Managing a Patient with Alcohol-Related Cognitive Impairment

If cognitive impairment is present, determine if it is acute (delirium) or chronic or acute on chronic (that is, acute exacerbation of a chronic condition). 

Where the patient appears to be in an acute confused state: 

• Hospitalise where appropriate.  
• Consider Wernicke’s encephalopathy. Treat urgently with parenteral thiamine (see Chapter 22). 
• Rule out and treat other causes of confusion, such as sepsis, dehydration, metabolic disturbances, subdural haematoma, post-ictal confusion, substance intoxication, ischaemia/infarction, hepatic encephalopathy. Carry out appropriate investigations: urinalysis, blood alcohol concentration, blood tests, x-rays, EEG, CT or MRI. 
• Orientate the patient with familiar staff and relatives, use of calendars and clocks, bright lights at night. 
• Use benzodiazepines with or without antipsychotic medication for acute behavioural disturbance; however, keep in mind that these medications also may have acute cognitive impairment effects that could obscure results of any cognitive screening. 

Where cognitive impairment is non-acute or slow to resolve, consider the presence of alcohol-related cognitive-impairment/ brain damage, Wernicke-Korsakoff’s syndrome: 

• Carry out more detailed bedside tests of cognitive function e.g. MoCA (see Box 19.1). 
• If available, refer for neurocognitive assessment with clinical psychologist/neuropsychologist. The timing of assessment will depend on the reason for referral (e.g. inpatient referrals may request assessment to assist evaluate decision-making capacity early on in treatment). If abstinence is likely to be maintained, comprehensive testing post an initial acute period is preferable (1-2 months), however this needs to balanced against the risk of potential relapse.  
• Investigate and treat where possible other potential causes of cognitive impairment, such as Alzheimer’s disease or other forms of dementia, vitamin B12 deficiency, cholinergic medications, neoplasm, ischaemia/infarction, traumatic brain injury, epilepsy, or other CNS disorder. 
• Rule out psychiatric comorbidity, which may present with cognitive changes; for example, major depressive disorder, severe anxiety, psychosis. 
• Emphasise the importance of abstinence for brain recovery to the patient and their support networks. Implement environmental interventions to optimise brain recovery and minimise risk of relapse (e.g. alcohol-free, low-stress, structured environment with emphasis on nutrition).  
• Consider engagement in structured daily activities (e.g. community groups, volunteer work) as a way of promoting routine and structure. Consider social groups (drop-in coffee groups) that are not excessively cognitively demanding but facilitate social engagement. Alcoholics Anonymous or similar treatment groups which have an emphasis on structure and routine may also be appropriate for some people with CI. 
• Conduct a risk assessment of the patient’s safety to live independently in the community. Include a social worker and occupational therapist as part of this assessment process.  
• Consider placement options. Meet with the family to discuss the patient’s limitations and requirements for activities of daily living. Review supported accommodation options where appropriate. Consider the need for guardianship if the patient is significantly impaired, unsafe to live independently but has limited insight about requirements for care. 
• Limiting access to resources (e.g. financial management, limiting access to places where alcohol may be obtained) may be an appropriate intervention if the patient does not have capacity to make informed decisions about his/her substance use or finances.  
• Consider the need for involuntary treatment if the patient continues to drink and does not engage in appropriate treatment. 
• Consider selected rehabilitation options if cognitive impairment is minimal and there is some capacity to learn new material and skills. Use strategies described above to engage patient in treatment and maintain contact. 
• Where possible, focus on teaching appropriate behavioural management and relapse prevention in a repetitive, relatively concrete manner (see Box 19.2. for more suggestions). 
• Consider the possibility of improvement in cognitive function after a significant period of abstinence and adjust treatment plan accordingly.