Reducing aggression in brain injured patients – Heather’s story

Heather*, mother to two young children, sustained a very serious penetrating brain injury as result of an assault. The blow to her head was delivered using an edged weapon.

Heather was admitted to hospital for medical treatment to stabilise the physical trauma that she sustained. However, whilst she was in hospital, Heather’s behaviour was a disturbance to the rest of her ward and she was deemed as being a risk to herself and others. This led to her being cared for in a side room, segregated from the other patients, with constant supervision from hospital security staff.

As the risks and her challenging behaviour increased in the mainstream hospital, she was admitted to The Priory Burton Park, in Melton Mowbray, Leicestershire. The Priory Burton Park provides highly specialised neurobehavioural rehabilitation, specifically designed to manage people, like Heather, with an acquired brain injury (ABI) whose behaviour prevents management and progress in other, more general healthcare settings.

Behaviour on admission

Assessment by Heather’s treatment team found that her ABI had caused her to have a neurobehavioural disability, which resulted in cognitive and behavioural impairments.

Heather was agitated and unsettled and was assessed by her team as being in post-traumatic amnesia, a state of confusion that occurs immediately following a brain injury in which the injured person is disoriented and unable to form a continuous memory of events.

Heather’s concentration was poor and her mood was very low. Her behaviour was characterised by impulsiveness and aggression, which mainly took the form of physical assaults on staff, which prevented her from being able to have contact with her children.

Heather’s impulsiveness also increased the risk of falls and the possibility of incurring further physical injury.

Rehabilitation

Heather’s team immediately developed and implemented a holistic neurobehavioural rehabilitation programme designed specifically to meet her needs and to manage and reduce her risks.

By avoiding cues that had frequently led to Heather displaying aggression, the team were able to help Heather to reduce her aggressive incidents. This technique, known as positive behavioural support, helped to increase Heather’s personal autonomy.

As Heather’s post-traumatic amnesia resolved and her orientation improved, a structured timetable of meaningful activity was gradually introduced.

After the positive behavioural support and introduction of meaningful activity, Heather’s risk of aggression decreased significantly and as a consequence, she started to have supervised contact with her family.

By providing a low stimulus environment, a graded approach to rehabilitation (moving from low to higher expectations as Heather improved), regular medication, and fatigue and pain management, the difficulties with Heather’s concentration and impulsiveness improved.

As Heather progressed, her occupational therapist continued to support her in reacquiring lost skills using a series of structured programmes, which incorporated errorless learning and verbal prompts. A problem solving approach was further incorporated into Heather’s treatment programme to help her to become more independent.

Outcomes for Heather

After 10 weeks, Heather was discharged from Burton Park to her parents’ home to continue her rehabilitation and reintegration into the community.

A transitional rehabilitation programme was designed by her treatment team and was implemented with support from her parents and community services.

Heather carried on gradually assuming increased responsibility for the care of her children and she met with her employers and agreed a phased return to work.

She continued to make a remarkable recovery, progressing to living independently in her own home, assuming full-time responsibility for her children, resuming driving and returning to work ahead of the agreed schedule.

The role of Heather’s care team and programme

Heather’s participation in the highly-specialised neurobehavioural rehabilitation programme at Burton Park was key to facilitating her extraordinary progress and return to independence.

Research has shown that without specialist rehabilitation, long-term prognosis for brain injured patients like Heather is poor. In cases such as hers where aggressive behaviour is a consequence of brain injury, outcomes without specialist treatment are associated with prolonged detention in psychiatric facilities, care homes and forensic secure units.

Heather’s case demonstrates the effectiveness of neurobehavioural rehabilitation in reducing aggression in people with an ABI.

A word from Heather

Life is now much different for Heather compared to when she was first admitted to Priory.

“I believe much of my recovery comes down to the confidence I regained thanks to the team at The Priory Burton Park.

“They always listened and showed great empathy and encouragement to me – particularly when it came to wanting to get home to my children. As well as my own determination to recover, I feel Burton Park played a huge part in making this happen. I was discharged a lot sooner than was ever expected and I am now at home living independently and taking care of my two children and living life to the fullest.

“I feel so lucky and grateful to Burton Park and all those that helped me gain my confidence and the strength to succeed. Thank you.”

For more information or to enquire about Priory’s Brain Injury Services at Burton Park, call 0800 090 1356 or email prioryenquiries@nhs.net

*Name changed to protect patient identity