When a friend or family member experiences a traumatic brain injury, your natural reaction may be to ask how severe the injury was and what kind of recovery can be expected.
Medical providers and those involved in acute, sub-acute, and long-term rehabilitation are also interested in understanding the severity of the injury, as this is important information to have in order to address the second question: how will the injured individual recover?
There are multiple methods to assess the severity of a traumatic brain injury (TBI). Providers look at loss of consciousness score on the Glasgow Coma Scale, and how long it takes someone to follow directions after their injury. Providers also consider the length of time an individual who experienced a TBI remains in post-traumatic amnesia (PTA).
PTA was described in the 1930s by Russell (1932) and Symonds (1937) as a loss in full consciousness and therefore an inability to make new memories (Trzepacz, Kean, & Kennedy, 2011). This definition was tweaked some so that for the past several decades PTA was defined as a period of disorientation and difficulty consistently making new memories following TBI. The resolution of PTA was complete when an individual was consistently oriented and able to make new memories. However, many researchers and clinicians recognized that this definition of PTA did not fully capture the spectrum of impairments commonly found early in the recovery from a TBI.
Post-traumatic confusion (PTC) is a term that better captures the deficits individuals may experience as they recover after their injury. Specifically, Stuss et al. (1999) described a post-traumatic confusional state as a “transient organic mental syndrome with acute onset characterized by a global impairment of cognitive functions with a concurrent disturbance of consciousness, increased psychomotor activity, and a disrupted sleep-wake cycle.” Individuals who have regained consciousness after a TBI but who remain in PTC may demonstrate decreased daytime arousal, fluctuations in cognitive and behavioral symptom severity, psychomotor agitation, affective lability, perceptual disturbances, and impaired cognition (in particular, difficulty with attention and memory) (Nakase-Richardson, Sherer, Yablon, Nick, & Trzepacz, 2004; Sherer, Nakase-Richardson, Yablon, & Gontkovsky, 2005).
Regarding cognitive impairments, deficits in attention and memory are particularly pronounced during PTC. These difficulties with sustaining attention and forming new memories add to the individual’s overall confusion and misinterpretation of their surroundings. Additional behaviors that may be observed in someone in PTC include difficulty sitting still and a desire to pace, or someone who is often fidgeting with their feeding tubes or wheelchair lap belt. Agitation may also be noted when someone curses, yells at family, and refuses therapies. As noted above, some fluctuation in abilities is not uncommon during PTC. An individual in PTC may appear able to focus during therapy one day and unable to focus and follow instructions the next day. This does not mean that the individual is motivated one day and not the next, although variations in motivation are normal and to be expected during the long course of recovery.
Clinicians can track PTC proactively and serially until an individual “clears” from the confusional state. This measurement can be carried out by neuropsychologists or therapists with standardized tools. Understanding how long someone is in PTC is important in labeling the severity of the injury and it can be helpful predicting outcomes from the injury as well. The duration of post-traumatic confusion or post-traumatic amnesia has been shown to predict return to work (van der Naalt, van Zomeran, Sluiter, & Minderhoud, 1999) and level of cooperation (Silva et al., 2012) in rehabilitation. Severity of confusion has been shown to predict productivity and employment one year after injury (Nakase-Richardson, Yablon, & Sherer, 2007; Sherer, Yablon, Nakase-Richardson, & Nick, 2008). It is also important for us to understand whether someone is in PTC, because it influences how clinicians target treatments and expectations.
There are resources available for family members and friends who have loved ones in PTC. The Rancho Los Amigos Levels of Cognitive Functioning Scale describes the cognitive and behavioral functioning of a TBI survivor as it is likely experienced by family and therapists. Levels IV, V, and VI all describe the period of post-traumatic confusion. The scale also provides expectations for behavior and recommendations for interacting with an individual in PTC.
Clinicians at Rainbow can also serve as a resource to understand your family member who remains in PTC. Given the cognitive deficits present in an individual in PTC, much of the treatment is repetitive and environmental in nature. For example, an environment with reduced stimulation (low lights, no television/limited background noise and distractions, and limited simultaneous visitors) can be helpful. Individuals should be exposed to natural daylight to assist in reducing daytime fatigue and resetting circadian rhythms. When communicating with an individual who is in PTC, statements should be clear, brief and at a slower pace in order to maximize comprehension.
