New Year’s Disorientation

As 2014 comes to a close and 2015 is upon us, some brain injury survivors may find themselves facing greater than normal levels of disorientation.  Often brain injury survivors, particularly those with memory deficits or in the earlier stages of recovery, will have trouble keeping track of basic orientation information such as the month or the day of the week.  The change in year represents yet one more piece of new information they have to worry about remembering.  Survivors may seem confused or express doubt when told of the change in year.  Some survivors may even argue that therapists, staff and family are giving them false information.

 
Many patients with orientation difficulties can get stuck on the last date or location they remember and have trouble incorporating new information.  For example, a survivor may last remember living in Dallas and struggle with integrating into his or her life knowledge of moving in post-injury with his or her parents in Houston.  This same issue can occur with a change in year.  As the survivor last remembers the year being 2014, it takes considerable effort to make the switch to recognizing that it’s now 2015 (and to making realization of that switch stick).  To put it in perspective, people often temporarily forget the correct year during the first few days of January and will then write the wrong year on checks.  But imagine if instead of being stuck on the wrong year for a few moments, you continually find yourself stuck on the wrong year for weeks upon weeks.  This is what brain injury survivors with orientation deficits may experience when confronted by a change of year.

 
Brain injury survivors can be helped by keeping relevant orientation information presented in many easily accessible locations.  Families and survivors may want to place more calendars around the home.  If a survivor has considerable problems with disorientation, he or she will likely do best with a one page per day calendar, one that displays on each page the day, date and year.  This type of calendar can generally be found at teller stations in banks in order to help ensure that customers write the correct date on checks.  This is in contrast to the month at a glance calendar, in which the entire month is shown on a single page.  The date can also be written on a dry erase calendar in a bedroom or on a refrigerator so that the survivor can easily see the new year.

 
Families can also make extra effort to insert the correct year into daily conversation.  This can be done simply by saying more often than one might otherwise things like “Wow, 2015 has really started off well for us” or “I’m glad that 2015 has rolled around as last year was quite difficult.”  The more that a survivor is exposed to the correct information, the more quickly and permanently he or she will learn this new information.

 
Lastly, please make sure to dispose of old calendars and similar items displaying the old year as quickly as possible.  Some brain injury survivors will become confused or distressed when confronted by both an old calendar and a new calendar.  This can cause a temporary (and entirely avoidable) setback in efforts to properly align orientation.

 

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

 

Holiday Adjustments-Part 4: Drinking

This is part 4 of a series on holiday adjustments.  As mentioned in the previous blog posts in this series,  deficits suffered in the wake of a brain injury may impact brain injury survivors’ ability to participate in holiday celebrations to the degree that they had in previous years so adjustments may need to be made in order to provide a greater likelihood of those survivors enjoying a successful holiday.  Part 4 will be focusing on issues related to drinking alcohol during holiday celebrations.

 
Alcohol consumption is associated with several holidays.  A champagne toast is often at the center of New Year’s Eve celebrations.  Eggnog with an alcohol such as rum or brandy added is featured at many Christmas parties.  However, alcohol can be highly problematic for a brain injury survivor.  Anyone who has suffered a brain injury should always consult with a physician prior to drinking alcohol.

 
There are a number of reasons why a brain injury survivor should avoid alcohol absent a physician’s approval.  First, for many survivors alcohol played an integral role in the circumstance that led to the survivor sustaining a brain injury in the first place.  For instance, if a survivor suffered a motorcycle accident because he or she was driving drunk home from a bar, clearly he or she faced difficulty managing alcohol safely prior to the injury.  There may be any number of issues underlying such a problem that need to be addressed with a substance abuse counselor, a psychiatrist or a psychotherapist.  Suffering a brain injury does nothing to remove or address a pre-existing problem with alcohol or life issues that may have set the stage for the injury.  Far too often a brain injury survivor will return in his or her post-injury life to old habits with regards to alcohol and consequently suffer yet another injury.

