Alcohol and Dementia
is estimated that:
dementia affects over 300,000 Canadians aged 65 or over (about 8.0% of seniors)
over 750,000 Canadians 65 and older will be affected by dementia by the year 2031.
Alcohol's Relationship to Dementia
There are many different ways in which alcohol can be tied to dementia:
- Some people who have had a history of alcohol abuse may develop alcohol related dementia (Alcohol leading to dementia).
- Some people who have Alzheimer disease or another dementia may also have an alcohol problem (Alcohol + dementia)
- Some people who are developing Alzheimer disease or other dementia, in the early stages may turn to alcohol as their way of dealing with what can be frightening changes in their memory. (Dementia may lead to increased alcohol use by some people to cope).
Alcohol problems among people who have dementia are probably much more common than we might think. The problem affects thousands of people in Canada of all classes and stations in life. In September 1, 2001, the National Post carried an article on the famous Canadian opera singer Maureen Forrester, who has both conditions and is now living in a nursing home. (1)
Does Alcohol Abuse Cause Dementia?
Alcohol abuse can lead to several forms of dementia, but it does not seem to cause Alzheimer disease.
Recent research suggests that people who drink moderately (which is one drink a day for women, or two drinks a day for men) have less risk of developing Alzheimer disease than people who are heavy drinkers, or people who have never been drinkers. The potential protective effect, which is small to start with, may be related to the anti-oxidants contained in some alcohol beverages such as red wine.
However, there are still many important
questions in the way the existing research information is gathered (who is
included, who drops out, how is the dementia identified) that leave the issue
Family giving care may be concerned about whether they might develop Alzheimer disease, and they may wonder will alcohol consumption prevent that from happening. Right now, research wise, it is too early to tell. The big problem is that it is not always easy to separate out moderate drinking from other health or environmental factors. For some individuals, it is important to take a very cautious approach: it can be easy to slip from "moderate drinking" into riskier levels of drinking.
What is the Connection Between Alcohol and Dementias?
This is what we currently know about alcohol and dementia generally:
- Alcohol has a serious negative effect on the central nervous system.
- Alcohol can affect the brain directly as a neurotoxin.
- Alcohol can affect the brain indirectly - either when the higher alcohol use leads to malnutrition and vitamin deficiencies (especially Vitamin B) if the person is not eating properly or when the alcohol use causes liver damage. Both of vitamin deficiency and liver damage can lead to brain shrinkage and brain damage.
We know that general alcohol dementia is characterized by damage throughout the brain. Other kinds of alcohol abuse problems (e.g. Wernicke's encephalopathy and Korsakoff's syndrome) cause damage specifically to the frontal lobes. Alcohol dementia is not easily classified into "cortical" or "subcortical" (3) It seems to have some features of both,
We also know that 15 to 25 percent of dementia cases are tied to alcohol abuse. (4) Alcohol related dementia tends to show up at a younger average age than Alzheimer disease (about 10 years younger). (5, 6) Alcohol related dementia tends to lead to an earlier death than Alzheimer disease. (7)
The good new is that people who have alcohol related dementia seem to have a milder form of impairment than that seen in Alzheimer disease (8) and are less affected in their daily activities (9).
Also, alcohol-related dementia, in contrast to Alzheimer disease, appears to be a reversible form of dementia (10). In other words, if the person is able to abstain from drinking or significantly reduce the amount he or she is drinking, the memory impairment is reduced and may go away. There can be permanent damage however.
Alcohol, Dementia, and Abuse or Exploitation
On the other hand, giving care when the person has alcohol related dementia can sometimes be more challenging for family. Research suggests there is a higher frequency of anger, agitation, and personality changes in people who have dementia and a history of alcohol abuse.
People who have alcohol-related dementia or other dementias are also at risk of abuse and exploitation by others. People who have alcohol-related dementia can have good verbal intelligence and their language skills are preserved. (11) In other words, if just talking with the person casually, you may not notice anything unusual. However they can have impaired abstraction (e.g. being able to plan to do something and carry it out), and poor short-term memory.
For example, if the adult paid a delivery person for alcohol, and the delivery person came back later in the day and said "You haven't paid me yet", the adult with alcohol dementia likely would not remember whether or not he or she had paid. This kind of memory impairment leaves the adult extremely vulnerable to financial exploitation. Reputable delivery service operators do not take advantage of this. However, treatment services for seniors who have alcohol problems find that some delivery services (or specific members of their staff) are not reputable in this regard.
