Alcohol related brain damage. A service model

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1 Alcohol related brain damage A service model

2 pathway cognitive assessment ARBD ACE 111 (Addenbrookes cognitive examination) MOCA (Montreal cognitive Assessment) incapacitated/severe Capacitated/mild Management of cognitive damage Alcohol treatment Services Adapted management plans

3 pathway assessment ARBD incapacitated/severe Capacitated/mild Management of cognitive damage Alcohol treatment services

4 Wirral service severe ARBD Teams purpose: (Principle referrals from acute medical care) To enhance quality and longevity of life To reduce hospital bed days Reduce time spent in acute beds Prevent readmission

5 Service profile The team 2 days of a consultant psychiatrist 3 FTE senior social workers 1.75 FTE RMNs 2 care assistants 1 FTE admin support The case load (population 310,000) 120 cases are working aged adults with dementia 30 cases are ARBD The resources 1 trained up nursing home for working aged adults 1 trained up residential home for working aged adults 1 supported living accommodation for working aged adults Trained up domestic agency No direct access to inpatient units but working relationship with colleagues: Access to acute psychiatric and oldage beds

6 Identifying cases on the acute wards: a simple approach All three criteria should be positive 1. Probable history of heavy, long standing alcohol drinking for at least five years. 2. Confusion, memory problems, doubt about capacity and concerns about risk on discharge, after withdrawal/physical stabilisation. 3. Thee or more admissions into hospital and/or A&E in one year probably associated either directly (withdrawal, unconscious) or indirectly (trauma, organ disease, etc.) with alcohol ingestion. Or One or more delayed discharges from general hospital wards in the last 12 months. (a delayed discharge is defined as patients staying on the acute medical/surgical ward because of social and/or psychiatric problems). (Adapted through pilot work from Oslin s criteria relating to diagnosis of alcohol related dementia. (Oslin DW, Carey MS. Alcohol related dementia; Validation of diagnostic criteria. American Journal of Geriatric Psychiatry 2003;11(4): )

7 Overview of management phases Phase 1 Acute in patient care on medical/surgical ward Phase month assessment phase Phase 3 3 year program of management/improvement Phase 4 Placement and provision of optimum support Phase 5 On-going social support and integration

8 Overview of facilities Assertive in-reach Acute medical/surgical ward Possible assessment unit Assertive community team supervision, monitoring and care planning Intensive/custodial Specialist NH Non spec. NH with treatment package Residential Home with treatment package Socially Supported Sheltered with treatment package Supported living with treatment package Decreasing dependency Community based Domestic care with treatment package

9 Patient profile Medical and psychiatric presentation/history N=41 History of, or presentation with Number of History of, or presenting Number of patients co-morbid physical conditions patients co-morbid mental illness Unspecified encephalopathy 8 Depression 17 Convulsions 10 Aggression 8 Peripheral neuropathy 8 Cerebral ischaemic/infarcts 9 Upper motor neurone signs 3 Subdurals/ significant head 6 trauma or anoxic brain damage Cerebella signs 4 Polydipsia 1 History of portal 4 Bipolar affective disorder 1 hypertension/oesophageal varicies Deep venous thrombosis 4 PTSD 1 Diabetes 4 Hoarding 1 Chronic urinary incontinence/renal 4 Heroine dependency 1 disease (on methadone) Hepatitis C positive 2 Heart failure/fibrillation 5 Pancreatic disease 2 Duodenitis/gastritis/ulcers 5 History of significant fractures/dislocations 6 (N=22) ACE 111 score 65.7 (range 30-93) MMSE score 23.3 (range: 11 30) 1 patient went through PICU 5 patients on CTOs and 1 on guardianship

10 Clinical phases of rehab programme Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting Phase 1 Physical stabilisation (variable time) acute hospital management of encephalopathy, delirium tremens and withdrawal in the context of physical stabilisation and appropriate thiamine therapy (NICE 2010). If Wernicke s encephalopathy is suspected or established, parenteral thiamine (i.m. or i.v.) >500 mg should be given for 3 5 days (i.e. two pairs of ampoules Pabrinex three times a day for 3 days), followed by one pair of ampoules once daily for a further 3 5 days depending on response. If patient is at high risk of Wernicke s encephalopathy (e.g. malnourished, unwell) prophylactic parenteral treatment should be given, using 250 mg thiamine (one pair of ampoules Pabrinex ) i.m. or i.v. once daily for 3 5 days or until no further improvement is seen.

