Acquired Brain Injury

An Acquired Brain Injury is any injury to the brain that has occurred since birth. This can be caused by a trauma, for example a road traffic accident, a fall, an assault or an accident at home or at work, or non-traumatic brain injuries including alcohol-related brain damage, haemorrhages, brain tumours or strokes, to name but a few.

This section of our website is all about acquired brain injury and we have also included some links to outside sources for further information. Here at the Upstreet Project we specialise in the care of individuals with alcohol-related brain damage or related conditions, often as a result of an acquired brain injury through long term alcohol abuse.

The effects of brain injury can be divided into three categories:

Physical Effects While many of the people we support suffer from peripheral neuropathy (numbness of the extremities), most remain very mobile and present with few outward signs of a brain injury. However, acquired brain injury often causes physical problems that are not so apparent, but can have a serious impact on day-to-day living.

These problems can include:

Movement, Balance, Coordination and Dyspraxia
Speech and swallowing disorders
Loss of sensation
Tiredness and Headaches
Bladder & bowel incontinence
Epilepsy

Emotional and behavioural problems

Brain injuries often cause changes in behaviour and emotional reaction. These issues are often referred to as ‘hidden disabilities’ as they are much more difficult to spot than the obvious problems affecting coordination, speech etc but can be much more challenging for the sufferer and those around to cope with.

There are several discrete areas of emotional and behavioural effects of a brain injury, for example:

• Agitation
• Explosive anger, irritability, lack of emotional control
• Lack of awareness, insight, impulsivity, and disinhibition
• Self-centredness
• Apathy, poor motivation & depression
• Anxiety
• Inflexibility and obsessionality

Cognitive (e.g. memory, concentration, language)
An acquired brain injury can affect the way a person thinks and learns as well as their memory. Different cognitive abilities are located in different regions of the brain. This means that an acquired brain injury can cause damage to some but not necessarily all cognitive skills. These include how quickly one thinks, short and long term memory, understanding, ability and length of concentration, problem-solving and use of language.

Cognition can be divided up into six separate areas:

• Memory
• Attention span and concentration
• Speed of information processing
• Executive function (eg planning, organising and problem solving)
• Visuo-spatial and perceptual difficulties
• Language skills
  

Please scroll down to find out more about acquired brain injuries, how they can affect day-to-day living and some of the strategies we have developed at The Upstreet Project to help the people we support to cope and move forward.

Physical Effects

Movement, Balance, Coordination and Dyspraxia
Damage to the brain that causes movement difficulties usually happens to the motor cortex, the brain stem and the cerebellum. As one side of the brain affects the motor co-ordination on the opposite side of the body, a person often experiences a weakness or paralysis of one side.

Damage to the cerebellum affects fine co-ordination of the muscles, and can mean continuing problems with dexterity even after a period of improvement.

Difficulties with balance can be caused by damage to a small mechanism at the back of the skull, called the vestibular system. This delicate organ can be upset by the smallest of brain injuries, making the person often feel dizzy. It is sometimes necessary to learn to walk again after a head injury and this involves re-learning the basic stages of how to walk and balance.

Dyspraxia is a disorder affecting deliberate voluntary actions, or sequences of actions and is discrete from problems with motor co-ordination or movement. The person may not have a problem moving per se, rather with being able to put movements together deliberately and intentionally. This can often be mistaken for a lack of co-operation on the part of the sufferer.

Here at The Upstreet Project we build on the basics begun by the hospital and the client themselves and employ a lot of patience and plenty of exercise to build confidence as well as helping muscles to compensate where necessary. We also access specialist physiotherapy and hydrotherapy where necessary.

Speech and Swallowing Disorders
Brain damage, particularly to the cranial nerve, can result in dysarthria (a weakening and malcoordination of the muscles needed for articulation of speech). This can variously cause speech to become slurred, slower or quieter that normal.

At The Upstreet Project, we access speech and language therapists to help clients relearn muscle movements which can improve the quality of speech to a point. We also help to improve our clients’ social confidence by encouraging them to take part in regular speaking activities, such as Current Affairs discussion groups and Book Club.

