Developing services for Alcohol related brain damage. Management of severe alcohol related brain damage (Wernicke-Korsakoff type problems)

Transcription

1 Developing services for Alcohol related brain damage Management of severe alcohol related brain damage (Wernicke-Korsakoff type problems)

2 Prevalence and nature s Post mortem studies: 40,000 post mortem studies from community: Europe, Australia and USA Characteristics of WE in 0.5~1.5 % of patients of the general population at post mortem 1,2 Looking at post mortems of people clinically diagnosed as alcohol misusers: 12.5% have changes of classical of WE, 3 Increasing to 30% if cerebellar damage is included 3 Only 18% of patients diagnosed during their life time (PM studies) 3 Consumption: female: 30 units, male: 50 units a week for five or more years 4 (this will vary dependent on nutritional status)

3 Cortical and subcortical involvement Classical changes of W/K: mammillary bodies, Thalamic, cerebellar and frontal 1,2 Limbic system involvement: Hippocampus, medial temporal, limbic, frontal pathways 3,4 Fronto-pontine-cerebellar circuit 5,6

4 The problem: (a practical perspective) 1. Acute effects of alcohol Drunk Withdrawal Encephalopathies 2. Medium term effects of alcohol (transient ARBD) 1 In heavy, long term abusers: may last 3-4 months Often dramatic improvement 3. Long term effects of alcohol/thiamine deficiency 2,3 Deficits may show some improvement over 3-5 years. 4. Permanent alcohol/ thiamine related damage 3 Lasts indefinitely May be some improvement in terms of social and behavioural adaptation over time

5 ALCOHOL RELATED BRAIN DAMAGE Frontal, Limbic Temporal symptoms Vascular disease and trauma Neurological Disorders and rarer disorders WK Central Pontine myelosis Marchiafava-Bignami syndrome

6 The 5 steps of non-intervention for severely cognitively impaired alcohol dependents A&E Drunk/confused 1 2 Withdrawal/ admission Physical Stabilisation on ward 3

7 The 6 steps of non-intervention for cognitively impaired alcohol dependents (<65) A&E Drunk/confused 1 2 Withdrawal/ admission alcohol treatment services Physical stabilisation 3 Not cognitively assessed 4 Discharged from acute care Institutional care e.g. elderly

8 The 6 steps of non-intervention for cognitively impaired alcohol dependents A&E Drunk/confused 1 2 Withdrawal/ admission Back to drinking Alcohol treatment services: Non engagement with (memory problems) Denial Not cognitively assessed, no follow up Lost to service 4 Discharged from acute care Physical stabilisation Return to drinking environment 2.Don t remember hospital admission 3.No insight, Poor impulse control Inappropriate Institutional care Elderly mental Illness homes Institutionalisation morbidity & mortality Undue expense

9 Based on evidence review Examples from the literature Specialisation (experienced) service provision seems better than general adult service provision. 1,2 Specialist institutions seem to perform better than general institutions 3 Both generic and targeted cognitive/behavioural exercises and interactional groups seem to have benefit across 3 years 4,5,6,7 (no RCTs) Care planning across 3-5 years is recommended 5 (see fuller summary of literature: The clinical rehabilitation of people with alcohol related brain damage in: Alcohol and the adult brain; Eds Svanberg, Withall, Draper and Bowden; Current issues of Neuropsychology; Pubs Psychology Press Glasgow. )

10 Overview of the service Cheshire and Wirral Partnership NHS Foundation Trust 1. Purpose of the service 1. To reduce acute hospital use 2. To promote autonomy and independence of ARBD patients 3. To prevent relapse into alcohol misuse 2. Design of service 1. Carries approximately 30 ARBD patients at any one time referral per 100,000 per month 3. No inpatient beds 4. 1 nurse and 1 social worker and half day consultant

11 The intervention The model is: Easily generalisable Low cost (or cost saving) Involves relatively little medical involvement. Care planning (and potential case management) An adoption of basic nursing and occupational therapy skills A method by which non specialist carers, family and staff can be supervised A method by which nursing homes, institutions and domestic agencies can be informally trained and supported through supervised management

12 Overview of management 1 Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Acute in patient care on medical/surgical ward Physical stabilisation and thiamine 2-3 month assessment phase Protection from alcohol, nutrition, on-going assessment 3 year program of management/improvement Behavioural, educational training in ADLs Placement and provision of optimum support Optimising help around remaining deficits and housing On-going social support and integration Social integration and occupation development

