Alcohol Related Brain Alcohol Related Brain DamageDamageCharlie Place York Street Health Practice Sep 2014Charlie Place York Street Health Practice Sep 2014

What is ARBD?What is ARBD?

Alcohol Related Brain Damage (ARBD) is Alcohol Related Brain Damage (ARBD) is a relatively new term that has begun to a relatively new term that has begun to be used in practice and the literature to be used in practice and the literature to describe cognitive impairment related to describe cognitive impairment related to alcohol usealcohol use

ARBD umbrellaARBD umbrella

‘‘umbrella’ term to describe a range of umbrella’ term to describe a range of conditions including:conditions including:

Wernicke’s encephalopathyWernicke’s encephalopathyKorsakoff’s syndromeKorsakoff’s syndromeAlcohol dementiaAlcohol dementiaAlcohol related brain injuryAlcohol related brain injury

Wernicke’s encephalopathyWernicke’s encephalopathy

Wernicke’s encephalopathy is the Wernicke’s encephalopathy is the acute neuropsychiatric reaction to thiamine neuropsychiatric reaction to thiamine deficiency deficiency

Characterised by problems with walking, Characterised by problems with walking, balance, coordination, confusion, eye balance, coordination, confusion, eye movement movement

Wernicke’s is a medical emergency – untreated Wernicke’s is a medical emergency – untreated can lead to death in 20% of cases or can lead to death in 20% of cases or Korsakoff’s syndrome in 85% of survivors Korsakoff’s syndrome in 85% of survivors (Kopelman et (Kopelman et

al, 2009)al, 2009)

Korsakoff syndromeKorsakoff syndrome

Memory disorder associated with chronic Memory disorder associated with chronic alcohol abuse and thiamine deficiencyalcohol abuse and thiamine deficiency

Associated with Wernicke’sAssociated with Wernicke’s Characteristically patient gives Characteristically patient gives

impression of being unimpaired and often impression of being unimpaired and often use ‘confabulation’ to cover gapsuse ‘confabulation’ to cover gaps

Chronic conditionChronic condition

Why is ARBD preferable?Why is ARBD preferable?

There is rarely a clear clinical pictureThere is rarely a clear clinical picture For example, Wernicke’s encephalopathy For example, Wernicke’s encephalopathy

is well-known amongst clinicians but is well-known amongst clinicians but rarely seen in practicerarely seen in practice

Drinker (or ex-drinker) with cognitive Drinker (or ex-drinker) with cognitive impairment will often have multiple impairment will often have multiple possible factors that are likely to have possible factors that are likely to have contributed to cognitive impairmentcontributed to cognitive impairment

ARBD advantages cont…ARBD advantages cont…

Almost impossible to ‘unpick’ storyAlmost impossible to ‘unpick’ story Multiple factors in play: unassisted withdrawal, Multiple factors in play: unassisted withdrawal,

nutritional defiencies, toxic effects of alcohol on nutritional defiencies, toxic effects of alcohol on brain, brain injuriesbrain, brain injuries

25% presenting with ARBD evidence of 25% presenting with ARBD evidence of vascular dementia and/or head trauma vascular dementia and/or head trauma (Wilson et al, (Wilson et al, 2012)2012)

ARBD is useful umbrella to describe condition ARBD is useful umbrella to describe condition – currently no appropriate term in DSM and – currently no appropriate term in DSM and ICD ICD (RCP 2014)(RCP 2014)

Why not call it Alcohol Related Why not call it Alcohol Related Dementia?Dementia?

Fundamental difference from dementia:Fundamental difference from dementia: Evidence suggests that some degree of Evidence suggests that some degree of

recovery is possible for recovery is possible for most people with people with ARBD. Prognosis estimated:ARBD. Prognosis estimated:

25% full recovery25% full recovery 25% significant recovery25% significant recovery 25% slight recovery25% slight recovery 25% no recovery 25% no recovery (Smith and Hillman 1999)(Smith and Hillman 1999)

First three months of abstinence First three months of abstinence associated with significant improvement associated with significant improvement (RCP 2014)(RCP 2014)

PrevalencePrevalence

Surprisingly little dataSurprisingly little data Due to diagnositc problems, patients not being Due to diagnositc problems, patients not being

aware, variability of presentation, poor levels of aware, variability of presentation, poor levels of awareness amongst clinicians, and stigma awareness amongst clinicians, and stigma related to ‘self inflicted’ alcohol problems related to ‘self inflicted’ alcohol problems (RCP 2014)(RCP 2014)

Most robust evidence is from post-mortems: Most robust evidence is from post-mortems: between .5% and 1.5% of general adult between .5% and 1.5% of general adult population have changes to brain from alcohol population have changes to brain from alcohol misuse and most do not have this recorded misuse and most do not have this recorded (Cook (Cook et al, 1998)et al, 1998)

Prevalence cont..Prevalence cont..