 
Second, alcohol chemically alters functioning in certain parts of the brain responsible for controlling skills with which survivors often already face substantial struggles.  For instance, alcohol depresses functionality in the prefrontal cortex, the part of the brain involved in decision-making and planning.  It also affects the cerebellum, which coordinates muscle movements for skills like walking.  If you think of a stereotypical drunk individual, the image that usually comes to mind is that of a person who has trouble walking, talking, coordinating body parts and effectively remembering  activities in which they are engaged.  In many cases, these are precisely the areas that the survivor is working to improve following his or her injury.  Alcohol is ostensibly a voluntarily induced temporary chemical brain injury and the last thing a brain injury survivor needs is that voluntary chemical brain injury on top of the current brain injury which was most certainly not chosen.

 
Third, alcohol interacts poorly with medication.  One compelling illustration of this dynamic can be found in brain injury survivors who take Dilantin (Generic name: Phenytoin) to prevent post-injury seizures.  Alcohol can change Dilantin levels in the blood, which then leads to an  increased risk of seizures.  Other brain injury survivors, particularly stroke survivors, may take the blood thinner Coumadin (Generic name: Warfarin).  Alcohol can magnify the effect of Coumadin, which then leaves those survivors at risk of excessive bleeding.  Anti-anxiety medications such as Ativan (Generic name: Lorazepam) and Xanax (Generic name: Alprazolam) may have interaction effects with alcohol that can range from increased dizziness to serious respiratory problems.  These are just a few of the many medications that when mixed with alcohol can threaten terribly dangerous consequences.  The National Institute of Alcohol Abuse and Alcoholism has a more complete list of medications and the negative effects of mixing those medications with alcohol:

 
http://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm

 
Fourth, alcohol often affects the survivor far more strongly post-injury than experiences prior to the injury would tend to indicate.  As example, a patient at TLC once tried a beer while with his family when out on pass.  He reported to staff that he had not even finished drinking enough beer to empty the neck of the bottle before feeling potent symptoms of inebriation.  This scared him so much that he handed the bottle back to his family and swore off drinking then and there.

 
Now that the risks associated with drinking alcohol after a brain injury have been made more clear, here are a few suggestions as to how survivors and their families can make maintaining sobriety easier during the holidays.  First, survivors, families and friends can simply have a party without alcohol.  If no one is drinking alcohol because there is none available, then there is obviously no risk that the survivor will drink.  Holiday celebrations are ultimately about spending valued time together and celebrating as a community, not drinking.  Second, sparkling juices and imitation non-alcoholic beers can easily be substituted for alcoholic beverages.  Sparkling juices look like champagne or wine but are non-alcoholic.  TLC has a “Sparkling Juice Taster” twice a year and patients often find brands and flavors that they enjoy as a substitute for alcohol.  Sparkling juices and imitation beers can be purchased at low cost at most supermarkets.  Third, most people understand that someone on medication cannot consume alcohol.  In many cases, survivors need only point out that they are taking medication and other party-goers will understand why the survivors are not drinking (and then refrain from offering alcohol and/or insisting that those survivors partake).

 
Hopefully this post has been helpful in its elucidation of the specific and substantial risks to brain injury survivors contemplating alcohol consumption and has offered a few effective ways to approach managing those risks during holiday celebrations.

 

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Holiday Adjustments-Part 3: Social Interactions and Attention

This is part 3 of a series on holiday adjustments.  As mentioned in parts 1 and 2, deficits suffered in the wake of a brain injury may impact brain injury survivors’ ability to participate in holiday celebrations to the degree that they had in previous years so adjustments may need to be made in order to provide a greater likelihood of those survivors enjoying a successful holiday.  Part 3 will be focusing on issues regarding social interactions and attention during holiday celebrations.

