Brain And Cognition 2 PDF

Ch 18. hal-Disorders. 1 Introduction alcohol consumption conseg · - A risk of cardiovascular...

Ch 18. hal-Disorders. 1 Introduction alcohol consumption conseg · - A risk of cardiovascular disease - Cancer deronic inflammatory reactions -. 2 Alcohol Lisorder · alcold addiction is not used due to Instead DSM-5 defines it stigmatisation - as Alcohol use disorder al Problematic pattern (Il Symptoms) - · 3 varinuts > - wild 213 sympt. > - moderate 314 sympt > - several above 6 sympt.  ARBD alcohol related brain dawge. 3 Alcola related Cognitive Disorders - umbrella term long-term cognit impairm. - associated with problematic alcold use al consequences aufe mild major ↓ rateytree↓ snoynopeda drunkness alcoholic misuse Wernicke Korsakol fast normaliz 1y abstinence recovery irreversable -. temporary prefrontal volume loss Diencephalon Diencephalon Accou dimentit partial recovery widespread 4. Acute ↑ has global effect since mimicking maine inhibitor Alcohol mimics GABA-main necotr. that inhibits activity · small amount - froctal lobe inhibition ex. thinking ↓ analysing · more amount-crebellum hippocanyus parietal cate skills memory gaps to ex. motor ,  · more consumption broinstem - ex - breathingto = coma. 5 Chronic (mild-major Al Brain - damage volume loss of frontal lose ↑ - cerebrospinal fluid in areas of tissue loss diencephalon (Holamus mamillary body - Alcoholic encephalopathy abnorm. caused - chronic acold by Obse R Cognitive Cousey · executive function. · social cognition ·WM/episodicwea 20 % with alcoted disorder exp pp · use. cognitive probleces Older had wild adults who already · UCI cognitive impairm ; faster decime + alcold showed + alold-faste uncomplicated potients = good recovery. 6 Aetiology of Chronic a) Neurotoxi · 17 Not certain if cityis ethand the neurotoxic " probable Cause loss due to volume demyelination · : rateer than cell deater · the athophy (shinkage of brain) is reversable => Lue to remyclimation after stopping drinking factors b) A dose-response relationship the account of alcohol consumed the frequency started of drinking the duration age of use drinking N= No stopping drinking Current views : It's more based of Linkers types↓ = : anxitive valus (tacles of diff Liseases 2 to light drinkers heavy Grinkers of - moderate consumpt - long periods - - short few period cuittings - excessive multiple drinking relapse  the continuity hypothesis direct relation: between & I severity of consumpt Kand/ severity of extent. cognitive conseg. - in uncomplicated only cases seen didn't recent study : show of relate between cohol and severity use changes in grey/white matter how 1) Comonette, 4 typ TBI-head due to acoed · injury use Falling while drunk-common > - because alcohol consumption leads to muscle weakness + acute alcohol intox Cardiovasculardisease · > - type 2 diabetes · Liver damage Alcohol-broken the liver by > - down => excessive alcoud leads : to liver or hepatitis (inflamation) use or liver failure scarrie · Malnutrition > - I to hunger leadingbutpeople to eat less > - few nutrients calories , alcold = ex , Wernicke's  2) Alcoho retarded during Pregnancy growth - intell (lower thau) disability -. - facial abnorm. - problems with social interaction 7. Recovery a) Detox-complete stopping Consequences · - broin volume ↑ - cognitive functioning a in the first 4 to - 8 weeks abstinence is the biggest But for further improveme to recovery l up. year -. - Greeks until assesment · Recovery and cognitions varies - across diff. domaines WM/ attention ex. emot. - early recognition later -  ⑧. Wernicke's Encephalopathy a) aetiology - malnutrition um lack of B1 b) Characteristics acte Lisorder neurolog ·. least At 1 of the symptoms · - confusion/delirium - motor problems (ataxial Lisor. eye movem - v I Nustagmus Optedmoplegia rapid/involuntary eye muscle paralysis repetitive eye movem. · Infections - respiratory - UTI - abdominal - sepsis - menivigitis male Case : fired due alcohol influence 57y to - - 2 falls - confusion Treatment - Tweeks abstinence then assesment taken  inmemorthe Results wild impo : cognitive I not severe enough for Korsakoff) Rey Verbal AuditoryTest Learning tests used : 200 Map a) Brain