What is
alcohol-
related
brain damage
(ARBD)?
Factsheet 438 What is alcohol-related brain
damage (ARBD)?
June 2020
Together we are help & hope
for everyone living with dementia
This factsheet explains what ARBD is, including
the main types. It outlines the causes, symptoms,
diagnosis and treatment. It also includes practical tips
about how to support someone who has ARBD.
Contents
1 What is alcohol-related brain damage
(ARBD)? 1
2 Who gets ARBD? 2
3 Alcohol-related ‘dementia’ 4
4 Treatment and support for
alcohol-related ‘dementia’ 7
5 Wernicke-Korsakoff syndrome 10
6 Tips for supporting a person with ARBD 14
Other useful organisations 15
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What is alcohol-related brain damage (ARBD)?
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1 What is alcohol-related
brain damage (ARBD)?
If a person regularly drinks much more than the recommended
limit of alcohol, it can damage their brain. It will cause their
memory and ability to think clearly to get worse over time,
especially if the person drinks too much over many years. This
is known as alcohol-related brain damage (ARBD) or alcohol-
related brain injury (ARBI).
Some people with ARBD will only have small changes to their
thinking and memory, known as mild cognitive impairment (MCI).
They are at risk of more serious brain damage unless they stop
drinking. For more information see factsheet 470, What is mild
cognitive impairment (MCI)?
Other people with ARBD will have more serious problems
with their memory and thinking. Alcohol-related ‘dementia’ or
Wernicke-Korsakoff syndrome will cause them to struggle with
day-to-day tasks. This is similar to someone living with dementia,
such as Alzheimer’s disease.
A person who has ARBD won’t only have problems caused by
damage to their brain. They will usually also be addicted to
alcohol. This means that they have become dependent on it.
Addiction can make it much more difficult to treat a person with
ARBD. This is because professionals need to treat the person’s
alcohol addiction together with their symptoms related to
memory and thinking. See ‘Treatment’ on page 7.
How much is too much alcohol?
A unit is a measure of alcohol. You can find out how many
units are in an alcoholic drink by reading the label. The NHS
recommends not drinking more than 14 units of alcohol each
week. This should ideally be spread over three or more days
because ‘binge-drinking’ is particularly harmful to the brain.
When a person starts drinking more than around 25 units per
week on a regular basis, it may start to affect their ability to think
and function properly.
Drinking a large amount of alcohol in a short space of time (such
as a single evening) is known as ‘binge-drinking’. It is equivalent
to drinking 8 units or more for men and 6 units or more for
women. It has been suggested that older people should have
lower limits because they are at greater risk of the damaging
effects of alcohol.
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2 Who gets ARBD?
About one in 10 people with dementia have some form of ARBD.
In people with young-onset dementia (who are younger than 65
years old) ARBD affects about one in eight people. It is likely –
for a wide range of reasons – that the condition is under-
diagnosed. This means that the number of people living with
ARBD is probably higher.
People who are diagnosed with ARBD are usually aged between
about 40 and 50. This is younger than the age when people
usually develop the more common types of dementia, such as
Alzheimer’s disease. It is not clear why some people who drink
too much alcohol develop ARBD, while others do not.
ARBD affects men much more often than women. However,
women who have ARBD tend to get it at a younger age than
men, and after fewer years of alcohol misuse. This is because
women are at a greater risk of the damaging effects of alcohol.
What causes ARBD?
ARBD is caused by a person regularly drinking or binge-drinking
much more alcohol than the recommended limit. Alcohol
can damage the brain in several different ways, but the most
common are:
Damage to nerve cells – If a person regularly drinks too
much alcohol it can be toxic to their nerve cells. Over time,
drinking too much alcohol can cause brain cells to die and
a person’s brain tissue to shrink. This means there are fewer
cells to carry the messages that the brain needs to do
different tasks.
Damage to blood vessels –Regularly drinking too much
alcohol damages blood vessels in a person’s brain and
can lead to high blood pressure. Both increase their risk
of having a stroke (when the brain does not get enough
oxygen and is damaged).
Low levels of thiamine (vitamin B1) – A lot of the brain
damage that is caused by alcohol happens because it
prevents the body from getting enough thiamine (vitamin B1).
This is a vitamin that the brain needs to work properly. People
who are addicted to alcohol are also much less likely to have
a balanced diet. They often get a lot of their energy from
alcoholic drinks. This means that over months and years they
have a higher risk of malnutrition, including a lack of vitamins
such as thiamine (vitamin B1).
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Increased risk of head injuries: If a person regularly drinks
too much alcohol, they also have a higher risk of repeated
head injuries. While under the effects of alcohol they may
fall and hit their head, or receive blows to the head in fights
or as victims of violence. Both can cause lasting damage
to the brain.
