Category Archives: Holiday Adjustments

July 4th Fireworks

Every July 4th, Americans across the country light up the sky with fireworks.  This patriotic spectacle is commonly enjoyed at large outdoor celebrations, though often fireworks are also set off at private homes.  This circumstance brings to the fore an issue that we as a society may not generally afford sufficient attention.  Namely,  how do our family and neighbors react to fireworks?

After a brain injury, many survivors are highly sensitive to loud noises.  Fireworks can be quite disturbing to a survivor, even if he or she enjoyed them in the past.  Fireworks may lead to agitation, frustration and acting out.  Prior to attending a fireworks celebration (whether public or private), loved ones should check with survivors and their therapists as to whether those survivors would do well at a fireworks display.  If the survivor chooses to attend a display event, loved ones should have an exit plan prepared just in case the event goes poorly for the survivor.  Neighbors should check with survivors and their families prior to setting off fireworks.  Fireworks are not truly a “private” matter, since everyone in the nearby vicinity will be hearing them whether they wish to or not.  It is not fair for the survivor to be put in serious distress just because a neighbor likes to set off fireworks.

This issue may prove even more pertinent when a survivor is a combat veteran.  Many combat veterans who suffered injuries in battle also have Post-Traumatic Stress Disorder (PTSD).  PTSD symptoms can include flashbacks in which the veteran feels like he or she is back contending with the relentless stressors of life in combat, painful memories of the trauma of friends dying and serious sleep disturbances. Fireworks can trigger all of these symptoms and more.  Additionally, many in the South have a custom of shooting guns in the air on July 4th.  If fireworks are a bad idea around combat veterans with PTSD, then shooting guns is a horrible idea.  (As a sidebar this practice is simply remarkably dangerous.  This writer knows a woman who was hit by a bullet that was shot by an unknown individual in the air to celebrate a holiday. The bullet fell into an open restaurant area and lodged in her lung.)  The combined effects of a brain injury and PTSD can make these situations especially tricky for veterans.  Loved ones should check with survivors and their therapists as to whether these veteran survivors may have a PTSD-type reaction around fireworks or guns.  Again, neighbors should check with combat veterans to ensure that the neighbors’ celebrations do not harm the psychological well-being of these individuals.  Some combat veterans have taken to putting signs on their lawns identifying themselves as combat veterans and asking others to be courteous with fireworks.  These signs should be taken seriously and neighbors should not shoot fireworks or guns near these veterans.  Again, no one should be forced to suffer in service of a neighbor’s idea of “fun.”

Wishing everyone a Happy July 4th!

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

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Passover Adaptations-A Brief Guide

Passover is the central family holiday on the Jewish calendar.  Jewish families come together to celebrate at the Passover Seder the Exodus of the ancient Israelites from Egypt.  Tables are packed with guests and overflow with food as participants read through the Passover Haggadah.  Weeks of cooking, cleaning and preparation all come together on the Seder nights into a full-blown celebration of freedom from Egyptian bondage.  Unfortunately, brain injuries suffered in the wake of a stroke or traumatic brain injury event can impact a survivor’s holiday experience.  There is a tremendous beauty in the Passover Seder but after a brain injury, there are new concerns that survivors and their families may need to consider.  This post will identify some of those concerns and make a few suggestions to aid in addressing them.

There are a number of issues that may need to be addressed regarding the location of a Passover Seder.  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 sufficiently accessible?  Keep in mind that it is much easier to get a wheelchair across a hard floor than across carpeting.  Even thin carpet can present difficulties when attempting to turn a wheelchair.  Additionally, 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 clean up or change clothes if necessary?  Some families of brain injury survivors may find that it is easier to host Seders at their own homes rather than travel to the homes of others since their own homes have already been adapted to the needs of the survivors. 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.   Often, seders take place around a large table.  The survivor may find it easier to sit at the end of the table, particularly if he or she is in a wheelchair, than to sit at the side of that table.  Also, how close does the survivor need to be to a bathroom or an exit?  Some survivors have urinary urges that need to be attended to particularly quickly or may need to make a quick exit in order to counteract the detrimental effects of over-stimulation.  There are many other practical issues to consider regarding the set-up of 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 or will the table need to be raised?  If the survivor uses an augmentative speech device like a letter board, 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  the Passover celebration.

Survivors and their families will also want to put thought into how loud a seder may be.  Some survivors find that they are more sensitive to noise than previously and that loud noises may now provide a catalyst for unwanted agitation and/or anger.  These survivors may benefit from attending smaller seders or from being sat away from loud children and other factors contributing unduly to agitation.

