L9: Cognitive and Behavior Management Strategies

________% of patients with TBI exhibit challenging behaviors in the inpatient setting

30 - 70

Agitation occurs in ________% of hospitalized patients with TBI in the early recovery phase

44

(may persist beyond acute phase of recovery)

Challenging behaviors may cause increased ________, ________ & ________, ________ & ________ for family members of patients with TBI

Burden, Emotional strain, Distress, Lower QOL, Mood

What can we do to help understand behavioral problems

• You cannot control other people's lives — Manage your own behavior

• You cannot totally eliminate negative behaviors — Minimize inappropriate behavior

• Do not take behavioral outbursts personally — Emotional distancing

What does the ICAR model provide info on

Diagnosis and what is is

Explain the ICAR model

• Information = Neuropsychological assessment of cognitive abilities and neuropsychiatric dysfunction

• Contingencies = Relationship between the behavior and the event or response that follows

• Self Awareness = Facilitating a person's awareness of behaviors in context

• Relationships = Building therapeutic alliance by being non-judgemental & fact based

Individualized behavior analysis does what?

• Defines the behavior

  • Qualify the behavior

    • Yelling, outbursts, picking, rocking, standing up, refusing treatment, wandering

    • “patient is agitated” is NOT sufficient

  • Quantify the behavior

    • Frequency, duration, intensity

What does the behavior analysis: antecedent do

Identify the antecedent

What is the goal of behavior analysis: antecedent

Reliably predict stressors, behavioral responses

What could be included in the antecedent

• Time of day

• Specific activity

• Lack of control

• Environmental issues

• Caregiver behavior

• Specific language

• Changes in routine

• Physical need

Behavior analysis sequence of events

• ABCs

  • Antecedent

  • Behavior

  • Consequence

As a PT, the antecedent control goal is to

Manage your behavior to modify behavioral antecedent

Behavior management strategies

• Positive reinforcement

• Extinction

Effective rules in behavior management planning should include:

1. Specific description of behavior you want to see/not see

2. Circumstances rule should be followed

3. Realistic consequences

4. Meaningful consequences

5. Deadline for reward

What is anosognosia

• Lack of physical or cognitive self-awareness

  • Mostly used when a patient isn’t aware of their deficits

In stroke, anosognosia is more frequently associated with?

Right cortical damage

In TBI ________% of patients demonstrate some lack of self-awareness

52 - 68

3 levels of pyramid model of self-awareness

• Top = Anticipatory awareness

• Middle = Emergent awareness

• Bottom = Intellectual awareness

What is anticipatory awareness

Something could go wrong

(Pt knows they have neglect & leg will give out when walking)

What is emergent awareness

Something is wrong right now

What is intellectual awareness

Something is generally wrong

(Pt knows something is wrong, but doesn’t know what)

What does the dynamic comprehensive model of awareness look at

• Meta cognition

  • How you think about things

  • “Thinking about thinking”

What is denial?

Pt refutes the facts & doesn’t want to address their deficits

(can be conscious or subconscious)

Denial presentation

• Appears to be a psychological reaction

• Demonstrates resistance or anger with feedback regarding limitation

• Demonstrates an active struggle to work with new info about themselves and may rationalize or make excuses

• May be accompanied by reactions of depression or anger and can co-occur with impaired self awareness

With denial, the pt has ________ or ________ knowledge about impaired function

Partial, Implicit

Higher levels of denial are associated with

Increased avoidant-coping strategies = Related to higher levels of depression

________ might be needed for those with high levels of denial

Ongoing psychological support and monitoring

What is lack of self awareness

Pt has a true non-understanding of their deficits

Lack of self awareness presentation

• Appears rooted in neurologic dysfunction

• Client lacks information about themselves

• Are perplexed and surprised or confused when given feedback regarding limitation

• Exhibits cautious willingness or indifference when asked to work with new information about themselves

Lack of self awareness can co occur with ________

Denial

Lack of self awareness is associated with

• Other impairments

  • Decreased initiation, planning, & self-monitoring/regulation

If there are high levels of neurologic-based unawareness, what might be done to increase awareness?

Challenges structured to highlight problems

OCM to measure self-awareness

Patient competency rating scale (PCRS)

The ________ usually administers the PCRS

Neuropsychologist

Is The Awareness Questionnaire (AQ) used for TBI or stroke

TBI

To be classified as having a level of function similar to pre-injury on The Awareness Questionnaire, the patient must score

>51/85

On The Awareness Questionnaire, self awareness is determined by

Comparing pt score to that of the score from the caregiver or clinician

How to promote self-awareness

• Motivating tasks

• Video feedback

• Gaming

  • Board games specific to patient (more SLP)

• Pause-prompt-praise