Connect with us
  • Elysium

Insight

A holistic perspective on Post-traumatic amnesia 

Specialists at St Andrew’s Healthcare explain how clients are supported through PTA

Published

on

Post-traumatic amnesia (PTA) can be defined as the period following traumatic brain injury (TBI) during which continuous memories are unable to be established.

This is the time after a period of unconsciousness when the injured person is conscious and awake, but is behaving or talking in a bizarre or uncharacteristic manner.

The terminology of PTA is misleading as the name alludes to a single primary deficit in memory. While the inability to consolidate new memories or anterograde amnesia is the hallmark of PTA, further characteristics include impairment in orientation, attention and executive functioning along with retrograde amnesia and disinhibition

This article is based on a narrative review supported by the clinical experience of delivering interventions following traumatic brain injuries in patients on the brain injury assessment ward, at St Andrew’s Healthcare. The review included the definition of PTA, presentation, assessments and management. 

Pathophysiology

PTA can occur when the force of an injury results in breakage, bruising and/or swelling of the axons with the consequence that message pathways are interrupted and/or broken. This is commonly described as Diffuse Axonal Injury (DAI). Diffuse axonal injury has been shown to be the main determinant of the relationship between PTA and severity of injury.

The amnesia resulting from trauma may be retrograde amnesia, particularly where there is damage to the frontal or anterior temporal regions. However, in some cases, anterograde amnesia develops several hours after the injury. 

PTA may be either short term or longer-lasting, in some cases over a month, but is rarely permanent. When continuous memory returns, the person can usually function normally.

Retrograde amnesia sufferers may partially regain memory later, but memories are never regained with anterograde amnesia because they were not encoded properly. Memories from just before the trauma are often completely lost, partly due to the psychological repression of unpleasant memories (psychogenic amnesia), and partly because memories may be incompletely encoded if the event interrupts the normal process of transfer from short-term to long-term memory.

There is also some evidence that traumatic stress events can actually lead to a long-term physical reduction of the volume of the brain’s hippocampus, an organ integrally involved in the making and processing of memories.

Why is PTA important?

PTA has long been considered one of the strongest predictors of global outcome in severe TBI, and it is used as an instrument for determining the required level of patient supervision, as well as the timing and planning of discharge.

In addition, PTA has been demonstrated to have more precise predictability of outcome, in terms of functional independence level, disability severity, and determining the level of required supervision than either the Glasgow Coma Scale and the presence of loss of consciousness and cognitive impairment in TBI. 

Clinical presentation and MDT assessment – the need to undertake a comprehensive multidisciplinary assessment

Patients with PTA may present with confusion, agitation, distress and anxiety. Other features seen are uncharacteristic behaviours such as violence, aggression, swearing, shouting, disinhibition, inability to recognise familiar people, and a tendency to wander. However, in other cases, individuals may be uncharacteristically quiet, docile, loving and friendly. Other features may include headaches, nausea, vomiting, dizziness, unsteady gait and intolerance to bright light or loud noise*

In all patients, it is essential to undertake a comprehensive multidisciplinary assessment of their health, impairments, as well as care and support needs.  This enables staff to provide appropriate levels of support and intervention and should include neurological impairment, cognitive and communication abilities, eating and drinking  abilities, nutrition and hydration status and psychological and behavioural difficulties. 

The assessment should include the gathering of a comprehensive medical, psychological, psychiatric, occupational, educational, forensic and social history including any history of substance misuse. This will involve obtaining information from a variety of sources including interviews with family and friends and a detailed review of all multisource case records. The assessment should continue after the period of PTA has ended as the person progresses to the rehabilitation phase.

There should also be consideration of the use of the appropriate legal framework, such as detention under the Mental Health Act or provisions of the Mental Capacity Act during treatment and hospital stay.

The importance of family and friend engagement

It is important to work with the family and friends of the patient to help increase their awareness and understanding of the presentation and the likely prognosis. It can also sometimes be beneficial to the patient if visits are short and to acknowledge that too many visitors at once may be overwhelming and difficult for the patient to manage. All this will help the family understand the patient’s need for rest and quiet without excessive stimulation.

At times it may be better just to sit quietly with the person rather than engage in too much conversation which the person may find overwhelming and may struggle to follow.

