Alcohol Related Brain Injury | Martin Jackson | Ausmed Lectures

I suppose that what I'd like you to leave today with is a few key pieces of information one alcohol is the most common form of brain injury in the age group 35 to 55 under 35 its head injury over 55 it becomes stroke but is actually the most common form of brain injury in 35 to 55 practically nobody knows that - one in eight Australians drinks alcohol at a level which is likely to cause a brain injury in the long term so whether you know it or not a substantial proportion of your clients people you see are likely to actually be drinking alcohol at a level that might cause a brain injury three it sneaks up on you doesn't happen overnight unless you have an acute illness like Wernicke's encephalopathy and so people don't see it coming and bar and if that includes the person themselves and the the others around them family friends workmates so by the time that people actually think there might be a problem with their thinking skills and stuff it's usually too late they usually already have a problem and I'll show you some stats about that and the next one is I guess that there are safe levels of drinking so it isn't a drug where you know total abstinence is the recommendation it's not because there are actually safe levels of alcohol consumption so there some of the I suppose basic things are likely to take home if you can you leave home go home with those in your mind I think and that awareness that will improve your ability to identify it potentially manage it when it turns up in your workplace because it turns up all the time and there are certain workplaces where it turns up more often than others so if you happen to be a nurse who works in the forensic system if you happen to work in jail for example anybody having any idea about the prevalence of brain injury in prisons yeah 40 percent we did a research project back in 2008 through directions Victoria and gave Cyril neuropsychological assessments to prisoners being sent to jail after sentencing and it's the first study of its kind in the world because people had estimated on self-report but no one had actually ever assisted and the assessment levels were 40% and the research actually won an international award for doing this so there are groups like prisoners where it's extremely high and the most common cause of brain injury in prisoners is drug and alcohol now we are focusing on alcohol today because it is the most common drug and you've heard a bit of this preamble stuff already that all neuro toxic substances all drugs alcohol have an acute toxic aiding effect and withdrawal even if you're not addicted or you're not dependent if we go out and have a heavy night we're not going to feel too good the next day is our body's cope with the substance leaving our body they all have the potential to cause damage to our thinking skills in our brain certainly in the the acute tone like if you go and overdose on something if you go and drink you know two bowls of scotch and you're not a regular drinker if you're lucky you'll just pass out if you're unlucky you'll actually kill yourself by going to a spirit for your rest but most of them also have a long-term cognitive profile part of the problem when looking this in research terms is that there is not a direct correlation between substance use including alcohol and brain injury because there are safe levels of function and so research in the past has made the mistake of saying or there must be a direct correlation you know you have one drinking it's so much percentage you have ten drinks you get so much percentage doesn't work that way with alcohol you have to you'll only be susceptible to a brain injury if you've drunk enough in other words you reach that threshold and you've drunk it for long enough so you reach the time threshold and in males those thresholds are eight standard drinks a day for at least ten years there are there is certainly a gray area so four to eight standard drinks de for males it's a gray area because I'm not talking about other physical or health issues I'm talking about brain injury unfortunately for females it's harford so for females it's only for standard drinks a day for ten years or more puts you at risk of getting a brain injury it's not a lot of alcohol for standard drinks half a bottle of wine for three studies it's not a lot of alcohol let's this is why one in eight people drink at a level which might cause themselves brain injury in the long term the other interesting thing about brain injury and substance use is that the brain injury syndrome of cognitive impairment is often wider or more than the the acute syndrome and one of the classic examples of this for example is in benzodiazepine abuse and that's my other area of interest that apart from alcohol we've done quite a bit of research on benzos so the short term effects all related to speed of processing and attention and memory but one of the long term brain injury affects of benzos is a visual spatial disorder which you do not see in the acute setting so this is one of the ways when we still we're doing assessments on people who are still using whatever that using is to determine whether we're just seeing an acute toxic effect on functioning or actually seen potentially some evidence of long-term brain injury because unfortunately people still turn up intoxicated when I do assessments there are neuropsychologist who say I won't assess somebody when they turn up intoxicated because I don't know what's going on if they're you know high on something I say well what if this is how they are everyday you can still do an assessment if someone blows 0.35 on the breathalyzer it just means that you're saying this is how they function on a day to day basis like this if they stopped drinking they may improve but this is how they function so I mean yesterday's client turned up having drunk 1/3 of a cup of vodka that morning and they drinks the third of a bottle of day so he'd had his morning she had a couple of bonds before he came in for an assessment funnily enough he didn't do very well on assessment didn't in these complains about having a memory problem I think well are you surprised you know I use a first you've got a memory problem in him he was 40 44 and that's another issue which will come to about why don't we pick people up because it does take 10-15 years generally for alcohol to cause a brain injury you don't see people until their mid-30s late 30s generally showing these signs and if you try to explain to people well this could be alcohol doing that then of course they say well drunk like this fee is it can't be the alcohol it must be something