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The first few weeks after brain injury

INTRODUCTION

This section focuses on the first few weeks and the stages of cognitive recovery (the relearning of the processes involved in thinking, understanding and reasoning) from brain injury and the role of family and friends in helping in that process. It is a general introduction only. It is meant to supplement the more detailed information and suggestions you get from doctors, nurses, therapists and others about the unique needs of your “patient”. Many of the suggestions we’re making were originally developed by the Thomas Rehabilitation Hospital in North Carolina and the Rancho Los Amigos Medical Centre in California.

LEVELS OF RECOVERY

Unfortunately, real life brain injured patients don’t resemble television brain-injured patients or Sleeping Beauty. In real life, patients in the Intensive Care Unit don’t instantly sit up in bed after being unconscious and ask, “Where am I? What happened to the last eight days?” (or two or twenty)? The long slow process of rehabilitation experienced by most patients and their families just doesn’t make good television.

The levels of recovery that we’re going to discuss describe what a brain-injured person goes through as he “wakes up”. The type and severity of the initial head injury, the length of time until medical help was available, the presence of other injuries and complications, the age and general health of the person, and your involvement as a concerned family, all play a role in determining how long this process takes. It always requires patience. In general, the more serious the head injury, the longer the person is unconscious (in a coma), and the more likely it is that there will be some long-term disability. Therefore, the longer the person is unconscious, the longer the rehabilitation process. The coma is a result of, and caused by, the head injury, it’s not a separate problem-Rancho Los Amigos Medical Centre has defined eight levels of recovery:


LEVEL 1 NO RESPONSE
LEVEL II GENERALIZED RESPONSE
LEVEL III LOCALIZED RESPONSE
LEVEL IV CONFUSED AGITATED
LEVEL V CONFUSED-INAPPROPRIATE
LEVEL VI CONFUSED-APPROPRIATE
LEVEL VII AUTOMATIC-APPROPRIATE
LEVEL VIII PURPOSEFUL-APPROPRIATE

It is important to realize that these levels are descriptive of the overall pattern of recovery following injuries. We usually describe a patient’s condition or behaviour, we do not label or number a level. People with brain injury don’t usually quickly and clearly move from one level to another; they frequently show characteristics of more than one level at the same time or they can skip levels.


LEVEL I: NO RESPONSE

The person looks as if he is in a very deep sleep and does not respond to stimulation. He is usually on a ventilator (respirator) in the Intensive Care Unit. He is not suffering, physically or emotionally; at this stage, YOU are the one experiencing the most pain.

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LEVEL II: GENERALIZED RESPONSE

At this level, the person appears to be asleep most of the time, but does respond, inconsistently and nonpurposefully to some stimulation. His responses are limited in nature, and are often the same regardless of the stimulus, and are likely to be delayed. He may groan or make a face when he is sponged, when blood is taken, or even when he hears your voice…all very different stimuli. Responses may be physiological changes (a change in blood pressure), gross body movements (squirming) or vocalization (moaning). Pain will likely cause the first response. He may pull away from stimuli like injections or being suctioned. (The staff may purposely stimulate him to see if he moves his right and left side equally.) It is not that he is paralyzed or “locked in” and just unable to communicate. He does not have well developed thoughts and feelings yet.

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LEVEL III: LOCALIZED RESPONSE

The person appears more alert for several minutes at a time and responds more consistently to general stimulation. He may follow simple commands, such as closing his eyes or sticking out his tongue, although not every time and usually very slowly. Eye opening may not be to command, for it is a normal response for a person to open his eyes to any noise. As well, hand squeezing is a basic reflex seen even in the newborn. These are good signs of responsiveness, but aren’t the best way to assess the ability to understand a command.

At this level, a person usually begins to respond more to nursing care by turning away when being suctioned or pulling at his catheter or nasogastric tube (feeding tube).

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SUGGESTIONS FOR THE FAMILY FOR LEVEL I (NO RESPONSE), LEVEL II (GENERALIZED RESPONSE) AND LEVEL III (LOCALIZED RESPONSE)

(The later suggestions may only be possible at Level III).

Speak to him in a calm, slow, normal voice. Say the things that are important to you.

