In this guest post, Dr Tony Rao, a consultant and visiting researcher in Old Age Psychiatry, considers recent media coverage over drinking and Alzheimer’s disease in the context of the research and his clinical experience.
When I started as consultant old age psychiatrist in an area of high socio-economic deprivation nearly 20 years ago, the thought of taking on the challenge of alcohol related problems in older people couldn’t have been further from my mind.
What shocked me was the number of referrals for older drinkers who also had memory problems. Traditional thinking was that any form of alcohol misuse can only be coincidental in the development of common forms of dementia such as Alzheimer’s Disease. In fact, there was very little consideration given at that time as to whether heavy drinking could really damage the brain to such an extent that it actually caused dementia.
Almost every month, the media sways us one way and then the other. One day, drinking red wine is ‘good for the brain’; the next day drinking within recommended guidelines ‘gives you brain damage’. If there’s one thing I’ve learned about the media, it is that their selective abstraction for the sake of a story often has little bearing to what might be an evidence based conclusion. If this were the case, such headlines would be qualified with the statement ‘there are several limitations to the study and a firm conclusion about causality cannot be drawn’. Wouldn’t that be a turn up for the books!
After 5 years as a consultant, I had what can only be called a medical epiphany when I looked at my ward round list to find that half the patients had alcohol related problems of one sort or another. The most obvious problem was dementia. It was time to do something and I threw myself in at the deep end, taking on a postgraduate degree that included both public health and clinical components. After emerging from the other end with both clinical and research knowledge, skills and attitudes relevant to addictions, I was now equipped to care for older people with alcohol misuse, many of whom had problems such as dementia.
So what has changed over the past 18 years? Well, the number of people whom I am now diagnosing with alcohol related dementia has increased beyond belief. This isn’t just because I am looking for it more carefully. It is also because the sheer number of older people with this diagnosis has also increased. There is also the ‘baby boomer’ effect of a sudden surge of substance misuse in those people in the UK born between 1947 and 1964. The youngest of this cohort have now crossed their half century. This is also reflected in the fact that the average age at which I am seeing alcohol related dementia is people in their mid to late 60s.
Many might argue that I see the extreme end of the picture and that alcohol in ‘moderation’ may still confer health benefits and be a ‘brain tonic’ in the general population. After the all, we read it in the paper.
Most of the evidence about the relationship between alcohol and dementia is taken from studies of health and aging, in which alcohol consumption is ‘nested’ in follow-up mortality. Few of these drill down into detailed quantity/frequency measures and couple this with detailed cognitive testing or changes in functional abilities. This research fog is clouded still by problems in selecting a control group that is supposedly free of the brain changes seen in alcohol misuse.
It would be true to say that, on the whole, researchers have still not cracked the problem of finding a representative control group. This often means that groups labelled as moderate drinkers are being compared against groups that include former drinkers who have given up (so called ‘sick quitters’). We also have the problem of those who supposedly drink moderately, under-reporting their alcohol consumption.
There are two main conclusions from what would be regarded as robust research in this area. The first is that there is no consistent evidence that drinking within recommended guidelines is associated with the development of dementia. However, this is qualified with an equally relevant conclusion that there is also little evidence to suggest that moderate drinking actually prevents the onset of dementia. These findings suggest that older people should not be advised to take up drinking to prevent dementia. Nor does it suggest that those who drink within the guidelines should necessarily become abstinent.
Additionally we must remember that the adverse effects of alcohol on both the body and on some prescribed medication increase with age.
Let’s now turn back to how heavy drinking affects the aging brain. Firstly, alcohol is a toxin, with increasingly damaging effects if taken in high enough amounts over long periods of time. In younger people, it may only affect memory but in older people its effects can mimic Alzheimer’s Disease. What helps to distinguish it from an Alzheimer’s type dementia is the early presence of changes in personality and behaviour. This is borne out in my own clinical practice, with most of the severe and challenging behaviours present in those people with a history of heavy drinking.
Further to dispelling misconceptions about the preventative effects of alcohol on dementia, it is time to move on and develop strong public health preventions strategies to support lower risk drinking. This needs to be complemented by care pathways for people with alcohol related dementia, most of who are often batted between services until they are finally in long term care.
There remains much that we can do prevent dementia in people with alcohol misuse. In this age of austerity, we need committed groups of people to join up the writing on the wall and link up public health interventions with clinical services to provide integrated care. At the moment, it is too little, too late.
With thanks to Dr Tony Rao for this guest post. You can follow him on Twitter at @oldagepsych or visit www.alcoholandolderhealth.co.uk for resources and information.
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