else so this is often a problem when people turn up in the system and they usually turn up because they're sick and I'll show you some stats about that too I should say that one of my other jobs I've got lots of hats now I actually no no longer work at little attribute I took a very nice redundancy package as part of their restructure having been there for 17 years so I now new full-time private practice and then I've distracted myself and forgot what I was going to tell you what was I saying now the other jobs that's right so as well as doing our bias I work at TAC I do medical legal work in prisons they're going after prisoners quite regularly and do assessments I suppose that one of the things that comes across in this area is that even when blot you think blind Freddie should be able to tell this person has a problem people often don't and I'll get lawyers refer clients to me say oh you know I don't think they're quite right there's just something doesn't seem to be going on in there and your system they were seriously seriously impaired and you wonder how did you get this far without someone raising this question it's a common problem with alcohol how do they get this far before someone starts questioning the problem so if you can take that away with you and say I really need to be thinking about this all the time when I'm working with clients and I've been never fails to flabbergast me as to how many people don't ask clients about their drug and alcohol use they just differ ask if I see files and reports where it's never been mentioned and people will often say no one's ever asked me that before and you sort of think well why not it's something everybody should ask um what I said that already the the other issue I was gonna say that's right is that our brains also become more susceptible to things over the age of 40 whilst they still develop up to age 25 and particularly the frontal lobes you have a period of where I suppose you on a plateau and then once you get to 40 unfortunately the old neurons start to drop out and so if you are using substances you so they hit this double bang hey I've been drinking long enough now and now my brains not as it's not as able to cope with this as much as it used to be and you can see people go down heal quite quickly we won't go through that because it's already been covered abuse diagnosis so alcohol affects us in many ways it affects our nervous systems got a toxic effect it affects blood flow it affects cause dehydration it affects your uptake of thiamine which is a important point because a lotta people with alcohol problems don't eat well so they get nutritional deficits and the most common nutritional deficit is fireman deficiency and which leads to Wernicke's encephalopathy and korsakoff's psychosis so even if you have clients who are being given thiamine because they were known alcoholic if they're still drinking it actually reduces the positive effect of taking thiamine so it's important to keep that in mind alcohol brain injury comes in two forms you have the memory impairment and then you have the the dis executive syndrome we're talking about thinking emotion behavior and physical movement the physical movement is related to the the thiamine deficiency when we'll talk about a tax here in uropathy but the memory impairment physical movement syndrome is quite distinct from the dis executive syndrome people often call the dis executive syndrome to mention so if you look at a DSM and criteria for what is alcoholic dementia it's memory impairment plus problems with language or executive skills etc I actually don't like the term alcoholic dementia it's a very medical term the reason I don't like the term alcoholic dementia there's several reasons actually one if I ask the man in the street what is someone with dementia what I look like everybody thinks about Alzheimer's disease - if you stop drinking you won't get worse you could in fact get better three it does not affect all your cognitive functions and one of the reasons we poor picking up early alcohol later brain injury is that the person still very good at many things they know and so I just personally don't like this tune to mention because of the connotations of of what people attach to the word dementia but it is still commonly used it's very popular with the Americans it's not so popular with the Europeans and Americans and Europeans rarely agree on any medical issue and this is one that they don't it's also not the same as having an intellectual disability so alcohol brain injury occurs generally on a device of brain that's been developed so you already have a lot of skills very different to someone with an ID who might have a general lowering of skills so the Wernicke korsakoff's didn't go through this very quickly so it's thiamine deficiency it affects various our aspects of the brain but the most commonly affected areas are the milleri bodies and the thalamus so if you do niro pathological examinations you'll see microhemorrhages in the thalamus and milleri bodies both of these are extremely important for memory and so that is why someone who has an acute Wernicke's encephalopathy or well then recovers but is left with memory impairment this is why the interesting thing though is that there is a clear connection between alcoholism and thiamine deficiency and the permanency of memory impairment because people who get Wernicke's encephalopathy but aren't drinkers usually recover really well so this is people for example who go on starvation diets get lost in the bush they did huge studies and all the prisoners of war from Changi and I'm sure you've seen the their photos where their skill lethal and they were all firemen deficient yet not one of them had korsakoff's psychosis so there's something about alcohol and environment deficiency which interact with each other to causes permanent condition called korsakoff's psychosis so it's not just a simple issue of the thiamine deficient so the Kiwanuka kozakov ataxia so wide-based gate is the general a taxi gate for the alcoholic the neuropathy so they walk at the high-stepping gate because their feet fingers are burning or numb and you put the two together you get someone who walks like a Thunderbird you know I'm sure have you seen that the people walking like this they've got alcohol brain damage if they have a taxi or neuropathy they have alcohol related brain damage the only question is how bad is it you really see all these signs of these days and this is why we're Nick isn't careful up these under-diagnosed because the most common symptom of Wernicke's is confusion so someone who turns up with confusion at the emergency department