The ARBD service in Greater Glasgow The ARBD service in Greater Glasgow serves a population of around 900,000 serves a population of around 900,000 and estimates three to four new cases and estimates three to four new cases each week and over 500 established each week and over 500 established cases with long-term care needs cases with long-term care needs identified over a five year period. identified over a five year period. Average age at referral to the Glasgow Average age at referral to the Glasgow service is 55 years with 74% of the service is 55 years with 74% of the referrals being male referrals being male (Smith in Thomson et al 2012).(Smith in Thomson et al 2012).

Prevalence cont…Prevalence cont…

Screening of 266 homeless hostel Screening of 266 homeless hostel residents in Glasgow found 82% had residents in Glasgow found 82% had degree of cognitive impairmentdegree of cognitive impairment

21% could be said to have ARBD 21% could be said to have ARBD (Gilchrist and (Gilchrist and Morrison 2005)Morrison 2005)

Prevalence appears very high – drinking Prevalence appears very high – drinking at time?at time?

But functionally impaired – ultra high risk But functionally impaired – ultra high risk group?group?

ARBD often overlooked…why?ARBD often overlooked…why?

Ignorance of ARBD amongst clinicians leading Ignorance of ARBD amongst clinicians leading to misdiagnosis of other forms of dementia or to misdiagnosis of other forms of dementia or mental illnessmental illness

StigmaStigma Commonly used assessments not well suited Commonly used assessments not well suited

(eg MMSE)(eg MMSE) Difficulty differentiating between prolonged / Difficulty differentiating between prolonged /

permanent effects and short term intoxicationpermanent effects and short term intoxication People with ARBD often socially isolated People with ARBD often socially isolated (Alcohol (Alcohol

Concern 2014)Concern 2014)

Screening toolsScreening tools

Mini-Mental State Examination (MMSE) Mini-Mental State Examination (MMSE) is widely used in clinical practiceis widely used in clinical practice

Concerned that it may not be Concerned that it may not be sophisticated enough to pick up ARBD sophisticated enough to pick up ARBD type cognitive impairmenttype cognitive impairment

Two tools recommended by RCP:Two tools recommended by RCP: Montreal Cognitive Assessment (MoCA)Montreal Cognitive Assessment (MoCA) ACE-RACE-R

Montreal Cognitive AssessmentMontreal Cognitive Assessment

Montreal Cognitive Assessment (MoCA) is a Montreal Cognitive Assessment (MoCA) is a brief (10 minute approx) cognitive screening brief (10 minute approx) cognitive screening instrument instrument

Developed to be sensitive to mild cognitive Developed to be sensitive to mild cognitive impairment (MCI)impairment (MCI)

More sensitive to cognitive decline than Mini-More sensitive to cognitive decline than Mini-Mental State Examination (MMSE)Mental State Examination (MMSE)

Validated for use with substance use Validated for use with substance use (Copersino et al (Copersino et al 2009)2009)

Recommended by RCP report on ARBDRecommended by RCP report on ARBD

Summary (nationally)Summary (nationally)

Drinkers, professionals and the public Drinkers, professionals and the public lack awareness of ARBDlack awareness of ARBD

ARBD is underdiagnosdARBD is underdiagnosd There is a lack of researchThere is a lack of research There are a lack of servicesThere are a lack of services There is a lack of trainingThere is a lack of training

Summary (locally)Summary (locally)

Local situation reflects national pictureLocal situation reflects national picture There is no service for this groupThere is no service for this group Specialist CMHT for younger people with Specialist CMHT for younger people with

dementia excludes drinkersdementia excludes drinkers Memory services exclude younger Memory services exclude younger

peoplepeople Nothing vs. care home?Nothing vs. care home?

Recommendations (RCP 2014)Recommendations (RCP 2014)

All new patients referred for alcohol treatment All new patients referred for alcohol treatment should have a cognitive assessment (should should have a cognitive assessment (should be all addiction services??)be all addiction services??)