Brain damage can also cause dysphasia, which is the mixing up of words and using the wrong ones. We help clients who present with this symptom to communicate in other ways if necessary.

Loss of Sensation
Different parts of the sensory cortex deal with sensations in different parts of the body. After a head injury, people may experience a loss of sight, hearing, taste, smell (anosmia) and so on without actually damaging any of the sense organs. If the sensory cortex has been bruised, a gradual recovery of sensation may be possible. If the area has been torn, it is unlikely to return to normal functioning.

Processing what the eyes see is carried out in the occipital lobes at the back of the brain. Damage here can result in either full or partial blindness, or gaps in the visual field. Temperature control can also be affected, particularly by damage to the brain stem.

Many of our clients at The Upstreet Project suffer from peripheral neuropathy as a result of long term alcohol abuse. We have found that exercise and a strengthening of muscles can help overcome some of the balance and coordination problems that this condition causes.

Tiredness and Headaches
Fatigue after head injury can be one of the most limiting symptoms because it affects everything a person does. It is often better to rest than deplete energy stores which can be easily sapped.

Roughly 25% of people with severe head injuries still suffer from headaches two years after the injury. These can range from quite mild to completely incapacitating and are normally made worse by stress and getting overworked.

Headaches can be helped by a stress management programme, the same medication as is used for migraine treatment, muscle relaxation or acupuncture.

Bladder and Bowel Incontinence
Continence is a cognitive skill since the subtle signs that a person needs to use the toilet must be recognised. It is also a physical skill, in that the person needs to be able to act on the signs. After a head injury, a number of basic skills like this need to be relearned.

Other factors affect continence, such as medication, physical disability, communication difficulties and embarrassment, and all need to be taken into account.

When purely physical problems have been eliminated, sometimes a person may continue to be incontinent as a way of objecting to a situation, or as a way of getting attention. A behaviour modification programme can be worked out with the help of nursing staff, or a clinical psychologist for more severe problems.

Many of our clients are incontinent when they arrive at The Upstreet Project and we have a good track record of helping our clients regain full continence, sometimes with the help of our GP and a Continence Nurse.

Epilepsy

Scar tissue in the brain increases the risk of epileptic seizures and is more likely to happen in a penetrating injury to the brain where the skull has been fractured and the brain has been pierced by an object or part of the skull itself. Scar tissue can also be caused by the debulking or removal of a brain tumour.

Although the wound heals, the resulting scar causes the electrical activity in that area to be unstable and liable to bursts of uncontrollable activity. Seizures brought on by a head injury often occur within the first week after the injury, but the first may not appear until one or two years have passed. A person is not considered free of seizures until 2 or 3 seizure-free years have passed. Many of the people we support here at The Upstreet Project suffer from seizures; often they have had seizures for years and have not taken their medication regularly as a result of a chaotic lifestyle so our structured medication management produces immediate results in this regard. The care team and the active therapy team also carry out comprehensive risk assessments to make sure that clients are protected from potential injury at all times.

Emotional & Behavioural Effects

Agitation

This mainly occurs immediately after the brain injury and may show itself as extreme restlessness or agitation and an inability to sit still. This may be as a result of direct neurological damage, and can be a coping mechanism for the patient, who may be confused, frustrated and disorientated. It is often a stage through which a person passes, rather than a permanent change.

Explosive anger, irritability and lack of emotional control

Acquired brain injuries can cause extreme irritability and lack of emotional control which can present in many different ways. One of the most common kinds is as an exaggerated and disproportionate angry reaction to apparently minor annoyances.

Direct damage to the frontal lobes, which is the part of the brain which controls emotional behaviour and tolerance of frustration, can create emotional lability (moving from one emotional state to another very quickly), and a lack of emotional control. This means emotions can swing to extremes. The stress of coping with even minor crises, such as misplaced shoes or a noisy vacuum cleaner, can be too much and trigger an angry outburst.

Loss of control over emotions also means the person has lost the ability to discriminate about when and how to express their feelings. This can be very tiring and embarrassing for family members to deal with, but in time a person can begin to re-learn emotional control. The team at Roberta & Elizabeth House receives ongoing training in how to help clients with this.