Alcohol and Medications
There are over 150 medications commonly prescribed to older adults that interact with alcohol. Depending on the drug, alcohol may make a particular drug work less well or not at all, can heighten its effect, or can be toxic. If a person drinks and is being prescribed any medication, it is very important to know the effect of alcohol on that particular medication.
Does Alcohol Interact with Any of the Drugs Used for Alzheimer Disease?
Unfortunately we do not know as much as we should about the effect of alcohol and these medications. That may not change for the near future because research on Alzheimer drugs often exclude people who are showing memory impairment but who have a substance abuse history (12).
This is what we do know:
Rivastigmine (Exelon)- Apparently, rivastigmine causes a large number of patients to have problems with their stomachs and intestines (13). Older adults who drink at more than moderate amounts and those who have had a long standing alcohol problem often have stomach problems. Rivastigmine may increase the problem.
Donepezil (Aricept): Use of Aricept can affect and be affected by certain medical problems, especially (14):
· Lung disease,
· Peptic ulcers, or history of,
· Seizures, or history of or
· Urinary tract blockage--Donepezil may make these conditions worse
· Heart problems--Donepezil may have unwanted effects on heart rate
· Liver problems--Higher blood levels of donepezil may result and increase the chance of side effects
Many of these medical conditions (particularly lung disease, peptic ulcers and liver problems) are more common among older adults who drink at more than moderate amounts.
So, physicians are likely to be cautious about prescribing these if the person has an alcohol problem.
Does Alcohol Interact With the Drugs Given for
Agitation in Dementia?
The drugs Respiridone (Respiridol) and Alzapam (Xanax) are often prescribed to help a person who has Alzheimer disease and is agitated. Respiridol is used to manage delusions.
Tranquillizers such as Valium©, Ativan©, Xanax©, Tranxene©, Halcion© lead to considerable increase in depression of central nervous system (increased sedation) and are potentially lethal in high doses when combined with alcohol.
How and Whether to Control a Cognitively
Impaired Family Member's
It has been suggested that alcohol can worsen the neurological, cognitive, and behavioral changes that people are experiencing in the early stages of Alzheimer disease. (15) Which raises an important question, "Should family members try to control the person's drinking?"
This is one of the most difficult areas, and we currently do not have a lot of reliable information. Like much in the area of caregiving for people who have Alzheimer disease and other dementias, it is very much trial and error. It is important to see what seems to work best with that individual. What works in one case may not work in another.
Part of the answer depends on how far along the dementia has progressed.
- Does drinking leave them more confused?
- It is increasing their risk? What kind of risks is it causing?
Possibly one of the most important things to do is to help assure the older person who is showing memory or cognitive impairment is getting adequate nutrition (particularly in terms of vitamin B12) to slow down or minimize the deterioration.
Some people try to control the family member's drinking by not bringing in any alcohol into the house and asking that others to not do so either. Sometimes the alcohol is coming from an outside supplier such as a bottle delivery service, and family may decide to ask the supplier not deliver to particular residence. A reputable delivery service will usually honour that request.
Sometimes alcohol has an important ritual or social role in the life of the person who has dementia (e.g. they always had a drink before dinner, or a beer while watching hockey on T.V.). Taking away that ritual of "normalcy" can be frightening and upsetting for the person, because it becomes "yet another" symbol of the growing loss of independence and the fact that others are taking over more and more of the person's life.
Family members can try a variety of ways to reduce the potential harm of the drinking while respect the importance of the ritual of alcohol for the person. These are some of things that family members try:
o substituting good quality "no alcohol" beer or wine for the regular beer or wine;
o diluting the alcohol in the liquor bottle so that when the person pours the drink, he or she is consuming less alcohol.
Whether these actually work will depend on the individual ("I'm not stupid, I just have dementia"), and the stage of the dementia.
Family may find themselves in a very difficult position where the person who is developing Alzheimer disease goes out to the liquor store and buys his or her own supply. Or the person giving care may be put in the difficult situation where the person who has dementia is becoming very angry about any restriction put on drinking. Family giving care struggle with the reality of whether it is less harmful to "give in" than to force abstinence, particularly where the person is reacting verbally (threatening the caregiver) or physically (hurting the caregiver).