A person with ARBD may experience all of these types of
damage. The different types of damage are linked to different
types of ARBD. For example, Wernicke–Korsakoff syndrome is
most closely linked with low levels of thiamine (vitamin B1).
Types of ARBD
Usually a person is diagnosed with a specific type of ARBD.
Depending on their symptoms, they may have one of several
conditions, including:
alcohol-related ‘dementia’
Wernicke–Korsakoff syndrome (also called amnestic
syndrome)
traumatic brain injury
alcohol-related stroke
other rarer forms of ARBD.
The two main types of ARBD that can cause symptoms of
dementia are alcohol-related ‘dementia’ and Wernicke–Korsakoff
syndrome. Neither of these are actual types of dementia,
because you cannot get better from dementia, and there is some
chance of recovery in both of these conditions.
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3 Alcohol-related
‘dementia’
If a person has alcohol-related ‘dementia’ they will struggle with
day-to-day tasks. This is because of the damage to their brain,
caused by regularly drinking too much alcohol over many years.
The person may have memory loss and difficulty thinking things
through. They may have problems with more complex tasks, such
as managing their finances. The symptoms may cause problems
with daily life. For example, the person may no longer be able to
cook a meal.
Symptoms of alcohol-related ‘dementia’
The symptoms of alcohol-related ‘dementia’ can change a lot
from person to person.
If a person with the condition has a brain scan, it will often show
that some areas of the brain have shrunk much more than others.
Alcohol particularly affects the frontal lobes of the brain. If these
are damaged, the person may have difficulty with:
staying focused on a task without becoming distracted
solving problems, planning and organising
setting goals, making judgements and making decisions
being motivated to do tasks or activities (even essential ones
like eating or drinking)
controlling their emotions – they may become irritable or
have outbursts
understanding how other people are thinking or feeling (their
behaviour may seem insensitive or uncaring).
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A person with alcohol-related ‘dementia’ may also have problems
with their memory. They might not be able to understand new
information – for example, they may quickly forget the details of
a conversation. They may also not be able to recall knowledge
and events, such as where they lived previously or places where
they have been on holiday.
Alcohol-related ‘dementia’ can also cause problems with
a person’s mood, such as apathy, depression or irritability.
These can make it even harder for the person to stop drinking –
and make it difficult for people close to them to help. For more
information see factsheet 444, Supporting a person with
dementia who has depression, anxiety or apathy.
A person with alcohol-related ‘dementia’ may be unsteady on
their feet and more likely to fall over – even when they are
sober. This is because alcohol damages the part of the brain
that controls balance, co-ordination and posture.
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Diagnosis of alcohol-related ‘dementia’
It can be very difficult to diagnose alcohol-related ‘dementia’.
If a doctor is unaware of the person drinking too much alcohol
over many years, they may not consider alcohol-related
‘dementia’ as a possible diagnosis. The person may not get the
right treatment and support, which is why it is important to tell
doctors about drinking too much alcohol.
A person can be diagnosed with alcohol-related ‘dementia’ if
they have problems with memory, thinking or reasoning that
severely affect their daily life, and are most likely to have been
caused by drinking too much alcohol.
For a clear diagnosis, the person needs to have these symptoms
even when they have stopped drinking and are not suffering
from the effects of alcohol withdrawal. The doctor will also need
to make sure that these symptoms don’t indicate another type of
dementia, such as Alzheimer’s disease or vascular dementia.
In order to make a diagnosis of alcohol-related ‘dementia’,
a doctor may ask the person to do a paper-based test to check
for problems with memory and thinking. For more information
see booklet 78DD: Diagnosing dementia: A practical guide
to assessment.
The doctor will also do a full physical examination and take a
detailed history of the person’s symptoms and how they are
affecting their life. They should also take an account from
someone who knows the person well, as this can help if the
person has gaps in their memory. The doctor may also ask
about problems with mood, such as anxiety or depression.
It is likely that a person will need a brain scan to rule out other
causes of their symptoms. These include a stroke, a bleed
caused by physical trauma, or a tumour.
It can be difficult to get an assessment, as some GPs will insist
that the person has stopped drinking for several weeks before
they can assess the person’s memory. Some experts think that a
person can be assessed for alcohol-related ‘dementia’ while they
are still drinking too much, as long as they aren’t intoxicated at
the time of the assessment. The diagnosis is less certain than if
they had been sober for a long time. If the person is refused an
assessment by the GP, they can contact NHS England to make a
complaint (for details see ‘Other useful organisations’ on page 15).
