Accounting for Cognitive impairment in AOD treatment, it truly is a no-brainer

1. Accounting for Cognitive impairment in AOD treatment, it truly is a no-brainer By Jo Lunn & Antoinette Sedwell

2. We would like to a Acknowledge the traditional owners of the land that we meet on – the Gadigal People of the Eora Nation. We pay our respects to Elders past and present and extend that respect to other Aboriginal people present here today.

3. Acknowledgements Agency for Clinical innovation: Antoinette Sedwell Skye Russell Megan James Dr Jamie Berry – ANTS Talia Nardo – Macquarie University Dr Peter Kelly – Wollongong University Dr Anthony Shakeshaft – NDARC Dr Daniel Barker – Newcastle University

4. Agenda • Case study • Prevalence and consequences of CI • ACE Project update progress • Review skills and strategies that you can use now • Case study review • Just a quick comment about change management

5. Case Study

6. Gemma is 42 years old and has transferred to your OTP service after moving into the local area. Gemma has a long history of being on opioid substitution treatment; of late she has been drinking approximately two bottles of wine every evening and smoking between 6-12 cones of marijuana daily. She has a history of depression (medicated with Prozac) and although never formally diagnosed describes symptoms consistent with PTSD linked with two main traumas • a serious to a car accident which occurred 3yrs ago. • a physical assault occurring while serving a short prison sentence for high range DUI (her only incarceration) Gemma has literacy issues (left school at 14yrs old), however she can read and write at a basic level and has worked on and off as a waitress in cafes. Although, she doesn’t keep a job for more than four months, generally quitting after verbal altercations with her employers. Gemma reports she has no family she is in contact with or any close long term friendships. Gemma has had a number of partners in her life, the longest of which lasted 6 years, he overdosed three months ago. Gemma stated when asked at admission that she hasn’t experienced family and domestic violence, however you are starting to suspect that she may have given some of her comments last time you saw her.

7. There are a couple of issues that have been raised by staff that you now need to address • Gemma requires breathalysing on a daily basis due to her evening consumption of alcohol. At times her evening drinking is taking her over the limit of what is acceptable to receive her OST. • Gemma at times misses dosing for up to two days in a row. Staff believe it is due to having to be breathalysed and she is considered at risk if she is not stable on her OST. • Gemma has been late to most appointments with her Prescriber and case worker and does not yet have a documented care plan in place. • When Gemma is challenged about any behaviour by staff she becomes defensive and engages in long justifications for her behaviour which quickly get off track and don’t relate to the issue at hand.

8. Case Study Questions Underline the potential risk factors Gemma has for CI in the above case study? If Gemma does have CI, what factors may be contributing to the problems that you need to speak to her about? Identify 3 strategies you could talk with Gemma about which may help manage the issues you need to raise that came up in the staff meeting?

9. Slido Code – dana19 • When you think of the term Cognitive Impairment-what comes to mind? • How does cognitive impairment impact your clients?

10. What is Cognitive Impairment? • Reduced capacity to process information in comparison to population norms or a person’s baseline (e.g. pre injury). Can involve reduced: • memory, • attention/concentration, • visuo-spatial skills, • language skills, and/or • executive functioning • The term CI covers a broad range of disorders

11. Slido questions • What are the rates of mild cognitive impairment in an AOD compared to a general population? • What are the rates of moderate cognitive impairment in an AOD compared to a general population? • What are the rates of severe cognitive impairment in the AOD compared to a general population?

12. Cognitive Impairment Prevalence in AOD populations • Estimated between 30% and 80% of clients accessing AOD treatment have CI (Copersino, et al., 2009) • Utilising the MoCA • 43.8%of clients attending WHOS services scored in the CI range Marceau et al (2016). Using a Brief Screening Tool to assess Cognitive Impairment in residents of an Alcohol and other drug Therapeutic Community. Journal of Substance Abuse Treatment • 53% of clients receiving OST at Langton scored within the CI range

13. Why use the Brief A? Hagen et al (2016) Assessment of executive Function in patients with substance use disorder: A comparison of inventory and performance based assessment. Journal of Substance abuse treatment • Polysubstance SUD (n = 126) • Healthy controls (n = 32) • Measures • Iowa Gambling Task • Stroop • Trail Making Test • Behavior Rating Inventory of Executive Function (BRIEF-A) • Social adjustment • The BRIEF-A most sensitive measure of executive functions • The BRIEF-A was more ecologically valid than the other measures as it related to: criminal lifestyle, conflict with caregiver, and stable housing

14. Brief A results Ace program trial (N=496) 39% of those scored within the moderate to severe range In total 53% of the AOD population scored within the impaired range

15. Brief A results Ace program trial (N=496)

16. In summary.. • People accessing AOD residential treatment 5xmore likely to have executive functioning impairmentsthan the general population • People accessing AOD residential treatment are 13xmore likely to have severeexecutive functioning impairments than the general population

17. So what.. What has Cognitive Impairment got to do with AOD treatment? • Length of stay has been linked to neurocognitive capacity (Fals-Stewart & Lucente, 1994; Fals-Stewart & Schafer, 1992, Fernández-Serrano, Pérez-García, Perales, & Verdejo-García, 2010). • Brorson et al (2013). Drop-out from addiction treatment: A systematic review of risk factors. Clinical Psychology Review • Cognitive Impairment • Younger Age • Personality Disorder (Brorson, AjoArnevik, Rand-Hendriksen, & Duckert, 2013).

18. Common causes of Cognitive Impairment • Acquired brain injury • Traumatic Brain injury • Stroke • Hypoxic brain injury • AOD use • Developmental • FAS • Learning disorders • ADHD • Autism Spectrum • Intellectual Disability

19. Common causes of Cognitive Impairment • Neurological disorder and dementia • MS, Huntington’s disease Parkinson's • Alzheimer's, Vascular dementia • Mental illness • Depression • Anxiety • PTSD • Psychosis/ schizophrenia

20. Just take a moment to think about a client that you work with that hasn’t • Got a mental health condition • Hasn’t had a traumatic head injury • Hasn’t overdosed • Did well in school

21. Parietal lobe Frontal lobe What is happening right now? What should I do next? Occipital lobe What has happened in the past? Temporal lobe 21

22. Parietal lobe Frontal lobe CVA / NEUROL DEVELO-MENTAL MENTAL HEALTH HYPOXIC BRAIN INJURY IN UTERO SUBSTANCE EXPOSURE Occipital lobe IMPULSE CONTROL HEAD INJURY Temporal lobe 22

23. ACE Program trial n=527

24. Key neurological areas associated with planning . FUTURE PRESENT PAST Limbic Neocortex Reptilian What should I do based on what is happening right now, on what happened in the past and what I want in the future? What should I do based on what is happening right now and on what happened in the past? What should I do based on what is happening right now?

25. . FUTURE PRESENT PAST ARRESTED VIOLENCE HOMELESSNESS RISK OF EVICTION What should I do based on what is happening right now? What should I do based on what is happening right now and on what happened in the past? What should I do based on what is happening right now, on what happened in the past and what I want in the future? 25

26. What are we supporting our clients to do in AOD treatment? change behaviour while being potentially physiologically compromised and most likely environmentally compromised

27. Impact of impairment in executive function • If clients have impaired cognitive function particularly executive functioning they have: • Reduced capacity to organise, plan, solve problems • Reduced capacity to make decisions quickly • Reduced capacity to moderate emotions How successfully could you change your lifestyle/behaviour with these additional difficulties? .