Alcohol Use

1
Alcohol Use Behaviour Change Manifestations
ALCOHOL AND DRUG TREATMENT SERVICE PROVIDERS
CONFERENCE 2008 Beyond the Hangover Awareness
for Treatment Providers

• Martin Jackson
• La Trobe University
• August 2008

2
ALCOHOL RELATED BRAIN INJURY

• Alcohol is the major cause of brain injury in
  people between 35 and 55 years of age
• Alcohol brain injury is much more common than it
  is realised
• It is estimated that up to 1 in 10 Australians
  will suffer from cognitive impairment due to
  alcohol
• There is growing evidence that teenage binge
  drinkers are damaging their brains and affecting
  their cognitive abilities

3
ADULTS AND ALCOHOL RELATED BRAIN INJURY

• Assuming you are an adult and do not suffer an
  acute neurological event, those at risk of
  developing an ABI are people who
• drink alcohol for at least ten years or more
• drink above a particular threshold (eg over 4
  standard drinks per day)
• are over the age of 40

4
ADOLESCENTS AND ALCOHOL RELATED BRAIN INJURY

• However, there is evidence that teenagers that
  drink six drinks on one occasion per week over a
  period of one year are showing
• a decrease in the size of their hippocampus
• lower metabolism in their frontal lobes

5
ADULTS AND ALCOHOL RELATED BRAIN INJURY

• The majority of adults that suffer a brain injury
  (from any cause) do so on the basis of a fully
  developed brain and cognitive skills.
• Therefore, problems are generally related to
  functions that were once there are now lost.
• Generally, a person will have a variety of intact
  cognitive functions that can assist in terms of
  compensating for and coping with lost functions

6
ADOLESCENTS BRAIN DEVELOPMENT

• In adolescents, brain injury does not always take
  the form of functions that were once there are
  now lost, but often takes the form of functions
  that were not there, now cant develop.
• This is particularly so for executive functions.
  The frontal lobes and executive functions
  experience rapid development between the ages of
  eight and eighteen
• Therefore, an adolescent may not have developed
  important cognitive functions that could assist
  in terms of compensating for and coping with lost
  functions

7
MAJOR MEDICAL COMPLICATIONS

• (presented as percentages - young/old)
• Cerebellar ataxia 14/46
• Peripheral neuropathy 11/42
• Head Injury 21/22
• Liver disease 10/22
• Other neurological disorders 13/18
• Seizures 13/14
• Korsakoff's Psychosis 0/10
• Wernicke's encephalopathy 2/5
• Dementia 0/5

8
ALCOHOL RELATED BRAIN INJURY SYNDROMES

• Memory impairment
• Attention impairment
• Executive dysfunction
• Behaviour impairment

9
MAIN FEATURES OF MEMORY IMPAIRMENT

• Immediate memory is not affected
• Difficulty remembering recent events or recently
  learned information
• Achronogenesis - loss of time tags
• Retrieving information stored in memory
• Confabulation - a tendency to make up memories
• Preserved learned behaviour

10
MEMORY PROBLEMS

• Find it hard to learn or remember new things
• Forget things they have done
• Forgets things they are supposed to do
• Remember things incorrectly or get details mixed
  up
• Forget things they are told
• Lose things

11
CLINICAL PRESENTATION OF MEMORY IMPAIRMENT

• Misses appointments
• Doesnt follow through with information
• Doesnt pass on messages
• Doesnt pay bills
• Trends to talk about the same things and things
  they know well
• Forgets what was discussed last week
• Has inaccurate memories of events
• Loses temporal information
• Has difficulty learning new things

12
ATTENTION PROBLEMS

• Slow information processing speed
• Multiple task processing problems
• Can't focus, distractible
• Can't cope with too many steps to a task

13
CLINICAL PRESENTATION OF ATTENTION PROBLEMS

• Is slow to do tasks
• Takes a long time to complete tasks
• Cant do two things at the same time
• Cant stay on task
• Doesnt complete tasks
• Cant cope with long tasks
• Gets steps of a task mixed up

14
EXECUTIVE DYSFUNCTION

• Difficulties with
• Attention and concentration
• Planning, organisation, problem solving
• Complex, abstract and flexible thinking
• Initiative
• Emotional and behavioural change
• Self awareness and insight

15
EXECUTIVE PROBLEMS

• Have problems working out the steps of a task
• Have trouble organising their thoughts and
  explaining things to others
• Have trouble of thinking of possible solutions to
  a problem - make poor decisions
• Having trouble thinking of alternative solutions
  to a problem
• Having trouble seeing the consequences of their
  actions
• Having trouble monitoring their actions and
  behaviours and know that there is anything wrong
• Having trouble changing their ideas, actions and
  behaviours

16
CLINICAL PRESENTATION OF EXECUTIVE DYSFUNCTION

• Makes the same errors again and again
• Doesnt like or cope well with change
• Cant see other possible solutions
• Has very black and white thinking
• Cant work out how to solve new problems
• Tends to use old strategies, even if they dont
  work
• Has poor awareness or insight
• Uses defence mechanisms to hide problems

17
Awareness and Insight

• Awareness
• Insight

YES
YES
NO
NO
YES
NO
YES
NO
18
BEHAVIOURAL CHANGE

• Disorders of drive and control
• Disorders of emotional content
• Disorders of monitoring

19
BEHAVIOURAL PROBLEMS

• Control
• Impulsivity, disinhibition, irritability, poor
  social skills, outbursts, excessive talking
• Drive
• adynamia
• Monitoring
• Lack of awareness and insight, egocentricity,
• Emotional content
• over-reacts to situations, mood swings

