Psychiatric Bulletin (2000) 24: 264-266. doi: 10.1192/pb.24.7.264
© 2000 The Royal College of Psychiatrists
Psychiatric Bulletin (2000) 24: 264-266
© 2000 The Royal College of Psychiatrists
In-patient neuropsychiatric brain injury rehabilitation
Fernando Lazaro, Research Fellow,
Rob Butler, Honorary Senior Registrar and
Simon Fleminger, Consultant Psychiatrist and Honorary Senior Lecturer
Brain Injury Rehabilitation Unit (BIRU), Edgware Community Hospital,
Edgware, London HA8 0AD
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Abstract
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AIMS AND METHOD
To discuss the service offered by an in-patient neuropsychiatric brain
injury rehabilitation unit. To examine the demographic details of patients
admitted to the unit. To find the commonest reasons for referral.
RESULTS
The notes of 78 patients admitted to the unit, over a two-year period, were
examined. Seventy-three per cent were male and the mean age was 45 years.
Seventy-five per cent of admissions had a severe brain injury. Two-thirds of
the patients were admitted within six months of their injury. The most common
reasons for referral were memory difficulties (n=61), verbal
aggression (n=31) and temper control (n=25).
CLINICAL IMPLICATIONS
In-patient neuropsychiatric brain injury rehabilitation units offer
management of patients referred with a wide range of cognitive, behavioural,
functional and physical problems.
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Introduction
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Brain injuries are common, with an annual incidence in the UK of 300 per
100 000 (Barnes et al,
1998). Although the majority of brain injuries are minor, they are
expensive to manage, create considerable stress and are an emotional drain to
relatives and others (Leathem et
al, 1996). Neuropsychiatric symptoms following a brain injury
are responsible for at least as much disability as physical symptoms
(Lishman, 1998).
Three phases of recovery have been described
(Mazaux & Richer, 1998). Different rehabilitation units tend to focus on problems occurring at each
stage. In the first stage, the main focus is to prevent physical
complications, and to facilitate the return of clear consciousness. Acute
rehabilitation usually takes place on medical or surgical wards, although in
some regions, rapid transfer to an acute rehabilitation unit is available. At
the second stage, sub-acute rehabilitation addresses mobility and cognitive
problems and other activities of daily living. The majority of in-patient
rehabilitation units focus on this stage of recovery and on physical abilities
such as walking and continence. For the final stage, the goals are to achieve
physical, domestic and social independence, and allow participation in
activities in the community. Over the last decade, there has been increasing
interest in this aspect of rehabilitation.
The Royal College of Psychiatrists have recommended that each region in the
UK has a neurobehavioural unit (Barrett
et al, 1991). However, only a handful of in-patient
units, particularly within the NHS, focus on neuropsychiatric symptoms.
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Neuropsychiatric Brain Injury Rehabilitation Unit, Edgware
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The Brain Injury Rehabilitation Unit, Edgware, London (BIRU) offers
intensive rehabilitation for cognitive, behavioural and other neuropsychiatric
problems following brain injury. A recent study at BIRU found that in-patient
admission was associated with improved functioning
(Bajo et al, 1999).
The unit has 16 beds (with discretionary locking) and admits patients over 16
years of age. It is staffed (in full-time equivalents) by 2.0 psychiatrists,
2.5 psychologists, 2.0 occupational therapists, 1.2 physiotherapists, 1.0
social worker, 0.8 speech and language therapists, 8.0 nurses (Registered
Mental Nurses, Registered General Nurses or Registered Nurses for the Mentally
Handicapped) and 8.0 rehabilitation assistants. The team uses a
multi-disciplinary approach to assessing, planning and implementing a
programme of care and rehabilitation. This has been shown to be more effective
than a single discipline approach (Semlyen
et al, 1998). The programmes are oriented and tailored to
the patients. After an initial assessment, a number of goals are set with the
patient, for the following periods of rehabilitation, which are offered in
three-month blocks. The goals are reviewed in regularly held meetings. They
are modified in accordance to the degree of rehabilitation achieved. Community
Programme Approach meetings are held regularly, and family members are invited
to attend. Families play an important part in the rehabilitation programme and
the family situation is taken into account for setting up future care.
