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Ben, the self-destructive character portrayed by Nicolas Cage in the 1995 film Leaving Las Vegas, had a condition known as Korsakoff's syndrome, named after the Russian doctor who discovered it. For John O'Brien, the author of the original novel, this story was biographical. He, like the Cage character, had intended to drink himself to death (as Ben said, "drinking is not a way of killing myself, killing myself is a way of drinking") but in 1994, aged 33, he committed suicide by shooting himself.

For a resource centre providing day care services and respite support for 126 older people, the staff were used to coping with people with varying degrees of dementia. But the case presented by 62-year-old Sandy Benson, who had Korsakoff's syndrome, an alcohol-related dementia, proved a unique challenge. Single and living with his sister, Benson's lifestyle and behaviour was putting their relationship under intense strain. If this accommodation broke down it could trigger a self-destructive end.

Unit manager Marion Bell and her staff had to consider carefully how to manage the situation. "While we were managing his risks, we were concerned about the risks to other service users," she says. "His alcohol abuse could have violent effects and, because of Korsakoff's, his interaction with others might not always be appropriate. But we didn't want to discriminate against him. We wanted to be aware of his condition but didn't want to label him."

Richard Carter, then a social care worker, was the allocated key worker. "There was a feeling that this was his last chance. It was about building a relationship, being someone he could trust and making him feel part of that process," he says. "He was having a tough time, but he was eager to try. And that was a big step forward."

Benson, agreeing to stay dry during his visits, attended for trial periods, with each day being reviewed, until he was offered a more permanent place. "We then looked at respite care," says Bell. "Having him here 24 hours a day presented a new challenge to us. The advice from Benson's GP was that he shouldn't drink alcohol at all as there was a real danger to his physical health."

But Benson could not function without some alcohol. "We met him - he was central to all this - and his social worker and GP, and it was agreed that he could bring in two cans of beer," says Carter. "It was recognised that there will never be a time when he doesn't drink alcohol," adds Bell.

In trying to manage his alcohol dependency, things have fluctuated. Benson has smuggled in spirits at times. But at least he admitted it. And staff recognise that at particular times of stress, his beer consumption goes up. So the centre permits occasional controlled increases. But, as Bell observes, "where in the continuum does it become out of control?".

Clearly the policy of involving him in decision-making has borne fruit. "He is running the woodwork group now," says Carter, smiling. "Our woodwork instructor left and he has virtually taken over. He tells me when the orders are wrong and things like that. He has come a long way." Bell agrees: "It was important that he had some meaningful activity. He loves it; it's like his work. It has given him a purpose in his life."

She adds: "The biggest thing for Benson has been that nobody has done anything behind his back. We won't contact his GP or do anything without talking to him first. For his self-worth and control this has been vitally important."

"He has a lot of friends here and is well respected," says Carter. "He does a lot of work with new members coming in."

Staff also understood that they had to see things outside of the resource centre. "He worries a lot about his drinking at home and how this makes his sister feel let down," says Bell. "We facilitate regular meetings between the two."

Carter's relationship with Benson has been crucial to the success of their work, says Bell. And, although he has since been promoted, he still works closely with Benson. "I see him two, three times a week. I think that continuity is very important."

Carter summarises the success of this work: "Being part of the decision-making process from the beginning and making sure he has the support has helped him incredibly. He does feel he is control of his life."

The names of family members mentioned in this article have been changed.

Case notes

Practitioner: Marion Bell, unit manager and Richard Carter, senior social care worker

Field: Older people

Location: Fife, Scotland

Client: Sandy Benson, 62 and single, had a long history of alcohol abuse. He had been diagnosed with Korsakoff’s syndrome - an alcohol-related form of dementia.

Case history: Benson, seriously ill, at risk on his own and unable to sustain his own tenancy, had moved in with his sister, Elizabeth Patten, who provided his main support. Patten lives with her adult son but he has a poor relationship with Benson (his uncle) and as such Benson cannot be left in his care. This has meant that although Benson’s alcohol dependency is the main focus to his life, he is strongly dependent on his sister also. Both Benson and Patten believe that day care and respite support were necessary to sustain their relationship. However, an arranged respite break had been unsuccessful and both feared the worst.

Dilemma: If Benson was to remain in the community it was clear that both he and his sister would need support. However, his behaviour presented risks to those who share group care.

Risk factor: If his home situation broke down, Benson’s ability to manage his alcohol dependency and his health would be seriously jeopardised.

Outcome: Benson’s needs have been successfully managed: he is blossoming in his role within the day and respite service, and continues to live with his sister.

Independent comment

Alcohol-related brain damage (ARBD) is a spectrum of disorders that includes Korsakoff’s syndrome. Unlike many types of dementia, there is potential for prevention and some hope of improvement especially for those who stop drinking. Much more research is needed on the effectiveness of treatment and rehabilitation regimes.

The case study illustrates in a graphic way some of the challenges and dilemmas in providing care and support for people with this condition.

It is unclear from the case study whether there is a multidisciplinary assessment and treatment plan. Reassessment should be carried out every three to six months for at least two years because improvement may be gradual.

Many elements of intensive care management for people with dementia are evident: a person-centred approach, recognition of individual worth and autonomy, involvement in meaningful activity, to name a few.

The centre is to be commended for having an alcohol policy - this is rarely available in care settings. The big question is about the future. Is it realistic that the centre can go on supporting Benson for the next 10 years or longer? A man of 62 may be more appropriately supported in a service that is geared to younger people with dementia. Such services are thin on the ground but the lessons learned from this case could provide an excellent basis for innovative developments locally.

Sylvia Cox is planning consultant at the Dementia Services Development Centre, University of Stirling.

Arguments for risk

• Without support the relationship between Benson and his sister would break down.
• As she was all he had, this would leave him isolated and vulnerable. His alcohol use would inevitably increase, the Korsakoff’s syndrome would escalate and death was a real possibility.
• The centre had clear procedure for managing the risks posed by Benson. As Bell says: "For us, it’s about being clear about evidence. We also needed to bring in as many other agencies and people involved as possible to make an informed decision about how we manage the risks."
• There were indications that Benson was motivated to manage his dependency. For example, although he smuggled in alcohol he did face the situation and admit it.
• By ensuring that the resource centre was able to provide Benson with respect and meaningful activities it would provide time and space for him to build his self-worth, independence and relationships.

Arguments against risk

• Benson was referred to the centre after a failed placement. Even Carter admitted that he had an "extremely bad experience. It was a terrible time". All other attempts to deal with his chronic alcoholism had similarly failed.
• It would further jeopardise his mental and physical health if he was again offered a service, which was then withdrawn. Undoubtedly, his low self-esteem would adversely affect his future.
• While managing the risks around Benson’s behaviour, it was possible that the risks presented to the other service users would be less well managed. Other users at the centre were physically and mentally very frail and might find Benson’s potentially erratic behaviour difficult and damaging.
• During his day care or respite support there was a danger that Benson might not be able to manage his alcohol use. How might potential incidents caused by alcohol overuse or the effects of Korsakoff’s syndrome be managed effectively?