Managing behavior in brain injury patients requires a calm, structured and compassionate approach. Clinicians can reduce agitation and encourage participation by adjusting the environment, offering clear communication and planning activities with intention. These strategies lead to safer, more successful therapy sessions for patients recovering from acquired brain injuries.
At Encompass Health, we have experience in treating patients with brain injuries, and we understand how overwhelming this phase of recovery can be for both patients and clinicians. These behavior changes are a normal part of healing, and with the right strategies, sessions can remain safe, productive and meaningful.
Summary
- Understanding behavior changes after an acquired brain injury (ABI)
- Interacting with patients with ABI
- Core strategies for managing behavior in brain injury patients
- Environmental and scheduling interventions
- Helping patients participate in activities
- What to do if your patient is refusing therapy
- How to handle inappropriate comments or touching
- Putting it all together
Understanding behavior changes after an acquired brain injury
Behavior issues are fairly common in acquired brain injury patients. Studies suggest behavioral deficits, including agitation, impulsivity and restless behavior, occur in up to 70% of patients hospitalized with different types of brain injury. Many of these patients are experiencing post-traumatic amnesia, which is a stage of recovery involving disorientation, distractibility and decreased short-term memory.
These behaviors can feel surprising or personal in the moment, but they are symptoms of the injury. With preparation and a steady approach, clinicians can support functional outcomes and successful community re-entry during brain injury rehabilitation.
Interacting with patients with ABI
Your first interaction sets the scene for the entire session. Clinicians at Encompass Health use consistent verbal and nonverbal communication to prevent many behavior issues before they start.
- Use a social greeting. Re-introduce yourself in case the patient doesn’t remember who you are.
- Speak slowly and clearly. Simple and concise instructions give the patient time to process.
- Correct gently. Correct the error once, but avoid arguing or repeatedly disagreeing.
- Explain your intentions. Let patients know what you plan to do ahead of time to avoid a startled reaction.
- Avoid sudden touching. Approach from the front and use gentle pressure instead of grabbing or pulling. Also consider sitting on a chair rather than towering over them.
- Re-direction at early signs of frustration. Switch topics or activities to prevent escalation.
- Clearly end your contact. Patients with ABI often aren’t aware of social cues that you intend to exit the room. Use direct statements such as, "The therapy session has ended, and it's time for me to leave the room."
Core strategies for managing behavior in brain injury patients
It's important to consider basic behavior principles. You don't have to be an expert, but understanding these concepts can re-focus your perspective.
Key principles
- All behaviors have a purpose. We have to understand why behaviors occur before we can have a chance to change them.
- Minimize, not eliminate. Eliminating behaviors entirely isn’t realistic.
- Manage your own behavior. We can always manage our own behavior more easily than that of another.
- Build rapport. A positive therapeutic relationship can reduce behavior issues and predict a more successful outcome.
- Be proactive, not reactive. Anticipating challenges ahead of time can prevent escalation.
What to do if your patient becomes aggressive
Agitation is a state of verbal or physical aggression that occurs when the brain is healing from injury. Caregivers can manage agitation by learning strategies and techniques to promote a safe experience.
Here's how to respond if it happens:
- Remove and minimize triggers. Identify things that may upset the patient, such as feeling rushed, corrected or overwhelmed.
- Allow time for de-escalation. Change the subject or switch tasks. Sometimes, a break is needed to recover.
- Explain unacceptable actions. If physical harm occurred, calmly explain it's not acceptable. Be direct about the inappropriateness of the behavior.
- Discuss triggers, if possible. When calm, ask what triggered them.
Environmental and scheduling interventions for ABI
A healing brain can only handle so much stimulation. Thoughtful adjustments to the environment can make a major difference.
Environmental changes
- Reduce light, noise and clutter. Draw the curtains, turn off the TV and remove clutter.
- Encourage calm communication. One person should speak one at a time, using slow, low voices.
- Minimize restraints. Avoid restraints when possible. Consider a sitter, low bed or enclosure bed instead.
- Limit tubes and lines. Cover lines with an abdominal binder or clothing when they cannot be removed.
- Create a familiar space. Personal items and familiar music can make the patient comfortable and encourage participation.
- Limit visitors. Too many people at once can be overwhelming.
Scheduling considerations
- Consistent schedule and staff. Familiar routines allow patients to know who and what to expect each day.
- Shorter sessions throughout the day. In addition to cognitive and physical fatigue, ABI patients have limits on how much frustration they can handle.
- Sleep cycle and quality. A sleep log is helpful for identifying disruptions which can impact daytime agitation.
Maximize orientation
- Re-orient the patient. Cover basic information like where they are, what has happened or what day it is.
- Use assistive devices. Hearing devices and glasses reduce confusion and frustration levels.
Helping patients participate in activities
- Allow pacing or movement. Many patients with brain injuries have motor restlessness, where they feel better when they're moving.
- Timed toileting. Using the toilet on a timed schedule, such as every two hours. This helps patients who may not be able to initiate or express the need on their own.
- Diversional activities. Occupy the patient during down time with activities, such as playing cards, magazines or activity kits.
Team-based approaches
Inpatient rehabilitation offers an interdisciplinary approach. Physical therapy, occupational therapy and speech therapy teams work together to support our patients with brain injuries. This teamwork reduces behavioral challenges, improves safety and promotes meaningful progress in mobility, cognition and communication.
- Co-treatments. A clinical psychologist can model strategies or assist with an actual behavior contract if needed.
- Interdisciplinary behavior rounds. Team members review behaviors, triggers and strategies to proactively address situations ahead of time.
- Alternate caregivers, when necessary. If a patient gets agitated at a specific staff member, switch staff when possible.
- Educate family members. Teach family members how to re-direct instead of confront, and encourage them to take breaks.
What to do if your patient is refusing care
Non-compliance is when the patient is unwilling to participate in daily living activities, such as taking medications, dressing or eating.
- Provide choices. Give the patient a sense of control by presenting options as an either/or decision, as too many choices can be overstimulating.
- Bargaining. Identify something that motivates the patient and use it as a negotiating tool.
- Positive reinforcement. Reward a positive behavior with a compliment or praise to encourage progress.
- Avoid power struggles. Statements like, "because I said so," often backfire.
- Adjust the task to meet expectations. Sometimes patients will make an unrelated request before participating in your task. When safe to do so, incorporate this task into your plan, like reorganizing their closet before putting on pants.
How to handle inappropriate comments or touching
Inappropriate sexual behavior is also possible after a brain injury. Some patients lose awareness of social rules. This type of behavior is more common in men, younger patients and those in prolonged post-traumatic amnesia.
In the moment
- Ignore the behavior. Continue with the task without a reaction that could aggravate the patient or give unnecessary attention.
- Redirect and explain. Tell the patient the behavior is inappropriate and re-orient them to what is happening.
Additional strategies
- Plan ahead. Plan for situations where the behavior tends to occur and request extra support.
- Provide alternative activities. Smaller or a second activity option are helpful if the patient isn't appropriately handling the initial task.
- Keep distance. Create space so the patient has less opportunity to touch, grab or get too close.
Putting it all together
Behavior issues are a common and challenging part of brain injury recovery. Consider these tips to set the scene for a positive experience with minimal disruptions. Behavior management is a team effort, and we can all work together to support functional independence and community integration with this population.
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