08.c.vi • Behavioural management guidelines

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

These guidelines are intended to provide useful information for staff working with patients who have cognitive deficits and who may present with challenging behaviour. Staff should find them particularly helpful for patients in the first few weeks of their admission to the ward, when problems are more severe. They are designed to provide useful background information to help staff understand the patient’s difficulties and behaviour and then to offer practical guidance in terms of management. Suggestions for management may focus on things the team needs to do, things staff can ask relatives/carers to do, and changes which could be made to the patient’s environment.

It is important to remember when seeking to change behaviour that consistency of approach is vital. Therefore all staff working with the patient need to be aware of the guidelines and use them every time they interact with the patient.

These guidelines have been written for staff. There may be information which staff feel it would be useful for relatives/carers to know and it is intended that in such cases this information would be discussed with the relatives / carers by a member of the team, rather than simply being given to them. If a member of staff wishes to give a relative or carer a copy of any of these guidelines, this should only be done with the agreement of a psychologist (if available) or occupational therapist (OT) who knows the patient.


Further help in managing this patient group

Managing patients with neuro-behavioural disorder in an acute setting can be very challenging. For patients being treated outside of the Major Trauma Centre, please flag up any behavioural problems with your Trauma Link who can contact the Network Co-ordination Service for further advice.



08.c.vi • Behavioural management guidelines: post traumatic amnesia (PTA)

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

Everyday memory and general functioning is disrupted.


Presentation

In the early stages after brain injury the person may still be in PTA. PTA is a phase marked by sometimes severe confusion/disorientation associated with memory loss for some events immediately before the injury and memory loss for events since the injury. Therefore, although the person may be conscious and responsive their everyday memory is not working at all. This is because their brain function is so disrupted that they are unable to lay down new memories. The person may be agitated and/or aggressive, which may be related to the bewilderment he or she often feels due to being unable to always remember what has happened.

  • The person may be unable to work out what is happening to them and thus become frightened and/or agitated. Their behaviour may appear bizarre and they might become fixed on an idea, eg. they firmly believe that they have to get to a meeting, or that the hospital is a hotel or a prison.
  • It may take some weeks for the person to remember important information, eg. they are in hospital; they have had a brain injury; who people are.
  • The person is often disorientated in time, ie. not remembering the day of the week, month or year.
  • The person may have great difficulty in finding their way around the unit and they may wander, putting them at risk.
  • In the first few weeks the person will tire easily doing very simple things and will only be able to concentrate on what you are saying or doing for very short periods.

The duration of PTA is linked with the severity of the head injury. The longer the period of PTA, the more severe the head injury, with PTA lasting more than seven days being considered representative of a severe head injury. PTA can last from hours to days to weeks and is a difficult period to manage. If the period of PTA is prolonged, consideration should be given to transferring the patient to a specialist neuro-behavioural environment (see Directory of Services and seek advice via the Network Co-ordination Service).


Attention

In the early stages of recovery following a brain injury the person will often have difficulty with many aspects of attentional function. Therefore he or she may only be able to concentrate or focus on something for very short periods of time. He or she may also have difficulty in attending to more than one thing at a time. There may also be difficulties in switching from one task to another. This often improves quickly over the first few weeks. It will be necessary to keep any instructions you give the person very short and concise.

Clinical management issues to consider

Team

  • Try and organise a single room for the patient.
  • For the first week or two following admission the person should not be permitted to leave the ward unless accompanied by a member of staff (consider Deprivation of Liberty (DOL)). If confusion and/or disorientation is severe and the person presents a risk, eg. wandering, it may be necessary to provide ‘specialing’ to reduce risk.

  • General communication:

      • Do:

    • remain calm at all times during communication
    • expect to have to repeat yourself time and time again
    • use an errorless learning approach, ie. give the patient correct biographical and situational information

      Don't:

    • become frustrated with patient or with lack of progress – this phase is usually shortlived (days) but can last for weeks
    • try and test the patient’s memory or orientation unless performing a formal cognitive assessment
  • Orientation:
    An orientation kit consisting of a board with cards giving current information (year, month, date, day of the week, name of hospital) should be put on the person’s wall in their room and the person should have their attention directed to it frequently during the day. Encourage visitors to do the same. As the person improves they can be encouraged to change the cards on the boards themselves.
  • Programme:
    A large copy of the person’s weekly programme will be put on their wall. Attention should be drawn to it frequently throughout the day to assist with orientation, eg. what the person is doing next. As the person gradually improves, encourage them to refer to the programme each day themselves.
  • Overstimulation:
    Balance the need for a regular programme of activities with the person’s need for lots of rest at this stage. If the person is in PTA or does have significant attentional problems, this may mean that therapy sessions will be very short at first. Cognitive assessment should be kept to a minimum, but if any longer than 20 minutes should be conducted in stages over several days. Make use of bed rest or ‘quiet time’ at regular intervals and especially if the person is upset or agitated.

