Tag Archives: alcohol

Alcohol, Seizures and Brain Injury

A drunk driving accident.  A fight at a bar after a night of drinking.  Many brain injury survivors received their brain injuries while under the influence of alcohol.  In fact, studies have shown that between 35% and 81% of people who received a traumatic brain injury had been drinking at the time of their injury.  Doctors and therapists routinely recommend that survivors abstain from alcohol after a brain injury but some survivors ignore this advice.  But drinking after a brain injury has a new and more dangerous risk than before, namely post-injury seizures.

In general, brain injury survivors are more prone to developing a seizure disorder than are people without brain injuries.  Depending on the severity and location of a traumatic brain injury, research shows that post-traumatic brain injury seizure rates are between 2-50%.  Similarly, post-stroke seizure rates are between 5-20%.  Both of these are significantly higher than the seizure rate in the general population.

Unfortunately, alcohol can raise both the likelihood and frequency of post-injury seizures.  Alcohol lowers the threshold for seizures to occur, making a seizure more likely to happen.  For those already taking anti-seizure medication, alcohol can interfere with the performance of the medication, causing the medication to be ineffective and allowing more seizures to occur.  As a seizure can be a potentially life-threatening medical issue, anything that raises the likelihood of seizures should be avoided.

Overall, it is smart for many reasons to avoid consuming alcohol after an injury.  But the risk of seizures is an important reason which should not be ignored.

Learn about brain injury treatment services at the Transitional Learning Center! Visit us at: http://tlcrehab.org/

 

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

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

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

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