Delayed discharge in alcohol-related dementia: consequences and possibilities for improvement
Aleece MacPhail A E , Michael McDonough B and Joseph E. Ibrahim C D
+ Author Affiliations
- Author Affiliations
A Ballarat Health Services, 102 Ascot Street South, Ballarat, Vic. 3350, Australia.
B Addiction Medicine and Toxicology, Western Hospital Melbourne, Gordon Street, Footscray, Vic. 3011, Australia.
C Subacute Services, Ballarat Health Services, 102 Ascot Street South, Ballarat, Vic. 3350, Australia.
D Prevention Research Unit, Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Vic. 3800, Australia.
E Corresponding author. Email: aleece.macphail@gmail.com
Australian Health Review 37(4) 482-487 https://doi.org/10.1071/AH13027
Submitted: 25 January 2013 Accepted: 7 May 2013 Published: 15 July 2013
Abstract
Individuals with alcohol-related dementia (ARD) are over-represented among ‘difficult to discharge’ patients. ARD is associated with prolonged hospital stay and high rates of discharge at own risk. Risk factors for delayed discharge in patients with ARD include: a lack of appropriate medical and social support; multiple and complex needs; psychiatric symptoms; challenging behaviours; and an unmet need for appropriate residential care. Integration into present services is problematic and aged care is not an acceptable option for these patients. The present paper identifies three key possibilities to reduce the burden of prolonged hospitalisation of patients with ARD. These are: improved availability of specialised, multidisciplinary care pathways for patients with ARD, many of which could be developed out of existing services; the development of flexible supported-accommodation options, including harm minimisation, for the subset of patients who are not able to live independently; and improved practice in the emergency department (ED) to ensure timely administration of parenteral thiamine to all patients at risk of developing ARD.
What is known about the topic? Overuse of acute services contributes to strain in the ED and high healthcare costs. ARD is a relatively common but frequently under-recognised condition that is disproportionately associated with delayed discharge, contributing to hospital ‘bed block’.
What does this paper add? This paper provides a review of the relevant literature to identify contributing factors to delayed discharge in ARD, and strategies for improvement. Patients with ARD have several risk factors for delayed discharge, including a complex clinical profile, psychiatric symptoms, challenging behaviours, limited social support and a lack of appropriate accommodation. Negative discharge outcomes in ARD are reduced through improved administration of thiamine in the ED and the use of specialised services and care pathways, which can be developed out of existing services. For the subset of patients with highly complex needs who have undergone repeated cycles of detoxification and relapse, flexible, supported residential care with a harm-minimisation approach is cost effective and improves outcomes.
What are the implications for practitioners? Increased awareness of ARD as a causative factor in delayed discharge and discharge at own risk is called for to allow identification of patients at risk. Improved use of thiamine in the ED and the development of clinical pathways and specialised services for patients with ARD are needed to address systematic gaps in service delivery and reduce the burden on acute care.
Additional keywords: brain injury, cognitive impairment, health service accessibility, length of stay.
References
[1] National Health and Hospitals Reform Commission. A healthier future for all Australians: final report June 2009. Canberra: Department of Health and Ageing; 2009. Available at http://www.health.gov.au/internet/nhhrc/publishing.nsf/content/nhhrc-report [verified 17 May 2013][2] Black D, Pearson M. Average length of stay, delayed discharge, and hospital congestion. BMJ 2002; 325 610–1.
| Average length of stay, delayed discharge, and hospital congestion.Crossref | GoogleScholarGoogle Scholar | 12242160PubMed |
[3] Bryan K. Policies for reducing delayed discharge from hospital. Br Med Bull 2010; 95 33–46.
| Policies for reducing delayed discharge from hospital.Crossref | GoogleScholarGoogle Scholar | 20647227PubMed |
[4] Kydd A. The patient experience of being a delayed discharge. J Nurs Manag 2008; 16 121–6.
| The patient experience of being a delayed discharge.Crossref | GoogleScholarGoogle Scholar | 18269541PubMed |
[5] Thomson A, Guerrini I, Bell D, Drummond C, Duka T, Field M, et al Alcohol-related brain damage: report from a Medical Council on Alcohol Symposium, June 2010. Alcohol Alcohol 2012a; 47 84–91.
| Alcohol-related brain damage: report from a Medical Council on Alcohol Symposium, June 2010.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC383lsFGlsw%3D%3D&md5=70d67ff883860faa48dd63f39eff408bCAS | 22343345PubMed |
[6] Kopelman MD, Thomson AD, Guerrini I, Marshall EJ. The Korsakoff Syndrome: clinical aspects, psychology and treatment. Alcohol Alcohol 2009; 44 148–54.
