Study on alcohol and its neurological complications.
Alcoholism is characterised by alcohol tolerance, signs and symptoms of withdrawal and continued use in spite of insidious physical or psychological consequences. Recent diagnostic criteria define Alcohol Use Disorder by the presence of at least 2 out of the given conditions for more than a yeartolerance, signs and symptoms of alcohol withdrawal, drinking in excessive amount, a strong desire to use alcohol, unsuccessful efforts to reduce drinking, spending more time in alcohol and alcohol related activity, affecting one's personal work and social lifestyle due to alcohol, continuous alcohol use despite persistent social, interpersonal problems, alcohol use in spite of persistent recurrent physical and psychological consequences (DSM-5, 2013). Chronic alcohol abuse causes several distinct diseases affecting many organs including the liver, lung, stomach and the brain. However, the alcohol affecting the brain is the most significant factor for maintaining this alcohol abuse. These effects include emotional and behavioural changes as well as defective judgement, learning disability and memory dysfunction. Studies have shown that radio-imaging studies have documented presence of damage in the brain of alcoholics like shrinkage of the brain and atrophy of the nerve cells. At the basic cellular level, alcohol affects the functioning of the brain by affecting the gamma-aminobutyric acid, glutamate and other neurotransmitters. (1) The neurological complications of alcoholism includes both the peripheral and the central nervous system.
They are the alcohol withdrawal syndrome which includes alcohol withdrawal seizures, delirium tremens, alcohol hallucinosis.
The other neurological complications are the alcoholic peripheral neuropathy, alcoholic myopathy, Wernicke encephalopathy, combination of Wernicke encephalopathy with Korsakoff's psychosis. (1) Besides these complications less common complications have been identified which includes Marchiafava-Bignami Syndrome, subacute encephalopathy with seizure activity (SESA Syndrome), alcohol cerebellar degeneration which are usually diagnosed by their characteristic MRI and EEG findings. (2)
Incidences and Prevalence in India
According to the WHO 2014, global status report on alcohol and health, 38.3 % of the total world population consumes alcohol and 30% of the total population in India. (3) The prevalence of alcohol dependence is 12.5% and the prevalence of alcohol abuse is 17.8% in a lifetime. (3) The per capita consumption of alcohol globally is 6.6 litres, in India it is 2.2 litres. Around 200 different health conditions covered by the ICD-10 is associated with alcohol consumption. Out of which 3.3 million deaths are attributed to alcohol globally. (3) These statistical data encourages and contributes towards the importance of further researches in alcoholism and its underlying mechanism.
AIMS AND OBJECTIVES
1. To study the prevalence of various neurological related complications in alcoholism.
2. To study the correlation of duration and quantity of alcohol intake leading to neurological complications.
MATERIALS AND METHODS
The present study was undertaken under the Department of General Medicine, Govt. Stanley Hospital, Chennai. The study consists of 150 patients with history of alcohol intake satisfying the inclusion and exclusion criteria, presenting in medical OPD/wards/ICU, after proper consent were subjected to questionnaires, complete physical examination and relevant laboratory investigations as per proforma. A prospective observational study design was chosen and descriptive statistics was done for all data and suitable statistical tests of comparison for a period of 6 months.
Patients with history of alcoholism.
1. Patients with Chronic liver disease/Hepatic Encephalopathy.
2. Patients with known Seizure disorder.
3. Patients with Diabetes Mellitus.
4. Patients with Psychiatric illness.
5. Patients with Congenital disease.
6. Patients with Cerebrovascular accidents.
7. Patients with acute CNS infections.
Study Duration: Jan. 2015 to Sept. 2015
Study Design: Prospective Observational Study.
Sample Size: 150
This study is an observational prospective study, wherein 150 alcoholic patients satisfying inclusion and exclusion criteria were subjected to answer a set of questionnaires, complete physical examination and relevant laboratory investigations as per proforma, exclusively designed for the study. Prior permission from Institutional Ethics Committee was taken, written/informed consent from every subject was taken.
