11.8a Management challenges: the person with the TBI

i) Understanding

Do they have the capacity to understand what is going on?

If the patient does not think there is anything wrong with them they are not going to comply with treatment.  This is not only pharmacological management but also behavioural management.

The person who checks 20 times a day because that way they will not forget may not see that as being necessarily abnormal and therefore will not necessarily understand why they need to resist the urge to check so many times a day.

When someone has a brain injury is their capacity to understand what is going on can be reduced. This becomes a real challenge for psychiatry is getting them to consent to treatment.

A number of psychiatric agents that we use can have substantial side effects, in some cases life threatening side effects, such as with the medication Clozapine.

If a person has an impaired capacity to consent to treatment they will also then have an impaired capacity to consent for mental health treatment. You then need to look at what other strategies or techniques you could use to get appropriate consent. Using legal mechanisms to consent is important in this.

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ii) Is the person cognitively able to pursue treatment?

Many clinicians often do not want to work with people with organic impairment because they may lack the memory, initiative, organisation and planning to make it to regular appointments.

One of the things often heard from mental health services is "Oh they do not want any treatment because they do not come". But the problem is that the traumatic brain injured patient does not have the capacity to get themselves to treatment. They will forget their appointments, they will forget to take their medication, they will forget the strategies that have been taught to them.

The brain injury in its own right has a profound impact on that person's ability to benefit from treatment, partake in the treatment and follow through. So they might want to get better but they do not have the cognitive ability to do what is necessary to get better.

Once they are on the treatment they often do not remember what is happening with the treatment. So when you see them for follow up they cannot tell you about the side effects that they have had and they often cannot tell whether they are getting better or whether they have got worse.  Their ability to report their response to treatment is impacted upon by their cognitive impairments in particular, their memory impairment.

Some of these patient issues can be easily overcome by changing management strategies.   For example, ringing patients to remind them of treatment, using dosette boxes or Webster packs to improve their compliance, to help them to see whether they have or have not taken their treatment, using family members to prompt and remind.  Utilising technology like iphones or smart phones to prompt.

In the case of Sam, the family administered the medication and that was not without its pitfalls because they never gave the amount of medication he really needed to get better because they were worried it was too much.  Generally family members can be convinced to give the person the medication in the prescribed dose and it can really help. Family can be used to reinforce behavioural strategies and to remind people about using diaries and programs. You can overcome these brain injury issues by manipulating the environment, but it is important to recognise that they are issues so that you can do something about it.

 

iii) Sensitivity to treatment

Another challenge for patient management is their sensitivity to treatment.

In the past it was often thought that patients who had an organic brain injury were resistant to treatment or had a poorer response. It was not that they had a poor response, the problem was we were using medication in sub-therapeutic doses because they could not tolerate the side effects.

Typically people with an acquired brain injury have a reduced neuronal reserve and as a result they get an exaggeration of side effects. With the modern or newer drugs, in particular the newer antipsychotic agents and antidepressants we can achieve therapeutic doses and get a good response to treatment. But we have to remember the patients are much more sensitive to the side effects of treatment . We need to monitor and modify the dosage accordingly.