Protecting a person’s right to privacy

Protecting the patient’s right to privacy and dignity is also an important consideration for the treating team. The family should be supported to think about who should be permitted to visit. The patient may behave in a manner which is out of character and perhaps embarrassing for them and it may be helpful to wait until the patient is more settled and potentially more able to communicate effectively and appropriately. 

Visitors may find it appropriate to visit on a rota, especially if they feel unable to leave the patient without familiar faces for any length of time. It is also useful to provide guidance on how best to support communication with the patient.

Testing 

The Westmead Post-Traumatic Amnesia Scale (WPTAS) is the most commonly used method for measuring PTA (Kosch et al, 2010). WPTAS is a standardised and validated instrument which is suitable for patients with moderate-to-severe traumatic brain injury. It is a prospective measure of PTA and has been shown to have a high level of interrater reliability.

The scale contains 12 questions related to orientation and memory. These include seven in relation to normal day-to-day orientation and five for testing the laying down of new information as well as autobiographical memory, such as age and date of birth. It can be conducted by any trained member of the multidisciplinary team in a variety of settings.

A care approach for people suffering with PTA

The care of a patient suffering from PTA requires a multidisciplinary approach that addresses the patient’s environment, their interactions within that environment and their cognition and behaviour

Patients with PTA require a consistent team approach to create and maintain a low-stimulus, quiet and supportive environment. These patients require a lot of rest with only short periods of stimulus. The following are recommended: 

  • To be nursed in a single room where possible, in a quiet and calm environment
  • Reduction or minimisation of external stimuli
  • Develop a consistent routine and structure. This will include clustering activities so patients are not overwhelmed, and allowing enough rest in between activities or tasks
  • Carefully managing visits
  • Create a familiar environment; using a few key personal objects and photos.
  • Clear communication within the multidisciplinary team, by using appropriate yet discreet signage on the patients’ room door to notify all staff that the patient has PTA 
  • Using a modified approach to ward rounds, assessment, meals and care. 
  • Keeping instructions simple during communication 
  • Appropriate Occupational Therapy and nursing interventions during PTA to include introducing the patient to simple tasks such as personal care. 
  • Family support by the multidisciplinary team to ensure a focus on education and the provision of support for family and friends
  • An understanding that management strategies for patients who present with aggression that involve negotiation and problem solving are unlikely to be successful
  • The use of sedation to manage behavioural problems to reduce the patient’s level of arousal can increase confusion and prolong agitation as indicated by inconclusive studies relating to this area.
  • Restraints should also be avoided as they can lead to greater agitation.

Our experience of PTA at St Andrew’s Healthcare

The Brain Injury Assessment unit, Tallis ward, at St Andrew’s Healthcare often receives referrals for patients with PTA who present with severe and challenging behaviour. The team has adopted a holistic, multidisciplinary approach based on the points described above. This includes ascertaining a robust and comprehensive history from family and other professionals alongside assessments undertaken in relation to physical health, functional ability, cognition, behaviour and communication. 

Physical health considerations include seizure management, mobility and falls assessments, dysphagia and nutritional assessments and ongoing maintenance of skin integrity. Each of these is modified and adapted to the individual patient and their presentation at the time. Environmental adaptations like the use of an extra care area on the ward associated with concerted efforts to reduce external stimuli are also employed. 

Assessments related to the use of appropriate and least restrictive legal frameworks is usually continuous and relate to timely and decision specific capacity assessments, including those related to consent to treatment and care.  

This wide range of comprehensive interventions enable the team to effectively implement risk manage and treatment strategies to safely support patients through an episode of Post Traumatic Amnesia to reach a point where they can embark on their rehabilitation journey. 

By: Dr Vishelle Kamath (consultant neuropsychiatrist – St Andrew’s Healthcare)

Dr Sanjith Kamath (executive medical director – St Andrew’s Healthcare)

Dr Awut Majak (speciality doctor – St Andrew’s Healthcare)

To find out more about St Andrew’s brain injury services visit Stah.org/brain-injury

* (Liersch et al, 2020: Liersch, K., Gumm, K., Hayes, E., Thompson, E. and Henderson, K. (2020). TRM 01.01 POST TRAUMATIC AMNESIA SCREENING AND MANAGEMENT GUIDELINE Trauma Service Guidelines Title: Post Traumatic Amnesia Screening and Management Developed by: K. Gumm, T, Taylor, K, Orbons, L, Carey, PTA Working Party Created: Version 1.0, April 2007.

