Long-term Problematic Alcohol Use and the Older Person

WINTRINGHAM Alice Rota-Bartelink

OVERVIEW Introduction Safe Drinking Standards Alcohol and the Ageing Body The Brain, Brain Injury – Acquired (ABI) & Alcohol Related

(ARBI) The Long-term Drinker Underdiagnosis & Stigma Challenging Behaviour in ARBI Managing Challenging Behaviour The Downward Spiral of Negativity Wintringham Aged Care Services The Wicking Project - Residential Care Model Conclusion

Effects of Alcohol On the Body

Toxic effect on central nervous system

Changes to metabolism and blood flow

Affects the bodies use of thiamine (Vit B1)

Is associated with poor diet

Causes dehydration

Leads to falls, fights and other medical conditions

that may injure the brain(Ref: www.betterhealth.vic.gov.au)

Alcohol Related Brain Injury Alcohol Related Brain Injury NEUROANATOMYNEUROANATOMY

Alzheimer’s Australia (2008)

ABI = Acquired Brain InjuryAny injury to the brain that occurs after birth.

Traumatic Brain Injury (TBI):Contact sports, work, assault, road accidents

Stroke or cerebral haemorrhage: Disruption of the blood supply to the brain

Alcohol and Drug Abuse:ARBI/ARBD = Alcohol related brain injury/disease/disorder

Hypoxia:Disruption of the oxygen supply to the brain (> 3 minutes)

Brain Tumour & Infectious Disease:Brain tissue can be damaged through cancer, meningitis and encephalitis.

Degenerative Neurological conditions:Unlike other forms of ABI, these conditions do not stabilize or improve

with time. e.g. Alzheimer's, Parkinson's and multiple sclerosis.

Alcohol Related Brain Injury (ARBI)Sometimes referred to as ARBD – Alcohol Related Brain Injury

• Cerebellar atrophy – poor balance & gait• Peripheral neuropathy – poor mobility & dexterity• Hepatic encephalopathy – chronic liver disease

toxins leading to progressive memory loss, disorientation, tremors & dementia. • Frontal lobe impairments – behavioural changes;

eg. disinhibition, aggression, irritability or impulsivity, “Impulse Control Disorder”• Wernicke’s encephalopathy - acute neurological

disorder due to thiamine (Vitamin B1) deficiency • Korsakoff’s dementia – severely impaired mentation

(Ref: www.betterhealth.vic.gov.au)

Enlargement of the VentriclesReduction in Volume of Frontal Lobes

and Cerebellum

Normal BrainNormal Brain Alcohol Related Brain Alcohol Related Brain InjuryInjury

Ref: www.niaaa.nih.gov

Frontal LobeMRI and CT scan of alcoholics show extensive brain shrinkage

with ageing shrinkage may be irreversiblefrontal lobe structures are particularly vulnerableshrinkage is largely due to loss of white matterMRI studies show decreased activity

Causes confusion, lack of judgment, clouded thinking, etc. Many of the regions of the brain can retain normal functioning even with severe ARBI eg vocabulary

Executive DysfunctionLong-term drinkers experience difficulties with:• Attention and concentration• Planning, organisation, problem solving• Complex, abstract and flexible thinking• Initiative• Emotional and behavioural change• Self awareness and insight

www.minddisorders.com

Memory Impairment in ARBI Primarily caused by thiamine deficiency

It can occur at any stage of ARBI

Due to haemorrhage in midline structures in the brain

“Amnestic Syndrome”

Can range from mild (benign forgetting, short term memory) to profound (disorientation and confusion).

Assessment for ARBI

• Where ABI is suspected, evaluation includes:–History –Neurological examination–Neuropsychological examination–Neuroimaging

• Structural• Functional

• Best evaluation involves weighing all of the above

Factors influencing the onset of ARBI“Usually seen after 7-10 years of alcohol dependence”?

• Gender; • Age of commencement;• Diet;• Premorbid capacity & IQ • Family history; • Lifestyle;• Drinking history - the amount of alcohol ingested

and period of alcohol use; • Number of detoxifications; • Medical history and complications; • Other drug use.

