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Neuropsychology of Alcohol Abuse

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Title: Neuropsychology of Alcohol Abuse


1
Neuropsychology of Alcohol Abuse
  • Bernice A. Marcopulos, Ph.D.
  • Neuropsychology Lab
  • Western State Hospital

2
Goals of Lecture
  • Review the effects of alcohol on the brain
  • Neuropsychological findings
  • Fetal Alcohol Syndrome
  • Impact of alcohol-related cognitive deficits on
    treatment and rehabilitation

3
Alcohol and the brain
  • Mostly bad news, however
  • MODEST alcohol, especially red wine, use may
    lower the risk of dementia
  • Protective effect on cardiovascular and
    cerebrovascular health
  • Attributed to polyphenic antioxidants

4
(No Transcript)
5
Effects of Alcohol on the Brain
  • 3 main categories
  • (1) acute intoxication
  • (2) withdrawal syndrome from sudden abstinence
  • (3) a varied group of acute or subacute
    disorders secondary to chronic alcohol abuse
  • Neuropsychologists most interested in 3

6
Alcohol Dependence/Abuse
  • Heavy intake 4 or 5 drinks per day
  • Craving
  • Social, occupational, and. or legal problems
    dysfunction
  • Tolerance
  • Withdrawal
  • Continued use despite negative consequences

7
Pathophysiology of Alcoholism
  • Alcohol is a neurotoxin
  • Cerebral atrophy most common finding
  • White matter more affected than gray
  • Frontal and parietal regions most affected
  • Subcortical atrophy
  • Cerebellum
  • Caudate nucleus
  • Limbic system

8
Pathophysiology of Alcoholism
  • Alcohol reduced dendrites in hippocampus and
    cerebellum
  • Disrupts hippocampal connections

9
From Oscar-Berman Marinkovic, NIAAA, 2004
10
Figure 1 Schematic drawing of the human brain,
showing regions vulnerable to alcoholismrelated
abnormalities.
11
Progressive Cerebellar Degeneration
  • Anterior and superior vermis are preferentially
    affected,
  • Ataxic stance and gait.
  • Wide-based gait and an inability to tandem walk

12
Midsagittal view of an MRI of the brain of an
alcoholic, showing severely shrunken folia of the
anterior superior vermis compared with an age
matched control man. (Sullivan et al., 2003)
13
From Oscar-Berman Marinkovic, NIAAA, 2004
14
Alcohol causes premature aging?
  • Older patients (age 50 and older) are especially
    susceptible to the cumulative effects of
    alcoholism,
  • Although alcoholismrelated brain changes may
    mimic some of the changes seen in older people,
    alcoholism does not cause premature aging
  • Rather, the effects of alcoholism are
    disproportionately expressed in older alcoholics
    (OscarBerman 2000)

15
Vitamin Deficiency
  • Poor dietary habits in some alcoholics, indicates
    that thiamine deficiency (vitamin B1) can
    contribute to damage deep within the brain,
    leading to severe cognitive deficits
    (OscarBerman 2000)

16
Wernicke Korsakoff syndrome
  • 1881, Carl Wernicke had described a neurologic
    syndrome of acute onset characterized by ataxia,
    ophthalmoplegia, nystagmus, polyneuropathy in the
    arms and legs, and a global confusional state.

17
Korsakoff Syndrome
  • 1887 Korsakoff
  • characteristic problems in new learning
    (anterograde amnesia) as well as the deficits in
    remembering past events (retrograde amnesia), and
    emphasized that these occurred in the context of
    clear attention and consciousness

18
Wernicke Korsakoff syndrome
  • Not until several years later was it realized
    that the symptoms described by Wernicke and
    Korsakoff often occur sequentially in the same
    patients (Gudden 1896)
  • The syndrome is also referred to as Wernicke
    Korsakoff syndrome.

19
Wernicke Korsakoff Syndrome
  • Patients tended to confabulate, sometimes making
    up stories or events entirely, but more
    frequently confusing the temporal context of
    actually experienced events

20
Wernicke Korsakoff syndrome
  • Primarily in the acute (Wernicke) stage of the
    disorder
  • Confabulation is not specific to Korsakoff
    syndrome, also seen in patients with lesions in
    the frontal lobes, basal forebrain, or both.
  • Caused by disruption in one or more cognitive
    processes needed for effective reality
    monitoring, such as temporal discrimination,
    source monitoring, and self-initiated memory
    retrieval (Johnson et al 1997).