| The Korsakoff Syndrome: clinical aspects, psychology and treatment.Crossref | GoogleScholarGoogle Scholar | 19151162PubMed |
[7] Popoola A, Keating A, Cassidy E. Alcohol, cognitive impairment and the hard to discharge acute hospital inpatients. Ir J Med Sci 2008; 177 141–5.
| Alcohol, cognitive impairment and the hard to discharge acute hospital inpatients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1czhtlCqsA%3D%3D&md5=46f85335170fb162861b6dac9258b0ceCAS | 18283510PubMed |
[8] Draper B, Karmel R, Gibson D, Peut A, Anderson P. Alcohol-related cognitive impairment in New South Wales hospital patients aged 50 years and over. Aust N Z J Psychiatry 2011; 45 985–92.
| Alcohol-related cognitive impairment in New South Wales hospital patients aged 50 years and over.Crossref | GoogleScholarGoogle Scholar | 21961480PubMed |
[9] MacRae S, Cox S. Meeting the needs of people with alcohol related brain damage: a literature review on the existing and recommended service provision and models of care. Stirling: University of Stirling, Dementia Services Development Centre; 2003.
[10] Northern Residential Mental Health Services Reference Group The housing deficit report: no vacancy. parity 2003; 16 8–9.
[11] Rota-Bartelink A. Models of care for elderly people with complex care needs arising from alcohol related dementia and brain injury. Flemington: Winteringham; 2006.
[12] Price J, Mitchell S, Wiltshire B, Graham J, Williams G. A follow-up study of patients with alcohol-related brain damage in the community. Drug Alcohol Rev 1988; 7 83–87.
| A follow-up study of patients with alcohol-related brain damage in the community.Crossref | GoogleScholarGoogle Scholar |
[13] Gupta S, Warner J. Alcohol-related dementia: a 21st-century silent epidemic? Br J Psych 2008; 193 351–3.
| Alcohol-related dementia: a 21st-century silent epidemic?Crossref | GoogleScholarGoogle Scholar |
[14] Ross HE, Glaser FB, Germanson T. The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry 1988; 45 1023–31.
| The prevalence of psychiatric disorders in patients with alcohol and other drug problems.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL1M%2FisFShug%3D%3D&md5=b61f760031b133217a38560c414f27d0CAS | 3263100PubMed |
[15] Blow FC. Age-related psychiatric comorbidities and level of functioning in alcoholic veterans seeking outpatient treatment. Hosp Community Psychiatry 1992; 43 990–5.
| 1:STN:280:DyaK3s%2FhtlKltg%3D%3D&md5=317f12209815d80323527216a68ccb40CAS | 1328023PubMed |
[16] Cox S, Anderson I, McCabe L. A fuller life: report of the Expert Group on Alcohol Related Brain Damage. Stirling: Dementia Services Development Centre; 2004.
[17] Gilchrist G, Morrison DS. Prevalence of alcohol related brain damage among homeless hostel dwellers in Glasgow. Eur J Public Health 2005; 15 587–8.
| Prevalence of alcohol related brain damage among homeless hostel dwellers in Glasgow.Crossref | GoogleScholarGoogle Scholar | 16162595PubMed |
[18] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn (DSM-IV-TR). Washington, DC: American Psychiatric Publishing; 2000.
[19] Oslin D, Atkinson RM, Smith DM, Hendrie H. Alcohol related dementia: proposed clinical criteria. Int J Geriatr Psychiatry 1998; 13 203–12.
| Alcohol related dementia: proposed clinical criteria.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1czhtVWitw%3D%3D&md5=f30e3be8a3d4d12e9855a265a9be7f77CAS | 9646147PubMed |
[20] Pierucci-Lagha A, Derouesné C. [Alcoholism and aging. 2. Alcoholic dementia or alcoholic cognitive impairment?] Psychol Neuropsychiatr Vieil 2003; 1 237–49.
| 15683959PubMed |
[21] Moriyama Y, Mimura M, Kato M, Kashima H. Primary alcoholic dementia and alcohol-related dementia. Psychogeriatrics 2006; 6 114–8.
| Primary alcoholic dementia and alcohol-related dementia.Crossref | GoogleScholarGoogle Scholar |
[22] Lennane KJ. Patients with alcohol-related brain damage: therapy and outcome. Drug Alcohol Rev 1988; 7 89–92.
| Patients with alcohol-related brain damage: therapy and outcome.Crossref | GoogleScholarGoogle Scholar |
[23] Zahr NM, Kaufman KL, Harper CG. Clinical and pathological features of alcohol-related brain damage. Nat Rev Neurol 2011; 7 284–94.
| Clinical and pathological features of alcohol-related brain damage.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXlvFCkt78%3D&md5=6274b0eea3dfd2439c956301344aef7aCAS | 21487421PubMed |
[24] Ferran J, Wilson K, Doran M, et al The early onset dementias: a study of clinical characteristics and service use. Int J of Geriatric Psychiatry 1996; 11 863–9.
