The document summarizes lessons learned from the first nine years of the Glasgow Alcohol Related Brain Damage (ARBD) Team. It discusses how the team was set up, missed opportunities at the beginning, and what they have learned over time. Key points include broadening the referral criteria, conducting thorough multidisciplinary assessments, using legislation to help with harm reduction, providing rehabilitation services, and training other services on ARBD. It emphasizes the need for a public health approach, clear strategy, and person-centered flexible services for those with ARBD.

1. Mr Grant Brand: Team Leader, ARBD Team Glasgow
Lessons Learned in the first nine years of the Glasgow ARBD Team
ARBI: A Best Practice Seminar: Royal College of Physicians, 20th April 2015

2. Alcohol Related Brain
Damage Team
86 Millbrae Road
Langside
Glasgow G42 9DM
Phone: 0141 276 2299 Fax: 041 276 2296

3. Action on Alcohol Week 2015
• Setting up the ARBD Team in Glasgow
• What could have been different?
• What did we learn?
• How did we respond?
• A “diagnosed mental disorder”
• A more “hidden” harm
• What works for service users…… and services?
• What do we need to make it all happen?

4. Background to Setting Up
• 1998 – Discussions started between NHS & GCC
• NHS Mental health services reported having 63
inpatients (1998) both over and under 65 wards.
• Modernising Mental Health (1999)
• MWC concerned about lack of monitoring of
progress outside of hospital
• “A Fuller Life” Report published (2004)
• Estimated 21% prevalence in Glasgow hostel dwellers
(Gilchrist & Morrison; 2005)
• Investigation into the Care and Treatment of Mr H
(2006)

5. A Team to Focus on…..
• Assessment – recognising diversity of age, need,
and level of cognitive impairment
• Liaison – across the range of statutory and third
sector service provision
• Person centred support and care planning to
optimise recovery
• A reduction in admission to care homes
• Joint working with existing services – not to
replace them or to take on care management

6. Original Remit 2006
• A recent onset or diagnosis of ARBD – alcohol as
main cause of cognitive impairment
• Promote optimal functional recovery and
maximise potential for independent living
• Potential for new learning (abstinent)
• Assessment and rehabilitation (joint work for up
to 2 years)
• Assist and educate others to work with this client
group
• User and carer involvement

7. Team Structure in 2006 and 2015
• Nurse Team Leader (GCC Team Leader since 2008)
• Senior Addiction Nurses x 2 (2 x Band 6 as at March 2014)
• Senior Addiction Workers x 2 (Posts now not filled)
• Social Care Officers x 4 (4 x full time as at March 2014)
• Occupational Therapy x 1 (1 x full time)
• Psychiatry x 5 sessions (5 sessions per week as at March
2014)
• Psychology x 5 sessions ( 8 session post as at March 2014)
• Dietician (One session per week equivalent as of 2012)
• Admin (2 x full time)

8. Missed Opportunities at Set Up?
• No one Lead Care Group - no system of care
• Addiction Services developed ‘Diagnostic,
Assessment and Liaison Team’ & Nursing Care Beds
• Homelessness Services commissioned Supported
Accommodation and Supported Living places.
• 1998 – 2004 – was there a missed opportunity to
develop a Managed Network in Glasgow?
• What were the other priorities at the time?
• What if ARBD sat “under one banner”?

9. Referrals – Early Experience
• Referrals being passed from service to service
– highlights gaps – cost?
• Co-morbidity – physical and mental health
• Complex ABI patients managed in Addiction
Services (continuing drinkers)
• Services designed around aetiology as
opposed to need -“gate-keeping” prevalent
• Serious need to improve links with other areas
of service (e.g. Mental Health / ABI)

10. Referrals by Source Since 2006
• G.P. 3%
• C.A.T. 27%
• Acute 25.5%
• Acute Liaison 6.5%
• C.M.H.T. 7.5%
• Social Work 12%
• Care Homes 2%
• Homelessness 2%
• 3rd Sector 3%
• 2ndary Services 2%
• Others 2%
• Psychiatry 7.5%
• (Addiction Psychiatry
and Acute Addiction
Wards – 4.5% of total)

11. Referrals and Gender
Referrals by Decade of Age
M + F Male Female
30’s 4% 2.7% 8.4%
40’s 21% 21% 21%
50’s 37% 30% 33.6%
60’s 30% 38% 32.4%
70’s 7% 8% 4.6%
80’s 1% 0.3% 0%

12. Did We Get it Right?
• Many referrals were not accepted and
caseload remained low
• Referrals did not meet our criteria (diagnosed
within two years)
• “How are we meant to get them sober?”
• Were we “gate-keeping”?
• Did the remit reflect either a) need or b) the
history of the condition itself?
• With no system of care how would these
specific individuals be referred to the Team?