Family and visitors

  • Write a simple account of the accident which led to the hospital admission.
  • Keep a diary in the room for visitors to use. They can record simple information, eg. who visited and when, what was done or talked about.
  • Ask visitors to leave some photographs of people/pets/home with labels underneath.
  • Ensure visitors do not try to ‘test’ their relative by asking lots of questions. At this early stage it is much better to just give information, rather than expect them to remember it.


Outcome measures/ assessment tools

  • perform risk assessment regarding risk to self or others, including risk of absconding
  • Westmead PTA Scale
  • seek specialist advice

References

Rehabilitation following acquired brain injury: national clinical guidelines, BSRM & RCP (2003)

Delirium: diagnosis, prevention and management (NICE, July 2010) (same principles apply)

Post Traumatic Amnesia factsheet, www.headway.org.uk


Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: agitation

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

Brain injured people at an early stage of recovery tend to have a very low tolerance for frustration and fatigue, eg. if you are late, if they cannot do something easily or if they need a break.

When first admitted to hospital it is common for many patients to go through a stage of agitation, maybe because the environment is new and unfamiliar to them and they are struggling to adjust to their situation. They could be worried about physical or cognitive changes or simply desperate to get home and concerned about their future. In particular, cognitive changes may make it difficult for the person to be aware of and control their agitation.

As time progresses and the person adjusts to their environment and their situation and begins to make relationships on the ward, agitation generally decreases.


Clinical management issues to consider

  • Consider the potential for the presentation being due to drug or alcohol withdrawal or other medical factors.
  • Remember brain injury patients are very sensitive to the psycho-active properties of drugs.

Team

  • Remember that the person may not recognise that they are beginning to become agitated and it is therefore necessary for you to take the lead.
  • If the person becomes agitated find out why if you can. Try to calm them down, eg. by reminding them why they are in hospital. If the agitation does not reduce, distract the person’s attention to something else or if it is safe to do so leave them to be alone for a short period.
  • Try to keep the environment as quiet as possible and encourage the person to have rests at regular intervals.
  • Structure the person’s day to balance stimulation and relaxation. Remind the person about what they are meant to be doing and when, as routine can provide familiarity and reassurance.
  • Try not to take the person’s behaviour personally. It is important to be calm and speak quietly. The person cannot control the way they are behaving at this early stage.
  • When the person has calmed down they are often apologetic. Use this opportunity to reinforce information you want them to learn, eg. ‘you tend to get worked up because you have had a brain injury’.

Family and visitors

  • Try to encourage only one or two visitors at any one time.
  • At the early stage visitors should be limited to several people the person knows really well. It is often useful to agree who these people will be with a key family member (if other visitors arrive unannounced it may be necessary to refuse access with appropriate explanation).
  • Discourage visitors from questioning or testing the person about what they can remember or do. Avoid direct confrontation as much as possible.
  • Early on, visits should be kept short, in some cases as short as 15–20 minutes if the person gets very agitated. Try to ensure visitors keep to this even if the person seems to be coping well. It is better to end the visit on a good note.
  • If the person becomes agitated before the normal end of the visit, try to calm down and distract them onto another topic of conversation or onto another activity, eg. by taking them for a walk. It may be necessary to leave earlier than planned. Remind relatives that the person will have good and bad days.

Outcome measures / assessment tools

  • Agitated Behaviour Scale (ABS)
  • Antecedent, Behaviour, Consequence (ABC) chart
  • perform risk assessment
  • seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: disinhibition

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

Early in recovery after brain injury disinhibition may result because the person lacks full control of their behaviour, being unable to distinguish between socially appropriate and inappropriate behaviour. This is often a result of frontal brain injury, particularly the orbito-frontal regions.


Presentation

  • Over-familiarity, eg. willingness to divulge too much personal information or where the person expects staff or other patients to divulge too much personal information.
  • Using language that the person would not normally use in this setting, eg. swearing.
  • Inappropriate sexual behaviour, eg. inappropriate sexual remarks or advances.
  • Laughing inappropriately or silliness.

