Episodes at home

- In addition to episodes, it is recommended that the professionals involved gain an understanding and experience regarding the treatment of TBI, and in particular concerning cognitive disorders following a traumatic brain injury (see therapeutic strategy);

- Within the framework of the life project, the MDPH must refer the patient to the most suitable medico-social organisations depending on the patient's region and life project.

- During episodes, it is important to promote the use of treatment techniques as defined in question 3 and to envisage possible medicinal treatments (cf. chapter 6.2) as well as physical and occupational activities.

R89: Neurological and cognitive-induced behavioural disorders are particularly common and require a specialised, coordinated follow-up by the family physician involving the PMR physician, psychiatrist, and psychologists throughout the follow-up; the development of specialist mobile teams must be encouraged (EC).

R90: The patient and their family must be told about organisations available: family physician, the referring consultant's department (PMR, psychiatrist), emergency calls (fire service 18, ambulance centre 15, police 17), specialist mobile teams, family associations, day care, mutual support groups... (EC).

R91: When calling the ambulance service regarding behavioural disorders in traumatic brain injury patients, it is important to specify that the patient has a history of traumatic brain injury (EC).

R92: The psychological and physical impact on helpers (family and carers) must systematically be investigated, measured and treated (EC).

R93: The family should be offered support, listening, and care (EC).

R94: Admissions or sequential hospitalisation in medico-social institutions, SSR departments or psychiatric institutions (in consultation with the patient and carers who refer the patient) can be envisaged throughout the progression in the event of behavioural disorders within the framework of the care pathway (EC).

R95: Traumatic brain injury patients confronted with addiction problems must be offered the same treatment strategies as patients without a traumatic brain injury, even if the

anosognosia and more generally cognitive disorders often present in traumatic brain injury patients can make compliance with the treatment difficult (EC).

5.6. Treatment strategy regarding default behavioural disorders

Apathy hinders rehabilitation, affects autonomy at home, professional future and the burden felt by the families.

In the absence of sufficient proof, it is not possible to propose recommendations for treatment strategies. Nevertheless, it is advisable to look for an endocrine disorder, and opt for holistic approaches and neuropsychological remediation due to the links between apathy and cognitive disorders. Depending on the case, amantadine could be tried if the symptoms persist; in the absence of specific MA for this indication, prescribing this drug must be evaluated case by case according to the criteria associated with treatments prescribed beyond MA, in addition to the precautions of use.

5.7. Psychiatric care

R96: Neurological and cognitive-induced behavioural or mood disorders are relatively common and require easy access to trained consultant psychiatrists and/or psychologists who have acquired an understanding and experience in the treatment of TBI, and in particular cognitive disorders following a traumatic brain injury (EC).

R97: Throughout the progression and follow-up, the traumatic brain injury patient must be able to receive advice from a psychiatrist and a psychologist (EC).

R98: In the case of behavioural disorders that do not respond to non-medicinal or medicinal therapy, and which concern the recommendations described herein, hospitalisation in a psychiatric unit may be useful in consultation with the healthcare teams and if possible with the patient's consent; the duration of the stay is defined according to the psychiatric needs (EC).

R99: Care without the patient's consent may be necessary in accordance with law 2011-803 of 5 July 2011 on the rights and protection of persons receiving psychiatric care and the conditions of their treatment (EC).

R100: Dual PMR-psychiatric units need to be created, as well as affiliations between PMR and psychiatric departments (EC).

R101: The development of mobile teams made up of PMR physicians, psychiatrists, psychologists, ergotherapists, and social workers must be encouraged (EC).

R102: Specialist medico-social organisations (MAS, FAM) that receive traumatic brain injury patients with behavioural disorders on a temporary or long-term basis (day centre, temporary accommodation) must be created or developed according to the territorial needs, which must be evaluated (EC).

5.8. Suicidal crisis

R103: In the case of a suicidal crisis, the recommendations published by the ANAES must be applied (EC) (Consensus conference. Suicidal crisis: recognition and treatment. ANAES 2000).

5.9. Forensic incidence

5.9.1. Behaviour resulting in forensic consequences, misdemeanour, crime

Observation: In civil law, three measures of assistance can be initiated to protect an individual according to their self-sufficiency, their need for protection, and the urgency of the situation:

legal guardian, guardianship, and curatorship. Three new contractual, judicial, and administrative measures of protection have been created for social reasons linked to

insecurity and exclusion: personalised social support (PSS), judicial support (JS), and lasting power of attorney.