Specialisation in recognition and management Specialisation in recognition and management of mild/moderate ARBD should be built within of mild/moderate ARBD should be built within alcohol servicesalcohol services

Specialist services for ARBD should be Specialist services for ARBD should be commissionedcommissioned

Local developmentsLocal developments

Over past 18 monthsOver past 18 months Effort made to raise problem in cityEffort made to raise problem in city Commissioners and public health aware Commissioners and public health aware Ceryl Harwood (public health registrar) Ceryl Harwood (public health registrar)

lead with project for public health Leedslead with project for public health Leeds Can’t find people in the data!Can’t find people in the data! No extra moneyNo extra money

Possible plan for LeedsPossible plan for Leeds

With no extra resources, build pathway With no extra resources, build pathway for ARBD into health and social carefor ARBD into health and social care

Recommissioning of drug and alcohol Recommissioning of drug and alcohol service provides opportunity to build into service provides opportunity to build into new structure?new structure?

Raise awarenessRaise awareness ScreeningScreening

Possible pathways?Possible pathways?

Improve access to specialist assessmentImprove access to specialist assessment Improve ASC awareness / skillsImprove ASC awareness / skills Provide rehabilitation pathwayProvide rehabilitation pathway Have ARBD route within detox / rehab?Have ARBD route within detox / rehab? Have ARBD route within supported Have ARBD route within supported

housing? THUs?housing? THUs? Rely on interest from organisations?Rely on interest from organisations? Avoid nothing vs. care home Avoid nothing vs. care home

Anyone interested?Anyone interested?

Over coming months, recommendations Over coming months, recommendations will be madewill be made

If you as an individual or your If you as an individual or your organisation are interested, please get in organisation are interested, please get in touchtouch

References:References:

Alcohol Concern (2014) Alcohol Concern (2014) All in the MindAll in the Mind, Alcohol Concern Cymru, Cardiff. , Alcohol Concern Cymru, Cardiff. (available at (available at www.alcoholconcern.org.uk/cymruwww.alcoholconcern.org.uk/cymru)) Royal College of Psychiatrists (2014) Royal College of Psychiatrists (2014) Alcohol and Brain Damage in AdultsAlcohol and Brain Damage in Adults, College , College

Report 185, RCP London.Report 185, RCP London. Cook C, Hallwood P, and Thomson A (1998) ‘B vitamin deficiency and Cook C, Hallwood P, and Thomson A (1998) ‘B vitamin deficiency and

neuropsychiatric syndromes in alcohol misuse’ neuropsychiatric syndromes in alcohol misuse’ Alcohol and AlcoholismAlcohol and Alcoholism, 33, , 33, pp.317-36.pp.317-36.

Copersino et al (2009) ‘Rapid Cognitive Screening of Patients with Substance Use Copersino et al (2009) ‘Rapid Cognitive Screening of Patients with Substance Use Disorders’, Disorders’, Experimental and Clinical PsychopharmacologyExperimental and Clinical Psychopharmacology, 17, pp.337-344., 17, pp.337-344.

Gilchrist, G, Morrison, D (2005) ‘Prevalence of alcohol related brain damage Gilchrist, G, Morrison, D (2005) ‘Prevalence of alcohol related brain damage among homeless hostel dwellers in Glasgow’ among homeless hostel dwellers in Glasgow’ European Journal of Public HealthEuropean Journal of Public Health, , 15, p.587-588.15, p.587-588.

Kopelman et al (2009) ‘The Korsakoff Syndrome: Clinical Aspects, Psychology and Kopelman et al (2009) ‘The Korsakoff Syndrome: Clinical Aspects, Psychology and Treatment’, Treatment’, Alcohol and AlcoholismAlcohol and Alcoholism, 44, pp.148-154., 44, pp.148-154.

Smith, I and Hillman, A (1999) ‘Management of Alcohol Korsakoff Syndrome’, Smith, I and Hillman, A (1999) ‘Management of Alcohol Korsakoff Syndrome’, Advances in Psychiatric TreatmentAdvances in Psychiatric Treatment, 5, pp. 271-278., 5, pp. 271-278.

