Specialist Training in Neuropsychological and Functional

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Specialist Training in Neuropsychological and Functional Powered By Docstoc
					ENGAGING AND RETAINING COMPLEX CLIENTS IN PHARMACOTHERAPY TREATMENT
Martin Jackson

November 2005

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

SUBSTANCE RELATED BRAIN INJURY (SRBI)

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 it’s secondary effects (hypoxia etc)

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

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

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.

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

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

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

Performance of Social Drinkers and Alcoholics on the Rey Auditory Verbal Learning Test
16 14
Words Recalled

Controls Heavy Social Drinkers Self Referrals Alcoholics with Neurological Disease 1 2 3 Trial 4 5 Alcoholics Without Neurological Disease

12 10 8 6 4 2 0

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.

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

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

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

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

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

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)

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

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

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

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

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)

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

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

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

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

ISSUES RELATED TO THERAPY AND INTERVENTION

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

TREATMENT ISSUES
• This clearly requires reasonable:
– – – – – attention memory planning and organisation flexibility impulse control

UNDERTAKING THERAPY WITH A CLIENT WITH SRBI
• The way this is done will depend on the client’s 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 welllearned behaviours

Awareness and Insight

• Awareness

YES

YES

NO

NO

• Insight

YES

NO

YES

NO

IMPACT OF AN ABI ON DAILY FUNCTIONING

IMPACT OF ATTENTION DEFICITS ON DAILY FUNCTIONING
• • • • Misses details Is slow to complete tasks Can’t do two things at once Gets overwhelmed by two much information • Gets distracted easily • Makes mistakes

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

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

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

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

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

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

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

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


				
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posted:1/29/2010
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