Tips on managing challenging situations after brain injury

1
Tips on managing challenging situations after
brain injury

• For Survivors, Caregivers, and Clinicians What
  can you do to help?

2
Goals

• Neurobehavioral Difficulties Confusion,
  Agitation, Impatience, Impulsivity, ? Initiation,
  Perseveration, ? Awareness
• Emotional Difficulties Depression, Emotional
  Lability, Anger
• Everyday Concerns Changes in Sexual Interest,
  Fatigue, Boredom

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Confusion

• Examples
• confuses times / tasks in schedule of activities
• confuses past and present events
• confabulates (makes up convincing stories to fill
  memory gaps this in not intentional lying or
  delusions)

4
Confusion

• Management Techniques
• encourage the use of a notebook to log events and
  encourage the person to refer to it for details
  of daily events
• gently remind the person of correct details of
  past and present events
• confirm accurate information with other people
• arrange for consistency in routine tasks (use
  calendar and notebook)
• limit changes in daily routine
• provide detailed explanations of even the most
  basic changes in daily routines

5
Agitation

• Definition includes various observable behaviors
  including
• (1) constant movement
• (2) inability to focus ones attention
• (3) pacing
• (4) repetitive purposelessness activity
• (5) self-destructive actions.
• Engaging in these agitated behaviors is a coping
  mechanism.

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Agitation

• Example
• Becoming agitated when a family member or friend
  does not visit when expected.
• Nothing at home seems to please the loved one
  he or she complains about everything
• The survivor finds it difficult to allow others
  to watch TV because the noise is annoying to him
  or her
• The survivor becomes very anxious and agitated
  when he or she has to go to therapies

7
Agitation

• Management Techniques for prevention of
  agitation
• keep volume of the television or stereo low
• limit visitors to one or two at a time
• avoid noisy areas
• give simple directions
• if there are certain persons the survivor finds
  irritating, try to limit time that is spent with
  them as much as possible
• keep surprises and changes to a minimum
• add structure to the day, knowing how the day
  will go may help
• do not take the irritability personally

8
Agitation

• Management Techniques to calm when agitated
• minimize noise and even accompany the survivor to
  a quite area
• direct the survivors attention away from the
  source of agitation
• let him or her keep moving or talking
• do not scold or confront him or her, this will
  only increase the level of agitation
• model calm behavior, speaking in a quiet and even
  tone
• develop methods for compromising, you dont have
  to give in entirely, but it may be necessary to
  make allowances

9
Irritability/Impatience

• Definition
• a mild form of agitation
• general bad mood or grouchiness
• may be more easily annoyed by small matters
• Example Becoming annoyed by children playing,
  television blasting, etc.

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Irritability/Impatience

• Management Techniques
• Negotiate in a calm manner
• Involve everyone in decision making and activity
  planning
• Try not to challenge or confront about the
  persons apparent bad mood
• Take breaks as needed
• Try to be aware of triggers in order to prevent
  situations

11
Impulsivity

• Definition the lack of behavioral control over
  either action, verbalizations, or both.
• Examples Rushing or acting in a quick manner
  that can lead to difficulty with a simple task
• which can lead to increased frustration.

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Impulsivity

• Management Techniques
• Use a reward system for small periods of
  self-control
• Redirect attention to more appropriate behaviors.
  Suggest alternatives for more desired behaviors
• Encourage them one to slow down and think through
  tasks or responses
• Anticipate when likely to have difficulty and
  give reminders before they engage in certain
  behaviors that have been identified as impulsive

13
Lack of Initiation / Motivation

• Definition difficulty coming up with and
  planning activities.
• Projects, however small, can seem overwhelming so
  it is less threatening and anxiety provoking to
  not attempt to do it.
• Examples
• Spending the entire day watching TV
• Saying one will get to chores but never gets
  around to doing them

14
Lack of Initiation / Motivation

• Management Techniques
• Break activities into smaller steps to avoid
  becoming overwhelmed.
• Significant others can help make decisions
• Make a to-do list
• Help them develop a structured daily routine

15
Lack of Initiation / Motivation

• Management Techniques
• If the survivor asks for help on a task that he
  or she used to be able to complete independently
  before the injury, never assume that they dont
  need help. In fact, assume that he or she does
  need help until he or she can complete the task
  on his or her own
• Set a realistic time frame in which to complete
  the task, allowing them extra time than they may
  have needed before the injury

16
Lack of Initiation / Motivation

• Management Techniques
• Provide specific choices for tasks, such as,
  Would you like to do A or B?
• Provide them with praise when he or she gets
  started on a task without assistance and/or
  completes a task on his or her own
• Problem-solve and get them involved Establish
  goals

17
Perseveration

• Definition
• Talking about something over and over or
  obsessing on an action or idea over and over.
• Secondary to short-term memory problems ?
  problem-solving.
• The person may not remember that he just told you
  about a certain issue 30 minutes ago, and/or he
  is having difficulty coming up with a solution to
  the issue and therefore feels a need to continue
  to discuss it.

