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Alcohol-related brain injury: Impact on family and society

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Dr Helen McMonagle BSc. MSc. PGDip. DCounsPsych …

Dr Helen McMonagle BSc. MSc. PGDip. DCounsPsych
ARBI Rehabilitation Coordinator

Published in Healthcare , Health & Medicine
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  • Alcohol Related Brain Injury can exist in various forms.
    Alcohol is thought to have a neurotoxic effect on the brain
    • Repeated cycle of intoxication, withdrawal and dehydration causes damage
    • Dietary neglect, thiamine (Vitamin B1) and other vitamin deficiencies contribute to impairment in brain structure and function
    Long-term excessive consumption of alcohol has a harmful effect on almost all organs of the body. People who have been drinking large amounts of alcohol for long periods of time run the risk of developing serious and persistent changes in the brain. ARBI refers to the structure and functional changes in the brain.
    Those particularly affected include the brain and the. The effect of protracted excessive consumption on the brain varies from person to person for reasons, which are not yet clear.
    Damage may be a result of the direct effects of alcohol on the brain such direct toxic effects of alcohol on brain cells
    the effects of dehydration on the brain
    vitamin and nutritional deficiencies
    disturbances to the blood supply of the brain
    Or may develop indirectly from factors such as
    Poor General Health (diseases of the gastro-intestinal system )
  • Surface rendered brains (top) and rendered ventricular system (bottom, green) of a 59-year-old healthy man (A and C) and a 53-year-old man with WKS (B and D). Note the shrinking of the cortical gyri and widening of the sulci (B) and expansion of the ventricles (D) of the WKS compared with the control (A and C).
  • Currently, the care pathway for ARBI service users effectively begins with crisis response at an acute level. Recurrent ‘subclinical’ episodes of damage may not be diagnosed. We propose that a future ARBI service should incorporate an anticipatory care model with an enhanced role for Primary Care. Currently there is little contribution from preventative models of intervention. Recent reports (e.g ) conclude that general practices should be making greater efforts to diagnose ARBI in its early stages and emphasizes the need for early detection with an enhanced role for primary care. We would argue that there is indeed a need for timely prevention, detection and early intervention that will prevent crises and the progression of neurological damage leading to brain damage. In relation to ARBD there is, in society in general and amongst some professionals, an apparent lack of awareness of the potentially damaging consequences of prolonged excessive drinking.
    On the other hand, there is often an unjustified pessimism about the possibility of rehabilitation or recovery for those who suffer them. Such attitudes and perspectives may affect individuals in organisations responsible for screening, identification, service provision and service planning, because they are reluctant to make what feel like value judgements about someone else's drinking. many of them are hidden in the community, ARBD is often a hidden condition until a crisis occurs.
    Blockage 3:Detoxification – Current literature highlights the importance of effecyive detoxification services to halt the progress of Wernicke-Korsakoff syndrome. However, the HSE Working Group on Residential Treatment & Rehabilitation (Substanc Abuse), (2007) noted that there were no stabilisation services, no community based residential detox units, no medical detoxification units.
    There appeared to be a link between this perceived lack of diagnosis and assessment with the lack of ownership within the NHS. Social work staff in particular stated that it was difficult to ascertain who or what department in the HSE was responsible for making diagnoses. An individual's needs will change and fluctuate, requiring ongoing assessment, monitoring and review. Identifying people with ARBD and planning services for them is made difficult by the wide range of individual patterns and outcomes. It may require the exclusion of other disorders or co-existing conditions. Often only a 'clinical suspicion' of ARBD will be found. A confirmed diagnosis only becomes possible following detoxification and thorough assessment. An individual's longer-term needs will be dependent on the degree of brain damage they have sustained, and it is only possible to assess this accurately after a period of up to one year after cessation of drinking.
    Blockage 6 – Rehabilitation Services: People with ARBD have a range of individual needs, social and medical, and it is important that these are comprehensively assessed and due consideration is given to both. There is anecdotal evidence of people with ARBD facing stigma within services, either through exclusion from them or from being 'bounced' between services. Those with a significant degree of cognitive impairment will also need support to maintain
    abstinence, but may in addition need help with accommodation, aspects of their daily life,
    finance and social activities. There will also be people who have a more severe impairment, and who show no, or only slight,
    signs of recovery. They will require 24-hour care over a long period of time.
    Blockage 7 – Residential Services There are a number of issues with current provision; service providers report that some care homes are unwilling to accept referrals for people with complex needs through alcohol misuse, care homes may be age inappropriate and residents report that some staff are not skilled in working with people with alcohol misuse issues. It is, however, difficult to predict outcomes and recommend appropriate placement of an individual in the early stages of assessment due to uncertainty about the extent of recovery that may occur. People with ARBD have often been seen as a difficult group to support in their own homes owing to the variety and complexity of their social and medical needs, and the range of possible or perceived risks. This has sometimes led to people being placed and remaining in age inappropriate residential facilities. The scarcity of move-on accommodation means many people with ARBD remain in psychiatric beds or unsuitable community settings, with their progress unmonitored. In these situations the social needs of the individual are neglected.
  • family experiences highlight the lack of diagnostic expertise, general ignorance of psychiatric, medical and nursing staff, no evident pathways of care, being ‘passed from pillar to post’, stigma and lack of resources.