21
Korsakoffs
  • Visuospatial and visual-perceptual deficits are
    also observed on a variety of concept formation
    tests that require discrimination and
    classification of complex visual stimuli
    (Kopelman 1995)

22
Korsakoffs
  • deficits in planning, decision making, and
    problem solving, deficits linked to impaired
    frontal executive control (Brand et al 2005)
  • perform poorly on clinical tests of frontal
    function such as the Wisconsin Card Sorting test,
    verbal fluency, and Trails B (Squire 1982
    Jacobson et al 1990

23
Wernicke Korsakoff syndrome
  • Retrograde amnesia a typical feature, commonly
    extending back 25 years or more
  • Memory for autobiographical information as well
    as knowledge of public events and facts are
    affected
  • Memories from childhood and early adulthood are
    remembered better than memories from the recent
    past. (Kopelman 1989 Fama et al 2004)

24
Korsakoffs Syndrome
  • Variability in the level of general intellectual
    functioning
  • Many patients perform in the average range on
    standard IQ tests, but others demonstrate more
    widespread cognitive deficits (Jacobson et al
    1990a)

25
Korsakoffs Syndrome
  • Changes in personality
  • Patients lack insight, are
  • Apathetic about ongoing events, and
  • Unconcerned about personal appearance.
  • A lack of interest in alcohol is also striking.

26
Comparing Korsakoff and non-Korsakoff alcoholics
  • Korsakoff patients are impaired on tests of
    memory, fluency, cognitive flexibility, and
    perseveration
  • Non-Korsakoff alcoholics may show some frontal
    system deficits as well, but these are milder
    (Oscar-Berman et al 2004)

27
Korsakoffs vs. Alcohol Dementia
  • In Korsakoff syndrome patients have a
    disproportionate disorder of memory,
  • Patients with Alcoholic dementia have more global
    cognitive impairment (Salmon et al 1993).

28
Korsakoffs vs. Alcohol Dementia
  • The nosological distinction between Korsakoff
    syndrome and alcoholic dementia is highly
    controversial
  • Clinical differentiation is imprecise
  • No distinct neuropathological basis has been
    established for alcoholic dementia (Victor and
    Adams 1995)
  • Cognitive disorders secondary to alcoholism can
    more appropriately be seen as varying along a
    continuum of severity (Bowden 1990)

29
Risk Factors and Comorbid Conditions that
Influence AlcoholRelated Brain Damage
  • Medical conditions
  • Malnutrition
  • Liver disease
  • Cardiovascular disease

30
Risk Factors and Comorbid Conditions that
Influence AlcoholRelated Brain Damage
  • Psychiatric conditions
  • depression
  • anxiety
  • posttraumatic stress disorder
  • schizophrenia
  • use of other drugs

31
Secondary Effects of Alcoholism
  • Subdural and epidural hematoma
  • Cerebral contusion
  • Posttraumatic epilepsy

32
End Stage Liver Disease
  • Encephalopathy, tremors, myoclonus, and asterixis
    may be encountered in end-stage liver disease
    from alcoholic cirrhosis (Neiman et al 1990)

33
Central Pontine Myelinolysis
  • Caused by rapid changes in electrolyte
    concentration,
  • most commonly of sodium
  • Rapid onset of quadriparesis, pseudobulbar palsy,
    pupillary abnormalities, and sometimes coma

34
Marchiafava- Bignami Disease
  • Slowly progressive psychomotor slowing,
    incontinence, frontal release signs, and
    wide-based gait.
  • Dysarthria, hemiparesis, apraxia, or aphasia may
    be present in other patients.
  • Occasional patients may present in stupor or
    coma.
  • MRI or CT may reveal lesions in the corpus
    callosum, anterior commissure, and, less
    commonly, in the centrum semiovale (Niclot et al
    2002) and lateral-frontal regions of the cortex
    (Johkura et al 2005).