 
Our social skills are at the heart of what it means to be a connected person in our society, and holiday celebrations invariably present what can only be understood as key social situations.  It’s incredibly common for brain injury survivors’ proficiency in employing vital social skills to markedly suffer as they navigate post-injury life.  As a result, holiday celebrations can be tricky for brain injury survivors to negotiate.  In many cases, holiday celebrations are the first time that friends and family members have seen a survivor since his or her injury.  In other cases, holiday celebrations are the first time that friends and family members have seen the survivor since he or she was in the intensive care unit of the hospital since people are most likely to visit in that initial period immediately following an injury.  Often, holiday celebrations present dual areas of stress with which a brain injury survivor must contend.  The survivor is learning how to negotiate life with newly acquired often significant deficits commonly experienced in multiple distinct arenas.  At the same time, survivors must learn to accommodate an increase in the attention afforded them by friends and family as those loved ones understandably seek to spend extra time with survivors as an expression of concern felt.

 
Near death experiences catch our interest and spark our concern.  As such, friends and family often give survivors far more time and attention than they may have at previous holiday celebrations.  After a brain injury, many survivors are surprised to find that they are now the most popular person in the room.  Each family member comes by and asks what happened, how is the survivor doing, how is therapy, etc.  Even if one family member was standing right behind another while that member asked each of these questions, the second family member still may ask the exact same questions as the first.  These queries are generally made with the best of intentions.  Family and friends want to show their concern and caring for their injured loved ones.  However, many survivors find this to be a frustrating and annoying experience.  It is important for survivors to prepare for some version of this experience to occur at the holidays, particularly if many people have not seen a survivor since the initial injury.  And it’s just as important for survivors to remember that such a situation is just a reflection of the caring felt by those around them.  Family and friends are often searching for a way to show their feelings to the survivor.  Preparing a good deflection script can often be helpful (For example: “Thank you for asking about my health.  I appreciate the questions but it seems like that is all I have been talking about lately.  Can we please talk about something else?”)  Family and friends need to remember that constant questions can be stressful.  If the questioning goes well, the questions can be experienced as a friendly interview would.  If it goes poorly, it might start to resemble more a police interrogation.  Loved ones should put effort into talking about other issues as well, such as the Thanksgiving football games or favorite music.  Some survivors and/or their families may find a handy solution in sending an e-mail or some similar communication updating everyone on the latest information and requesting that brain injury questions be kept to a minimum.

 
A more positive aspect of this extra attention is that brain injury survivors may find that they receive more phone calls, cards and gifts at holiday times than in previous years.  Sometimes these come from people who are not very close to the survivor but are more distantly acquainted with the situation, such as a congregant at a family member’s church.  Again, though this may feel slightly strange to the survivor it still represents someone trying to reach out and show that he or she cares.

 
Changes in social skills can create big hurdles for survivors to overcome during social interactions at holidays.  Survivors and their families must keep in mind potential problems due to changes in social skills.  When a survivor has difficulties that impact social skills, it is important that friends and family members at holiday parties are informed of the best ways to interact with that survivor.  For survivors with language difficulties this may include giving extra time for the survivor to speak, having the survivor’s conversation partner slow his or her rate of speech, writing important words down for the survivor, pantomiming words or having the survivor use an augmentative communication device such as an Ipad equipped with a special speech program.  If survivors have problems with impulsivity issues, family and friends may need to pay extra attention to cueing those survivors to slowing down and maintaining the topic of conversation instead of going on tangents.  For survivors that have difficulty with nonverbal skills such as making eye contact or reading social situations accurately, family and friends may need to cue them to utilize proper nonverbal skills such as looking at the conversation partner’s face while speaking.  If a survivor now struggles with a newly intensified propensity to engage in clearly inappropriate behaviors, family and friends may need to cue that survivor in order to aid in avoiding such behaviors (obvious examples being cursing and sexual jokes).  It is important in all cases that family and friends who will be interacting with the survivor be given adequate information to best help the survivor succeed in his or her social interactions.  This information can be shared via e-mail, phone call or simple face-to-face personal discussion.  If a family member or friend is caught unawares in a situation in which a survivor’s social deficits are seeing expression, this can lead to a strain in relations.  For instance if a survivor’s friend does not know that the formerly soft-spoken survivor now needs help to reduce foul language, the foul language may be taken as a personal insult rather than as a function of the injury.
Survivors and their families should also consider the possibility of the survivor faring better in a smaller holiday celebration.  Some survivors find that larger parties lead to more stress, agitation and/or social errors.  Also, the noise and activity of larger parties can become overwhelming for some survivors.  Certain survivors find that young children, with their noise and activity, can be quite problematic.  Further, some survivors would rather have a small celebration, especially in the early stages of recovery when they are not yet sufficiently comfortable with their injury in public.  They may feel embarrassed by their deficits and would rather not have a large number of individuals learn so casually about the depth of their struggles.