Descriptive statistics was done for all data and were reported in terms of whole observed values and percentages. Suitable statistical tests of comparison were done. Categorical variables were analysed with the Chi-Square Test. Statistical significance was taken as P<0.05. The data was analysed using SPSS version 16 and Microsoft Excel 2007.
National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine defines alcoholism as a primary, chronic disease characterized by impaired control over thinking, pre-occupation with the drug alcohol, use of alcohol despite adverse consequences and distortions in thinking. DSM-IV defines alcoholism as maladaptive alcohol use with clinically significant impairment.
Neurological Complications in Alcoholics
In our study patients, alcohol withdrawal seizures (38%) was the most common neurological complication followed by acute hallucinosis (20%). Alcoholic myopathy (2%) and WernickeKorsakoff syndrome (8%) were the least common neurological complications seen.
Study showed that in 26-35 yrs., acute hallucinosis (35%) was more prevalent. In 36-55 yrs., alcohol withdrawal seizures (46%) was more prevalent, whereas in 56-65 yrs. alcohol polyneuropathy (21%) was more prevalent. The study also concluded that the incidence of alcohol hallucinosis was significantly and consistently higher in younger age group patients and the incidence of alcoholic polyneuropathy, Wernicke's encephalopathy, Wernicke's-Korsakoff syndrome were significantly and consistently higher in very older age group patients.
The alcohol intake and its associated neurological complications were found to be more prevalent among the males (90%) as compared to females and transgender. There was a contribution of 5% of female alcoholics and 4% of transgender alcoholics in the study group.
Brand of Alcohol
It was observed that brandy (29%) was the most common brand of alcohol used among the study group followed by whiskey (22%). Of the brands, wine (2%) and country liquor were the least commonly used.
Duration of Alcohol Intake
It was found in the study that alcohol withdrawal seizure was the most common neurological complication seen except in the group with history of alcohol intake for a duration 0-5 years, alcohol hallucinosis was more prevalent.
The study also concluded that incidence of alcohol hallucinosis was significantly and consistently higher in patients with lesser duration of alcohol intake, whereas the incidence of alcoholic polyneuropathy and WernickeKorsakoff encephalopathy was significantly and consistently higher in patients with longer duration of alcohol intake.
Quantity of Alcohol Intake
The participants taking alcohol of around 840 gm/week had alcohol hallucinosis more common as a neurological complication, whereas the prevalence of alcohol hallucinosis and alcohol withdrawal seizure was equally seen in participants with alcohol intake of around 770 gm/week. For the rest of the group alcohol withdrawal seizure was the most common neurological complication. The study also concluded that the incidence of alcohol hallucinosis, Wernicke's encephalopathy and Wernicke-Korsakoff syndrome was significantly and consistently higher in patients with higher quantity of alcohol intake. The incidence of alcoholic polyneuropathy was significantly and consistently higher in patients with lower quantity of alcohol intake.
Age of Onset of Alcohol Consumption
In our study, it was found that the maximum age of onset of alcohol consumption was between 26-30 years of age.
Excessive indulgence of an individual in alcohol causes many problems and chaos at the individual level as well as at the society level. The chronic effects of alcohol abuse include neurological complications through both direct and indirect effects on the central and peripheral nervous system. These complications include alcohol withdrawal syndrome in the form of delirium tremens which is characterized by a state of intense acute withdrawal state in the form of mental confusion, diaphoresis, agitation, fluctuating levels of consciousness, visual and auditory hallucinations associated with tremors and autonomic activity!4) Alcohol withdrawal seizures occur within 48 hours of alcohol cessation and occur either as a single generalized tonic-clonic seizure or a brief episode of multiple seizures usually with a normal EEG record!5) In alcohol hallucinosis the patients have transient visual, auditory or tactile hallucination, but are otherwise clear. Principally Wernicke's encephalopathy is a nutrition deficiency disorder due to brain damage caused by lack of thiamine, most frequently seen in chronic alcoholic patients characterised by a triad of mental confusion, ataxia and ophthalmoplegia. Wernicke-Korsakoff Syndrome includes symptoms of Wernicke's encephalopathy along with global amnesia, which includes both retrograde and anterograde amnesia and confabulation. (6) Here, MRI findings may show hyperintense T2 lesions in mammillary bodies, medial thalami, tectal plate, periaqueductal area. Alcohol polyneuropathy is characterised by axonal degeneration and demyelination. Symptoms include paraesthesias, pain and weakness, reduced pain and temperature sensations confirmed by nerve conduction study. In alcohol myopathy, the main complaints include muscle pain, severe cramps in the muscles, weakness of limbs, mostly the proximal muscles and associated swelling of muscles and tenderness. Chronic alcoholic myopathy is characterized by a gradual long-term involvement of the muscles, which are usually painless and involves the weakness of the proximal muscles with associated muscle atrophy.
