TBI Support and Tools for Diagnosis and Therapy

1. TBI Support and Tools for Diagnosis and Therapy Presenter: Rebecca L. Stewart, M.A., CCC-SLP Speech-Language Pathologist Warrior SALUTE

2. Goals for today • Overview of general assessment tools that professionals, including Speech-Language Pathologists (SLP’s), commonly use to identify cognitive and communicative issues related to Traumatic Brain Injury (TBI) • Review of current treatment strategies for use with people who have cognitive-communicative issues related to TBI

3. Goals for today (continued) • Support for the Veteran and Family Identify a variety of ways that families can support their loved ones through the cognitive and communicative challenges that may occur with a TBI

4. Traumatic Brain Injury • Challenging and complex diagnosis that can affect a person globally, including their cognitive and communicative processes • Many individuals are left to their own devices once out of hospital rehabilitation • Chronic (ongoing) health condition • Public health crisis

5. What is cognition? Cognition is a person’s ability to: • Think • Process information • Remember and recall events • Pay attention • Solve problems • Demonstrate awareness of surroundings and self • Plan and organize

6. What are “cognitive-communicative skills”? • How a person uses cognitive skills, along with language, to communicate • Following TBI, some or all of these skills may have changed as a result of the person’s injury • The SLP evaluates the person with TBI to determine their strengths and areas for improvement and develop an individualized cognitive-communicative therapy plan

7. TBI’s impact on cognitive-communicative functioning • Trouble concentrating when there are distractions • Slower processing or "taking in" of new information • Problems with recent memory- new learning can be difficult (long term memory generally less affected)

8. Impact on cognitive-communicative functioning • Executive functioning problems: -starting tasks and setting goals to complete them -planning and organizing a task is an effort -self-evaluation of work is difficult -disorganization and need for the assistance of families and friends -difficulty solving problems -may react impulsively

9. Impact on cognitive-communicative functioning • May have trouble finding the words they need to express an idea or explain themselves through speaking and/or writing • Understanding both written and spoken messages may be difficult • May have difficulty with spelling, writing, and reading

10. Impact on cognitive-communicative functioning • May have trouble with social communication, including: -taking turns in conversation -maintaining a topic of conversation -using an appropriate tone of voice -interpreting the subtleties of conversation (e.g., the difference between sarcasm and a serious statement) -responding to facial expressions and body language -keeping up with others in a fast-paced conversation

11. Evaluation of cognitive-communicative skills should include • Pre-injury characteristics • Stages of development and recovery • Communicative demands of the everyday environment- including personally meaningful activities (i.e. hobbies) as well as other life and communicative contexts

12. Evaluationshould include • Multiple sources of information- should include not only standardized tests, but non-standardized information as well • Integration with other professionals who also would evaluate cognitive skills (i.e. neuropsychologist)

13. Evaluation • Continues to be comprised mostly of standardized tests • Cognitive-communicative tests specific to TBI are not developed, as of yet, for adults • Interview and discourse (conversation) is used to gain more evaluative information

14. Tools for evaluation • The American Speech-Language Hearing Association Functional Assessment of Communication Skills in Adults (ASHA FACS) • Behavior Rating Inventory of Executive Function (BRIEF) • Communication Activities of Daily Living, 2nd Edition • (CADL-2) • Functional Independence Measure ( FIM) • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) • Western Aphasia Battery (WAB)

15. Treatment of cognitive-communicative deficits in TBI • Rote drill-type practice and workbook-type tasks have not been shown to be effective for carryover to everyday life • Pre-teaching is an effective strategy to “set up” expectations for the person and gives relevance of the task to their life (“this is what we are going to do, and why we are going to do it”) • Task itself is not the most important aspect of therapy, but rather, what cognitive-communicative skills are we addressing through the task

16. Treatment of cognitive-communicative deficits in TBI • Tasks are “graded” over time to make tasks more challenging to make progress - cues may change - level of distractions may change - using novel versus familiar tasks - set-up or pre-organization provided

17. Treatment of cognitive-communicative deficits in TBI • Focus on the functional, and include tasks that are tailored to interests and to lifestyle and setting after discharge from program- look at what skills are needed -sorting mail -organizing a photo album -following a recipe that needs to be doubled -taking phone messages at desk -organizing a Rolodex

18. Treatment of cognitive-communicative deficits in TBI • Internet search about topic and make presentation • Plan seasonal garden and organize project • Plan a household project or car maintenance plan • Official “greeter,” orientation of new Veterans to program • Plan week’s menu and grocery list • Set up weekly home schedule

19. Support Begins with taking care of yourself as a caregiver/family member: • Take care of yourself and your body • Take breaks • Take off “the cape” • Get comfortable with your family member being independent without feeling guilty • Connect with others • Find time to do things that replenish your soul

20. Support Other ways to care for yourself: • Talk to someone you trust • Set boundaries for yourself- saying “no” when needed • Schedule time to worry • Create a team of professionals to help you and educate you about your family member’s condition • Accept help • Hold a family meeting to gain support and assistance

21. Support strategies for processing difficulties • Slow down and simplify information • Break complex tasks and activities into smaller steps • Allow extra time to respond to directions and to questions, and to learn new information • Avoid situations that are overstimulating • Encourage family member to ask others to slow down

22. Support strategies for attention difficulties • Focus on one task at a time • Be sure you have your family member’s attention before beginning a discussion or task • Reduce clutter at home and in the work environment • Perform tasks in a quiet environment • Remove distractions and noises that you don’t need • Use timers (watches, smart phones, PDAs, or other devices) and checklists in a calendar/memory notebook to help with completion of tasks

