Lecture # 410:
Care of Persons with Stroke or Brain Trauma (continued)

Depression
More than half of all those affected by brain injury have depression. There is appetite loss, fatigue, sleep disturbance, and anxiety. To be treated, the doctor needs to know the cause. Often, the cause is that persons recognize that they are not the same. This causes depression. Most abilities diminished by head injury or stroke return either partially or fully in the first few weeks after the injury. The brain cells that were damaged are able to resume their activity. Also the brain compensates for its losses by reorganizing itself and assigning functions to other undamaged areas.

Meditate Word By Word On These Verses:
Matt. 9:1-8.

Rehabilitation
It used to be that victims of stroke were put in a back room. Then research showed that many of them could improve greatly and do quite well. Seven of ten persons can learn to handle daily activities again and regain independence.

Physical exercises

Physical therapy
Exercises and training designed to improve problems with walking, balance, and coordination often begin while a person is in a hospital bed. These exercises stop contracture and begin to help the brain to reorganize itself. As soon as the person is medically stable, the staff should be mobilizing the patient by helping him to sit at the edge of the bed and eventually transfer to a wheelchair. This approach promotes quicker return of motor and mental functions.

Mobilizing a person MUST BE DELAYED in the following cases:

a comatose state
recent injury
recent heart attack
evidence of expanding stroke, i.e., a person is admitted to the hospital with weakness in the arm or leg and the next day there is complete paralysis
the person experiences a sharp drop in blood pressure when coming to a sitting position
the person has a thrombophlebitis in the leg

Question 1: Research has shown that:
(Only one of the following answers is correct.)
it is better to ignore victims of stroke and head injury.
most of these people can learn daily activities again.
after stroke, people have stability.

Occupational therapy
The focus of occupational therapy is to help people with the skills of daily living - eating, cooking, dressing, and bathing. If necessary, some people need to learn new ways of doing things - perhaps doing tasks one handed or using certain tools to help them do things.

Speech therapy
Speech-language pathologist teaches persons to speak again depending on the deficit. He also educates the family in how to communicate more effectively with the speech impaired person. This specialist is also able to help persons learn to swallow better.

You can also help the person with a swallowing problem. Be sure to put a spoon or fork on his lip when you offer it to him. We are used to guiding a spoon or fork there and making our throats ready to swallow food. Put the food in the strong side of the mouth so that the person can feel it is there. If it is on the weaker side, there is a tendency to store it in the cheek next to the teeth and not swallow it. When first trying to give food by mouth you can GENTLY stroke the throat in an effort to make the person swallow. Be sure to give liquids in between giving solid foods so that each mouthful of food is swallowed.

If the person has trouble eating regular table food, try grinding up the food you have prepared in a meat grinder or coffee grinder. You may also purchase foods prepared for small children. Once the person has mastered these foods, you can gradually add foods that are chopped and then add normal table foods as served at home. Also, please do not give these people cottage cheese with a high content of fat, they already have atherosclerosis and added fat only makes the problem worse. Give them low-fat yogurt or kefir.

Question 2: To help a person swallow better:
(One or more of the following answers may be correct.)
present food to him on his lip first.
gently stroke his throat to help him begin to swallow.
try giving ground foods.

With liquids, try a straw on the side unaffected by the stroke. Sometimes people are not able to suck through a straw. Then try to use a small plastic cup with a cover so that the amount of fluid a person drinks is limited. Usually, you can buy these at children's markets. The stroke victim can drink while lying down, without spilling. These cups also improve hand-to-mouth coordination following stroke.

If the stroke victim has significant problem swallowing, meaning that every time he swallows he chokes or coughs, he needs thickened liquids. You can thicken liquids by using cornstarch or kisel. A thickened consistency helps the person to take in liquids without choking on them. If all else fails, one can use a baby bottle with the nipple cut wider so that thickened fluids can come out easily. I dislike this bottle method very much since it seems to me that no one is taking time to properly rehabilitate the stroke victim.

Here is a way to help make a decision about rehabilitation for your loved one:
1. Is your loved one medically stable or moderately stable?
NO: Recommendation: Delay your decision on rehabilitation until the person is fully stabilized. Until then, recovery should continue at home or in a nursing home.
YES: continue.

2. Does your loved on have a functional disability? This means there is a bowel or bladder control deficit, problems with thinking ability, emotional difficulties, swallowing or language problems, and the inability to do daily life activities such as bathing, dressing, etc.
NO: Recommendation: No rehabilitation is necessary.
YES: continue.

3. Does your loved one have more than one functional disability?
NO: Recommendation: individual rehabilitation services performed at home or in a rehab center
YES: continue.

4. Is your loved one able to learn and expected to make improvements in function?
NO: Recommendation: Custodial care at home or a rehabilitation center. Custodial care means helping a person with daily life activities which a non-professional person or family member can do.
YES: continue.

