The Cloaked Dementia: Long Term Effects of Alcohol Abuse WINTRINGHAM Alice Rota-Bartelink alicerota@wintringham.org.au
OVERVIEW Safe Drinking Standards Alcohol & the Body Alcohol & Ageing ARBI & Challenging Behaviour Wintringham service profile The Wicking Project The Challenging Behaviour Toolkit Where to from here?
Alcohol - Safe Drinking Australian Standards 2 standard drinks per day 2 alcohol-free days per week No more than 4 standard drinks on a single occasion Even less for older adults (Ref: www.alcohol.gov.au 2010
Effects of Alcohol On the Body Toxic effect on central nervous system Changes to metabolism and blood flow Affects the bodies use of thiamine Is associated with poor diet Causes dehydration Leads to falls, fights and other medical conditions that may injure the brain (Ref: www.betterhealth.vic.gov.au)
Eyes & Nervous System
Chronic alcohol misuse in older people increases the: Risk of chronic heart disease, hypertension & stroke; Incidence of malabsorption, pancreatitis & liver damage; Risk of falls and accidents; Likelihood of incontinence and gastrointestinal problems; Prevalence of memory loss and the development of dementia, psychiatric problems & Parkinson s disease; Effects of self-neglect, such as poor nutrition and hygiene; The duration of recovery and healing.
Client Profile Older Long Term Drinkers Homelessness Premature ageing Limited finances Little or no family or friends Self-neglect & malnutrition Traumatic injuries and assaults Reluctant to seek appropriate, timely medical care & poor compliance
Social Isolation Client Profile Cont. Coexisting mental illnesses Ongoing addictions alcohol, other drugs, gambling Impaired sense of safety or trust Imprisonment & Institutionalisation Complex/Challenging behaviours Acquired Brain Injury alcohol and other Guardianship & Administration Orders
Alcohol Related Brain Injury (ARBI) Sometimes referred to as ARBD Alcohol Related Brain Damage Cerebellar atrophy poor balance & gait Peripheral neuropathy poor mobility & dexterity Hepatic encephalopathy chronic liver disease toxins leading to progressive memory loss, disorientation, tremors & dementia. Frontal lobe impairments behavioural changes; eg. disinhibition, aggression, irritability or impulsivity, Impulse Control Disorder Wernicke s encephalopathy - acute neurological disorder due to thiamine (Vitamin B1) deficiency Korsakoff s dementia severely impaired mentation (Ref: www.betterhealth.vic.gov.au)
Enlargement of the Ventricles Reduction in Volume of Frontal Lobes and Cerebellum Normal Alcohol Related Brain Injury Ref: www.niaaa.nih.gov
Executive Dysfunction Long-term drinkers experience difficulties with: Attention and concentration Planning, organisation, problem solving Complex, abstract and flexible thinking Difficulty with new learning tasks Initiative Emotional and behavioural change Self awareness and insight
COMORBIDITY (35 70%) People living with both a psychiatric disorder and an addictive disorder or AOD (alcohol and other drug) use disorder. The presence of a mental health condition may lead to an AOD use disorder, or vice versa. In some cases, the AOD use disorder occurs as a consequence of repeated AOD use to relieve mental health symptoms. This is often described as the self medication hypothesis. Alternatively, AOD intoxication and withdrawal can induce a variety of mental health symptoms and disorders, such as depression, anxiety, and psychosis. Mills, K. et al (2009)
Slade, et al. 2007 2007 National Survey of Mental Health & Wellbeing ABS Australian Males Australian Females
COMORBIDITY cont d DISORDER % Men %Women %Total Affective disorders Major depressive disorder 16.1 20.3 17.4 Dysthymia (Chronic Depression) 7.5 7.9 7.6 Bipolar affective disorder 3.9 5.1 4.3 Any affective disorder 19.1 22 20 Anxiety disorders Generalised anxiety disorder 11.5 10.7 11.3 Social phobia 10.9 14.7 12.1 Post traumatic stress disorder 9.3 19.8 12.6 Panic disorder (with or without agoraphobia) 6.6 4.1 5.8 Obsessive compulsive disorder 9.1 10.2 9.5 Agoraphobia (without panic disorder) 2.3 4.7 3.1 Any anxiety disorder 28.1 38.5 31.4 Any disorder (affective/anxiety) 31.1 44 35.2