23. Support strategies for attention difficulties • Refocus attention to the task at hand • Expect a shorter attention span and schedule rest breaks and/or stop activity when you notice drifting attention • When signs of distraction arise, insert a rest break (“Let’s do this for another 5 minutes and then take a 15 minute break.”) • Present verbal or visual information in limited amounts

24. Support strategies for memory difficulties • Gain person’s attention • Break information into “chunks” • Set up routine of daily tasks and stick to it • Help family member use memory aids (i.e. calendar) and check off tasks when done • Explore use of “high tech” memory aids • Use a labeled, compartmentalized pill box and keep track of medication administration on calendar • Keep personal and household items in consistent spots • Pair new information with things the person already knows

25. Support strategies for memory difficulties • Provide verbal cues for memory recall and fill in gaps • Talk about events of the day to build memory • Review plans for the next day • Learn and use a cueing system • Present information in more than one way (i.e. not just seeing, but seeing, hearing, and doing) • Role play to reinforce new learning

26. Support strategies for planning and organizing difficulties • Begin with small, realistic tasks • Get organized at home with calendar, reminder notes and cue cards • Check off tasks on calendar • Turn off distractions • Use of a tote bag or backpack to organize needed items for the day

27. Support strategies for decision-making and problem-solving • Avoid making decisions when tired, hungry or under stress • Help family member weigh options and also the consequences of making each decision • Give time to make decisions • Limit the number of possible choices- two or three are best • Avoid making last-minute decisions

28. Support strategies for speech difficulties • Ask your family member to repeat what they said more slowly if speaking rapidly • Use a gesture or other cue to remind the person to speak slower if speech too rapid or slurred or if they need to speak more loudly due to soft speech • Allow time for expression

29. Support strategies for starting conversation • Help family member start a conversation by asking a leading question such as, “What do you think about …?” • Encourage discussion about topics of interest or familiar topics • Ask open-ended questions (e.g., questions that cannot be answered with a “yes” or “no”), such as, “Tell me more about your day.” • Give your family member your full attention

30. Support strategies for starting conversation • Give family member time to organize his or her thoughts • Use redirection, if necessary (e.g., “So what do you think about….?”) • Reinforce all efforts to start a conversation and show that you value contributions to conversations

31. Support strategies for word-finding difficulties • Give person time to locate the word he or she is looking for • If he or she still cannot locate the word after some time, guess at what he or she might mean or ask him or her to write it down • Try to be patient- it can be very frustrating for your family member when he or she knows what he or she wants to say but cannot locate the right word or phrase • Encourage him or her to use another word that is close in meaning • Suggest that he or she use many words (or a description) instead of using a single word (This is called circumlocution, a strategy speech language pathologists will often teach.)

32. Support strategies for problems following conversation • Get your family member’s attention before speaking • Be clear and to the point-keep it simple • Reduce distractions • Every so often, stop and ask your family member to restate what he or she heard to ensure understanding • Reduce your rate of speech and pause frequently to allow the person time to process and respond • Avoid abrupt topic changes • In group conversations, help set a slower pace of conversation

33. Support strategies for interrupting conversation • Politely interrupt and ask for a chance to speak or tell your family member you would like to say something • Develop a hand signal which indicates to the person that he or she may be monopolizing the conversation • Gently alert him or her to the fact that the topic change was too abrupt or that he or she has interrupted and will be given a chance to say his or her piece in a moment • Use positive reinforcement for all attempts at listening rather • than talking • Interruptions may occur because he or she is “lost” in the conversation- encourage him or her to let you know if he or she doesn’t understand what is being said

34. Support strategies for reading comprehension difficulties • Read with your family member • Review the reading material, using the 5W strategy – Who, What, Where, When, Why: - Who are the characters? - What happened to the characters in the book? What did they do about it? - Where did it happen? - When did it happen? - Why did it happen? • The 5W’s should be related, that is, they should refer to the same • characters or portion of the story

35. Support strategies for writing difficulties • Practice writing with your family member- letters to friends or relatives may be an option • Make a list of openings (i.e., Dear, Hello, Hi, etc.) and closings (i.e. Thank You, Sincerely, Yours Truly) and the reasons for selecting them • Suggest saying words out loud before writing them • Suggest reading what is written to make sure it makes sense

36. Support strategies for non-verbal communication difficulties • Role play the right way to behave in a particular setting • Work with the health care team to practice appropriate behavior • Talk to your family member about how to act in certain situations before he or she is in those situations • Give feedback on the right amount of eye contact to keep with another person and praise all improvements • Decide on a signal to indicate problematic behavior

37. Support strategies for non-verbal communication difficulties • If there are concerns with providing personal space, politely ask your family member to stand closer or further away • Explain how a given behavior is making you feel uncomfortable • Tell your family member you are confused by the difference in body language and spoken message- briefly explain what you saw and heard

38. Support strategies for hearing loss • Have hearing checked with an Audiologist as soon as concerns arise, and obtain hearing aid(s) if needed • Use of other assistive listening devices and alerting devices may be helpful (i.e. Bluetooth devices, FM systems) • Avoid further exposure to prolonged, excessive noise • Drug therapy may be an option in treating some types of hearing loss (i.e. corticosteroids for inflammation)

39. Support strategies for tinnitus • Seek guidance from an Audiologist • Audiologist may collaborate with ENT (ear, nose, throat doctor) for optimal treatment • Current forms of treatment include: -hypnosis -relaxation -biofeedback -electrical stimulation -counseling -habituation therapies -masking