Lack of Awareness and Insight

The mental ability to monitor personal behaviour and adjust it accordingly is a sophisticated skill contained in the frontal lobes of the brain. Damage to this area affects the ability to be self-aware, have insight into the effects of personal actions, show sensitivity or feel empathy.

An acquired brain injury can cause a total lack of inhibition and an inability to control basic impulses. This can include speaking your mind regardless of the circumstances with no heed to the consequences, or inappropriate touching of other people and any other action which may even be dangerous without considering the possible implications or consequences.

This is caused by neurological damage to the frontal lobes and often goes hand in hand with lack of awareness, and the person may not be aware of breaching any social rules or etiquette.

Our Client Development programme at The Upstreet Project includes both one-to-one and group activities to help our clients regain this skill, with psychiatric counselling for clients who need extra help.

Self-Centredness
For example, not showing any interest in anybody else or their feelings, and only being concerned with personal needs. This can be partly due to direct brain injury affecting a person’s ability to judge how another person is feeling, and may also be partly due to a person becoming accustomed to the huge amount of attention focused on a head injury survivor while they were in hospital. This can cause social isolation and can also be hard for family members to cope with.

Apathy, Poor Motivation and Depression

This can show as a lack of interest in hobbies that someone with an acquired brain injury has enjoyed previously, or simply not being bothered to get up or out of a chair all day. A lack of motivation or spontaneity, or apathy, can be a direct result of brain injury to frontal lobe structures that concern emotion, motivation or forward planning. This lack of motivation can lead to social isolation and a lack of ability to find pleasure in the long run. Over time, lack of motivation can lead to social isolation and lack of pleasure.

This can also lead to, or be linked to depression, which is a very common emotional reaction which comes on in the later stages of rehabilitation, often when a person realises the full extent of the problems caused by the brain injury. This can be seen as a good sign, that a person is aware of the reality of the situation, and is coming to terms with the emotional consequences. ‘Healthy’ depression can be worked through in time, as adjustments are made, and this self-awareness is often the first step towards independence for many of our clients here at The Upstreet Project. Brain injury brought about as a result of long-term alcohol abuse, and often in conjunction with Korsakoff’s syndrome, often causes our clients to be in denial of what has happened to them and why they are in residential care.

If a client appears to be emotionally blocked and unable to move on, we often refer them to external psychiatric and/or psychological counselling services in addition to the social therapies we employ in-house.

Anxiety

This can present itself variously in the form of nightmares, feelings of insecurity and a crippling lack of confidence, or as panic attacks, even agarophobia or other developed phobias.

Any traumatic experience can quite naturally cause anxiety and a loss of confidence afterwards when one is faced with situations and tasks which are difficult to cope with. While many of our clients’ short term memory problems will make it difficult for them to return to independent living in the community, we encourage independence rather than dependence from the people we support and provide help and encouragement to face situations that they may consider to be challenging or difficult. We also encourage people to communicate openly about their fears and concerns and help them to develop their own methods of staying calm in situations they find stressful.

We also offer more practical ways of helping our clients feel less anxious and more secure. Many of our clients have an acquired brain injury as a result of a fall or an assault whilst intoxicated and often when they were homeless as a result of long term alcohol abuse. One of the most basic support mechanisms we have is the comfort of a routine: meals are always at the same times and in the same place (unless of course we are on an outing!); the staff turnover is low and we employ agency staff only for specific roles and never as a supplement to our main staff team; clients have the same room for the entire duration of their residency (unless they choose to move); clients are escorted to the village shop every morning to get their own paper, tobacco etc. For clients who have come from a totally chaotic lifestyle, this is therapy in itself.

Inflexibility and Obsessionality
For example, unreasonable stubbornness, obsessive compulsive patterns of behaviour such as washing or checking things, or fear of possessions being stolen.

Some of the people we support sometimes present with an inability to reason and can become ‘stuck’ on one particular thought. This type of rigid behaviour stems from cognitive difficulties resulting from damage to the frontal lobes.

This type of behaviour is often made worse by anxiety or insecurity, so we seek to reassure our clients and also offer practical solutions where possible (such as the key to their bedroom door) to more common anxieties.

