Dealing with TBI

1. Dealing with TBI An Overview of Behavioral Symptoms and Interventions

2. Facts About Mild Traumatic Brain Injury (MTBI) • Approximately 80% of all brain injuries are mild • Males outnumber females 2:1 • 5.3 million people are estimated to have ongoing problems related to MTBI • Direct care costs are estimated at 5.3 billion annually, with indirect care estimated at 37.8 billion dollars annually

3. Diagnostic Criteria for MTBI • Traumatically induced physiological disruption of the brain (an injury occurs) • Any period of loss of consciousness not to exceed 30 minutes • Loss of memory for events immediately before of after the accident • Any alteration in mental state at the time of the accident

4. MTBI • Focal neurological deficits that may or may not be transient • Post-traumatic amnesia does not exceed 24 hours • Glasgow Coma Scale of 13-15 after 30 minutes • Eyes open spontaneously • Oriented to place/time (Verbal output) • Obeys Commands (Motor output)

5. Assessment Questions • Have you ever been told you have suffered a brain injury or concussion? • Have you ever hit your head hard enough that you saw stars or had a headache that lasted the rest of the day? • Have you ever been knocked unconscious? If so, for how long? • Did you seek medical treatment?

6. Assessment Questions • When you hit your head, did you feel nauseated or dizzy afterwards? • Did you have any speech or coordination problems? • Is there any part of the incident you cannot remember? • Did you have any visual problems?

7. Assessment Questions • Currently- • Do you have any memory problems? • Do you have problems keeping up with conversations or what people are saying? • Do you have problems concentrating or staying on task? • Are you sensitive to light? Does it cause you to have headaches? • Do you have problems pulling up words (are they on the tip of your tongue?)

8. Assessment Questions • Are you more irritable than before the incident? • Do people often say you act before you think? • Do you have problems multi-tasking? • Are you having any current balance or coordination issues? • Are you having any sensory problems (hearing, smell, taste, etc.) ? • Are there any changes you have noticed since the incident that I did not ask you about?

9. Frontal Lobe Injury • Higher cognitive functioning or “executive functioning” • Focusing attention • Generating and following through on decisions • Poor judgment • Self-awareness of deficits self-monitoring • Planning and carrying out activities (maintaining a job, grocery shopping, completing household duties, repairs, etc.)

10. Frontal Lobe TBI • Concrete thinking • Trouble staying on task • Possible disinhibition and immaturity • Possible decreased energy, motivation and spontaneity • Possible speech and motor problems

11. Temporal Lobe TBI • Storing NEW memories • Right: Visual memory • Left: Verbal memory • Behavioral problems • Irritability • Aggression • Modulating behavior • Word-finding and naming

12. Parietal Lobe TBI • Processing sensory information • Right: Visual-spatial information • Left: Comprehension of spoken/written words • Get lost in familiar surroundings • Confused by multi-step instructions

13. Occipital Lobe TBI • Processing of visual information • Visual deficits • Field cuts • Blindness • Inability to know objects

14. Cerebellum TBI • Coordination of movement • Walking and control of upper extremities for day-to-day tasks • Possible tremors associated with injury

15. In the majority of individuals symptoms of MTBI resolve in 6 months or less after injury In some cases, symptoms can persist longer (12 – 18 months) and even life-long The majority of people with moderate to severe TBI do not return to their full pre-injury status and will have ongoing cognitive and behavioral issues Course of Recovery of MTBI

16. Overview of Diffuse Symptoms of MTBI • Cognitive • Memory, Attention, Processing Speed & Intelligence • Psychological • Depression, Anxiety, Irritability, and Sleep & Personality change • Physical • Light/sound sensitivity, dizziness & fatigue

17. Dealing with Impaired Attention/Concentration • Work slowly • Break your work down into small, manageable increments • Double check your work • Prepare all materials for tasks prior to starting • Take regular breaks to minimize fatigue

18. Attention and Concentration Con’t. • When reading and studying, read small passages, take a break, and then read them again • Clear away any materials not needed for tasks/work • Maintain a quiet environment with minimal distractions when focus is needed

19. Learning and Memory Difficulties • Daily organizer/calendar to record appointments and important tasks • Multiple modalities to learn new material • Read it aloud (hearing) • Picture it (visual) • Set realistic goals • It will take longer to learn new things • Break material down into smaller portions • Allow breaks between studying to allow material to consolidate into memory • Be patient with yourself!