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4 Treatment and support
for alcohol-related
‘dementia’
Unlike Alzheimer’s disease or vascular dementia, alcohol-related
‘dementia’ is not certain to get worse over time. With the right
treatment and support, there is often a good chance that it will
stop getting worse or improve. For example, if the person stops
drinking alcohol, takes high doses of thiamine and starts eating
a balanced diet. However, if the person keeps drinking alcohol
and doesn’t eat well, alcohol-related ‘dementia’ is very likely to
get worse.
It is not easy to help a person with alcohol addiction to stop
drinking. However, it can be even more challenging when the
person has alcohol-related ‘dementia’. Problems with thinking
and reasoning (caused by dementia) can prevent a person from
understanding that they need to stop drinking. They may also
find it very difficult to stay motivated if they do stop drinking,
because losing motivation is a symptom of dementia.
Treatment
The first part of treatment usually lasts up to several weeks.
It aims to stop the person drinking alcohol and make their
health more stable. Most people with alcohol-related ‘dementia’
will need to stay in hospital for this.
Alcohol withdrawal usually causes a person to have delirium,
which can make them easily distracted and confused,
disorientated, and prone to mood swings. They may also
experience intense sweating, anxiety and a high heart rate.
They may become agitated or hallucinate. They may be
treated with drugs that mimic the effect of alcohol on the
brain to reduce withdrawal symptoms. These drugs can be
safely reduced slowly. The person will also be given fluids and
salts, and high doses of thiamine (vitamin B1) by injection.
Many people with alcohol-related ‘dementia’ have to wait in
hospital for a long time before they can get specialist care.
Depending on how serious their condition is, they could be
supported in residential care, sheltered accommodation or in
their own home – with support in the community.
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Support
After the first part of treatment, a person with alcohol-related
‘dementia’ will need support from different kinds of services.
Firstly, the person is likely to need support to help them stop
drinking alcohol (see ‘Other useful organisations’ on page
15). They may be given special prescription drugs to reduce
their craving for alcohol. They will also need to take high-dose
thiamine (vitamin B1) tablets and eat a healthy, balanced diet.
As well as medication, the person will need a lot of non-drug
support. This often includes counselling or ‘talking therapies’
that help them to stay alcohol-free. They may also be
encouraged to attend self-help groups. See ‘Other useful
organisations’ on page 15.
Some of the common symptoms of alcohol-related ‘dementia’
may make it harder for a person to take part in an alcohol
treatment programme. These symptoms can include denial, lack
of insight and being impulsive. The person may struggle to stay
focused during therapy sessions.
Staying alcohol-free can be particularly challenging if the
person is homeless or isolated from their family due to drinking
too much, or if they have poor physical or mental health.
Dealing with all these issues is important for helping the
person to stay alcohol-free, and to reduce the symptoms of
alcohol-related ‘dementia’.
A professional who has experience of supporting people
with alcohol-related ‘dementia’ should be involved in the
person’s care. The type of support they get will depend on
the person’s individual situation and what they need. People
with alcohol-related ‘dementia’ tend to be younger and
physically more active than most people who have other
types of dementia. They may benefit from services designed
for people with young-onset dementia.
Supporting a person with alcohol-related ‘dementia’ can be
challenging for their carer, friends and family. They will need
different kinds of support, which may not always be easy
to access. Most alcohol support services are designed to
help people stop drinking and stay sober and there may
sometimes be less immediate support available to deal with
the dementia-related parts of rehabilitation. However, many
support services have a ‘complex needs’ team which are better
equipped to support the different needs of someone with
alcohol-related ‘dementia’.
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Rehabilitation
As well as staying alcohol-free, a person with alcohol-related
‘dementia’ will need help to get better. This is known as
rehabilitation and is support that is matched to the person’s
needs. It works towards goals that the person agrees with
a health professional. This could include practising ways to
improve their memory, and learning to use memory aids or other
supportive technology.
For more information see booklet 1540, The memory
handbook and factsheet 437, Using technology to help
with everyday life.
Rehabilitation may be provided by a dementia service,
community mental health team or rehabilitation service for
people with a brain injury (for example, following an accident or
stroke). The availability of these local services may be different
across the country.
A person should usually see the most improvement in their
abilities during the first three months after they stop drinking
alcohol. However, for some people this improvement could
continue for as much as two or three years.
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5 Wernicke–Korsakoff
syndrome
Wernicke–Korsakoff syndrome is a condition that is similar to
dementia and is caused by drinking too much alcohol. Very
rarely, it can be caused by factors other than alcohol. The
majority of cases are caused by alcohol, and alcohol-related
‘dementia’ is the focus of this information.
