Dr Mark Hogan: Neuropsychological Correlates of ARBI: Implications for Rehabilitation

Dr Mark Hogan: Senior Clinical NeuropsychologistNeuropsychological Correlates of ARBI: Implications for Rehabilitation

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

Dr Mark HoganSenior Clinical NeuropsychologistDonegal Community Neurological

Rehabilitation Service

Neuropsychological Correlates of ARBI: Implications for Rehabilitation

Alcohol Related Brain Injury

Session Outline Brief Orientation to continuum of impairment, Treatment

and Neuropathology

KEY FOCUS: Complex impairments Cognitive, behavioural and Safety Concerns - Vulnerability Estimating needs with ongoing assessment Rehabilitation Planning

Typical History and Presentation

Neuropsychological Considerations

ARBI – Falling Between Stools

Addiction Services- Counselling, Group interventions, After Care- Harm Reduction, Relapse Prevention- Impact of Cognitive Impairment

Adult Mental Health - Mental Health

- Primary issue – severe or enduring MH difficulty

Dedicated service or reconfiguring/expanding existing teams?


Alcohol Related Brain Injury= the umbrella term for the spectrum of neurocognitive changes resulting from chronic alcohol excess.

Multiple overlapping terms

Chronic Alcohol Use (Clinical Level 1)

Wernicke Encephalopathy (Clinical Level 2)

Significant Impairment including Korsakoff Syndrome (Clinical Level 3)


‘a wide range of neuropathological and related psychoneurological syndromes including Wernicke’s-Korsakoff’

(Wilson et al. 2012)

Multiple mechanisms of action - Vitamin Deficiency

- Direct Neurotoxic action of alcohol

- Metabolic factors from multiple intoxifications and withdrawals

(Kopelman et al. 2009)


Chronic Alcohol Use Complex cognitive difficulties across multiple areas- Continuum of memory impairment- Evidence of some Executive Functioning deficits- Less impaired cognitive profile vs KS (Pitel et al. 2008)

Wernicke EncephalopathyAcutely unwellTriad of Impairments – Ataxia, Confusion, Eye movementsThiamine 85% develop Korsakoff Syndrome

Korsakoff Syndrome “memory and learning are affected out of all proportion to

other cognitive functions”(Kopelman 2002)

Physically well/mobile

General intellectual functioning/profile largely preserved

Working Memory intact

Confabulation

Increasing evidence of Executive Functioning deficits

(Maharasingham et al. 2013)


Neuropathological Changes:

Frontal lobes most vulnerable: decreased neuron density in superior frontal cortex, shrinkage.

Atrophy also seen in cerebellum (grey and white matter of vermis), thalamus, mammillary bodies, hippocampus, amygdala, insula, alterations to brainstem, compromised white matter integrity.


Current Service Provision at Level 1 and 2Limited input from Neuropsychology

Addiction services (Alcohol Free/ Harm Reduction)Direct medical Intervention (Detox, Thiamine)

Screening assessments (Primary Care) RelapseSpontaneous RecoveryFunctional/Safety issues

Case co ordination

Typical Presentation

Chronic alcohol use Multiple hospital admissions (detox, head

injuries) Limited engagement with addiction services Multiple relapses Family/Interpersonal difficulties Limited social support Decline in physical state and poor rate of

recovery over time or at most recent admission

Safety concerns at Discharge Planning

Cognitive Changes

May have insidious onset

May occur in the context of existing psychosocial disruption

May not be recognised as cognitive change

Deterioration may be accompanied by decline in social support, financial & occupational stability

May be comorbid and/or pre-existing difficulties – brain injury, dementia (vascular, fronto-temporal)

Estimation of baseline can be difficult

Multidisciplinary Assessment

Stabilisation allows clear assessment.

Comprehensive, multidisciplinary, multi-agency over time.

Cognitive screening and neuropsychological assessment key to outline strengths and weaknesses, and support/treatment planning.

Can also support differential diagnosis e.g. ARBI v dementia

Assess risk: vulnerable adults, child protection, health and mental health risks

Assessment will inform care planning and allow formulation of appropriate interventions.

Korsakoff Syndrome

Key Neuropsychological Elements:

i) a profound anterograde amnesia affecting the ability to learn new information;

ii) a retrograde amnesia impeding the ability to recall personal autobiographical information and

iii) executive functioning impairments impacting on person’s ability to plan, organise information and think with flexibility

(Evans and Svanberg 2013)

Neuropsychological Assessment

Timing

Role of Assessment and ExpectationsEstimate Profile, Diagnostic, Awareness of deficits and impact, Rehabilitation planning

Multiple Elements/Methods


Korsakoff Syndrome profile as template

Significant impairment of LTM (somewhere within encoding, consolidation, storage, retrieval)

Confabulation (Spontaneous vs Provoked)

Attention/Executive Functioning Deficits

Impacting day to day functioning


Multiple MethodsCase HistoryHospital recordsClinical interviews (self report and collateral information)Staff reportFunctional skills (personal care, dressing, ADL safety)Direct observationTargetted formal testing


