Alcohol Related Brain Damage Alcohol-Related Brain Injury Rehabilitation Alcohol Alcohol Forum

1. Dr Scott Payne & Dr Mark Owens: Consultant Psychiatrist in Addiction
Psychiatry & ARBD Researcher
Alcohol-Related Brain Damage in the Northern Irish Context
ARBI: A Best Practice Seminar: Royal College of Physicians, 20th April 2015

2. Dr Mark Owens
ARBD Researcher WHSCT
Dr Scott Payne
Consultant in Addiction Psychiatry WHSCT

3. ARBD Project WHSCT
 Big Lottery Impact of Alcohol Programme
 18 month ARBD Project Team
 Recruitment:
– Alcohol Liaison Nurse
– Research Assistant
– 2 support workers Apex Housing
 Project Aim and Purpose:
– Scope out the prevalence in the West, assess any
gaps in service provision for this client group and
develop ways to improve services

4. ARBD Project Team
 Head of Service for Primary Care & Specialist Services
 Alcohol Liaison Nurse
 Trust Research Associate and Research Assistant
 Apex Housing
 Foyle Haven (De Paul Ireland)
 Team Managers, Drug and Alcohol Team
 Primary Care Liaison Team Manager
 Consultant Clinical Psychologist, PCOP
 Consultant Clinical Psychologist, Brain Injury Service
 Senior Social Worker, Women & Children Directorate
 Discharge Co-ordinator, Altnagelvin Hospital
 Consultant Addiction Psychiatrist

5. Scoping Exercise Of ARBD in
WHSCT Area
Period Scoped: 1st April 2012 through to
31st March 2013.
Two pronged approach
with data collection.
Electronic. Questionnaire

6. • Both the prevalence & incidence of ARBD show
marked increases over recent years, (McCall et al,
2010; Ramayya & Jaunhar, 1997; Kok, 1991)
• The Hague (KAS)........... 5 / 10,000 (Blansjaar et
al, 1987)
• Argyll & Clyde (ARBD).......... 7 / 10,000 (Chiang,
2002)
• One G.P. Practice estimated 14.4 / 10,000 for
same area (McRae & Cox, 2003).
Previous Studies Have Reported

7. Data collection
Electronic databases Epex & PAS systems were searched
for discharges.
ICD 10 codes:
• Either F10.6 (Amnesic Syndrome) or F10.7 (Late onset
psychotic disorder).
• F01 (Vascular dementia) or F03 (unspecified dementia) but
only with harmful or dependent alcohol consumption.
• G31.2 (degeneration of the nervous system due to alcohol)
with F10.6, F10.7, F01 or F03

8. In the Scoping Questionaire respondents were asked to
tell us about those clients who had a formal diagnosis of
 KAS, Alcohol-related Dementia, or ARBD
 And were also asked to include those patients or residents
without a formal diagnosis but for whom in their opinion (or
that of their staff) there existed substantial memory
impairment that was related to sustained heavy
alcohol abuse.
Data collection 2

9. EPEX / PAS
 33 across Trust who met coding criteria
 22 SWAH / AAH / T and C
 11 T and F / Gransha

10. Cost
 WHSCT acute beds are listed as costing £434 per day,
psychiatric beds £330 per day:
– If patients were in for on average 22 days (as per
Liverpool) for our 33 patients that would cost £ 210,056
+ £79,860 = £289,916
– An 80% saving to this would be £231,932

11. Community Groups
 126 agencies contacted – across health and social care
spectrum – stat, C and V, residential
 99% response rate with assertive Fup
 66 positive responses
 278 separate individuals recorded
 45 at more than one service
 1 patient recorded at 8 different services
 2 patients at 5 different services

12.  Prevalence = 0.09% or 9.4 in 10,000
 The mean age (SD) for the cohort was 57.68 (13.49)
Min = 22; Max =91
 A ratio of M : F 3.5 : 1
 Males Mean Age (SD) = 58.01 (13.76) Min = 23; Max = 91
 Females Mean Age (SD) = 56.53 (12.56) Min = 22; Max = 79
Results & Analysis

13. Age Stem-and-Leaf Plot
Frequency Stem & Leaf
2.00 2 . 23
6.00 2 . 666679
6.00 3 . 012223
13.00 3 . 5566677788899
15.00 4 . 001122223333444
33.00 4 . 555555566667777777888888999999999
37.00 5 . 0000000011111111122222222233333333344
38.00 5 . 55555566666777777777888888888999999999
41.00 6 . 00011111111111222222222333333333334444444
31.00 6 . 5555666666777777888888999999999
29.00 7 . 00000000111111122222222334444
15.00 7 . 555667778899999
7.00 8 . 0112224
4.00 8 . 5778
1.00 9 . 1

14. Qualitative Results And Analysis;
Respondents were asked to report on
 What they were doing well.
 The main difficulties.
 Requirements/needs.
The data were examined for themes.

15. Respondents Outlined What they Were
Doing Well including;
 Meeting Basic Needs
 Managing Alcohol.
 Team Working
 Therapeutic Interventions.
 Providing Person-Centered Care.

