Back to reality – treating ARBD

Getting the right treatment can reverse effects of alcohol-related brain damage, says Alyson Smith.

Read the full article in June 2018 issue of DDN

Alcohol-related brain damage (ARBD) refers to the damaging effects of long term alcohol consumption on the brain. Alcohol toxicity, vitamin deficiencies and disrupted blood supply to the brain can result in a range of serious conditions, including Wernicke’s Encepalopathy, Korsakoff’s Syndrome, alcohol-related dementia and alcohol amnestic syndrome.

It has been suggested that these disorders are best regarded as occurring on a spectrum (Jacques and Stephenson 2000). It is not the same thing as age-related dementia; ARBD occurs when a person is deficient in thiamine (vitamin B1) and if untreated can lead to memory problems and frontal lobe dysfunction (Chiang, 2002).

The impact of ARBD ranges from mild to very severe. The good news is that this need not necessarily be progressive if people can engage in cognitive rehabilitation, abstain from alcohol and maintain a good diet. While intellectual functioning appears to remain intact, memory and social functioning can be improved through targeted rehabilitation. Smith and Hillman (1999) suggest that 75 per cent of clients can expect some level of recovery, with 25 per cent making full recovery.

 

Cognitive and memory problems

  • Confusion regarding time and place
  • Impaired attention and concentration
  • Difficulty processing new information
  • Inability to screen out irrelevant information
  • Confabulation – filling gaps with irrelevant information
  • Apathy – loss of motivation, spontaneity and initiative
  • Depression and irritability
Physical problems

  • Ataxia – poor balance, disordered gait
  • Damage to liver, stomach, and pancreas
  • Possibility of traumatic brain injury
  • Peripheral neuropathy – numbness, pins and needles in hands, feet, or legs
  • Nystagmus and opthalmoplegia – involuntary eye movement

It is very difficult to obtain accurate prevalence figures for ARBD. However, a service for those under 65 years of age in Cheshire and the Wirral reportedly receives three new referrals per month, suggesting an annual incidence of 13.9/100,000 in those aged under 65 (Wilson quoted in Smith and Emmerson, 2015).

Research (Wilson, 2014) suggests that the experiences of people with ARBD within the healthcare system are very poor. They include a lack of diagnostic expertise, general ignorance of psychiatric, medical and nursing staff, lack of care pathways and resources and stigma. Patients can fall between services and have higher rates of morbidity and mortality.

A report from Public Health Wales (Emmerson and Smith, 2015) suggested that given the estimated prevalence of ARBD, residential rehabilitation required for this group is inadequate. In 2014, a task and finish group was set up at Brynawel Rehab to address this gap in service provision locally.

********************

The Brynawel approach

A six-month programme was developed at Brynawel which focuses upon both neuropsychological rehabilitation as well as problematic alcohol use. Admission criteria are shown in the table below.

Clients are admitted to Brynawel following initial diagnosis and physical stabilisation (detox). Each client undertakes formal psychiatric and neuropsychological assessment at the beginning, middle and towards the end of their stay. Alongside qualitative daily observations, the results of these assessments are used to inform their individual rehabilitation plan during their stay and make any recommendations for their ongoing support needs upon discharge. Clients are supported by a dedicated ARBD team throughout their stay, with a support ratio of three to one, with the option to ‘step this up to one-to-one support’ if needed.

The assessment phase is an opportunity for clients to settle into a calm stable environment. During this time, a holistic approach is taken to supporting clients with abstinence (including thiamine), nutrition, regular sleep, and other aspects of lifestyle. Psychosocial support is introduced very early on, and engagement of family/significant others is encouraged. Individual progress is assessment via daily observations and neuropsychological and psychiatric assessments. This data informs the care plan and is used to determine readiness to enter the treatment stage.

The aims of treatment are to develop personal autonomy and promote functional recovery. The focus is on supporting clients to improve their orientation and memory, managing their alcohol consumption and developing good relationships. The programme also focuses on working with managing impulses and behaviours, apathy and motivation.

The programme is structured around a timetable which is designed to help clients to familiarise themselves with the routines and activities of daily living. The physical environment is set up to facilitate understanding (through signs, colour coding and whiteboards) and an appropriate level of stimulation (eg noise management). Assistive technology, such as memory apps on an iPad, is used where this will be helpful.

