Tips on managing challenging situations after brain injury For Survivors, Caregivers, and Clinicians: What can you do to help?

Tips on managing challenging Tips on managing challenging situationssituations

after brain injury after brain injury

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

Goals:Goals:

Neurobehavioral Difficulties: Neurobehavioral Difficulties: Confusion, Confusion, Agitation, Impatience, Impulsivity, Agitation, Impatience, Impulsivity, ↓ ↓ Initiation, Perseveration, ↓ AwarenessInitiation, Perseveration, ↓ Awareness

Emotional Difficulties: Emotional Difficulties: Depression,Depression, Emotional Lability, AngerEmotional Lability, Anger

Everyday Concerns: Everyday Concerns: Changes in Sexual Changes in Sexual Interest, Fatigue, Boredom Interest, Fatigue, Boredom

Confusion:Confusion:

ExamplesExamples confuses times / tasks in schedule of confuses times / tasks in schedule of

activitiesactivities

confuses past and present eventsconfuses past and present events

confabulates (makes up convincing stories confabulates (makes up convincing stories to fill memory gaps; this in not intentional to fill memory gaps; this in not intentional lying or delusions)lying or delusions)

Confusion:Confusion:

Management TechniquesManagement Techniquesencourage the use of a notebook to log events and encourage the use of a notebook to log events and encourage the person to refer to it for details of daily encourage the person to refer to it for details of daily eventseventsgently remind the person of correct details of past and gently remind the person of correct details of past and present eventspresent eventsconfirm accurate information with other peopleconfirm accurate information with other peoplearrange for consistency in routine tasks (use calendar arrange for consistency in routine tasks (use calendar and notebook)and notebook)limit changes in daily routinelimit changes in daily routineprovide detailed explanations of even the most basic provide detailed explanations of even the most basic changes in daily routineschanges in daily routines

Agitation:Agitation:

DefinitionDefinition:: includes various observable includes various observable behaviors includingbehaviors including (1) constant movement(1) constant movement (2) inability to focus one’s attention(2) inability to focus one’s attention (3) pacing(3) pacing (4) repetitive purposelessness activity(4) repetitive purposelessness activity (5) self-destructive actions. (5) self-destructive actions. Engaging in these agitated behaviors is a Engaging in these agitated behaviors is a

coping mechanism.coping mechanism.


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


Management Techniques for Management Techniques for prevention prevention of agitation:of agitation:keep volume of the television or stereo lowkeep volume of the television or stereo lowlimit visitors to one or two at a timelimit visitors to one or two at a timeavoid noisy areasavoid noisy areasgive simple directionsgive simple directionsif there are certain persons the survivor finds irritating, try if there are certain persons the survivor finds irritating, try to limit time that is spent with them as much as possibleto limit time that is spent with them as much as possiblekeep surprises and changes to a minimumkeep surprises and changes to a minimumadd structure to the day, knowing how the day will go add structure to the day, knowing how the day will go may helpmay helpdo not take the irritability personally do not take the irritability personally


Management Techniques to Management Techniques to calm calm when agitated:when agitated:minimize noise and even accompany the survivor to a minimize noise and even accompany the survivor to a quite areaquite areadirect the survivor’s attention away from the source of direct the survivor’s attention away from the source of agitationagitationlet him or her keep moving or talkinglet him or her keep moving or talkingdo not scold or confront him or her, this will only increase do not scold or confront him or her, this will only increase the level of agitationthe level of agitationmodel calm behavior, speaking in a quiet and even tonemodel calm behavior, speaking in a quiet and even tonedevelop methods for compromising, you don’t have to develop methods for compromising, you don’t have to give in entirely, but it may be necessary to make give in entirely, but it may be necessary to make allowancesallowances

Irritability/Impatience:Irritability/Impatience:

Definition:Definition: a mild form of agitation a mild form of agitation general bad mood or “grouchiness”general bad mood or “grouchiness” may be more easily annoyed by small mattersmay be more easily annoyed by small matters

Example:Example: Becoming annoyed by children Becoming annoyed by children playing, television “blasting”, etc.playing, television “blasting”, etc.

