Dr Tony Rao Consultant Community Old Age Psychiatrist South London and Maudsley NHS Foundation Trust and Institute of Psychiatry Psychology and

Transcription

1 Dr Tony Rao Consultant Community Old Age Psychiatrist South London and Maudsley NHS Foundation Trust and Institute of Psychiatry Psychology and Neurology

2 It would be too optimistic to suppose that the relative under-representation of subjects in the older age groups among clients of information centres is just explained by older people having generally got the treatment they required or having reverted to normal drinking...it seems likely that this finding is in part a hint of the diminished life expectancy of the alcoholic Professor Griffith Edwards British Medical Journal 1967

3 1986 WHY NOW? 2011 The Baby Boomers Turn 65

4 Projected population in England for people aged 65 and over Population of England (million) % of Total

5 Older Drinkers- A Growing Public Health Burden Population of aged 65+ age group and above in England and Wales increased by only 11% between 2001 and 2011 Over 65+ age group more likely to drink on 5 or more days of the week Between 2000 and 2012, percentage of men and women in England drinking over recommended limits increased by 50% and 100% respectively Number of people aged 65 and over admitted to hospitals in England for alcohol specific disorders has increased by 40% over the past 6 years In 60+ age group and over, hospital admissions in England for mental and behavioural disorders associated with alcohol use outnumber those with alcohol related liver disease. Number of people aged 60 and over admitted to hospitals in England with alcohol related brain injury has risen by over 140% over the past 10 years, with an almost static rise in the age group

6 Trends in drinking patterns in older people General Lifestyle Survey (ONS, 2013) Between 2005 and 2013, percentage of men drinking 8 or more units of alcohol on any 1 day in past week reduced by 5% in 65+ age group 12% in age group 19% in the age group 30% in the age group Older people more likely to: Drink every day Drink alone Drink wine and spirits Compared with working age population

7 WHY HERE?

8

9

10

11

12 Older people drinking above recommended limits referred to N Southwark Community Mental Health Team 43% showed alcohol dependence 21% showed harmful use of alcohol 71% suffered physical problems 57% admitted to mental health unit or went to A&E

13 Alcohol-related mortality in men - London (Office of National Statistics) Men aged /100, /100,000 Alcohol-related mortality in men - Southwark (Office of National Statistics) Men aged /100,000

14 Policy into Practice

15

16 Recommendations from Our Invisible Addicts Policy level Developing clinical guidelines through care pathways Public health level Developing consensus on drinking limits Educational level Developing training packages for health professionals

17 Other recommendations and strategic direction Service delivery level- Removing barriers to assessment and treatment Treatment intervention level- Exploring drug treatment interventions Research and development level- Improving knowledge base for effective treatments from epidemiological research and exploring barriers to service provision from clinical audit Ethical level- Developing, implementing and promoting service delivery based on need, in age-appropriate way via multi-agency partnership

18 Dr Bully wants to snatch granny s sip of sherry No doubt there are geriatric problem drinkers but that does not justify this puritanical mass bullying When Jeanne Calment of Arles reached her 117th birthday in 1992, a local paper reported that she was being pressed by those in her nursing home to give up cigarettes though she smoked only one or two a day and port, which she loved. I was reminded of that hateful story last week, when the Royal College of Psychiatrists announced that people over 65 are drinking far more than is good for them, and that each day women should restrict themselves to a small glass of wine and men to less than a pint of average-strength pub beer

19

20

21 Editorial Group Dr Tony Rao (Chair) Professor Ilana Crome (Addictions Faculty) Professor Peter Crome (British Geriatrics Society) Dr Anand Ramakrishnan (Old Age Faculty) Professor Steve Iliffe (Royal College of General Practitioners) Other members of Working Group Mike Ward (Alcohol Concern) Dr Amit Arora (Royal College of Physicians) Vivienne Evans (AdFam) Acknowledgements Martin Barnes (Drugscope) Ruthe Isden (Age UK) Dr Owen Bowden Jones/Professor Colin Drummond Dr Peter Connelly/Dr James Warner

22 Background Developed over 3 years by experts working across health, social care and voluntary sector Primarily for health and social care professionals, but can inform commissioners, researchers, educators, policy makers and voluntary/private sector Aims Recommend good practice for wide range of problems Assist clinician decision making Improve health and social outcomes Terms of reference Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions (including dual diagnosis)

23 Substance Misuse in Older People: An Information Guide (2015) General approaches to assessment, treatment and care Initial assessment of substance misuse in older people Psychosocial Interventions for substance misuse in older people Supporting families and carers Legal and ethical considerations Specialist Approaches to Substance Misuse The emergency physical presentation The emergency psychiatric presentation Managing withdrawal syndromes in the community Managing heroin/benzodiazepine substance misuse in the community Alcohol related brain injury Challenges to recovery Older women and alcohol misuse Drug interactions with substances Driving and substance misuse in older people

24 Alcohol and the Brain

25 Mechanism of alcohol neurotoxicity Direct toxicity- frontal and hippocampal damage Malnutrition-Wernicke s encephalopathy/korsakoff s syndrome Metabolite toxicity Electrolyte imbalance Hepatic encephalopathy/infection Inflammatatory (e.g. TNF α) Modifying factors (e.g. Apo allele/elevated homocsyteine)

26 Emergency Presentations Blackouts-predictive for both transient and permanent brain damage Behavioural changes-judgment, attention, psychomotor problems Falls-leading to traumatic brain injury Seizures Delirium Tremens Wernicke encephalopathy