[25] Access Economics. Making choices, future dementia care: projections, problems and preferences. Sydney: Access Economics; 2009.
[26] Werner P, Stein-Shvachman I, Korczyn AD. Early onset dementia: clinical and social aspects. Int Psychogeriatr 2009; 21 631–6.
| Early onset dementia: clinical and social aspects.Crossref | GoogleScholarGoogle Scholar | 19470199PubMed |
[27] Harvey RJ, Skelton-Robinson M, Rossor MN. The prevalence and causes of dementia in people under the age of 65 years. J Neurol Neurosurg Psychiatry 2003; 74 1206–9.
| The prevalence and causes of dementia in people under the age of 65 years.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3szps1WrsQ%3D%3D&md5=fc9769f82517d544444f0946f87540d3CAS | 12933919PubMed |
[28] Draper B, Karmela R, Gibsona D, Peuta A, Andersona P. The Hospital Dementia Services Project: age differences in hospital stays of older people with and without dementia. Int Psychogeriatr 2011; 23 1649–58.
| The Hospital Dementia Services Project: age differences in hospital stays of older people with and without dementia.Crossref | GoogleScholarGoogle Scholar | 21902861PubMed |
[29] Smith I, Hillman A. Management of alcohol Korsakoff syndrome. Adv Psychiatr Treat 1999; 5 271–8.
| Management of alcohol Korsakoff syndrome.Crossref | GoogleScholarGoogle Scholar |
[30] Bisset H, Campbell S, Goodall J. Appropriate responses for homeless people whose needs require a high level and complexity of service provision: summary. Canberra: Department of Family and Community Services; 1999.
[31] Rota-Bartelink A, Lipmann B. Supporting the long-term residential care needs of older homeless people with severe alcohol-related brain injury in Australia: The Wicking Project. Care Manag J 2007; 8 141–8.
| Supporting the long-term residential care needs of older homeless people with severe alcohol-related brain injury in Australia: The Wicking Project.Crossref | GoogleScholarGoogle Scholar | 17937212PubMed |
[32] Department of Health and Ageing. Technical paper on the changing dynamics of residential aged care prepared to assist the Productivity Commission Inquiry Caring for older Australians. Canberra: 2011.
[33] Thomson A, Guerrini I, Marshall E. The evolution and treatment of Korsakoff’s Syndrome. Neuropsychol Rev 2012; 22 81–92.
| The evolution and treatment of Korsakoff’s Syndrome.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38nhsF2itw%3D%3D&md5=cb59d76511ec940920a3988c45460d3aCAS | 22569770PubMed |
[34] Brandt J, Butters N, Ryan C, Bayog R. Cognitive loss and recovery in long-term alcohol abusers. Arch Gen Psychiatry 1983; 40 435–42.
| Cognitive loss and recovery in long-term alcohol abusers.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL3s7nsleltQ%3D%3D&md5=424e8675ba183c6eb9c3759cb89f73f1CAS | 6838323PubMed |
[35] Bates ME. Neurocognitive impairment associated with alcohol use disorders: implications for treatment. Exp Clin Psychopharmacol 2002; 10 193–212.
| Neurocognitive impairment associated with alcohol use disorders: implications for treatment.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD38XntFGku70%3D&md5=f5d9dbec22b73539f5a33a266304fcddCAS | 12233981PubMed |
[36] Rota-Bartelink A, Lipmann B. Older people with alcohol-related brain injury and associated complex behaviors: a psychosocial model of residential care (The Wicking Project). Care Manag J 2010; 11 112–21.
| Older people with alcohol-related brain injury and associated complex behaviors: a psychosocial model of residential care (The Wicking Project).Crossref | GoogleScholarGoogle Scholar | 20560522PubMed |
[37] Hamilton M, Elford K. Report on 5 years of the Multiple and Complex Needs Panel 2004–2009. Melbourne: Department of Human Services; 2009.
[38] Barrow S, Soto Rodríguez G, Córdova P. Final report on the evaluation of the Closer To Home Initiation. New York: Corporation For Supportive Housing; 2004.