Introduce him to the nurses and other staff: his job, his hobbies, the things that make him unique.

Make sure you meet his main doctors and feel free to ask questions. Sometimes the answer will be “We don’t know”, or “It’s too soon to say.” Nobody is hiding bad news from you or trying to mislead you – the answers to all questions just aren’t known early in treatment. (When someone is in the Intensive Care Unit, the responsibility for his care is usually shared by a neurosurgeon and an Intensive Care specialist. They are helped by “residents” – doctors who have completed an internship and are now doing specialty training.)

Most families find that communication is least confusing when the one or two closest family members take the responsibility for obtaining information. This helps to establish clearer, more consistent lines of communication and usually increases understanding all around.

Speak in reassuring tones. We know the ability to hear comes back long before the ability to understand the content of what is being said. Think of how a baby smiles and giggles when held and spoken to lovingly by a parent, even though he may not understand the words used, for the parent may be counting or reciting a poem. Therefore, in these early stages, although a relaxed tone may not come easily, it is far more meaningful to the person than the actual message.

Even though the person, at this stage, cannot understand everything that is being said, do not discuss his condition as if he were not there. This is a bad habit to develop and can lead to talking about him later on, when he is aware of being treated like a non-entity.

Stimulate him when he begins to have periods of being awake. If you are helping with the bath, for instance, you can say, “I’m washing your right hand now.” Stimulation time should be brief, 5 – 10 minutes, and should be as meaningful as possible. Do not overtire him.

Continue to calmly show affection in whatever way you can.

Check with the occupational therapist or the nurse about an organized way to try to stimulate the senses. For instance, for taste and smell, a “Q-tip” can be flavored with lemon or mint or salt and touched to his tongue. Or, hold some garlic powder, shaving lotion, a clove or raspberry jam under his nose. Tell him what it is and ask him to stick out his tongue if he can smell it.

Intermittently play music (tapes or radio) which he would enjoy. Don’t leave it on all the time or it will become “white noise” (meaningless background sounds). Turn off or dim lights for periods of time in order to increase the possibility of response when the lights are bright.

Ask him to follow one-step commands such as, “Raise your arm”, “Close your eyes”, “stick out your tongue” , “Show me your teeth” , “Wiggle your toes”. Allow plenty of time for the response.

Each time you see him, say who you are. Tell him the day and date and that he is in the hospital. Tell him how he was hurt and that now he is getting better.

Limit the overall number of visitors and explain to visitors about speaking calmly and about appropriate forms of stimulation.

Talk to him about familiar people and things – names of family members and close friends, school and jobs, vacations, hobbies, etc.

It is especially helpful to illustrate conversations about familiar people and things with pictures. Bring in the family album and show him pictures of who and what you are talking about. In addition, have a family member or a close friend take some “ordinary” pictures…whether they are photos of his favorite chair, the kitchen, the curling rink, his baseball glove, the crop, the school gym, his stamp collection, his office or the vegetable garden. These photos form a picture of ordinary, everyday life, not just special occasions.

As he gradually becomes more alert, help him to start doing routine, self-care activities, such as washing his face with a washcloth.

Sometimes a person may be alert enough during Level III that you can ask him questions about his past that have “yes” or “no” answers. Allow him time to respond as his reaction time will be slow. Don’t yell at him as if he were deaf. His hearing is probably as good as it ever was. The problem is in his brain, not his ears. Speaking too loud will not help get the message through.

Many families find it useful to establish a journal, in which a daily record of the person’s progress can be documented. (Later, this journal can become the head-injured person’s personal record). This can also serve as a means of communication between family members and members of the health care team.

In general, Level I is characterized by no response to the environment and Level II and III by greatly decreased response to the environment. This is a time of low activity or under activity. The goal is to first elicit responses to sensory input, then slowly increase the frequency, rate, duration, variety, and quality of responses. GO SLOWLY. MAKING EXCESSIVE DEMANDS AND PROVIDING TOO MUCH STIMULATION WILL NOT MAKE THE BRAIN HEAL ANY FASTER.

