How can we improve assessment, treatment and recovery for alcohol related dementia?

Posted 28.01.2019

By Dr Tony Rao, Consultant Old Age Psychiatrist

30 years ago, the concept of a dementia associated with alcohol misuse was viewed with huge scepticism. This may have arisen from reduced survival of people with a history of heavy drinking, many of whom would not have seen their 60th birthday. Then came the “baby boomers”. In addition to older people living longer, baby boomers began to age. Born between 1946 and 1964, all in this age group are now in their mid-50s and over and have shown the fastest rise in alcohol related morbidity and mortality than any other generation in the UK.

Dementia is a mental disorder affecting orientation and memory, but also behaviour, direction sense and language. Every decade, we know something new about it. Indeed, the past 30 years has seen an improvement in our understanding of the disorder. For example, we now have firm evidence that alcohol related dementia is more likely to affect behaviour, planning and judgement rather than the characteristic word-find problems seen in Alzheimer’s Disease.

Much of our understanding about the relationship between alcohol misuse and dementia has arisen from studies that have followed up people without dementia into later life, comparing the onset of dementia in people with different patterns of alcohol use. From these studies, we now know that drinking within current low risk guidelines is not consistently associated with dementia. However, heavy drinking increases the likelihood of dementia, particularly drinking over the equivalent of a bottle of wine a day for men and three quarters of a bottle for women, over 5 years or more. Dementia may also arise with levels of drinking that are lower than this and over a shorter time frame if there are other disorders present.

Both traumatic brain injury and intracranial haemorrhage can worsen cognitive impairment from alcohol misuse and are often present in people with a history of frequent heavy drinking. Pre-existing mental disorders such as Korsakoff’s (amnestic) syndrome from chronic thiamine deficiency may also exacerbate alcohol related memory impairment.

Over the past 12 months, Drink Wise, Age Well has teamed up with South London and Maudsley NHS Foundation Trust to develop a training programme aimed at improving knowledge, skills and attitudes around alcohol related dementia.

Why is this important?

Often people with alcohol related dementia may struggle to engage with treatment services. They may find it difficult to remember appointments or struggle to retain information and may be unresponsive to more structured interventions

Frontline workers can feel frustrated by lack of progress, and worry they lack the skill set to appropriately respond to people with ARD. Indeed a survey of Drink Wise, Age Well staff found that they wanted more training on understanding how alcohol related cognitive impairment affects people and how to best adapt interventions to support them. Additionally we wanted to embed cognitive screening into our practice as both the Royal College of Psychiatrists (2014) and NICE recommend that routine cognitive impairment screening should be carried out in substance misuse services. Drink Wise, Age Well staff have all completed the on-line Montreal Cognitive Assessment training and we are currently piloting our ARCI training in partnership with the Maudsley NHS Trust. Changes in our practice include shorter more regular appointments, problem–solving and goal setting, home safety plans, regular prompts and reminders, advocating on health and social needs and where appropriate working closely with family members. The hope is people who are affected by Alcohol Related Cognitive Impairment and dementia are given the best opportunity to be supported and engaged in treatment, and where someone receives a score indicating cognitive impairment we are providing supportive responses and pathways for referral.