Dr Tony RaoIn this guest blog to coincide with Alcohol Awareness Week, Dr Tony Rao discusses a relatively little known – and diagnosed – type of dementia associated with alcohol misuse.

Almost 50 years ago, the late Professor Griffith Edwards wrote of older people presenting to his alcohol information centres: “It would be too optimistic to suppose that the relative under-representation of subjects in the older age groups among clients of information centres is just explained by older people having generally got the treatment they required or having reverted to normal drinking... it seems likely that this finding is in part a hint of the diminished life expectancy of the alcoholic.”

Over the past 20 years, older people have shown comparatively larger rises in drinking over recommended limits, frequent heavy (‘binge’) drinking, alcohol-related admissions and deaths compared with younger people. Much of this rise has been attributed to the ‘Baby Boomer’ population born after the Second World War, for whom attitudes to alcohol were shaped by widespread advertising on television and becoming intoxicated was treated with some degree of light-heartedness to say the least.

Thirty years ago, renowned neuropsychiatrist Professor Alwyn Lishman noted that although alcohol is known to be associated with types of memory disorder such as Wernicke-Korsakoff’s (also known as ‘amnestic’ syndrome, as it affected memory only), its relationship with more widespread damage such as dementia was less certain in that it was not easily distinguishable from Alzheimer’s disease. The other problem was, of course, that many older people experiencing alcohol problems for many years also commonly experienced other forms of brain damage such as head injury and bleeding within or outside the brain. This amalgamation of different processes may have made it more difficult still to identify alcohol as the true culprit.

As increased life expectancy has combined with higher numbers of older people with alcohol misuse, there has been renewed interest in the observation in a specific type of dementia arising as a direct consequence of alcohol. There has been a 140% increase in the number of people aged 60 and over admitted to hospitals in England with amnestic syndrome over past 10 years vs almost static rise in 15-59 age group. So, what about alcohol-related dementia?

More recently, I found that just shy of 40% of older people seen by hospital-based psychiatrists had some form of alcohol-related brain injury. This did not distinguish between those with Wernicke-Korsakoff’s syndrome and those with dementia, but made me think that I needed to look at alcohol and dementia more closely.

In what appears to be the first study in the UK of its kind, a paper recently published in the journal Advances in Dual Diagnosis describes a study of patients under the Clinical Academic Group of the Mental Health of Older Adults and Dementia community teams at South London and Maudsley NHS Foundation Trust. Out of 66 patients with alcohol use disorders on the caseload of community mental health services over a 6-month period, cognitive impairment was assessed in 25 of these. Fewer than half scored below the cut-off point for language impairment, which is central to the diagnosis of Alzheimer’s disease. It also found that the area of cognitive function most commonly affected by alcohol-related dementia was frontal lobe function.

Frontal lobe function is core to our personality, governing our level of motivation, judgement, planning and problem solving. It may also present with what some may report as someone being ‘stubborn’, ‘irritable’ or ‘awkward’ and be passed off without a second thought. It is also such changes in behaviour that add to caregiver stress and mean that long-term care may be the only alternative.

If all 66 patients with alcohol use disorders were included in the final calculation, it still meant that 1 in 3 of older people with alcohol misuse had a probable alcohol-related dementia. 

The findings give new hope for older people with alcohol-related dementia who may remain undetected across a range of care settings, often being given an incorrect diagnosis of Alzheimer’s disease. It is also known that the most commonly used bedside screening test for Alzheimer’s disease does not test frontal lobe function and will therefore miss the possibility of alcohol-related dementia. By being able to spot a pattern of early changes in frontal lobe function and a relative sparing of language abilities when comparing alcohol-related dementia to Alzheimer’s disease, the potential for further interventions to address alcohol misuse can have far reaching implications. What is more, there is now considerable evidence to suggest that some aspects of cognitive impairment associated with alcohol-related dementia are partially reversible. This is particularly so of areas of the brain connecting with the frontal lobes. 

If we can detect alcohol-related dementia early, we can offer hope to those affected by a type of dementia that has not only remains under-detected, but the extent of which we are yet to fully uncover. It is the tip of a clinical iceberg that has taken me nearly 20 years to build up a complete picture. During Alcohol Awareness Week 2016, let us make sure that is picture not just taken, but is fully developed and shared.

About the author

Dr Tony Rao is a consultant old age psychiatrist and visiting researcher at the Institute of Psychiatry. He is also MHOA and Dementia Clinical Academic Group Lead for Dual Diagnosis and a member of the Royal College of Psychiatrists.