Dr Scott Payne & Dr Mark Owens: Consultant Psychiatrist in Addiction Psychiatry & ARBD Researcher

Alcohol-Related Brain Damage in the Northern Irish Context

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

Dr Mark Owens

ARBD Researcher WHSCT

Dr Scott Payne Consultant in Addiction Psychiatry WHSCT

ARBD Project WHSCT Big Lottery Impact of Alcohol Programme 18 month ARBD Project Team Recruitment:

– Alcohol Liaison Nurse– Research Assistant– 2 support workers Apex Housing

Project Aim and Purpose:– Scope out the prevalence in the West, assess any

gaps in service provision for this client group and develop ways to improve services

ARBD Project Team Head of Service for Primary Care & Specialist Services Alcohol Liaison Nurse Trust Research Associate and Research Assistant Apex Housing Foyle Haven (De Paul Ireland) Team Managers, Drug and Alcohol Team Primary Care Liaison Team Manager Consultant Clinical Psychologist, PCOP Consultant Clinical Psychologist, Brain Injury Service Senior Social Worker, Women & Children Directorate Discharge Co-ordinator, Altnagelvin Hospital Consultant Addiction Psychiatrist

Scoping Exercise Of ARBD in WHSCT Area

Period Scoped: 1st April 2012 through to 31st March 2013.

Two pronged approach with data collection.

Electronic. Questionnaire

• Both the prevalence & incidence of ARBD show marked increases over recent years, (McCall et al, 2010; Ramayya & Jaunhar, 1997; Kok, 1991)

• The Hague (KAS)........... 5 / 10,000 (Blansjaar et al, 1987)

• Argyll & Clyde (ARBD).......... 7 / 10,000 (Chiang, 2002)

• One G.P. Practice estimated 14.4 / 10,000 for same area (McRae & Cox, 2003).

Previous Studies Have Reported

Data collection

Electronic databases Epex & PAS systems were searched for discharges.

ICD 10 codes:

• Either F10.6 (Amnesic Syndrome) or F10.7 (Late onset psychotic disorder).

• F01 (Vascular dementia) or F03 (unspecified dementia) but only with harmful or dependent alcohol consumption.

• G31.2 (degeneration of the nervous system due to alcohol) with F10.6, F10.7, F01 or F03

In the Scoping Questionaire respondents were asked to tell us about those clients who had a formal diagnosis of

KAS, Alcohol-related Dementia, or ARBD

And were also asked to include those patients or residents without a formal diagnosis but for whom in their opinion (or that of their staff) there existed substantial memory impairment that was related to sustained heavy alcohol abuse.

Data collection 2

EPEX / PAS

33 across Trust who met coding criteria 22 SWAH / AAH / T and C 11 T and F / Gransha

Cost

WHSCT acute beds are listed as costing £434 per day, psychiatric beds £330 per day: – If patients were in for on average 22 days (as per

Liverpool) for our 33 patients that would cost £ 210,056 + £79,860 = £289,916

– An 80% saving to this would be £231,932

Community Groups

126 agencies contacted – across health and social care spectrum – stat, C and V, residential

99% response rate with assertive Fup 66 positive responses 278 separate individuals recorded 45 at more than one service 1 patient recorded at 8 different services 2 patients at 5 different services

Prevalence = 0.09% or 9.4 in 10,000

The mean age (SD) for the cohort was 57.68 (13.49)

Min = 22; Max =91

A ratio of M : F 3.5 : 1

Males Mean Age (SD) = 58.01 (13.76) Min = 23; Max = 91

Females Mean Age (SD) = 56.53 (12.56) Min = 22; Max = 79

Results & Analysis

Age Stem-and-Leaf Plot

Frequency Stem & Leaf

2.00 2 . 23

6.00 2 . 666679

6.00 3 . 012223

13.00 3 . 5566677788899

15.00 4 . 001122223333444

33.00 4 . 555555566667777777888888999999999

37.00 5 . 0000000011111111122222222233333333344

38.00 5 . 55555566666777777777888888888999999999

41.00 6 . 00011111111111222222222333333333334444444

31.00 6 . 5555666666777777888888999999999

29.00 7 . 00000000111111122222222334444

15.00 7 . 555667778899999

7.00 8 . 0112224

4.00 8 . 5778

1.00 9 . 1

Qualitative Results And Analysis;

Respondents were asked to report on

What they were doing well.

The main difficulties.

Requirements/needs.

The data were examined for themes.

Respondents Outlined What they Were Doing Well including;

Meeting Basic Needs

Managing Alcohol.

Team Working

Therapeutic Interventions.

Providing Person-Centered Care.

Diagnosis.

Stigmatisation.

Management of Alcohol.

Care Planning & Risk Assessment.

Lack of Resources.

Challenging Behaviours.

Respondents Main Difficulties Included

Specialism / Specialisation.

Training & Education.

Assessment & Diagnosis.

Care Pathway & adequate Service Provision.

Appropriate therapeutic interventions.

