark the keys I need for my computer games with Blu Tac. I cook the same meal every day because I know how to cook it and for how long. I know when to cook it because my cat, Herbert, always lets me know when he’s hungry!

Nick from Oxfordshire, talking to the charity Young Dementia UK

This fact sheet was written by our predecessor organisation Alcohol Concern with the support of Garfield Weston Foundation.

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