Neuropsychology of Alcohol Abuse

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Neuropsychology of Alcohol Abuse

• Bernice A. Marcopulos, Ph.D.
• Neuropsychology Lab
• Western State Hospital

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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

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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

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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

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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

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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

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Pathophysiology of Alcoholism

• Alcohol reduced dendrites in hippocampus and
  cerebellum
• Disrupts hippocampal connections

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From Oscar-Berman Marinkovic, NIAAA, 2004
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Figure 1 Schematic drawing of the human brain,
showing regions vulnerable to alcoholismrelated
abnormalities.
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Progressive Cerebellar Degeneration

• Anterior and superior vermis are preferentially
  affected,
• Ataxic stance and gait.
• Wide-based gait and an inability to tandem walk

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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)
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From Oscar-Berman Marinkovic, NIAAA, 2004
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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)

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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)

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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.

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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

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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.

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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

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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).

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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)

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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

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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)

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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)

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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.

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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)

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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).

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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)

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Risk Factors and Comorbid Conditions that
Influence AlcoholRelated Brain Damage

• Medical conditions
• Malnutrition
• Liver disease
• Cardiovascular disease

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Risk Factors and Comorbid Conditions that
Influence AlcoholRelated Brain Damage

• Psychiatric conditions
• depression
• anxiety
• posttraumatic stress disorder
• schizophrenia
• use of other drugs

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Secondary Effects of Alcoholism

• Subdural and epidural hematoma
• Cerebral contusion
• Posttraumatic epilepsy

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End Stage Liver Disease

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

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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

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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).

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Cognitive Deficits in Alcoholics

• 50 to 80 of persons with alcohol use disorder
  display deficits on neuropsychological tests

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Cognitive Deficits in Alcoholics

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

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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)

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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

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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)

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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)

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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

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Fetal Alcohol Spectrum Disorder

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

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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

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Distinctive Dysmorphic Facial Features

• Short palpebral fissures
• Thin upper lip
• Long flat philtrum
• Flat mid-face
• Short stature
• Microcephaly

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Fetal Alcohol Spectrum Disorder

• Mental retardation
• Learning disabilities
• Attention deficits
• Hyperactivity
• Problems with impulse control,
• Language, memory, and social skills

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Case Example

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

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Medical complications

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

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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?

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Neuropsychological Testing

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

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Rey Complex Figure Copy for 64 year old female
with Alcohol Abuse
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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

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Neuropsychological Findings

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

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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)

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Treatment Implications

• Different treatment approaches for cognitively
  impaired clients