Mental Health in Scotland: Closing the Gaps - Making a Difference: Commitment 13

Alcohol Related Brain Damage ( ARBD)/Acquired Brain Injury ( ABI)

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.

A Fuller Life outlined the complexity of brain damage and cognitive impairment related to alcohol. 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. The term "Alcohol Related Brain Damage" covers a wide range of circumstances. For instance some contributors have suggested that Foetal Alcohol Spectrum Disorder should be regarded as a form of ARBD. In real world practice those affected often have a number of causes for brain damage and cognitive impairment interacting and the consequences of the damage can also be highly variable in terms of behaviour and cognitive deficit. We thus recommend a needs based rather than cause based approach to the care of those classed as having ARBD.

Prevention

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 coming (2008) guidance from NHS Quality Improvement Scotland on Alcohol in the A & E setting will further inform practice, identification and options.

Service commissioners should ensure awareness among services in their area of the risks of ARBD and that services dealing with high risk groups include ARBD prevention in their range of service responses. The separate needs of those with ABI should be considered.

Assessment, identification and relapse prevention

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. The full assessment and diagnosis of cognitive impairment 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.

Alcohol care and treatment services have a key role in detoxification and relapse prevention in those with suspected ARBD in order to allow meaningful assessment of cognitive function to take place. For many with mild ARBD, the most important element of care will be to achieve prevention of relapse back into alcohol use and in these instances alcohol agencies should be the main providers of care.

Care Planning, Treatment and Rehabilitation for more severe ARBD and multi-factorial Cognitive Impairment

The complexity of the contribution of alcohol to brain damage and cognitive impairment, the variability of the impact on individuals and their carers and the regular co-occurrence of a range of causal factors such as head injury, vascular disease and progressive degenerative disease (such as Alzheimer's Disease) alongside high levels of alcohol consumption mean that there is no single approach to the provision of care for those who are diagnosed with Alcohol Related Brain Damage.

One of the guiding principles of our approach is that care should be based on need, not on age or causation.

The issues in providing care and treatment for those diagnosed with moderate to severe ARBD described in A Fuller Life have much in common with those faced by people with Huntingdon's Disease, Acquired Brain Injury and Early Onset Dementia (see SEHD summary 2003 of the Scottish Needs Assessment Programme review). The care needs will vary depending on whether the problem is likely to be static or progressive and this will modify the goals of rehabilitation.

The limited capacity of services for younger people with cognitive impairment was commented on by several of the respondents in the consultation process for this report. There appears to be less difficulty in obtaining services for those over 65.

The remit of this report was to cover services in the mental health field, but there are many similarities in issues faced by rehabilitation medicine and physical disability services for a client group with many shared characteristics and contributors suggested exploration of a model of a needs based neuro rehabilitation approach which would build on the evidence base examples of good practice in the statutory and voluntary sector.