Working with people impaired by alcohol related brain impairment (ARBI) presents case managers with many issues and problems unique to this population, and may require the development of new skills. The guidelines for case managers aim to increase the case managers' awareness of these issues and describe the principles of arbias' outreach case management services.

It is now recognised that social drinkers may incur partially reversible structural and functional neurological changes that might not be readily apparent.

Permanent, irreversible brain impairment is incurred by a small but significant proportion of alcohol abusers. These are usually drinking more, and also have episodes of nutritional deficiency.

The more alcohol is used, the more likely such impairment is to occur. There can be some spontaneous improvement if a person remains abstinent and maintains a balanced diet and a healthy lifestyle. It is advisable to take a multivitamin supplement containing a high level of thiamine together with vitamin C.

Whether this improvement indicates a reversal of neurological changes, or an increasing ability to cope with living with a disability, or a combination of both, is yet to be established. Recovery would seem to be age-dependent, with younger persons (those under 40 years) having better chance of restitution of function.

Knowledge and Understanding of ARBI

People with ARBI often do not present to hospitals or other health services. Information about the incidence of ARBI is not readily available. As a result, ARBI is a syndrome about which community awareness is limited, and a syndrome that is not well understood by health professionals.

The Stigma Associated with Alcohol Consumption

The stigma associated with excessive alcohol or drug consumption can act to prevent people and carers advocating for services. This may be one significant reason for ARBI remaining an invisible disability.

Diagnosis of ARBI

In most cases, diagnosis of ARBI requires comprehensive neuropsychological and neurological assessment. Currently, assessment and diagnostic facilities with the necessary expertise are limited in their availability. Furthermore, no standardised screening instrument is available that can be easily administered by health care practitioners, and that is reliable and valid.

Over-reliance on screening tools such as minimental status examination (MMSE) means that ARBI may not be identified in the early stages. The MMSE taps many skills that are preserved in people with ARBI, and does not provide meaningful data about memory or frontal lobe functions. The MMSE will usually only detect severe ARBI.

An Invisible Problem

ARBI is referred to as the invisible disability because it frequently goes unrecognised by the person, their families and health professionals. This is particularly so for mild and moderate levels of impairment. People affected by ARBI usually function well in a familiar environment or structured setting where no demands are placed on their short-term memory or problem solving skills.

Well-established knowledge and skills (acquired before impairment to the brain) are usually intact, as are language and verbal functions. People often present very superficially, masking even significant cognitive impairment. These people pose a particular challenge to health professionals for identification and management of ARBI.

A Multi-Disciplinary Approach

People with ARBI may have co-existing psychiatric disorders, intellectual disability or acquired brain impairment of other origin (for example, traumatic brain injury, tumor, stroke, or infection). The ARBI population have a high incidence of traumatic brain injury. People with ARBI may also have significant social problems, family and relationship difficulties, health complications, legal problems, and many other issues. People with ARBI may be in contact with a number of different health professionals - health professionals that may not have an adequate understanding of ARBI.

Management of ARBI requires a multi-disciplinary approach, and the case manager is central to coordinating a range of services and providing education and information about the disability to a variety of health care practitioners.

Special Skills Needed

As an ARBI case manager:

• You will often be called upon to provide information about ARBI and about the nature of a person's impairment
• You need to avoid judging people and you need to be prepared for obstacles caused by lack of understanding and stigma