Recovery of Cellular Function• Some improvement may be expected when a person

stops using alcohol. • The potential for recovery or stabilisation of cell damage

is dependent on:– The severity of ARBI progression; – The person’s age, diet and health;– Their ability to achieve and maintain sobriety;– Other Social, Physical and Psychological determinants eg.

support, money, mental health, housing stability• Younger sufferers have a better chance of recovery;

however, this may come at the cost of loss in potential capacity due to slowed brain development as well as the development of a psychological dependence on alcohol

Chronic alcohol misuse in older people increases the:

• Risk of chronic heart disease, hypertension & stroke;

• Incidence of malabsorption, pancreatitis & liver damage;

• Risk of falls and accidents;• Likelihood of incontinence and gastrointestinal

problems;• Prevalence of memory loss and the development of

dementia, psychiatric problems & Parkinson’s disease;

• Effects of self-neglect, such as poor nutrition and hygiene;

• The duration of recovery and healing.

Client Profile – Long Term Drinkers

• Homelessness

• Premature ageing

• Limited finances

• Little or no family or friends

• Self-neglect & malnutrition

• Traumatic injuries and assaults

• Reluctant to seek appropriate, timely medical care & poor compliance

Client Profile Cont.• Social Isolation

• Coexisting mental illnesses

• Ongoing addictions – alcohol, other drugs, gambling

• Impaired sense of safety or trust

• Imprisonment & Institutionalisation

• Complex/Challenging behaviours

• Acquired Brain Injury – alcohol and other

• Guardianship & Administration Orders

Under DiagnosisAlcohol abuse and ARBI is grossly under-diagnosed among the older population. • Alcohol problems may not be identified as the

awareness of ARBI is low among frontline workers in health and social care.

• Older people rarely access specialist alcohol services. • Inaccuracy or inappropriateness of generic

assessment/evaluation tools• Symptoms masked by dementia or other age-related

conditions• The social stigma attached to ARBI; eg. hidden by

relativesMc Cabe, L (2005)

Stigma• People living with alcohol-related dementia receive less

empathy and often attract more judgemental attitudes in the public view than people living with age-related dementias.

• Stereotypical images of a “wino on a park bench” or a “beggar”.

• Many people view alcohol and other drug use behaviour as a ‘personal choice’ long after the person is rendered unable to regulate their drinking due to alcohol related brain injury.

15

Care providers/ Agencies

Consultancy Employment Agencies

Training Organisations

Community Care

Networks & Partnerships

Dementia-specific Services

A.C.A.S & Support Services

Fire

Consultancy

Consultancy

C.A.L.D

Disability Support

M.A.C.N.I

Dental

Allied Health

Residential Care

Detox & Rehab

G.Ps

Police

O.P.A

Social

Specialised Services

Education & Employment

Aged Care

Alcohol & Drugs

Justice

Emergency Services

S.R.S

Emergency Dept.HospitalAmbulance

State Trustees

Prisons

Office of housing

Courts

Supported

Crisis Services & Accommodation Outreach

Contact Tracers

Centrelink

Grants & FundingResearch & Development

A.T.S.I

Veterans Affairs

Housing

Income Support

Physical Health

Homelessness

Case Management

Case Management

Disability Services

Case Management

Mental Health

Assessment Services

Acquired Brain Injury

Assessment Services

Uncoordinated Service Systems

Why are behaviours challenging?A person’s behaviour can be labelled as challenging as a result

of reduced physical, cognitive ability, intense emotions about the situation they are in, or as a result of them denying their physical and cognitive limitations.

It is important to keep in mind that people do not generally set out to intentionally disrupt or challenge others. The behaviours that we see as challenging is their way of endeavouring to meet their perceived needs.

Often referred to as: “Behaviours of Unmet Need”

A key question is therefore “How else can the person’s need be met ?”

Common Types of Challenging Behaviour in ARBI

• Perseveration (repetitive or cyclic behaviours)• Verbal Aggression• Physical Aggression• Sexually Inappropriate • Lack of motivation • Withdrawal & Social Isolation• Antisocial• Suspicion & Paranoia• Confusion & Confabulation • High Risk Behaviours• Ongoing Intoxication

Why do people with ARBI exhibit these behaviours?

• ARBI & Frontal Lobe damage• Disinhibition and poor impulse control• Perseveration (repetitive behaviour)• Poor insight and decision making• Memory loss

• Other brain injuries• Coexisting Mental Illness• Coexisting Age-related Dementia• Personality Disorders• Ongoing episodes of intoxication • Past life experiences / lifestyles;

eg. homelessness, abuse, violence, hardship, trauma

Common Characteristics of a Person living with ARBI

• More likely to become aggressive• Difficulty learning new information• Concrete thinking• Impatient – does not like to wait• Disorganised – appointments, commitments• Easily overwhelmed by complex tasks / information• Continues to drink / binge• High risk behaviours undertaken in the pursuit of

alcohol or as a direct effect of being intoxicated

Common Causes of Aggression in people living with ARBI

• Loss of control and choice• Inability to comprehend due to impaired logic and

reasoning• Inability to express/articulate needs or emotions • Not being heard, noticed or understood• Inability to recall or put together

the pieces due to memory loss• Triggered memories of past

abuse, threatening or emotional situations

Neuro-psycho-social Approach

• Change the world to fit the person• Creating an environment in which demands are

within the capabilities of the person and the person can function well

Routine and Consistency

ABCD Approach to IncidentsA = Antecedents or Causes – What were the

background factors leading up to an incident?