 
It is often helpful for survivors, their families and their therapists to try to problem-solve in advance potential pitfalls and to practice skills such as how best to talk to others about an injury experience.
Hopefully, this post provided insight on a few holiday adjustments that can be made to mitigate attention and social interaction issues.

 

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Holiday Adjustments-Part 2: Participation

This is part 2 of a series on holiday adjustments.  As mentioned in part 1, deficits suffered in the wake of a brain injury may impact brain injury survivors’ ability to participate in holiday celebrations to the degree that they had in previous years so adjustments may need to be made in order to provide a greater likelihood of those survivors enjoying a successful holiday.  Part 2 will be focusing on some thoughts regarding participation in holiday celebrations.
One of the most difficult aspects of having a brain injury at holiday time is changes in the ability to participate in the holiday celebrations.  For instance, a brain injury survivor may have been the main cook for Thanksgiving but can no longer do so due to memory deficits or newly acquired physical disabilities (such as losing use of the entire right side of the body).  This can serve a tremendous blow to the survivor’s self-esteem and pride.  Family members may try to be helpful by telling the survivor to “not worry” and that the family members will “take care of everything.”  Many survivors will appreciate this effort at mitigation, but unfortunately some survivors will receive such an effort as an even further attack to their self-esteem.  If we were to choose a single most important guideline governing brain injury survivors’ participation in holiday festivities, rehabilitation therapists and professionals would encourage brain injury survivors and their families to find tasks contributing to holiday celebrations in which the survivor can fully participate.

 
The first part of identifying holiday tasks that the survivor can participate in is to take a realistic assessment of the survivor’s skills and deficits.  Safety concerns should always be held in priority, but they should not be allowed to unnecessarily overshadow consideration of reasonable options.  If a survivor has ataxia (inability to fully control muscle movement) in his or her arms, the survivor should not be lighting menorah candles for Chanukah.  Similarly, a survivor with balance issues should not be climbing on to the roof of a home to put up Christmas lights.  With this in mind though, a survivor will always have some form of identifiable strengths.  In fact, it is incredibly rare that a survivor would be unable to contribute anything at all to holiday celebrations.  For instance, though a survivor in a wheelchair may not be able to put up all of the decorations on the Christmas tree, he or she may be able to put up the decorations on the lower part of the tree.  A survivor may not be able to be fully responsible for the cooking of a turkey, but perhaps he or she could cut some of the vegetables for a salad or help set the table.  Even if a survivor cannot use his or her arms or legs, perhaps a role can be found such as leading the family in a prayer before eating or giving recipe directions to family members that are cooking.  Survivors with aphasia can sometimes sing, with help, familiar songs as the songs are so familiar that the action of singing them can have become almost automatic.  For example, many aphasic survivors that struggle to name a common item like an apple can sing a holiday tune like “Jingle Bells” or “We Wish You a Merry Christmas” if given extra time and if someone sings with them.  If survivors and their family members look closely enough, there is almost always something the survivor can do or help with.  Even a small task will help boost the survivor’s pride and self-esteem.  Moreover, injury or no injury, working together on holiday celebrations brings family together for a joyful opportunity to bond.

