Professor Kenneth Wilson: Consultant Psychiatrist in ARBD Alcohol-Related Brain Damage: A Service Model

ARBI: A Best Practice Seminar: Royal College of Physicians, 20th April 2015

Alcohol related brain damage

A service model

pathway cognitiveassessment

ARBD

incapacitated/severe Capacitated/mild

Management of cognitive damage

Alcohol treatment ServicesAdapted management plans

ACE 111 (Addenbrookes cognitive examination)MOCA (Montreal cognitive Assessment)

pathwayassessment

ARBD

incapacitated/severe Capacitated/mild

Management of cognitive damage

Alcohol treatment services

Wirral servicesevere ARBD

Teams purpose: (Principle referrals from acute medical care)

To enhance quality and longevity of life To reduce hospital bed days

Reduce time spent in acute beds Prevent readmission

Service profile The team

2 days of a consultant psychiatrist

3 FTE senior social workers 1.75 FTE RMNs 2 care assistants 1 FTE admin support

The case load (population 310,000) 120 cases are working aged

adults with dementia 30 cases are ARBD

The resources

1 trained up nursing home for working aged adults

1 trained up residential home for working aged adults

1 supported living accommodation for working aged adults

Trained up domestic agency

No direct access to inpatient units but working relationship with colleagues: Access to acute psychiatric

and old-age beds

All three criteria should be positive1. Probable history of heavy, long standing alcohol drinking for at

least five years.

2. Confusion, memory problems, doubt about capacity and concerns about risk on discharge, after withdrawal/physical stabilisation.

3. Thee or more admissions into hospital and/or A&E in one year probably associated either directly (withdrawal, unconscious) or indirectly (trauma, organ disease, etc.) with alcohol ingestion.

Or One or more delayed discharges from general hospital wards in the last 12 months. (a delayed discharge is defined as patients staying on the acute medical/surgical ward because of social and/or psychiatric problems).

(Adapted through pilot work from Oslin’s criteria relating to diagnosis of alcohol related dementia. (Oslin DW, Carey MS. Alcohol related dementia; Validation of diagnostic criteria. American Journal of Geriatric Psychiatry 2003;11(4):441-7. )

Identifying cases on the acute wards: a simple approach

Overview of management phases

Acute in patient care on medical/surgical ward

2-3 month assessment phase

3 year program of management/improvement

Placement and provision of optimum support

On-going social support and integration

Phase 1

Phase 2

Phase 3

Phase 4

Phase 5

Overview of facilitiesAcute medical/surgical ward

Possible assessment unit

Intensive/custodial

• Specialist NH• Non spec. NH with

treatment package• Residential Home

with treatment package

Socially Supported

• Sheltered with treatment package

• Supported living with treatment

package

Community based

Domestic carewith treatment

package

Assertive community team supervision, monitoring and care planning

Decreasing dependency

Assertive in-reach

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 17Convulsions 10 Aggression 8Peripheral neuropathy 8 Cerebral ischaemic/infarcts 9Upper motor neurone signs 3 Subdurals/ significant head

trauma or anoxic brain damage

6

Cerebella signs 4 Polydipsia 1History of portal hypertension/oesophageal varicies

4 Bipolar affective disorder 1

Deep venous thrombosis 4 PTSD 1Diabetes 4 Hoarding 1Chronic urinary incontinence/renal disease

4 Heroine dependency

(on methadone)

1

Hepatitis C positive 2Heart failure/fibrillation 5Pancreatic disease 2Duodenitis/gastritis/ulcers 5History of significant fractures/dislocations

6

Patient profileMedical and psychiatric presentation/history

N=41

1 patient went through PICU

5 patients on CTOs and 1 on

guardianship

(N=22) ACE 111 score 65.7 (range 30-93)MMSE score 23.3 (range: 11–30)

Phase 1 Physical stabilisation (variable time) acute hospital management of encephalopathy, delirium

tremens and withdrawal in the context of physical stabilisation and appropriate thiamine therapy (NICE 2010).

If Wernicke’s encephalopathy is suspected or established,

parenteral thiamine (i.m. or i.v.) >500 mg should be given for 3–5 days (i.e. two pairs of ampoules Pabrinex® three times a day for 3 days), followed by one pair of ampoules once daily for a further 3–5 days depending on response.

If patient is at high risk of Wernicke’s encephalopathy (e.g. malnourished, unwell)

prophylactic parenteral treatment should be given, using 250 mg thiamine (one pair of ampoules Pabrinex®) i.m. or i.v. once daily for 3–5 days or until no further improvement is seen.

Clinical phases of rehab programme

Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting

Phase 2 Psycho-social assessment (usually 2-3 months:)

The brain is likely to demonstrate a significant degree of recovery over three months of abstinence. Patients may have:

Recovery is enhanced through:Abstinence

Good nutritionCalm environment

Promotion of routine and structureRegularisation of sleep and mood stabilisation

Development of therapeutic relationshipsEarly engagement with family and carers

Introduction of memory cues, diary keeping, alcohol education

On going psycho-social assessment

Clinical phases of rehab programme

Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting

Phase 3; ‘therapeutic phase’ of treatment programme

Derived from literature (head injury rehab, ARBD and alcohol treatment): and modified through piloting

Organisational processes: On-going care planning On going capacity assessments Working with care agencies

Principles of therapeutic engagement Intense Personalised Collaborative Socialization and developing relationships Planning activities Learning skills

Therapeutic interventions

Dairy keeping Activity scheduling Graded task assignment Memory and orientation cuing Alcohol education/management Impulse and behaviour control Managing apathy and motivation

Phase 4 Adaptive rehabilitation (variable duration) Adapting the environment so as to compensate for residual cognitive and

functional deficits

Dangerous time Assessing levels of dependency and residual cognitive/functional

impairment Working with families/carers Identifying appropriate physical environment Initially provide more support than is needed then, in new

environment reduce support to enhance independence and autonomy

Phase 5 Social integration and relapse prevention (on-going) Probably most important phase: good integration will prevent relapse

Patient based outcomes Employment Social networking

Phase 4&5‘adaptation and social integration

phases’Derived from literature (head injury rehab, ARBD and alcohol treatment): and

modified through piloting

Case study 1 complex case (concurrent physical problems and head

trauma) DOB 1959 ; age 53 Referred to us 7 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 picked him up and set him up in a rented house in the Wirral (as he lived on the Wirral) so as to ‘keep an eye’ on him.