Respondents Outlined Needs & Requirements

Appropriate services

Reduce acute hospital bed usage by 85% Significant reductions in relapse Significant reductions in mortality Improvements in 75% of patients over 3 years with

appropriate rehabilitation Maintain 75% in non institutional community

settings

Principles of good care Multi-disciplinary – Psychiatry, Rehab Psychology, SW, OT Involve family and carers Experienced key worker Active care plan Ongoing review of cognition, capacity, behaviour, risks Carefully managed transitions from community to institutional care First 3/12 important

– Abstinence– Good nutrition

3 years rehab – regularisation of routines e.g. eating, sleeping, personal hygiene

Introduction of memory and orientation cues Further cognitive rehabilitation

Alcohol and brain damage in adultsRoyal College Guidelines : College report CR185

Clinical commissioning groups should commission clinically appropriate services to provide multidisciplinary, specialist care for the

assessment and rehabilitation of patients with severe ARBD. In the absence of established specialist services, consideration should

be given to the embedding of ‘specialisation’ within the most appropriate established generic mental health service provision.

Such specialisation should provide advice and support to other services who are managing people with mild to moderate ARBD, including community teams and alcohol services.

Alcohol and brain damage in adultsRoyal College Guidelines : College report CR185

Clinical commissioning groups should commission appropriate services for facilitating early hospital discharge and short-term psychosocial assessment (up to 3 months).

Arrangements should be in place to provide safe and active institutional rehabilitation for those patients who are not well enough to be rehabilitated into non-institutional settings after the initial 3-month period of assessment.

Funding for long-term institutional care for supporting people with permanent brain damage should be made available.

Draft Hospital ARBD Referral & Care Pathway. Revised

19/02/14

Suspected Alcohol Related Brain

Damage

Patient with heavy alcohol use or identified as alcohol dependant.

(See guidance notes for staff)

With patient agreement and if required commence

detoxification and adhere to WHSCT ‘Management and Guidelines of Acute Alcohol

Withdrawal Policy’.NB. Give iv. Pabrinex

Immediately following detoxification and

stabilisationCognitive impairment

identified using clinical judgement, YES/NO?

YES

No ARBD input required. Refer to alternative

service.

NO

6 CIT completed by ALN result >10/28

Exclude possible physical/ mental health/transient causes for cognitive impairment e.g, infection /medication). Consider CT / MRI (brain) scan.

ARBD Team to screen referral and complete initial assessments.

YESReview placement for suitability for longer term

ARBD rehabilitation i.e. specialist care or supported environment with input from ARBD team over a

2-3 year period.

On-going assessment and multidisciplinary care planning in partnership with other services.

• Addictions Services• Brain Injury service• Mental Health Teams• Physical and Sensory

Disability Team• Primary Care Services

(GP)• No input

ARBD Team to identify a keyworker who will liaise with hospital SW to enable discharge planning to home or other appropriate setting. Ongoing assessments and multi-disciplinary care planning over a 3 month period i.e.• Psycho-Social Assessments • Risk Assessments• Neuropsychological Tests• Mental Capacity Assessments. • Functional Assessments. • Abstinence support.

Complete ARBD Referral Formproviding the following information:• Functional assessment

completed by OT• Mobility assessment by Physio

(if required)• Social circumstance report

(including assessment of home situation) by hospital SW.

• Cognitive assessment by ALN.

Further assessment

required

No

Yes

Patient with history of heavy alcohol use or identified as

alcohol dependant. (see guidance notes for staff)

Draft Community ARBD Referral & Care Pathway revised 19/02/14

Concerns about cognitive impairment/ memory

+/- risks to themselves.

• If the person is already abstinent or is continuing to drink then the GP in collaboration with other community staff /support workers to complete the ‘ARBD Referral Form’ providing information on the persons:

• level of risk/vulnerability• social circumstances (including

assessment of home situation)• functional ability• cognitive ability – i.e. complete 6 CIT and note period of abstinence.

ARBD Team to identify a keyworker and complete assessments over a 3 month period i.e:• Psychosocial Assessments• Risk Assessments.• Neuropsychological Tests• Mental Capacity Assessments.• Review Home situation.• Ongoing Functional Assessments• Abstinence support.

• Addiction Services• Mental Health Teams• Physical and Sensory

Disability Team• Primary Care/GP• Brain Injury Service• No input

Suspected Alcohol Related Brain Damage ARBD Team to screen referral and

complete initial assessments.

YESReview placement for suitability for longer

term ARBD rehabilitation i.e. specialist care or supported environment with input from ARBD team over a 2-3 year period.

On-going assessment and care planning in partnership with other

services.

NO

Collaborative working across services during 3 month assessment period is an essential requirement.

Refer to GP

If detox appropriate refer to detox nurse and follow WHSCT community detox pathway. Following detox consider

referral to ARBD team if concerns remain - see below.

Refer to ARBD Team

Further assessment

required

Yes

Inappropriate referral. Refer to alternative service.No

Summary.

• We have established a crude prevalence rate of 9/10,000.

• The current work goes beyond previous studies that concentrated on Acute hospital discharge & admission data exclusively.

• Carepathways have been informed and developed from the data presented.