In Wernicke–Korsakoff syndrome the damage to the brain is
caused in a very specific way. Alcohol prevents the body from
getting enough thiamine (vitamin B1), which is vital for brain cells
to work properly. This lack of vitamin B1 can have severe and
long-lasting effects on the brain.
Wernicke–Korsakoff syndrome has two separate stages.
First there will be a brief time when a person has intense
inflammation (swelling) of their brain. This is known as ‘Wernicke’s
encephalopathy’. If this condition isn’t treated quickly, the person
may develop a more long-term condition called ‘Korsakoff’s
syndrome’. This has many of the same symptoms of dementia.
About a quarter of the people affected by Wernicke–Korsakoff
syndrome who get treatment make a good recovery. About half
make a partial recovery and still need support to manage their
lives. About a quarter of people with the condition make no
recovery and may need long-term care in a specialist residential
care home.
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What is Wernicke’s encephalopathy?
Wernicke’s encephalopathy develops if a person’s brain doesn’t
get enough thiamine (vitamin B1). This is almost always caused by
a person drinking too much alcohol.
Alcohol prevents thiamine from being absorbed properly in the
gut, stops it from being used properly in the body, and increases
the amount of thiamine that the body loses in the urine.
Symptoms of Wernicke’s encephalopathy
Wernicke’s encephalopathy can be difficult to identify –
particularly if a person is still intoxicated with alcohol. The
symptoms can sometimes be mistaken for alcohol withdrawal.
The symptoms of Wernicke’s encephalopathy include:
being disorientated, confused or having mild memory loss
having difficulty controlling eye movements
having poor balance, being unsteady and walking with their
legs wide apart
being undernourished – for example, being very underweight
or having lost a lot of weight in the previous months.
It is unusual for someone with Wernicke’s encephalopathy
to have all of these symptoms. However, most people will be
disoriented and confused.
Diagnosis of Wernicke’s encephalopathy
Because a person with Wernicke’s encephalopathy is in a very
serious condition, diagnosis is often carried out in a hospital.
The doctor will look for symptoms of the condition and may also
carry out a brain scan to confirm their diagnosis.
As with other forms of ARBD, a diagnosis can be more
challenging if the doctor doesn’t know how much alcohol the
person drinks.
Treatment for Wernicke’s encephalopathy
The treatment of Wernicke’s encephalopathy is for the person to
immediately stop drinking alcohol and be given several injections
of high doses of thiamine (and other B vitamins).
After a person has had this treatment, they may be referred
to a service that can help them to stop drinking alcohol. See
‘Support’ on page 8, ‘Rehabilitation’ on page 9 and ‘Other useful
organisations’ on page 15.
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What is Korsakoff’s syndrome?
Korsakoff’s syndrome is a long-term condition that develops
when Wernicke’s encephalopathy is left untreated, or is not
treated soon enough. Over time, the damage to the brain
becomes more difficult to recover from.
Because Korsakoff’s syndrome often follows on from untreated
Wernicke’s encephalopathy, many people refer to it as Wernicke–
Korsakoff syndrome.
Symptoms of Korsakoff’s syndrome
The main symptoms of Korsakoff’s syndrome are confusion and
memory loss – particularly memory of events that happened
after the person developed the condition. Because the person
is less able to form new memories, they may also repeat the
same question several times. For some people with the
condition, memories of the more distant past can also become
lost or distorted.
Other symptoms of Korsakoff’s syndrome can include:
difficulty understanding new information or learning new skills
changes in personality – the person may become apathetic
(lacking emotional reactions), become very talkative, or do the
same things over and over
lack of insight into the condition – even a person with
large gaps in their memory may believe their memory is
working normally
confabulation – a person’s brain may fill in the gaps in their
memory with things that didn’t happen. For example, a person
who has been in hospital for several weeks may talk about
having just visited a person or a place earlier that day (this
is more common in the early stages of the condition). It is
important to remember that the person thinks this is a real
memory. It may seem as if they are purposefully lying – but
often this isn’t the case
problems with concentration, planning, making decisions or
solving problems.
Diagnosis of Korsakoff’s syndrome
A person may be diagnosed with Korsakoff’s syndrome if they
show some of the symptoms and have a history of drinking too
much. A brain scan can be helpful but is not always necessary.
People with Korsakoff’s syndrome are often diagnosed in hospital
after they have been admitted for other medical reasons.
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Treatment for Korsakoff’s syndrome
As with Wernicke’s encephalopathy, the main treatment for
Korsakoff’s syndrome is to give the person high doses of thiamine
immediately. They may also need to be given other types of
nutrition and hydration to get their body working properly.