Cognitive Effects

Memory
Memory is easily damaged by an acquired brain injury as there are several structures within the brain involved in the processing, storage and retrieval of information. Damage to those parts of the brain on which these abilities depend can lead to poor memory.

‘Amnesia’ is the absence of any memory but in practice it is extremely unusual for someone to have and hold no memories whatsoever. The vast majority of the people we support at The Upstreet Project have very poor short term memory and this is often as a result of a combination of an acquired brain injury in the form of a fall or an assault, and the chemical damage done by long term alcoholism. Often their long term memory, particularly of their life before alcohol-dependence, is relatively unaffected. Short-term memory loss is the most common type of memory problem and can manifest itself in many way. This can range from repeating the same statement or question over and over, forgetting what has just been said, struggling to learn a new skill, not being able to remember people’s names, forgetting where the toilet is and so on. There are no quick fixes for this kind of problem but we help our clients where possible (eg clear signage within the building) and aid them to develop coping strategies (eg ‘chunking,’ making associations, visualisation, rehearsal etc).

Attention and Concentration
It is very common for individuals with an acquired brain injury to experience a reduction in attention span afterwards, and/or a decreased ability to multitask. This problem is usually caused by damage to the frontal lobe of the brain. These problems can be made worse by stress, tiredness or worry and other skill areas can be affected.

We formally coach our clients in concentration skills and attention span in a variety of ways, from computer games to memory exercises, but we also find that working quietly with as few distractions as possible can greatly improve our clients’ ability to hold a train of thought or an idea, or concentrate on one thing at a time for an extended period.

Speed of Information Processing

Axonal damage is often the cause of the brain slowing down the speed at which it transmits messages around the brain. This can manifest itself in many ways and can be extremely frustrating. It can mean problems in understanding speech that is unclear, too fast, or in a noisy environment, as well as the inability to reply quickly to a given question.

Executive Functions – Planning, Organising, Problem Solving
Damage to the frontal lobe can affect these skills, resulting in a subtle set of deficits which have been called ‘Dysexecutive Syndrome’. This covers problems in making long-term plans, goal setting and initiating steps to achieve objectives. The ability to stand back and take an objective view of a situation may be lacking, as may the ability to see anything from another person’s point of view.

The people we support also suffer from Korsakov’s syndrome, a telltale symptom of which is a lack of insight into, and denial of, their condition and its provenance, so this particular challenge is often masked by other aspects of their condition.

Many of the exercises conducted with our clients seek to improve upon this skill set by breaking down tasks into steps and then executing them. This can be basic living skills such as going shopping (making a list, planning how to get there and back, budgeting etc) or more formal exercises in group classroom setting
Visuo-Spatial and Perceptual Difficulties
An acquired brain injury can result in the sensory organs themselves functioning well, ie the ears, eyes etc, but the brain is not processing the information sent to it appropriately. This causes a number of challenges, such as misjudging distances and a lack of orientation.

It can also cause visual neglect, which is when the person can only see half or one side of whatever they are looking at. This can manifest itself as only eating half the food on the plate or only reading one side of a page, and can also cause sufferers to be unable to recognise objects from an unusual angle.

Language Skills

There are two areas of the brain involved in speech: Broca’s area, located on the left side of the brain, responsible for producing speech, and Wernicke’s area, located between the frontal and temporal lobes and responsible for understanding the speech of others. These two are connected but can be affected separately. Receptive language loss means that you cannot make sense of the language you hear or read, and expressive language loss affects the ability to speak or write the right words. Difficulties with these areas are known as aphasia. When both problems are present the condition is known as ‘global aphasia’.

Some of the people we support at The Upstreet Project suffer from aphasia or dysphasia to varying degrees. For them we employ a mixed programme of speech therapy and less formal exercises to compensate for the challenges presented by this condition.

Care and support provision

The management team and staff at The Upstreet Project have both comprehensive training and years of experience of caring for and supporting people with Korsakov’s syndrome, acquired brain injury, alcoholic dementia and related conditions. If you would like a frank and confidential discussion about how we can help you or your relative, please  contact us here.
We look forward to hearing from you.