Not all alcoholics are alike. The degree of impairment differs from individual to individual and the aetiology of a particular disease has different origins for different people. With the known existing harmful nature of alcoholism in the society, its complications have been already recognised clinically for years, hence the current recent advances are emphasizing more in understanding the biochemical targets of ethanol and the pathophysiology of the complications. In current scenario, it is still a subject of active research as to what characteristic features makes certain group of alcoholics more vulnerable to brain damage. This study contributes to daily practice when encountering patients with chronic alcohol abuse to identify and differentiate the neurological complications of chronic alcoholism and at the same time understand its pathophysiology so that these treatments can be tailored to individual patients. Also to encourage further researches on advanced technology, to design newer therapies and medicines for diagnosis and to ameliorate alcoholism and alcohol related neurological disorder.
Table 1: The Percentage of Neurological Complications in Alcoholics Neurological Complications in Alcoholics Number Percentage Alcohol Withdrawal Seizures 57 38.00 Delirium Tremens 28 18.67 Alcohol Hallucinosis 30 20.00 Alcoholic Polyneuropathy 14 9.33 Alcoholic Myopathy 4 2.67 Wernicke Encephalopathy 9 6.00 Wernicke-Korsakoff Encephalopathy 8 5.33 Total 150 100 Table 2: Age Wise Distribution of the Various Neurological Complications in Alcoholics Neurological Complications In 26-35 % 36-45 % Alcoholics-Age Distribution years years Alcohol Withdrawal Seizures 12 28.57 30 46.88 Delirium Tremens 11 26.19 14 21.88 Alcohol Hallucinosis 15 35.71 13 20.31 Alcoholic Polyneuropathy 2 4.76 3 4.69 Alcoholic Myopathy 2 4.76 2 3.13 Wernicke Encephalopathy 0 0.00 1 1.56 Wernicke-Korsakoff 0 0.00 1 1.56 Encephalopathy Total 42 100 64 100 Neurological Complications In 46-55 % 56-65 % Alcoholics-Age Distribution years years Alcohol Withdrawal Seizures 10 33.33 5 35.71 Delirium Tremens 3 10.00 0 0.00 Alcohol Hallucinosis 0 0.00 2 14.29 Alcoholic Polyneuropathy 6 20.00 3 21.43 Alcoholic Myopathy 0 0.00 0 0.00 Wernicke Encephalopathy 6 20.00 2 14.29 Wernicke-Korsakoff 5 16.67 2 14.29 Encephalopathy Total 30 100 14 100 Neurological Complications In P value Chi Alcoholics-Age Distribution Squared Test Alcohol Withdrawal Seizures 0.258 Delirium Tremens 0.082 Alcohol Hallucinosis 0.003 Alcoholic Polyneuropathy 0.028 Alcoholic Myopathy 0.579 Wernicke Encephalopathy 0.001 Wernicke-Korsakoff 0.003 Encephalopathy Total Table 3: The Distribution and the Percentage of Neurological Complications in Alcoholics-Gender Wise Neurological Complications in Male % Female % Alcoholics-Gender Distribution Alcohol Withdrawal Seizures 53 38.97 3 37.50 Delirium Tremens 28 20.59 0 0.00 Alcohol Hallucinosis 27 19.85 0 0.00 Alcoholic