Insight

Dementia care – how to use storyboards

Dementia Carers Count look at how this valuable creative tool can be used at home

Published

on

Do you know that people living with dementia often process visual stories and information better than verbal communication?

Misunderstandings, distress, fear and worry all impact heavily on us and can place strain on relationships. Visual aids such as storyboards can help maintain mental wellbeing for both the person with dementia and for the carer.

Sue Hinds, head of services at Dementia Carers Count, takes us through a range of techniques that carers can adopt (or adapt).

When and why visual support might be useful

There may be times when you need to support a person with dementia in attending events which are important to them. This might include appointments with the GP or other services, family events, shopping excursions, planning a trip and opportunities to engage in hobbies and pastimes.

We know that people with dementia often have challenges in both understanding information provided to them and/or retaining the information for long enough for it to be meaningful.

Carers tell us that a range of situations and emotions can arise. This could include the person with dementia refusing to go because they genuinely believe they were never told about it. Anxiety about where they are going, confusion, disorientation, agitation, distress, tearfulness, a sense of unease, and many more emotions can all emerge.

These situations can also provoke a range of emotions for you as a carer including stress, worry, fear, frustration, and anger.

Things we know:

  • Providing information in bitesize chunks can help a person with dementia.
  • Providing visual reminders can help.
  • Visual information is often better understood than verbal information.
  • Visual information can be referred back too, spoken descriptions (unless recorded are fleeting).
  • Step-by-step instructions help.
  • Visual formats can help a person express their concerns more clearly.

What are story boards?

Image of a storyboard example to use with someone with dementia

Storyboards are one way to help support a person to understand, remember and engage fully with a meaningful visit, event or routine either inside or outside the home. They can capture key elements and stages of an event with images which can help the person to understand the event and will help to describe the actions at each stage.

By creating a storyboard, it can help you to identify all the stages and can help you think about what situations might arise, and can support a person with dementia to express areas which give them concerns.

Often storyboards can then be adapted or used again for other events.

Misunderstandings, distress, fear and worry all impact heavily on us and can place strain on relationships, and a storyboard can help maintain mental well being for both the person with dementia and the carer.

They provide a way to cope, help to maintain relationships and provide a new way of coping with challenges – providing a new way of thinking, behaving and interacting together even when things are tough.

How to create a storyboard

Generally, a story board can look how you want it to look, but they should not have too much information on a page as this can be overwhelming.

You may wish to create a storyboard on one page, or a storybook where you flick from one page to the next, or even a storymat where you can add, remove drop things down into a ‘we are here now’ section.

Follow the steps:

Think about the task e.g. Going to the doctors, and then think of all the steps which will happen (this is unique to your own routine):

For example:

  • We need to get up and out of bed at 8am
  • We will go downstairs
  • We will have breakfast
  • We will go to the bathroom and have a wash
  • Clean teeth
  • Get dressed
  • Go to the car
  • Travel to the surgery
  • Wait in the waiting room
  • Go in to see the doctor and talk to the doctor
  • Say goodbye and leave the surgery
  • Get back in the car and drive home
  • Arrive home
  • Sit down in the kitchen for a cup of tea and a cake

Ideas of things you can use to help you

There are lots of symbols and resources which you can purchase to help with this, but a good tip is to also take photos within your own home and when you are out and about with the people and places you visit. This will help you to tell the story with as many familiar pictures as possible.

It’s also often worth taking photos during a familiar event so these can be used in the future.  However, if you need some symbols there are various sites you can purchase them from and I have listed a couple below.

The creative visual aids website also gives a wonderful explanation of how visual aids can be used to support children, but the principles are exactly the same. The video below talks about the use of storyboards with children and I am currently in discussion with Gina regarding storyboards for people with dementia.

Talking Mats is another incredibly useful resource for supporting conversations, with videos and case studies of how visual aids can help a person with dementia in conversation and day to day life.

Good luck creating one, and have fun – we would love to hear from you with photos, descriptions and stories of how and when you use them. Perhaps you could also inform other carers through our forum: Virtual Carers Centre | Dementia Carers Count

Continue Reading

Insight

Supporting mental and physical needs in complex dementia

St Andrew’s Healthcare look at the importance of meeting the needs of this client group

Published

on

Designed to recreate the feel of a village environment with a post office, pillar box, village hall, bandstand and bus stop, Lowther’s outside space helps to maintain familiar routines, encourage activities and provide essential distractions and engagement

In supporting the mental and physical healthcare needs of people living with complex dementia, specialist expert support is vital to achieving the best possible quality of life. 

