GHP September 2015

ghp September 2015 | 37 health and social care Mike is 52. I was asked to see him a few months ago on a mental health inpatient unit in my health board. Mike has Alcohol Related Brain Damage (ARBD) and when I first saw him his cognitive function was extremely poor, his capacity limited and his ability to self care virtually non-existent. Continuing Healthcare funding was being considered for a long term place- ment in a residential home for adults with acquired brain injury (quite a costly placement) and I was asked to contribute to the assessment. In my report I pointed out that, although a significant degree of su- pervision was required for Mike at that time, with the correct intervention, things could improve to the point that he would need a less supportive environment. Today I went back to see Mike. The inpatient team decided to keep him on the ward so that he could be given the ‘intervention’ there and, as a result, his cognitive function has indeed improved. Now we are looking at supported accommodation in the commu- nity, a much more prudent option saving the NHS around £350 per week. What is this amazing intervention that can improve cognitive functioning in patients with ARBD? Is it something incredibly technical? Is it a new drug with a big price tag? Let me leave you in suspense a little longer while I first explain what ARBD is. ARBD is an umbrella term for a number of conditions where excessive alcohol consumption leads to cognitive impairment. Many clinicians will be aware that one of the cardinal features is short term memory impairment but there is evidence to show that frontal lobe dysfunction is the earliest sign. Hence, in addition to short term memory problems, sufferers experience difficulties in decision-making, goal-setting, action-planning, impulse control and motivation. The root cause is the direct toxic effect of alcohol on the brain combined with difficulties in repairing the damage because of a deficiency of the vitamin thiamine. Thiamine is found in whole grains and various vegetables, something the diet of a dependent drinker is fairly deficient in, but the additional problem is that alcohol blocks thiamine’s absorption from the gut. For a number of patients the condition develops slowly in the community but episodes of alcohol withdrawal (particularly if not treated or inadequately treated) will speed up the deterioration. Many people do not realise they have signs of ARBD. In fact Bates et al (2002) estimated that 50-80% all patients presenting to standard alcohol treatment services have some evidence of cognitive impairment - and a lot of them are unaware. Think back to that list of frontal lobe symptoms as these are the ones that often go unrecognised and we can instantly see how they might impact on the ability of an individual to engage in treatment. Treatment services expect them to be motivated, to set goals, plan how they will achieve goals and then sigh in despair when they fail to control impulses to drink. So let’s get back to my remarkable intervention. What can prevent this terrible condition deteriorating further and, in up to 75% of cases, actually improve cognitive function (Smith and Hillman, 1999)? Abstinence and a good diet rich in thiamine. That’s it. Nothing more complicated than that. In fact, the development of ARBD is a process and that process offers us several points for effective interventions. For instance, identifying when individuals start to become problematic drinkers and delivering brief motivational interventions at that point, a remit for primary care perhaps? Adopting a more assertive outreach ap- proach to those referred to treatment services due to their problems engaging. Ensuring dependent drink- ers not ready to achieve abstinence are prescribed supplemental thiamine. Identifying those at risk of alcohol withdrawal when they get admitted to hospital and ensuring their withdrawal is managed adequately. Making sure those at risk are prescribed parenteral thiamine during withdrawal. Identifying complicated forms of withdrawal (e.g. delirium tremens, Wernicke’s Encephalopathy) at an early stage and implementing the correct medical management. Picking up on signs of ARBD as soon as possible and placing patients into supportive environments where they can be protected from the effects of alcohol (possibly using legislation such as the Mental Capacity Act, 2005). Developing clinicians with expertise in the management of estab- lished ARBD and specialist residential placements for those with no further scope for cognitive improvement (able to provide cognitive rehabilitation). And only a small proportion of that menu of inter- ventions requires specialist services. The majority depends on awareness raising amongst existing health and social care staff and education on the cognitive effects of dependent alcohol consumption. This would require a small investment for a significant health gain. But not only a gain in the health of the individual and the chance to return a family member to a more independent level of functioning - the financial gains can be significant. On average even non-complex patients with late stage ARBD requiring residential placements cost around £700-800 per week. With appropriate interventions the same patients end up costing around £200-300 per week - and the savings are even greater for the complex needs patients (Prof Ken Wilson, personal communication). If we were claiming an intervention that would improve cognitive function in up to 75% cases of Alzheimer’s dementia there would be no hesitation in investing. Those with ARBD are often younger adults with years ahead of them and with the help of some awareness raising those years need not be spent in a haze of unknowing. Dr Julia Lewis is Consultant Addiction Psychiatrist and Clinical Director for Adult Mental Health and a Director of Pulse Addictions Training- Pulse Addictions Training provide training and consultancy to profes- sionals to various sectors, agencies and organisations in all areas of substance misuse. References Bates M, Bowden S and Barry D (2002) Neuro- cognitive impairment associated with alcohol use disorders: implications for treatment. Experimental and Clinical Psychopharmacology 10: 193-212 Department of Health (2005). Mental Capacity Act. London, HMSO. Smith I and Hillman A (1999) Management of Alcohol Korsakoff Syndrome. Advances in Psychiatric Treatment, Vol 5, pp 271-278.