B = Behaviour – Precisely what happened? How did the behaviour play out?

C = Consequences – What happened after the behaviour occurred? Short-term & Longer term.

D = Discuss and Debrief – Brain storm all aspects of the incident and consider future actions to avoid or minimise the impact of this behaviour in the future.

TIME/DATE SITUATION/ TRIGGER (what triggered the behaviour or what occurred just before the incident)

A

WHAT HAPPENED? (describe the incident/behaviour)

B

WHAT DID YOU DO? (What was done)

C

WHAT WAS THEIR RESPONSE?

C17.00

22/1/10

Mary demanded a cigarette from another client but when this was refused she persisted and was eventually told to “Piss Off”.

Physical aggression: Mary pushed the client against the wall swearing repeatedly and waving her fist in the threatening manner.

The client yelled at Mary to “stop” and reception staff informed Mary that they had called the police.

Mary quickly released the client and ran out of the building

Behaviour Monitoring

Problem Solving Approach

Identify the real issue or concernLook beyond the incident and ask why this person

may be behaving in this way. If we can establish a cause then we have a better

chance of developing an intervention. An Intervention can reduce, eliminate

or reduce the severity, frequency or impact of a behaviour.

?

“It’s not Personal”• The ‘person’ living with an ARBI is not the ‘problem’.

• The behaviour occurs as a result of changes to brain functioning and is an expression of unmet need.

• The behaviour is directed ‘at you’ not ‘to you’ personally.

• It is important to remember that there is a person (possibly a very distressed person) behind the behaviour that we find disturbing.

• By focusing on the objective of maximising each client’s potential it becomes clear that it is us who need to change – our care practices, our understanding, the social and physical environment etc.

The Downward Spiral1. The PERSON with ARBI is

“difficult,” “hard to manage,” or even “aggressive”

2. Caregivers attempt to change the PERSON’s

behaviour

3. If they aren't successful, the PERSON may be labeled: “Problem person” -“Impossible” - “Mean” -“Unappreciative” - “Manipulative” - “a Pain”

4. No new interventions are tried because THE PERSON IS the "PROBLEM"

5. Caregivers “cope” by ignoring or avoiding the PERSON

6. The PERSON is NOT comforted or assisted

and behaviours become more intense

7. Caregivers feel even more

distressed and frustrated by the

behaviours

8. Caregivers avoid, ignore, or even "fight back"

9.The PERSON’s behaviour continues, and often becomes even more intense

The behaviour is….For The Care Giver

• Not about WHO YOU ARE• It’s about WHAT YOU DO

For The Person living with an ARBI • Not about WHO THEY ARE

(i.e. does not define the person)

• It’s about WHAT THEY DO and WHY?

Remember these Do’s in supporting someone living with an ARBI.

• Avoid overloading the person • Break down information and present one idea at

a time • Discuss one point at a time • Tackle one problem at a time, one step at a time • Allow sufficient time for the person to work at

their own pace • Minimise distractions and stressors in the

environment • Allow frequent breaks or rest periods

Remember these Don’ts to reduce challenging behaviours from arising.

• Use judgemental language - avoid the use of labels, such as difficult, aggressive, agitated, nasty etc. Replace them with a comprehensive description of what actually happened before, during and after an incident.

• Labelling – When referring to an individual or their behaviour, separate out your opinion and subjective feelings and establish objective facts. This can change your point of reference in interactions with the person.

• Labels create generalisations and can foster negativity which is transferred between staff and will invariably be directed toward the individual.

Remember these Do’s to reduce challenging behaviours from arising.

• Encourage the cooperation and involvement of the person living with ARBI in the process of behaviour modification but this may not always be possible (poor insight, denial, unwillingness to change)

• Listen to what someone is saying by watching the whole person and not just their words. This helps us to understand their wants, fears, hopes, values and beliefs.

• Respond to each client with empathy and respect at all times.