yes they might be hyperglycemic they might be having a diabetic attack they may also actually he'd be having a thiamine deficiency attack and it resulted in the ambulance operators changing their protocol some years ago because the the general protocol for an undiagnosed coma or confusional state was to give somebody glucose and that's the worst thing you can do if someone's actually thiamine deficient because they can't metabolize the glucose and they become hypoglycemic and die so the the protocols changed some years ago that in undiagnosed comas and things they they would give both thiamine and and glucose just in case and you may or may not know that in mid 1990s they started fortified flour with thiamine did you know that no the government decided they needed to do something about all the people who are turning up with Korsakoff psycho this is a fortified flour and the the prevalence of Wernicke's encephalopathy went down greatly because most people who are alcoholic and aren't eating well tend to take eat junk food so pies and stuff and so they they actually get some benefit out of that so those just a couple of brains to show you a a non alcoholics brain with a reasonably sized third ventricle and an alcoholics brain with a clearly atrophied outside of the brain as well as a significantly dilated to ventricles so you brain shrinks basically and the reason your brain shrinks is for two reasons one a bit of dehydration but the other reason is that what alcohol does to your brain is it actually burns your white matter it literally burns away your white matter and so eventually when you're being enough of it it dies the neurons die and then they the brain starts to shrink because the white matter is not as robust as it used to be now this I put this table up because this is the the way that people generally present to places like our bias they turn something they've been referred because of suspected alcohol-related brain injury this is the first time they've ever been referred for such an assessment and yet in young and old is a below and above 40 and yet nearly half the people above the age of 40 have a cerebellar a texture and a peripheral neuropathy it's the first time they're being assessed and even you know 1 in 10 have under 40 have a neuropathy in one in 7 havin a tax year so when you see these people say again how did you get to this stage without anybody actually asking or doing anything about it and they're usually the reason they get to this state is because they're now really sick so most of the referrals for these assessments come through doctors emergency departments it's 90 percent of them are actually medically based and I'll show you the stats of how their lives have actually already fallen apart before they come for our assessments and as you can see there's a a low low rates of formal diagnosis of korsakoff's Wernicke's or dementia some of the interesting symptoms of alcohol and why do we miss it is that because it gets misdiagnosed as other things so people assume for example that you only have seizures when you worth drawing not true you can have seizures when you're intoxicated and so there's quite a few people with alcohol-related seizures who get misdiagnosed as having epilepsy because they weren't in tuk they weren't going through withdrawal when they had the seizure simple solution is to actually stop drinking and they won't have seizures add medication on top of it it creates a new problem the other issue is that people often get misdiagnosed of having psychotic disorders because there is alcoholic hallucinosis and alcoholic hallucinosis generally takes the form of conspiratorial auditory hallucinations so most people with alcoholism notices so here's hearing somebody in the room next door making plans to do something to them and things like that they generally don't get visual they get auditory and so we will often see people who've been diagnosed with schizophrenia and you're trying to look for the evidence of all this and you say mmmm that no that's true I think it might just simply be a case of alcoholic hallucinosis so people will often go to all sorts of extremes to find a medical reason that's not alcohol before eventually the penny drops and and this I guess some was rammed home to me when I was a very young neuropsychologist in Sydney and a client was referred for an assessment they it was an interesting way they came around because this client woke up on me they lived in a two-bedroom unit on the second floor they woke up one morning on the entrance of their block of apartments and on the sort of covering the roof having knotted together sheets and climbing down during the night and they went to see their doctor who thought they might have been having sleepwalking or having a you know a seizure disorder sent him off to a neurologist who kudos to the neurologist to the side of this person actually might have an alcohol problem send him off for an assessment well anymore ain't blind Freddie could tell this bloke had an alcohol problem because you walk in the door you could smell him and he was a white wine drinker and white wine drinkers have a really particular odor to them I can pick them from a mile off if they're intoxicated so if you're gonna if you gotta be an alcoholic try not to choose white wine something else good people can tell and he he was a policy adviser to a state government minister and swore black and blue that he drank no more than half a bottle of wine a day and he blew point three two on the breathalyzer and he was walking and talking quite coherently so the so there were two morals to that story there's a third one I'll get to the two mores are you can't believe what people tell you if they're an alcoholic they seriously under tell you how much they're drinking the general rule of thumb is you generally doubled in the extreme cases you might even triple it and people will look for another reason for why they're unwell of them their alcohol the third mole to that story was in why young you know days I said to this bloke can't test you like this go away don't drink for a day and come back funnily enough he did he actually didn't drink for a day and came back blue point one-one on the breathalyzer and then proceeded to have a total seizure on my floor so I learned very very early don't ever do that to a client who's clearly addicted intolerant you don't tell them to go away and come back and don't drink because this is what you gonna do

Channel: Ausmed

Views: 82,907

Keywords: Ausmed, Ausmed Lectures, Alcohol Related Brain Injury, Nursing, Healthcare

Id: f954qZZxK9E

Length: 21min 38sec (1298 seconds)

Published: Thu Jan 28 2016