British Journal of Addiction (1986) 81,77-80

The Severity of Alcoholism and its Relation toIntellectual Impairment and Cerebral Atrophy

B. MELGAARD, M.D., U. T. DANIELSEN Cand. Psych.,H. S0RENSEN Cand. Psych. & P. AHLGREN' M.D.

Department of Neurology, Gentofte Hospital, Faculty of Medicine, University of Copenhagen,DK 2900 Hellerup and 'Department of Neuroradiology, Glostrup Hospital, Faculty of Medicine,University of Copenhagen, DK 2600 Glostrup, Denmark

Summary .The severity of alcoholism has been evaluated in a group of chronic alcoholics by means of a modified MissouriAlcohol Severity Scale and an alcohol exposure index. No correlation could be established between severity scoresand intellectual impairment or cerebral atrophy.

IntroductionThe prevalence of alcoholic cirrhosis increases withincreasing alcohol consumption, and it may beassumed that the prevalences of other organdamages are associated with the severity of alcoholabuse and with the distribution of alcohol con-sumption within a society, i.e. the more heavydrinkers the more frequent the organ damages.'No epidemiological data are available on theoccurrence of intellectual impairment in normalpopulations but in groups of alcoholics referred for

1 treatment it has been estimated at 9%.̂ It has beenshown that this cognitive dysfunction may affecttreatment outcome.' Several studies have relateddetails of alcohol consumption to cognitive per-

I formance.'*' Evenson et al.'' have developed analcohol severity scale—Missouri Alcohol Severity

I Scale (MASS)—consisting of 20 items which focusnot only on alcohol consumption but also onphysical symptoms indicating tolerance and de-pendence occurring in chronic alcoholics. Thisseverity scale has been applied to treatment

1 outcome but never related to long-term complica-tions of alcoholism such as cirrhosis, intellectual

I impairment or Wernicke-Korsakoff s syndrome.The purpose of this study was to correlate

clinical impairment of neuropsychological per-formance and cerebral atrophy evaluated by CT-scanning to alcoholism severity as assessed by amodified MASS and an alcohol exposure index(AEI).

Subjects and MethodsThe patients were 46 men with a median age of 43years (range 26-61). All patients were chronicalcoholics fulfilling the following two criteria:'

Criteria I. Either: (i) Had been drinking dailyfor at least 1 year and had six or more drinks atleast two or three times a month, or: (ii) Drank sixor more drinks at least once a week for longer than1 year.

Criteria 2. Must have had alcohol problems in atleast three of the following four groups: (i) Socialdisapproval of drinking by friends, parents; maritalproblem from drinking, (ii) Job trouble fromdrinking; traffic arrests from drinking; other policetrouble from drinking, (iii) Frequent blackouts;tremor' withdrawal hallucinations; withdrawal

77

78 B. Melgaard et al.

convulsions; delirium tremens. (iv) Loss of con-trol; morning drinking.

Patients were referred because polyneuropathyor intellectual impairment were suspected when noother etiological factor than alcoholism could bedemonstrated. No overt Korsakoff patients wereincluded and no patients had previous episodeswhich were considered possible cases of Wer-nicke's encephalopathy. Two patients did notaccomplish the neuropsychological testing. Onebecause he refused to participate and one becauseof language problems.

Table 1. Modified Missouri Alcohol Severity Scale(MASS). Item description

1. Average amount alcohol drunk2. Nightmares or fright3. 'Need a drink on waking'4. Problems with memory5. Frequent blackouts6. Confusion when drinking7. Problems with vision8. 'Shakes'9. Problems with walking or balance

10. Numbness in hands or feet11. 'Cannot stop drinking by myself12. Not eating regularly13. Tolerance decreasing14. Losing control of drinking15. Headaches16. Withdrawal seizures17. Delirium tremens18. Usually drinks 'most of the time'19. Number of years with blackouts and shakes

All MASS interviews were performed on the dayof admission by the same two interviewers trainedfor this particular purpose in order to obtainunifortn information. Since all patients were ad-

mitted following at least 2 weeks abstentation(mean 5 weeks) no patient suffered from intoxica-tion or withdrawal symptoms. The original MASShas been modified slightly (Table 1). The alcoholconsumption, is comprised in one question. Ques-tions on votniting blood and severe hangovers havebeen omitted and the number of years withblackouts and shakes included. One questionabout withdrawal seizures has been added. Seven-teen of the nineteen items are scored 0-1 (absent-present) while the remaining two (average alcoholintake and number of years with blackouts) arescored 0-6, and 0-5 respectively. Additionally theexposure index (AEI) has been constructed bymultiplying the number of years the patient hadbeen drinking daily with estimated average dailyalcohol consumption during this period. Theneuropsychological examination included anam-nestic information and behaviour observation withreference to primary intellectual level and cogni-tive and affective changes. Psychometric testing(Table 2) investigated different learning andmemory dimensions, functions of abstraction,strategy and control as well as vigilance-tenacity atdifferent levels of complexity. Test scores wereranked according to fixed criteria—^which includedresults from age-matched normal controls—vindi-cating seven impairment degrees (from none tosevere). In addition a clinical assessment of theoverall cognitive function was based on anamnesticdata and accumulation of impairment in the testsand scored similarly. CT-scanning was performedon a Siemens Siretom (Matrix 256x256). Evansratio was measured from the normal computerpicture, whereas cortical sulci were measured on anenlarged image. For statistical analysis normalrank correlation and Chi square tests were used.

