The complications of alcoholism: an epidemiological, statistical and nutritional study on alcoholics admitted to a general hospital psychiatric unit

1) A study of alcoholics admitted to a general hospital psychiatric unit over a period of 4 years (527 males and 148 females) is presented. The various demographic, social and drinking characteristics are given and the male and female alcoholics are compared. The complications and associated physical conditions were studied epidemiologically and with special reference to blood vitamin levels in an attempt to elucidate their aetiology. A follow-up study was carried out to find the causes of death in these patients and at the same time the prognosis studied to ascertain its relationship to these complications.2) There were more alcoholics in social classes I, II and 7 and in the widowed and divorced. The age pattern of alcoholics was similar to other studios with an almost normal distribution curve around the mean of 43.7 years in males and 45.4 years in females. The religion of the patients was similar to that of the surrounding area.3) Over half of the alcoholics were admitted as emergencies} a quarter did not finish the course of in-patient treatment and one-fifth of the total were re-admitted during the four year period.4) Whisky was the preferred drink among male alcoholics and "fortified wine" among females. The former had been drinking for considerably longer than the latter (a mean of 16.2 years compared to 9.9 years) and they drank, on average, much more, (the equivalent of a bottle of whisky a day compared to the equivalent of a bottle of sherry per day).5) A quarter of all the patients were given an associated psychiatric diagnosis of which most were in the personality disorder group.6) There was a large incidence of behavioural disturbance, so that only one-third of men, but two-thirds of women, had no previous convictions. However more women (33%) than men (18%) had previous suicide attempts and more abused drugs than men (25% compared to 11%.7) Male and female alcoholics were shown to have a number of differences especially in drinking habits noted above. Female alcoholics were older, and they were admitted via other hospital wards or by Alcoholics Anonymous, They stayed longer in hospital and were admitted more frequently. They had more spouses who were alcoholic than males. They showed more evidence of malnutrition in the form of weight loss and clinical signs of nutritional disease and they had a higher incidence of alcoholic dementia and of the "rare" neuropsychiatric disorders. They had a lower incidence of alcoholic epilepsy, delirium tremens, alcoholic hallucinosis and E.E.G. abnormalities, as well as hepatitis and previous gastric operations, but similar incidences of cirrhosis, neuropathy and anaemia8) Only 18% of patients had no associated physical condition. Almost one-fifth of the patients had each of the following: anaemia, peripheral neuropathy, gastritis, hepatitis, severe withdrawal signs and E.C.G. abnormalities and one-tenth had cirrhosis. These results are very similar to other studies despite differences in drinking habits and social class. There were only 8 patients who had had previous venereal disease and 4 who had previous pancreatic disease.9) There was no objective evidence of withdrawal in 40% of the patients, on the other hand 20% had severe effects including delirium tremens. Alcoholics with delirium tremens tended to have associated cirrhosis, anaemia, peripheral neuropathy and epilepsy, as well as abnormal levels of whole blood thiamine and serum folate.More female patients had alcoholic dementia which was related to increased age, increased length of excess drinking and peripheral neuropathy as well as subnormal whole blood thiamine and nicotinic acid levels.Alcoholic epilepsy was associated with delirium tremens and with drug abuse, abnormal levels of S.G.O.T., S.G.P.T., serum proteins, whole blood thiamine and serum folate levels.Alcoholic hallucinosis was associated only with paranoid psychosis though there were more patients in this group with raised S.G.O.T. levels and low whole blood thiamine levels.Thus the alcoholic psychoses as a whole appear to have a relationship to nutritional factors.10) Peripheral neuropathy was associated with delirium tremens, cirrhosis and dementia. Food intake was poorer in these patients and on admission they had more evidence of wight loss, whole blood thiamine levels were low in 70% of the patients and there was an increase of abnormal protein levels. These findings confirm that nutritional factors are of importance in the condition, but there was also a relationship with the increased daily amount of alcohol, especially of fortified wine, and with the length of time of excess alcohol intake .`11) Whereas cirrhosis was related to delirium tremens, peripheral neuropathy, alcoholic cardiomyopathy and E.C.G. abnormalities, acute liver disease was related to no other physical condition. Similarly an increased number of cirrhotics load abnormal whole blood thiamine levels which were not found in patients with acute liver disease. Patients with cirrhosis were older and had been drinking for longer than other alcoholic patients.12) Gastritis, diagnosed on clinical grounds, was found in 17% of these alcoholics, was only related in male patients to various behavioral abnormalities. Most patients with gastric operations, found in 11% of male alcoholics and 4.5% of female alcoholics had their operations years after the start of heavy drinking. There was evidence of an increased incidence of peptic ulceration in these alcoholics.15) Alcoholic cardiomyopathy was present in only nine male alcoholics, all of whom had been drinking to excess for over 20 years and had a heavy daily intake of alcohol. However 113 patients were shown to have E.C.G. abnormalities usually of a minor degree.14) Anaemia was found in one-fifth of the patients, but was varied in nature, though in two-thirds of female alcoholics and a half of male alcoholics it was iron deficient in type. It was associated with increased alcohol intake, especially "crude spirits". Nutritional factors were important and there was an association with cirrhosis and delirium tremens.15) Female alcoholics were shown to have more evidence of nutritional deficiencies on most of the parameters utilised than male alcoholics. It would seem that nutritional deficiency is important in delirium tremens, alcoholic dementia, alcoholic epilepsy, cirrhosis and peripheral neuropathy.16) The average length of follow-up was four years, 10% of patients were untraced. Twenty-five per cent of patients were found to be improved, 20% worsened and 10% had died. The indicators of good prognosis were those in social classes I and II compared to social class V, decreased length of drinking and absence of behavioral abnormalities. Female patients did no better than male patients.17) Hale patients died mainly from cirrhosis, cardiovascular or respiratory disorders, including carcinoma of the bronchus, whereas females were much more likely to commit suicide.18) There were many associated physical and behavioral abnormalities in this group of alcoholic in-patients. No clear pattern as to exact aetiology of the different conditions emerged though nutritional factors appear to play a part in the conditions which are classically considered to be the "complications" of alcoholism