Under Diagnosis Alcohol abuse and ARBI is grossly under-diagnosed among the older population. Alcohol problems may not be identified as the awareness of ARBI is low among frontline workers in health and social care. Inaccuracy or inappropriateness of generic assessment/evaluation tools Older people rarely access specialist alcohol services. Symptoms masked by dementia or other age-related conditions Symptoms misattributed to personality disorders The social stigma attached to ARBI, ageing, mental illness
Stigma People living with alcohol-related dementia receive less empathy and often attract more judgemental attitudes in the public view than people living with age-related dementias. Stereotypical images of a wino on a park bench or a beggar. Ageism & high representation of minority population groups. Many people view alcohol and other drug use behaviour as a personal choice. Guilt Old enough to know better
15 Uncoordinated Service Systems Case Management Networks & Partnerships Consultancy Community Care Dementia-specific Services Care providers/ Agencies Grants & Funding Detox & Rehab Residential Care A.C.A.S & Support Services Consultancy Case Management M.A.C.N.I Disability Support Alcohol & Drugs Aged Care Assessment Services Case Management Research & Development Acquired Brain Injury Consultancy Disability Services Assessment Services Crisis Services & Accommodation Mental Health G.Ps Dental Homelessness Hospital Physical Health Outreach Allied Health Specialised Services Emergency Services Emergency Dept. Contact Tracers Veterans Affairs A.T.S.I Housing Education & Employment Justice Police Supported Income Support O.P.A Ambulance C.A.L.D Office of housing Social Training Organisations Employment Agencies Fire S.R.S State Trustees Courts Centrelink Prisons
Common Types of Challenging Behaviour in ARBI Perseveration (repetitive or cyclic behaviours) Verbal Aggression Physical Aggression Sexually Inappropriate Lack of motivation Withdrawal & Social Isolation Antisocial Suspicion & Paranoia Confusion & Confabulation High Risk Behaviours Ongoing Intoxication
Why do people with ARBI exhibit these behaviours? ARBI & Frontal Lobe damage Disinhibition and poor impulse control Perseveration (repetitive behaviour) Poor insight and decision making Memory loss Coexisting Mental Illness Other brain injuries Coexisting Age-related Dementia Personality Disorders Ongoing episodes of intoxication Past life experiences / lifestyles; eg. homelessness, violence, hardship, trauma
Alcohol V s Alzheimer s ARBI predominantly male relatively young physically strong often aggressive working class background long-term personal and financial hardship repeated episodes of acute intoxication little to no contact with family and friends sporadic progression and possible remission Alzheimer s Disease predominantly female older physically weaker can be aggressive middle-class background comfortable, uncomplicated lives relatively consistent behavioural profile maintains social connectedness with family and friends. steadily progressive disease
Factors influencing the onset of ARBI Usually seen after 7-10 years of alcohol dependence? Gender; Age of commencement; Diet; Premorbid capacity & IQ Family history; Lifestyle; Drinking history - the amount of alcohol ingested and period of alcohol use; Number of detoxifications; Medical history and complications; Other drug use.
SUMMARY - ARBI Excessive & prolonged alcohol consumption can lead to changes to structure and function of multiple body organs and systems leading to premature ageing. Brain changes in ARBI lead to: Reduced behaviour control including drinking A range of cognitive problems, including memory and executive skills New learning disability Changes to physical functions Personality changes Unstable mood 22
WINTRINGHAM Delivering dignified aged care services to elderly homeless men and women www.wintringham.org.au
Wintringham Wintringham is a specialised not for profit welfare company working with elderly homeless men and women in Melbourne Australia. Established in 1989 as a response to closure of night shelters and inability of aged homeless people to gain access to mainstream aged care services. In recognition of the high incidence of premature aging among our client population Wintringham provides the full spectrum of aged care services to people aged 50 years and older.
