The Management of Alcohol Related Brain Damage

Transcription

1 The Management of Alcohol Related Brain Damage Dr Julia Lewis Consultant Addiction Psychiatrist & Clinical Director Adult and Specialist Mental Health Services Aneurin Bevan University Health Board

2 Disclosures Director of Pulse Addictions Training Advisory Group for Lundbeck Pharma Honoraria from Lundbeck Pharma Honoraria from Reckitt Benckiser Pharma

3 Workshop Outline What is ARBD? An Ideal Service? How Do We Start?

4 Umbrella Concept Cerebellar/ Frontal pathway disorders Personality change, Mood disorder, Dysexecutive Syndrome Posterior lobes of cerebellum (connect to prefrontal cortex via pons) Brain Injury Traumatic or vascular Korsakoff s Nystagmus/ eye movement paralysis Poor balance, staggering gait or inability to walk Drowsiness and confusion (Adapted from Prof Ken Wilson, 2015) Neuro syndromes e.g. Central Pontine Myelinolysis, Marchiofava Bignami Syndrome, hepatic encephalopathy

5 Alcohol Withdrawal glutamate activity energy metabolism demand for thiamine direct cell damage less thiamine available for myelin repair Cell Death

6 Brain Pathology Frontal Lobe (especially Pre-frontal Cortex) Diencephalon hypothalamus thalamus pineal gland

7 Dysexecutive Syndrome Poor decision making Difficulties in task shifting Poor impulse control Poor motivation Problems with strategic planning Difficulties with goal setting and problem solving Problems updating stored information with newer more relevant information (including environmental feedback)

8 Memory Impairment Anterograde amnesia Later retrograde amnesia Mainly impairment of episodic memory Encoding and retrieval Working memory preserved

9 Natural History Acute Medical Acute Global Confusion Non-permanent Cognitive Dysfunction Permanent Cognitive Dysfunction days - weeks 2-3 months up to 3 years ongoing

10 Recovery Rates No Recovery Minor Recovery Moderate Recovery Significant Recovery

11 Your Experience What happens in your area?

12 An Exemplar Service

13 Educating Stakeholders Public Frontline NHS staff Primary Care Addiction Services MH Services

14 Screening ARBD (Wilson et al, 2013) dependent drinking history confusion, memory problems, capacity issues, concerns re: level of risk multiple admissions to hospital and/ or A&E attendances

15 Acute Medical Stage 1 Aim Tasks Manage withdrawal Physical Stabilisation Withdrawal Treat acute medical conditions May need MCA Make presumptive diagnosis

16 Modified Oslin Criteria Wilson et al Criteria for diagnosis of ARBD include: 1. Evidence of cognitive impairment (as demonstrated by clinical examination or use of instruments such as ACE-III) 2. Significant alcohol use as defined by a minimum average of 35 standard drinks per week for men and 28 for women, for a period of 5 years minimum. The period of significant alcohol use must occur within 3 years of clinical onset of the cognitive deficits Assessment ideally occurs after at least 60 days

17 Consider Also Assessment of capacity regarding continued drinking & accommodation OT assessment Risk assessment MRI scan

18 Acute Global Confusion Stage 2 Aim Tasks Keep abstinent & maintain nutrition Psychosocial assessment May need discharge to residential (MCA) Normalisation Memory supports Continual assessment and reassurance

19 Non-Permanent Cognitive Dysfunction Stage 3 Aim Tasks Develop autonomy Promote functional recovery Therapeutic Rehabilitation Orientation & memory support Impulse & behaviour control Managing apathy & motivation Managing alcohol Developing relationships

20 Transition Stage 4 Aim Tasks Adaptive Rehabilitation Adapt into routine life with ongoing deficits Can step down social setting at this point

21 Permanent Cognitive Dysfunction Stage 5 Aim Tasks Prevent relapse Social Integration & Relapse Prevention Maintain optimum level of independence & quality of life

22 Financial Considerations 85% reduction in hospital readmission rates Average residential costs dropped from 750/ patient/ week to 390/ patient/ week (total saving of 14,000/ week) Costs for complex patients increased by 180/ patient/ week Costs for non-complex patients decreased by 500/ patient/ week 42:8 (Figures from Wilson et al, 2010 (personal communication))

23 Your Practice What happens in your area?

24 Julia or If you build it, they will come

25 Education Training sessions for: Alzheimer s Society Mental Health Services (especially OA) District General Hospitals Third Sector Addiction Services Awareness raising Use of MoCA

26 Diagnosis Weekly clinic (3 slots) Clinical history (including collateral) ACE-III, ADL assessment, MRI Patient Health Passport, info and advice on legal issues Quality of Life, Enjoyment and Satisfaction Questionnaire Severity of Alcohol Dependence Questionnaire Detox - which ward? Information booklet An attempt at liaison

27 Diagnosis 3 monthly medical clinics Modified Relapse Prevention Contribution to social care planning (SS and CHC) Information booklet

28 Bits & Bobs Pabrinex PGD MoCAs (all new service users with alcohol problems) Involvement with local residential rehab providing ARBD programme

29 Thank you