Mary O'Brien, a sturdy, jovial, sixty-four-year-old woman, complained of a gradually worsening memory over a three-year period. She lived with her husband and was close to her four grown children and nine grandchildren. I completed an extensive neurological, psychiatric, and neuropsychological evaluation that showed moderately severe deficits in recent memory associated with generalized brain atrophy on MRI scan. These results strongly suggested Alzheimer's disease. But as I usually do before I drop this diagnostic bombshell, I spent a little extra time double-checking all aspects of the patient's history.
I recalled that at her first visit, she had responded to the question about alcohol use by stating that she drank a little every day. After I received her alarming test results, I decided to probe further into this issue. Mary then revealed that she had four shots of whiskey every evening, a long-standing habit. Her husband confirmed her report. He also mentioned that she had begun to make up stories to fill the gaps in her recent memory, a tendency that is called "confabulation." Mary said that she had played with her grandchildren the previous weekend when in fact she hadn't seen them for a month. Confabulation is common in both Alzheimer's disease and Korsakoffs syndrome, which is the diagnostic term for a common type of alcohol-induced brain damage and memory loss. Heavy drinking damages the liver, which in turn causes thiamine (vitamin B1) deficiency. Thiamine is essential for proper utilization of glucose, which is the brain's main energy source. As a result, alcohol-induced thiamine deficiency causes damage to nerve cells in the hippocampus and two nearby structures called the amygdala and mammillary bodies that are also involved in memory processes. This leads to memory loss for recent events while most other intellectual abilities remain intact.
The neuropsychologist had concluded that Mary's test performance was consistent with a diagnosis of Alzheimer's disease, but her history of alcohol consumption made me think otherwise. So I decided to launch a systematic campaign to get Mary to stop drinking, or at least to reduce her alcohol consumption. Getting people to stop drinking or smoking is never an easy task, and these efforts are often doomed to fail. When I broached the subject, Mary fussed that there was nothing wrong in having a few "tonics" every day. After some thought, I realized that her husband, Sean, was the key. I spoke to him alone.
"Mary's four or five drinks a day are probably the cause of her memory loss," I said. "With age, her brain cannot handle the same amount of alcohol, which didn't create a problem when she was younger."
He paused to digest this new information. "I think I understand what you mean, doc," he ventured. "To tell you the truth, I was getting a little worried about that. But I can't get her to stop. She won't admit that she's drinking too much for her age."
"Does she drink alone? Or with you?" I asked.
"Oh, I have a coupla beers in the evening. Just to keep her company. Never more than a coupla beers. That's about it."
"I'd like to switch gears for a moment, Mr. O'Brien. You know the line about children doing what their parents do and not what their parents say?"
Sean O'Brien nodded with a quiet chuckle. "You're sayin' I've gotta stop first, right?"
True to his word, he stopped drinking altogether. He also brought in a reinforcement; his oldest daughter joined the prohibition campaign against her mother. To my pleasant surprise, at her next visit Mary told me that she had cut back to two drinks a day. Sean confirmed that she had indeed reduced her alcohol intake. Eventually, she was able to stay off alcohol completely. Over time, her short-term memory gradually began to get better. During the following year, her memory showed modest further improvement, and during the next five years she maintained this performance level on tests of memory. Significant improvement in memory is virtually unknown in Alzheimer's disease, particularly over a prolonged period of time, while partial recovery after the patient stops drinking is typical of Korsakoff-type alcohol-brain syndrome. I was finally certain about the accuracy of my diagnosis.
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