18
Perseveration

• Examples
• They talk daily about getting back to driving
• They continue to repeat the story of his or her
  injury even to those persons who have heard the
  story before
• They constantly complain about his / her dislike
  of someone else

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Perseveration

• Management Techniques
• Set up a time each day for him or her to talk
  about favorite topics. Be sure to stick to the
  time frame, however, and hold off anymore talk
  about the subject until the next day at that
  time.
• Try to divert the conversation to another topic

20
Perseveration

• Management Techniques
• Write down the answer to a recurrent topic to
  help remind the individual that the issue has
  been resolved or when and how the issue will be
  resolved
• Talking can sometimes be helpful for your loved
  one, but only to a point.
• You can refuse to discuss a certain topic any
  further, using nonverbal cues such as time outs
  or excusing yourself. Choose something
  respectful however.

21
Decreased Awareness

• Definition
• A neurological part of the brain injury and
  should not be confused with a psychological or
  intentional denial.
• Individuals may be completely be unaware of or
  minimize their deficits.
• It is more common to have decreased awareness of
  cognitive and behavioral problems than physical
  problems.

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Decreased Awareness

• Definition
• When problem areas are pointed out to the
  individual, many times the individual is
  unconcerned or does not believe the concerns that
  others have.
• Implications of decreased awareness include
  difficulty regulating social behavior, increased
  safety risk, and decreased compliance with
  therapy as they see no need for rehabilitation or
  goals.

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Decreased Awareness

• Examples
• Making excuses when not able to adequately engage
  in tasks
• inaccurate self-image/self-perception
• Becoming frustrated after repeated attempts to
  engage in activities that he or she can no longer
  perform
• Appearing confused by the difficulty that he or
  she is having with previously simple tasks

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Decreased Awareness

• Management Techniques
• Provide them with consistent and supportive
  feedback, re-orientation is often needed due to
  memory impairments
• Give realistic feedback as you observe behavior
• Cue them to use of accurate self-statements
• Predict-Perform exercises
• Clickers

25
Decreased Awareness

• Management Techniques
• Using an educational approach
• Have them track their behaviors or log
  activities self-monitoring
• Goal-setting approaches

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Depression

• Depression (often a sad and scary topic)
• Most common emotional difficulty following TBI
• More common in persons with TBI than in persons
  with other disabilities or without a disability
• Major depression is the psychiatric difficulty
  most commonly associated with suicide

27
Depression

• If not addressed, depression can affect ones
  overall rehabilitation (returning to work,
  functioning in the home, thinking, sleep, energy,
  etc)

28
Depression

• Continual feelings of sadness, blue, or empty
  mood (sometimes mood may be more irritable)
• Loss of interest or pleasure in hobbies and
  activities that were once enjoyed, including sex
• Negative thoughts about oneself, ones world, or
  ones future or feeling hopeless about the future
• Feeling of guilt or worthlessness

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Depression

• Becoming more quiet and/or withdrawing from
  family and friends
• Keep thinking about death or feeling that I would
  have been better off had I not lived thoughts of
  how I could harm myself
• Feeling like you cant do anything to change the
  situation or feeling helpless
• Increase in use of alcohol or illicit substances

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Depression

• Difficulty concentrating, remembering, making
  decisions, cant focus on things well
• Have difficulty falling asleep, staying asleep,
  or sleeping too much
• Do not really feel like eating much or eating
  more than usual

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Depression

• Feeling like you have no more energy or slowed
  down
• Cant seen to sit still, or just dont get up
  and move around as I should
• All of these symptoms can also occur with brain
  injury

32
Depression

• Management Techniques for families
• Try to help loved one to get out and socialize
  with others
• Listen and dont shut him or her out
• Celebrate your loved ones progress, no matter
  how small
• Point out your loved ones strengths and let him
  or her know what it is you value about them

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Depression

• Management Techniques
• Encourage them to inform a inform a loved one.
• Encourage them to consult a professional such as
  a doctor.
• Encourage them to seek out psychological
  treatment.
• Educate them on the benefits of medications which
  may be significantly helpful relieving your
  symptoms.

