International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Brief Review on Alcohol Related Dementia; Scope of Occupational Therapy

Dr. Parag Sawant1, Dr. Preetee Gokhale 2

1Assistant Professor, Occupational Therapy School & Centre, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, India 2Assistant Professor, Occupational Therapy School & Centre, Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, India

Corresponding Author: Dr. Parag Sawant

ABSTRACT

This article is an effort to review course and impact of Alcohol related dementia following chronic alcoholism. It is well established that excessive and prolonged alcohol use can lead to permanent damage to the structure and function of the brain. There is not much literature on the characteristics of a dementia syndrome related to sustained alcohol abuse. Alcoholism causes a multitude of social and health problems with negative impact on quality of life and secondary costs to society. Cognitive impairments observed in alcohol-dependent patients not presenting any other neurological complications are increasingly becoming the focus of attention amongst medical fraternity. Alcohol Related Dementia has little recognition as a discrete clinical entity and this is due to lack of a distinct pathophysiological profile. However, autopsy evaluations suggest that up to 78% of individuals with diagnosed alcoholism demonstrate some degree of brain pathology leading to minimal cognitive impairment. Assessment tool like Montreal Cognitive Assessment (MoCA) Test appears to be the most appropriate screening test for detection of cognitive impairments in these patients. It is mostly irreversible condition but a period of several months of abstinence allows some improvement of cognitive functions with targeted Occupational Therapy intervention. This results in improving Quality of life of patients with diagnosis of Alcohol dependence.

Key words: Alcohol related dementia, Minimal cognitive impairment, Montreal Cognitive Assessment, Occupational Therapy, Cognitive rehabilitation.

INTRODUCTION negative impact on quality of life and Alcohol dependence or alcohol secondary costs to society. [2-4] addiction, is a destructive pattern of alcohol From a neurobiological perspective, use that includes tolerance to or withdrawal alcohol-dependence is a chronic disorder, from the substance, using more alcohol or which implies the dopaminergic system. As using it for longer than planned, and trouble seen in other drugs abuses, alcohol reducing its use. It is well established that consumption acutely stimulates dopamine excessive and prolonged alcohol use can (DA) release from the major terminal area lead to permanent damage to the structure of the mesolimbic DA system, nucleus and function of the brain. [1] There is not accumbens (NAC). Enhanced DA much literature on the characteristics of a transmission in the NAC plays a critical role dementia syndrome related to sustained in the positive rewarding aspects of drugs alcohol abuse. Alcoholism causes a abuses and the initiation of addictive multitude of social and health problems with process. Chronic administration is

International Journal of Health Sciences & Research (www.ijhsr.org) 376 Vol.9; Issue: 5; May 2019 Parag Sawant et.al. Brief Review on Alcohol Related Dementia; Scope of Occupational Therapy associated with functional alterations of this presentation of dementia represents another important part of the brain reward system. underlying pathology (that is, thiamine Globally, dysregulation of the dopaminergic deficiency) or multiple factors (for example, system caused by chronic alcohol neurotoxicity in combination with consumption produces drug dependence nutritional deficiencies). In some countries, reinforcement and is most likely involved in terms such as ‘alcohol related brain damage’ the development of drug addiction. [5-7] or ‘alcohol-related brain injury’ are The harmful effects of chronic preferred over ARD to reflect the alcohol consumption on the brain and heterogeneity of alcohol-related cognitive cognitive functioning have been well disorders in both aetiology and clinical described in the literature over recent presentation. [11] decades. [8] Cognitive impairments observed in alcohol-dependent patients not presenting The pathophysiology of Alcohol-related any other neurological complications are dementia increasingly becoming the focus of attention Autopsy evaluations suggest that up amongst medical fraternity. However, to 78% of individuals with diagnosed detailed neuropsychological assessment or alcoholism demonstrate some degree of screening of these cognitive impairments brain pathology. [12] appears to be fundamental to optimally Neuroimaging and adapt patient management strategies. neuropathological evidence show prominent The relative paucity of research into white matter loss (most notable in the the epidemiology of alcohol-related prefrontal cortex, corpus callosum, and dementia could be partly due to problems in cerebellum) and neuronal loss in the nosology and recognition, variable superior frontal association cortex, ascertainment of drinking patterns and hypothalamus, and cerebellum. [13] difficulty in establishing exposure using The frontal lobes of individuals with case–control methods. Various studies have diagnosed alcoholism appear particularly suggested the prevalence of alcohol-related susceptible to damage, with evidence of dementia to be about 10% of all cases of markedly decreased neuron density, volume dementia. `Heavy alcohol use' was seen as shrinkage, and altered glucose metabolism possible contributing factor in 21–24% and perfusion. [14] cases of dementia in a review of Partial recovery of white matter epidemiological, neurological, cognitive and disturbances can occur with abstinence, and imaging data. magnetic resonance imaging studies indicate early reversibility of white matter shrinkage What is Alcohol related Dementia...? that is accompanied by clinical Present diagnostic criteria for improvement in cognitive and motor alcohol-associated cognitive disorders focus abilities. [15,16] on two main syndromes of impairment: The mechanism behind recovery Wernickes Korsakoff Syndrome and from white matter damage is thought to Alcohol Related Dementia. (ARD) involve the restoration of myelination and Alcohol Related Dementia has little axonal integrity, but is vulnerable to recognition as a discrete clinical entity and repeated disruption if drinking is resumed. this is due to lack of a distinct One of the studies concludes that the brain pathophysiological profile. [9,10] pathology of abusers of alcohol likely has Much of the debate surrounding two components: one of permanent change, ARD encompasses whether it is possible to the other transient. have a dementia that is the direct result of Cognitive impairments associated with ethanol neurotoxicity – a primary alcoholic excessive Alcohol use. [29] dementia –or whether the clinical

