Transcript Post Traumatic Amnesia

Post Traumatic Amnesia
Gemma Hardy
Clinical Psychologist
Neuropsychology Department, Addenbrooke’s Hospital
[email protected]
Outline
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Overview
Symptoms
Assessment
Rehabilitation
Management
Case study
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
PTA Duration
Severity of Injury
5 – 60 minutes
Mild
1 – 24 hours
Moderate
1 – 7 days
Severe
1 – 4 weeks
Very severe
> 4 weeks
Extremely severe
PTA
• Amnesia
• Impaired attention
• Anterograde
• No ability to form dayto-day memories
• Retrograde
• Loss of memory for
events prior to TBI
• Disorientation
• Time
• Place
• Person
• Behavioural change
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Agitation
Disinhibition
Emotional lability
Childlike persona
Wandering
Fatigue
Confabulation
PTA
• Impaired attention
– Poor concentration
– Highly distractible
– Impaired awareness
• Slowed reaction time
• Fatigue and Fluctuation
• NB. fight or flight in response to fear
PTA what is it like?
A Case Study
• Susan, 40 year old teacher
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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?
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
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 longterm impairment
PTA recovery
• Gradual
• Currently determined by PTA test performance
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• Many qualitative features absent on testing
• Difficult to distinguish from chronic memory
impairment
• Sequence of cognitive recovery
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Person
Recognition memory
Place
Time
Free recall / continuous memory
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
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
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
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?)
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
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
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
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:
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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
Thank you very much!
If you would like a copy of slides please email
[email protected]
Key References
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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.
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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.
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Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed head injuries.
Archives of Neurology, 5, 4-17.
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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.
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Wilson, B.A., Herbert, C.M., & Shiel, A. (2003). Behavioural approaches in
neuropsychological rehabilitation. Hove: Psychology Press.