20. Dealing with Executive Control Dysfunction • Work on one task at a time • Work slowly and carefully • Check your work for errors • Use a pocket organizer, smart phone or palm pilot • Make a “to do” list and post it in a designated place • Be willing to allow family members/friends provide reminders without being upset

21. How to detect brain injury • There are often no outward physical signs of Injury – Invisible Wounds • We need to focus on observable behavioral Indicators of TBI

22. Dealing with TBI • Signs to look for: • Distractibility • Difficulties focusing on what is being said • Answering slowly or answering questions that are not asked (poor comprehension issues or low comprehension) • Long pauses in speech (word retrieval issues)

23. What to Look For • Client’s with TBI are often very anxious, look for: • Restlessness • Face flushed • Sweatiness • Shakiness • Increased breathing rates

24. What to Look For cont. • Talking very loud/yelling • Self-awareness and self-monitoring • Staring • Inattentiveness • Shakiness • Can be neurologically based • Difficulty following orders • Delayed processing or comprehension problems

25. What to Look For cont. • Have significant short-term memory issues • They seem to understand instructions, then minutes later cannot remember what you told them • May become agitated/irritable very quickly and appear disinhibited due to frontal lobe injury • May have significant coordination issues and involuntary movements that are neurologically based • Fail field test, NOT due to substance use/intoxication • May have visual field cuts

26. What to Look For cont. • Flat affect and seem apathetic • Poor initiation of conversations • Provide short & concrete answers to complex questions • Suspect’s body language and poor verbal output (yes/no responses) suggests disinterest in what you are saying (flat affect) • Remember this is neurologically based

27. Interventions • Tell individual one thing at a time; no multistep directions • Be willing to repeat instructions slowly and clearly • Memory, Processing speed, and Comprehension • Keep questions as simple as possible • Make sure you have eye-contact with individual • Attention

28. Interventions • Have them reflect what you have told them • “Can you tell me what I ask you to do?” • Loud speech does not always imply anger or opposition • More likely confused or anxious; Inability to self-monitor

29. Interventions cont. • Individuals with TBI often get overwhelmed with environments that are over-stimulating (too much noise, lights, movement around them), so: • When trying to talk to them or directing them, try to get them in quieter areas away from crowds, noise, lights, etc.

30. Interventions Write down any follow-up and encourage them to put in PDAs -Memory vs. non-compliance For anxious or agitated individuals, encourage breathing and grounding skills -Stress ball -Sensory loaded modalities Allow a time-out if necessary

31. Therapy Interventions- TBI • Structure/routine • Pill reminder • Marker board • Symptom journal • Disorganization • Questions they want answered • Take notes in session • Involve family • Educational aspects • ADD-like aspects • They often won’t admit deficits

32. TBI and PTSD: Overlapping and Differentiating symptoms • TBI: • Concentration • Memory • Commonly STM • Irritability • Fatigue • Constant detours • Headaches • Light sensitivity • Apathy • Flat affect • Sexual inhibition or impulsivity • PTSD • Concentration • Memory • Dissociative or amnestic • Irritability • triggers • Headaches • SNS arousal • Apathy • Secondary depression • Sexual aggression, heightened interest, or inhibition

33. TBI and PTSD: Overlapping and Differentiating Symptoms TBI: • Sleep problems • REM cycle disruption • Problems processing • Slowed • Word retrieval • Problems shifting focus • Emotional lability • Without external triggers • Overly emotional to small events • Personality changes • Flat • Lack of initiation • Loss of self-awareness/self-monitoring • Lack of spontaneity PTSD: • Problems sleeping • Nightmares • Hyperarousal • hypervigilance • Problems processing • Scattered • Preoccupied • Emotional Lability • Anxious, irritable, numbing, laughing • Personality Changes • Self-esteem • Sense of damage • Everything pre-planned • Severe numbing

34. REFRENCES Brain Injury Association of Indiana PO Box 24167 Indianapolis, Indiana 46224 P: (317) 356-7722 F: (317) 481-1825biausa.org/Indiana Brain Injury Association of America Inc. 1608 Spring Hill Rd Suite 110 Vienna, VA 22182 Biausa.org

35. Reference Family Caregiver Alliance/National Center of Caregiving 180 Montgomery Street Suite 1100 San Francisco, CA 94104 Caregiver.org Defense and Veterans Brain Injury Center Dvbic.org