Wilson et al (2012)Wilson et al (2012)

Local case studyLocal case study

AB is a 56 year old man with a history of homelessness, alcohol AB is a 56 year old man with a history of homelessness, alcohol dependence and mental health problems. He took an overdose in dependence and mental health problems. He took an overdose in response to voices and was admitted to acute community mental health response to voices and was admitted to acute community mental health services. Whilst under their care, AB attended the primary care practice services. Whilst under their care, AB attended the primary care practice and was seen by the alcohol nurse. AB said he had spent over £1200 in and was seen by the alcohol nurse. AB said he had spent over £1200 in a two week period and could not recall doing this – he had a bank a two week period and could not recall doing this – he had a bank statement confirming these withdrawals. There was no evidence of fraud statement confirming these withdrawals. There was no evidence of fraud and it appeared AB had withdrawn the money himself but was not able to and it appeared AB had withdrawn the money himself but was not able to remember doing so. AB identified his memory as very poor. He was not remember doing so. AB identified his memory as very poor. He was not drinking at this time. He completed the Montreal Cognitive Assessment drinking at this time. He completed the Montreal Cognitive Assessment (MoCA) scoring 4 out of 30 (26 and above is normal range). The acute (MoCA) scoring 4 out of 30 (26 and above is normal range). The acute mental health services had not been aware of his cognitive impairment mental health services had not been aware of his cognitive impairment until this point. The Community Mental Health Nurse allocated as care until this point. The Community Mental Health Nurse allocated as care coordinator referred AB to a specialist Community Mental Health Team coordinator referred AB to a specialist Community Mental Health Team (CMHT) for working age people with dementia who would not agree to (CMHT) for working age people with dementia who would not agree to assess AB due to his history of problem drinking. He was discharged assess AB due to his history of problem drinking. He was discharged from the CMHT to primary care and currently has no specialist support.from the CMHT to primary care and currently has no specialist support.

Local case studyLocal case study

AF is a 48 year old male who was referred to York St alcohol service by AF is a 48 year old male who was referred to York St alcohol service by Leeds Addiction Unit when inpatient in LTHT. Identified problems with Leeds Addiction Unit when inpatient in LTHT. Identified problems with memory which were creating problems at home with leaving on cooker, memory which were creating problems at home with leaving on cooker, for example. Discussed with friend / carer who confirmed AF’s account for example. Discussed with friend / carer who confirmed AF’s account and suggested social care needed. Requested social work referral in and suggested social care needed. Requested social work referral in LTHT but ward would not agree to refer as did not feel AF had significant LTHT but ward would not agree to refer as did not feel AF had significant cognitive impairment – ‘he can go out for a cigarette and come back’ was cognitive impairment – ‘he can go out for a cigarette and come back’ was the comment of one nurse. MoCA score when sober = 8 out of 30. the comment of one nurse. MoCA score when sober = 8 out of 30. Assessment at home confirmed problems and suggested problems with Assessment at home confirmed problems and suggested problems with vulnerability as living in shared home with other male who had assaulted vulnerability as living in shared home with other male who had assaulted him. AF no longer staying in tenancy but ‘sofa surfing’ with others in local him. AF no longer staying in tenancy but ‘sofa surfing’ with others in local area. Referred to Leeds Adult Social Care by York St who accepted area. Referred to Leeds Adult Social Care by York St who accepted referral and assessed. Regular LTHT admissions due to liver failure. referral and assessed. Regular LTHT admissions due to liver failure. Continues to drink when out of hospital – approx 2 to 4 x cans 5%. Adult Continues to drink when out of hospital – approx 2 to 4 x cans 5%. Adult social care looking at options – possible temporary placement in Bradford social care looking at options – possible temporary placement in Bradford care home?care home?

