Managing risk in brain injury HEADWAY 2017 BRUCE MOORE neuropsychiatrist Risk management Its all a balancing act Whats best for the Client Promoting independence Enhancing quality of life Positive risk taking ID: 768936
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Managing risk inbrain injuryHEADWAY 2017 BRUCE MOORE neuropsychiatrist
Risk management :Its all a balancing act Whats best for the Client Promoting independence Enhancing quality of life Positive risk taking Risk assessment Applying frameworks What is YOUR goal ?
What do the different parts of the brain do? The brain is divided in two (connected by the corpus callosum) Left hemisphere – Logic, language, planning, analysing Right hemisphere – Social awareness, intuition, creativity In women the hemispheres are very well connected hence they can feel and think simultaneously (!) but men have feeble connections so they can either do listening OR logic but not both together Frontal lobes have 3 main areas: Dorsolateral (where horns might grow!) Mediofrontal (down the middle behind the eyes) Orbitofrontal (over the orbits/eye-sockets)
Function of Frontal lobe regions: Dorsolateral – planning ( ie what needs to be done) Damage leads to poor planning and prioritising ) Mediofrontal – initiates activity (connected to limbic/emotion circuits) Damage leads to avolition or worse ( abulia = zombie-like absence of initiative) Orbitofrontal – monitors activity and inhibits unwanted impulses Damage leads to socially disinhibited behaviour and aggression
Areas of risk – DIAGNOSTIC ISSUES COGNITIVE IMPAIRMENT & DYSEXECUTIVE SYNDROME CHAOTIC AIMLESS IMPOVERISHED LIFESTYLE PERSONALITY DISORDER DISINHIBITION & IMPULSIVITY INITIATIVE AND MOTIVATION AGGRESSIVE BEHAVIOUR DEPRESSION & SUICIDE – CUMULATIVE RISK ORGANIC PSYCHOSIS, PROSOPAGNOSIA, MORBID JEALOUSY PATHOLOGICAL GAMBLING ABSCONDING, WANDERING, FALLS, SEIZURES, RISK OF HARM & VULNERABLE TO EXPLOITATION & SELF NEGLECT
The effects of brain injury: know exactly what you’re treating Intellectual deficits impaired attention, memory, concentration, orientation, planning, problem solving, and executive function. Behavioural problems impulsivity disinhibition, aggression, lack of initiative and motivation, fatigue, irritability, anxiety, mood swings, depression psychosis, OCD Neurological problems headache, epilepsy, dysphasia, dysphagia, autonomic instability, hyperhidrosis , paresis, diabetes insipidus, orthostatic hypotension,
SECONDARY COMPLICATIONS PSYCHOTROPIUC MEDICATION – SEIZURES, DIABETES, DEATH DRIVING HAZARDS AND DRUG DRIVING ALCOHOL & DRUG USE ANABOLIC STEROIDS AND LIQUORICE ALLSORTS (SHOE BOX!) FAMILY DYNAMICS MUM OR DAD – OR THE GIRLFRIEND PARENTING SKILLS SOCIAL MEDIA (DID YOU KNOW SHE WAS ONLY 15?) MAY NEED TO RESTRICT USE UNDER MCA WHEELCHAIR WARS KNIVES, MACHETES AND BASEBALL BATS AND SO MUCH MORE
Neurological complications Headache Gabapentin for pain (and agitation/anxiety) Epilepsy Lamotrigine, Carbamazepine, Leviteracetam Hyperhidrosis Botox, propranolol, sympathectomy Paresis/paralysis Botox for spasticity Orthostatic hypotension Avoid hypotensives eg Beta-blockers Diabetes insipidus Medical emergency (&SIADH) Dysphagia SLT assessment and advice Autonomic instability Temperature regulation vasopressin / propranolol Cardiovascular instability medical emergency
MR ANGRY-ALL-THE-TIME SEVERE TRAUMATIC BRAIN INJURY RTA IN TEENS TENANT IN VERY SQUALID TERRACED HOUSE PROBLEMS WITH LANDLORD – MADE THREATS DEFENDANT INSURERS – VIDEO SURVEILLANCE BECAME INCREASINGLY PARANOID ESCALATING CANNABIS USE (MEDICATION ‘RUBBISH’) SACKED ME – THEN GOT THE PHONE CALL AFTER ASSAULT CASE SETTLED – POSH HOUSE – CANNABIS – PARANOIA CCTV INSTALLED – PARANOIA – KITCHEN KNIVES LEFT OUT CRISIS TEAM & POLICE FAMILY SUPPORT INVOLVED
MISS TAKE-ADVANTAGE-OF-MEKICKED IN HEAD BY HER HORSE AT 20 SEVERE TRAUMATIC BRAIN INJURY EMOTIONALLY LABILE AND VERY SOFT FOR A SOB-STORY MEETS MEN (IN PUBS OR ON THE STREET) INVITES THEM HOME THINGS GO MISSING – PURSE, HANDBAG SHE MAKES THREATS TO KILL THEM POLICE GET INVOLVED BUT THE CYCLE REPEATS ITSELF RECOMMEND RESIDENTIAL BRAIN INJURY SERVICES UNDER MCA
MR MELANCHOLYHYPOXIC BRAIN INJURY (HANGED SELF IN HOSPITAL) MUM DIED BY SUICIDE (GUILT – BAD SON) & STEP-DAD BY SUICIDE 7 YEARS IN RESIDENTIAL SETTING & SECTIONED AGAIN TEXTING CASE MANAGER AT NIGHT RE SUICIDAL IDEATION OUT WITH SUPPORT WORKERS LOOKING OVER BRIDGES PSYCHOLOGICAL TREATMENT DIFFICULT DUE TO MEMORY IMPAIRMENT SEVERE DEPRESSION LIFETIME RISK OF SUICIDE 7-10% SEVERE BRAIN INJURY INCREASES RISK BY 4:1 CRS 30% PARENTAL SUICIDE INCREASES RISK BY 5:1 CRS 150% TWO PARENTS ?? NO STATISTICS
TOP TIPS FOR RISK MANAGEMENTDON’T BE SHY – BE EXPLICIT ABOUT RISKS YOUR SAFETY AND WELFARE IS OUR PRIORITY IF I’M DOING MY JOB RIGHT YOU WONT LIKE ME AT TIMES SHARE RISKS AND CONCERNS WITH TEAM & LAWYERS ASSESS MENTAL CAPACITY HEALTH AND WELFARE, CARE & RESIDENCE INVOLVE RELEVANT AGENCIES POLICE FAMILY SUPPORT, SOCIAL SERVICES BE PREPARED TO DISCHARGE IF NO ENGAGEMENG OR SUPPORT
HEALTH AND WELL-BEING REGIME INCENTIVISE ENGAGEMENT Financial reward or special events Best done with agreement of Financial Deputy Ensure no family collusion Mental Capacity Act (MCA 2005) Need to be explicit about legal frameworks NOT a punishment but aimed at health and well-being Best interests MDT re mental capacity for health carte and residence
THANKYOU FOR LISTENING ! DR BRUCE MOORE HABITAT HEALTH Ltd & Abbey Court appointments.braininjury@gmail.com