Help for Alcohol Problems Among People Who Have Alzheimer Disease
Most alcohol treatment programs in Canada are not geared to older adults, let alone suited to older adults whose memories are becoming impaired. Some Canadian communities are fortunate to have programs and agencies that specifically help older adults who have alcohol problems. Several of these are outreach programs where a counsellor can go to the person's home. That can be very helpful for both the senior and for the family member giving care. Staff in these programs is more likely to understand the challenges that caregivers are experiencing when alcohol and dementia intersect.
The Need for a Very Special Approach
When There is Cognitive Impairment
General adult treatment alcohol programs focus a lot on cognitive-behavioural changes --- helping the person to develop other ways of dealing with problems and more positive ways of thinking about problems in their lives. This can be helpful for caregivers. This may also work for people in the very early stages of dementia, but does not seem to be useful as the dementia progresses.
Even in senior -specific programs, staff is often in the process of learning to find the best ways of helping when the client is cognitively impaired. They will often work with family members to help reduce the harms of alcohol for the senior.
(1) Christie Blatchford, "Maureen Forrester's life out of the spotlight", National Post, September 1, 2001.
(2) "Wine Reduces Risk for Alzheimers" www.alzheimersupport.com/library/showarticle.cfm?ID=1444
For a recent discussion of strengths and weaknesses of the current research on alcohol and dementia risk, see Ritchie. K. (June, 2003) Alcohol consumption and dementia. Lancet, (Neurology) 2, 333. http://neurology.thelancet.com/
(3) Monro, C. A., Saxton, J. & Butters, M.A. (2001). Alcohol dementia: 'cortical' or 'subcortical dementia. Archives of Clinical Neuropsychology.16, 523-533.
(4) Smith, D.M. & Atkinson, R.M. (1995). Alcoholism and Dementia. International Journal of the Addictions, 30(13-14), 1843-1869.
Also Lopez, O.L., Becker, J.T., Klunk, W., et
al. (2000). Research evaluation and diagnosis of possible Alzheimer's disease over the last two decades: II. Neurology,
(5) Thomas, V.S. & Rockwood, K.J. (2001). Alcohol abuse, cognitive impairment, and mortality among older people. American Geriatrics Society, 49 (4), 415-20.
(65) Carlen, P. L., McAndrews, M.P., Weiss, R.T. et al. (1994). Alcohol-related dementia in the institutionalized elderly. Alcoholism: Clinical and Experimental Research, 18(6), 1330-1334.
(7) Thomas, supra note 5.
(8) Woodburn, K.& Johnstone, E. Measuring the decline of a population of people with early-onset dementia in Lothian, Scotland. International Journal of Geriatric Psychiatry, 14(5), 355-361, 1999.
(9) Larkin, J.P.& Seltzer, B. (1994). Alcohol abuse and Alzheimer's disease. Hospital and Community Psychiatry, 45 (10), 1040-1041.
(10) Jackson, J.E., Kogel, K., & Renvall, M.J. (1998). Effect of alcohol abuse on adverse behaviors in patients with Alzheimer's disease. Journal of the American Gastroenterology Society, 46(9), P206.
(11) Saxton, J., Butters, M.A., & Shelton, C. (1999). Alcoholism, Dementia, and Alzheimer's Disease: Neuropsychological Characteristics and Differential Diagnosis. St. Francis Journal of Medicine, 5(1), 72-77.
(12) For example, NIA Launches National Study to Treat Mild Cognitive Impairment -- March 15, 1999, www.alzheimers.org/nianews/nianews19.html refers to a major Memory Impairment Study being conducted at 65-80 medical research institutions located in the United States and Canada. It is looking at and comparing the effects of Donepezil, vitamin E, and a placebo. However, the researchers decided to exclude people with memory impairments who have a substance abuse history.
(13) See Medline Plus, "Rivastigmine": www.nlm.nih.gov/medlineplus/druginfo/uspdi/500151.html
(14) See Medline Plus "Donepezil": www.nlm.nih.gov/medlineplus/druginfo/uspdi/203748.html
(15) Wiscott,R., Kopera-Frye, K., & Seifert, L. (2001). Possible consequences of social drinking in the early stages of Alzheimer disease. Geriatric Nursing, 22 (2), 100-104.
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