Post Traumatic Amnesia

Gemma Hardy
Clinical Psychologist
Neuropsychology Department,
Addenbrookes Hospital
gemma.hardy@addenbrookes.nhs.uk

Outline

Overview
Symptoms
Assessment
Rehabilitation
Management
Case study

PTA
Confusional state of clouded consciousness
following TBI
Present in 70% patients

Transient stage between loss of consciousness

and return to full consciousness
Duration correlates well with GCS, length of
hospital stay
PTA
Severity of
Predicts outcome
Cognitive recovery
Functional abilities
Return to work

Duration

Injury

5 60
minutes

Mild

1 24 hours

Moderate

1 7 days

Severe

1 4 weeks

Very severe

> 4 weeks

Extremely
severe

PTA
Amnesia

Impaired attention

Anterograde
No ability to form
day-to-day
memories

Retrograde
Loss of memory for
events prior to TBI

Disorientation
Time
Place
Person

Behavioural
change

Agitation
Disinhibition
Emotional lability
Childlike persona
Wandering
Fatigue
Confabulation

PTA
Impaired attention
Poor concentration
Highly distractible
Impaired awareness

Slowed reaction time

Fatigue and Fluctuation
NB. fight or flight in response to fear

PTA what is it like?

A Case Study
Susan, 40 year old teacher

RTA with multiple brain contusions, 2 weeks ago

On J2
In side room with bed facing window
She keeps asking why she is here
She is confused as she doesnt know where she is
She doesnt know why he should be there and thinks she
needs to get home
She is frequently shouting and swearing and distressing
patients and staf

How does she feel?

She is confused, doesnt know where she is or why she is
there
Over-fatigued, anxious, frustrated, frightened?

PTA Assessment
Determine duration of PTA
Standardised measures
GOAT (Galveston Orientation and
Amnesia Test)
10 items
Orientation (person, time, place)
Recall for events (anterograde and retrograde)

Score 0 100
Consecutive scores > 75 = end of PTA

PTA Assessment
However
Qualitative features absent on testing
Cant account for fluctuation
Difficult to distinguish from chronic memory
impairment

Informal assessment
Obvious change to awareness and orientation
(Russell & Smith, 1961)
Continuous day-to-day memory
Sustained attention
Orientation to season, surroundings, visitors
OR plateau to cognitive improvement in cases of
severe long-term impairment

PTA recovery
Gradual
Currently determined by PTA test
performance
However
Many qualitative features absent on
testing
Difficult to distinguish from chronic
memory impairment

Sequence of cognitive recovery

Person
Recognition memory
Place
Time

PTA Research
Research project within department
Service development
Developed CAM-PTA (Cristina BlancoDuque from MRC-CBU and the team
from MTC)
Evaluate use by correlating against
current tools and MDT opinion

PTA Rehabilitation
Can be problematic given memory
difficulties
Difficult to learn facts but can acquire
procedural knowledge
Reality orientation programmes can be efective

Other therapies (OT/physio) still efective

as often more reliant on procedural
memory
Errorless learning approach
Modifications to sessions may be required

PTA Rehabilitation
Psychological approaches to
managing challenging behaviours
Verbal / non-verbal de-escalation
Goal Setting
Assessment (e.g. ABC analysis)
Tailored Intervention (Environmental
modification, Behavioural Reward
program

PTA Management
Keep in mind they have memory and
attention difficulties!
Give information in short sentences and
repeat
Always tell patient what you are doing and
why you are doing it
Avoid over-fatigue (allow for breaks, keep
visitors to minimum)
Think of environment (over or under
stimulated?)

PTA Management
Be prepared for challenging behaviours
Discuss specific behaviours in MDT
meetings
Check behavioural guidelines in notes
Approach Clinical Psychologist for support

Try to be understanding and empathic

People in PTA have little control over their
behaviour and emotions
Remember it is not personal

PTA Management
Minimise frustrations and aggravations
Provide reassurance wherever possible, as
many times as possible
Dont ask patient to do more than one thing
at a time
Keep noise / other stimulation to a minimum
(where possible)

Validation approach empathise and

distract

PTA Back to case

Susan (TBI 2 weeks ago, 40 year old
teacher)
She is frequently shouting and swearing
and distressing patients and staf
She is confused, doesnt know where she is or
why she is there, over-fatigued, anxious,
frightened, frustrated ?

GOAT assessment indicates ongoing PTA

Behavioural assessment:
ABC observations show Susan settles when
nurse enters room and is reassured but
resumes shouting and screaming when left

PTA Back to case

Hypothesis
Forgets she has been reassured
Continues to feel confused and frightened
Needs reassurance which only lasts as long as some
one is with her, and which is provided upon shouting
and swearing

Goal: reduce distress (frequency of

shouting and swearing)
Intervention:

Move to small bay where she can see nurses station

Staf greet her whenever they pass
Orientation board alerting her to time and place
Other patients asked to remind her of the board
periodically

Thank you very much!

If you would like a copy of slides please
email
Fiona.aschmann@addenbrookes.nhs.uk

Key References

Ahmed, S., Bierley, R., Sheikh, J.I., & Date, E.S. (2000). Posttraumatic amnesia after closed head injury: a review of the
literature and some suggestions for further research. Brain Injury,
14, 9, 765-780.

Langhorn, L., Sorensen, J.C., & Pedersen, P.U. (2010). A critical

review of the literature on early rehabilitation of patients with
post-traumatic amnesia in acute care. Journal of Clinical Nursing,
19, 2959-2969.

Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed

head injuries. Archives of Neurology, 5, 4-17.

Thomas, H., Feyz, M., LeBlanc, J., Brosseau, J., Champoux, M.C.,
Christopher, A., et al. (2003). North star project: reality orientation
in an acute care setting for patients with traumatic brain injuries.
The Journal of Head Trauma Rehabilitation, 18, 292-302.

Wilson, B.A., Herbert, C.M., & Shiel, A. (2003). Behavioural

approaches in neuropsychological rehabilitation. Hove: Psychology
Press.