Broadly speaking, people with ARBD may present to health services in one of two ways:
An acute presentation is often as part of a hospital admission, where comorbid physical health issues (such as encephalopathy, delirium tremens or pancreatitis) will be the initial focus for treatment. This is also often complicated by the presence of multiple comorbidities including features such as a head injury and vascular trauma.
A more chronic presentation is where there is a gradual cognitive decline in the community which may be recognised by the person, family members or as a result of routine cognitive screening in community services. Some of these people will be abstinent from alcohol but most will still be alcohol dependent.
Of course, the picture is rarely that simplistic and the 2 will often overlap.
Research (Wilson and others, 2012) has described a framework for understanding the natural history of in people who present with acute problems. This framework is split into 5 stages, which was developed from retrospective clinical studies, clinical consensus statements and studies on the rehabilitation of patients presenting with acquired, traumatic brain injury. The 5 stages are:
Not all people with present with acute problems. Those presenting to community services with more gradual cognitive decline may need to initially focus on becoming abstinent from alcohol (in the most appropriate setting) and then engage in interventions relevant to their stage of recovery. Although it may not be appropriate for them to move through the 5 stages above in sequence, clinicians can take relevant elements from the stages to form a comprehensive treatment plan for the person based on their presenting need. It is possible that some people regain near normal cognitive function in the earlier stages of the process. So, it is extremely important to maintain a flexible and dynamic care plan that can adapt to the changes in a person's function.
Physical stabilisation is concerned with preventing or treating withdrawal and ensuring that any comorbid acute medical conditions are treated. Sections 10.3 and 10.4 in chapter 10 on pharmacological interventions provides guidance on medically assisted withdrawal and section 10.5 in chapter 10 provides guidance on prescribing for relapse prevention.
If a person can maintain abstinence from alcohol following the treatment of acute conditions, their cognitive and functional abilities usually improve over the next 3 to 4 months. So, support to maintain abstinence is of vital importance, but clinicians may need to adapt standard treatment approaches to take into account any cognitive impairment (MacRae and Cox, 2003). Advice for adapting psychosocial interventions is provided later in this section.
There are a number of principles and interventions that should be considered during the psychosocial assessment phase. These include:
At this point it may also be helpful to encourage people to start a personal journal. This may be a useful thing for them to do because it can:
A therapeutic rehabilitation programme aims to gradually improve a person's skills for daily living as their cognition improves. There are a number of targets for interventions in this phase, which include the following.
You can help a person to develop autonomy by helping them to become more independent and improve their ability to self-manage where cognitive or functional deficits remain (Wilson and others, 2021).
You can promote functional recovery through maintaining a journal, planning activities and learning skills. Occupational therapists or other healthcare staff with expertise in neurorehabilitation can support people in re-learning everyday tasks and establishing routines that are important for regaining skills, confidence and orientation.
You can support a person's memory with strategies such as:
Some people with have problems with executive function. Executive function describes a set of skills needed to:
People with problems with executive function are likely to need a lot of help to use strategies. For example, staff may need to prompt and help people to make use of their journal. It is helpful to give people simple repeated instructions about carrying out tasks and avoid giving them unnecessary information.
For some people, can result in apathy and problems with motivation. Staff need to take a persistent and consistent approach to encouraging people to carry out tasks and participate in activities. They need to explore approaches and activities that can support the person's motivation. Establishing a motivating environment is important. For example, routines can be helpful and these should be obvious in the setting, such as through information on a noticeboard.
You can help the person manage alcohol by using adapted psychosocial interventions and considering the appropriateness of relapse prevention medication. As with all medication, the clinician needs to obtain the person's informed consent before they start the medication, and they will need to get their consent on a regular basis. Cognitive impairment can affect a person's capacity to consent to medication and their ability to observe a regular dosing schedule. So, clinicians may need to carry out a mental capacity assessment to assess the person's capacity to consent to that treatment.
Developing relationships is important to support the person to build relationships with their keyworkers and to improve relationships with people who care about them, such as family and carers. This will strengthen their informal community support structure for times when professionals are not so closely involved.
Adaptive rehabilitation is a transitional phase that takes place when clinicians consider that the person has reached their optimal level of cognitive and behavioural improvement. It is important to reassess their functional ability and the amount of support they will need, encouraging autonomy but ensuring safety.
A full assessment of activities of daily living should take place. This should include a review of the person's environment and care package to see if anything needs to be adapted. Phase 4 often involves transferring care from a setting with a high level of support to a less dependent environment or reducing carer support.
During this phase, the person is at increased risk of returning to problem alcohol use, particularly if they are returning to their previous environment (where they may be exposed to previous triggers for drinking). So, any transfers of care must occur in a managed, planned way, involving all relevant health and social care agencies as well as the person and their family or carers. An identified person should co-ordinate the care plan and ensure that regular reviews are undertaken.
The main therapeutic principles of social integration and relapse prevention are to maintain abstinence from alcohol and an optimum level of independence and quality of life moving forward.
Staff can reduce and manage a person's exposure to drinking triggers by supporting them to engage in non-drinking social networks, including peer support networks and finding new, more suitable accommodation. Ongoing training and education to develop employment and life skills as well as support to manage their own finances may be appropriate. It is also important to support people to make healthy lifestyle choices, such as eating healthy diets and engaging in positive activities and hobbies.
Standard psychosocial interventions rely on a degree of cognitive flexibility and abstract thinking which may be impaired in people with . This does not exclude their use for people with but means that standard approaches need to be adapted and tailored to the needs of the person. Adaptations could include:
You can find more information on psychosocial interventions in chapter 5 on psychosocial interventions. Section 5.5 on structured support can be adapted for people with .
Dependent on social needs, people with may access rehabilitation interventions in a variety of settings and it is important for their recovery that they receive an appropriate level of support. Support settings and interventions should reduce risk while enhancing autonomy and independence.
People living in residential environments on the basis of care needs may receive psychosocial interventions as part of an rehabilitation package. However, this is not the same as engaging in a dedicated residential rehabilitation programme. There are a small number of dedicated residential programmes in the UK. A recent evaluation of a 12-week dedicated residential programme in Scotland showed significant reductions in attendances at emergency departments and the use of inpatient beds, as well as significant improvements in cognitive function (Smith and Willenborg, 2024).
Receiving cognitive rehabilitation in a residential setting should usually have advantages over similar programmes in the community, as the person with would be shielded from their specific triggers for drinking within their own environment. To date, there is no evidence-base to confirm this. However, the alcohol guidelines development group recommends that access to residential and community forms of cognitive rehabilitation should be available, so that people with can be placed in the most appropriate treatment setting based on their individual needs.