Another practical issue relates to the drinking of the four cups of wine on Passover.  The cups of wine take center stage during much of the seder, yet many survivors are unable to drink alcohol as it now presents that much more significant a health risk.  For instance, alcohol mixes poorly with many medications and this dangerous mixture can lead to serious health problems.  This obstacle to full participation may lead  survivors to feel conflicted about the four cups of wine.  The first thing to keep in mind is the vital relevance of consultation with a doctor.  If a doctor has identified consumption of alcohol as a serious health risk for the survivor in question, then by Jewish law that person cannot drink the alcohol.  It is important to keep in mind that maintaining one’s health is one of the 613 commandment in the Torah and it cannot be violated even to honor the four cups of wine at seder.  Many rabbis including Rabbi Soloveitchik (recognized as one of the great rabbinical minds of the 20th century) have ruled that grape juice can be used at seder instead of wine.  Families may wish to have grape juice for all seder attendees instead of wine so that a survivor does not feel left out.  For those that are unable to drink at all due to swallowing issues and may be worried that they are violating Jewish law by not drinking the four cups, a little historical perspective may provide some particularly helpful insight.  The idea that everyone needs to drink four cups is a stricture instituted by Tosafos (a group of rabbis in the Middle Ages).  Technically only the seder leader is required to drink.

There are other considerations that bear mention when it comes to the eating and drinking done on Passover.  Some individuals cannot eat green, leafy vegetables because they interact poorly with medicines such as blood thinners.  This can be an issue as many families use items like parsley during their seder meals.  Survivors and their families should consult with doctors to assess if the amounts of these substances being eaten in these circumstances will be enough to interfere with the the medications in question.  If that does prove to be the case, rabbis and doctors can help identify alternatives.  As example, instead of using parsley as the Karpas vegetable some people use potatoes.  Consulting with a doctor and rabbi can help one to make the best adjustments while still adhering to the requirements of the seder meal.

Some brain injury survivors utilize certain dietary aids after their injuries, such as meal supplements and drink thickeners.  Survivors and their families may have concerns about whether these items violate the laws of Passover due to being chametz (made from leavened items) and for Ashkenazim, if they are kitniyot (legumes).  However, most major supplements and thickeners are kosher for Passover use by those who are sick or are in medical need.  The Orthodox Union (OU) has a lengthy list of such options that are kosher for Passover.

https://oukosher.org/passover/guidelines/medicine-guidlines/nutritionals-and-dietary-supplements/

The OU also provides a brief guideline on caring for the infirm on Passover:

https://oukosher.org/passover/guidelines/medicine-guidlines/caring-for-infants-and-the-infirm/

For those who are Sephardic, as long as the items do not have chametz, they are kosher for Passover as the issue of kitniyot is just an Ashkenazic issue.

Again, as each survivor’s case differs from the next, it is important to check with both the survivor’s doctor and rabbi prior to deciding if something can or cannot be used or ingested.  For instance, many times people will believe that something is prohibited only to later find that a rabbi rules that it is in fact allowed.

Another issue that can arise is that seder meals tend to be very large with lots of food and this may impact a survivor’s blood sugar levels if he or she has diabetes.  It is important to plan meal choices around this health issue.  Survivors and families should tailor their Passover menus as needed to reduce the chance of dangerous fluctuations in blood sugar.  Also, it should be kept in mind that seder meals tend to be eaten later than is typical of a normal dinner.  For those that have diabetes, it is vital to discuss with a doctor what type of adjustments to medication schedules may be appropriate on the seder nights.  The Jewish Diabetes Association (via the Star-K Kosher organization) has a Passover guide for diabetics:

http://www.star-k.org/kashrus/kk-passover-diabetics.htm

Passover cleaning and meal preparation can be almost as big a component (and sometimes even  bigger) of the overall celebration as the actual seder meal itself.  Individuals spend many hours cooking and cleaning in preparation for the holiday.  This may be difficult for many survivors who are used to doing the cooking and/or cleaning themselves.  This may cause survivors to confront feelings of uselessness or worthlessness and can represent a significant alteration to roles as they have been thus far understood.  It is important that survivors be allowed to participate in this process in any way that they may be capable.  The survivor may not be fully able to cook the chicken that will be eaten as the main course, but perhaps he or she could chop some of the vegetables for the meal or the nuts to be used for the charoset.  The survivor may not be able to handle a vacuum to clean the carpet, but perhaps he or she could help with sweeping the floors.  The survivor may also be able to help set the table or put out the haggadahs.  There is almost always something identifiable that the survivor can help out with if all involved will simply put sufficient effort into determining just what that thing might be.  If a survivor is living on his or her own and is unable to sufficiently manage Passover cleaning unassisted, he or she may want to ask friends or family to clean for him or her.  Also, many synagogues and Jewish organizations can share means to contact individuals willing to volunteer to clean for those in need or can connect survivors with those willing to do so for a reasonable cost.

