Mr Grant Brand: Team Leader, ARBD Team Glasgow Lessons Learned in the first nine years of the Glasgow ARBD Team

ARBI: A Best Practice Seminar: Royal College of Physicians, 20th April 2015

Alcohol Related Brain Damage Team

86 Millbrae RoadLangsideGlasgow G42 9DMPhone: 0141 276 2299 Fax: 041 276 2296

Action on Alcohol Week 2015

• Setting up the ARBD Team in Glasgow• What could have been different?• What did we learn?• How did we respond?• A “diagnosed mental disorder”• A more “hidden” harm• What works for service users…… and services?• What do we need to make it all happen?

Background to Setting Up

• 1998 – Discussions started between NHS & GCC • NHS Mental health services reported having 63

inpatients (1998) both over and under 65 wards.• Modernising Mental Health (1999)• MWC concerned about lack of monitoring of progress

outside of hospital• “A Fuller Life” Report published (2004)• Estimated 21% prevalence in Glasgow hostel dwellers

(Gilchrist & Morrison; 2005)• Investigation into the Care and Treatment of Mr H (2006)

A Team to Focus on…..

• Assessment – recognising diversity of age, need, and level of cognitive impairment

• Liaison – across the range of statutory and third sector service provision

• Person centred support and care planning to optimise recovery

• A reduction in admission to care homes• Joint working with existing services – not to

replace them or to take on care management

Original Remit 2006

• A recent onset or diagnosis of ARBD – alcohol as main cause of cognitive impairment

• Promote optimal functional recovery and maximise potential for independent living

• Potential for new learning (abstinent)• Assessment and rehabilitation (joint work for up

to 2 years)• Assist and educate others to work with this

client group• User and carer involvement

Team Structure in 2006 and 2015

• Nurse Team Leader (GCC Team Leader since 2008)• Senior Addiction Nurses x 2 (2 x Band 6 as at March 2014)• Senior Addiction Workers x 2 (Posts now not filled)• Social Care Officers x 4 (4 x full time as at March 2014)• Occupational Therapy x 1 (1 x full time)• Psychiatry x 5 sessions (5 sessions per week as at March

2014)• Psychology x 5 sessions ( 8 session post as at March 2014)• Dietician (One session per week equivalent as of 2012)• Admin (2 x full time)

Missed Opportunities at Set Up?

• No one Lead Care Group - no system of care• Addiction Services developed ‘Diagnostic,

Assessment and Liaison Team’ & Nursing Care Beds• Homelessness Services commissioned Supported

Accommodation and Supported Living places.• 1998 – 2004 – was there a missed opportunity to

develop a Managed Network in Glasgow?• What were the other priorities at the time?• What if ARBD sat “under one banner”?

Referrals – Early Experience

• Referrals being passed from service to service – highlights gaps – cost?

• Co-morbidity – physical and mental health• Complex ABI patients managed in Addiction

Services (continuing drinkers)• Services designed around aetiology as

opposed to need -“gate-keeping” prevalent• Serious need to improve links with other areas

of service (e.g. Mental Health / ABI)

Referrals by Source Since 2006

• G.P. 3%• C.A.T. 27%• Acute 25.5%• Acute Liaison 6.5%• C.M.H.T. 7.5%• Social Work 12%• Care Homes 2%

• Homelessness 2%• 3rd Sector 3%• 2ndary Services 2%• Others 2%• Psychiatry 7.5%

• (Addiction Psychiatry and Acute Addiction Wards – 4.5% of total)

Referrals and Gender

Referrals by Decade of Age

M + F Male Female

30’s 4% 2.7% 8.4%40’s 21% 21% 21%50’s 37% 30% 33.6%60’s 30% 38% 32.4%70’s 7% 8% 4.6%80’s 1% 0.3% 0%

Did We Get it Right?

• Many referrals were not accepted and caseload remained low

• Referrals did not meet our criteria (diagnosed within two years)

• “How are we meant to get them sober?”• Were we “gate-keeping”?• Did the remit reflect either a) need or b) the

history of the condition itself?• With no system of care how would these

specific individuals be referred to the Team?

Diagnosis - Our Experience• There is a varied understanding of the diagnosis of

ARBD (algorithm?)• Few cases seemed to be “clear cut”• The diagnosis is dynamic – presentation changes

significantly in early stages• Assessment for rehabilitation potential meant re-

evaluation in many cases• Neuropsychological assessment was not easily

available in acute settings (pressure for beds)• Should be a “diagnosis of exclusion”

Mr H Report – Key Issues

• Assessment of capacity and risk was poor• Impact of alcohol on capacity misunderstood• Poorly co-ordinated service provision• Poor communication• Prevailing critical attitudes to heavy drinkers• No evidence that key Health or Social Work

professionals understood that legislation could have been used to facilitate assessment

• ARBD is “..a diagnosed mental disorder”

The More Hidden Harm of ARBD?