11 Clinical phases of rehab programme Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting Phase 2 Psycho-social assessment (usually 2-3 months:) The brain is likely to demonstrate a significant degree of recovery over three months of abstinence. Patients may have: Recovery is enhanced through: Abstinence Good nutrition Calm environment Promotion of routine and structure Regularisation of sleep and mood stabilisation Development of therapeutic relationships Early engagement with family and carers Introduction of memory cues, diary keeping, alcohol education On going psycho-social assessment

12 Phase 3; therapeutic phase of treatment programme Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting Organisational processes: On-going care planning On going capacity assessments Working with care agencies Principles of therapeutic engagement Intense Personalised Collaborative Socialization and developing relationships Planning activities Learning skills Therapeutic interventions Dairy keeping Activity scheduling Graded task assignment Memory and orientation cuing Alcohol education/management Impulse and behaviour control Managing apathy and motivation

13 Phase 4&5 adaptation and social integration phases Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting Phase 4 Adaptive rehabilitation (variable duration) Adapting the environment so as to compensate for residual cognitive and functional deficits Dangerous time Assessing levels of dependency and residual cognitive/functional impairment Working with families/carers Identifying appropriate physical environment Initially provide more support than is needed then, in new environment reduce support to enhance independence and autonomy Phase 5 Social integration and relapse prevention (on-going) Probably most important phase: good integration will prevent relapse Patient based outcomes Employment Social networking

14 Case study 1 complex case (concurrent physical problems and head trauma) DOB 1959 ; age 53 Referred to us 7 years ago; Relevant personal history: One of four brothers. Parents were heavy drinkers. Always a bit slow at school, left when he was 16 and worked as a refuse collector. Made redundant after 15 years as not attending work through excessive alcohol drinking. Formed a relationship with a female alcoholic and drug abuser; very chaotic relationship including her physically assaulting him on numerous occasions. Relationship broke down, made homeless, park benches and ended up in a hostel in Liverpool Brother picked him up and set him up in a rented house in the Wirral (as he lived on the Wirral) so as to keep an eye on him. Brother managed his finances and limited him to two cans of beer a day. Receives incapacity benefit (I have changed some medical and biographical details on this case)

15 Useful bit about medical history Case study 1 a complex case Numerous episodes of alcohol admissions with evidence of encephaolpathies: either hepatic/wernicke or withdrawal related delirium Multiple fractures and collapses, multiple trauma to head, culmination in a fractured skull in 1998 and related subdural haematoma and related convulsions demonstrated a cerebral infarct; right temporal lobe. Convulsions are recurrent and partially stabilised with sodium valporate. Admitted into acute care: hallucinating, fitting

16 When seen on ward: Case study 1 a complex case Needed a security guard outside side room. Disorientated in time, place and person Did not understand why he was in acute care Profound short term and long term memory problems Had significant reasoning problems Significant problems with regard to language

17 Case study a complex case Referred to team, moved to supported living. Neurocognitive treatment programme set up by team working with supported living and carers Enhanced hrs per day (under supervision) Team visiting once-twice a week Brother brought in as appointee

18 Case study a complex case When patient drinks 3-4 cans of alcohol: Refuses or non compliant to medication Disruptive and abusive Grand mal convulsions Patient thinks that his only problem is convulsions due to head injury Patient does not have long term recall of personal life events and alcohol history Patient cannot relate alcohol ingestion to convulsions Patient is insistent that he has access to alcohol Patient is able to maintain some memories of agreements and plans relating to exposure to alcohol with support.

19 Case study Current situation 1:1 support closed down Living in supported living for working age adults with mental health problems. Managed best interest under agreement with patient, staff and next of kin: Brother. Brother controls finances, staff facilitate in daily activities Prone to occasional outbursts associated with brother not visiting. Requires on-going supervision and structure. Four admissions due to fits in last 6 years, admissions (A&E).