 
Many survivors struggle with the tradition of giving gifts at certain holidays such as Christmas and Chanukah, since they often find themselves contending with greatly worsened financial status in the aftermath of the injury suffered.  They have often lost jobs and can have high medical expenses which dramatically sap their funds.  Many now rely on financial support from family members.  Usually, families and friends understand that the survivor is in a different financial state but the survivor may still feel significant guilt over the inability to purchase gifts as he or she once did.  Simply reassuring a survivor that the family members and friends understand the changes and are not worried about not receiving a gift or are perfectly fine with receiving a smaller gift can help alleviate concerns.   Alternatively, a survivor could always put together a handmade gift or card with the help of a family member as necessary.  Everyone appreciates a homemade gift or card.  Families may choose to switch to a gift exchange in which everyone buys just one gift, places that gift in a bag, and then randomly chooses a gift from those assembled.  One gift is far less costly than multiple gifts.  A limit on the cost of gifts purchased can also be placed so as to further make participation easier and to help make the survivor feel less left out due to costs.  If an effort is put into de-emphasizing the role finances play in holiday celebrations, the survivor is often better able to focus on those more essential and meaningful aspects of the holidays.

 
Another consideration regarding holiday celebration participation is fatigue.  Holiday celebrations often go quite long and brain injury survivors may find that they become fatigued more easily than they did previously.  This is a particularly common issue during New Year’s celebrations.  Survivors who have grown accustomed to staying up until midnight to celebrate the new year may find that they now are exhausted by 8 p.m.  Sometimes, shifting the length of time that the survivors will be attending the celebrations in question can increase opportunity for participation.  Three good hours of participation is better than five hours of exhaustion.  Moreover, some families change the time of the celebrations entirely to make it easier on the survivors.  “Early” New Year’s eve celebrations are relatively common.  After all, it’s midnight somewhere.  Instead of a late Thanksgiving dinner, a survivor’s family might find that a Thanksgiving lunch is more feasible.  Perhaps gift opening can be done prior to a holiday meal rather than after the meal, which would speed up the main parts of the holiday celebration considerably.  These are just a few of the ways in which post-injury fatigue can be better managed at a holiday celebration.

 
Hopefully this post was able to raise awareness of adjustments in participation that can be made in order to increase a brain injury survivor’s enjoyment of the holiday season.  The next part of this series will focus on holiday adjustments that may need be made related to social interactions and attention.

 

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Holiday Adjustments-Part 1: Location

As Thanksgiving approaches, it is important to be aware of the potential need for adjustments to be made to holiday celebrations in order to accommodate a brain injury survivor’s injury-related deficits.  Having a brain injury does not stop a survivor from celebrating a holiday, but it may put a few wrinkles into holiday plans.  Part 1 in this series on holiday adjustments will focus on some thoughts regarding the location of celebrations.

 
There are a number of issues that need to be addressed regarding the location of holiday celebrations in such a scenario.  First, if the survivor is in a wheelchair or uses another assistive device to aid mobility and is going to someone else’s home, is that home accessible?  Keep in mind that it is much easier to get a wheelchair across a hard floor than across carpeting and that for some survivors, a large pile (a term used to denote length of carpet fibers) carpet can provide quite the inconvenience.  Also, is there enough room in the bathroom for a wheelchair?  Should the survivor bring along a urinal if it is too hard to access the toilet?  If the survivor has problems with incontinence, is there somewhere available that the survivor could  be cleaned or change clothes if necessary?  Some families of brain injury survivors find that it is easier to host holiday celebrations at their own homes rather than travel to the homes of others since their homes have already been adapted to the needs of the survivor.

 
Survivors and their families should also consider the physical layout of the rooms where a celebration will take place.  For instance, it may help to move tables and chairs into a different configuration in order to make it easier for the survivor to move through.  A big issue to look for in the consideration of a given room is trip hazards, particularly around Christmas.  It is important that toys and gifts not be left around on the floor as these can easily become trip hazards and could cause the survivor to suffer a bad fall.  Alternatively, most toys tend not to fair well when a wheelchair runs them over.  Cords from Christmas trees or lights can also become trip hazards and should be placed in a manner that will not pose danger to a mobile survivor.  There are many other practical issues to consider regarding the holiday meal.  Can the survivor reach a given dish or will he or she need help?  Has silverware been left on a counter that is too high for the survivor to reach?  Can the front of the survivor’s wheelchair fit under the table?  If the survivor uses an augmentative speech device like an Ipad, is there room at the table for it?  Is a side table perhaps needed for the device to be placed upon?  Small changes in room and furniture layouts can make a huge difference to both a survivor’s sense of inclusion and his or her overall enjoyment of a holiday celebration.