Another issue that can come up involves the structure of the Passover Seder.  Many brain injury survivors have shorter attention spans than they had previous to their injuries, and many seders tend to be quite lengthy.  Fortunately, in recent years there have been a number of haggadahs published designed specifically to make seders shorter.  For those with extreme difficulties with attention, Rabbi Yonah Bookstein of the Pico Shul states that he has the shortest kosher haggadah available (which allows one to complete the seder in around 10 minutes):

https://rabbiyonah.files.wordpress.com/2012/04/the-10-minute-haggadah.pdf

The 30 minute Seder is another haggadah option available to those seeking a briefer service.  This haggadah was edited by Rabbi Bonnie Kappel of Temple Chai and the US Army Reserves:

http://30minuteseder.com/

The seder is a very language-heavy service which may present particular difficulties for brain injury survivors with aphasia.  Gateways has published a haggadah which is more picture-oriented and includes the use of Boardmaker symbols that many survivors with aphasia already use in conjunction with augmentative speech devices.  This haggadah was written by Rebecca Redner and reviewed by a number of rabbis including Rabbi Neal Gold of Temple Shir Tikvah.  It was created more to aid youth with special needs, but may be more appropriate than other haggadahs for adult survivors with aphasia.

http://jgateways.org/Resources/GatewaysHaggadah

Matan, an organization serving Jewish youth with disabilities, has a number of Passover resources that translate verbal parts of the Seder into visual representations.  Though these picture-centered resources are strictly speaking intended for use by children, adults with aphasia may benefit from an integration of such materials into their Passover activities.

http://www.matankids.org/tag/passover/

As it is common for family and friends to take turns reading  sections of the haggadah during the seder, survivors with aphasia may feel especially left out of during the seder service.  But just as with the Passover preparation and cleaning, there is almost always a role the survivor can play in this portion of the seder.  For instance, it could be the responsibility of the survivor to dip the green vegetables into the salt water and/or to hand out pieces of matzah to everyone at the seder.  The survivor could have the job of pointing to the shankbone, matzah and bitter herb during the section regarding Rabbi Gamliel.  Survivors with aphasia do also tend to do better with familiar songs.  In spite of a survivor’s struggles with language, he or she might still be just as able to sing the refrain “Dayenu”, as this is a common line that a survivor may well have sung for many years.

Lastly, at some seders there is a general desire to rush through the haggadah to reach the meal or to finish the second half of the haggadah quickly.  Family members and loved ones need to take care to afford sufficient consideration to survivors now contending with slower processing speeds and keep in mind that these survivors will now require that the seder be proceeded through at a slower pace than most may be inclined to attempt.

These are just a few suggestions regarding areas in the Passover Seder that may need to be adjusted after a brain injury in order to better ensure a survivor’s full participation and enjoyment.  Wishing to all a wonderful and meaningful post-injury Passover!

Thank  you to Rabbi Joel Levinson of Temple Beth El of Patchogue for reviewing the content of this post and Rabbi Daniel Masri of Beth Rambam of Houston for providing information on Sephardic practice.

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

Valentine’s Day

Valentine’s Day is coming in just a few days so this is a good time to talk about a few ways that brain injuries may affect Valentine’s Day for injury survivors and ways in which a brain injury survivor can make his or her Valentine’s Day experience a more successful one.

For survivors with speech deficits (generally referred to as “aphasia”), Valentine’s Day can be particularly stressful.  On Valentine’s Day people say “I love you” to loved ones and survivors with aphasia may find it frustratingly difficult to reciprocate, as effecting this once simple vocalization is for them no longer simple in any way to achieve.  They know what they want to say but cannot get the words out.  Some survivors may feel let down that they are not able to adequately express this heartfelt sentiment.  Speech therapists often work with survivors struggling with aphasia in order to help them to say important phrases like “I love you” and it is generally a good idea for those survivors to practice repeating these useful phrases on a daily basis.  Many survivors with aphasia can say simple phrases if someone starts to say the phrase with them or just accompanies them through the entire vocalization.  For instance, the survivor may be able to say “I love you” if his or her loved one helps him or her to initiate by saying “I lo….”.  Even if it takes some help getting the words out, most brain injury survivors will feel good about the accomplishment of having said the full phrase correctly.  Even if the survivor cannot quite get the words out, he or she is clearly trying to express his or her love.  Loved ones should accept and acknowledge the emotion behind the attempt.  In the end, it is truly the emotion that counts.