13 Referrals from acute hospital inpatient wards and homeless mental health services Patient physically stabilised Confused with alcohol as main cause; multiple admissions, hard to place/bed blocking, Hospital/GP 213 referrals (59) Older persons services Too ill, died, discharged prior to assessment Drunk (in community) ARBD management Declined ARBD service capacitated incapacitated (66) (1 out of area) capacitated incapacitated (21) (51) Alcohol treatment services Declined help

14 Patient reviews (N=41) 1 Medical and psychiatric presentation/history Referral from acute medical wards History of, or presentation with co-morbid physical conditions Number of patients History of, or presenting co-morbid mental illness Number of patients Unspecified encephalopathy 8 Depression 17 Convulsions 10 Aggression 8 Peripheral neuropathy 8 Cerebral ischaemic/infarcts 9 Upper motor neurone signs 3 Subdurals/ significant head 6 trauma or anoxic brain damage Cerebella signs 4 Polydypsia 1 History of portal 4 Bipolar affective disorder 1 hypertension/oesophageal varices Deep venous thrombosis 4 PTSD 1 Diabetes 4 Hoarding 1 Chronic urinary incontinence/renal 4 Heroin dependency 1 disease (on methadone) Hepatitis C positive 2 Heart failure/fibrillation 5 Pancreatic disease 2 Duodenitis/gastritis/ulcers 5 History of significant fractures/dislocations 6 Cerebro-vascular disease/head trauma in 1/3cases 1 patient went through PICU 5 patients on CTOs and one on guardianship

15 Case study DOB 1959 ; age 53, male Referred to us 3 years ago; Relevant personal history: One of four brothers. Parents were heavy drinkers. Always a bit slow at school, left when he was 16 and worked as a refuse collector. Made redundant after 15 years as not attending work through excessive alcohol drinking. Formed a relationship with a female alcoholic and drug abuser; very chaotic relationship including her physically assaulting him on numerous occasions. Relationship broke down, made homeless, park benches and ended up in a hostel in Liverpool Brother Stephen picked him up and set him up in a rented house Brother managed his finances and limited him to two cans of beer a day. Receives incapacity benefit

16 Case study Useful bit about medical history Numerous episodes of alcohol admissions with evidence of encephaolpathies: either Wernicke or withdrawal related delirium Multiple fractures and collapses, multiple trauma to head, culmination in a fractured skull in 1998 and related subdural heamatoma and related convulsions demonstrated a cerebral infarct; right temporal lobe. Convulsions are recurrent and partially stabilised with sodium valporate.

17 Case study Referral from liaison Admitted into acute medical ward: Hallucinating and confused. Unsteady on his feet At 5 days post admission: Hallucinations and confusion improved; Speech normal, mood subjectively ok, no thought disorder, thought content unremarkable, perception Ok

18 Case study Cognition: MMSE: Thought year was /5 for orientation Problems in repeating no ifs, ands or buts Never been able to write, poor speller 3/5 in months backwards 3 minute recall ; 2/3 Total score 22/30 Frontal Luria test poor Proverb interpretation poor Word fluency poor: categorisation and listings. Failed with prompting Insight No insight into difficulties of ADLs.

19 Case study Problems When patient drinks 3-4 cans of alcohol: Refuses or non compliant to medication Disruptive and abusive Grand mal convulsions: multiple hospital admissions Patient thinks that his only problem is convulsions due to head injury Patient does not have long term recall of personal life events and alcohol history Patient cannot relate alcohol ingestion to convulsions Patient is unable to memories agreements and explanations. Patient is insistent that he has access to alcohol

20 Case study Discharged from acute care to own house, with support of brother and hospital acute team (visiting an hour a day for?6 weeks). Referred to ACAS team Care plan of rehabilitation set up

21 Case study Individualised care plan: Conducted under auspices of best interest MCA Moved to Supported living with enhanced supervised therapeutic package Key worker(s) identification Medication supervision Joint financial management Diary management Activity scheduling, Graded task assignment, Managed exposure to alcohol Behavioural management

22 Cognitive profile MSSE Total ACE-R Total Atten/ orien memory fluency lang Visuo/ spac 12/8/09 17/30 33/100 9/18 3/26 0/14 10/26 10/16 27/4/10 26/30 56/100 18/18 10/26 2/14 11/26 15/16 28/10/10 23/30 48/100 14/18 6/26 3/14 10/26 15/16 25/5/11 24/30 61/100 16/18 18/26 1/14 15/26 11/15 11/1/12 25/30 56/100 14/18 15/26 2/14 13/26 12/16 2/3/12 24/30 63/100 14/18 18/26 4/14 13/26 14/16