13. Diagnosis - Our Experience
• There is a varied understanding of the diagnosis
of ARBD (algorithm?)
• Few cases seemed to be “clear cut”
• The diagnosis is dynamic – presentation changes
significantly in early stages
• Assessment for rehabilitation potential meant re-
evaluation in many cases
• Neuropsychological assessment was not easily
available in acute settings (pressure for beds)
• Should be a “diagnosis of exclusion”

15. Mr H Report – Key Issues
• Assessment of capacity and risk was poor
• Impact of alcohol on capacity misunderstood
• Poorly co-ordinated service provision
• Poor communication
• Prevailing critical attitudes to heavy drinkers
• No evidence that key Health or Social Work
professionals understood that legislation could
have been used to facilitate assessment
• ARBD is “..a diagnosed mental disorder”

16. The More Hidden Harm of ARBD?
Region/system Impact of
alcohol
function
Cerebrum Frontal and parietal
atrophy
Planning, problem
solving, self reflection
etc
Limbic system, e.g.
hippocampus
Reduces connections Memory and emotion
Cerebellum Atrophy Movement, gait, also
cognition (link to frontal
lobes)
Neurotransmitter
systems
Several systems
affected
Involved in
communication
throughout brain

17. Executive Function Problems
• “Between 50% and 80% of individuals with alcohol use
disorders experience mild to severe neurocognitive
impairment.” (Bates et al, 2002)
• “This has major implications for treatment outcome,
given the emphasis of many treatment programs on
motivation to change, and the possibility that impaired
brain functioning as a result of alcohol use may prevent
some from engaging with standard treatment programs”
(Svanberg et al, 2015)
• “It may be thought that they are “poorly motivated” or
are “pre contemplative” about their addiction.” (Bell & Craig,
2013)

18. A Change in our Thinking
“More widely, we would hope that this report
will remind health and social work services
across Scotland that staff awareness of ARBD
needs to be improved and that services need
to be able to respond to this very vulnerable
group of individuals much earlier than is often
the case at present.”
“Investigation into the care and treatment of Mr H” – Mental Welfare Commission(2006)

19. Broadening the ARBD Team Remit
• To provide assessment of individuals at high risk of
developing cognitive problems as a result of heavy drinking
• Support care plans aimed at facilitating harm reduction,
detoxification, diagnosis and assessment of capacity where
appropriate
• To see every service user referred where practical
• To support early legislative intervention to reduce alcohol
related harm, and crisis presentations to a range of already
over-burdened services
• To provide assessment for suitable resettlement of those in
longer term care
• To provide tailored training packages to those who work
with, come into contact with, or even live with drinkers

20. So…..What Works?

21. The Key Functions of the Team
• Raising awareness of ARBD
• Promoting Harm Reduction and Prevention
• Assessment
• Legislation
• Rehabilitation
• Support with Placement and Re-settlement
• To be a Resource for advice and support
• Training

22. Harm Reduction and Prevention
• ARBD is a preventable condition
• Addiction Services’ Dietician has designed a range of
leaflets for drinkers, abstinence, carers
• Empowering carers – “there’s nothing we can do.”
• Pabrinex P.G.D. – i.m. vitamin treatment can be
administered in the community again
• Pabrinex clinics – bring complex drinkers closer to
services and allow monitoring
• Promote thiamine and nutrition – opportunistic
interventions

23. Multidisciplinary Assessment
• Assemble all collateral information and speak
to relatives / carers / friends
• Assemble preliminary investigative
assessment – records / service history
• Cognitive Screen (ACE-111)
• Psychiatric assessment
• Occupational Therapy
• Neuropsychological assessment

24. Thorough Assessment Saves….
• Lives - early detection Wernicke’s –lower
mortality
• Cognitive damage - early intervention
• Resources – targeted allocation through
improved diagnosis and formulation
• Rehabilitation – maximised treatment gains
• Budget – fewer care home admissions
• Savings for Service Users, Services, and Society

25. Legislation Impacts On..
• Physical Health – less drinking days
• G.P. Services – fewer appointments
• A + E – less presentations
• Acute Hospitals – less bed days
• Increased Independence – less reliant on service
providers
• Placement – safer transition through services
• Services – eventual move out of services
• Families – relationships re-built

26. Rehabilitation
• Multidisciplinary involvement in interventions
• Social Rehabilitation
• Neurorehabilitation – individualised, goal-
directed care plans
• Memory Rehabilitation – use of compensatory
techniques (errorless learning)
• Rehabilitation of executive functioning
• A “staged approach” (Wilson et al, 2012)

27. Training and Being a Resource for:
• Carers and family members
• Home Care Services
• Care Home Staff
• Acute Hospitals
• Third Sector Support Staff and Fieldworkers
• Addiction Workers / Nurses and Social Workers
• Mental Health Officers
• Psychology and Psychiatry peer training

28. A Fuller Life – Then….and Now
• Highlights the potential for recovery
• Need for health promotion and prevention
• Need to challenge the stigma: ‘self-inflicted’
• ARBD crosses service boundaries – need for staged
assessment, integration and follow up support.
• Importance of support networks
• Appropriate placement
• Care Pathways
Scottish Exec 2004; the Expert Group on ARBD

29. Supported Accommodation and Living
• Penumbra – 8 Group Living S.A. places
• SAMH – 8 S.A. Tenancies (registered as Care
Home)
• Loretto Care – 12 S.A. Tenancies ( 4 at each of
three different sites (Harm Reduction Model)
• Loretto Care – 22 bedded S.A. unit in Tollcross
area of Glasgow. To function as a rehabilitation
unit with a stay of up to two years if required
• Supported Living hours available through SAMH
and Penumbra into service users’ own tenancies

30. So what do we need?
• A strong public health message raising
awareness of signs and symptoms, and the
risks of poor nutrition and alcohol
• A strategy and a clear sense of direction
• A clearer message about legislation and
recovery – are they “making a choice?”
• Accessibility, Flexibility and Training
• Shared Purpose, Vision and Understanding
• Commitment and Determination

31. Person Centred?
“Providing a person-centred service for those
with ARBD means trying to highlight the need
for flexibility and change in a sometimes
service-centred culture.”
ARBD Team Submission to NHS Scotland Event, 2010