damage - atrophy im mamillary bodies un taalamus Diencephalom D) Reversible - in Acute state usually with immeed. after of a fall (first hours/ high dosage B1 If untreated can lead to : Korsakoff - 9. Korsakoff's Syndrome Al Wernicke's Aetiology-delayed/untreated encephalopathy B) Characteristics - neuropsychiatric disorder · Prevalence : 4,8 : 10 , 000  2) Criteria · having expo with Wernicke's disorder in Episodic · disproportionate memory · lack of illness insight · contabulations = memory error (fabricated/distorted memories Alcold D Korsakoff itself is not the cause of & syndrome => this mine is the deficien cause d) (B1) Comorbity - After hypermesis gravidarum Isevere pregnancy vomitting) for surgery obesity - cancer - Case male 1st Wernicke's : bby -. Sypdos-not bottedby the illness insigent of back home because his go - work was there (incorrect) = consulations Other details - no contact with children -no of the test after memory 3 days=retrograde amnesia wood (observations - gloomy ausry irritability abothy - c ,  Results : ↓ performance on all episodic memory impairment in ↳ couldn't executive functioning complex figure copy a e) Cognitive prosive Memory mainly Episodic · - > Anterograde amnesia insility to encode - - ↑ and store new information difficulty placing memories correctly - =>> Proactive interference - old memories Lishob new old A is intrusive to ex - story new B => Retroactive interference : new memories distrib old B story ex new is intrusive to old A > - Retrograde amnesia to - inability of to Korsak. remember int. poor development => temporal gradient : new retrieved memories slower dra ↓ ex. what whath id was your you eat profession for dinner X remembering old int. Easter test : Autobiographical Memory Interview  learning) > - Non-declarative - unimpaired - able to acquire new skills · Vismospatial + Executive Functions deficit -copying complex Figures - task switching - planning test : 200 map Test 6 elem Test. social · cognition enot recognition -. ↓ Intelligence - · Fluid Prehea ↓ reasoning crystalized unimpaired - knowl. ) due to Lgeneral overlap with executive functioning · Neuropsych Symptoms > - provoked and sportan · confnsulations ↓ ↓ unintentionally without a prompt recalling non-exist inthe that. memory eX - believing is not true ex. what have you done ? ↳ recall an action that didn't happen  > - Cause of Contasulations - NOT Amnesia to be more likely - Gue to old in time source incorrectly memories impaired placed memory being · Brain Abnormalities thalamus - + mamillary bodies - Biencephalon ( more towards anterior thalamus) only Korsakoff with Alcoholic - prefrontal / hippocampal athophy 10· Alcold Dimentia - irreversable can develop one even without you - for Korsakoff meeting the criteria male case : z8y. > - ↑ forgetfulness fogetting medicine - coagulations > Lifs events in time placing - , > - apathy Assesment episodic Memog↓ : executive fluid intell Functioning. + Dinobrain & abnormalit a Diagnose :  10/09/2024 ALCOHOL-RELATED COGNITIVE DISORDERS 3 “NHG-STANDAARD” VERSION 4.1, 2014 TERMINOLOGY ❖ Problematic alcohol use (‘alcohol misuse’): drinking pattern resulting in physical complains and or psychological or social problems. The amount of alcohol units consumed is not leading for the diagnosis ❖ Alcohol Use Disorder (AUD): problematic alcohol use meeting the DSM-5-TR criteria for this classification ❖ Binge drinking: consumption of large amounts of alcohol (men ≥ 5 AU, women ≥ 4 AU) in a short time period, with periods of full abstinence Acute Symptoms ❖ Alcohol intoxication: result of excessive alcohol use in a short period of time, with dose related symptoms (disorientaion, sexual/agressive disinhibition, inability to make judgments) and a (risk of) severe complcations, e.g. loss of consciousness, shock, breathing problems, hypothermia and hypoglycaemia ❖ Alcohol withdrawal syndrome: result of sudden withdrawal after long-term excessive alcohol use than its more 21 - for Lisorder 4 2  10/09/2024 ALCOHOL-RELATED COGNITIVE DISORDERS Broad concept, describing (long-term) cognitive impairment associated with problematic alcohol use In DSM-5-TR terminology: Mild or major alcohol-induced neurocognitive