Irritability/Impatience:Irritability/Impatience:

Management Techniques:Management Techniques: Negotiate in a calm mannerNegotiate in a calm manner Involve everyone in decision making and Involve everyone in decision making and

activity planningactivity planning Try not to challenge or confront about the Try not to challenge or confront about the

person’s apparent “bad mood”person’s apparent “bad mood” Take breaks as neededTake breaks as needed Try to be aware of triggers in order to Try to be aware of triggers in order to

prevent situationsprevent situations

Impulsivity:Impulsivity:

Definition:Definition: the lack of behavioral control the lack of behavioral control over either action, verbalizations, or both.over either action, verbalizations, or both.

Examples:Examples: Rushing or acting in a quick Rushing or acting in a quick manner that can lead to difficulty with a manner that can lead to difficulty with a simple tasksimple task which can lead to increased frustration.which can lead to increased frustration.

Impulsivity:Impulsivity:

Management Techniques:Management Techniques: Use a reward system for small periods of self-Use a reward system for small periods of self-

controlcontrol Redirect attention to more appropriate behaviors. Redirect attention to more appropriate behaviors.

Suggest alternatives for more desired behaviorsSuggest alternatives for more desired behaviors Encourage them one to slow down and think Encourage them one to slow down and think

through tasks or responsesthrough tasks or responses Anticipate when likely to have difficulty and give Anticipate when likely to have difficulty and give

reminders before they engage in certain reminders before they engage in certain behaviors that have been identified as impulsivebehaviors that have been identified as impulsive

Lack of Initiation / Motivation:Lack of Initiation / Motivation:

Definition:Definition: difficulty coming up with and difficulty coming up with and planning activities. planning activities. Projects, however small, can seem Projects, however small, can seem

overwhelming so it is less threatening and overwhelming so it is less threatening and anxiety provoking to not attempt to do it.anxiety provoking to not attempt to do it.

ExamplesExamples:: Spending the entire day watching TVSpending the entire day watching TV Saying one will get to chores but never gets Saying one will get to chores but never gets

around to doing themaround to doing them


Management TechniquesManagement TechniquesBreak activities into smaller steps to avoid Break activities into smaller steps to avoid becoming overwhelmed.becoming overwhelmed.

Significant others can Significant others can help help make decisionsmake decisions

Make a to-do listMake a to-do list

Help them develop a structured daily routineHelp them develop a structured daily routine


Management Techniques:Management Techniques:If the survivor asks for help on a task that he or she used If the survivor asks for help on a task that he or she used to be able to complete independently before the injury, to be able to complete independently before the injury, never assume that they don’t need help. In fact, assume never assume that they don’t need help. In fact, assume that he or she does need help until he or she can that he or she does need help until he or she can complete the task on his or her owncomplete the task on his or her own

Set a realistic time frame in which to complete the task, Set a realistic time frame in which to complete the task, allowing them extra time than they may have needed allowing them extra time than they may have needed before the injurybefore the injury


Management Techniques:Management Techniques:Provide specific choices for tasks, such as, Provide specific choices for tasks, such as, “Would you like to do A or B?”“Would you like to do A or B?”

Provide them with praise when he or she gets Provide them with praise when he or she gets started on a task without assistance and/or started on a task without assistance and/or completes a task on his or her owncompletes a task on his or her own

Problem-solve and get them involved; Establish Problem-solve and get them involved; Establish goalsgoals

Perseveration:Perseveration:

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


Examples:Examples:

They talk daily about getting back to They talk daily about getting back to drivingdriving

They continue to repeat the story of his or They continue to repeat the story of his or her injury even to those persons who have her injury even to those persons who have heard the story beforeheard the story before

They constantly complain about his / her They constantly complain about his / her dislike of someone elsedislike of someone else


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

Try to divert the conversation to another Try to divert the conversation to another topictopic


Management Techniques:Management Techniques:Write down the answer to a recurrent topic to help Write down the answer to a recurrent topic to help remind the individual that the issue has been resolved or remind the individual that the issue has been resolved or when and how the issue will be resolvedwhen and how the issue will be resolved

Talking can sometimes be helpful for your loved one, but Talking can sometimes be helpful for your loved one, but only to a point. only to a point.

You can refuse to discuss a certain topic any further, You can refuse to discuss a certain topic any further, using nonverbal cues such as “time outs” or excusing using nonverbal cues such as “time outs” or excusing yourself. Choose something respectful however.yourself. Choose something respectful however.

