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17. Alcohol Related Brain Damage
A Fuller Life reviewed the issue of Alcohol Related Brain Damage. In 2006 the Scottish Association for Mental Health produced Looking Forward: Recovering from Alcohol Related Brain Damage, a practical guide to working with people with ARBD.
Recent Scottish studies have shown this group to represent a major proportion of the homeless and hostel population (Morrison 2003, Communities Scotland 2007)
A Fuller Life outlined the complexity of brain damage and cognitive impairment. There are often multiple factors contributing to impairment such as head injury, vascular disease and degenerative neurological disease processes as well as the long term neurotoxic effect of alcohol and the specific vitamin deficiency, often associated with heavy drinking, which leads to Korsakoff's syndrome.
Effective action to reduce rates of alcohol dependence and effective interventions to help behaviour change in alcohol dependent individuals will reduce rates of ARBD. Programmes of vitamin supplementation for people at high risk of ARBD such as those with severe alcohol dependence, poor nutrition, and the socially isolated should be part of substance misuse service provision. (Smith and Hillman 1999, McIntosh and Chick 2004.)
It is now established that recovery of memory and other cognitive function in ARBD occurs more frequently than was previously thought (ref Looking Forward). Recovery rates are improved by early identification and by extended contact with services including re-assessment of cognitive function at regular intervals.
The primary and secondary prevention of ARBD should be part of the responsibility of Alcohol and Drug Action Teams ( ADATs) and the services they commission. Measures to prevent alcohol misuse will reduce rates of ARBD as will the provision of effective care and treatment services for alcohol problems. The measures to improve the systematic early identification of risk of ARBD and the development of vitamin protocols (ref A Fuller Life) are specific actions which ADAT's should implement.
Recommendation
Service commissioners should ensure awareness among services in their area of the risks of alcohol related brain damage ( ARBD) and that services dealing with high risk groups include ARBD prevention in their range of service responses.
Assessment for any form of brain damage is complex and it there is no single simple test. The Group recommends the checklist developed by SAMH and their partners ARBIAS as a helpful aid for frontline workers in identifying possible indicators ( see Annex B). The full assessment and diagnosis of ARBD involves a stepped approach involving generic mental health assessment skills, specialist psychology and psychiatry, highly specialised neuropsychology and neuropsychiatry and imaging approaches such as MRI. Access to specialist practitioners and facilities should be widely available.
There are brief assessments of cognitive function such as the Mini Mental State Assessment ( MMSE) and Adenbrooke's Cognitive Assessment ( ACE) which can be of value in ARBD assessment. However these are not diagnostic tools for ARBD.
Should the SAMH/ ARBIAS checklist and brief assessment tools indicate more fuller assessment is required, a number of standardised assessments have been identified by the group which can be used by specialist clinical psychologists and neuropsychologists.
These assessments should only be carried out following a period of 3-6 weeks abstinence (Ryan and Butters 1986). This ensures the resolution of the effects of intoxication and withdrawal leaving a more stable neuropsychological status which will allow for accurate assessment and facilitate the identification of care and treatment needs.
- WAIS111 - to assess overall profile (eliminate other problems)
- WTAR - to identify previous predicted level of functioning for comparative purposes
- Rey Auditory Verbal Learning Test - a list learning test which provides useful information re individual's capacity to learn. Useful for care planning.
- The Delis-Kaplan Executive Function System Subtests - can be used independently to assess executive functioning.
- Wechsler Memory Scale to assess different aspects of memory.
The needs of those with suspected or diagnosed ARBD are for assessment and diagnosis, assistance with maintaining abstinence from alcohol, memory strategies, social care and support which can involve intensive home support or residential care. Regular re-assessment is crucial to establish the degree of recovery. Substance misuse services will have a contribution in helping maintain abstinence, but the other needs are in line with those with other form of acquired brain damage. Access to care should be dictated by need, not on the basis of age or the cause of the cognitive impairment.
Recommendation
Primary responsibility for supporting individuals with severe ARBD rests with providers of services to those with other forms of acquired brain injury and cognitive impairment and not alcohol treatment services. NHS boards and partner agencies should review their services for those with brain damage or cognitive impairment, in particular for younger people (under 65), to ensure that the needs of those with ARBD are met.
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