34
Depression

• Management Techniques for general providers
• Build rapport
• Validate their experiences
• Provide psychoeducation
• Teach relaxation techniques

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Depression

• Management Techniques for general providers
• Cognitive Behavioral Techniques
• Identifying situations that relate to depression
• Identify their consequences
• Identify their Beliefs
• Challenge their beliefs
• Help them develop more appropriate and reassuring
  perceptions
• Help them develop problem-solving techniques

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Emotional Lability

• Definition Loss of control over emotions.
  Often shown by quick and frequent mood swings.
• Examples
• Mention of a family member brings a bout of
  crying.
• Mention of anything with sentimental value can
  bring tears.

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Emotional Lability

• Management Techniques
• Try not to be critical of this increased
  sensitivity
• Address the behavior rather than the feelings
• Remove unnecessary stressful factors
• Model calm behavior
• Try to remind them that this can be a normal
  experience after and injury and there is nothing
  wrong with them.

38
Anger

• Definition An emotional ranging from mild
  irritation to intense fury and rage.
• Examples
• Going off on loved ones around you
• feeling on-edge and easily provokable.

39
Anger

• Management Techniques
• Help each other to know that you have the power
  to control your anger, despite the injury
• Anger control skill that will get better with
  practice
• Discourage each other from saying the first thing
  that comes to mind
• Teach each other to think about other peoples
  reactions before speaking or acting out.

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Anger

• Encourage each other to be positive and sensitive
  to others feelings.
• Explain yourself calmly and doing so will make it
  easier for others to understand and help you.
• Take time outs and try to catch those early
  warning signs (deep breathing, counting slowly).
• Ignoring problems can sometimes makes things
  worse. Be willing to give feedback to others.

41
Anger

• Develop new ways to release anger and manage
  stress including exercising, writing, talking to
  trusted loved ones.
• Identify and prevent troublesome situations.
  Make a plan to successfully deal with situations
  and practice ahead of time.
• Talk to your doctor or a counselor for help
• Give praise when your loved one controls his or
  her anger and expresses feelings in positive
  ways.
• Be a good role model. Use good skills yourself.

42
Increased or decreased sexual interest

• Definition
• Feel as if they no longer look appealing or that
  anyone could respond to them sexually.
• Obsessed with thoughts about sex and may behave
  inappropriately (making passes at people of the
  opposite sex, talking about sexual activity, etc.)

43
Increased or decreased sexual interest

• Example of decreased sexual interest
• continuing to sleep in the extra bedroom even
  after health issues have been stabilized.

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Increased or decreased sexual interest

• Management Techniques for decreased sexual
  interest
• Do not take the disinterest personally
• Do not pressure or attempt to embarrass them into
  having sex before they are ready
• Disinterest may be masking other issues
• Non-intercourse affection and petting is OK
• Try to communicate to your loved one so they do
  not think it is about them.
• Seek professional help if medical condition

45
Increased or decreased sexual interest

• Examples of increased interest
• Making sexually inappropriate remarks to other
  females.
• Offering sexual innuendoes either to significant
  other or someone else while at a social
  gathering.

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Increased or decreased sexual interest

• Management Techniques for increased sexual
  interest
• Provide reminders that such behavior is
  unacceptable
• Do not feel obligated to respond to sexual
  demands every time
• Provide positive reinforcement for more accepting
  behaviors

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Fatigue

• Definition a feeling of weariness, tiredness,
  or lack of energy
• Example - feeling tired after putting away the
  dishes.
• Management Techniques for Survivors
• Use relaxation techniques
• Dont try to do too much at one time
• Pace yourself
• Seek professional help
• Consider a formal sleep evaluation

48
Fatigue

• Tips for Family Members (Same as for survivors
  and.)
• Split up the responsibilities others will
  usually be glad to help
• Try to take time for oneself.

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Boredom

• Examples
• The individual sits and watches TV all day
• They complain that there is just nothing to do

50
Boredom

• Management Techniques
• Make a to-do list of activities and be
  responsible for carrying-out those activities.
• Take others up on their offers to accompany them
  to places.
• Practice therapies at home.

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Boredom

• Take up hobbies, if possible.
• Volunteer time.
• Get involved in community activities / events.

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Summary

• These changes in personality and behaviors can be
  the most distressing for family members to adjust
  to.
• It is often easy to become upset at your loved
  one for acting inappropriately or in ways that
  may be bothersome.
• Remember that all of these difficulties can be
  direct effects of the brain injury and it is
  important to manage them with care.
• Always get the family involved in the process