Medical Information Neuroimaging, treatment, rate of recovery

History of Alcohol UseDuration, levels of consumption, impact on functioning over time (physical, cognitive, social)

Length of abstinence/Timing of assessment or intervention

Current Presentation


Standard Elements of Formal Assessment

Consent, Comprehension, Concentration, Effort

Estimate Premorbid Functioning

Subtests of WAIS


Memory Working Memory intact (WAIS IV) Implicit/Procedural Memory

OrientationAutobiographical memory (temporal gradient)Episodic memoryRecall of recent events


Formal Tests

WMS Logical Memory

Rate of Verbal Learning CVLT/List Learning

Confabulation

Historically a significant emphasis on memory

Executive Functioning

“a collection of functional deficits in the higher order cognitive skills required to initiate, plan execute and monitor complex goal directed activities” (Miotto et al. 2009)

Key higher level cognitive skills associated with Frontal Lobe function

Key element of KS presentation (not universal)

Lack of conceptual clarity and consensus on precise definition of Executive Functioning and dysfunction


Potential COGNITIVE consequences of Frontal Lobe pathology

Planning, organisation, strategy application, problem solving, reasoning, decision making, sequencing, problems with forming and shifting concepts, rigidity of thought processes, awareness, MEMORY

Multiple interrelated higher level cognitive skills not amenable to a single test or the standard test environment


Assessment

Novel, unstructured events

Ecological Validity

Formal tools – highly structured, time limited and have a clear outcome measurement

“Patient impairment less likely to manifest in the test situation” (Shallice and

Burgess 1991)


Key Assessment tools:

Naturalistic Observation

Functional Assessment (ADL’s real life situations)

Staff report

FAS TMT Sorting Tests BADS, DKEFS

Neuropsychological Findings

Memory and New LearningProfound anterograde amnesia affecting ability to learn new informationRetrograde amnesia impacting AMMore severe in KS vs Chronic (Brokate et al. 2003)Confabulation

Executive FunctioningIncreasing evidence of EF deficits (all BADS subtests)More severe in KS (very large clinicall significant difference) – key difference vs Chronic (Van Oort & Kessels, 2009)

Clinical Implications

Interaction of significant memory impairment with a combination of executive skills deficits including initiation, planning, problem solving, self monitoring, learning from experience, judgement and self awareness

Explaining profile and implications to person, family and staff

Cognitive and Social Vulnerability

Safety Concerns

Challenging Behaviour (Awareness of Deficits, poor emotional regulation)

High and ongoing support needs

General Considerations for Rehabilitation

Prevention

Training and consultation (Hospital, care staff, Individual and Family)

Evidence drawn from other fields e.g. brain injury, mental health, addiction

Need for comprehensive and holistic approach for treatment e.g. Wilson et al 2012

Multi-disciplinary, multi-agency.

Promote a staged approach.

Rehabilitation

Initial Goals: Engagement of person and family

Process of assessment, feedback

Develop a framework for understanding initial advice/planning

Goal setting

Regular monitoring

Consistent formulation of case understood by all team members

Timeframe of rehabilitation planning

Rehabilitation

Potential for change/improvement vs loss of function

ENGAGEMENT

Explaining the nature of the condition to person (written feedback), family meetings over time, staff training

Heterogeneous group with complex needs

MDT involvement with assessment over time

Phases of Input from medical intervention to holistic rehabilitation (Wilson et al. 2012)

Memory Rehabilitation

Memory compensation strategies: diaries, whiteboards, calendars, memory systems.

Information in small chunks Repetition Errorless learning, vanishing cues techniques Life story work (parallels with dementia

therapies) Technological aids: phones, pager systems,

Neuropage, SenseCam Benefit of external aids as maximise

independence without relying on e.g. carer prompting

Executive Functioning Rehabilitation

Environmental structure and routine Clear ‘rules’ for action Support to develop personal goals Goal Management Training STOP and THINK strategies In Situ Feedback

(Evans and Svanberg 2013)

Rehabilitation

Adapted from Wilson et al. 2012

Rehabilitation

Case Co Ordination with clear service pathways for identification, MDT assessment, funding rehabilitation and possible residential support

A continuum of Support options from outreach to optimal environment residential care

Rehabilitation and Optimising function and independence vs Care

(Wilson et al. 2012)

(Svanberg 2015)

Current Service Provision

Case Co Ordinator (Key Step)

Early Detection and treatment in acute setting/addiction services

Agreed initial care pathway

Work with private agency to provide environment and increase expertise with this group

Access to MDT community based disciplines

Needs Assessments including mental health

Current Service Provision

Challenges Early Intervention (reduce prospect of increased

impairment)

Timely and ongoing MDT assessment and monitoring

Moving between phases and associated risks

Holistic Rehabilitation (skill acquisition)

Health & Medicine

Dr Mark Hogan: Neuropsychological Correlates of ARBI: Implications for Rehabilitation