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Alcohol-Related Brain Damage (ARBD):

Raising awareness,
reducing stigma

Prof Gareth Roderique-Davies

Prof Bev John
(Addictions Research Group)

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How Does Alcohol Damage the Brain?

Etiopathogenesis

Direct Withdrawal Cerebrovascular Head Nutritional

Liver failure neurotoxic experiences disorders injuries deficiencies
effect

           

ARBD

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Overview

• What is ARBD?
• Why practitioners need to be aware of ARBD
• Multiple stigma associated with ARBD
• Important points to take away

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Classical View of Alcohol Related Neurocognitive

Disorders

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Wernicke-Korsakoff Syndrome (WKS)

Overview

• 2 stage/ phase disorder

- Initially viewed as two distinct disorders
- 85% of (surviving) WE cases develop KS
- Some cases of KS with no history of WE (poor documentation?)

• Aetiology: a vitamin B1 (thiamine) deficiency:

- primarily caused by excessive alcohol intake in contemporary western
societies.
- eating disorders, bariatric surgery, hyperemesis gravitas

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Wernicke’s Encephalopathy
(Wernicke, 1885)

Classic triad of symptoms:

- Ophthalmalgia & nystagmus
- Ataxia
- Confusion

Only 16.5% present with all 3 symptoms (Harper et al., 1986)

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Korsakoff’s Syndrome

“an abnormal mental state in which memory and learning are affected out of
all proportion to other cognitive functions in an otherwise alert and responsive
patient” (Kopelman, 2002; 2009)

Profound amnesia: retrograde & (primarily) anterograde (new memories):

---> “Confabulation”
Category Specific memory type Impaired in KS:
Declarative Episodic Severely
Semantic Yes? (inconsistent findings)
Non-declarative Procedural Preserved?

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Alcohol-Related Dementia (ARD)

Overview
- Aetiology: alcohol neurotoxicity
and related factors (e.g.,
withdrawal)

- More gradual in onset and

development that WKS

- Associated with a general

decline in intellectual
functioning

- Cerebral & cerebellar atrophy

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The Confusing Picture

Other forms of ARBD: Common comorbidities:

• A-R Cerebellar atrophy • TBIs/ Head injuries

• Hepatic encephalopathy • Dementias
• Pellagra • Cerebrovascular disorders
• Marchiafava-Bignami • Delirium
Disorder • Psychiatric disorders
• Alcoholic neuropathy • Intoxication
• Poly-substance misuse

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The Confusing Picture: Nosological
General diagnostic terms
Wernicke’s encephalopathy
Korsakoff’s syndrome
Alcohol-related dementia
Cerebral atrophy (alcohol-related)
Alcoholic neuropathy
Hepatic encephalopathy (alcohol-related)
Marchiafava Bignami disease (alcohol-
related)
Pellagra (alcohol-related)
Alcohol-related brain damage/ injury.
* = diagnoses used outside of the UK.
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Heterogeneity
Alcohol-related brain damage diagnoses
Associated ICD nomenclature Associated DSM nomenclature
Wernicke’s encephalopathy Alcohol induced major neurocognitive disorder
(amnestic-confabulatory type)
Amnesic syndrome (alcohol-related) Alcohol induced major neurocognitive disorder
(amnestic-confabulatory type)
Alcohol dependence with alcohol-induced persisting  
amnesic disorder*
Alcohol use, unspecified with alcohol-induced  
persisting amnesic disorder*
Alcohol dependence with alcohol-induced persisting Alcohol-induced major neurocognitive disorder
dementia* (non-amnestic-confabulatory type)
Alcohol use, unspecified with alcohol-induced Alcohol (mild neurocognitive disorder)
persisting dementia*
Degeneration of nervous system due to alcohol No related diagnosis
Alcoholic neuropathy No related diagnosis
Alcoholic hepatic failure without coma No related diagnosis
Alcoholic hepatic failure with coma No related diagnosis
Central demyelination of corpus callosum No related diagnosis
Niacin deficiency (Pellagra) No related diagnosis
All of the above All of the above
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Alcohol-Related Brain Damage: A solution?

A conceptual spectrum or diagnostic category:

Acute Delirium/ Mild alcohol-related Alcohol-related Wernicke’s Korsakoff’s

intoxication withdrawal cognitive impairment dementia/ / syndrome/
effects syndromes and/ or cerebellar or Hepatic Pellagra Marchiafava
cerebral atrophy/ encephalopathy Bignami
Alcoholic neuropathy disorder

Accounts for heterogeneity in pathogenesis and presentation

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What is ARBD?

• Well…it’s complicated!

• A spectrum of neurocognitive impairments caused by drinking too much

alcohol.

• Symptoms include  memory loss, difficulty planning and changes in

personality. 

• But…if identified early and treated appropriately cognitive decline can be

reversed.