35
Cognitive Deficits in Alcoholics
  • 50 to 80 of persons with alcohol use disorder
    display deficits on neuropsychological tests

36
Cognitive Deficits in Alcoholics
  • Complex visuospatial abilities
  • Psychomotor speed
  • Executive functions
  • Learning and memory
  • Sensorimotor (peripheral neuropathies)
  • Some functions intact
  • Language
  • Academic skills
  • Attention

37
Cognitive Deficits in Alcoholics
  • Frontal lobes are particularly vulnerable to
    alcoholismrelated damage
  • Most prominent as alcoholics age (OscarBerman
    2000 Pfefferbaum et al. 1997 Sullivan 2000)

38
Cognitive Deficits in Alcoholics
  • Severity of deficit depends on
  • Age of onset
  • Quantity
  • Neuromedical factors
  • Age
  • Chronic heavy drinkers have more deficits than
    binge drinkers

39
Effects of Abstinence
  • Most alcoholics with neuropsychological deficits
    show at some improvement in brain structure and
    functioning within a year of abstinence
  • some people take much longer (Bates et al. 2002
    Gansler et al. 2000 Sullivan et al. 2000)

40
Effects of Abstinence
  • Abstinence of less than a month can result in an
    increase in cerebral metabolism, particularly in
    the frontal lobes
  • Continued abstinence can lead to at least partial
    reversal in loss of brain tissue (Sullivan 2000)

41
Effects of Alcohol on the Developing Brain
  • Alcohol can trigger cell death in a number of
    ways, causing different parts of the fetus to
    develop abnormally
  • Alcohol can disrupt the way nerve cells develop,
    travel to form different parts of the brain, and
    function.
  • Constricts blood vessels which interferes with
    blood flow in the placenta
  • hinders the delivery of nutrients and oxygen to
    the fetus
  • Toxic by-products of alcohol metabolism may
    become concentrated in the brain

42
Fetal Alcohol Spectrum Disorder
  • Fetal alcohol syndrome (FAS)
  • Alcohol related neurodevelopmental disorder
    (ARND)
  • Alcohol related birth defects (ARBD)

43
Fetal Alcohol Spectrum Disorder
  • Brain damage
  • Facial anomalies
  • Growth deficiencies
  • Defects of the heart, kidneys, and liver
  • Vision and hearing problems
  • Skeletal defects
  • Dental abnormalities

44
Distinctive Dysmorphic Facial Features
  • Short palpebral fissures
  • Thin upper lip
  • Long flat philtrum
  • Flat mid-face
  • Short stature
  • Microcephaly

45
Fetal Alcohol Spectrum Disorder
  • Mental retardation
  • Learning disabilities
  • Attention deficits
  • Hyperactivity
  • Problems with impulse control,
  • Language, memory, and social skills

46
Case Example
  • 64 year old female
  • Retired from the CIA
  • 16 years education
  • Long history of alcohol use
  • Alcohol abuse following retirement

47
Medical complications
  • Alcohol related problems
  • Hepatic cirrhosis
  • Gastrointestinal bleeding
  • Delirium tremens
  • Alcohol de-toxification 20 times

48
Neuropsychological Evaluation
  • Referred because she faced legal charges
  • Repeated calls to emergency services
  • Appeared confused about legal charges
  • Questioned competency to stand trial
  • Referral to evaluate cognitive functioning in
    light of long history of alcohol abuse
  • Does she have cognitive problems that would
    interfere with her competence to stand trial?

49
Neuropsychological Testing
  • Verbal IQ 110 PIQ 76
  • Average verbal memory
  • Moderately impaired visual memory
  • Visuoconstruction severely impaired

50
Rey Complex Figure Copy for 64 year old female
with Alcohol Abuse
51
Neuropsychological Assessment
  • Poor executive functioning
  • WCST 2 categories, above average number of
    perseverative errors
  • Sensorimotor tests impaired
  • Dexterity (Grooved pegboard)
  • Sensory perceptual
  • Consistent with peripheral neuropathy

52
Neuropsychological Findings
  • Clear evidence for alcohol related cognitive
    impairment
  • However, not demented
  • Capable of understanding her legal situation

53
Implications for Treatment and Rehabilitation
  • Low motivation and minimization and denial may be
    attributable to cognitive deficits
  • Cognitively impaired patients might benefit from
    cognitive rehabilitation in addition to
    traditional alcohol treatment (Allen, Goldstein
    Seaton, 1997)

54
Treatment Implications
  • Different treatment approaches for cognitively
    impaired clients
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