Facteurs socioéconomiques associés à la consommation d’alcool en France : une étude des différents modes de consommations

Abstract

Les troubles cognitifs dans l’alcoolodépendance restent assez largement sous diagnostiqués dans la pratique clinique. Pourtant, ils peuvent représenter un véritable frein dans la prise en charge addictologique avant même d’atteindre le tableau bien connu du syndrome de Korsakoff. L’atteinte du circuit fronto-cérébelleux et du circuit de Papez est à l’origine de troubles neuropsychologiques de sévérité variables qui concernent notamment les fonctions exécutives, la mémoire épisodique, et les capacités motrices et de visuo-construction. Ces troubles, associés à une altération de la cognition sociale, peuvent entraver le processus motivationnel, limiter les capacités des patients à bénéficier des prises en charge et favoriser la rechute. Des outils spécifiques de dépistage rapide ont été développés afin d’aider les cliniciens dans leur pratique et de leur permettre d’argumenter l’orientation des patients qui le nécessitent vers une évaluation cognitive extensive réalisée par un neuropsychologue. La présence de troubles, ainsi que leur caractère réversible, devraient conduire à un aménagement du parcours de soins pour favoriser la récupération ou pour compenser un éventuel handicap cognitif séquellaire. Dans cette revue, nous avons présenté le profil d’atteintes cérébrales et neuropsychologiques des patients alcoolodépendants. Puis nous avons étudié le retentissement de ces troubles sur la prise en charge des patients. Nous avons ensuite réalisé un focus sur les méthodes de dépistage actuellement existantes en pratique clinique. Enfin, un point a été fait sur la prise en charge des déficits cognitifs en alcoologie et sur les aménagements possibles.Alcohol-related cognitive impairments are largely underestimated in clinical practice, even though they could limit the benefit of alcohol treatment and hamper the patient's ability to remain abstinent or to respect his/her therapeutic contract. These neuropsychological deficits can impact the management of patients well before the development of the well-known Korsakoff's syndrome. Indeed, even in the absence of ostensible neurological complications, excessive and chronic alcohol consumption results in damage of brain structure and function. The frontocerebellar circuit and the circuit of Papez, respectively involved in motor and executive abilities and episodic memory, are mainly affected. Those brain dysfunctions are associated with neuropsychological deficits, including deficits of executive functions, episodic memory, social cognition, as well as visuospatial and motor abilities. Such cognitive disorders can interfere with the motivation process to abandon maladjusted drinking behavior in favor of a healthier lifestyle (such as abstinence or controlled alcohol consumption). They can also limit the patient's capacity to fully benefit from treatment (notably psychoeducation and cognitive-behavioural treatments) currently widely proposed in French Addiction departments. In addition, they may contribute to relapse which is multi-determinated. A neuropsychological assessment appears therefore crucial to take relevant clinical decisions. However, very few addiction departments have the human and financial resources to conduct an extensive neuropsychological examination of all patients with alcohol dependence. Some brief screening tools can be used, notably the MOntreal Cognitive Assessment and the Brief Evaluation of Alcohol-Related Neuropsychological Impairments, which has been especially designed to assess cognitive and motor deficits in alcoholism. These tools can be used by non-psychologist clinicians to detect alcohol-related cognitive deficits, which require an extensive cognitive examination conducted by a neuropsychologist. The presence of cognitive dysfunctions in patients early in abstinence should encourage clinicians to adjust the modalities of the treatment. The fact to favor recovery of cognitive functions and brain volumes with abstinence or drastic reduction of alcohol consumption could be a first way to make it possible for patients to be cognitively able to benefit from treatment. Further studies are required to determine whether specifically designed cognitive remediation could boost (accelerate or increase) the recovery of brain functioning. Additionally, a potential effect of thiamine to limit alcohol-related cognitive deficits before the development of neurological complications remains to be determined. In this review, we presented the pattern of structural brain damage and the associated cognitive and motor impairments in alcohol-dependent patients. We then emphasized the harmful effects of neuropsychological deficits in the management of these patients. We also pointed how relevant it is to screen patients with neuropsychological impairments and we focused on the presentation of two brief screening tools for cognitive impairments, especially designed for alcohol-related deficits or not. Finally, we reported how these neuropsychological impairments could be taken into consideration the treatment of alcohol addiction by adjusting its timing and modalities.