International Journal of Health Sciences & Research (www.ijhsr.org) 377 Vol.9; Issue: 5; May 2019 Parag Sawant et.al. Brief Review on Alcohol Related Dementia; Scope of Occupational Therapy

Assessment of cognitive deficit improvement of executive functions and verbal episodic memory. The detection of cognitive impairments in In parallel, it has been shown that alcohol- dependent patients is therefore new brain regions can be recruited by essential and should be systematic. The recently weaned alcohol-dependent patients Montreal Cognitive Assessment (MoCA) to compensate for alcohol- related brain Test appears to be the most appropriate damage. Neuro adaptation mechanisms screening test for detection of cognitive there for eenable patients to maintain a impairments in these patients. [24] This tool similar level of performance on cognitive is more sensitive than the Mini Mental State tasks to that of control subjects. For Examination (MMSE) for mild-to-moderate example, alcohol-dependent patients recruit cognitive impairments. [25] In the alcohol- neuronal networks parallel to the fronto- dependent population, the most susceptible cerebellar circuit normally used by control executive processes to be evaluated are subjects to perform executive tasks. working memory, mental flexibility, However, although abstinence inhibition, processing speed, concept allows an improvement of cognitive formation, planning, and problem-solving functions, this is only achieved after a capacities. Evaluation of verbal and visual period of several months. memory must focus on encoding, recall, A recent meta-analysis showed that, storage, learning, and recognition capacities, despite studies showing early Cognitive while assessment of visuo-spatial functions recovery, a global deficit was still presents must focus on visuo-spatial organization everal months after installation of and visuo-construction capacities. abstinence and the cognitive profile tended Occupational therapists conduct holistic to become normal only after 1year of assessment of people with Alcohol use abstinence, while certain residual cognitive disorder using various models like impairments may persist. For example, the Occupational Therapy performance measure presence of visuo-spatial function deficits (OTPF), Model of Human Occupation may be observed after several years of (MOHO). [30] This includes assessment of abstinence, related to the decreased volume various performance components such as of the right parietal cortex. [24,29] Physical (Sensory, Motor coordination & balance, Cognitive), Social, Cultural, Efficacy of Occupational Therapy- Environmental, assessment of various Cognitive remediation approach to Performance areas like Activities of Daily maintain the function Living (ADL), Work & Leisure. Appropriate management of alcohol Occupational Therapy focuses on Quality of withdrawal is mandatory to prevent severe life of patient as well as caregiver using complications like delirium tremens or various models of assessment and epileptic seizure. From Occupational intervention. [27] Therapy perspective long-term abstinence is the main goal and cognitive behavioural Prognosis: Is it reversible? therapy (CBT) and psychosocial programs The study of alcohol- dependent patients are necessary. This is achieved using Model also constitutes model of brain plasticity, as of Human occupation (MOHO) [30] which an increase of brain volume characterized emphasizes on Physical and mental health by increased white matter and grey matter of the individual. The model considers volumes and a reduction of the size of sulci individual’s personality traits, educational, and ventricles is observed right from the sociocultural, economical background and first months of abstinence. The cognitive plans treatment goals using concepts of effects of this recovery consist of Personal causation, values and interests, skill. The presence of cognitive impairments