Particularly in the very early stage you may be afraid to even leave the hospital, because you’re worried and want to help. Indeed, you worry about whether or not he will even survive. In the later stages, there’s more you can do to help, so it’s important to learn early to pace yourself. Get enough sleep. Schedule some relaxation and some physical exercise. Eat at least one nutritious meal a day. Work out rotating visiting schedules with other family members. Learn to ask for and accept help from friends and relatives – whether it’s to mow your lawn, help with the children, or take your car to the garage. Such favors reduce your other worries and allow friends and family to feel helpful.

Not everybody has the same feelings at the same time. Mom may be saying “He’s got to live. He’s just got to live…no matter how disabled.” Grandma and Grandpa may criticize with, “Don’t ever talk like that, he’ll be back playing football before you know it.” Meanwhile, Dad may be thinking, “If he can’t have a good recovery, I almost hope he dies.” Obviously, everybody is worried and overwhelmed by their fears. However, despite the common concern for the head injured patient, some family members are distressed to learn about the feelings of others. Don’t be embarrassed to discuss these conflicts with the social worker or another member of staff.

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LEVEL IV: CONFUSED-AGITATED

This new stage is very different from Level I-III. The pendulum has swung: the person has gone from under-activity to over-activity. His needs have changed from stimulation to structure because he overreacts. The person will usually be very active and may behave very strangely. He may cry, yell or scream, flail his arms, or thrash about in bed as an overreaction to stimuli, even after they are removed. He may show aggressive behaviour, like hitting out at others or he may attempt to remove tubes or to crawl out of bed. He shows “all or nothing” behaviour…he’s either asleep or he’s awake and too active. This can be frightening for some family members.

He can only pay attention for very short periods of time. When he does pay attention, even for a minute or two, he may look and act so much like himself that it’s a common mistake to overestimate his abilities. Although improving, he is still severely cognitively disabled. As he has become alert, he has become more aware of the stimulation from his environment, but his brain is still not functioning well enough to make order or sense out of all that stimulation…extreme confusion is the result.

The only memory he has is for events that happened before the head injury.

If he is able to speak, he may use the wrong words, mix up the order of words or tell disconnected or inappropriate stories. He cannot be held accountable for his behaviour; he is not yet capable of producing thought-out action. He is usually unable to co-operate directly with treatment efforts. The brain is like a computer. It processes, stores and retrieves information. Everything that happened before the accident was well processed and stored…now it only needs to be retrieved. On the other hand, recent events or new information is being processed, stored and retrieved by this “computer” that is still “short-circuited”.

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SUGGESTIONS FOR THE FAMILY FOR LEVEL IV (CONFUSED-AGITATED)

Always remember, this is a stage, a sign of improvement, it is not a personality change. It is one of “the shades of grey” that are part of the process of recovery.

When he is not agitated, use this time to improve his ability to respond correctly. Work in a quiet environment.

Encourage him to try simple self-care tasks such as brushing his teeth and washing his face. Place the objects he needs within reach. Don’t expect co-operation at this stage, be pleased when you get it.

Do not startle him, especially when you wake him up from sleep.

If you visit him during a meal, give him only one choice of food at a time and let him do as much for himself as possible.

Limit the number of visitors to one or two at a time. Don’t talk to the head-injured person, play the radio, feed him, stroke his arm and visit with other visitors all at the same time. He needs structure and order…too many things happening at once just adds to his confusion.

Communication is important for a person’s recovery. If the person is not speaking, use another consistent way of communicating such as head movement or finger tapping to indicate “yes” or “no”. The speech therapist and/or occupational therapist may be able to help you with this.

Continue to calmly reorient him to both his past and present. As he becomes more alert, make sure that there aren’t mixed-up family patterns which may increase his confusion. For instance, if a 35 year old man is being treated like a baby by both his mother and his 12 year old daughter, he will have even more difficulty sorting out that he is an adult, as well as a son and a husband and a father.

Correct inappropriate or inaccurate responses matter-of-factly. If he thinks he is at the farm, don’t ever agree and make a comment about the cows. Gently but clearly tell him how he was injured and that he’s in hospital. Repeat this once if necessary. If he continues to insist that he’s at the farm, don’t argue. Change the topic. Comment on the weather or tell him what he’s having for lunch.