27 Symptoms of Wernicke Encephalopathy Classic triad of ocular motor abnormalities, cerebellar dysfunction & altered mental state- only 20% of patients present with the full triad Altered mental state occurs in 80% mental sluggishness, apathy, impaired awareness of an immediate situation, disorientation, poor attention, agitation, hallucinations Cerebellar dysfunction occur in 25% (loss of equilibrium, gait disturbance, truncal ataxia, dysdiadochokinesia and occasionally, limb ataxia or dysarthria)

28 WERNICKE S ENCEPHALOPATHY

29 Korsakoff s Syndrome Results from chronic alcoholism and consequent thiamine deficiency Severe anterograde amnesia Severe retrograde amnesia extending years before damage Confabulation - make up stories to fill in absent memories Preserved short term memory Often unaware of deficit

30 Alcohol related dementia - proposed criteria (Oslin 1998) Evidence of cognitive impairment Significant alcohol use as defined by the minimum average of 35 standard drinks per week for men and 28 for women, for a period of greater than 5 years The period of significant alcohol use must occur within three years of clinical onset of cognitive impairment

31 A probable diagnosis of ARD is supported by presence of: 1. Alcohol related hepatic, pancreatic, gastrointestinal, cardiovascular or renal disease or other end organ damage. 2. Ataxia or peripheral polyneuropathy (not attributable to other non-alcohol related causes). 3. Neuroimaging evidence of cerebellar atrophy (esp. vermis) 4. Cognitive damage and evidence of ventricular or sulcal dilatation are likely to improve within the first 60 days, residual damage will be slower to improve and may be permanent The following cast doubt on a probable diagnosis of ARD 1. Significant language impairment (e.g. nominal dysphasia) focal neurological signs or symptoms (except ataxia or peripheral sensory polyneuropathy) 2. Neuroimaging evidence of cortical or subcortical infarction, subdural haematoma or other focal brain pathology 3. Elevated Hachinski Ischemia scale score

32 Differentiating Alcohol Related Dementia from other dementias Consistent findings of frontal lobe impairment from: MRI and fmri imaging PET and SPECT imaging Neuropathology Neuropsychological testing (n.b. limitations of conventional bedside tests such as SMMSE and AMTS) Frontal lobe function most affected in verbal fluency tasks

33

34 (Wilson, 2014) ALCOHOL RELATED BRAIN DAMAGE

35 SOME UN-ANSWERED QUESTIONS 1. Rate of progression and possible reversibility 2. Interplay with other pathology and traumatic brain injury 3. Role of drug treatment in managing BPSD 4. A clear dose-response relationship between alcohol intake and irreversible cognitive impairment remains unclear, but safe limits in older people more likely to be adversely affected by co-morbidity

36 Improving Care for alcohol related dementia

37 Access to specialist alcohol services Poor access to services exacerbated by: Sensory deficits Poor mobility Social and cultural isolation Stigmatisation Depression and cognitive impairment Further compounded by different routes of access Primary care services Social services Voluntary agencies Housing Old age psychiatry services Accident and emergency departments Care of the elderly day centres and hospitals.

38 Helping older people into treatment Accessing Services- Knowledge, Stigma, Denial, Ageism, Family Collusion Specialist service provision- Tailoring services to cohort, culture, ethnicity, biological/physiological aging, personality and social factors Time commitment - also a richer vein of experience Home based service delivery Empty bottles in the kitchen bin

39 Advantages of assessment using home based approach CLEANLINESS Untidy/cluttered Squalid/infested WARMTH Adequate heating Adequate ventilation SAFETY, SECURITY & STRUCTURE of everyday routine Smoke alarm Falls hazards Safe storage of medication Security (includes bogus/ cold callers) Face to face contact

40 Multi-agency partnership Likely to be several agencies involved- substance misuse services, old age psychiatry, geriatrics, primary care and social services Some voluntary sector organisations may have experience with older people but most do not Others such as wardens in sheltered accommodation, district nurses, housing officers and community pharmacists also invaluable

41 General health screening Brief Intervention Safeguarding SOCIAL SERVICES Day Centre/ Home Care Foundation 66 PRIMARY CARE HOUSING VOLUNTARY SECTOR Alcohol screening Falls ACCIDENT AND EMERGENCY Alcohol withdrawal Age UK Alcoholics Anonymous Adfam BME support

42 Community detoxification Community care coordination Old Age Psychiatry Substance Misuse Psychiatry Health and Social Care Psychological Interventions Physiotherapy Care of the Elderly Medicine OT and Psychology Wet Hostel Specialist Housing & Continuing Care Specialist residential rehabilitation Comprehensive medical review Specialist Dementia Care

43 Integrated care in dual diagnosis (Rao, 2013) First UK naturalistic study to show positive outcomes from community treatment of alcohol misuse and dual diagnosis Retrospective case note study Referrals to four older adult liaison psychiatry services 2006 to unique case notes identified; 108 patients eligible for inclusion 60 alcohol withdrawal syndrome (42 of whom had alcohol-related brain injury) 14 were placed in continuing care facilities 50 taken on by community mental health teams (CMHTs): at 6 month follow-up, 19 (38%) achieved abstinence from alcohol or controlled drinking Patients with ARBI less likely than those without it to have changed their drinking behaviour after

44 Middle age is also the time when social drinking merges insensibly with the early manifestations of chronic alcoholism. It may be many months before the store of gin bottles is discovered in the kitchen cupboard In any event, in no case with a decline in memory for recent events, an unexplained attack of delirium or hallucinosis or a change in personality, should the possibility of alcoholism fail to be considered Professor Sir Martin Roth Journal of the College of General Practice 1964