Local case studyLocal case study

AC is a 60 year old man who was referred to the primary care alcohol service by AC is a 60 year old man who was referred to the primary care alcohol service by the hospital addictions team. AC was drinking dependently but in a controlled way the hospital addictions team. AC was drinking dependently but in a controlled way (approx 8 x cans of 5% lager daily) and living in sheltered housing. AC was (approx 8 x cans of 5% lager daily) and living in sheltered housing. AC was referred to hospital addictions team during admission and they had continued to referred to hospital addictions team during admission and they had continued to support him after discharge home, including becoming involved in helping him to support him after discharge home, including becoming involved in helping him to get money and shopping as due to cognitive impairment he was not able to do so get money and shopping as due to cognitive impairment he was not able to do so himself. A referral to adult social care was made and a social worker appointed as himself. A referral to adult social care was made and a social worker appointed as case manager. AC did not want to change his drinking habits and felt his drinking case manager. AC did not want to change his drinking habits and felt his drinking was under control. He scored 11 out of 30 when scored on the Montreal Cognitive was under control. He scored 11 out of 30 when scored on the Montreal Cognitive Assessment (26 and above = normal range). AC appeared stable with home care Assessment (26 and above = normal range). AC appeared stable with home care helping with meals and medication however his behaviour deteriorated as he helping with meals and medication however his behaviour deteriorated as he became increasingly agitated, causing serious problems in the housing complex became increasingly agitated, causing serious problems in the housing complex (such as going into other’s rooms) and showing persecutory beliefs. He was (such as going into other’s rooms) and showing persecutory beliefs. He was admitted twice in a week into an acute medical bed and settled in hospital but his admitted twice in a week into an acute medical bed and settled in hospital but his behaviour again became a problem on discharge and he was eventually admitted behaviour again became a problem on discharge and he was eventually admitted informally to an acute mental health bed. He was detained whilst an inpatient informally to an acute mental health bed. He was detained whilst an inpatient under Section 2 of the Mental Health Act and his level of cognitive impairment under Section 2 of the Mental Health Act and his level of cognitive impairment improved significantly over the period of admission as he was abstinent from improved significantly over the period of admission as he was abstinent from alcohol and eating well. Discharged back to sheltered housing, AC was referred to alcohol and eating well. Discharged back to sheltered housing, AC was referred to the dementia service whilst an inpatient but not accepted so has generic CMHT the dementia service whilst an inpatient but not accepted so has generic CMHT support at present.support at present.

Local case studyLocal case study

AE is a 60 year old man who has been sleeping rough for many years. He was AE is a 60 year old man who has been sleeping rough for many years. He was recently registered with the homeless primary care service when the Street recently registered with the homeless primary care service when the Street Outreach Team brought him to the practice after they found him wandering in town. Outreach Team brought him to the practice after they found him wandering in town. AE has been drinking dependently for many years and has been known to the AE has been drinking dependently for many years and has been known to the Street Outreach Team for a long time. He was brought to see the alcohol nurse in Street Outreach Team for a long time. He was brought to see the alcohol nurse in primary care several months ago but was not registered, however he presented as primary care several months ago but was not registered, however he presented as so cognitively impaired at this point (unable to say where he was, what was so cognitively impaired at this point (unable to say where he was, what was happening) that he was sent to the emergency department due to concerns of happening) that he was sent to the emergency department due to concerns of Wernicke’s encephalopathy. Following admission to a medical bed and treatment Wernicke’s encephalopathy. Following admission to a medical bed and treatment with parental thiamine, there was some recovery and AE was discharged from with parental thiamine, there was some recovery and AE was discharged from hospital then returned to sleeping rough. Supported housing was arranged but he hospital then returned to sleeping rough. Supported housing was arranged but he did not appear to stay there. He presents currently as seriously impaired although did not appear to stay there. He presents currently as seriously impaired although he was orientated to place and time, but does not appear aware of housing, health, he was orientated to place and time, but does not appear aware of housing, health, dietary or financial arrangements. He would not engage in formal cognitive dietary or financial arrangements. He would not engage in formal cognitive assessment. There is only ad hoc contact with AE when found by professionals assessment. There is only ad hoc contact with AE when found by professionals and so the city Street Outreach Team arranged assessment under mental health and so the city Street Outreach Team arranged assessment under mental health act. AE was detained due to vulnerability and cognitive impairment and admitted act. AE was detained due to vulnerability and cognitive impairment and admitted to the Becklin centre. No significant recovery during admission.to the Becklin centre. No significant recovery during admission.

Case studies highlight problems:Case studies highlight problems:

Cognitive impairment had not been identified for some time Cognitive impairment had not been identified for some time despite repeated contact with a range of health despite repeated contact with a range of health professionals. professionals.

‘ ‘ad hoc’ support often put in place by agencies (such as ad hoc’ support often put in place by agencies (such as community drug and alcohol services) as no more community drug and alcohol services) as no more appropriate service was available. appropriate service was available.

More intensive support only became available in a crisis More intensive support only became available in a crisis situation, sometimes leading to admission to acute medical situation, sometimes leading to admission to acute medical or mental health care. or mental health care.

Even when engaged with secondary mental health care, Even when engaged with secondary mental health care, individuals with ARBD did not have access to specialist individuals with ARBD did not have access to specialist support from memory services or staff skilled in the support from memory services or staff skilled in the assessment of cognitive impairment.assessment of cognitive impairment.

None of the individuals currently has support from services None of the individuals currently has support from services with expertise in cognitive impairment.with expertise in cognitive impairment.