Brother managed his finances and limited him to two cans of beer a day. Receives incapacity benefit

(I have changed some medical and biographical details on this case)

Case study 1 a complex case

Useful bit about medical history Numerous episodes of alcohol admissions with evidence of

encephaolpathies: either hepatic/Wernicke or withdrawal related delirium

Multiple fractures and collapses, multiple trauma to head, culmination in a fractured skull in 1998 and related subdural haematoma and related convulsions.

2007 demonstrated a cerebral infarct; right temporal lobe. Convulsions are recurrent and partially stabilised with

sodium valporate. Admitted into acute care: hallucinating, fitting

Every time he drinks more than a pint or two he throws a major convulsion

Case study 1 a complex case

When seen on ward: Needed a security guard outside side

room. Disorientated in time, place and person Did not understand why he was in acute

care Profound short term and long term

memory problems Had significant reasoning problems Significant problems with regard to

language

Case study a complex case

Referred to team, moved to supported living.

Neurocognitive treatment programme set up by team working with supported living and carers Enhanced 1-1 3 hrs per day (under

supervision) Team visiting once-twice a week

Brother brought in as appointee

Case study Current situation

1:1 support closed down Living in supported living for working age adults

with mental health problems. Managed best interest under agreement with

patient, staff and next of kin: Brother. Brother controls finances, staff facilitate in daily

activities Requires on-going supervision and structure. Controlled exposure to alcohol Prone to occasional ‘outbursts’ associated with

brother not visiting. Four admissions due to fits in last 6 years,

admissions (A&E).

Case study 2an uncomplicated case

A few years ago: a very intelligent, 45 year old female executive Waiting for a bus in London:

(Permission given by patient to use case for teaching purposes and conferences)

Case study 2 Assessment

Main findings: Preoccupation with being pregnant Apparent retrograde memory problems characterised by amnesic

episodes and lack of memory regarding amount and duration of alcohol ingestion and related issues

MMSE score of 30, but with problems with anterograde memory Some minor reasoning issues with slightly reduced word fluencyManagement issues:Wanted to have custody of children but was pragmatic about thisDid not want to comply with institutional rehabilitationDid not accept that she had an alcohol addiction problem Placed on guardianship:

To protect her from alcohol To facilitate access and rehabilitation

Case study 2

In a residential home for 1.5 years, undergoing phase 3 treatment

Graded home visits with support of parents (building relationships with family)

Re-introduction to children One alcohol relapse Went home with six hours treatment programme each day,

monitored by the team. Now discharged from team;

Living near parents Children staying over night a few nights a week Voluntary job Still got some short term memory problems (copes with a

diary/reminder pad) Alcohol free.

outcomes

Review 1: Clinical improvementN=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

injuryHowever, emerging depression may well be a problem

5 years preceding end of index admission: 205 patient years 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 295 days of inpatient care in acute medical or surgical

wards 0.08 acute medical/surgical inpatient days per patient

each patient-year

Reduction of acute medical surgical beds by 85%

Review 1Impact on acute care

Review 2: institutional/community outcomes

N=57 completed programme 36 patients in non- institutional care

(sheltered accommodation, supported living, domestic care) Of these : 5 are uncontrolled drinking:

1 has a personality disorder and is about to go to prison

2 have minor ARBD with capacity to make decisions about alcohol drinking

1 is a binge drinker (no capacity) 1 lost to follow-up (transferred out of area)

4 died at home (abstinent) 9 patients were rehabilitated home through

institutional care 27 (75%) of the 36 patients well in the

community

Review 2: institutional/community outcomes

21 patients in Institutional care 9 of these are profoundly ill (multiple

mental and physical illnesses) 3 have died in institutions 6 are under assessment and probably

will be rehabilitated 3 are in active rehabilitation and will

leave the institution.

Review 2: summaryN=57

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

Review 3: care package costN=39

Total costs to the NHS funding authority (excluding cost of team). Average patient cost per week:

Initial: £747.93 End: £387.00 per patient per week

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

Review 3: Care package cost

Average cost per week (per patient)

Complex cases (N=8)Initial End913.63 1093.87 increase of £180.25 per week

8/8 complex cases continued on either joint LA/Health or Health funding

Simple cases (N=31)Initial End705.17 204.70 reduction £500.47

per patient per week(70% reduction)

20/31 simple cases had no health costs by the time they had been through the programme

summaryThe 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 reduced cost of care across three years in most cases (70%)

51% are cost free to health services by end of programme (some needing on-going social support)

There is a relatively low mortality rate (12%) There is a relatively low relapse rate into uncontrolled

alcohol misuse (12%)

CR 185 Royal College of PsychiatristsARBD Guideline (free of charge)

Management manual (free of charge)

Cheshire and Wirral Partnership NHS Trust/Mersey Care NHS Trust

k.c.m.wilson@liverpool.ac.uk

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