Wintringham Services - Overview 5 Residential Aged Care Facilities - 4 low care hostels & 1 nursing home 2 Rooming Houses 800 Community & Outreach Clients CACP & EACH-D 450 Housing Units Melbourne Metro & Regional Victoria Recreation Program 500 staff 1400 clients in total Barry & Kerry
Wintringham is driven by a simple and overwhelming conviction: we believe in social justice
Mental Health, Homelessness & AOD Flatau, P et al (2010)
The Wicking I & II Projects Older People with Acquired Brain Injury and Associated Complex Behaviours: A Psychosocial Model of Care In October 2006 Wintringham was awarded a $900,000 J.O and J.R Wicking Trust Research grant administered by ANZ Trustees to develop and trial a specialised model of care to support older people living with an acquired brain injury (ABI), in particular older homeless people with challenging behaviour as a result of an alcohol related brain injury (ARBI). In January 2012 Wintringham was awarded a $1.3M J.O and J.R Wicking Trust Research grant to further refine and develop the support program. 28
The Wicking II Project Intensive Transition Support Program Trial Assisting the successful transition of older people (aged >50YO) living with an ARBI and high-risk behaviours from the hospital and crisis-driven service system into specialist residential care at Wintringham Dandenong with the aim of attaining and maintaining improved life quality. 3 year research project commenced May 2012 n = 24 6-month intensive support program Austin Health Human Research Ethics 5/16/2013
Wicking II Selection Criteria Fifty years of age and older; Ambulant; Resident of Melbourne s metropolitan region; Assessed as being eligible for Aged Care (ACAS) Relatively low medical support needs; Moderate to high levels of ARBI as determined by a neuropsychological assessment; High level of behavioural disturbance secondary to an ARBI;
Selective recruitment for A history of unsuccessful or problematic tenancies arising from behaviours associated with an ARBI; Continuing alcohol dependence - still drinking; Multiple failed attempts at sobriety/detoxification/ rehabilitation; Voluntary participation; Absence of a mental health condition such that collaboration with recurrent assessment and a shared home environment is unlikely; The absence of addictions to drugs other than alcohol & cigarettes. 5/16/2013
Key Program Components Neuropsychological assessment and ongoing neuropsychologist behaviour support Individual Case Management 1:4 Harm Minimisation - Alcohol & Cigarette Program 1:1 Individual Attendant Care Support - 25 hrs per week Structured Activity & Lifestyle Program Individual Behaviour Management Planning 5/16/2013
WICKING I 2006-2011 Project Outcomes Cost Benefits Economic modelling has demonstrated a cost to government saving of $30 per person per day for The Wicking Program relative to crisis driven service interventions. Avoiding excessive use of crisis and emergency services or the need for institutionalisation or locked wards Improved Quality of Life Outcomes In addition to positive changes in psychological health and general health, all indicators of life quality and wellbeing underwent significant positive change for Wicking Model participants.
Neuro-psycho-social Approach Change the world to fit the person Creating an environment in which demands are within the capabilities of the person and the person can function well Unlike trying to fit a square peg into a round hole this approach adapts the service delivery model around the client s needs like play dough.
The Care Providers Toolkit Managing the Challenge of ARBI 1. Behaviour as a Means of Communication 2. The Use of Language 3. Avoiding the Downward Spiral 4. Routine & Consistency 5. The ABC of Behaviour Management 6. Education & Training 5/16/2013
Long Term Aims Continuing Long-term Residential care Enduring engagement in meaningful activities Hand over to local care & support services Continuing long-term community service engagement Continuing Administration and Guardianship support as required. Maintaining Improved life quality and wellbeing 5/16/2013
Where to next?