5. Does your loved one have the endurance to sit for one hour and participate in rehabilitation?
NO: Recommendation: Rehabilitation at home with low-intensity activities
YES: continue.

6. How much help does your loved one need with walking or daily living activities?
INDEPENDENT: go to question 8
NEEDS MODERATE, MAXIMUM, OR TOTAL ASSISTANCE: go to question 10
NEEDS SUPERVISION OR MINIMAL ASSISTANCE: continue

7. Is there adequate help in the home for the patient?
NO: Recommend an inpatient rehabilitation facility
YES: a home rehabilitation program or daily trips to a rehabilitation program

8. Can your loved one manage more complex tasks such as fixing meals, housekeeping, shopping, and telephoning?
NO: Go to question 9
YES: Recommendation: home rehabilitation program

9. Is there adequate help in the home for the patient?
NO: Recommendation: rehabilitation services in a nursing home or rehabilitation center
YES: Recommendation: home rehabilitation

10. Can your loved one tolerate intense rehabilitation of more than 3 hours a day?
NO: Recommendation: rehabilitation in a nursing home or rehabilitation center with low-intensity activities
YES: continue.

11. Does your loved one need medical care or monitoring 24 hours a day?
NO: Recommendation: rehabilitation in a place with intense rehabilitation services and adequate medical coverage such as a rehabilitation center, a nursing home, or home program
YES: Recommendation: an inpatient rehabilitation center with intensive rehabilitation program and adequate acute medical care coverage.

Realizing that in some countries, there are few inpatient rehabilitation centers and fewer people can even get their loved one to a rehabilitation center every day, the home is the place where rehabilitation is done. For this reason, we are trying to give you the most information to help those people who are in need of rehabilitation.

©Family Caregiver Alliance Fact Sheet:
Coping With Behavior Problems After Head Injury

Identifying Behavior Problems
Head injury survivors may experience a range of neuropsychological problems following a traumatic brain injury. Depending on the part of the brain affected and the severity of the injury, the result on any one individual can vary greatly. Personality changes, memory and judgment deficits, lack of impulse control, and poor concentration are all common. Behavioral changes can be stressful for families and caregivers who must learn to adapt their communication techniques, established relationships, and expectations of what the impaired person can or cannot do.

In some cases extended cognitive and behavioral rehabilitation in a residential or outpatient setting will be necessary to regain certain skills. A neuropsychologist also may be helpful in assessing cognitive deficits. However, over the long term both the survivor and any involved family members will need to explore what combination of strategies work best to improve the functional and behavioral skills of the impaired individual.

Personality Changes
Even a person who makes a "good" recovery may go through some personality changes. Family members must be careful to avoid always comparing the impaired person with the way he/she "used to be." Personality changes are often an exaggeration of the person's pre-injury personality in which personality traits become intensified. Some changes can be quite striking. It may be, for example, the head injury survivor used to be easy going, energetic, and thoughtful and now seems easily angered, self-absorbed, and unable to show enthusiasm for anything. Nonetheless, try not to criticize or make fun of the impaired person's deficits. This is sure to make the person feel frustrated, angry, or embarrassed.

Memory Problems
Head injury survivors may experience short-term problems and/or amnesia related to certain periods of time. Generally, new learning presents the greatest challenge to memory or remembering. In contrast, pre-injury knowledge is more easily retained.

The ability to focus and concentrate is key to addressing some short-term memory problems. Keep distractions (e.g., music, noise) to a minimum and focus on task or train of thought at a time.

Have the person repeat the name of a person or object, after you, if memory impairment is severe.
Whenever possible, have the person write down key information (e.g., appointments, phone messages, list of chores).

Keep to routines. Keep household objects in the same place. Use the same route to walk to the mailbox or bus stop.

If getting lost is a problem, you can label doors or color code doors inside the house or hang arrows to indicate directions. When going out, the person should be accompanied initially to ensure the route is understood. A simple map can be sketched from the bus stop to the house. And make sure that the person always carries his/her address and emergency phone numbers.

Establishing Structure
A structured environment can be essential in helping a head injury survivor relearn basic skills. A written routine schedule of activities and repetition make it easier to remember what's expected and what to do next.

Lack of Emotion
After a head injury a person may lack emotional responses such as smiling, laughing, crying, anger, or enthusiasm or their responses may be inappropriate. This may be especially present during the earlier stages of recovery.

Recognize that this is part of the injury. Try not to take it personally if the person does not show an appropriate response.

Encourage the person to recognize your smile at a humorous situation (or tears if you are sad) and to take note of the proper response.

Emotional Lability
In some cases, neurological damage after a head injury may cause emotional volatility (intense mood swings or extreme reactions to everyday situations). Such overreactions could be sudden tears, angry outbursts, or laughter. It is important to understand that the person has lost some degree of control over emotional responses. The key to handling lability is recognizing that the behavior is unintentional. Caregivers should model calm behavior and try not to provoke further stress by being overly critical. Help the person recognize when his/her emotional responses are under control and support/reinforce techniques that work.

