Penny, aged 58, lives in her own property in Lee-on-Solent, supported and supervised by 24 hour carers. She suffered severe cognitive impairment secondary to Korsakoffs syndrome in 1996 following a long history of alcohol misuse and depression. Since her illness, Penny suffered with severe amnesia accompanied by emotional lability associated with refusal of medication, food and verbal aggression.
Penny also demonstrated reduced awareness of her difficulties. She experienced notable fatigue following activity but had great difficulty monitoring this herself, significantly increasing the risks associated with her poor balance and emotional/behavioural difficulties. Her relationships with her family were often strained and problematic. Penny would also describe experiences that were inaccurate or confused, suggestive of confabulation associated with Korsakoffs syndrome, leaving support workers feeling vulnerable to complaints or accusations.
A brain injury case manager was employed to oversee Penny’s care and support her with her consistently stated wish to remain in her own property for as long as she could. A referral to Clinical Psychology was made by the case manager to provide an initial assessment to inform a package of teaching, training and support to the care team.
Intervention from Psychology delivered by a Consultant Clinical Neuropsychologist, comprised the following core components:
- Close liaison/communication with the case manager and review of all available medical records, Psychiatric reports and support workers notes
- Initial psychological assessment of Penny, including clinical interview, assessment of her cognitive processing, including her level of awareness and assessment of emotional state.
- Discussions with support workers regarding issues related to delivering support to Penny, particularly in relation to her emotional lability and challenging behaviour
- Provision of detailed report of the above assessment, including recommendations for future psychological intervention and support
- Delivery of teaching/training sessions to all of Penny’s support team; included a psycho educational framework for understanding her condition, management of her cognitive difficulties (particularly her amnesia and confabulation) by use of clear strategies and feedback; establishing a clear, consistent staff approach to Penny’s verbal aggression, refusal of medications and food and resistance to accepting support. Boundary setting and associated action plans provided staff with a clear rationale for their intervention and direction for dealing with difficulties.
- Provision of ongoing consultation regarding Penny’s management and monitoring/adaptation of the above interventions via regular training days.
The effectiveness of this intervention was assessed by measuring key behavioural indicators; after 6 months Penny’s medication/meal refusal was significantly reduced, whilst episodes of verbal aggression were reduced in frequency, as measured on a staff Behaviour rating Scale. In contrast to the 3 ‘crises’ necessitating admission to hospital in the previous year, Penny was not admitted in the 12 months following the introduction of clinical psychology intervention. The staff group reported improved levels of confidence and reduced levels of stress associated with delivering Penny’s day to day support and her case manager described significant improvements in the general management of her support package, including reduced turnover of staff and reduced use of agency staff.
The psychological intervention continued in the form of reviews of staff recordings and ongoing monitoring of Penny’s behaviour via ‘sampled’ staff recordings. Improvements have been maintained over the subsequent 12 months.