When post-traumatic confusion resolves, an individual may continue to demonstrate deficits related to their injury. Regardless of where they are in their cognitive recovery, the clinicians and rehabilitation assistants at Rainbow are equipped to help manage the symptoms they demonstrate and help propel them towards recovery.
What follows is an example of a client who arrived for treatment in a post-traumatic confusional state.
Case Study: Mr. Jones
Mr. Jones is a 45-year-old man who was injured when the car he was driving was struck by another vehicle that lost control and crossed the highway median. EMS was called by a witness to the accident and when they arrived, Mr. Jones was found to be unconscious in his car. Mr. Jones was transported to the hospital where he was found to have a fracture to his left leg and several ribs, and he had cuts and bruising on his arms and face. Imaging of his brain demonstrated a TBI with subarachnoid hemorrhage, intracranial hemorrhage, and hemorrhagic contusions in both frontal lobes and the left temporal lobe.
After being stabilized medically, Mr. Jones transferred to an acute rehabilitation unit at the local hospital. He then transferred to a residential rehabilitation facility for continued rehabilitation services and a supported environment. When Mr. Jones arrived, he remained confused (Rancho level V) and therapists began to assess his cognition so that therapies and the environment around him could be targeted to maximize his recovery.
On a standardized measure of orientation, Mr. Jones was noted to know his name and birthday but he could not remember his age. He was able to identify the month but not the date or year and when asked what time it was, he glanced at a nearby clock to provide the right answer. Mr. Jones knew he was in rehabilitation and working on his legs in therapy, but he could not recall how he had been injured or provide further details about the consequences of his accident. When given prompts, Mr. Jones became more accurate, but he remained confused. He could not remember the name of the team member who worked with him daily, but he was able to remember the names of his children and wife. Furthermore, Mr. Jones was noted to be unable to focus on a conversation or therapy exercise for longer than a few minutes.
At times, Mr. Jones became irritable. He would pace around the home, swear at therapists or direct care staff, and refuse therapies. His family noted that this behavior was not typical for Mr. Jones. They were embarrassed despite reminders from his therapy team that this agitation was not uncommon for someone who had an injury like his and who was at that point of recovery. In addition, Mr. Jones had disturbed sleep.
The treatment team worked together to determine if there were specific triggers for Mr. Jones’ agitation and discovered that he felt he had been treated like a child in the hospital and that he wanted more independence. To address his concern, therapists and team members provided options whenever possible to improve Mr. Jones’ sense of control over his environment. Environmental cues to help orient Mr. Jones were added to his room, and he was encouraged to wear his watch. This sense of control and assistance with reorientation resulted in more appropriate language and fewer refusals of therapy.
To address sleep issues and pacing, Mr. Jones was encouraged to be up and active during the day, and the drapes in his room were opened to increase his exposure to sunlight. Mr. Jones was also directed toward pleasant activities when he paced or became irritable. Therapists worked to improve Mr. Jones’ span of attention in sessions and team members provided frequent breaks, repeated instructions, and checked for comprehension in consideration of Mr. Jones’ level of confusion and difficulties with attention. Working with his physician, medications were reviewed to minimize any negative side effects that they may have on cognition. Family members and Mr. Jones were provided with education about brain injury and recovery from injury.
Over time, Mr. Jones became more oriented to his surroundings and less irritable. Serial evaluations indicated that Mr. Jones cleared post-traumatic confusion after 67 days. While he continued to demonstrate areas of cognitive weakness, his progress in therapy accelerated, and discharge plans were developed so that Mr. Jones could return to his home safely while continuing therapy as an outpatient. His successful transition was another indication of progress in his recovery from brain injury.
Carolyn A. Scott, Ph.D.
Dr. Scott earned her Ph.D. at Wayne State University in Clinical Psychology. After an internship at the John D. Dingell VA Medical Center, she completed specialized post-doctoral training in Neuropsychology and Rehabilitation Psychology at the Rehabilitation Institute of Michigan. While there, Dr. Scott worked with individuals who had experienced traumatic brain injuries, stroke, spinal cord injuries, and other neurological and orthopedic conditions on both an inpatient and outpatient basis. In addition to other responsibilities, Dr. Scott provides client and team consultation services and brief and expanded neuropsychological evaluations at Rainbow Rehabilitation Centers, Inc. [/toggle]
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