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Why is ARBD problematic?

• The study and treatment of ARBD has been impeded by poor understanding
of:

• Its prevalence
• Its assessment and diagnosis
• Its treatment

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ARBD Research Project

• We’ve spent over 7 years working with Pobl to collect data on

• ARBD’s characteristics and Prevalence in South Wales

• The number of ARBD-related Hospital Admissions in South Wales
• The neuropsychological tools used to assess ARBD
• Service provider perspectives on the challenges associated with treating
ARBD

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ARBD Research Project

• Prevalence and Characteristics of ARBD in South Wales

• Survey of 60 clinical, social and housing organizations across South Wales

• 490 individuals were identified which corresponded to an age-specific
rate of 0.034%, or 34 individuals per 100,000 (cf 3-6 for MND)
• Mostly male (71.8%) and those with a confirmed diagnosis were 57.6
years of age on average.

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ARBD Research Project

• Prevalence and Characteristics of ARBD in South Wales

• 10 Year hospital admissions date

• 366.9 admissions per year on average, which calculates to a prevalence
of 0.014% of the four health boards under study.
• The average length of hospital stay for this population was 28.8 days per
individual
• Age of ARBD onset is decreasing
• Across the 10-year analysis showed there has been an increase of over
20% of hospital admissions related to ARBD

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ARBD Research Project

• Appropriate Assessment and Diagnosis of ARBD

• Large scale systematic review of neuropsychological tests
• Findings suggest that several tests may be useful in this domain and can
accurately identify ARBD symptoms – including the ACE-III
• Preliminary validation the ACE-III as a cognitive test for ARBD screening.
• ACE-III demonstrated an excellent ability to differentiate those with
ARBD from those without, supporting its continued use in clinical
practice.

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ARBD Research Project

• Treatment of ARBD: Professional Perspectives on Challenges and

Recommendations

• A series of semi-structured interviews were conducted with 17 health

and social care professionals
• The most commonly reported challenges were resource-related, such as
the lack of funding and appropriate treatment services.
• Barriers included: Physical and mental health needs; lack of clarity as to
which services and specialities are responsible for treating this
population; and lack of understanding and awareness of ARBD.

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ARBD Research Project

• Treatment of ARBD: Professional Perspectives on Challenges and

Recommendations

• Strategies that were reportedly helpful included the use of a

comprehensive assessment process to ensure accurate diagnosis.
• Clearly defined treatment pathways with designated services at each
phase and the need to implement individualised care and treatment
programs.
• Improved education regarding ARBD and the development of specialised
ARBD services were all reported as recommendations for the future
management and treatment of ARBD.
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ARBD Research Project

• The evidence we collected is the most comprehensive and up to date study

of ARBD in the World.

• Welsh Government Substance Misuse Treatment Framework for ARBD

• Welsh Governments Substance Misuse Delivery Plan 2019-2022
consultation document.
• Primary recommendation relates to raising awareness

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ARBD Research Project: translating research

into practice

It has informed Awareness

the Welsh training across
Government’s organisation
Substance Encouraging
Misuse The first staff to
Our research Treatment recommendation implement new Conducting
evidence Framework for relates to raising knowledge follow-up
collected (over ARBD awareness in within their role evaluations
past 6+ years) is H&SC Adjust materials
the most professionals
Plan roll out to
comprehensive The training other areas of
and up to date programme is Health and
study of ARBD underpinned by Social Care
our research
findings

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ARBD Research Project: translating research

into practice
Two self-guided e-learning
modules. The content focusses on
identifying ARBD, the prevalence
and characteristics, and the
importance of treatment and
early intervention.

There are a range of interactive

elements, scene-based slides and
information sections. There is an in-
built evaluation which captures pre and
post awareness, understanding,
confidence & attitudes

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ARBD Research Project: translating research

into practice

Handbooks & leaflets Website: www.arbdwales.co.uk

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ARBD Research Project: translating research

into practice
Attitude
I am definitely going to be more aware of
towards ARBD this condition and have a much better
The training has improved my knowledge and idea of what I can do to help or support
understanding of ARBD and has given me a someone with ARBD. 
better insight in how to support clients with
ARBD and what can be put in place to help
the individual.
90%
Said that their attitude
towards ARBD had
changed after completing
I knew very little about ARBD so my the training.
understanding, attitude and I now understand a lot more about ARBD
awareness has greatly increased. I and have identified some of my clients that
found the course very interesting may be suffering from it.
and informative. I will be more able
to look for the signs of ARBD when
supporting my clients.

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Key points to take away

Increased understanding & awareness of ARBD is critical to:

• Improve diagnoses, prevalence data and service needs identification
• Reduce multiple levels of stigma
• Increase patient recovery opportunities through timely and appropriate
intervention
• Improve outcomes for service users and their families

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