Another big Valentine’s Day change possibly seen in a survivor’s post-injury life relates to the way in which the holiday may now be celebrated.  For example, many survivors are accustomed to arranging for loved ones extensive meals, large events or extravagant celebrations on Valentine’s Day.  They may be used to purchasing huge bouquets, pricey wines or expensive chocolates.  After a brain injury, survivors and their families are often forced to adapt to a considerable decrease in potential household income and just as often struggle with substantial medical debts.  Some survivors may feel guilty that their injuries cause this change in holiday celebrations.  Many survivors that are hospital-bound may feel like they have ruined the holiday with their injuries.  From the perspective of those family members though, the joy of simply being able to celebrate another holiday with the survivor after the survivor’s near-death experience is greater than any gift that could be purchased.  There are a number of helpful ways in which to approach these issues.  Survivors may need to be reminded that they did not ask for the brain injury to happen, so they should therefore not blame themselves inappropriately.  Instead of purchasing items, they may be encouraged to make a gift or a card for their loved ones.  Families often appreciate hand-made items at least as much as (if not even more than) purchased items.  In cases in which survivors  do purchase items, loved ones may wish to take special care to reassure those survivors that a small item purchased is appreciated just as much as a larger such item would be.  In some situations, such as when a survivor is spending time as a patient in an inpatient rehabilitation facility, that survivor may need a friend or family member to purchase on the survivor’s behalf an item the survivor intends to give as a gift.  Most importantly, loved ones may need to help the survivor focus on what everyone values the most.  Above all else, those involved should never lose sight of how precious the opportunity to celebrate their love together is.  That this opportunity for shared appreciation was very nearly permanently lost as a result of the injury suffered should only emphasize its incomparable value.

Sometimes there are dietary issues that may be brought to the fore when engaging in Valentine’s Day festivities.  Valentine’s Day gifts tend to involve copious amounts of chocolate and sweets.  For survivors with diabetes, eating large amounts of chocolate and sweets is invariably accompanied by significant risk of serious health complications.  Loved ones may want to give non-food gifts like flowers or other such items to diabetic patients.  Also, people tend to go out to eat for Valentine’s Day meals.  Any instructions by speech therapists such as using thickener to make drinking liquid less of a hazard or adhering to safe swallowing techniques need to be carried out in restaurants just as they would be at a home or at a rehabilitation facility.  It may not seem romantic to thicken a drink during a candlelit dinner at a white tablecloth dining establishment, but there is certainly nothing romantic about contending with an identified swallowing issue leading to a serious problem such as aspiration pneumonia.

As mentioned above, many people like to go out for Valentine’s Day.  This may include going to restaurants, movies or plays.  As Valentine’s Day tends to be a busy day for these venues, there are a few issues that may need to be considered as regards a brain injury survivor’s participation.  If a survivor has physical mobility issues, that survivor and his or her loved ones need to hold accessibility as a key aspect of any venue selection.  Though all public buildings must by law meet a minimum threshold of accessibility, some venues are simply better suited to the needs of those with significant mobility issues than others.  One relevant question to consider would be which restaurants have wider spaces between tables allowing greater ease in wheelchair navigation.  Is there a separate accessible entrance that a survivor can use to make it easier to enter the venue?  As an example, many movie theaters have separate entrances for those with mobility deficits so as to make it easier to enter and leave while avoiding the normal crowd of movie-goers.  If a survivor would do best with a particular seating arrangement (such as being closer to the door to limit the distance he or she will be required to walk), venues will almost always assist in such a scenario as long as they are contacted in advance.  A simple phone call to a restaurant can often guarantee that the most appropriate seating will be reserved for the survivor and his or her loved ones.  Survivors and loved ones may also want to consider patronizing any of these establishments at off-peak hours.  This can not only mitigate challenges faced by those with mobility issues, but it is also usually the best choice for survivors that have a tendency to become easily agitated when in large crowds.  Some survivors may do best with a home-based or facility-based celebration rather than going out into the community if they have too significant a difficulty with mobility or managing agitation.  Others may do best by celebrating Valentine’s Day a day early or a day late so as to avoid the holiday rush and stress.

One oft-ignored issue is that many brain injury survivors simply do not feel attractive faced daily as they are by ever-evident knowledge of permanent changes their injuries have wrought.  They may look at themselves and see body parts that do not move, now necessary constantly present aid devices, prominent scars or other injury-related alterations to their physical appearance that make them feel ugly.  In almost all cases, loved ones will still feel  strong love for and a powerful sense of connection to the survivors.  Sometimes, contending with life in the aftermath of such an injury will have the effect of even increasing these feelings.  It is vital for loved ones to express their feelings to the survivors and to be sure that they let the survivors know how much the survivors are loved.   Survivors may need more encouragement and reassurance of their attractiveness than they needed in the past.  Further, survivors should be encouraged to dress as they normally would have (or as best as they can now manage given their needs).  For instance, if a survivor normally wore make-up prior to her injury, she should be encouraged to still wear make-up.  We tend to feel better when look better, even when we do not have an injury.  When we see ourselves in the mirror looking our best, we are more likely to feel our best.

I hope this post helped to explain a few of the issues that may accompany Valentine’s Day celebrations and offered some useful suggestions to aid brain injury survivors in maximizing their holiday experiences.

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

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