Clinical management issues to consider

It is important to be aware of certain factors either internal or external which may be acting to trigger inappropriate behaviour. Thus, if the person is over-tired, bored, or over-stimulated, these are examples of internal factors which may be influencing their behaviour. Examples of external factors which can trigger inappropriate behaviour are noise, other patients, a change in routine, or being asked to do something they do not want to do, or find difficult to do. It is therefore necessary when trying to change behaviour to consider all of these factors and change them where possible, eg. moving the person to a single room, or giving them shorter therapy sessions.

Disinhibited or inappropriate behaviour can be very upsetting and even frightening to family members or in some cases may cause the family to become angry themselves. It is therefore essential for the team to explain to the family what is causing the behaviour and advise them on simple ways of dealing with it. This may include things like leaving the person if they become agitated to go and have a drink or even cutting a visit short and trying again later.


Discourage

When behaviour is inappropriate calmly but firmly discourage the inappropriate behaviour immediately. When inappropriate behaviour is more subtle or in a group situation you can try to ignore it and distract the person onto something else.


Feedback

Give the person immediate feedback about the inappropriate behaviour. Be very specific about what aspects of the person’s behaviour is inappropriate and why, eg. if the person is undressing in public you could say: “This is not the time nor place for taking your clothes off”. Explain the need for privacy or the possibility of offending others. Be aware that the person may be unaware of when they are behaving inappropriately or how bad it is. Often after brain damage people have problems with monitoring their behaviour. Often, providing regular feedback can itself be enough to trigger improvement.


Coach

Encourage the person to behave appropriately by encouraging the behaviour you consider appropriate for the situation, eg. “In a group of people it is polite not to shout. People will listen better if you speak calmly.”. Praise the person when they manage to behave or interact appropriately and provide a reward if possible, eg. a drink, a walk in the garden, etc.

Due to cognitive problems such as poor attention or poor memory, be prepared to repeat yourself often. Changing behaviour takes time!


Redirect

After providing constructive feedback and coaching, redirect the person in order to re-focus their attention on the activity they were engaged in before the inappropriate behaviour occurred. If the person was not actively doing something before find something for them to do.



Outcome measures / assessment tools

  • perform risk assessment to clarify level of risk to self and others. If risk demonstrated, seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: confabulation

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

Confabulation has been defined as ‘a falsification of memory occurring in clear consciousness in association with an organically derived amnesia’ (Berlyne, 1972). Confabulation manifests after brain trauma particularly when there is a combination of memory loss and frontal lobe injury.

Confabulation is usually temporary but may in some cases continue to be a long term problem.

Examples of confabulation

  • Bizarre explanations about how the accident happened.
  • Getting information or details of conversations mixed up.
  • Talking with conviction about something which did not happen.

Clinical management issues to consider

  • Never encourage or reinforce inaccurate information. Calmly but firmly correct the information, eg. ‘This is what did happen or this is what we talked about’.
  • Some people will become agitated or confrontational when corrected. After giving correct information distract their attention onto something else.
  • Provide explanation to family about why confabulation occurs.
  • Encourage family and friends not to ask the person to explain why they believe what they have said. This simply results in confrontation or long tiring explanations and reinforces the incorrect information. Advise them to correct the person quickly but in a kind and matter of fact way.

Outcome measures / assessment tools

  • perform risk assessment to clarify level of risk to self and others. If risk demonstrated, seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: perseveration

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services


This refers both to:

  • Perseveration of ideas: where the person is unable to move onto another topic of conversation, returning to the same theme repeatedly.
  • Perseveration of behaviour: where the person repeats the same action and is unable to break the cycle without help, resulting in them repeating the same mistakes.

Clinical management issues to consider

Perseveration of ideas

Signal to the person that you are going to change the topic so they can try to clear their mind and concentrate on a new topic. Move on, but be prepared to give a reminder that you are now talking about something else, eg. ‘No we are going to talk about this (whatever it is) now’.


Perseveration of behaviour

It can be helpful to model what you want the person to do instead. If this does not work after a few tries it is better to take a break. Try not to allow the person to become agitated as this can make things worse.


With family

Explain to the family why the person is so repetitive in their conversation or behaviour as otherwise the behaviour can be irritating or seen as being ‘difficult’.


Outcome measures / assessment tools

  • seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: lack of insight/denial

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services


Impaired insight is a common feature of frontal brain injury.

