Our memories are important to us as they are the scrapbook to the moments of our lives. People who experience acute traumatic brain injuries (TBI) often are left with severe memory deficits. Caused by physical and chemical changes in the brain, this post-traumatic amnesia (PTA) can confuse and disorient individuals due to their inability to store new memories and retrieve existing ones.

“When someone is in a state of PTA, they are not oriented to their surroundings and unable to make new memories or remember recent events,” notes Elizabeth Marcy, PT, DPT, NCS, therapy team leader for the Drucker Brain Injury Center and the stroke program. “Communication often becomes difficult and frustrating for patients.”

During rehabilitation, patients with PTA are asked numerous questions from caregivers who want to gain a better understanding of their medical history, symptoms, and responses to treatment. However, answering questions is often challenging to patients with PTA who cannot tap into their explicit memory to recall information and events.  

“The healthcare team asks a lot of questions, whether to gather information, establish rapport, or build a relationship in the management of medical care,” explains Marcy. “However, posing a host of questions can distress individuals with PTA who can’t provide seemingly obvious information. This can lead to a breakdown in communications. At the same time, patients with PTA who do answer questions are not reliable sources of information, which is problematic for treatment.”

Looking to optimize care practices for patients with memory deficits, a team of Moss Rehabilitation Research Institute (MRRI) researchers and clinicians from various rehabilitation discipline at MossRehab (physiatrists, physical therapy, occupational therapy, speech, nursing, education, etc.) collaborated on developing a protocol to identify, communicate and treat patients with PTA.

The workgroup, led by Amanda Rabinowitz, PhD, institute scientist and director of the Brain Injury Neuropsychology Laboratory at MRRI and Mary Ferraro, PhD, OTR/L,coordinator of the MossRehab occupational therapy fellowship program, created strategies that structure communications and treatment for patients in a state of PTA for better outcomes. For example, verbal exchanges avoid asking questions that require retrieval from explicit memory. Instead, clinicians are encouraged to use “here and now questions” and gather clinical information via observation, medical records, or a reliable family member. The new PTA protocol was introduced to the inpatient population at the Drucker Brain Injury Center at MossRehab Elkins Park in 2019. 

“The first step after developing these protocols was educating everyone who supports care for these patients. In addition to nurses and therapists, this includes dieticians, social workers, consultants, and housekeeping,” says Marcy who served on the research team. “We want everyone who interacts with the patient to be on the same page when communicating with them.”

After a speech pathologist identifies a patient in a state of PTA, the healthcare team is contacted so everyone starts using the recommended strategies across the continuum of care. Signage in the patient room also lets visitors and consultants readily know about an individual’s condition.

Now, instead of asking “Is your pain better today? or “How did you sleep last night” that requires the patient to rely on explicit memory to answer, a healthcare team member will ask “Are you in pain right now” or may check a sleep log to get needed information. Reverse questions such as “Are you comfortable” are posed to verify responses.  So, if the patient says “yes” to both, the information may not be reliable and must be verified from other sources.

“The protocols are very thoughtful not only in how we ask questions but why we’re asking them,” Marcy remarks. “If we are trying to get information for medical care, the healthcare team must refer to each other or the medical chart. If needing to know historical data of a patient’s status before hospitalization, we will interview family members. The protocol recognizes that we can’t use the patient as a primary source in certain situations.”

The protocols also outline specific ways – dos and don’ts - that clinicians should follow when communicating and providing treatment to patients with PTA. For example, when meeting a patient for the first or fifth time, a therapist should not quiz but provide information that explains where and why they are providing therapy and how they will work together to rehabilitate a particular problem.

Activities also follow a very structured routine with the same sequence every time. While patients with PTA may have trouble with explicit memory, implicit memory may remain intact that enables the learning of new skills and routines. “Helping patients develop habits and routines can improve performance of tasks,” explains Marcy.

By reducing the frequency of questions that rely on stored memories and following a structured approach to care, clinicians have identified positive changes in their practice. “The new protocols provide a clear understanding of who is in a state of PTA as well as how to support them,” says Marcy. “By optimizing our therapies, I have observed less patient distress and agitation while increasing engagement during rehabilitation sessions. I have also seen more consistency across the team in our communication strategies and treatment.”

The MossRehab protocols also offer support to families on ways to better interact with loved ones who are in a state of PTA. Often, family members ask questions or show pictures in hopes of triggering a memory. However, these activities may upset and frustrate both parties. “One of the goals of our protocols is providing information to families to have a good interaction and the right expectations,” says Marcy. “The healthcare staff continually educates family members as patients move through the recovery process.”

As visits are limited due to COVID, MossRehab currently relies on video chat to share information. Healthcare teams are always available to answer questions to family members.

 Find out more about the new MossRehab protocol and the “do’s and don’ts” used during patient treatment.