16.  Diagnosis.
 Stigmatisation.
 Management of Alcohol.
 Care Planning & Risk Assessment.
 Lack of Resources.
 Challenging Behaviours.
Respondents Main Difficulties Included

17.  Specialism / Specialisation.
 Training & Education.
 Assessment & Diagnosis.
 Care Pathway & adequate Service
Provision.
 Appropriate therapeutic interventions.
Respondents Outlined Needs &
Requirements

18. Appropriate services
 Reduce acute hospital bed usage by 85%
 Significant reductions in relapse
 Significant reductions in mortality
 Improvements in 75% of patients over 3 years with
appropriate rehabilitation
 Maintain 75% in non institutional community
settings

19. Principles of good care
 Multi-disciplinary – Psychiatry, Rehab Psychology, SW, OT
 Involve family and carers
 Experienced key worker
 Active care plan
 Ongoing review of cognition, capacity, behaviour, risks
 Carefully managed transitions from community to institutional care
 First 3/12 important
– Abstinence
– Good nutrition
 3 years rehab – regularisation of routines e.g. eating, sleeping,
personal hygiene
 Introduction of memory and orientation cues
 Further cognitive rehabilitation

20. Alcohol and brain damage in adults
Royal College Guidelines : College
report CR185
 Clinical commissioning groups should commission clinically
appropriate services to provide multidisciplinary, specialist care for the
assessment and rehabilitation of patients with severe ARBD.
 In the absence of established specialist services, consideration should
be given to the embedding of ‘specialisation’ within the most
appropriate established generic mental health service provision.
 Such specialisation should provide advice and support to other
services who are managing people with mild to moderate ARBD,
including community teams and alcohol services.

21. Alcohol and brain damage in adults
Royal College Guidelines : College report
CR185
 Clinical commissioning groups should commission appropriate services
for facilitating early hospital discharge and short-term psychosocial
assessment (up to 3 months).
 Arrangements should be in place to provide safe and active
institutional rehabilitation for those patients who are not well enough to
be rehabilitated into non-institutional settings after the initial 3-month
period of assessment.
 Funding for long-term institutional care for supporting people with
permanent brain damage should be made available.

22. Draft Hospital ARBD
Referral & Care Pathway. Revised
19/02/14
Suspected Alcohol
Related Brain
Damage
Patient with heavy alcohol use or
identified as alcohol dependant.
(See guidance notes for staff)
With patient agreement and if
required commence
detoxification and adhere to
WHSCT ‘Management and
Guidelines of Acute Alcohol
Withdrawal Policy’.
NB. Give iv. Pabrinex
Immediately following
detoxification and
stabilisation
Cognitive impairment
identified using clinical
judgement, YES/NO?
YES
No ARBD input required.
Refer to alternative
service.
NO
6 CIT completed by ALN
result >10/28
Exclude possible physical/ mental
health/transient causes for
cognitive impairment e.g,
infection /medication). Consider
CT / MRI (brain) scan.
ARBD Team to screen referral
and complete initial assessments.
YES
Review placement for suitability for longer term
ARBD rehabilitation i.e. specialist care or supported
environment with input from ARBD team over a
2-3 year period.
On-going assessment and
multidisciplinary care planning in
partnership with other services.
• Addictions Services
• Brain Injury service
• Mental Health Teams
• Physical and Sensory
Disability Team
• Primary Care Services
(GP)
• No input
ARBD Team to identify a keyworker who will
liaise with hospital SW to enable discharge
planning to home or other appropriate
setting. Ongoing assessments and multi-
disciplinary care planning over a 3 month
period i.e.
• Psycho-Social Assessments
• Risk Assessments
• Neuropsychological Tests
• Mental Capacity Assessments.
• Functional Assessments.
• Abstinence support.
Complete ARBD Referral Form
providing the following
information:
• Functional assessment
completed by OT
• Mobility assessment by Physio
(if required)
• Social circumstance report
(including assessment of home
situation) by hospital SW.
• Cognitive assessment by ALN.
Further
assessment
required
No
Yes

23. Patient with history of heavy
alcohol use or identified as
alcohol dependant.
(see guidance notes for staff)
Draft Community ARBD Referral & Care Pathway
revised 19/02/14
Concerns about cognitive
impairment/ memory
+/- risks to themselves.
• If the person is already abstinent or
is continuing to drink then the GP
in collaboration with other
community staff /support workers
to complete the ‘ARBD Referral
Form’ providing information on the
persons:
• level of risk/vulnerability
• social circumstances (including
assessment of home situation)
• functional ability
• cognitive ability – i.e. complete
6 CIT and note period of abstinence.
ARBD Team to identify a keyworker
and complete assessments over a 3
month period i.e:
• Psychosocial Assessments
• Risk Assessments.
• Neuropsychological Tests
• Mental Capacity Assessments.
• Review Home situation.
• Ongoing Functional Assessments
• Abstinence support.
• Addiction Services
• Mental Health Teams
• Physical and Sensory
Disability Team
• Primary Care/GP
• Brain Injury Service
• No input
Suspected Alcohol
Related Brain Damage ARBD Team to screen referral and
complete initial assessments.
YES
Review placement for suitability for longer
term ARBD rehabilitation i.e. specialist
care or supported environment with input
from ARBD team over a 2-3 year period.
On-going assessment and care
planning in partnership with other
services.
NO
Collaborative working across services during
3 month assessment period is an essential requirement.
Refer to GP
If detox appropriate refer to detox nurse
and follow WHSCT community detox
pathway. Following detox consider
referral to ARBD team if concerns remain
- see below.
Refer to ARBD
Team
Further
assessment
required
Yes
No

24. Summary.
• We have established a crude prevalence
rate of 9/10,000.
• The current work goes beyond previous
studies that concentrated on Acute hospital
discharge & admission data exclusively.
• Carepathways have been informed and
developed from the data presented.