Decreased Awareness:Decreased Awareness:

Definition:Definition: A neurological part of the brain injury and should A neurological part of the brain injury and should not be confused with a psychological or not be confused with a psychological or intentional denial. intentional denial.

Individuals may be completely be unaware of or Individuals may be completely be unaware of or minimize their deficits. minimize their deficits.

It is more common to have decreased It is more common to have decreased awareness of cognitive and behavioral problems awareness of cognitive and behavioral problems than physical problems. than physical problems.


Definition:Definition: When problem areas are pointed out to the When problem areas are pointed out to the individual, many times the individual is individual, many times the individual is unconcerned or does not believe the concerns unconcerned or does not believe the concerns that others have. that others have.

Implications of decreased awareness include Implications of decreased awareness include difficulty regulating social behavior, increased difficulty regulating social behavior, increased safety risk, and decreased compliance with safety risk, and decreased compliance with therapy as they see no need for rehabilitation or therapy as they see no need for rehabilitation or goals.goals.


Examples:Examples: Making excuses when not able to adequately Making excuses when not able to adequately engage in tasksengage in tasks

inaccurate self-image/self-perceptioninaccurate self-image/self-perception

Becoming frustrated after repeated attempts to Becoming frustrated after repeated attempts to engage in activities that he or she can no longer engage in activities that he or she can no longer performperform

Appearing confused by the difficulty that he or she Appearing confused by the difficulty that he or she is having with previously simple tasksis having with previously simple tasks


Management Techniques:Management Techniques: Provide them with consistent and supportive Provide them with consistent and supportive feedback, re-orientation is often needed due to feedback, re-orientation is often needed due to memory impairmentsmemory impairments

Give realistic feedback as you observe behaviorGive realistic feedback as you observe behavior

Cue them to use of accurate self-statementsCue them to use of accurate self-statements

Predict-Perform exercisesPredict-Perform exercises

ClickersClickers


Management Techniques:Management Techniques: Using an educational approachUsing an educational approach

Have them track their behaviors or log activities: Have them track their behaviors or log activities: self-monitoringself-monitoring

Goal-setting approachesGoal-setting approaches

Depression:Depression:

Depression (often a sad and scary topic):Depression (often a sad and scary topic):• Most common emotional difficulty following TBIMost common emotional difficulty following TBI

• More common in persons with TBI than in More common in persons with TBI than in persons with other disabilities or without a persons with other disabilities or without a disabilitydisability

• Major depression is the psychiatric difficulty Major depression is the psychiatric difficulty most commonly associated with suicidemost commonly associated with suicide


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


• Continual feelings of sadness, blue, or “empty” mood Continual feelings of sadness, blue, or “empty” mood (sometimes mood may be more irritable)(sometimes mood may be more irritable)

• Loss of interest or pleasure in hobbies and activities that Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sexwere once enjoyed, including sex

• Negative thoughts about oneself, one’s world, or one’s Negative thoughts about oneself, one’s world, or one’s future or feeling hopeless about the futurefuture or feeling hopeless about the future

• Feeling of guilt or worthlessnessFeeling of guilt or worthlessness


• Becoming more quiet and/or withdrawing from family and Becoming more quiet and/or withdrawing from family and friendsfriends

• Keep thinking about death or feeling that I would have Keep thinking about death or feeling that I would have been better off had I not lived; thoughts of how I could been better off had I not lived; thoughts of how I could harm myselfharm myself

• Feeling like you can’t do anything to change the situation Feeling like you can’t do anything to change the situation or feeling helplessor feeling helpless

• Increase in use of alcohol or illicit substancesIncrease in use of alcohol or illicit substances


* Difficulty concentrating, remembering, making * Difficulty concentrating, remembering, making decisions, can’t focus on things welldecisions, can’t focus on things well

* Have difficulty falling asleep, staying asleep, or * Have difficulty falling asleep, staying asleep, or sleeping too muchsleeping too much

* Do not really feel like eating much or eating * Do not really feel like eating much or eating more than usualmore than usual


* Feeling like you have no more energy or * Feeling like you have no more energy or “slowed down”“slowed down”