disorder (formally incorrect terminology!) Amnestic-confabulatory subtype (or nonamnestic subtype) Korsakoss syndrome But ranges from short-term, reversible effects on cognition to chronic and irreversible deficits consumption alcohol s not the cause 5 ALCOHOL-RELATED COGNITIVE DISORDERS you CAU develop even without DMS-5 classification Acute cognitive effects Mild neurocognitive disorder Major neurocognitive disorder Alcohol-related cognitive disorders I Korsakoff Cause Being drunk Chronic effects of alcohol misuse Wernicke’s Korsakoff’s syndrome Alcohol-related (alcoholic encephalopathy) encephalopathy (amnestic- dementia (non- confabulatory) amnestic- confabulatory) Cognitive profile Dose-dependent, from Executive, visuospatial and Acute confused Amnesic syndrome + Impairments in every disinhibition, numbness, social-cognitive impairments mental executive, visuospatial cognitive domain decrease in reaction times state/delirium and social-cognitive possible, but no to confused mental state impairments - amnesic syndrome and no confabulations. Confabulations and Somatic comorbidity lack of illness insight frequent Persistence Normalises after period Recovery possible until a year Recovery possible Chronic (irreversible) Chronic, but (partial) without alcohol after abstinence after timely recovery is possible, treatment with depending on its vitamin B1 aetiology injections Brain Temporary, works on Prefrontal volume loss Diencephalon Diencephalon Widespread cortical abnormalities GABA/glutamate (thalamus and (anterior and and subcortical neurotransmitter system mammillary mediodorsal abnormalities bodies), cerebellum thalamus, mammillary bodies), cerebellum C 6 3  10/09/2024 alced ! use is a trigger AMNESIC SYNDROME KORSAKOFF’S SYNDROME for nutrition depletion resulting in B1 drop - Victor et al. (1989): “an abnormal mental state in Cingulate gyrus which memory and learning are affected out of all proportion to other cognitive functions in an otherwise alert and responsive patient” Addition by Kopelman et al. (2009): “resulting from nutritional depletion, ie, thiamine deficiency” sudden onset after Wernicke encephalopathy frontal and diencephalic damage (mammillary bodies and thalamus) as a result of chronic thiamine deficiency (vitamin B1) often caused by chronic alcohol abuse in · combination with poor nutrition Mammillothalamic tract But vitamin deficiency can result from other causes, such as anorexia, pregnancy, severe illness with vomiting (eg covid-19) Mammillary body Video: Korsakoff patient 7 Case : lack of insight irritability CAINE CRITERIA WERNICKE’S ENCEPHALOPATHY The acute neurological disorder that preceeds Korsakoff’s syndrome Timely thiamine suppletion (B1) essential But diagnosis often missed in clinical practice (hospital, ER) Korsakoff’s syndrome may be the results in case of treatment delay © Sullivan & Pfefferbaum, 2008 8 L 4  10/09/2024 AMNESIC SYNDROME KORSAKOFF’S SYNDROME: DIENCEPHALIC AMNESIA Characteristics: Personality changes with irritability or apathy L Confabulations and lack of insight Amnestic syndrome characterised by: incorrect memories Anterograde amnesia -new events Retrograde amnesia with temporal gradient in autobiographical memory Retrieval problems (executive as well) Contextual memory: problems with placing memories in time Increased sensitivity to interference (proactive and retroactive) + - Executive dysfunction (and sometimes other cognitive deficits associated with AUD) 9 KORSAKOFF’S SYNDROME retrieval delicit memories (confusion ( - CONFABULATIONS - messing up O Provoked: incorrect response to a question or situation in which a person feels compelled to say something (“where are we now?” – “we’re in a hotel”) - Spontaneous: occur without a trigger, patient acts accordingly (e.g., suitcase packed to go to a meeting with the boss of Shell) Not just “filling in memory gaps” due to amnesia, but result of temporal confusion strategic retrieval deficit, and impaired reality monitoring (“executive-memory dysfunction”) Spontaneous confabulations may deminish over time, provoked confabulations still present in chronic phase (Kopelman, 1987) 10 5  10/09/2024 CONFABULATIONS NIJMEGEN-VENRAY CONFABULATION LIST 6 