Strategies for re-orientation in brain injury

NEUROMINDWORKS STRATEGIES FOR ORIENTATION

Verbal orientation

Clients may sometimes need orientating if they are presenting as confused (e.g. asking to leave the hospital/ care home to go to work). It can be distressing for the client if you re-oreintate them in a way that contradicts their current understanding of where they are in time. It may therefore help if you orientate them in a gentle way that gradually builds up their awareness through asking the following questions in the order below:

Question Rationale for asking the question
Do you know you are in hospital/ care home? This helps to direct their attention to their surroundings which provides cues for orientating themselves (e.g. if there is a hospital there will be hospital beds).Asking a yes/ no question does not contradict them and provides them with a prompt for recalling the correct information about where they are.
Do you know that you are in hospital because you have had a head injury/ X neurological condition? This provides the client with a prompt for recall about why they are in hsopital and helps to prevent confabulation (i.e. filling in memory gaps with false information).
Do you know that you sometimes get confused because you have a head injury? This provides the client with an explanation for why they may be confused, which may help to alleviate anxiety.
Do you know that you no longer work? The previous questions are asked with the aim to have built up a yes response bias and facilitate orientation in a gentle manner.   If this has been established it may then be possible to provide them with information which contradicts the belief you were trying to challenge (e.g. that they no longer work).

Orientation aids

The following are useful to keep in the client’s room as consistent reminders of orientation:

  • Clock
  • Orientation board with the year and month (this will be better than a calendar as the client will be more able to process information if it is presented in isolation)
  • Statement saying where the client is and what has happened to them

Example:

  • It is April 2014
  • My name is XX
  • I am in hospital
  • I have had a head injury

The client is likely to require prompting to process this information. For example, every morning you could ask them to read their orientation board.

Timelines

Clients who are disorientated often may be transfixed in a period of time prior to the head injury (e.g. they may believe that they are 10 years younger and still work whereas they may be retired).

Timelines can be used to help clients to re-develop an awareness of where they are in time and re-process memories within the correct temporal context. Timelines may include the following:

  • A display of photos on the wall of significant life events in the correct temporal order
  • 5-10 photos (too many photos will be confusing) and if possible a photo for each decade.
  • Each photo has a year and a short caption under it (e.g. birth of my son; graduation from university)
  • The first photo / year displayed is their date of birth
  • The last photo displayed is a current one of them in hospital/ care home with a caption under it explanation for why they are in hospital (e.g. I am now in hospital/ a care home because I have a head injury). Next to the current year it states “present”.
  • If possible get the client to write the captions themselves

Clients are likely to require staff to help them process the information displayed on the timeline. The more the staff can promote processing of this information the more likely it is to become stored and encoded. The following is recommended to promote processing of the information:

  • Ask the client to describe the photos in the sequence on the timeline and read the year and caption under each
  • After they have read the last caption stating they are in hospital ask them where they are.
  • If possible repeat this process several times a day.

Timelines can also be used to help clients re-orientate themselves during periods of confusion (e.g. rather than directly contradicting the client, just draw their attention to the timeline).


 

By Dr Vicki Hall

Consultant Neuropsychologist

Neuromindworks Director