Never scold or threaten or ridicule him by saying things like, “Grow up and act your age” or “You know better…”,or “Behave, or I won’t come back to visit.” It also doesn’t help to laugh at him, instead of with him.

When he becomes agitated, do NOT walk out on him or ignore him until he calms down. (Unless for some reason YOU seem to be triggering his agitation that particular day.) Human contact and reassurance by family usually have a soothing effect. Touch him, wash his face or body with warm water, or play soft music. Check with his nurse. If he is capable of swallowing, you can try giving him water, juice, a warm drink or finger foods to help calm him down.

It’s very normal for family members to sometimes get impatient and frustrated. After all, this childish behaviour you see doesn’t “fit” with an adult who probably by now looks very much like he did before the accident. If he swears at you or you witness a tantrum, don’t take it personally. Remember, it’s the “brain injury” swearing at you, not your son or husband. Be patient, for he doesn’t usually know what he’s doing or saying.

The great fluctuations from deep sleep to thrashing in bed which characterize this stage can cause additional problems within families. The patient’s wife may report to her in-laws that her husband is very restless and aggressive. The in-laws visit an hour later and he is calm. Then they might ask themselves, “Is our son mad at his wife?” Please remember that behaviour fluctuates greatly according to fatigue, amount of stimulation, time of day, etc. It is important not to “blame” these circumstances on each other.

By this stage, many family members feel as if they are on an emotional “roller-coaster”. They’ve gone from the initial “low” of worrying about survival to the “high” of seeing the person stabilize and become more alert. However, when alertness reflects confusion and agitation, illustrating the severity of the head injury, many people feel another “low”. It is common to feel overwhelmed as you begin to realize that some disability has resulted from this head injury and that rehabilitation is a long, slow process. These feelings are normal and you may feel better if you discuss them with a member of the team.

Don’t forget about the other people in the family. Try not to assume that children and adolescents “understand” that a brother/sister/mother/father has been hurt, so it “doesn’t matter” that no one asks about the math test or goes to watch the peewee hockey game. Because of the need for security, comfort and support, it probably matters more.

Medications to settle the head-injured person are used as little as possible because sedatives slow the thinking process and can make the confusion worse.

Remember tears and yelling do not represent great physical pain or emotions like anger, hatred or grief, but a generalized response to stimuli. Please do not label him stubborn or unco-operative.

HE IS UNABLE TO CO-OPERATE!!

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LEVEL V: CONFUSED-INAPPROPRIATE

The person appears alert and is able to respond to simple commands fairly consistently but has difficulty following more complex commands. He is able to concentrate longer but will need frequent redirection because he is so easily distracted. Memory for events in the past is now evident, but memory for everything that has happened since the accident is very poor. He may not remember what you told him five minutes ago. He may be able to do automatic, overlearned tasks such as eating and dressing, but he is still unable to learn new information. He may seem to have lost all good manners. He may be sexually inappropriate or he may gobble his food, and then belch proudly.

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LEVEL VI: CONFUSED APPROPRIATE

The person follows simple directions consistently and is able to remember how to do routine activities like feeding, dressing and bathing. Memory for recent events is still poor, which makes learning new information very difficult. The person’s mind wanders less often and he is more aware of time and place. His attention can sometimes be held for as long as 30 minutes and during that time he will talk and behave more appropriately, although he may act somewhat “robot-like” or “mechanical”.

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SUGGESTIONS FOR THE FAMILY FOR LEVEL V (CONFUSED-INAPPROPRIATE) AND LEVEL VI (CONFUSED-APPROPRIATE):

Go over information about family and friends. Use the photo albums you’ve put together as a way to stimulate memories.

The capacity to experience normal grief returns much later than the ability to understand and remember factual details. This does not represent psychological “denial”. Instead, this illustrates poor short term memory. Any bad news is another piece of “new learning”. By this stage, it is appropriate to tell the head-injured person the painful but important information that someone else was killed or badly injured in the accident. There is far, far more pain in the telling of this news than there is in the hearing of it. It will not “make him go back into the coma”.

