Post Traumatic Amnesia

Gemma Hardy Clinical Psychologist

Neuropsychology Department, Addenbrooke’s Hospitalgemma.hardy@addenbrookes.nhs.uk

Outline

• Overview• Symptoms• Assessment• Rehabilitation• Management• Case study

PTA• Confusional state of ‘clouded consciousness’ following

TBI• Present in 70% patients

• Transient stage between loss of consciousness and return to full consciousness

• Duration correlates well with GCS, length of hospital stay

• Predicts outcome• Cognitive recovery• Functional abilities• Return to work

PTA Duration Severity of Injury

5 – 60 minutes Mild

1 – 24 hours Moderate

1 – 7 days Severe

1 – 4 weeks Very severe

> 4 weeks Extremely severe

• Amnesia• Anterograde

• No ability to form day-to-day memories

• Retrograde• Loss of memory for

events prior to TBI

• Disorientation• Time• Place• Person

• Impaired attention

• Behavioural change• Agitation• Disinhibition• Emotional lability• Childlike persona• Wandering• Fatigue• Confabulation

PTA

• Impaired attention– Poor concentration– Highly distractible– Impaired awareness

• Slowed reaction time• Fatigue and Fluctuation• NB. fight or flight in response to fear

PTA

PTA what is it like?A Case Study• Susan, 40 year old teacher

– RTA with multiple brain contusions, 2 weeks ago– On J2 – In side room with bed facing window– She keeps asking why she is here– She is confused as she doesn’t know where she is– She doesn’t know why he should be there and thinks she needs to get

home– She is frequently shouting and swearing and distressing patients and

staff

• How does she feel?– She is confused, doesn’t know where she is or why she is there– Over-fatigued, anxious, frustrated, frightened?

PTA Assessment

• Determine duration of PTA

• Standardised measures• GOAT (Galveston Orientation and Amnesia Test)• 10 items

• Orientation (person, time, place)• Recall for events (anterograde and retrograde)

• Score 0 – 100• Consecutive scores > 75 = end of PTA

PTA Assessment• However

• Qualitative features absent on testing • Can’t account for fluctuation • Difficult to distinguish from chronic memory impairment

• Informal assessment• ‘Obvious change to awareness and orientation’ (Russell &

Smith, 1961)• Continuous day-to-day memory• Sustained attention• Orientation to season, surroundings, visitors

• OR plateau to cognitive improvement in cases of severe long-term impairment

PTA recovery• Gradual• Currently determined by PTA test

performance• However• Many qualitative features absent on testing• Difficult to distinguish from chronic memory

impairment• Sequence of cognitive recovery• Person• Recognition memory• Place• Time• Free recall / continuous memory

PTA Research

• Research project within department– Service development– Developed CAM-PTA (Cristina Blanco-Duque from

MRC-CBU and the team from MTC)– Evaluate use by correlating against current tools

and MDT opinion

• Can be problematic given memory difficulties– Difficult to learn facts but can acquire procedural

knowledge– Reality orientation programmes can be effective

• Other therapies (OT/physio) still effective as often more reliant on procedural memory

– Errorless learning approach– Modifications to sessions may be required

PTA Rehabilitation

PTA Rehabilitation

• Psychological approaches to managing challenging behaviours– Verbal / non-verbal de-escalation– Goal Setting– Assessment (e.g. ABC analysis) – Tailored Intervention (Environmental

modification, Behavioural Reward program

PTA Management

• Keep in mind they have memory and attention difficulties!– Give information in short sentences and repeat– Always tell patient what you are doing and why

you are doing it– Avoid over-fatigue (allow for breaks, keep visitors

to minimum)– Think of environment (over or under stimulated?)

• Be prepared for challenging behaviours– Discuss specific behaviours in MDT meetings– Check behavioural guidelines in notes– Approach Clinical Psychologist for support

• Try to be understanding and empathic– People in PTA have little control over their

behaviour and emotions– Remember it is not personal

PTA Management

• Minimise frustrations and aggravations– Provide reassurance wherever possible, as many

times as possible– Don’t ask patient to do more than one thing at a

time– Keep noise / other stimulation to a minimum

(where possible)

• Validation approach – empathise and distract

PTA Management

• Susan (TBI 2 weeks ago, 40 year old teacher)• She is frequently shouting and swearing and

distressing patients and staff– She is confused, doesn’t know where she is or why

she is there, over-fatigued, anxious, frightened, frustrated ?

• GOAT assessment indicates ongoing PTA• Behavioural assessment: – ABC observations show Susan settles when nurse

enters room and is reassured but resumes shouting and screaming when left

PTA Back to case

• Hypothesis– Forgets she has been reassured– Continues to feel confused and frightened – Needs reassurance which only lasts as long as some one is

with her, and which is provided upon shouting and swearing• Goal: reduce distress (frequency of shouting and

swearing)• Intervention:– Move to small bay where she can see nurses station– Staff greet her whenever they pass– Orientation board alerting her to time and place – Other patients asked to remind her of the board periodically

PTA Back to case

Thank you very much!

If you would like a copy of slides please emailFiona.aschmann@addenbrookes.nhs.uk

• Ahmed, S., Bierley, R., Sheikh, J.I., & Date, E.S. (2000). Post-traumatic amnesia after closed head injury: a review of the literature and some suggestions for further research. Brain Injury, 14, 9, 765-780.

• Langhorn, L., Sorensen, J.C., & Pedersen, P.U. (2010). A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care. Journal of Clinical Nursing, 19, 2959-2969.

• Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed head injuries. Archives of Neurology, 5, 4-17.

• Thomas, H., Feyz, M., LeBlanc, J., Brosseau, J., Champoux, M.C., Christopher, A., et al. (2003). North star project: reality orientation in an acute care setting for patients with traumatic brain injuries. The Journal of Head Trauma Rehabilitation, 18, 292-302.

• Wilson, B.A., Herbert, C.M., & Shiel, A. (2003). Behavioural approaches in neuropsychological rehabilitation. Hove: Psychology Press.

Key References