Koskinen (1998) found that many
families were still under strain, 10 years following a brain injury.
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The study
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Patients were included in the study if they were admitted to BIRU between 1
April 1997 and 1 April 1999 and their notes were available. Basic demographic
information and reasons for referral were recorded retrospectively from each
set of case notes. A severe brain injury was defined as having had a Glasgow
Coma Scale rating of below nine (Teasdale
& Jennett, 1974) ; loss of consciousness of more than a day ;
or post-traumatic amnesia of more than one week
(Kraus & McArthur, 1996).
All reasons for referral were recorded.
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Findings
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Over the two-year period, there were 80 admissions. Of these, notes were
available for 78 patients (97.5%), and these patients were included in the
study. Fifty-seven (73%) were male. The mean age was 45 years, and 27 (35%)
were under 40 years old. The type of injury was : traumatic n=36
(46%) ; anoxic n=19 (24%) ; stroke n=17 (22%) ; surgery
n=5 (6%) and infection n=1 (1%). Forty-five of the patients
(75%) had had a severe brain injury. The mean time between head injury and
admission was 49 months, and 41 patients (63%) were admitted within six months
of the brain injury. Table 1
shows the reasons for referrals. The most common reasons were memory
difficulties (n=61), verbal aggression (n=31) and temper
control (n=25).
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Discussion
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The study looked at the demographic details of patients admitted to a
neuropsychiatric brain injury rehabilitation unit, and the reasons for
referral. Other studies have examined the extent of neuropsychiatric
disability following brain injury (Barrett,
1999 ; Deb et al,
1998) or the effectiveness of in-patient rehabilitation on
functional improvement (Bajo et
al, 1999 ; Semlyen, 1998). Most of the admissions were male,
which is likely to reflect the fact that traumatic brain injury is more common
in men (Barnes et al,
1998). Most had a severe brain injury and were admitted within six
months of the injury. Major gains in the recovery of intellectual impairment
are usually made in the first year post-injury, the most substantial
improvement in the first six months
(Lishman, 1998). During
subsequent years gains are normally made from better coping strategies.
Cognitive problems (memory difficulties, concentration and attention
difficulties, language difficulties, disorientation, and difficulties with
planning and monitoring) were the most common reasons for referral. Cognitive
problems are common after a severe brain injury and are generally widespread
(Lishman, 1998). Inpatient
rehabilitation offers intensive training in the use of compensation aids such
as diaries, mnemonics, selfcueing and rehearsal. For those patients with an
extensive retrograde amnesia, autobiographical memory may be helped by using
life books. Behavioural problems (verbal aggression, poor temper control, poor
motivation, restlessness or agitation and physical aggression) were the next
most common reasons for referral. Temper disorders have been associated with
frontal and temporal damage (Barrett,
1999). Management starts with reviewing the physical state of the
patient and making sure that it is not accountable for the challenging
behaviour. This group of patients is sensitive to psychotropic medication and
its side-effects. Drug therapy should be tailored to each patient and kept as
a minimum dosage. Psychological interventions include the use of ABC charts
(functional analysis) and modelling. Cognitive-behavioural therapy may be
useful. Providing relatives with advice about managing behavioural and
emotional problems is associated with improved satisfaction
(Junque et al, 1997).
The final groups of reasons for referral were for help with functional
capacity (activities of daily living and continence) and physical health
(weakness or spasticity). These problems are managed concurrently with
cognitive and behavioural problems, with a multi-disciplinary approach.
Most brain injury rehabilitation units focus on sub-acute problems such as
activities of daily living and physical disabilities. However,
neuropsychiatric deficits are responsible for as much disability as physical
symptoms. In-patient neuropsychiatric brain injury rehabilitation units see
patients referred with a wide range of problems of which the most common are
cognitive and behavioural difficulties. These units offer intensive
multi-disciplinary input with the goals of improving deficits and helping
people and their families adjust to change.
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Acknowledgments
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We would like to thank Miss Gill Terry and her colleagues at the Edgware
Community Hospital Library for their kind help.
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Abstract
Introduction