In the longer term, the person will most likely need the same
kinds of support as a person with alcohol-related ‘dementia’ (see
page 7). They may also benefit from learning ways to help them
cope with their memory problems. See ‘Rehabilitation’ on page 9.
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6 Tips for supporting a
person with ARBD
Support the person to stop drinking alcohol. This will give
them the best chance of recovery.
Support the person do things that will help them to keep and
improve their skills. For example, if they are struggling with
shopping, aim to do it with them, not for them. You could give
them responsibility for the parts of the shopping trip they
enjoy and can manage, such as planning the meals or ticking
items off the shopping list.
Ask professionals who are involved in the person’s care how
you can best help them.
Encourage the person to keep a diary. They will benefit from
having a structure and a daily routine.
Break down complex tasks into smaller steps to make them
easier to follow, such as cooking a meal.
When you are talking to the person, be patient, use short
sentences and summarise what you have said. Give them
time to respond, and encourage them when they are
speaking. For more information see factsheet 500,
Communicating.
Support the person at home by labelling cupboards
and arranging rooms so that things are easy to find. For
information on helping the person to live independently, see
booklet 819, Making your home dementia friendly.
Encourage the person to eat a balanced diet. It’s important
to eat healthy meals every day to make sure they are getting
enough vitamins to help their brain to function. An alcohol
treatment service should be able to make suggestions about
healthy eating.
Help the person to look after their general wellbeing, such as
getting enough sleep.
Support the person to go to a self-help group for addiction.
Carers, friends and family can also join one (see ‘Other useful
organisations’ on page 15).
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Other useful organisations
With You
www.wearewithyou.org.uk
With You (previously called Addaction) is a drug and alcohol
treatment charity that has local services across England. It helps
individuals, families and communities to manage the effects of
drug and alcohol misuse.
Adfam
07442 137421
admin@adfam.org.uk
www.adfam.org.uk
Adfam is a national charity that works with families who are
affected by someone’s use of drugs and alcohol. It has an online
message board and a database of local support groups.
Alcohol Change UK
020 3907 8480
contact@alcoholchange.org.uk
www.alcoholchange.org.uk
Alcohol Change UK is a national charity. It works on alcohol
issues in England and Wales, campaigning for effective alcohol
policy and better services for people whose lives are affected by
alcohol-related problems.
Alcoholics Anonymous Great Britain
0800 9177 650
help@aamail.org
www.alcoholics-anonymous.org.uk
Alcoholics Anonymous provides support for people to recover
from alcoholism. You can use the website to find a meeting in
your area.
Al-Anon
0800 0086 811 (helpline, 10am–10pm every day)
helpline@al-anonuk.org.uk
www.al-anonuk.org.uk
Al-Anon provides support for family members and friends
of people who are addicted to alcohol. At regular Al-Anon
Family Groups people can share their experiences of living
with alcoholism.
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Drinkline
0300 123 1110 (9am–8pm Monday–Friday, 11am–4pm
Saturday and Sunday)
Drinkline is the national alcohol helpline. Calls to the helpline are
free and confidential.
National Association for Children of Alcoholics (Nacoa)
0800 358 3456 (helpline 12am–9pm Tuesday, Wednesday,
Thursday, 12am–7pm Monday, Friday, Saturday, )
www.nacoa.org.uk
The National Association for Children of Alcoholics (Nacoa)
has a free and confidential telephone and email helpline for
children of parents who are addicted to alcohol.
NHS England Complaints
0300 311 22 33 (8am–6pm Monday, Tuesday, Thursday,
Friday, 9.30am–6pm Wednesdays)
england.contactus@nhs.net
www.england.nhs.uk/contact-us/complaint/complaining-
to-nhse/
NHS England welcomes concerns, compliments and
complaints as valuable feedback that will help them learn
from your experiences and make improvements to services
they commission.
SMART Recovery
0330 053 6022
www.smartrecovery.org.uk
At SMART Recovery meetings people can get help to decide
whether they have a problem, build up their motivation to
change, and learn about proven tools and techniques to
support their recovery.
Factsheet 438
Last reviewed: June 2020
Next review due: June 2023
Reviewed by: Dr Tony Rao, Consultant Old Age Psychiatrist
and Directorate Lead for Dual Diagnosis in Older Adults,
South London and Maudsley NHS Foundation Trust
To give feedback on this factsheet, or for a list of sources,
please email publications@alzheimers.org.uk
This publication contains information and general advice.
It should not be used as a substitute for personalised advice
from a qualified professional.
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refer to our website for the latest version and for full terms
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for personal use, no part of this work may be distributed,
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