* Can’t seen to sit still, or just don’t get up * Can’t seen to sit still, or just don’t get up and move around as I shouldand move around as I should

* All of these symptoms can also occur with * All of these symptoms can also occur with brain injurybrain injury


Management Techniques for familiesManagement Techniques for families::Try to help loved one to get out and socialize Try to help loved one to get out and socialize with otherswith others

Listen and don’t shut him or her outListen and don’t shut him or her out

Celebrate your loved one’s progress, no matter Celebrate your loved one’s progress, no matter how smallhow small

Point out your loved one’s strengths and let him Point out your loved one’s strengths and let him or her know what it is you value about themor her know what it is you value about them


Management TechniquesManagement Techniques::Encourage them to inform a inform a loved one. Encourage them to inform a inform a loved one.

Encourage them to consult a professional such as a Encourage them to consult a professional such as a doctor.doctor.

Encourage them to seek out psychological treatment.Encourage them to seek out psychological treatment.

Educate them on the benefits of medications which may Educate them on the benefits of medications which may be significantly helpful relieving your symptoms.be significantly helpful relieving your symptoms.


Management Techniques for general Management Techniques for general providersproviders::Build rapportBuild rapport

Validate their experiencesValidate their experiences

Provide psychoeducationProvide psychoeducation

Teach relaxation techniquesTeach relaxation techniques


Management Techniques for general Management Techniques for general providersproviders::Cognitive – Behavioral TechniquesCognitive – Behavioral Techniques

Identifying situations that relate to depressionIdentifying situations that relate to depression Identify their consequencesIdentify their consequences Identify their BeliefsIdentify their Beliefs Challenge their beliefsChallenge their beliefs Help them develop more appropriate and reassuring perceptionsHelp them develop more appropriate and reassuring perceptions Help them develop problem-solving techniquesHelp them develop problem-solving techniques

Emotional Lability:Emotional Lability:

Definition:Definition: Loss of control over emotions. Loss of control over emotions. Often shown by quick and frequent mood Often shown by quick and frequent mood swings.swings.

Examples:Examples: Mention of a family member brings a bout of Mention of a family member brings a bout of

crying.crying. Mention of anything with sentimental value Mention of anything with sentimental value

can bring tears.can bring tears.

Emotional Lability:Emotional Lability:

Management TechniquesManagement Techniques::Try not to be critical of this increased Try not to be critical of this increased sensitivity sensitivity Address the behavior rather than the feelingsAddress the behavior rather than the feelingsRemove unnecessary stressful factorsRemove unnecessary stressful factorsModel calm behaviorModel calm behaviorTry to remind them that this can be a normal Try to remind them that this can be a normal experience after and injury and there is experience after and injury and there is nothing “wrong” with them.nothing “wrong” with them.

Anger:Anger:

Definition:Definition: – An emotional ranging from – An emotional ranging from mild irritation to intense fury and rage. mild irritation to intense fury and rage.

Examples:Examples: ““Going off” on loved ones around you Going off” on loved ones around you feeling “on-edge” and easily provokable.feeling “on-edge” and easily provokable.

Anger:Anger:

Management TechniquesManagement Techniques:: Help each other to know that you have the Help each other to know that you have the

power to control your anger, despite the injurypower to control your anger, despite the injury Anger control = skill that will get better with Anger control = skill that will get better with

practicepractice Discourage each other from saying the first Discourage each other from saying the first

thing that comes to mind thing that comes to mind Teach each other to think about other people’s Teach each other to think about other people’s

reactions before speaking or acting out.reactions before speaking or acting out.

Anger:Anger:

Encourage each other to be positive and Encourage each other to be positive and sensitive to others’ feelings. sensitive to others’ feelings. Explain yourself calmly and doing so will make it Explain yourself calmly and doing so will make it easier for others to understand and help you.easier for others to understand and help you.Take “time outs” and try to catch those early Take “time outs” and try to catch those early warning signs (deep breathing, counting slowly).warning signs (deep breathing, counting slowly).

Ignoring problems can sometimes makes things Ignoring problems can sometimes makes things worse. Be willing to give feedbackworse. Be willing to give feedback to othersto others..