• Break down tasks into simple achievable steps – encourage and reward small achievements. Keep focus on the positive steps that are achieved. Plan in advance to ensure small successes

WINTRINGHAM

Dignified services to elderly homeless men and women

Wintringham• Wintringham is a specialised not for profit

welfare company working with elderly homeless men and women in Melbourne Australia.

• Established in 1989 as a response to closure of night shelters and inability of aged homeless people to gain access to mainstream aged care services.

• In recognition of the high incidence of premature aging among our client population Wintringham provides the full spectrum of aged care services to people aged 50 years and older.

Wintringham Services - Overview

• 5 Residential Aged Care Facilities

• 350 Housing Units • 2 Rooming Houses• Community Aged Care & EACH

Dementia Packages• Housing and Outreach Services• Recreation Program• 400 staff• 1200 clients Barry & Kerry

Wintringham is driven by a simple and overwhelming conviction: we believe in social justice

The Wicking Project

In October 2006 Wintringham was awarded a $900,000 J.O and J.R Wicking Trust Research grant administered by ANZ Trustees to develop and trial a specialised model of care to support older people living with an acquired brain injury (ABI), in particular older homeless people with challenging behaviour as a result of an alcohol related brain injury (ARBI). This grant was the largest ever awarded by The Wicking Trust and regarded as a flagship project.

Older People with Acquired Brain Injury and Associated Complex Behaviours: A Psychosocial Model of Care

The Wicking Project• Participants were selectively recruited

for a history of homelessness & unsuccessful tenancies arising from ARBI behaviours.

• 14 volunteer participants were assigned to 2 groups; Wicking Model participants who lived in a four bedroom residence and control participants who continued to live in the community without additional research intervention beyond participation in periodical assessments.

• Clinically validated measures and frequency data were collected including Neuropsychological Assessments, HONoS –ABI, SWLS, AUDIT, HADS, CIQ, NPI-Q & OBS.

0 10 20 30 40 50 60 70 80 90 100

Primary Health Care in ED %Cigarettes %Marijuana %

Aware of drinking problem %Alcohol Problems (Ongoing) %

Mental Illness %Previous Imprisonment %

Freq Police Contact %Administration Order %

Guardianship Order %Exposed to Exploitation %Absent Family Support %History Homelessness %Years formal education

Age 1st HomelessAve Age

Number of partcipants

Wicking Participant Demographics

Psychosocial Model of Specialised Care :The Wicking Trial

• Individualised & specialised care, support, behaviour management strategies & structured activity program

• 24-hour specialist carer support at a ratio of 1.5 : 4• Encouragement and support to maximally utilise structured

activity programs focussed on community integration• Harm minimisation model e.g. alcohol and cigarette

programs• Highly trained & skilled personnel • Neuropsychological support, training & case management

Alcohol and Cigarette ProgramHarm Minimisation StrategyInvolves the provision of alcohol and cigarettes in accordance

with a prescribed administration regimen Due to the client’s inability to self regulate their consumption –

Inability to Rehabilitate

Requires 100 % consistencyInconsistent implementation by staff may avoid immediate challenges but will eventually lead to an escalation in the frequency and severity of behaviours.

Cantrell H, (2008) & Bobova L, (2009)

Wicking Project Overall Outcome Scores (Non- standardised scales)

-16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6

Average Change Over Time

HADS-Depression

HADS-Anxiety

No of Liferoles

CIQ-Home Integration

CIQ-Social Integration

CIQ-Productivity

CIQ-Overall

AUDIT

Life Satisfaction

HONOS-Total

OBS-Clusters

OBS-Total

NPI-Severity

No of Drinks

No of Cigarettes Control

Wicking

Challenging Behaviour

0

5

10

15

20

25

30

35

40

45

Time 1 Time 2 Time 3 Time 4 Time 5

No.

of I

ncid

ents

subject 1subject 2subject 3subject 4subject 5 subject 6subject 7 mean

Estimated Pre-Trial Average

Frequency of Incidents of Challenging Behaviours Overall among Wicking Participants Over Time (F= 4.820, p=0.008)

Wicking Project OutcomesSpecialised Intensive Transition Support

• Cost Benefit Economic modelling has demonstrated a cost to government saving of $30 per day for The Wicking Model relative to a crisis driven service interventions.

• Quality of Life OutcomesIn addition to positive changes in psychological health and general health, all indicators of life quality and wellbeing underwent significant positive change for Wicking Model participants.

Where to next?

Policy Recognition,Support &

Funding

Education&

Training

Research Prevention

Service ImprovementCultural

Establish Specialised

CareServices

Coordinated Service Delivery

PreventionNew Vs

Long -TermHomeless

Older Person

Living with an ARBI