  • Impaired insight usually improves over time as the person becomes more aware of their limitations. However, in some cases development of insight will be part of a longer process and may require specific intervention.
  • People with brain injuries, whilst usually able to recognise physical disabilities often have difficulty in recognising and accepting changes in thinking and behaviour.
  • In order to behave appropriately in social situations we need insight. Insight enables us to predict and evaluate the effect of our behaviour on other people and allows us to imagine how they feel.
  • Lack of insight in the early stages is often due to the extent of disruption of normal brain function and is therefore related to the extent of the damage.
  • Lack of insight often causes difficulty because the person often refuses to accept their limitations and may be reluctant to participate in rehabilitation seeing no need for it. It may therefore cause aggression.
  • Lack of insight may also reflect a psychological difficulty in accepting changes in oneself and one’s situation. In this case it is usually referred to as denial.

Clinical management issues to consider

  • Give simple, repeated explanations of why the person needs to be in hospital. Likewise, give clear, simple and frequent explanations of why the person is unable or less able to do something. It may be useful to have the above explanations written down for the person. The whole team should be aware that the same information usually needs to be repeated many times until it ‘sinks in’.
  • The person may have an unrealistic view of what they are able to do, eg. going home, going to work. Be cautious about telling someone just that he or she cannot possibly do something now. Instead, set specific smaller goals that are realistic and emphasise the importance of achieving these first in order to reach the patient’s goal. This enables the person to feel that they are still making progress and helps them see the point of what you are working on.
  • If, after a clear explanation the person still continues to refuse to accept problems or the need for help it is usually better to change the subject or do something else. Long attempts to reason with the person will only result in agitation and stress. You can emphasise the need for rest and relaxation at this stage of recovery and if necessary, leave the person alone for a short time.
  • It may be useful to agree set goals with the person and begin working first on those which they are most motivated to achieve. If a person is repeatedly reluctant to work on something it may be necessary to switch to something else.
  • Alternate between working on things that the person finds difficult and things that s/he enjoys.
  • Involve relatives and friends in reminding the person about the reasons why we need to work on something.
  • Go slowly and initially set out to achieve small goals, eg. the person will spend 10 minutes in the agreed activity. This can be gradually increased as motivation improves.
  • Assessments and functional tasks can be used as a means of demonstrating difficulties to the person. When a difficulty is encountered draw the person’s attention to it in a matter of fact way. Remember to emphasise progress made and potential for improvement, eg. if the person is doing some cooking and misses out a step, draw attention to it and try to work out with them why this happened (could this be due to a memory failure or not reading the whole recipe).

Outcome measures / assessment tools

  • seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service



08.c.vi • Behavioural management guidelines: poor motivation and initiation

Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services

Injury to the medial frontal regions of the brain is particularly associated with the presence of apathy. The apathy often has emotional, motor and cognitive dimensions and manifests as poor initiation and motivation.

Poor initiation is a difficulty in getting started. Typically the person will not do much at all when left alone and will have difficulty in generating ideas about what they could do. The person appears to lack motivation and/or interest in engaging in activities, but once started on activities may persist and enjoy them.

Poor initiation and motivation can often be mistaken as laziness. In other cases poor initiation and motivation may reflect the person’s lack of insight or be associated with depression. It can also be because the person does not yet understand the goals of rehabilitation or the process involved. The person may also lack initiation but still be motivated to do some things, eg. he/she may be motivated to smoke but show poor initiation for getting washed and dressed. This is due to different areas of the brain being damaged.


Clinical management issues to consider


Before tackling these problems it is important (if possible) to identify which of the above factors are involved.


Depression

If there is reason to think that the person may be depressed it is important to first address this by asking the doctor or psychologist to carry out a specific mood assessment. Management may then involve medication and/or psychological intervention.


Frontal lobe damage

In this situation it is often necessary for the therapist / nurse to take the lead. Ensuring that the person has a clear structure to the day is important in improving initiation as it allows the patient to experience repetition of a task, which makes learning easier.


Possible strategies

  • Provide opportunities for the person to engage in activities. Try to find out what the person might want to do and do not expect them to be able to choose between lots of different options. Provide two options for them to choose from.
  • Provide structure for the day, eg. in the programme and be prepared to give lots of encouragement, prompting and reinforcement.
  • Make use of timers and alarms to alert the person as to when an activity is about to start or when they are expected at therapy.
  • Make relatives aware of the reasons for poor initiation/motivation as otherwise the behaviour can be upsetting or misinterpreted as laziness or lack of interest.

Outcome measures / assessment tools

  • seek specialist advice

Good practice & clinical guidelines

Seek specialist advice via Network Co-ordination Service