20
CLINICAL PRESENTATION OF BEHAVIOUR CHANGE

• Cant get started on tasks
• Doesnt complete tasks
• Needs prompting to do things
• Over-reacts to situations
• Cries, laughs, yells more than others
• Is impulsive and disinhibited
• Doesnt know the effect they have on others
• Doesnt know when they have made mistakes
• Uses defence mechanisms

21
PSYCHOLOGICAL ADJUSTMENT PROBLEMS

• Depression
• Anxiety
• Denial
• Anger
• Blame
• Guilt

22
THINGS ARBI DOES NOT AFFECT

• Vocabulary and language
• Long term memory
• Any well learned skills
• Knowledge of facts and understanding of the world
• Knowledge of the social world
• ARBI is sometimes called the invisible disability
  because the person is still good at many things

23
REHABILITATION, COMMUNITY AND TREATMENT ISSUES
24
REHABILITATION, COMMUNITY AND TREATMENT ISSUES

• To participate in therapy or to change behaviour
  a person needs to
• know that there is an issue and what the issue is
• identify triggers and be able to think of a
  number of alternative solutions
• predict what the outcome of each solution may be
• learn and remember new skills
• decide what action to take
• carry out that action
• monitor performance
• change behaviour as required

25
TREATMENT ISSUES

• This clearly requires reasonable
• attention
• memory
• planning and organisation
• flexibility
• impulse control

26
DEVELOPING CARE PLANS AND MANAGING CLIENTS WITH
ABI

• The way this is done will depend on the clients
  cognitive abilities
• Before commencing therapy with a client or trying
  to change behaviour, some estimate or measurement
  of cognitive functioning should be undertaken
• Asking a client to do things that are not
  possible cognitively can only lead to failure
  and setbacks
• Concrete and inflexible thinking, as well as a
  lack of insight are the biggest barriers to
  counselling clients and trying to get behaviour
  change

27
MODEL FOR COGNITIVE AND BEHAVIOUR MANAGEMENT

• Use a team approach (whether in institution or in
  the home)
• Make a comprehensive assessment
• Set short-term and long-term goals
• Build a caring environment around the client
• Be outcome oriented
• Make emotional behaviour a priority
• Be prevention oriented

28
COMMON MISTAKES THAT MAY INCREASE "DIFFICULT"
BEHAVIOURS

• The environment is too busy or complex
• The environment is understimulating
• People only give attention to "difficult"
  behaviours
• People do not give attention to "appropriate"
  behaviours
• Trying to reason with the client
• Failing to make allowances for cognitive deficits
• Failing to make allowances for adynamia

29
COMMON MISTAKES THAT MAY INCREASE "DIFFICULT"
BEHAVIOURS

• People make "value laden" judgements about
  client's behaviour
• Personalisation of client's behaviour
• The worker goes it alone
• The worker becomes enmeshed at a social and
  personal level with the client or family
• The worker blames other workers for increasing a
  client's difficult behaviour or for mismanaging
  an incident.

30
PUTTING RECOMMENDATIONS INTO PRACTICE - ATTENTION

• Problem - Slow information processing speed
• Strategy - give the person more time
• Problem - multiple task processing
• Strategy - do only one thing at a time

31
PUTTING RECOMMENDATIONS INTO PRACTICE - ATTENTION

• Problem - can't focus, distractible
• Strategy - keep environment quiet and free of
  distractions
• Problem - can't cope with too many steps to a
  task
• Strategy - keep tasks simple, not too long, with
  only a few steps

32
PUTTING RECOMMENDATIONS INTO PRACTICE - MEMORY

• Problem - impaired immediate memory span or
  working memory, easily overloaded
• Strategy - break down information or tasks into
  smaller chunks and only give a little bit of
  information at a time
• Problem - forgets what has done, been told
• Strategy - write things down (diary, whiteboard
  etc) as prompts to remember, repeat information,
  give information in more than one modality

33
PUTTING RECOMMENDATIONS INTO PRACTICE - MEMORY

• Problem - forgets what us supposed to do
• Strategy - again write things down, give prompts
  or reminders just before the activity (e.g. a
  phone call), go and get them
• Problem - confabulates
• Strategy - you cannot change this behaviour, you
  need to check or verify what they are saying
  before you accept it as the truth

34
PUTTING RECOMMENDATIONS INTO PRACTICE - EXECUTIVE

• Problem - planning and organisation
• Strategy - will need an external source to help
  set up routines (where appropriate) and to help
  organise things
•  
• Problem - concrete and inflexible thinking
• Strategy - don't expect them to think of
  alternatives or change their behaviour, will need
  you to think of alternatives for them

35
PUTTING RECOMMENDATIONS INTO PRACTICE - EXECUTIVE

• Problem - problem solving and decision making
• Strategy - it is important that the person makes
  their own decisions (where possible), but it is
  up to the carer to provide them with all the
  possibilities and consequences to assist them
  make that decision
• Problem - disinhibited, impulsive
• Strategy - a clear and consistent message about
  what is appropriate behaviour, set up situations
  to minimise harm to self and others

36
Where to From Here?

• More research is needed into the effects of
  drinking from an early age on cognitive and
  behavioural functioning
• More research is needed into the effects of binge
  drinking versus regular drinking on cognitive
  functioning
• Heavy drinkers are not likely to know that they
  are acquiring problems
• Heavy drinkers are not likely to turn up in the
  system until they become sick, although cognitive
  decline is likely to have already begun

37
Challenges

• To effectively educate the public about the
  dangers of excessive drinking on future health
  and reduce alcohol consumption
• To be able to intervene and reduce alcohol
  consumption in heavy drinkers before it is too
  late and irreversible brain damage has resulted
• This must occur before a person becomes sick
  from alcohol and hard neurological damage has
  occurred