20 Case study 2 an uncomplicated case A few years ago: a very intelligent, 45 year old female executive Waiting for a bus in London: (Permission given by patient to use case for teaching purposes and conferences)

21 Case study 2 Assessment Main findings: Preoccupation with being pregnant Apparent retrograde memory problems characterised by amnesic episodes and lack of memory regarding amount and duration of alcohol ingestion and related issues MMSE score of 30, but with problems with anterograde memory Some minor reasoning issues with slightly reduced word fluency Management issues: Wanted to have custody of children but was pragmatic about this Did not want to comply with institutional rehabilitation Did not accept that she had an alcohol addiction problem Placed on guardianship: To protect her from alcohol To facilitate access and rehabilitation

22 Case study 2 In a residential home for 1.5 years, undergoing phase 3 treatment Graded home visits with support of parents (building relationships with family) Re-introduction to children One alcohol relapse Went home with six hours treatment programme each day, monitored by the team. Now discharged from team; Living near parents Children staying over night a few nights a week Voluntary job Still got some short term memory problems (copes with a diary/reminder pad) Alcohol free.

23 outcomes

24 Review 1: Clinical improvement N=41 Patients demonstrated improvement in all the following HONOS areas: problem drinking and drug use cognitive problems physical illness and disability experience of hallucinations delusions and confabulation problems with relationships problems with activities of daily living problems with living conditions and problems with activities No patients were rated as experiencing self directed injury However, emerging depression may well be a problem

25 5 years preceding end of index admission: 205 patient years Review 1 Impact on acute care 41 patients had 4418 days of admission 0.53 acute medical/surgical bed days per patient each patient year 41 patients were followed up for 85.6 patient-years 295 days of inpatient care in acute medical or surgical wards 0.08 acute medical/surgical inpatient days per patient each patient-year Reduction of acute medical surgical beds by 85%

26 Review 2: institutional/community outcomes N=57 completed programme 36 patients in non- institutional care (sheltered accommodation, supported living, domestic care) these : Of 5 are uncontrolled drinking: 1 has a personality disorder and is about to go to prison 2 have minor ARBD with capacity to make decisions about alcohol drinking 1 is a binge drinker (no capacity) 1 lost to follow-up (transferred out of area) 4 died at home (abstinent) 9 patients were rehabilitated home through institutional care 27 (75%) of the 36 patients well in the community

27 Review 2: institutional/community outcomes 21 patients in Institutional care 9 of these are profoundly ill (multiple mental and physical illnesses) 3 have died in institutions 6 are under assessment and probably will be rehabilitated 3 are in active rehabilitation and will leave the institution.

28 Review 2: summary N=57 7 died 5 in uncontrolled drinking 9 patients are permanently institutionalised (very dependent) 38 abstinent (and 2 in controlled drinking) 9 in treatment (phase 3) 30 settled (phase 5) in non-institutional settings (4 of which have died) 80% abstinent (2 of which are in controlled drinking) 78% either expected to be (9) or are at home/sheltered or in supported living (abstinent) 18% permanently institutionalised 12% mortality rate 12% alcohol relapse rate

29 Review 3: care package cost N=39 Total costs to the NHS funding authority (excluding cost of team). Average patient cost per week: Initial: End: per patient per week This includes complex cases; 8 Patients with two or more psychiatric diagnoses with increased cost Bipolar, behavioural problems and high risk (assault) Persistent water intoxication and dilutional hyponatraemia Vascular dementia, frontal infarcts and unpredictable violence Anoxic brain damage (referred from PICU) Resistant anxiety depression and acute agitation Resistant paranoid psychoses Personality disorder, psychoses (referred to CMHT) Severe Korsakoff psychoses and depression

30 Review 3: Care package cost Complex cases (N=8) Average cost per week (per patient) Initial End increase of per week 8/8 complex cases continued on either joint LA/Health or Health funding Simple cases (N=31) Initial End reduction per patient per week (70% reduction) 20/31 simple cases had no health costs by the time they had been through the programme

31 summary The vast majority of ARBD patients are likely to improve if provided with appropriate treatment and care. Outcomes: Improvement in HONOS scores (NB emergent depression) Significant reduction in acute hospital bed days (85%) Significant majority are able to live relatively independently without on-going institutionalisation (75%) An active treatment program is associated with reduced cost of care across three years in most cases (70%) There is a relatively low mortality rate (approximately (approx 10%) There is a relatively low relapse rate into uncontrolled alcohol misuse (approximately approx 10%)

32 For more information: CR 185 Royal College of Psychiatrists ARBD Guideline Management manual Cheshire and Wirral Partnership NHS Trust/ Mersey Care NHS Trust

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