Aggressive Behaviors
Provided a situation does not present a physical threat, various approaches may be used to diffuse hostile behavior:

Remain as calm as you can; ignore the behavior.
Try to change the person's mood by agreeing with the person (if appropriate) and thus avoiding an argument. Show extra affection and support to address underlying frustrations.
Validate the emotion by identifying the feelings and letting the person know these feelings are legitimate. Frustration over the loss of functional and/or cognitive abilities can reasonably provoke anger.
Do not challenge or confront the person. Rather, negotiate (e.g., if you don't like what's planned for dinner tonight, how about choosing Friday's menu?).
Offer alternative ways to express anger (e.g., a punching bag, a gripe list).
Try to understand the source of the anger. Is there a way to address the person's need/frustration? (E.g., make a phone call, choose an alternative activity).
Help the person regain a sense of control by asking if there is anything that would help him/her feel better.
Isolate the disruptive impaired person. Consider you own safety and his/hers. Treat each incident as an isolated occurrence as the survivor may not remember having acted this way before or may need to be prompted to remember. Try to establish consistent, non-confrontational responses from all family members (children may need to learn some "dos" and "don'ts" in reacting to the survivor).
Seek support for yourself as a caregiver. Support groups, professional counselors, and, if necessary, protective services or law enforcement may be contacted.

Self-Centered Attitude
The person who has survived a head injury may lack empathy. That is, some head injury survivors have difficulty seeing things through someone else's eyes. The result can be thoughtless or hurtful remarks or unreasonable, demanding requests. This behavior stems from a lack of abstract thinking.
Help cue the person to recognize thoughtlessness. Remind him/her to practice polite behavior. Realize that awareness of other people's feelings may have to be relearned.

Poor Concentration
"Cueing" or reminders can be helpful in improving concentration and attention. Repeat the question. Don't give too much information at once, and check to see that the person is not tired.
Head injury survivors should be encouraged to develop self-checks by asking themselves questions such as "Did I understand everything?" "Did I write it down?" "Is this what I'm supposed to be doing?" "Did I make a mistake?" or "I'm not sure" should lead to the conclusion, "let me slow down and concentrate so I can correct the error." Correct actions should be consciously praised, "I did a good job."

Lack of Awareness of Deficits
It is relatively common for a head injury survivor to be unaware of his/her deficits. Remember that this is a part of the neurological damage and not just obstinacy. Be aware, however, that denial can also be a coping mechanism to conceal the fear that he/she cannot do a particular task. The person may insist that the activity cannot be done or is "stupid."

Build self-esteem by encouraging the person to try a (non-dangerous) activity that he/she feels confident doing.
Give the person visual and verbal reminders or "hints" (e.g., a smile or the words "good job") to improve confidence in carrying out basic activities more independently.
If you feel the person can handle confrontation, challenge him/her to try the activity. Demonstrate that you can do the task easily.

Inappropriate Sexual Behavior
After a head injury, a person may experience either increased or decreased interest in sex. The causes could be a result of brain regulation of hormonal activity or an emotional response to the injury.

Sexual disinterest from a head-injured spouse should not be taken personally. Avoiding sexual contact could stem from fear or embarrassment about potential performance. Do not pressure the person to resume sexual activity before he/she is ready. Helping the person dress nicely and practice good hygiene may help increase his/her confidence in feeling attractive.

Increased sexual interest can be particularly stressful and embarrassing to families and caregivers. Without good impulse control, the survivor may make crude remarks out in public, make a pass at a married friend, try to touch someone in an inappropriate setting, or demand sexual attention from a spouse or significant other. It is important to remind the person that the behavior is not acceptable.

A spouse should not feel pressured into submitting to sexual demands that are unwanted.

A sexually aggressive person may need to be isolated from others where inappropriate behavior is not controlled. A call for help may be necessary, if physical threats are made.

Support groups may be useful in helping the person realize the consequences of inappropriate sexual behaviors.

Learning to Cope/Getting Support
Coping with behavior problems after a head injury requires identification and acknowledgment of the impaired individual's deficits. A comprehensive neuropsychological assessment is recommended. This may help both the survivor and the family to better understand neurological and cognitive deficits.

In some cases, it may be easier for the family caregiver to recognize personality changes than to resolve the problem behavior. Targeted strategies may be used to deal with specific behavioral issues.

Finally, it is critical that family members seek and receive support (family, friends, support group, counselor) in dealing with their own emotional responses to caring for a head injured loved one.

Lecture # 410: Care of Persons with Stroke or Brain Trauma (continued)

Lecture # 410:
Care of Persons with Stroke or Brain Trauma (continued)