 
The weather can also play a notable role in adjustment to different locations.  Walking up an icy pathway can be quite difficult and possibly dangerous.  Some survivors who normally use a walker may be safer in a wheelchair over these icy surfaces.  Moreover, some survivors in wheelchairs may need more help getting across an icy or snowy surface.  In such a situation a loved one may need to aid in pushing more than would otherwise be required or just pay attention to helping keep the chair from sliding in the wrong direction.

 
Families of brain injury survivors may want to put some thought into how loud they allow holiday celebrations to be.  Some survivors find that they are more sensitive to noise than previously and loud noises may provide a catalyst for unwanted agitation and/or anger.  These survivors may benefit from attending smaller celebrations or spending their time in a quieter room away from the main celebrations.  This can also be a relevant issue when considering attendance of holiday religious services.  Some survivors may find busier houses of worship  or busier times at those houses of worship to be problematic and may do better at less busy times or benefit from selecting a less busy house of worship.

 
One more such consideration associated with location relates to how many celebrations a survivor and his or her family may be planning to attend.  Some families have the tradition of going from house to house to multiple holiday celebrations throughout the day.  However, survivors often become fatigued quite easily and holiday celebrations tend to be long and active events.  For many survivors, attending multiple celebrations in the same day may be very difficult.  Some survivors may benefit from spending a shorter amount of time at each such celebration.  Survivors and families must also consider the fatigue sure to accompany constant transferring to and from vehicles and the necessary related packing up and unpacking of equipment.  For instance, getting a wheelchair in and out of a car repeatedly throughout a day can be very taxing on the backs of survivors’ families.

 
These are some of the considerations regarding the location of holiday celebrations that survivors and their families may wish to think about when identifying adjustments that may need be made to holiday celebrations.  The next part of this series will focus more specifically on brain injury survivors’ participation in holiday celebrations.

 

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

 

New Year’s and Brain Injury

New Year’s Eve is generally celebrated with laughter, noise and merriment.  However, there are a few pitfalls that brain injury survivors may encounter during these celebrations that they will want to watch out for.

It is typical to serve alcoholic beverages at New Year’s Eve celebrations.  However, drinking alcohol is almost always a bad idea for brain injury survivors unless a doctor has approved of it.  Alcohol may effect a brain injury survivor more quickly, strongly or drastically than it would have effected the same individual pre-injury.  Alcohol mixes poorly with medications and can cause serious medical complications.  Furthermore, the effects of alcohol consumption (such as an inability to sustain concentration and trouble walking) may put the survivor at particular risk for another injury.

Many New Year’s parties include noise makers, loud music and large crowds of people.  Some brain injury survivors find themselves more sensitive to noises and crowds than they did previous to their injury.  Situations containing these things may cause the survivor significant agitation or distress.  If a brain injury survivor experiences these sorts of difficulties, it may be worth skipping certain celebrations, changing methods of celebration and/or formulating a plan beforehand to manage pr0blematic situations that may arise at any such celebration.

Another issue arises from the fact that people typically stay up quite late on New Year’s Eve.  Brain injury survivors generally do best to maintain a strict daily schedule.  Brain injury survivors and their loved ones should carefully consider whether risking any possible problems due to a change in schedule is worth the practice of waiting up until midnight for the new year.  Some survivors choose to celebrate New Years’ Eve a few hours early so as to be able to maintain the same sleep-wake schedule.

These are a few issues for brain injury survivors and their families to consider.  I would like to wish everyone a healthy and a happy New Year!

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org