Post Traumatic Amnesia

1. Post Traumatic Amnesia Gemma Hardy Clinical Psychologist Neuropsychology Department, Addenbrooke’s Hospital gemma.hardy@addenbrookes.nhs.uk

2. Outline • Overview • Symptoms • Assessment • Rehabilitation • Management • Case study

3. PTA Confusional state of ‘clouded consciousness’ following TBI Present in 70% patients Transient stage between loss of consciousness and return to full consciousness Duration correlates well with GCS, length of hospital stay Predicts outcome Cognitive recovery Functional abilities Return to work

4. Amnesia Anterograde No ability to form day-to-day memories Retrograde Loss of memory for events prior to TBI Disorientation Time Place Person Impaired attention Behavioural change Agitation Disinhibition Emotional lability Childlike persona Wandering Fatigue Confabulation PTA

5. PTA • Impaired attention • Poor concentration • Highly distractible • Impaired awareness • Slowed reaction time • Fatigue and Fluctuation • NB. fight or flight in response to fear

6. PTA what is it like? A Case Study • Susan, 40 year old teacher • RTA with multiple brain contusions, 2 weeks ago • On J2 • In side room with bed facing window • She keeps asking why she is here • She is confused as she doesn’t know where she is • She doesn’t know why he should be there and thinks she needs to get home • She is frequently shouting and swearing and distressing patients and staff • How does she feel? • She is confused, doesn’t know where she is or why she is there • Over-fatigued, anxious, frustrated, frightened?

7. PTA Assessment Determine duration of PTA Standardised measures GOAT (Galveston Orientation and Amnesia Test) 10 items Orientation (person, time, place) Recall for events (anterograde and retrograde) Score 0 – 100 Consecutive scores > 75 = end of PTA

8. PTA Assessment However Qualitative features absent on testing Can’t account for fluctuation Difficult to distinguish from chronic memory impairment Informal assessment ‘Obvious change to awareness and orientation’ (Russell & Smith, 1961) Continuous day-to-day memory Sustained attention Orientation to season, surroundings, visitors OR plateau to cognitive improvement in cases of severe long-term impairment

9. PTA recovery • Gradual • Currently determined by PTA test performance • However • Many qualitative features absent on testing • Difficult to distinguish from chronic memory impairment • Sequence of cognitive recovery • Person • Recognition memory • Place • Time • Free recall / continuous memory

10. PTA Research • Research project within department • Service development • Developed CAM-PTA (Cristina Blanco-Duque from MRC-CBU and the team from MTC) • Evaluate use by correlating against current tools and MDT opinion

11. PTA Rehabilitation • Can be problematic given memory difficulties • Difficult to learn facts but can acquire procedural knowledge • Reality orientation programmes can be effective • Other therapies (OT/physio) still effective as often more reliant on procedural memory • Errorless learning approach • Modifications to sessions may be required

12. PTA Rehabilitation • Psychological approaches to managing challenging behaviours • Verbal / non-verbal de-escalation • Goal Setting • Assessment (e.g. ABC analysis) • Tailored Intervention (Environmental modification, Behavioural Reward program

13. PTA Management • Keep in mind they have memory and attention difficulties! • Give information in short sentences and repeat • Always tell patient what you are doing and why you are doing it • Avoid over-fatigue (allow for breaks, keep visitors to minimum) • Think of environment (over or under stimulated?)

14. PTA Management • Be prepared for challenging behaviours • Discuss specific behaviours in MDT meetings • Check behavioural guidelines in notes • Approach Clinical Psychologist for support • Try to be understanding and empathic • People in PTA have little control over their behaviour and emotions • Remember it is not personal

15. PTA Management • Minimise frustrations and aggravations • Provide reassurance wherever possible, as many times as possible • Don’t ask patient to do more than one thing at a time • Keep noise / other stimulation to a minimum (where possible) • Validation approach – empathise and distract

16. PTA Back to case • Susan (TBI 2 weeks ago, 40 year old teacher) • She is frequently shouting and swearing and distressing patients and staff • She is confused, doesn’t know where she is or why she is there, over-fatigued, anxious, frightened, frustrated ? • GOAT assessment indicates ongoing PTA • Behavioural assessment: • ABC observations show Susan settles when nurse enters room and is reassured but resumes shouting and screaming when left

17. PTA Back to case • Hypothesis • Forgets she has been reassured • Continues to feel confused and frightened • Needs reassurance which only lasts as long as some one is with her, and which is provided upon shouting and swearing • Goal: reduce distress (frequency of shouting and swearing) • Intervention: • Move to small bay where she can see nurses station • Staff greet her whenever they pass • Orientation board alerting her to time and place • Other patients asked to remind her of the board periodically

18. Thank you very much! If you would like a copy of slides please email Fiona.aschmann@addenbrookes.nhs.uk

19. Key References • Ahmed, S., Bierley, R., Sheikh, J.I., & Date, E.S. (2000). Post-traumatic amnesia after closed head injury: a review of the literature and some suggestions for further research. Brain Injury, 14, 9, 765-780. • Langhorn, L., Sorensen, J.C., & Pedersen, P.U. (2010). A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care. Journal of Clinical Nursing, 19, 2959-2969. • Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed head injuries. Archives of Neurology, 5, 4-17. • Thomas, H., Feyz, M., LeBlanc, J., Brosseau, J., Champoux, M.C., Christopher, A., et al. (2003). North star project: reality orientation in an acute care setting for patients with traumatic brain injuries. The Journal of Head Trauma Rehabilitation, 18, 292-302. • Wilson, B.A., Herbert, C.M., & Shiel, A. (2003). Behavioural approaches in neuropsychological rehabilitation. Hove: Psychology Press.