Even though you don’t feel calm, try to tell him calmly, “Unfortunately, Joe was killed in the accident…he didn’t suffer or have any pain…Joe died almost instantly…” The person may get momentarily upset but this is likely to pass very quickly. If someone stays upset, it is usually because he sees the distress of the person telling him and he responds to or possibly even mimics this.

You will notice that he may be more confused in spontaneous conversation than he is on direct questioning. For instance, if you sit with him quietly and wait for him to initiate conversation, he may say something bizarre, e.g. he has seven brothers all named Joseph who all ride motorcycles. However, when you ask him one minute later, he may be able to name the starting line-up for the National League in last year’ s all-star game. This illustrates how much he needs your help in focusing him on topics as part of reducing his confusion.

Work with him to help bring out the information which is stored in his brain but is not easy for him to recall without help. Ask him a question and if he can’t give the correct answer, give him some clues. For example, if you ask him immediately after breakfast what he ate and he cannot remember, be more specific. Ask him what he drank. If this doesn’t help, tell him it was white and see if he can remember that it was milk.

It sometimes happens that a person completely misinterprets kissing, embracing, or stroking as sexual messages, instead of affection and encouragement. If he is exhibiting sexually inappropriate behaviour (to the “wrong” person or at the “wrong” time or in the “wrong” way or in the “wrong” place), try to desexualize contact. Encourage him with lots of verbal praise and limit physical contact to a peck on the cheek or a warm handshake, or a pat on the shoulder. If the person does respond inappropriately, tell him so, in a calm, matter-of-fact way…such as, “I don’t want you to touch me like that.”

Ball games, memory games, simple card games, etc. are all good relearning experiences. Always remember though that concentration and attention are still impaired. He may play well for awhile, become distracted and then no longer remember how. Try again later, possibly in a quieter environment. Remember that his performance will often be inconsistent during recovery. Don’t criticize or nag him. Try to be patient…though some days this may be very difficult.

If he has trouble with his bowel and/or bladder control, do not reprimand him. Instead, try to be helpful by offering reminders/suggestions such as, “I’ll be ready to go for a walk as soon as you’ve gone to the bathroom.” This gentle prodding is more likely to work than asking, “Do you need to go to the bathroom?” He may not be able to interpret the warning “signals” from an almost full bladder. As well, when you take him home on pass, you may find it useful to limit his fluid intake in the evening. This reduces the chance of bedwetting and increases the chance of him sleeping through the night…then everybody will be more rested.

Encourage his success by praising everything that he is able to do. Success is far more effective than too much “challenge”. If a task is overwhelming, frustration is the result. The frustration sometimes leads to aggression and almost always increases confusion. For instance, if he is only able to play cribbage for ten minutes, don’t try to push him to play bridge instead. He may become so overwhelmed that he can’t even identify the cards and ends up throwing them in the air out of frustration.

He may laugh or cry easily and not always appropriately. Usually, the best thing to do is to ignore this response and/or suggest another activity and/or change the topic, until he calms down.

Assist him with “homework” or assignments that he is given by the speech therapist, occupational therapist, or physiotherapist. Help him to start making entries in his journal on his own.

Slowly increase independence by gradually decreasing the amount of help you give for specific activities.

Continue to keep his activity moderate. He is likely to need rest during the day, but may not have the insight to realize this. Therefore, don’t ask, “Are you tired?”, or, “Do you feel like a snooze?” Instead, suggest or model, “Why don’t you have a rest”, or “While you’re lying down, I’m going to rest in the waiting room.”

Ask him how to get from the gym back to the ward. Have him describe the best route from home to school or work.

Ask him to tell you about the hockey game on television, conversations, or other events, immediately after he has seen or heard them.

Despite the fact that he is now quite well oriented, he may occasionally still say something strange because he can’t sort out fact from fantasy, dreams or fears. Have you ever wakened from a deep sleep and not known whether the phone rang in the night or if you dreamt the phone rang? Particularly when tired or when first wakened he may not be able to differentiate between hoping his girlfriend would visit and an actual visit. He may not be able to tell the difference between worrying about a possible dispute and whether or not one actually happened. Always try to calmly re-establish “fact vs. fiction”.

