ENGAGING AND RETAINING COMPLEX CLIENTS IN PHARMACOTHERAPY TREATMENT

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ENGAGING AND RETAINING COMPLEX CLIENTS IN
PHARMACOTHERAPY TREATMENT

• Martin Jackson
• November 2005

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Aims of The Talk

• Describe the acute and chronic cognitive and
  behavioural presentations of substance-related
  ABI
• Outline important issues regarding treatment and
  therapy for a person with an ABI
• Describe how an ABI can impact on a persons daily
  functioning
• Outlines ways of intervening for cognitive and
  behavioural problems

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SUBSTANCE RELATED BRAIN INJURY(SRBI)
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SRBI CONSISTENT RESEARCH FINDINGS

• All substances have an acute intoxicating effect
  (and withdrawal effect) that produces changes in
  cognition, usually in the areas of attention,
  memory and executive function
• All substances have the potential to produce an
  acute brain injury, generally related to
  overintoxication (overdoses) and its secondary
  effects (hypoxia etc)

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SRBI CONSISTENT RESEARCH FINDINGS

• Most substances (if not all) will produce an
  acquired brain injury in the long term
• There is a consistent theme in the drug and
  alcohol literature that initial research into a
  substance suggests that there is no brain injury
  from the substance, but years later this is shown
  to be not true

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RELATIONSHIP TO DOSAGE

• Dosage related issues arise from
• The direct neurotoxic effect on the brain
• Generally, the greater the dose, the greater the
  neurotoxic effect.
• The probability of an acute neurological event
  (such as a stroke) is higher.
• Indirect effects such as respiratory and blood
  flow
• Generally, the greater the dose, the greater the
  probability of secondary complications
• Important factors include whether consciousness
  was lost, how long the down, was resuscitation
  needed

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RELATIONSHIP TO LENGTH OF USE

• Generally, the longer a substance is used for the
  greater the probability of direct cognitive
  impairment both in terms of occurrence and
  degree.
• Generally, the longer a substance is used for the
  greater the probability of indirect secondary
  complications.
• There is not necessarily a simple interaction
  between dosage and length of use.

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ALCOHOL

• It is the main cause of ABI in the 40 to 55 age
  group.
• Affects people in two ways
• Thinking, emotion and behaviour
• (memory and executive functioning)
• Physical movement
• Major medical problems
• Cerebellar ataxia
• Peripheral neuropathy
• Head Injury
• Liver disease
• Other neurological disorders
• Seizures

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MAIN FEATURES OF THE ALCOHOL AMNESIC SYNDROME

• 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

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ALCOHOL RELATED 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

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HYPOXIC BRAIN INJURY NEUROPSYCHOLOGICAL FEATURES

• Mild hypoxia - inattentiveness, poor judgement
  and motor inco-ordination - no lasting effects
• Moderate to severe hypoxia (e.g. cardiac arrest)
  - consciousness is lost within seconds, but
  recovery is likely to be complete if breathing,
  oxygenation of blood and cardiac action are
  restored within five minutes. Beyond five
  minutes there is usually permanent damage which
  correlates with the length of "down time".
• Deterioration in function can occur over the
  months following the episode as nerve cells "drop
  out". Demyelination can continue to occur over
  time also.

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NEUROPATHOLOGY OF HYPOXIA

• Areas of the brain most likely to be affected
  include
• "Watershed areas" (e.g. parieto-occipital area)
  which lie on the borders between the major
  cerebral arteries. Often are the first to
  experience a decrease in blood flow.
• Large cells of the hippocampus and cerebellum
  (generally have higher oxygen uptake, so are
  therefore vulnerable to lack of oxygen).
• Subcortical structures are particular vulnerable
  to carbon monoxide poisoning

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HYPOXIC BRAIN INJURY

• Neuropsychological effects can be highly variable
  and along a continuum from localized to
  generalized.
• Permanent anterograde amnesia with preserved
  performance on other tasks can exist.
• May or may not have retrograde amnesia
• Can have global impairment leading to dementia in
  more severe cases
• Visual deficits are common

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BENZODIAZEPINES

• Short term neurological effects
• Act at limbic, thalamic and hypothalamic levels
• Primary effects are anxiolytic, sedative,
  hypnotic, muscle relaxant and anticonvulsant
• CNS effects are drowsiness, ataxia, fatigue,
  confusion, weakness and vertigo
• Long terms physical effects
• Physiological and pharmacological dependence
• Withdrawal symptoms

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BENZODIAZEPINES

• Short term cognitive effects
• Anterograde amnesia is common and severity is
  dose dependent, memory for information presented
  under the influence is impaired
• Reported cognitive problems with verbal fluency,
  psychomotor speed, reaction time, attention,
  episodic memory, semantic memory
• No retrograde amnesia

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BENZODIAZEPINES

• Long term cognitive effects
• Whilst acute and subacute effects are well
  documented, chronic effects are less well known
• In chronic users, effects continue for some time
  after substance use is ceased
• There is evidence of (episodic) memory impairment
  that is independent of the sedative effect
• There is also impairment of
• concentration, attention, vigilance, speed of
  processing, sustained attention
• Visuospatial skills (not seen in acute stage)
• May improve after stopping

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MARIJUANA

• Physical/Neurological effects
• Increased rate of heart rate, but low blood
  pressure with resultant risk of increased stroke
• PET scans show increased cerebral blood flow
  (CBF) in paralimbic areas (orbital and mesial
  frontal lobes, temporal poles, cingulate and
  cerebellum) related to mood effects
• PET scans show decreased CBF in attention network
  (parietal lobe, frontal lobe, thalamus, temporal
  cortex)

