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Dr Mark Hogan: Senior Clinical NeuropsychologistNeuropsychological Correlates of ARBI: Implications for Rehabilitation
ARBI: A Best Practice Seminar: Royal College of Physicians, 20th April 2015
Dr Mark HoganSenior Clinical NeuropsychologistDonegal Community Neurological
Rehabilitation Service
Neuropsychological Correlates of ARBI: Implications for Rehabilitation
Alcohol Related Brain Injury
Session Outline Brief Orientation to continuum of impairment, Treatment
and Neuropathology
KEY FOCUS: Complex impairments Cognitive, behavioural and Safety Concerns - Vulnerability Estimating needs with ongoing assessment Rehabilitation Planning
Typical History and Presentation
Neuropsychological Considerations
ARBI – Falling Between Stools
Addiction Services- Counselling, Group interventions, After Care- Harm Reduction, Relapse Prevention- Impact of Cognitive Impairment
Adult Mental Health - Mental Health
- Primary issue – severe or enduring MH difficulty
Dedicated service or reconfiguring/expanding existing teams?
Alcohol Related Brain Injury
Alcohol Related Brain Injury= the umbrella term for the spectrum of neurocognitive changes resulting from chronic alcohol excess.
Multiple overlapping terms
Chronic Alcohol Use (Clinical Level 1)
Wernicke Encephalopathy (Clinical Level 2)
Significant Impairment including Korsakoff Syndrome (Clinical Level 3)
Alcohol Related Brain Injury
‘a wide range of neuropathological and related psychoneurological syndromes including Wernicke’s-Korsakoff’
(Wilson et al. 2012)
Multiple mechanisms of action - Vitamin Deficiency
- Direct Neurotoxic action of alcohol
- Metabolic factors from multiple intoxifications and withdrawals
(Kopelman et al. 2009)
Alcohol Related Brain Injury
Chronic Alcohol Use Complex cognitive difficulties across multiple areas- Continuum of memory impairment- Evidence of some Executive Functioning deficits- Less impaired cognitive profile vs KS (Pitel et al. 2008)
Wernicke EncephalopathyAcutely unwellTriad of Impairments – Ataxia, Confusion, Eye movementsThiamine 85% develop Korsakoff Syndrome
Korsakoff Syndrome “memory and learning are affected out of all proportion to
other cognitive functions”(Kopelman 2002)
Physically well/mobile
General intellectual functioning/profile largely preserved
Working Memory intact
Confabulation
Increasing evidence of Executive Functioning deficits
(Maharasingham et al. 2013)
Alcohol Related Brain Injury
Neuropathological Changes:
Frontal lobes most vulnerable: decreased neuron density in superior frontal cortex, shrinkage.
Atrophy also seen in cerebellum (grey and white matter of vermis), thalamus, mammillary bodies, hippocampus, amygdala, insula, alterations to brainstem, compromised white matter integrity.
Alcohol Related Brain Injury
Current Service Provision at Level 1 and 2Limited input from Neuropsychology
Addiction services (Alcohol Free/ Harm Reduction)Direct medical Intervention (Detox, Thiamine)
Screening assessments (Primary Care) RelapseSpontaneous RecoveryFunctional/Safety issues
Case co ordination
Typical Presentation
Chronic alcohol use Multiple hospital admissions (detox, head
injuries) Limited engagement with addiction services Multiple relapses Family/Interpersonal difficulties Limited social support Decline in physical state and poor rate of
recovery over time or at most recent admission
Safety concerns at Discharge Planning
Cognitive Changes
May have insidious onset
May occur in the context of existing psychosocial disruption
May not be recognised as cognitive change
Deterioration may be accompanied by decline in social support, financial & occupational stability
May be comorbid and/or pre-existing difficulties – brain injury, dementia (vascular, fronto-temporal)
Estimation of baseline can be difficult
Multidisciplinary Assessment
Stabilisation allows clear assessment.
Comprehensive, multidisciplinary, multi-agency over time.
Cognitive screening and neuropsychological assessment key to outline strengths and weaknesses, and support/treatment planning.
Can also support differential diagnosis e.g. ARBI v dementia
Assess risk: vulnerable adults, child protection, health and mental health risks
Assessment will inform care planning and allow formulation of appropriate interventions.