When you take him home on pass, vary the daily routine as little as possible. Simplicity, consistency and routine, all improve function. If, for instance, he has trouble “remembering” to shower, help him develop the habit of showering at approximately the same time every day.

Within his tolerance, use every situation as a learning experience. Everyday tasks may still be difficult for him. Help him count money and make change. Ask him about the steps involved in making orange juice or washing clothes or making a bed, and then have him actually do the task he has described.

How are the children doing? Remember, if they’re not getting enough attention, they’ll find their own way to make sure you notice them.

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LEVEL VII: AUTOMATIC-APPROPRIATE

By this time, the person appears normal on the surface, at the hospital and then at home. He performs daily routines automatically, with little or no confusion, but has limited recollection of what he has been doing. He has poor judgment, reduced problem-solving ability and cannot plan realistically for the future. He has very limited insight into these problems.

He is able to learn new information, but at a slower speed and with more difficulty. For the sake of his safety and learning, supervision is required both at home and in the community. He is able to take part in and enjoy more recreation and social activities.

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SUGGESTIONS FOR THE FAMILY FOR LEVEL VII (AUTOMATIC-APPROPRIATE)

Discuss with the person situations within the home that could be dangerous and have him tell you what he would do to avoid them. Go over safety and emergency measures. Have him take point form notes. Even if a person is able to tell you what he would do in a fire, in the real situation, he is likely to panic unless his response has been “well rehearsed”. The stress of a situation can slow a head-injured person’s response time and ability to function, both mentally and physically.

Encourage him to write in his journal daily.

Have him practice using the telephone directory and reading a map. Take him to the grocery store and have him locate items and estimate costs. Have him make up a “chore list” for the day so that he can make his bed, help with house-cleaning, fix light meals, carry out trash, do some weeding in the garden, etc.

Work on a computer may be helpful as a part of redeveloping step-by-step logic. This is particularly true if he was familiar with computers before his accident (then he won’t have to learn to use the computer as well). Discuss appropriate programs to be working on with the speech therapist and/or occupational therapist.

It is very important to make sure that your words, actions and gestures are all clear and congruent. For instance, don’t nod and say “yes, yes” out of impatience when you’re listening to him. Rushing him is not only stressful but he can easily interpret this way of doing it as complete agreement with everything he’ s said. For the same reasons, teasing, cajoling and sarcasm are frequently misunderstood by a head-injured person.

Do not let him drive a car, ride a motorcycle, take a boat out alone, or operate saws or farm equipment.

Many people occasionally find themselves “at odds” with both immediate and extended family, as well as friends, on the amount of supervision that is required. Teenagers may complain that their parents are “babysitting” an injured sibling. Friends may complain that a wife should allow her husband to drive or to return to work so that it will “cheer him up” and “make him better”. Especially if the head-injured person has a good physical recovery, it can be easy for others to ignore the cognitive disability. This usually leaves the family members feeling unappreciated by the patient and unsupported, even criticized, by others. Contacting other families from the Saskatchewan Head Injury Association may help to reduce the loneliness and isolation that can result from such interactions.

He may still be slow in responding to questions or hesitant in initiating conversation and/or activities. Be patient and be creative. He may appear “unmotivated” or “lazy” or “lethargic” because he can’t think of anything to do but watch television. Never label him in any of these ways.

If he is not overwhelmed by choices, make two suggestions and encourage him to choose between them. Would he like to….go for a walk or visit his friend, play a video game or go shopping, watch his kid brother play baseball or paint the fence? For necessary things, like homework, offer him a choice of when, not whether, he’ll do it…”Do you want to do your speech therapy exercises before, or after, dinner?”

Rather than being slow to respond, he may be too fast, blurting out what’s on his mind, without regard to social appropriateness. For instance, when the two of you are waiting in line at the grocery store, you may both notice the woman ahead of you. You may think, but he may say, “Gee, she’s fat!!” You need to calmly and matter-of-factly offer feedback about such behaviour as soon as it’s appropriate.