11 EPISODIC MEMORY ANTEROGRADE AMNESIA Inability to store and retrieve new information ? Specifically in episodic memory (‘everyday memory’; ‘what, where and when’) - Contextual confusion (target information related to wrong time and/or place) Increased (proactive) interference Can be established with any episodic memory test that includes Delayed recall Free recall vs recognition Verbal and nonverbal stimuli E.g. the Rivermead Behavioural Memory Test (RBMT-3), which is also an ecologically valid test 12 6  10/09/2024 KORSAKOFF’S SYNDROME PROACTIVE AND RETROACTIVE INTERFERENCE When asked about story B : she answered with ↑ Proactive interference: old memories disturb new memories int of A Story A Story B Test B Elements from story A (‘intrusions’) Retroactive interference: recent memories disturb older memories Story A Story B Test A Elements from story B time 13 KORSAKOFF’S SYNDROME See in Alzheimer TEMPORAL GRADIENT IN MEMORY memories for past are 100 remembered 90 80 better man Memory performance geheugenprestatie 70 memoces 60 50 from 40 30 recent 20 10 0 20 30 40 50 60 70 80 90 0 decade decennium 14 7  10/09/2024 AUTOBIOGRAPHICAL MEMORY THE GALTON-CROVITZ METHOD Francis Galton (1879) and Herbert Crovitz (1974): giving cue words, after which test participants have to indicate their memories Michael Kopelman: Autobiographical Memory Interview Part 3: Main secondary school (ages 12-18) Personal semantic questions 3.1 Do you remember the name of your secondary school? If the respondent attended multiple secondary schools, specify; can you remember the name of a school you attended at about age 13? Scoring: 1 for name (max. 1) 3.2 Where was this school? If you know the city or town, that will do. Scoring: 1 for town or village (max. 1) 15 TEMPORAL GRADIENT RETROGRADE AMNESIA I Autobiografical Memory Interview Rensen, Kessels … Kopelman, J Clin Exp Neuropsychol 20-17;39:534-546 Albert et al. Arch Neurol 1979;36:211–216 16 8  10/09/2024 AMNESIC SYNDROME ARE ALL MEMORY FUNCTIONS DISRUPTED? No Characterised by severe impairments in long-term episodic memory (anterograde and retrograde amnesia) However: Intact : Unimpaired working memory (like phone numbers) WM Intact long-term memory for skills (procedural memory) Skills Intact priming (previously presented information has an automatic beneficial effect on later performance) Intact emotional memory 17 INTACT MEMORY FUNCTIONS FLASHBULB MEMORIES - enot. events KS patients studied 7 months after 9/11 attacks in 2001 (Candel et al., 2003) >67% of the patients remembered this (intact ‘emotional tagging’) Also vivid recall of contextual details (‘flashbulb memories’) But less detailed and less consistent reports compared to HC 18 9  ↑ 10/09/2024 KORSAKOFF’S SYNDROME NON-MEMORY DOMAINS AFFECTED Executive function: shifting and updating most affected (Moerman et al., 2019) Social cognition: Theory of Mind: mentalising, the ability to infer thoughts (cognitive) and feelings (affective) of others (Drost et al., 2019) Emotion perception (Montagne et al., 2006) Relevant for successful social interaction but not part of the core concept KS – “alcoholic encephalopathy” 19 APATHY “a lack of motivation that is not attributable to intellectual impairment, emotional distress, or diminished level of consciousness” (Marin, 1991, p. 245) Three dimensions of apathy (Ang et al., 2017) Behavioural activation (eg. Immediately doing something after having planned this) Social motivation (eg. Starting a conversation with others) Emotional sensitivity (eg. Feeling bad when someone close to you was informed to be seriously ill) 20 10  10/09/2024 ALCOHOL-RELATED COGNITIVE DISORDERS THE EFFECTS OF ALCOHOL ON THE BRAIN Estimate: 50% of people with alcohol-use disorder (AUD) have cognitive impairments 10% have severe cognitive impairments (incl. Korsakoff’s syndrome) Mechanisms: demyelination Direct neurotoxic effect: alcohol damages neurons and axons (but possibly even reversible) Indirect neurotoxic effect: high calcium concentrations damage the neurons after sudden withdrawal/abstinence Indirect effect of vitamin deficiency (B1/thiamine) Indirect effect of comorbidities (hepatitis, multiple drug use, traumatic brain injury, cerebrovascular risk factors) - In clinical practice, it can be difficult to assess the individual contributions of these factors 21 ALCOHOL-RELATED COGNITIVE DISORDERS BRAIN VOLUMES IN KORSAKOFF AND ‘UNCOMPLICATED ALCOHOLICS’ Galances is critical mea Volume differences (KS < AL < CS; p < 0.01) of medial-thalamus, hypothalamus, mammillary bodies and left insula A.