R104: The more effective detection of prior severe traumatic brain injuries and cognitive sequelae in offenders, set against the consequential increase in legal proceedings initiated against them, raises the question of the pertinence of the criminal fate that awaits this population, sometimes evoked under the stigmatic term 'cerebro-delinquent' (EC).

R105: The designated legal expert must have clinical experience of TBI in order to understand as accurately as possible the disorders affecting the person and the most suitable measure of protection (EC).

R106: Questions concerning the history of traumatic brain injury must be added to the entrance medical questionnaire given to offenders when they enter prison so the right treatment can be proposed (EC).

Example: Have you already had an injury or knock on the head that knocked you out (boxing or fight), caused dizziness, faintness, or drowsiness in relation to a fall, a road traffic accident or sports accident? Yes No Don't know

If yes, please specify on what occasion...

If yes, please specify the notion of coma, loss of consciousness, or hospitalisation in order to distinguish mild, moderate or severe TBI.

5.9.2. Distribution of physical injury and legal distribution Recommendations:

R107: Early during a TBI patient's stay in hospital, the healthcare team and social services

must check eligibility for compensation and if necessary refer the patient and their relatives to a solicitor specialising in physical injury of traumatic brain injury patients (EC).

R108: If the patient is eligible for compensation and, if necessary following the

implementation of a measure of protection, early compensation in the form of an accrual must be established according to the needs (EC).

R109: The aim of the forensic assessment is to determine and quantify the different counts of damage to increase the possibility of compensation. The forensic tools in force in substantive law must evolve to take into account more effectively the specificities of the sequelae of brain damaged victims, in particular regarding cognitive disorders, behavioural disorders and their consequences on daily life and relations (EC).

R110: When a victim has brain damage, it is essential to request of the settling agent (amicable settlement) or the Judge that the mission entrusted to the physician be, not a common law mission, but a specific mission elaborated by the work group established by the Ministry of Justice and chaired by Mrs Elisabeth VIEUX (EC).

R111: It must be possible for the victim to be assisted by a medical officer, preferably specializing in traumatic brain injuries who can thus alert their colleague concerning the specificities of the subject (EC).

6. Question 6: Monitoring and prevention of behavioural disorders

6.1. Return to the community, GP, outpatient monitoring, support for families. Paramedical and social interventions (rehabilitation, information and training for the patient, family, relatives and helpers, support, etc.)

R112: A support project, including a life project and a care project, should be established as soon as possible with the patient and their family or the consultants (EC).

R113: The helpers should be informed about the social support available throughout the care pathway as this information is a crucial factor in family functioning, the patient's integration at home, and long-term social integration (EC).

R114: Coordination between the hospital and non-hospital teams is recommended via services and networks available in the region and depending on the patient's situation (SAMSAH, SAVS… etc). The personnel in these organisations and helpers must receive training relevant to the particularities of this treatment (EC).

R115: The organisation of human assistance adapted to each situation must be anticipated during the hospitalisation in conjunction with the MDPH, whilst endeavouring to ensure equality of treatment throughout the country. Due to the possible progression of the

behavioural disorders, it may be necessary to review the assistance plan agreed at the time of discharge from hospital, including during the first year (EC)

R116: The treatment of patients must also involve support at home and treatment systems specific to each geographic region. Assistance at home from professional helpers must be proposed regularly and systematically (EC).

R117: Preparation for the return home must be based on the consensus conference: "Leaving hospital and returning home for motor or neuro-psychologically impaired adults" from

September 2004 and in compliance with the TBI treatment plan (EC).

R118: Respite stays in a mental health hostel, specialist shelter or medical care hostel must be envisaged, particularly for severely disabled patients or patients with behavioural disorders. MDPH referral must be obtained in advance for this type of temporary shelter. In the absence of such organisations in a region, respite hospitalisation can be proposed in the heath care sector (EC).

R119: The development of therapeutic education programmes based on problem solving strategies and adaptive coping training must be encouraged to train and assist patients and

helpers (Grade C).

R120: Regular monitoring is recommended. A telephone follow-up can be useful to refer patients to specialist services and to help solve problems (EC).

R121: If a professional project is envisaged, a multidisciplinary approach is necessary in conjunction with occupational medicine, the COMETE teams and the UEROS branches, depending on the case (EC).