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MARIJUANA

• Short term effects low dose
• thinking and short term memory problems
• distorted judgement and sense of time and space
• relaxation and loss of inhibition
• increased appetite
• impaired coordination and balance
• reddened eyes
• feeling faint

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MARIJUANA

• Short term effects high dose
• Confusion
• Restlessness
• Feelings of excitement
• Hallucinations
• Anxiety or panic
• Decreased reaction time
• paranoia

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MARIJUANA

• Long term consequences
• impaired concentration, memory and the ability to
  learn
• a moderate decrease in IQ
• reduced verbal abilities (young users)
• disturbed sleep patterns
• amotivational syndrome

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SOLVENTS

• Acute symptoms include euphoria, giddiness,
  headache, ataxia, confusion, perceptual
  distortions, hallucinations
• High levels of acute exposure result in severe
  encephalopathy (nystagmus, diplopia, dysarthria,
  convulsions and coma)
• Chronic effects are less well known and are
  inconsistent across studies headaches, fatigue,
  irritability, memory impairment, depression, loss
  of drive and emotional instability

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SOLVENTS

• Neuropathology - MRI scans have show atrophy,
  white matter hyperintensity, hypointensity of
  basal ganglia and thalamus. SPECT scans have
  shown a decrease in regional cerebral blood flow
  in the bilateral prefrontal cortex.
• Neuropathological and neuropsychological
  impairments are similar to those seen in
  subcortical dementias (rostral brain stem,
  thalamus, basal ganglia, red nucleus and
  substantia nigra)

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SOLVENTS

• A correlation exists between the degree of
  neurological impairment and white matter disease.
  Frontal hypoperfusion may related to
  amotivational syndrome.
• Neuropsychological studies have shown a wide
  range of cognitive impairments including
  information processing speed, fine motor
  dysfunction, auditory discrimination, attention,
  memory, visuomotor function, psychosocial
  functioning

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THINGS GENERALLY NOT AFFECTED IN SRBI

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

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CONCLUSIONS ABOUT SUBSTANCE RELATED BRIAN INJURY

• Assuming you are an adult and do not suffer an
  acute neurological event, those at risk of
  developing an ABI are
• those who use a substance for at least ten years
  (if not fifteen)
• use above a particular threshold
• are over the age of 40

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CONCLUSIONS ABOUT SUBSTANCE RELATED BRIAN INJURY

• The common long term cognitive and behavioural
  sequelae of substance related brain injury are
• Slowed speed of processing
• Attention impairments
• New learning and memory impairment
• Executive impairment (planning and organisation,
  problems solving, abstract and flexible thinking)
• Problems with impulse control, emotional control
  and insight

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ISSUES RELATED TO THERAPY AND INTERVENTION
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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
• decide what action to take
• carry out that action
• monitor performance
• change behaviour as required

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TREATMENT ISSUES

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

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UNDERTAKING THERAPY WITH A CLIENT WITH SRBI

• The way this is done will depend on the clients
  cognitive abilities
• Asking a client to do things that are not
  cognitively possible only leads to failure
• Concrete and inflexible thinking, as well as a
  lack of insight are the biggest barriers to
  counselling clients and trying to get behaviour
  change
• There is a tendency to relapse back to old and
  well-learned behaviours

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Awareness and Insight

• Awareness
• Insight

YES
YES
NO
NO
YES
NO
YES
NO
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IMPACT OF AN ABI ON DAILY FUNCTIONING
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IMPACT OF ATTENTION DEFICITS ON DAILY FUNCTIONING

• Misses details
• Is slow to complete tasks
• Cant do two things at once
• Gets overwhelmed by two much information
• Gets distracted easily
• Makes mistakes

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IMPACT OF MEMORY DEFICITS ON DAILY FUNCTIONING

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

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IMPACT OF EXECUTIVE DEFICITS ON DAILY FUNCTIONING

• 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
• Have trouble making 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

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IMPACT OF BEHAVIOUR DEFICITS ON DAILY FUNCTIONING

• Get irritable and distressed and can't cope
• Have trouble with getting going - may appear
  unmotivated and apathetic, but will do things
  when prompted
• Have a low frustration tolerance and lose their
  temper quickly
• Be very self-centred - don't consider others,
  appreciate what others do for them and appear
  selfish
• Have a quickly changing mood and laugh or cry
  inappropriately
• Be perseverative - talk about the same topics or
  do the same tasks repeatedly
• Be impulsive and disinhibited

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IMPACT OF LANGUAGE DEFICITS ON DAILY FUNCTIONING

• Have trouble understanding what is being said to
  them
• Have trouble speaking or finding the right words
  to say
• Talk in gibberish
• Having trouble picking up social or nonverbal cues

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STRATEGIES TO ASSIST ATTENTION

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

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STRATEGIES TO ASSIST 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
• 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

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STRATEGIES TO ASSIST COMMUNICATION

• Problem - understanding what is being said to
  them
• Strategy repeat information, speak slowly,
  visual cues
• Problem - speaking or finding the right words to
  say
• Strategy use visual cues, verbal cues
• Problem - picking up social or nonverbal cues
• Strategy behavioural intervention

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STRATEGIES TO ASSIST EXECUTIVE FUNCTIONS

• 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
• 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