Supporting Your Family Member

Recovery from a brain injury can be a long and challenging process. If someone in your family has a brain injury, you can play an important role in their recovery.

Health professionals often use the Ranchos Los Amigos Scale to describe how a person moves through levels of recovery in the initial months following injury. The following is a general description of those levels with suggestions of how you can support someone at each stage. Find the level that most suits your family member and start from there.

It is important to remember that individuals with a brain injury move through the levels at their own rate. Some people may:

• move from one level to another
• never be at the lower levels
• never reach the higher levels
• be in more than one level at the same time

Stages Of Recovery

Rancho Levels I & II & III: Little or No Response to Surroundings

What you see:

• moans or moves to touch or pain
• people or noises may or may not get a response
• may follow simple commands
• may be agitated

What you can do:

• Touch and talk to your family member to improve awareness. Stimulate only when he or she is awake and for short periods of time.
• Speak in a calm, slow, normal voice.
• Let the staff know all about your family member, including his or her job, hobbies and interests. Put it in writing if possible.
• Make sure you meet the team and feel free to ask questions. Remember that a lot of answers are not known early in treatment.
• Although your family member may not understand everything that is being said, do not discuss medical concerns as if he or she were not there.
• Ask the team about ways to stimulate the senses:
  • To stimulate taste, a Qtip© can be dipped in lemon, mint or salt and touched to the tongue
  • To stimulate smell, hold some garlic powder, shaving lotion or peanut butter under the nose
  • Say what it is and ask your family member to indicate if he or she can taste or smell it
• Play music that your family member would enjoy. See if you get a reaction when the music is turned on or off; don’t leave music on all of the time or it will become meaningless background noise.
• Make one-step requests, such as “lift your finger”, and wait at least 5 seconds for a response.
• Each time you see your family member, say who you are, the date, and where you are. If advisable, let him or her know what caused the injury.
• Record your family member’s progress in a journal.
• You may need to limit the number of visitors to no more than two at a time. Encourage them to leave messages in the journal.
• Ask questions that require a simple answer such as “yes” or “no”
• Try to find what your family member can do to communicate “yes” or “no”. Consider using eye blinks, head nodding or a thumbs up/thumbs down signal.
• Ask your family member to focus on an object, sound or person as they move from side to side. This is called “tracking”.
• Talk about familiar people and things. Bring in the family album and pictures of objects to help explain your conversations.
• Help your family member do routine activities, according to his or her ability or as indicated by the treatment team.

Rancho Level IV: Confused – Agitated

What you see:

• may be confused
• seems more aware of information, but still unable to make sense of it
• can get easily agitated: may swear, hit or shout

What you can do:

• When your family member is not agitated, use this time to help him or her respond. As an example you may make simple requests, such as “hold my hand” or “look at me”. Be sure that the room is quiet and reduce distractions when possible.
• Help your family member practice daily tasks, such as brushing teeth. Use the scripts or steps outlined by the team.
• Be as active as possible in rehabilitation so you can learn how best to work with your family member.
• Talk quietly in simple words and sentences. Have only one person talk at a time.
• Limit the number of visitors at a time and reduce the amount of noise and activity. Too many things happening at once causes confusion.
• Correct wrong responses gently, but clearly. If your family member continues to give the wrong response, don’t argue and change the topic instead.
• Do not leave your family member alone if agitated or in danger of hurting him or herself, or others.

Rancho Level V: Confused – Inappropriate & Rancho Level VI: Confused – Appropriate

What you see:

• memory improved but still some confusion
• needs instructions and cues to do tasks
• simple problems can be solved but still needs supervision
• poor judgment about limitations and situations
• social behaviour can cause embarrassment
• appears self-centred

What you can do:

• Talk about family and friends. Photo albums may be a way to stimulate memories.
• If both you and the team feel that your family member is ready, tell him or her any painful information related to the accident, such as if someone else was killed or badly injured. The person’s upset may be temporary. While he or she can understand facts, the ability to grieve returns much later.
• Help your family member recall information that is not easy to recall. Ask a question and if the correct answer is not given, provide some clues. If clues don’t work, then give the missing information.
• Ball games and simple card games are all good for learning. If your family member’s performance is inconsistent, be patient.
• Your family member may sometimes confuse kissing, hugging or stroking as sexual messages. If he or she is sexually inappropriate, say so in a matter-of-fact way. If your intention is only to show affection and encouragement, use verbal praise and limit physical contact to pats on the shoulder or pecks on the cheek.
• Praise everything that your family member is able to do. Do not overwhelm him or her with more than one task at a time. It may lead to frustration and aggression.
• Help with “homework” that is given by the team. Either help your family member write in a journal or write your own observations and interactions in the journal. This can be helpful to team members.
• Your family member may need to rest during the day, but may not realize it. Don’t ask if he or she is tired. Instead, keep the activity level moderate and schedule rest periods.
• Ask your family member to tell you about things immediately after they are done. Ask what he or she watched on television and have the person record this if possible.
• Your family member may not be able to sort out events, times or actual occurrences after being unconscious. Calmly and gently distinguish fact from fantasy. Do not argue about false beliefs he or she may have. Instead, distract the person from the conversation.
• Every day tasks may still be difficult. Ask your family member to describe the steps involved in a particular task, such as making orange juice, then have him or her do it.
• Slowly increase independence.
• To speed recovery, keep things simple, consistent and maintain a routine.

Rancho Level VII: Automatic – Appropriate

What you see:

• functioning almost normally
• mostly independent at home
• insight and judgment are poorer than before the injury
• thinking and problem-solving are slower than before the injury
• needs help with new or complicated tasks

What you can do:

• Discuss safety and emergency measures with your family member.
• Have him or her tell you what to do to avoid dangerous situations.
• If there are problems with memory or the person is easily distracted, encourage your family member to write things down.
• Encourage your family member to make a list of things to do everyday.
• Try to do activities together, such as using a map or going grocery shopping.
• Work on a computer to help your family member follow steps and instructions.
• Ask the team about useful programs and activities. Learning how to follow steps can be applied to other tasks such as cooking.
• Make sure your words, actions and gestures are all clear and consistent. Teasing and sarcasm can be misunderstood.
• Do not let your family member drive a car, take a boat out alone or operate any dangerous equipment unless this activity is approved by the doctor.
• Involve your family member in choosing activities. This will help improve thinking skills.
• Be patient and creative. Involve the person in planning the activity.
• Your family member may be blurting out what is on his or her mind without regard to social manners. Offer calm and gentle feedback for such behaviour.

Rancho Level VIII: Purposeful – Appropriate

What you see:

• more able to learn new information
• able to plan and carry out most activities independently
• able to manage most social situations
• less able to reason, tolerate stress and use good judgment in unusual circumstances than before the injury
• some problems with thinking and memory may remain

What you can do:

• Keep the physical and mental limits of your family member in mind. Encourage him or her to get involved in various activities in the home or community, at a pace that is comfortable.
• Help your family member make schedules and reminder lists to manage time and remember important tasks.
• Encourage his or her participation in taking the correct dosage of medications at the proper times.
• Encourage your family member to do activities on his or her own, such as taking public transportation or balancing a chequing account.
• Keep the daily routine stable. Frequent changes can cause confusion, frustration or fatigue.
• Watch out for your family member when it comes to situations requiring insight. Others may take advantage if he or she is naïve and open to peer pressure or suggestions.
• Avoid sayings or clichés. They may seem confusing to a person who understands most things in a concrete way. For example, instead of saying: “killing two birds with one stone”, it’s better to say: “getting two things done at once”.
• Give feedback and explain things in a calm manner. Your family member may make the same mistakes over and over again. Generalizing from one situation to another may be difficult. Calm feedback and explanation can help the situation.
• Do not compare your family member to how he or she was before the injury.
• Throughout everything, be patient.
• Encourage and reward independence, yet provide support and feedback in more difficult situations.

Source: The booklet, “A Handbook for Families about Brain Injury”, by the ABI Program, Hamilton Health Sciences.