At the 2018 Insurance Rehab Synergy Group Annual Conference, Martin Waalkes, PhD, Director of Neuro Rehabilitation for Hope Network Neuro Rehabilitation discussed the challenges of behavior regulation and engagement in acquired brain injury rehabilitation.
One of the biggest challenges with brain injury patients can be with their behavior. Patients can have self-centered behavior and not understand the needs and perceptions of others. They also can have problems with self-control which can lead to issues with aggressiveness, outbursts, and anxiety. Up to 75% of brain injury patients can have issues with irritability. These issues with irritability and agitation can impact the patient’s participation in the rehabilitation process.
Other challenges for brain injury patients are behaviors of omission. This includes apathy, unawareness, avoidance and social disengagement.
Behaviors of dysregulation are another side effect of brain injury. This can include borderline personality disorders and frontal lobe syndrome.
Treating brain injury patients can be challenging and frustrating for the clinical staff because of the tendency toward inappropriate behaviors. As the patient becomes fatigued their behavior can deteriorate so caregivers later in the day can have a completely different experience with the patient than caregivers earlier in the day.
Impaired cognition brings impaired behavior. Coma emergent agitation is very common and typically lasts less than 10 days. If you cannot improve the patient’s cognition, it is very difficult to improve their behavior.
Early ABI treatment to reduce agitation and improve behavior:
- Reduce noise.
- Manage environmental extremes (light, temp).
- Limit visitors, visitor time, and visitor stimulation level.
- Support familiarity and simple routine.
- Provide safety and restraint whenever possible.
- Establish a normal cycle of day and night.
- Environmental mobility restores orientation.
- Support alternate communications avenues.
- Support cognition over control.
It is important to have consistent staff dealing with the patient. This helps bring familiarly and gives the patient confidence. You should also follow the impaired person’s lead as much as possible. Use redirection and avoid confrontation.
Cognitive strategies for post-emergent treatment:
- Timers and schedules.
- Consistent and predictable daily routines.
- Planners and memory aides.
- Coaching-style cueing.
- Establish self-moderating feedback systems for task completion and error awareness.
Mood and Interpersonal Strategies:
- Establish a consistent sleep, wake, nutrition and activity cycle.
- Medication interventions.
- Have a clear PRN strategy.
- Provide diversion and don’t reinforce the cycle of negative patterns.
- Provide appropriate outlets for normal emotions.
- Learn to say “no” without confrontation.
- Provide feedback with acceptable and useful techniques.
- Educate patients, families and staff on negative predictable behaviors.
In terms of medications, the goal is for the patient to be as healthy as possible while using as little medication as possible. Every patient will respond differently so this will involve some trial and error to find the right balance.