23 Cognitive profile MSSE Total ACE-R Total Atten/ orien memory fluency lang Visuo/ spac 12/8/09 17/30 33/100 9/18 3/26 0/14 10/26 10/16 27/4/10 26/30 56/100 18/18 10/26 2/14 11/26 15/16 28/10/10 23/30 48/100 14/18 6/26 3/14 10/26 15/16 25/5/11 24/30 61/100 16/18 18/26 1/14 15/26 11/15 11/1/12 25/30 56/100 14/18 15/26 2/14 13/26 12/16 2/3/12 24/30 63/100 14/18 18/26 4/14 13/26 14/16

24 Case study Current situation Living in residential setting for working age adults with mental health problems. Structured week programme Managed best interest under agreement with patient, staff and next of kin: Brother. Controlled finance agreed with brother, staff facilitate in daily activities Managed exposure to alcohol (2 cans a week) One or two A/E admissions in the last six years

25 Service reviews

26 Review 1: Clinical improvement 1 N=41 Patients demonstrated improvement in all the following HONOS areas: problem drinking and drug use cognitive problems physical illness and disability experience of hallucinations delusions and confabulation problems with relationships problems with activities of daily living problems with living conditions and problems with activities No patients were rated as experiencing self directed injury However, emerging depression may well be a problem

27 5 years preceding end of index admission: 205 patient years Review 1 1 Impact on acute care 41 patients had 4418 days of admission 0.53 acute medical/surgical bed days per patient each patient year 41 patients were followed up for 85.6 patient-years post treatment 295 days of inpatient care in acute medical or surgical wards 0.08 acute medical/surgical inpatient days per patient each patientyear Reduction of acute medical surgical beds by 85%

28 Review 2: institutional/community outcomes N=57 completed programme (unpublished) 36 patients in non- institutional care (sheltered accommodation, supported living, domestic). Of these 9 patients were rehabilitated home through institutional care 5 are uncontrolled drinking: 4 died at home (abstinent) 27 (75%) of the 36 patients well in the community

29 Review 2: institutional/community outcomes; N=57 21 patients in Institutional care 9 of these are profoundly ill (multiple mental and physical illnesses) and likely to remain 3 have died in institutions 9 were in the process of being discharged from the institutional care into community care (supported living or own homes)

30 Review 2: summary N=57 7 died 5 in uncontrolled drinking 9 patients are permanently institutionalised (very dependent) 38 abstinent (and 2 in controlled drinking) 9 in treatment (phase 3) 30 settled (phase 5) in non-institutional settings (4 of which have died) 80% abstinent (2 of which are in controlled drinking) 78% either expected to be (9) or are at home/sheltered or in supported living (abstinent) 18% permanently institutionalised 12% mortality rate 12% alcohol relapse rate

31 Review 3: care package cost (unpublished) N=39 Total costs to the NHS funding authority (excluding cost of team). Average patient cost per week: Initial: End: per patient per week 52% reduction This includes complex cases; 8 Patients with two or more psychiatric diagnoses with increased cost Bipolar, behavioural problems and high risk (assault) Persistent water intoxication and dilutional hyponatraemia Vascular dementia, frontal infarcts and unpredictable violence Anoxic brain damage (referred from PICU) Resistant anxiety depression and acute agitation Resistant paranoid psychoses Personality disorder, psychoses (referred to CMHT) Severe Korsakoff psychoses and depression

32 Review 3: Care package cost Complex cases (N=8) Average cost per week (per patient) Initial End increase of per week (allow for inflation) 8/8 complex cases continued on either joint LA/Health or Health funding Simple cases (N=31) Initial End reduction per patient per week (70% reduction) 20/31 simple cases had no health costs by the time they had been through the programme

33 summary The vast majority of ARBD patients are likely to improve if provided with appropriate treatment and care. Outcomes: Improvement in HONOS scores (NB emergent depression) Significant reduction in acute hospital bed days (85%) Significant majority are able to live relatively independently without on-going institutionalisation (75%) An active treatment program is associated with 52% reduced cost of care across three years and 70% in non complex cases There is a relatively low mortality rate (12%) There is a relatively low relapse rate into uncontrolled alcohol misuse (12%)

34 RCPsych Guideline CR185 (treatment manual) Wilson et al. Alcohol and Alcoholism (May/June 2012) 47(3): first published online January 25, 2012 doi: /alcalc/agr167

35 Cheshire and Wirral Partnership NHS Trust In collaboration with Wirral CCG (Invest to save programme)