Tah\e 2. Psychometric Tests. Test scores are ranked according to fixed criteria (incl. relevantage corrections) indicating seven impairment degrees—from none to severe

Mean Range

Selective reminding, 15 wordsStory recall, 18 elements, immediate and delayed recallVisual gestalts, 16 elements, immediate and delayed recallDigit spanRandom Letter TestSymbol Digit Modality TestAuditive reaction timeBlock Design (WAIS)Sorting Test, modified Kasanin-HanfmannWisconsin Card Sorting Test

4.43.74.4 .4.04.04.04.04.73.75.0

1-71-71-71-71-71-71-71-71-71-7

Alcoholism and Cerebral Damage 79

ResultsPsychometric test results are presented in Table 2,and clinical data in Table 3. When eliminatingalcohol consumption from MASS a mean score of13.2 (range 2-19) was found. The correlationbetween the two alcoholism indices was high(r=.78, /X.OOl) which was not surprising sincethe alcohol consumption is a major determinant inboth. If, however, alcohol consumption was eUtni-nated from the MASS the correlation remainedhigh (r = .75, /x.OOl). No correlation was foundbetween the two indices and age. Premorbid levelsof intelligence were within or above normal limitsin all patients.

Table 3. Clinical Data on 46 Male Alcoholics

AgeMASS scoreAlcohol Exposure

IndexOverall Cognitive

ScoreEvans RatioCortical atrophy

Median

43.117.5

289

4.40.301.6

Range

25-613-28

12-950

2-70.24-0.38

1-4

No correlation was found between the length ofabstentation and neuropsychological results. Alsono correlation was found between the two alcoholseverity indices and the psychometric tests (Table4). Some of the psychometric tests and the CT-results correlated with age (Table 4) in spite ofrelevant age corrections in the test scores. There

was no correlation between the alcohol severityindices and the CT-results (Table 4). For furtherstatistical analyses the material was divided intotwo groups with MASS score 15 of above andbelow 15 ahd two groups with overall cognitivefunction scoring 4 or above indicating moderate tosevere dysfunction and below indicating mild tomoderate dysfunction. No correlations were found.Additionally no correlation was found when com-paring MASS-scores above and below 15 withcentral and cortical cerebral atrophy (/> = .05 andp = .67 respectively).

DiscussionDifferent psychological test methods have beenapplied to abstaining alcoholics and fairly uniformresults have been obtained indicating intellectualimpairment covering most aspects of intellectualfunctioning.*' This is often associated with cere-bral atrophy as imaged by CT-scans,*'"" but noclear-cut correlation between the radiological andpsychological findings has been established.

Nervous system disorders related to alcoholismhas mainly been attributed to nutritional differ-ences previously commonly seen in alcohoUcs.There is now compeUing evidence—^mainly fromexperimental studies—that ethanol is neurotoxicper se." The demonstration of a dose-responserelationship between the severity of alcoholism andthe degree of intellectual impairment or cerebralatrophy would support this view. Some studieshave demonstrated several relations between neu-

Table 4. Correlation Coefficients Between Alcoholism Severity, Age,Psychometric and CT-Scan Results

Selective remindingStory recallVisual gestaltsDigit spanRandom Letter TestSymbol Digit Modality TestAuditive Reaction TimeBlock Design (WAIS)Sorting Test (Kasanin-Hanfmann)Wisconsin Card Sorting TestOverall Cognitive ScoreEvans RatioCortical atrophy

MASS

-0 .3-0.2-0 .1-0 .1

0.00.0

-0 .1-0 .1-0 .1

0.10.0

-0 .10.1

AEI

-0 .10.00.10.10.10.10.20.10.1

-0 .10.1

-0 .20.1

Age

0.5**0.20.6**0.3*0.4*0.30.10.4*0.10.4*0.5**0.5**0.5**

MASS: Modified Missouri Alcohol Severity Scale.AEI: Alcohol Exposure Index.Correlations coefficients: * p<.05; ** p<.01.

80 B. Melgaard et al.

ropsychological performance and alcohol con-sumption in alcoholics and social drinkers^*"while others have been unable to find any correla-tions'"" or correlations between drinking historyand cerebral atrophy.'"-" Different methods in theevaluation of alcohol consumption were used. Inour study the modified MASS does not onlyinclude alcohol consumption, but also a number ofalcoholism related symptoms, but we found nocorrelation by any of the methods employed.Different drinking habits, selection criteria, psy-chometric tests and individual genetic disposi-tions'* may explain some of these discrepancies.

Correlations between some psychometric testsand age found in our study may imply acceleratedaging in alcoholics as relevant age correlationswere already included in the scoring of each test.

The difficulties in self-reporting on alcoholconsumption are well known, and it is generallyassumed that alcohol consumption is underesti-mated by patients during interviews. This can beexplained by an unwillingness to admit an alcoholproblem previously undiagnosed. Chronic alcohol-ics, however, readily report high alcohol intakes,but memory disturbances may lead to inaccuracies.The validity of MASS in assessing the severity ofalcoholism has been evaluated by Evenson et a/."and a good internal consistency and stability overtime was found. Thus the symptoms reported arenot only recently experienced but have beenknown by the alcoholic for several years.

Since treatment outcome may be affected byintellectual dysfunction^ it is important to assessthe presence or absence of this condition butneither the MASS nor the AEI seem helpfulinstruments in this evaluation. Neuropsychologicaltesting may be needed before selecting treatmentstrategy and in the subsequent evaluation oftreatment results.

AcknowledgementsThis study was supported by grants from Sygekas-sernes Helsefond and Den LaegevidenskabeligeForskningsfond for Stork0benhavn, Faer0erne ogGr0nland.

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