Interventions are primarily based upon the behavioural model and include diary keeping, activity scheduling, graded tasking, problem solving and memory cueing. The ‘errorless learning’ approach is also used, so that clients do not make errors while learning new information.

It can take two to three years for clients to reach their full potential, and therefore resettlement and recovery in the community need to be carefully planned and psychologically informed. The individual’s support needs will need to be thoroughly assessed, and a longer-term plan will need to be made to support relapse prevention and develop an appropriate level of independence and structured activities.

Admission criteria for ARBD programme
Patients will:

  • have a diagnosis of ARBD made by a suitably qualified clinician using modified Oslin criteria. For more information see https://bit.ly/2Hm4TwV
  • have a standard assessment document as part of the referral, including attached baseline scores
  • have undergone physical stabilisation, ie detoxed and currently abstinent from alcohol. Be on oral thiamine supplements
  • be in phase two or early phase three of Royal College of Psychiatry/ Wilson et al five-phase recovery model – for more information see https://bit.ly/2xT5vuq
  • be thought to be able to engage in the components of the treatment package (eg diary keeping)

Exclusion criteriaPatients will:

  • still be in the acute confusional stage of the natural history of ARBD (and therefore still requiring medical management)
  • be in late phase three, phase four or phase five (signpost to appropriate services)
  • have significant physical health comorbidity where medical stabilisation is required

 

*****

Case study
Back to independence

Brynawel’s ARBD programme transformed Kate’s prospects

Fifty-year-old ‘Kate’ was referred to Brynawel Rehab in August 2016, following a diagnosis of ARBD from her consultant psychiatrist. She had been admitted to hospital in November 2015 with a range of symptoms caused by heavy alcohol use and malnutrition resulting in seizures, ataxia and problems with articulation and swallowing reflex. Kate had trained as a nurse and worked in the NHS before and after having her family, and had been very highly regarded by her colleagues.

The results of her first neuropsychological assessment on admission to Brynawel suggested that she had difficulty planning tasks. This was evident from Kate’s inability to maintain her room to a manageable standard or to plan basic self-care tasks such as showering and personal care. Initial findings from the assessment highlighted a variety of problems with her immediate memory, her visuospatial ability and her delayed memory, which was extremely low.

Her results were supportive of a diagnosis of Korsakoff’s with additional complications. She underwent follow-up psychological and psychiatric assessments in November and then again for the final time in January 2017, using different versions of a battery of tests.

Kate had been very emotional on arrival, with periods of intense crying. Her sleeping and eating were quick to settle, but by week two she was noticed to have incontinence, diagnosed by a GP as anxiety-related. By the end of the first month she had begun to engage more in activities but was still noted to be unable to spontaneously initiate tasks such as keeping her room clean, although she had been able to use memory aids.

Staff were able to report an improvement in her engagement and socialisation, it was apparent by the second month that she still had problems initiating communication or tasks and decision-making. Although she had managed memory tasks in sessions, her recall of these tasks later on was poor. Her symptoms of depression had lessened over the 26 weeks and her levels of anxiety were lower than when first admitted.

Kate’s daughter acknowledged a marked improvement in her mother’s functioning, following her admission to Brynawel. Within weeks Kate had been able to recall the daytime activities she had been engaging in and, following small prompts, she could continue an accurate conversation about what had been happening. This had been ‘the first time we had noticed such a change in our mother’… ‘We felt like we had our mother back!’

They were aware that Kate could not initiate memories, but she was now able to recollect things quite well with a prompt. She seemed happier and had been able to make friends with other residents. Staff from Brynawel continued to support Kate in the community for six weeks, providing support with her cognitive rehabilitation, offering assistance with memory aids and adaptations in her own home and continuing to support her reintegration into the community using a graded approach to her discharge.

A year on, Kate has maintained abstinence and lives independently. The alternative option, which was suggested before her admission onto Brynawel Rehab’s ARBD Programme, was placement in a care home for the frail elderly, at 50 years of age.

Dr Alyson Smith is consultant clinical psychologist at Brynawel Rehab

Leave a comment...