[39] Koffman J, Fulop NJ, Pashley D, Coleman K. No way out: the delayed discharge of elderly mentally ill acute and assessment patients in north and south Thames regions. Age Ageing 1996; 25 268–72.
| No way out: the delayed discharge of elderly mentally ill acute and assessment patients in north and south Thames regions.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK28vivVOlug%3D%3D&md5=135eb73056cb0c53056ac8d37d20bfe5CAS | 8831870PubMed |
[40] Becker HC. Kindling in alcohol withdrawal. Alcohol Health Res World 1998; 22 25–33.
| 1:STN:280:DC%2BD2M%2FnslOntQ%3D%3D&md5=958d0c38c5215f0514f908084add5740CAS | 15706729PubMed |
[41] Trevisan LA, Boutros N, Petrakis IL, Krystal JH. Complications of alcohol withdrawal: pathophysiological insights. Alcohol Health Res World 1998; 22 61–6.
| 1:STN:280:DC%2BD2M%2FnslOmsQ%3D%3D&md5=ac5f23c4666ab5741afd6cca4ce85ee3CAS | 15706735PubMed |
[42] Loeber S, Duka T, Marquez HW, Nakovics H, Heinz A, Mann K, et al Effects of repeated withdrawal from alcohol on recovery of cognitive impairment under abstinence and rate of relapse. Alcohol and Alcoholism 2010; 45 547
[43] Castaneda R, Lifshutz H, Galanter M, Medalia A, Franco H. Treatment compliance after detoxification among highly disadvantaged alcoholics. Am J Drug Alcohol Abuse 1992; 18 223–34.
| Treatment compliance after detoxification among highly disadvantaged alcoholics.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK383itF2rtA%3D%3D&md5=a13f1ef76dca4f79271135fd929442acCAS | 1314019PubMed |
[44] Harper C. Thiamine (vitamin B1) deficiency and associated brain damage is still common throughout the world and prevention is simple and safe! Eur J Neurol 2006; 13 1078–82.
| Thiamine (vitamin B1) deficiency and associated brain damage is still common throughout the world and prevention is simple and safe!Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28rmt1Sgtg%3D%3D&md5=e815edfd3eae783394df6b9bfb8cf5dcCAS | 16987159PubMed |
[45] Torvik A, Lindboe CF, Rogde S. Brain lesions in alcoholics. A neuropathological study with clinical correlations. J Neurol Sci 1982; 56 233–48.
| Brain lesions in alcoholics. A neuropathological study with clinical correlations.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL3s%2FosV2nsQ%3D%3D&md5=2bd2b0d88cdae70a6947b88d43a44e39CAS | 7175549PubMed |
[46] Harper CG, Giles M, Finlay-Jones R. Clinical signs in the Wernicke–Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry 1986; 49 341–5.
| Clinical signs in the Wernicke–Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL287pvVOmug%3D%3D&md5=2b16dca341c3ea845437037d1c3ce01dCAS | 3701343PubMed |
[47] Pitel A-L, Zahr NM, Jackson K, Sassoon SA, Rosenbloom MJ, Pfefferbaum A, et al Signs of preclinical Wernicke’s encephalopathy and thiamine levels as predictors of neuropsychological deficits in alcoholism without Korsakoff’s syndrome. Neuropsychopharmacology 2011; 36 580–8.
| Signs of preclinical Wernicke’s encephalopathy and thiamine levels as predictors of neuropsychological deficits in alcoholism without Korsakoff’s syndrome.Crossref | GoogleScholarGoogle Scholar | 20962766PubMed |
[48] Feeney GF, Connor JP. Wenicke–Korsakoff syndrom (WKS) in Australia: no room for complacency. Drug Alcohol Rev 2008; 27 388–392.
| Wenicke–Korsakoff syndrom (WKS) in Australia: no room for complacency.Crossref | GoogleScholarGoogle Scholar | 18584388PubMed |
[49] Hope LC, Cook CCH, Thomson AD. A survey of the current clinical practice of psychiatrists and accident and emergency specialists in the United Kingdom concerning vitamin supplementation for chronic alcohol misusers. Alcohol and Alcoholism 1999; 34 867
[50] Thomson AD, Cook CCH, Touquet R, Henry JA. The Royal College of Physicians report on alcohol: Guidelines for managing Wernicke’s encephalopathy in the accident and emergency department. Alcohol Alcohol 2002; 37 513–21.
| The Royal College of Physicians report on alcohol: Guidelines for managing Wernicke’s encephalopathy in the accident and emergency department.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD38XptFOku78%3D&md5=f2b4e4cd91add29db0c8c1926341739cCAS | 12414541PubMed |
[51] Roehrs T, Roth T. Clinical reviews: sleep, sleepiness, sleep disorders and alcohol use and abuse. Sleep Med Rev 2001; 5 287–97.
| Clinical reviews: sleep, sleepiness, sleep disorders and alcohol use and abuse.Crossref | GoogleScholarGoogle Scholar | 12530993PubMed |
[52] Oscar-Berman M, Shagrin B, Evert DL, Epstein C. Impairments of brain and behavior: the neurological effects of alcohol. Alcohol Health Res World 1997; 21 65–75.
| 1:STN:280:DC%2BD2M%2FnslOrsA%3D%3D&md5=8d3198ab031608f9f2a4ca62967c7b0dCAS | 15706764PubMed |