St Andrew’s Healthcare is renowned for its work in this area and for its support of people and their families. Based within its Northampton site, the St Andrew’s neuropsychiatry service supports people with the most complex neuropsychiatric needs.

The service extends across Kemsley, the hospital’s brain injury unit, which has pioneered specialist neurobehavioural care since it opened over 40 years ago, and Lowther dementia hub, a bespoke environment opened in 2020 that is designed to meet the needs of people living with complex dementia and other progressive neurological conditions.

Working with older people within a neuropsychiatric service requires a range of specialisms. Here, we meet two of the multi-disciplinary team at St Andrew’s as they explain the importance of meeting the mental health, but also the physical health, needs of this particular patient cohort. 

 

Muthusamy Natarajan, consultant forensic psychiatrist

My name is Muthusamy Natarajan, I’m a consultant forensic psychiatrist and also clinical director for the neuropsychiatry service at St Andrew’s Healthcare.

How do you approach the care and support of older people in a neuropsychiatric service?

It’s important when working with and supporting older adults with mental health problems to consider how their organic and functional illnesses intertwine and how we progress them in their pathway at St Andrew’s and onward into the community. Connections with the patient’s family are also key so we also need to make sure we work to maintain those links whilst offering support to family members too.                                                                                                                                                                                                                             

We have a lot of our patients who are living with dementia and obviously communication with those who are caring for them is a tricky challenge sometimes and making sure that their voices are heard. We have multiple methods do that including our advocacy services, but also our staff are really experienced and skilled in making sure that the patient’s voice is heard. 

How do we support people living with dementia and complex needs?

In 2020, we opened the Lowther village. The Lowther village was very much a critical part of our ability to deliver the best care for patients who are living with dementia and other complex progressive neurological conditions such as Huntington’s disease. 

The dementia village concept comes from the Netherlands, where the key area of focus is making sure that patients are able to experience familiar activities throughout their journey with dementia and that they are able to link with the community, and that’s what we try to do. Our aim is to make sure that patients have the least possibility of feeling like they are in an inpatient setting and that includes people who are on Mental Health Act sections and Deprivation of Liberty Safeguards (DoLS).

What key interventions do you use when working with people living with dementia?

When somebody comes to us, we carry out a comprehensive multidisciplinary assessment that is the basis of their care and treatment. 

An individual might require specific psychological therapies and that may include things like reminiscence therapy, individual sessions to look at what their actual cognitive impairment is meaning for them on a day to day basis and we will use tools such as life story work. 

One of the key things we will look at when an individual comes to us is what activities and supports are going to help them through their journey, and that will include activities within the unit, but it also may include activities within our grounds and also further afield in the community. 

The third intervention is obviously in terms of our medical support, and we have a full complement of doctors, a responsible clinician, a geriatrician who works alongside us and also our specialty doctors and the medical team who look at the treatments we’re offering and make sure that is the most holistic approach to that individual’s care.

Having worked across a number of organisations what do you think makes St Andrew’s different?

What makes St Andrew’s different is that the culture and the organisation are geared to deliver care to very complex patients who come to us. The challenge to us is that we need to be able to demonstrate we can meet the complex care needs of our patients and ensure their journey is delivered in the best possible way and that we maintain our links with the carers and family for that patient. St Andrew’s does that incredibly well, and it does it holistically and in some ways, effortlessly. So building on that is a key area I think within the neuropsychiatry division and also within the charity as a whole. 

Parul Shah, consultant geriatrician

My name is Parul Shah, I’m a consultant geriatrician, and I joined the St Andrew’s neuropsychiatry multi-disciplinary team in February 2021.

As a consultant geriatrician, what is your role within the neuropsychiatry team at St Andrew’s?

My role as a consultant geriatrician within the team is to pick up on the subtleties of medical issues amongst our older adult cohort of patients and implement proactive management of their conditions so that patients don’t deteriorate any further with their physical health, reducing visits to acute hospitals and improving their safety whilst they are in our care here.  

What are some of the key areas of focus for you with St Andrew’s neuropsychiatric service?

