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Routine, Structure and Environmental Considerations for Patients with Brain Injury

Imagine your day without any structure, routine, balance or flow: your world would feel out of control. When you get out of sync with your routine (think about when your in-laws visit or when you lose your keys and leave the house late), you become irritable but naturally take steps to adapt and rectify the situation. People with brain injury (BI) have difficulty adapting to disrupted routines. Impairments in memory, initiation, problem solving, organization and planning are common after BI, and providing daily predictable routines and structure allow people with BI more opportunities for success in their daily lives.

This article will discuss the benefits of a daily routine for people with BI, provide suggestions for building and adapting these routines, and give tips for patients, caregivers and case managers to successfully implement these routines.

Setting a Routine

The benefits of routine and structure for people with BI are significant. Routines allow people to know what is expected and allow them to put energy toward important tasks. During initial rehabilitation, patients are often issued a “memory book” to manage their daily routine. When learning to use the memory book, they may be regularly asked, “What are you doing next?” And then, with a cue, the patient looks in the book. Through procedural learning, this becomes routine, and the patient learns to cue themselves to manage their routine. They begin to gain a sense of control.

When activities and events are more predictable, patients feel safer, more at ease, and participation in daily activities improves. When considering the transition to the home setting, patients benefit from a predictable daily/weekly schedule, and transition from using a memory to using a planner. For patients who have poor initiation and decreased memory, it is recommended that they follow consistent morning and evening routines. Initially, self-care tasks, such as brushing teeth or combing hair, are most effective when performed side by side in the same order each day. Patients should consider using a timer to indicate when to start or end an activity. Patients tend to have better success with a structured and concrete routine. For example: breakfast 8:00 a.m., take medications 8:30 a.m., exercise 9:00 a.m., etc. As cognitive status improves, they may not need such prescribed times. It is important to schedule time for hobbies or to explore possible new interests.

Routine and structure are just as important for caregivers as they are for patients. With consistent routines, caregivers stay more organized and have more energy. During inpatient rehabilitation, caregivers should learn how to provide cues and facilitate generalization of skills to the home environment. When caregivers are able to share in the responsibilities of day-to-day tasks with patients, caregiver demands decrease while a sense of ownership for patients flourishes.

The speech language pathologist (SLP) helps determine which strategy is appropriate and instructs the patients and family in how to use organizational or memory aids. As patients progress, the goal is to decrease cues as they procedurally learn how to use their compensatory strategies. As the discharge date draws closer, it becomes increasingly important to address with family members or other caregivers the importance of maintaining a level of balance by providing routine and structure in their days, helping to create a smooth transition home or to the next setting.

Because caregivers often have other roles and responsibilities, how can the schedule of the caregiver and patient be coordinated? It may be helpful for the caregiver to make appointments later in the morning, rather than first thing, in order to ensure the morning routines go uninterrupted. Caregivers might consider coordinating the patient’s rest breaks with their own to ensure they also have time for rest or leisure.

To avoid burnout, caregivers should utilize their support systems so that they can have respite time or complete errands out of the home while family members or friends take shifts in supervising. Each person in the support system should be educated about the importance of consistently following the established schedule or routine. Keeping routines consistent, in general, will be of benefit to patients and caregivers. For example, keeping consistent times for sleep and wake, meals, medications or household chores will aid in a patient’s initiation, carryover and memory of tasks.

Planning for Transition

Many caregivers are anxious about how much supervision patients will need in the home after discharge from initial rehabilitation. Having these conversations early with the treatment team is critical for families to feel confident and comfortable transitioning into the next phase of the patient’s life. Questions may arise regarding the patient’s ability to be left alone, how much supervision (if any) is needed for the patient to prepare a snack or meal, or how much hands-on help is needed with self-care skills, such as toileting and showering. Having a list of “dos” and “don’ts” developed in collaboration with the team is helpful so that the patient understands that the boundaries were created in their best interest of safety and progress.

Outside of family and friend networks, it can be helpful to have other outside help from nurse aides or from an independent living skills trainer (ILST). The ILST can be a critical player in the rehabilitation process for follow-through with consistency and procedural learning of the self-care routine. The therapists can educate the ILSTs in safety, structure, areas of home exercise programs, how to assist the patient with learning or compensatory strategies, and how to use cueing for facilitating maximal independence. The ILST partners with the patient to increase independence in areas of self-care routines in the home, transfers and mobility, communication and community management activities, such as mobility, shopping, leisure and money management.

An Eye on the Environment

Another key concept in the rehabilitation of patients with BI in the hospital and at home is the strategic management, or “engineering,” of the environment to promote learning and help compensate for cognitive impairments. Environmental management is beneficial in assisting patients to be safe and successful, and it decreases the physical and psychological burden on caregivers. One important consideration of environment engineering is the amount of visual and auditory stimulation. Is there a lot of movement and noise? Patients with BI often have difficulty filtering which type of stimulation to attend to and which to ignore. As a result, attempting to process all stimuli surrounding them can be severely fatiguing, confusing and agitating.

Lighting is also a consideration. Something as simple as excessive brightness or the humming of fluorescent bulbs can be disturbing and can decrease one’s ability to attend to the environment. Similar to providing routines and structure, familiarity in the environment is also very beneficial to decreasing confusion, improving safety, and helping to visually cue a person as to what to do.

A good example that encompasses all of the above considerations can be illustrated in preparing a patient to go home to a household with two children. It is helpful to provide a separate room for the patient to retreat to if they are finding themselves overstimulated. Keeping a familiar, clutter-free room with baskets of activities that are appropriately matched with the patient’s cognitive status and a “to do” checklist can help give comfort in knowing what to do and what is expected of them. Another recommendation is for the room to be supplied with familiar personal items and for the room to be absent of objects that may be harmful, such as sharps or chemical cleaners. As a result, caregivers begin to feel more comfortable leaving the patient briefly unsupervised.

In conclusion, patients and caregivers will be more successful at home with routines that reflect a balance of structure, stimulation, enriching activities and rest. The goal is for the patient to spend more energy on healing and less energy on trying to manage an unpredictable environment. With these environmental elements in place, patients and families can be more functional and successful following brain injury.

Shauna Young, OTR, is an outpatient therapist in the TBI program at Craig Hospital. Shauna received an MS in Occupational Therapy from the Medical College of Georgia in 2007. She has been with Craig since 2008. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

Casey Roth, OTR, received her MS in OT from Colorado State University in 2006. She has been with Craig Hospital on the TBI team since February 2009.
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Sandra Zagyi, COTA, is a Certified Occupational Therapy Assistant (COTA) in the TBI program at Craig Hospital. Sandy received an A.A.S.O.T.A. from Westwood Institute of Technology in 1998. Sandra has worked at Craig since 2008.
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