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Severe alcohol dependence is the third leading cause of dementia. Alcohol-induced dementia is a relatively late occurrence, gener-ally following 15 to 20 years of heavy drinking. Dementia is more common in individuals with alcoholism who are malnourished. The CT scan shows cortical atrophy and ventricular dilatation after about 10 years with neuronal loss, pigmentary degeneration and glial proliferation. The frontal lobes are the most affected, followed by parietal and temporal areas. The amount of deterio-ration is related to age, number of episodes of heavy drinking and total amount of alcohol consumed over time.
Alcohol-induced dementia, secondary to the toxic effects of alco-hol, develops insidiously and often presents initially with changes in personality. Increasing memory loss, worsening cognitive processing and concrete thinking follow. The dementia may be af-fected by periodic superimposed delirious states including those caused by recurrent use of alcohol and cross-sensitive drugs, respiratory disease related to smoking, central nervous system
hemorrhage secondary to trauma, chronic hypoxia related to re-current seizure activity, folic acid deficiency and higher rates of some neoplasms among those with alcoholism (Table 32.6).
The presence of dementia makes the treatment of alcoholism more difficult. Most treatment programs depend on educa-tion about substance abuse, working the 12 steps, some degree of sociability, and such relatively abstract concepts as second-ary gratification and a higher power. Such treatment programs are often reluctant to engage in the painstaking repetition that patients with alcohol-induced dementia often require. These patients may become frustrated in peer support groups such as Alcoholics Anonymous. Despite these obstacles, patients with alcoholism who complete a treatment program and remain sober do have some improvement in their mental state. There is an ini-tial improvement that peaks at 3 to 4 weeks, followed by a slow but steady improvement detected at 6 to 8 months. In general, the presence of a cognitive deficit (dementia) dictates an alcohol treatment program that is behavior based, concrete, structured, supportive and repetitive.
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