Polyneuropathy 12 8.82 1 12.50 Alcoholic Myopathy 4 2.94 0 0.00 Wernicke Encephalopathy 6 4.41 2 25.00 Wernicke-Korsakoff 6 4.41 2 25.00 Encephalopathy Total 136 100 8 100 Neurological Complications in Transgender % P value Chi Alcoholics-Gender Distribution Squared Test Alcohol Withdrawal Seizures 1 16.67 0.545 Delirium Tremens 0 0.00 0.17 Alcohol Hallucinosis 3 50.00 0.068 Alcoholic Polyneuropathy 1 16.67 0.772 Alcoholic Myopathy 0 0.00 0.804 Wernicke Encephalopathy 1 16.67 0.033 Wernicke-Korsakoff 0 0.00 0.037 Encephalopathy Total 6 100 Table 4: The Percentage of Brand of Alcohol Used in Alcoholics Brand of Alcohol Used Number Percentage Beer 28 18.67 Wine 3 2.00 Whiskey 34 22.67 Brandy 44 29.33 Rum 25 16.67 Vodka 9 6.00 Country Liquor 7 0.00 Total 150 95 Table 5: The Relation between the Duration of Intake of Alcohol and the Development of Neurological Complications Neurological Complications in 0-5 % 6-10 % Alcoholics Vs Duration of years years Intake Alcohol Withdrawal Seizures 13 33.33 15 30.61 Delirium Tremens 8 20.51 13 26.53 Alcohol Hallucinosis 15 38.46 11 22.45 Alcoholic Polyneuropathy 0 0.00 4 8.16 Alcoholic Myopathy 1 2.56 3 6.12 Wernicke Encephalopathy 2 5.13 1 2.04 Wernicke-Korsakoff 0 0.00 2 4.08 Encephalopathy Total 39 100 49 100 Neurological Complications in 11-15 % 16-20 % Alcoholics Vs Duration of years years Intake Alcohol Withdrawal Seizures 19 52.78 6 30.00 Delirium Tremens 7 19.44 0 0.00 Alcohol Hallucinosis 1 2.78 3 15.00 Alcoholic Polyneuropathy 4 11.11 5 25.00 Alcoholic Myopathy 0 0.00 0 0.00 Wernicke Encephalopathy 4 11.11 2 10.00 Wernicke-Korsakoff 1 2.78 4 20.00 Encephalopathy Total 36 100 20 100 Neurological Complications in 21-25 % P value Chi Alcoholics Vs Duration of years Squared Test Intake Alcohol Withdrawal Seizures 4 66.67 0.103 Delirium Tremens 0 0.00 0.087 Alcohol Hallucinosis 0 0.00 0.003 Alcoholic Polyneuropathy 1 16.67 0.034 Alcoholic Myopathy 0 0.00 0.412 Wernicke Encephalopathy 0 0.00 0.402 Wernicke-Korsakoff 1 16.67 0.012 Encephalopathy Total 6 100 Table 6: The Relation of the Quantity of Alcohol Intake with the Neurological Complications Neurological Complications in 490 % 560 % Alcoholics Vs Quantity of g/week g/week Intake Alcohol Withdrawal Seizures 7 43.75 8 33.33 Delirium Tremens 2 12.50 2 8.33 Alcohol Hallucinosis 4 25.00 3 12.50 Alcoholic Polyneuropathy 0 0.00 5 20.83 Alcoholic Myopathy 1 6.25 0 0.00 Wernicke Encephalopathy 1 6.25 4 16.67 Wernicke-Korsakoff 1 6.25 2 8.33 Encephalopathy Total 16 100 24 100 Neurological Complications in 630 % 700 % Alcoholics Vs Quantity of g/week g/week Intake Alcohol Withdrawal Seizures 16 39.02 15 44.12 Delirium Tremens 7 17.07 10 29.41 Alcohol Hallucinosis 5 12.20 5 14.71 Alcoholic Polyneuropathy 4 9.76 3 8.82 Alcoholic Myopathy 2 4.88 1 2.94 Wernicke Encephalopathy 4 9.76 0 0.00 Wernicke-Korsakoff 3 7.32 0 0.00 Encephalopathy Total 41 100 34 100 Table 7: The Relation of the Quantity of Alcohol