Case Presentation:Robert, Hypoxic Brain

InjuryBy: Rachel Kennedy

11007281Clinical Placement 5

Summary of Presentation

Background to case: Client: RobertGender: Male Age: 34Presenting Condition: Hypoxic Brain Injury,

Secondary to Cardiac Arrest – Client has Fallot’s Tetralogy.

Brain Injury has caused a gradually recovering retrograde amnesia, anterograde amnesia and difficulties with aspects of short-term memory

History Chef Very supportive Parents, close

relationship with brother.Social Drinker. Smoker, x

10/day.Recreational illicit drug userLived with partner & younger

child at time of incident.

Record of Hospital Admittance: Chronological Cardiac Arrest, found 24-48 hours post

same, at home. Admitted to local hospital & intubated.

Transferred to the Mater. 1 x incidence aspiration pneumonia post extubation. No Issues with Dysphagia since. Trace dysphonia, spontaneously resolved

Referred to SLT days after admission, due to ? Issues with memory causing speech & language difficulties.

Stayed in Mater for approx. 35 days before returning home prior to admittance to NRH.

Description of Need for SLT at Initial AssessmentLanguage: Reduced output & non-retention of

verbal information at the level of conversation or with more complex language, generally

Dysarthria: hyponasality, monopitch and monotone

Current Client Profile (McCormack & Worrall, 1998)

Body Structures & Functions

Young Male, aged 34 Initial unsteadiness of balance and

gait at admission: since resolved with input from Physio during time here.

Language post-incident evidencing higher-level impairments secondary to hypoxic brain injury.

Memory loss, common outcome of type of injury (Geraghty & Torbey 2006, Mattiesen et al 2009).

Current Client Profile: ICFActivities & Participation

Environmental FactorsLived with partner and

younger child prior to admission. Worked full time.

Will live with parents between discharge from Mater and intake to National Rehabilitation Hospital.

Discussion of future limited & required sensitivity, due to client’s memory impairment.

Personal Factors

Assessment

Assessment Results Reduced output when patient asked to generate own

materials spontaneously…3-5 word sentences, telegraphic. Positive response to supporting cues with output

Pragmatic skills functionally intact, NAD. Functionally impaired retention of verbal and written

information - recalling 0-1 of 4 points from paragraphs heard or read some seconds previously.

Functional numeracy, literacy and written skillsDeemed an appropriate candidate for inpatient intensive

rehabilitative SLT (Constantinidou & Kennedy, 2013).

Patient Identified Difficulties: Remembering what people

had told him after a period of time had passed

Difficulty contributing as much at a conversational level as he had prior to admission

Occupational Therapist supplied patient with written diary to record activities day to day – memory aid.

DiagnosisIschemic Hypoxic Brain Injury (Powell, 2004)Primary Characteristic is Memory LossHigher Level Language Difficulties are related to

Memory LossDysarthria initially commented on by first

assessing SLT appeared to resolve without intervention across sessions - ? Effect of acute fatigue/loss of self-monitoring skills/acute medical condition earlier in admission.

7 Steps Case Management (Dodd, 1995)

Is Intervention Indicated?

Episode of Care

Clinical Observations

Clinical ObservationsIncreasing the cognitive effort required to produce

desired language output (via decrease in support or cueing) significantly decreased length and content of resultant expression

Robbie was initially able to recall information from a two paragraph passage heard less than a minute previously with maximal support and cueing only.

Robbie would intermittently draw on his general knowledge to assist in answering questions to comprehension tasks – useful mask for non-retention and at times a useful strategy too, but not always of best use to client, functionally

Goals

Ultimate Goal

Mattiesen et al (2009), Shum et al (2013)

Long Term Goal One

Shum et al (2013), Kessels & DeHaan (2003), Dunlosky et al (2005)

Long Term Goal: Two

Rider et al (2008), Ehlhardt et al (2008), Das Nair & Lincoln (2013)

Service Delivery

Direct TherapyUse of written and read

passages, based on Robbie’s interests … (Tottenham Hotspur, Thriller Novels, Electronica)

Discussion of topics, using a Semantic Features Therapy (modified use of this tool, to encourage longer sentences and more detail on specific topics, e.g. family, or work).

Critical Reflection: TherapyAdvantage that parents were very motivated

to help Robbie achieve this, and very in tune with his issues and challenges

Would every parent of an adult child be this motivated?

Increased practicality of tasks?May be prudent to consider family counseling

in the future (Schonberger et al, 2010).

Generalisation: how to achieve, how to measure? Robbie rehearsed strategies

on the wardParents used strategies Record of Robbie’s abilities

with activities taken every second session. Therapy used same tasks every day (Ylvisaker & Feeney, 1998).