One of my key areas of focus is to improve the overall strategy for older people’s health within the neuropsychiatry service with a particular emphasis on identifying frailty. Older people are often living with multiple conditions, and as they physically decline people become frailer, if we identify this and are aware of increasing frailty we can put approaches into practice such as exercise programmes and lifestyle changes that may prevent people’s physical health deteriorating.

Sometimes our patients exhibit very advanced stages of frailty, and then we need to recognise that they may be approaching end of life and that maintaining their quality of life is of prime importance, rather than necessarily focusing on physical health care interventions.

So I think that’s one of my main aims; to provide comprehensive assessments to older patients and identify why they’re getting frailer. If there are no reversible factors we then need to think about how to make them more comfortable and make the right decisions for them in their best interest by involving them.

To find out more about the St Andrew’s neuropsychiatry service visit: Neuropsychiatry services » St Andrew’s Healthcare (stah.org)

Continue Reading

Insight

The impact of stress on sleep

Dr David Lee at Sleep Unlimited offers advice on how to reduce stress and improve sleep

Published

on

In response to acute stress, our body produces adrenaline, to help us with the fight or flight response.

When our body perceives there is an immediate threat to our lives, this activates our Sympathetic Nervous System (SNS) to increase our heart rate, respiratory rate, stop non-essential functions such as digestion and produce stress hormones.

During acute stress you may experience issues falling asleep and entering the restorative sleep stage as your body believes your life is in danger and so prevents you from entering a deep sleep in case you need to fight or flee during the night.

Once the threat has diminished the Parasympathetic Nervous System (PNS) is activated to lower our heart rate, respiratory rate and stop the production of stress hormones.

Evolutionarily this response was useful as we had to fight for survival if, for example, a bear was going to attack us. However, now our stressors tend to be due to relationships, financial stresses, or work-related stress. Things we are unable to run from, which can cause long term stress and SNS dominance.

Long term stress increases our cortisol production. Cortisol is normally at its highest peak in the morning to help us wake up, get out of bed, and have enough energy for the day. Levels of cortisol steadily decrease during the day, reaching its lowest point at around 10pm. This is so we are relaxed and able to fall asleep.

When cortisol levels are low, the PNS is activated during sleep, and we enter the restorative period of sleep. Cortisol levels start to slowly rise again at around 2am. If you are experiencing long-term stress, you may wake up at around 2am/3am as cortisol levels are already high.

To help reduce stress, you need to allow your body to feel safe. Here are some tips to help reduce stress and improve sleep:

  • Stick to a good sleep routine but try to go to bed earlier rather than later. If we are constantly stressed the PNS system may only be dominant during times we are asleep. As PNS is only dominant until around 2am, going to bed around 10pm will provide you enough time to rest and restore. 
  • In times of acute stress, exercise is important, so we move our bodies as if we are acting upon the fight or flight response. However, in terms of long-term stress more restorative exercise, such as yoga, may be helpful as this activates our PNS. High-intensity exercise activates our SNS as it increases our heart rate and respiratory rate, so try to incorporate restorative exercises into your routine as well. Remember exercise outside in the morning is better as it increases melatonin production for release later in the day to help you fall asleep.
  • Try deep belly breathing when you are feeling stressed to helps you to feel relaxed. When we are stressed, we tend to breathe short quick breaths from our chest instead of long deep breaths from our stomach.
  • Allocate time during the day to write down your worries and your to-do list as this will prevent you from worrying about them as you try to fall asleep.
  • Try to reduce caffeine intake. When we do not enter the restorative stage of sleep, we can wake up feeling unrefreshed and groggy, this can cause us to make a cup of coffee to increase our energy. However, caffeine also increases cortisol so try to reduce the amount of caffeine you consume, at least try to stop caffeine intake after lunchtime as this can increase difficulty in falling asleep. If you improve your sleep practices you are likely to feel refreshed in the morning, making it easier to reduce your caffeine intake.
  • Avoiding screens and working in the 2 hours before bed allows us to wind down and help us to switch from SNS to PNS. If we engage in work or see something on social media that causes our stress levels to rise, then this may cause us difficulty falling asleep.

*  Dr David Lee BSc PhD CertEd CPsychol AFBPsS CSci is clinical director at Sleep Unlimited

Continue Reading

Newsletter

Sign up for the NR Times newsletter
I would like to receive by email other offers, promotions and services from Aspect Publishing Ltd and its group companies.*

Trending