Anger:Anger:

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

Increased or decreased Increased or decreased sexual interest:sexual interest:

Definition:Definition: Feel as if they no longer look appealing or Feel as if they no longer look appealing or

that anyone could respond to them sexually. that anyone could respond to them sexually. Obsessed with thoughts about sex and may Obsessed with thoughts about sex and may

behave “inappropriately” (making passes at behave “inappropriately” (making passes at people of the opposite sex, talking about people of the opposite sex, talking about sexual activity, etc.)sexual activity, etc.)

Increased or decreased sexual Increased or decreased sexual interest:interest:

Example of decreased sexual interest:Example of decreased sexual interest: continuing to sleep in the “extra bedroom” continuing to sleep in the “extra bedroom”

even after health issues have been even after health issues have been stabilized.stabilized.

Increased or decreased Increased or decreased sexual interest:sexual interest:

Management Techniques for decreased Management Techniques for decreased sexual interest :sexual interest : Do not take the disinterest personallyDo not take the disinterest personallyDo not pressure or attempt to embarrass Do not pressure or attempt to embarrass them into having sex before they are readythem into having sex before they are readyDisinterest may be masking other issuesDisinterest may be masking other issuesNon-intercourse affection and petting is OKNon-intercourse affection and petting is OKTry to communicate to your loved one so Try to communicate to your loved one so they do not think it is “about them.”they do not think it is “about them.”Seek professional help if medical conditionSeek professional help if medical condition


Examples of increased interest:Examples of increased interest: Making sexually inappropriate remarks to Making sexually inappropriate remarks to

other females.other females. Offering sexual innuendoes either to Offering sexual innuendoes either to

significant other or someone else while at a significant other or someone else while at a social gathering.social gathering.


Management Techniques for increased Management Techniques for increased sexual interest:sexual interest: Provide reminders that such behavior is Provide reminders that such behavior is

unacceptableunacceptable Do not feel obligated to respond to sexual Do not feel obligated to respond to sexual

demands every timedemands every time Provide positive reinforcement for more Provide positive reinforcement for more

accepting behaviorsaccepting behaviors

Fatigue:Fatigue:

Definition:Definition: – a feeling of weariness, tiredness, – a feeling of weariness, tiredness, or lack of energyor lack of energy

Example: Example: - feeling tired after putting away the - feeling tired after putting away the dishes.dishes.

Management Techniques for Survivors:Management Techniques for Survivors: Use relaxation techniquesUse relaxation techniques Don’t try to do too much at one time Don’t try to do too much at one time Pace yourselfPace yourself Seek professional help Seek professional help Consider a formal sleep evaluationConsider a formal sleep evaluation

Fatigue:Fatigue:

Tips for Family Members (Same as for Tips for Family Members (Same as for survivors and….):survivors and….): Split up the responsibilities – others will Split up the responsibilities – others will

usually be glad to helpusually be glad to help Try to take time for oneself. Try to take time for oneself.

Boredom:Boredom:

Examples:Examples:

The individual sits and watches TV all dayThe individual sits and watches TV all day

They complain that “there is just nothing to They complain that “there is just nothing to do”do”

Boredom:Boredom:

Management Techniques:Management Techniques:

Make a to-do list of activities and be Make a to-do list of activities and be responsible for carrying-out those responsible for carrying-out those activities.activities.

Take others up on their offers to Take others up on their offers to accompany them to places.accompany them to places.

Practice therapies at home.Practice therapies at home.

Boredom:Boredom:

Take up hobbies, if possible.Take up hobbies, if possible.

Volunteer time.Volunteer time.

Get involved in community activities / Get involved in community activities / events.events.

SummarySummary

These changes in personality and behaviors can These changes in personality and behaviors can be the most distressing for family members to be the most distressing for family members to adjust to.adjust to.

It is often easy to become upset at your loved It is often easy to become upset at your loved one for acting “inappropriately” or in ways that one for acting “inappropriately” or in ways that may be “bothersome.”may be “bothersome.”

Remember that all of these difficulties can be Remember that all of these difficulties can be direct effects of the brain injury and it is direct effects of the brain injury and it is important to manage them with care.important to manage them with care.

***Always get the family involved in the process***Always get the family involved in the process

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Tips on managing challenging situations after brain injury For Survivors, Caregivers, and Clinicians: What can you do to help?