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LEVEL VIII: PURPOSEFUL-APPROPRIATE

Memory for past information is good, while memory for recent events and “new learning” may still seem foggy or fuzzy. He is able to learn new information, although not as much as before the accident and not as quickly. If he was a university student before the accident, he is still likely to have difficulty returning to full-time studies.

Following severe head injury, a person frequently continues to show a decreased ability to reason, tolerate stress, or use good judgment in emergencies or unusual situations. Frequently, social, emotional and intellectual capacities continue to be less than before the injury, but are good enough for the person to function in most social situations. If he is unable to return to his former employment, vocational assessment and then retraining may be necessary.

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SUGGESTIONS FOR THE FAMILY FOR LEVEL VIII (PURPOSEFUL-APPROPRIATE).

Encourage maximum involvement in the home, school or job within the person’s physical and intellectual limits. Help him pace himself.

Involve him in complex tasks such as total meal planning and preparation, organization of several home tasks into a daily routine, planning leisure time, initiating activities independently and developing individual aids to plan his time such as schedules, reminder lists, etc. Have him assume responsibility for specific chores.

If he requires regular medication, it should be his responsibility to take the correct dosage at the proper time.

Have him practice balancing his chequing account, handling an allowance appropriately and budgeting.

He needs to practice using public transportation by himself. Initially, you will have to accompany him, to direct him and then to supervise him as he tries on his own.

Before driving a motor vehicle again, first he is required to complete a Supplementary Insurance form, explaining that he has suffered a head injury. (These forms are available from any Motor Licensing Office of Saskatchewan Government Insurance.) Next, he is likely to require some retraining before retesting.

Establish and maintain a relatively stable daily routine. This helps the person feel more secure in his environment. Frequent changes, even little ones, may be upsetting. For instance, he may not be able to adjust to the unpredictability of the hot meal of the day being served at noon one day, 5:00 p.m. another day and 8:00 p.m. the next.

The need for structure, order and direction, combined with a need for acceptance, can leave him very susceptible to the influence of cults or certain religious groups which have rules, regulations and prescribed patterns of behaviour.

As well, some people are very gullible and susceptible to peer pressure. They will readily do even foolish things because it’s “required”. Therefore, families sometimes need to watch out for others who may take advantage of the head-injured person.

Familiar sayings that we use to express a more complicated idea, such as “There’s no use crying over spilled milk”, can be very confusing. He may take your words very literally. For instance, you may, 2sk “What’s on T.V.?” and he may answer, vase with some flowers. He’s not being sarcastic or difficult, he’s answering the question … literally.

The inability, or reduced ability, to think abstractly (at more than one level) means that he may most enjoy concrete or slapstick humor. If a situation is not funny, simply disregard his laughter by not laughing yourself.

Don’t assume that a head-injured person will be able to learn from his mistakes as well as he did before his accident. For instance, he might go to the bar, drink beer all evening and have his wallet stolen. The next morning, hung over and without a wallet, he might be very remorseful. He realizes that his doctor was right when he told him that he should not drink beer at all. However, several days later he might consider going out to drink rum, not beer, because he sees no connection to his previous escapade. This is called a problem of generalization and when combined with poor judgment (drinking in the first place) it reduces the chance of learning from one’s mistakes. Calm feedback and interpretation from others can help “tie” situations together.

Try to measure improvement from the time of the accident and avoid comparing him to “how he used to be before”. As well, learn to appreciate the new person, who is likely to be different in many ways after the injury. There may be personality and behavioural changes as well as differences in his pattern of likes and dislikes and some ongoing problems with memory and judgment. However, he is still a person who needs your support, affection and companionship.

You need to demonstrate patience, tact and intelligence, while “walking the fine line” between encouraging and rewarding independence, yet still providing the necessary background support and interpretation required to deal with the world. It’s a delicate balance and difficult to achieve. Congratulate yourself whenever you’re successful.

Most people are referred for neuropsychological assessment. The person doesn’t pass or fail these tests. The tests provide more information about the head-injured person’s strengths and weaknesses in areas such as memory, attention, “mental speed” and learning ability. These tests are useful in helping to determine when and if someone is ready to return to work or school, full or part-time. Returning prematurely can be a major source of frustration.

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