Intake with the Neurological Complications Neurological Complications in 770 % 840 % Alcoholics Vs Quantity of g/week g/week Intake Alcohol Withdrawal Seizures 6 33.33 5 29.41 Delirium Tremens 5 27.78 2 11.76 Alcohol Hallucinosis 6 33.33 7 41.18 Alcoholic Polyneuropathy 1 5.56 1 5.88 Alcoholic Myopathy 0 0.00 0 0.00 Wernicke Encephalopathy 0 0.00 0 0.00 Wernicke-Korsakoff 0 0.00 2 11.76 Encephalopathy Total 18 100 17 100 Neurological Complications in 910 % P value Chi Alcoholics Vs Quantity of g/week Squared Test Intake Alcohol Withdrawal Seizures 4 44.44 0.302 Delirium Tremens 0 0.00 0.113 Alcohol Hallucinosis 3 33.33 0.025 Alcoholic Polyneuropathy 0 0.00 0.017 Alcoholic Myopathy 1 11.11 0.598 Wernicke Encephalopathy 1 11.11 0.045 Wernicke-Korsakoff 0 0.00 0.017 Encephalopathy Total 9 100 Table 8: Distribution of the Age of Onset of Alcohol Consumption Age of Onset of Alcohol Consumption No. % < 20 years 1 0.67 21-25 years 46 30.67 26-30 years 83 55.33 31-40 years 19 12.67 41-50 years 1 0.67 Total 150 100
(1.) In: Hunt WA, Nixon SJ, eds. Alcohol-induced brain damage. National institute on alcohol abuse and alcoholism research monograph no. 22.NIH Pub. No 933549. Bethseda, MD: the Institute 1993:121-156.
(2.) Evert DL, Berman OM. Alcohol-related cognitive impairments: an overview of how alcoholism may affect the workings of the brain. Alcohol Health & Research World 1995;19(2):89-96
(3.) Global status report on alcohol and heath. World Health Organisation 2014.
(4.) Alcohol and alcoholism. In: Ropper AH, Samuels MA, Klein J. Adams & Victor's principles of neurology. Chapter 42, 10th edn. McGraw Hill Professional 2014:pgs. 1584.
(5.) Alcoholism, alcohol withdrawal syndrome. Kasper DJ, Jameson L, Hauser S. Harrisons principle of internal medicine. Vol. 1 & Vol. 2. 19th edn. McGraw-Hill Education 2015:pgs. 3000.
(6.) Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff Syndrome. 2nd edn. Philadelphia: Davis 1989.
Financial or Other, Competing Interest: None.
Submission 01-06-2016, Peer Review 27-06-2016, Acceptance 02-07-2016, Published 07-07-2016.
Corresponding Author: Dr. Akumnaro Jamir, Ladies PG Hostel, Room No. 108, Stanley Medical College, Chennai-600001.
Akumnaro Jamir , A. Ramalingam , G. Vasumathi , S. M. Sujatha 
 Post Graduate, Department of General Medicine, Stanley Medical College, Chennai.
 Senior Assistant Professor, Department of General Medicine, Stanley Medical College, Chennai.
 Professor, Department of General Medicine, Stanley Medical College, Chennai.
 Senior Assistant Professor, Department of General Medicine, Stanley Medical College, Chennai.
|Printer friendly Cite/link Email Feedback|
|Author:||Jamir, Akumnaro; Ramalingam, A.; Vasumathi, G.; Sujatha, S.M.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jul 7, 2016|
|Previous Article:||Serum neopterin: a new novel biomarker in acute myocardial infarction.|
|Next Article:||All ceramic veneers: a case report.|