Comparison of baseline & performance at final session (NB the effect of fatigue)

Outcome and Efficacy Outcomes: Ability with recall at

every session (Constantinidou & Kennedy, 2013).

Outcomes: Patient report of confidence in abilities

Efficacy: Comparison of performance at baseline and shortly before discharge from MMUH SLT.

Outcome Measures: So FarFrom 30% to 70% recall

(at best session) – Fatigue still impacting

Robbie reports he feels that the SLT sessions have helped him feel he can express more.

OT & Medical team note patient ‘more talkative,’ ‘participates more.’

Critical Reflections: generalisation, outcome & efficacyPatient still has a long road to travel – will undergo

further rehabilitation once admitted to NRH. Greatest improvements are made in the six

months post incident (Powell, 2004)

Recommendations & Future PlansOngoing input and potential review of status at NRHLink in with Headway/Acquired Brain Injury IrelandContinued vigilance on part of patient and family Counseling for family and partner – and for patient, if

he indicates need for same. Decision making around potential for return to work

and/or need for change in career or lifestyle will likely become possible during/post time in NRH.

What if problems remainIncrease proportion of focus on strategies to aid

memory and language use – written reference & clarification requests, for example

Consider change in career

DischargeFrom Mater, on parental request – felt it would be

better that Robbie could return to his natural environment

From SLT altogether? Ideally once client no longer has any needs; practically, once his needs are no longer considered significant enough to merit priority.

Prognosis – Chronic, or not?Ultimate deciding factor: time We’re not sure – yet!SLTs at NRH will take up work with Robert, and ongoing assessment may tell more

Thank you! Any Questions?

ReferencesConstantinidou, F. & Kennedy, M. (2013) Traumatic Brain Injury in Adults. In: Papathanasiou, I., Coppens, P. & Potagas, C. (2012) Aphasia and Related Neurogenic Communication Disorders. Massachusetts: Jonas & Bartlett. 365 – 387

Das Nair, R. & Lincoln, N. (2013) The effectiveness of memory rehabilitation following neurological disabilities: A qualitative inquiry of patient perspectives. Neuropsychological Rehabilitation, 23(4), 528 – 545  Dunlosky, J., Hertzog, C., Kennedy, M, & Thiede, K. (2005) The self-monitoring approach for effective learning. International Journal of Cognitive Technology, 10(1), 4 - 11

Ehlhardt, L., Sohlberg, M., Kennedy, M., Coelho, C., Turkstra, L., Ylvisaker, M. & Yorkston, K. (2008) Evidence-based practice guidelines for instructing individuals with acquired memory impairments: what have we learned in the past 20 years? Neuropsychological rehabilitation, 18, 300 -342

ReferencesGeraghty, M. & Torbey, M. (2006) Neuroimaging and serologic markers of neurological injury after cardiac arrest. Neurologic Clinics 24(1) 107 – 121

Kessels, R. & DeHaan, E. (2003) Implicit learning in memory rehabilitation: a meta-analysis on errorless learning and vanishing cues methods. Journal of clinical and experimental neuropsychology, 25, 805 – 814

Mattiesen, W., Tauber, S., Gerber, J., Bunkowski, S., Bruck. W. & Nau, R. (2009) Increased Neurogenesis after hypoxic-ischemic encephalopathy in humans is age related. Acta Neuropathalogica 117(5) 525 – 534

McCormack, J., and Worall, L (2008) ‘The ICF Body Functions and Structures related to speech-language pathology’ International Journal of Speech-Language Pathology :10,(1-2) 9-17

ReferencesPowell, T. (2004) Head Injury: A Practical Guide. Revised Edition. Milton Keynes: Speechmark. Rider, J., Wright, H., Marshall, R. & Page, J. (2008) Using Semantic Feature Analysis to Improve Contextual Discourse in Adults with Aphasia. American Journal of Speech-Language Pathology 17, 161 – 172

Schonberger, M., Ponsford, J., Olver, J. & Ponsford, M. (2010) A longitudinal study of family functioning after TBI and relatives’ emotional status. Neuropsychological Rehabilitation, 20(6), 813 – 829

Shum, D., Cahill, A., Hohaus, L., O’Gorman, J. & Chan, R. (2013) Effects of aging, planning and interruption on complex prospective memory. Neuropsychological rehabilitation, 23(1), 45 – 63

Ylvisaker, M. & Feeney, T. (1998) Collaborative Brain Injury Intervention: Positive everyday routines. San Diego, CA: Singular Publishing