Korsakoff Syndrome
Key Neuropsychological Elements:
i) a profound anterograde amnesia affecting the ability to learn new information;
ii) a retrograde amnesia impeding the ability to recall personal autobiographical information and
iii) executive functioning impairments impacting on person’s ability to plan, organise information and think with flexibility
(Evans and Svanberg 2013)
Neuropsychological Assessment
Timing
Role of Assessment and ExpectationsEstimate Profile, Diagnostic, Awareness of deficits and impact, Rehabilitation planning
Multiple Elements/Methods
Neuropsychological Assessment
Korsakoff Syndrome profile as template
Significant impairment of LTM (somewhere within encoding, consolidation, storage, retrieval)
Confabulation (Spontaneous vs Provoked)
Attention/Executive Functioning Deficits
Impacting day to day functioning
Neuropsychological Assessment
Multiple MethodsCase HistoryHospital recordsClinical interviews (self report and collateral information)Staff reportFunctional skills (personal care, dressing, ADL safety)Direct observationTargetted formal testing
Neuropsychological Assessment
Medical Information Neuroimaging, treatment, rate of recovery
History of Alcohol UseDuration, levels of consumption, impact on functioning over time (physical, cognitive, social)
Length of abstinence/Timing of assessment or intervention
Current Presentation
Neuropsychological Assessment
Standard Elements of Formal Assessment
Consent, Comprehension, Concentration, Effort
Estimate Premorbid Functioning
Subtests of WAIS
Neuropsychological Assessment
Memory Working Memory intact (WAIS IV) Implicit/Procedural Memory
OrientationAutobiographical memory (temporal gradient)Episodic memoryRecall of recent events
Neuropsychological Assessment
Formal Tests
WMS Logical Memory
Rate of Verbal Learning CVLT/List Learning
Confabulation
Historically a significant emphasis on memory
Executive Functioning
“a collection of functional deficits in the higher order cognitive skills required to initiate, plan execute and monitor complex goal directed activities” (Miotto et al. 2009)
Key higher level cognitive skills associated with Frontal Lobe function
Key element of KS presentation (not universal)
Lack of conceptual clarity and consensus on precise definition of Executive Functioning and dysfunction
Executive Functioning
Potential COGNITIVE consequences of Frontal Lobe pathology
Planning, organisation, strategy application, problem solving, reasoning, decision making, sequencing, problems with forming and shifting concepts, rigidity of thought processes, awareness, MEMORY
Multiple interrelated higher level cognitive skills not amenable to a single test or the standard test environment
Executive Functioning
Assessment
Novel, unstructured events
Ecological Validity
Formal tools – highly structured, time limited and have a clear outcome measurement
“Patient impairment less likely to manifest in the test situation” (Shallice and
Burgess 1991)
Executive Functioning
Key Assessment tools:
Naturalistic Observation
Functional Assessment (ADL’s real life situations)
Staff report
FAS TMT Sorting Tests BADS, DKEFS
Neuropsychological Findings
Memory and New LearningProfound anterograde amnesia affecting ability to learn new informationRetrograde amnesia impacting AMMore severe in KS vs Chronic (Brokate et al. 2003)Confabulation
Executive FunctioningIncreasing evidence of EF deficits (all BADS subtests)More severe in KS (very large clinicall significant difference) – key difference vs Chronic (Van Oort & Kessels, 2009)
Clinical Implications
Interaction of significant memory impairment with a combination of executive skills deficits including initiation, planning, problem solving, self monitoring, learning from experience, judgement and self awareness
Explaining profile and implications to person, family and staff
Cognitive and Social Vulnerability
Safety Concerns
Challenging Behaviour (Awareness of Deficits, poor emotional regulation)
High and ongoing support needs
General Considerations for Rehabilitation
Prevention
Training and consultation (Hospital, care staff, Individual and Family)
Evidence drawn from other fields e.g. brain injury, mental health, addiction
Need for comprehensive and holistic approach for treatment e.g. Wilson et al 2012
Multi-disciplinary, multi-agency.
Promote a staged approach.
Rehabilitation
Initial Goals: Engagement of person and family
Process of assessment, feedback
Develop a framework for understanding initial advice/planning
Goal setting
Regular monitoring
Consistent formulation of case understood by all team members
Timeframe of rehabilitation planning
Rehabilitation
Potential for change/improvement vs loss of function
ENGAGEMENT
Explaining the nature of the condition to person (written feedback), family meetings over time, staff training
Heterogeneous group with complex needs
MDT involvement with assessment over time
Phases of Input from medical intervention to holistic rehabilitation (Wilson et al. 2012)
Memory Rehabilitation
Memory compensation strategies: diaries, whiteboards, calendars, memory systems.
Information in small chunks Repetition Errorless learning, vanishing cues techniques Life story work (parallels with dementia
therapies) Technological aids: phones, pager systems,
Neuropage, SenseCam Benefit of external aids as maximise
independence without relying on e.g. carer prompting
Executive Functioning Rehabilitation
Environmental structure and routine Clear ‘rules’ for action Support to develop personal goals Goal Management Training STOP and THINK strategies In Situ Feedback
(Evans and Svanberg 2013)
Rehabilitation
Case Co Ordination with clear service pathways for identification, MDT assessment, funding rehabilitation and possible residential support
A continuum of Support options from outreach to optimal environment residential care
Rehabilitation and Optimising function and independence vs Care
(Wilson et al. 2012)
Current Service Provision
Case Co Ordinator (Key Step)
Early Detection and treatment in acute setting/addiction services
Agreed initial care pathway
Work with private agency to provide environment and increase expertise with this group
Access to MDT community based disciplines
Needs Assessments including mental health