Mr. C, a Vietnam veteran, was admitted to an acute care unit with a new diagnosis of congestive heart failure (CHF). He was placed on oxygen via nasal cannula and given a low-sodium diet along with a fluid restriction. Throughout his hospitalization, staff members educated him concerning his diagnosis and how it would impact his daily life. They provided him with pamphlets with lists of foods that were high in sodium, handouts on the importance of weighing himself every day, and a wealth of other information. Each time, they asked if he understood and if he had any questions. And each time, Mr. C acknowledged that he did understand and had no questions.
By the time he was discharged from the facility, Mr. C had a folder full of information and brochures. He placed the folder in his bag, put it in the backseat of the car, and went home. Two weeks later, Mr. C presented to the ED with an exacerbation of CHF. He was admitted and labeled as being nonadherent. However, Mr. C wasn't deliberately nonadherent; if staff members had asked him if he had posttraumatic stress disorder (PTSD), they would have discovered that Mr. C spent years having flashbacks due to the traumatic events he witnessed during his military career. He had been on medication to help him sleep and decrease his nightmares, and he avoided friends who had also been through similar situations because he was afraid to remember.
What do the events of more than 40 years ago have to do with Mr. C being nonadherent? In this article, we'll discuss how PTSD affects the brain, including a person's ability to learn new information, and what the healthcare community can do to overcome these barriers.
The impact of PTSD
PTSD is diagnosed when a person experiences, witnesses, or confronts an event that's either severely injurious or threatening and the subsequent symptoms are present for at least 1 month, according to the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition. When the body experiences a traumatic event, the fight-or-flight response kicks into gear, releasing cortisol. In those with PTSD, the stress response becomes the norm, rather than the exception. The more excited or aroused the brain is through the secretion of adrenaline, epinephrine, and cortisol, the easier it is for a person to remember the information or event, which is why a flashback can be so vivid.
Oversecretion of glucocorticoids, combined with numerous glucocorticoid receptors in the hippocampus, results in decreased hippocampal volume. Glucocorticoids are produced by the adrenal cortex in response to stress, and the hippocampus is vulnerable to high levels of them. The repeated insult to the hippocampus by high levels of glucocorticoids can cause plasticity of the hippocampus, or a decreased hippocampal volume. The more insults that the hippocampus sustains, the less volume is available, which decreases the patient's ability to retain new information because the hippocampus plays a significant role in declarative memory (those related to facts and events). In the case of Mr. C, because his hippocampus is damaged, he isn't going to be able to retain information provided through the traditional fast-paced presentations in the hospital setting.
The other area that's insulted in PTSD is sleep, which plays an important role in the learning process and memory consolidation. The inability to sleep is one of the hyperarousal symptoms of PTSD. Studies have shown that learning and memory are impaired when a person is deprived of sleep. In addition to the negative effects on sleep caused by PTSD, sleep is difficult in an acute care setting. Lights, environmental noise, constant interruptions for vital signs, and pain all contribute to the disruption of sleep patterns, thus setting Mr. C up to not remember the information given to him by hospital staff.
According to the World Health Organization, 10% to 25% of hospital and long-term-care facility admissions result from patient nonadherence. One reason for nonadherence is a lack of patient understanding of the treatment regimen. Although we can't definitively state that PTSD causes a higher incidence of nonadherence, it's relatively easy to see how the trauma to the hippocampus and disruption in sleep could lead to nonadherence.
What to do
Unfortunately, it isn't as simple as making information more exciting for patients with PTSD and ensuring that they get better sleep. Once the brain has sustained repeated insults, it won't rebuild itself. Medications to promote sleep may help, but nightmares can plague a patient, creating additional fight-or-flight responses within the sympathetic nervous system.
To overcome the barriers that patients with PTSD face when learning new information, nurses and other healthcare professionals need to adapt the way they teach by using a more hands-on, creative approach. Keep these points in mind:
- Present information in small chunks so it isn't overwhelming.
- Tell a story that allows the patient to make an emotional connection, such as, “Do you remember how you felt right before you came into the hospital? That's an indication of...”
- Make the patient an active participant. Rather than just giving Mr. C a pamphlet about a heart-healthy diet, bring a tray of plastic food or pictures of popular food items and have him build a diet that he would be willing to eat for an entire day. Or rather than just watching a video about diabetes and how to give an insulin injection for a patient with a new diabetes diagnosis, use an insulin syringe and 0.9% sodium chloride solution to have the patient draw up a prescribed amount and give herself an injection. Training injector pens are also an option where the patient can dial the correct amount to administer.
- Use repetition. Don't just have the patient demonstrate his understanding; if possible, have him perform the skill at every opportunity using the teach-back method.
Most evidence-based research indicates that the best way to help patients retain information is to customize it to their personal learning style. Although there may not be time to customize the information for each patient, through interactive educational sessions, patients will be in a better position to learn and retain new information. And because patients retain the information, they'll be more apt to be adherent to the healthcare provider's recommendations.
Through the creative efforts of the healthcare team, patients with PTSD like Mr. C can learn new concepts and practices to maintain or improve their health and decrease hospital readmissions. Even though the primary focus of the admission is medical, PTSD still plays a key role in the patient's recovery. Tailoring teaching methods will help patients with PTSD overcome barriers to learning and increase adherence.
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