International Journal of Health Sciences & Research (www.ijhsr.org) 378 Vol.9; Issue: 5; May 2019 Parag Sawant et.al. Brief Review on Alcohol Related Dementia; Scope of Occupational Therapy requires substitution/adaptation approach processes involved in the mechanisms of for management of alcohol-dependent addiction, also constitutes a rapidly growing patients. Patients can be introduced to new field of research. Finally, the impact of Occupational group therapy which includes these impairments on the modalities and orientation groups, activity groups, intra and efficacy of the proposed management is a interpersonal skills group, coping skills & clinical problem systematically raised in family groups etc. Cognitive Behavioural research. The last domain to be developed in Therapy has been demonstrated to be the field of management of alcohol- effective in the management of alcohol- dependent patients is therefore that of dependence. [17,31] cognitive remediation, which can establish The efficacy of CBT would the link between the various problems therefore depend on the integrity of certain related to cognitive deficits in the clinical brain regions of interest. For example, it has management of these patients in order to been shown in schizophrenic patients that propose specific targeted follow-up in a the volume of grey matter in the frontal, remediation therapy program devoted to temporal (including hippocampus), parietal, these impairments. and cerebellar regions, brain regions that are Effective palliative &preventive also damaged in alcohol- dependent therapeutic strategies for Alcohol related patients, is predictive of the efficacy of dementia can bring about a change not only management [18] Similarly, the integrity of in patient’s life but also his family. This the frontocerebellar network, a site of helps in reducing the social burden of predilection for brain damage in alcohol- Alcohol dependence in community. [26,28] dependent patients, would play an essential role in the efficacy of CBT due to its role in REFERENCES [19] 1. Harper C: The neuropathology of alcohol-related executive functioning. brain damage. Alcohol 2009, 44:136-140 However, various studies have 2. Laramée P, Kusel J, Leonard S et al. The shown that alcohol-dependent patients with economic burden of alcohol dependence in the most severe cognitive impairment also Europe. Alcohol (2013) 48(3):259– have the least favourable prognosis. [20-22] 69.doi:10.1093/alcalc/agt004 2. 3. Rehm J. The risks associated with alcohol use A recent study demonstrated that a and alcoholism. Alcohol Res Health (2011) cognitive remediation program was able to 34(2):135–43. 3. improve divided attention, alert capacities, 4. Whiteford HA, Degenhardt L, Rehm J et al. working memory, and episodic memory. In Global burden of disease attributable to mental addition to cognitive improvement, and substanceuse disorders:findings from the Global Burden of Disease Study 2010. Lancet cognitive remediation therapy also improves (2013) 382(9904):1575–86.doi:10.1016/S0140- other non-cognitive domains, especially 6736 (13)61611-6) psychological aspects (well-being, self- 5. Gonzales RA, Job MO, Doyon WM. The role of esteem) and craving. [23] mesolimbic dopamine in the development and Thus, data published in the literature maintenance of ethanol reinforcement. Pharmacol Ther (2004) 103(2):121– suggest that it is essential to take into 46.doi:10.1016/j.pharmthera.2004.06.002 17. account the cognitive dimension of alcohol- 6. Pierce RC,Kumaresan V. The mesolimbic dependent patients in order to adapt their dopamine system: the final common pathway for treatment and to palliate their difficulties in the reinforcing effect to drugs of abuse? activities of daily living. The brain changes Neurosci Biobehav Rev (2006) 30(2):215– 38.doi:10.1016/j.neubiorev.2005.04.016 18. and the profile of cognitive impairments 7. Söderpalm B, EricsonM. Neurocircuitry presented by patients with chronic excessive involved in the development of alcohol alcohol consumption have now been very addiction: the dopamine system and its access extensively documented in the literature. points. Curr Top Behav Neurosci (2013) The role of these changes on drinking 13:127–61.doi:10.1007/7854_2011_170) 8. Fitzhugh LC,Fitzhugh KB,Reitan RM. Adaptive behaviour, especially via the cognitive abilities and intellectual functioning in

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How to cite this article: Sawant P, Gokhale P. Brief review on alcohol related dementia; scope of occupational therapy. Int J Health Sci Res. 2019; 9(5):376-380.

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International Journal of Health Sciences & Research (www.ijhsr.org) 380 Vol.9; Issue: 5; May 2019