Post Traumatic Amnesia

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Post Traumatic Amnesia

• Gemma Hardy
• Clinical Psychologist
• Neuropsychology Department, Addenbrookes
  Hospital
• gemma.hardy_at_addenbrookes.nhs.uk

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Outline

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

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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
gt 4 weeks Extremely severe
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PTA

• 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

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PTA

• Impaired attention
• Poor concentration
• Highly distractible
• Impaired awareness
• Slowed reaction time
• Fatigue and Fluctuation
• NB. fight or flight in response to fear

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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 doesnt know where she is
• She doesnt 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, doesnt know where she is or why
  she is there
• Over-fatigued, anxious, frustrated, frightened?

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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 gt 75 end of PTA

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PTA Assessment

• However
• Qualitative features absent on testing
• Cant 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

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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

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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

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PTA Rehabilitation

• 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

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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

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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?)

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PTA Management

• 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

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PTA Management

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

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PTA Back to case

• Susan (TBI 2 weeks ago, 40 year old teacher)
• She is frequently shouting and swearing and
  distressing patients and staff
• She is confused, doesnt 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

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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

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• Thank you very much!
• If you would like a copy of slides please email
• Fiona.aschmann_at_addenbrookes.nhs.uk

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Key References

• 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.