-L. Pitel et al. Neurology 2012;78:1330-1333 22 11  10/09/2024 HISTOPATHOLOGICAL STUDIES BRAIN ABNORMALITIES IN ARCD - AE = alcoholic encephalopathy WE = Wernicke encephalopathy KS = Korsakoff’s syndrome (Arts, Walvoort & Kessels, 2017; Harper et al. 2003) 23 ALCOHOL-RELATED COGNITIVE DISORDERS WHICH COGNITIVE FUNCTIONS ARE IMPAIRED? Executive functions Response inhibition Risk taking Decision making Abstract reasoning Mental flexibility Memory Learning & retrieval efficiency Not an amnestic syndrome Visuospatial functions ↑ Often with an executive component (e.g., Rey complex figure) Social cognition Affective prosody Perception of facial expressions Interpersonal interaction > - 24 12  10/09/2024 ARCD AFTER LONG-TERM ABSTINENCE Meta-analysis Moderate sizes after 1- 12 months abstinence Small effect sizes >1 yr abstinence Stavro et al. Addiction Biology 2012;18:203-213 25 ALCOHOL-RELATED COGNITIVE DISORDERS IS THERE A DOSE-RESPONSE RELATIONSHIP? Continuity hypothesis (Butters & Brandt, 1985) Quantity of alcohol intake and duration predict the severity of the cognitive disorders Continuity hypothesis also mentioned as explanation of the memory disruptions with temporal gradient in Korsakoff’s: old memories are better preserved than recent ones, with a gradient However: no recent support for this continuity hypothesis Current view: a combination of factors explains the brain dysfunction ex - aled encope + regular issues or brain But: developing brains may possibly be vulnerable! damage 26 13  10/09/2024 ALCOHOL-RELATED COGNITIVE DISORDERS THE EFFECTS OF ALCOHOL ON THE ADOLESCENT BRAIN No 27 probably related t lower SES ALCOHOL-RELATED COGNITIVE DISORDERS THE EFFECTS OF ALCOHOL ON ADOLESCENT COGNITION TRAILS Study (TRacking Adolescents’ Individual Lives Survey); Trimbos & Utrecht University 2230 Dutch adolescents aged 11 (in 2000) T2: aged 13; T3: aged 16; T4: aged 19 Group subdivided into 6 groups of drinkers (abstainers up to very heavy drinkers: >15 units/wk for 4 years) Cognitive functions tested on T4 No differences between groups However: no MRI measurements, duration of follow-up very limited No reason to revise alcohol use policy → more research needed 28 14  10/09/2024 ALCOHOL-RELATED COGNITIVE DISORDERS THE EFFECTS OF ALCOHOL ON THE ADOLESCENT BRAIN Study from Rotterdam/Leiden/ Utrecht 3 cohorts of adolescents Dichotomized in yes/no alcohol use Yes/no intoxication (having been drunk) 3 follow-up assessments El Marroun et al. Eur J Neurosci. 2021;54:6012–6026. 29 ALCOHOL-RELATED COGNITIVE DISORDERS THE EFFECTS OF ALCOHOL ON THE ADOLESCENT BRAIN Drinkers lower volumes of global grey and white matter Also in specific brain regions But only in the 2 ‘older’ cohorts No dose-response relation Explanations: Direct neurotoxicity? Effect of intoxications (drunk/hangover)? Cause or consequence? (risky behaviour) El Marroun et al. Eur J Neurosci. 2021;54:6012–6026. 30 15  10/09/2024 Study limitations: No correction for SES No cognitive tasks (or no MRI) Small samples No info on other drug use or very heterogeneous Causality/dose-response? Almost everybody used alcohol at the age of 18 More longitudinal research needed With correction for confounders (meta-analysis Lee et al., 2021) they didn't fate into account SES 31 Effects possibly stronger for cannabis than alcohol But many study limitations so far Small and heterogeneous samples Substanse (mis)use very heterogeneous Large methodological differences No clear dose-response relationship Effects of sociodemographic factors not always taken into account Lees et al. Alcohol Res. 2021;41(1):11 32 16  10/09/2024 TREATMENT AND CARE FOR PATIENTS WITH ARCD “LOW VOLUME, HIGH COMPLEXITY” Debts Mental Societal Burden Health Care ARCD Somatic Social Issues Complications Welfare 33 MENTAL HEALTH CARE IN THE NETHERLANDS General Practitioner “gatekeeper” Hospital