Genetic and Environmental Contributors to Neurodegeneration: An Exploration of the Effects of Alcohol on Clinical Features of Huntington's Disease Using the Enroll-HD Global Platform

Abstract

Huntington's disease (HD) is a neurodegenerative dementia with a well recognised genetic cause. Alcohol misuse is a major environmental factor relevant to numerous neurological presentations, including HD. We explored the effects of alcohol intake on clinical features of HD by means of data from the Enroll-HD, which is a global registry study. A retrospective observational study making use of the Enroll-HD periodic dataset up to 2020 (in accordance with the Enroll-HD guidelines, encompassing 16,120 subjects with the HD gene (CAG expansion > 36), was carried out. This included 180 sites in 21 countries. The study looked at the association of alcohol use with the clinical presentation of HD, specifically looking into the age of first symptoms and HD severity. We also describe a specific case with manifest HD, a participant in the Enroll-HD study, whereby the patient's obsessionality was central to her pattern of high alcohol intake and to her successful avoidance of alcohol thereafter. A record of past problems with high alcohol intake was more common in the group with manifest HD (9.0%, n = 1121) when compared with the pre-manifest carriers of the HD genetic abnormality (2.3%, n = 339). Age at onset of symptoms was not significantly influenced by current alcohol misuse, or past misuse. The severity of clinical impairments in HD was influenced by alcohol. Patients who reported high alcohol intake in the past had a statistically significant increase in motor impairments, by the Unified Huntington's Disease Rating Scale total motor score (Kruskal-Wallis, post hoc Dunn's, p < 0.001), and a significantly higher burden of psychiatric symptoms by the Problem Behaviours Assessment score (Kruskal-Wallis, post hoc Dunn's, p < 0.01) compared with those not reporting high alcohol use. However, the past alcohol group did not have a lower Mini Mental State Examination score (Kruskal-Wallis, post hoc Dunn's, p > 0.05) The first symptom of HD, as determined by the assessing clinician, was more likely to be psychiatric disturbance in patients currently misusing alcohol or those with prior history of alcohol misuse (55% and 31% respectively) when compared with controls (5%). Individual case experience, such as that presented in this study, shows that HD and alcohol, two major genetic and environmental contributors to neurodegeneration, interact in producing clinical problems. However, the complexities of these interactions are difficult to define, and may require larger studies dedicated to exploring the various factors in this interaction.

Keywords: Huntington’s disease; alcohol; neurodegeneration.

Figure 1

(a) Unified Huntington’s Disease Ratings Scale (UHDRS) scores, a measure of motor impairment, are lower in the control patient group, when compared with those who reported alcohol problems in the past (Kruskal–Wallis, post hoc Dunn’s, p < 0.0001); (b) Mini Mental State Examination (MMSE) when used as a measure of cognition is not related to alcohol or past alcohol use (Kruskal–Wallis, post hoc Dunn’s, p > 1). p values <0.01 shown as ‘**’ and p < 0.001 as ‘***’.

Figure 2

Problem Behaviours Assessments (PBAs) as a measure of psychiatric burden in Huntington’s Disease (HD) shows depression, apathy, irritability, psychosis and executive function are all significantly more sever when compared to controls (Kruskal Wallis, post hoc Dunn’s, p < 0.0001). p values <0.01 shown as ‘**’ and p <0.001 as ‘***’.