Transcript

  • 1. Alcohol-Related Brain Injury: Impact on Family and Society Dr Helen McMonagle BSc. MSc. PGDip. DCounsPsych ARBI Rehabilitation Coordinator
  • 2. What is an Alcohol-Related Brain Injury?  •Is a term used to describe the injury or damage caused to the brain as a result of excessive alcohol intake and related nutritional deficiencies. •A spectrum of psycho-neurological/cognitive conditions.
  • 3. Structural Changes Sullivan E V , and Pfefferbaum A Alcohol and Alcoholism 2009;44:155-165 Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
  • 4. Functional Changes Key cognitive skills affected by ARBI: •Memory •Executive functions •Balance & Coordination These can range from mild to severe.
  • 5. Who’s at Risk? • Men drinking 35 standard drinks per week or women drinking 28 standard drinks per week for 5-10 or more years. • Admitted to acute hospital in the past year due to drinking. • Those neglecting their nutrition. • Those with Alcohol-Related liver damage. • Multiple detoxifications. • Has a close relative who has a suspected ARBI • Oslin, D., Aktinson, R.M., Smith, D.M. and Hendrie, H. (1998) Alcohol-Related Dementia: Proposed Clinical Criteria. International Journal of Geriatric Psychiatry 13, 203-212.
  • 6. National Prevalence Autopsy Studies: 0.4% - 2.8% Irish Estimate: 18,320 - 128,240 Harper C, Fornes P, Duyckaerts C, Lecomte D, Hauw JJ. An international perspective on the prevalence of the Wernicke-Korsakoff syndrome. Metabolic Brain Disease 1995;10:17–24.
  • 7. Acute Hospitals in Ireland • 17% of alcohol-related hospital admissions will feature varying degrees of cognitive impairment • 84 days= Average length of stay per person in acute hospitals. • 16 = Lost bed days at acute hospital per person. Popoola A, Keating A, Cassidy E (2008); Alcohol, cognitive impairment and hard to discharge acute hospital inpatients. Ir J Med Sci 2008; 177:141–5.
  • 8. Homelessness Population 21% of homeless hostel dwellers. Gilchrist, G, and Morrishon, DS (2005) Prevalence of alcohol related brain damage among homeless hostel dwellers in Glasgow. European Journal of Public Health, 15 (6). Pp. 587-588
  • 9. Prison Population 15-42% of prison population “male impairment profile more resembled that seen in alcohol related brain injury- alcohol use was the main cause of brain injury among prisoners, while in the general community traumatic head injury is the most common cause” Arbias: Acquired Brain Injury in the Victorian Prison System & Famularo-Doyle, Jo. "Homelessness, Acquired Brain Injury and Corrections Victoria." Parity 23.1 (2010): 18.
  • 10. Dementia Population 10% of Dementia population = 4170 of Irish Dementia Population 12.5% of dementias in under 65's MacRae, Rhoda, and Sylvia Cox. Meeting the needs of people with alcohol related brain damage: a literature review on the existing and recommended service provision and models of care. Dementia Services Development Centre, 2003.
  • 11. Key Challenges
  • 12. Two Tier Service Response
  • 13. Case Study • Matthew – Aged 48 • Longstanding Alcohol- Dependence • Observations of deterioration in cognitive/functional abilities over 3 years. • Admitted to LGH • Structured routine of activities including placement in community gardening project – 4 days per week • Introduction of P.A • Graduated discharge. • Living successfully in the community. Remains abstinent
  • 14. Impact on Family • The hidden patient of ARBI • Caregiver ambivalence • Ambiguous loss • Repeated difficulties accessing services
  • 15. Impact on Family • Caring for someone with ARBI is a hugely challenging process. • But, if well supported can be mutually beneficial. • Families need attention, education, guidance and support if they are to survive, regroup and rebuild their lives.
  • 16. If you wish to receive a copy, please email: info@alcoholforum.org