Region/system Impact of alcohol

function

Cerebrum Frontal and parietal atrophy

Planning, problem solving, self reflection etc

Limbic system, e.g. hippocampus

Reduces connections Memory and emotion

Cerebellum Atrophy Movement, gait, also cognition (link to frontal lobes)

Neurotransmitter systems

Several systems affected

Involved in communication throughout brain

Executive Function Problems

• “Between 50% and 80% of individuals with alcohol use disorders experience mild to severe neurocognitive impairment.” (Bates et al, 2002)

• “This has major implications for treatment outcome, given the emphasis of many treatment programs on motivation to change, and the possibility that impaired brain functioning as a result of alcohol use may prevent some from engaging with standard treatment programs” (Svanberg et al, 2015)

• “It may be thought that they are “poorly motivated” or are “pre contemplative” about their addiction.” (Bell & Craig, 2013)

A Change in our Thinking

“More widely, we would hope that this report will remind health and social work services across Scotland that staff awareness of ARBD needs to be improved and that services need to be able to respond to this very vulnerable group of individuals much earlier than is often the case at present.”

“Investigation into the care and treatment of Mr H” – Mental Welfare Commission(2006)

Broadening the ARBD Team Remit

• To provide assessment of individuals at high risk of developing cognitive problems as a result of heavy drinking

• Support care plans aimed at facilitating harm reduction, detoxification, diagnosis and assessment of capacity where appropriate

• To see every service user referred where practical• To support early legislative intervention to reduce alcohol

related harm, and crisis presentations to a range of already over-burdened services

• To provide assessment for suitable resettlement of those in longer term care

• To provide tailored training packages to those who work with, come into contact with, or even live with drinkers

So…..What Works?

The Key Functions of the Team

• Raising awareness of ARBD• Promoting Harm Reduction and Prevention• Assessment • Legislation• Rehabilitation• Support with Placement and Re-settlement• To be a Resource for advice and support• Training

Harm Reduction and Prevention

• ARBD is a preventable condition• Addiction Services’ Dietician has designed a range of

leaflets for drinkers, abstinence, carers• Empowering carers – “there’s nothing we can do.”• Pabrinex P.G.D. – i.m. vitamin treatment can be

administered in the community again• Pabrinex clinics – bring complex drinkers closer to

services and allow monitoring• Promote thiamine and nutrition – opportunistic

interventions

Multidisciplinary Assessment

• Assemble all collateral information and speak to relatives / carers / friends

• Assemble preliminary investigative assessment – records / service history

• Cognitive Screen (ACE-111)• Psychiatric assessment• Occupational Therapy• Neuropsychological assessment

Thorough Assessment Saves….

• Lives - early detection Wernicke’s –lower mortality

• Cognitive damage - early intervention• Resources – targeted allocation through

improved diagnosis and formulation• Rehabilitation – maximised treatment gains• Budget – fewer care home admissions• Savings for Service Users, Services, and Society

Legislation Impacts On..

• Physical Health – less drinking days• G.P. Services – fewer appointments• A + E – less presentations• Acute Hospitals – less bed days• Increased Independence – less reliant on service

providers• Placement – safer transition through services • Services – eventual move out of services• Families – relationships re-built

Rehabilitation

• Multidisciplinary involvement in interventions• Social Rehabilitation• Neurorehabilitation – individualised, goal-

directed care plans• Memory Rehabilitation – use of compensatory

techniques (errorless learning)• Rehabilitation of executive functioning• A “staged approach” (Wilson et al, 2012)

Training and Being a Resource for:

• Carers and family members• Home Care Services• Care Home Staff • Acute Hospitals• Third Sector Support Staff and Fieldworkers• Addiction Workers / Nurses and Social Workers• Mental Health Officers• Psychology and Psychiatry peer training

A Fuller Life – Then….and Now• Highlights the potential for recovery• Need for health promotion and prevention• Need to challenge the stigma: ‘self-inflicted’• ARBD crosses service boundaries – need for staged

assessment, integration and follow up support.• Importance of support networks• Appropriate placement• Care Pathways

Scottish Exec 2004; the Expert Group on ARBD

Supported Accommodation and Living

• Penumbra – 8 Group Living S.A. places• SAMH – 8 S.A. Tenancies (registered as Care Home)• Loretto Care – 12 S.A. Tenancies ( 4 at each of three

different sites (Harm Reduction Model)• Loretto Care – 22 bedded S.A. unit in Tollcross area

of Glasgow. To function as a rehabilitation unit with a stay of up to two years if required

• Supported Living hours available through SAMH and Penumbra into service users’ own tenancies

So what do we need?• A strong public health message raising

awareness of signs and symptoms, and the risks of poor nutrition and alcohol

• A strategy and a clear sense of direction• A clearer message about legislation and

recovery – are they “making a choice?”• Accessibility, Flexibility and Training• Shared Purpose, Vision and Understanding• Commitment and Determination

Person Centred?

“Providing a person-centred service for

those with ARBD means trying to highlight

the need for flexibility and change in a

sometimes service-centred culture.”ARBD Team Submission to NHS Scotland Event, 2010