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

3. 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 one’s attention • (3) pacing • (4) repetitive purposelessness activity • (5) self-destructive actions. • Engaging in these agitated behaviors is a coping mechanism.

6. 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 survivor’s 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 don’t 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.

10. 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 person’s 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.

12. 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 don’t 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

19. 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.

22. 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.

23. 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

24. 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

26. 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 one’s 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, one’s world, or one’s future or feeling hopeless about the future • Feeling of guilt or worthlessness

29. 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 can’t do anything to change the situation or feeling helpless • Increase in use of alcohol or illicit substances

30. Depression: • * Difficulty concentrating, remembering, making decisions, can’t 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

31. Depression: • * Feeling like you have no more energy or “slowed down” • * Can’t seen to sit still, or just don’t 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 don’t shut him or her out • Celebrate your loved one’s progress, no matter how small • Point out your loved one’s strengths and let him or her know what it is you value about them

33. 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

35. 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

36. 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.

37. 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 people’s reactions before speaking or acting out.

40. 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 feedbackto 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.

44. 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.

46. 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

47. 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 • Don’t 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.

49. 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.