Role of agitation in prediction of outcomes after traumatic brain injury

Behavioural problems in the first year after Severe traumatic brain injury: a prospective multicentre study

OBJECTIVE

To investigate the occurrence of behavioural problems in patients with severe traumatic brain injury during the first year after injury and potential associations with outcome. An additional post hoc objective was to analyse the frequency of behaviours with need for intervention from staff.

DESIGN AND SETTING

In a prospective population based cohort study 114 patients with severe traumatic brain injury were assessed at three weeks, three months and one year after injury.

MAIN MEASURES

Assessments included clinical examination and standardised instruments. Agitation was assessed with the Agitated Behaviour Scale, the course of recovery by the Rancho Los Amigo Scale and outcome by Glasgow Outcome Scale Extended.

RESULTS

Agitation were most common at 3 weeks post injury and 28% ( n=68) of the patients showed at least one agitated behaviour requiring intervention from staff. Presence of significant agitation at 3 weeks after injury was not associated with poor outcome. At 3 months agitation was present in 11% ( n=90) and apathy in 26 out of 81 assessed patients. At 3 months agitation and apathy were associated with poor outcome at one year.

CONCLUSIONS

Most agitated behaviours in the early phase are transient and are not associated with poor outcome. Agitation and apathy are uncommon at three months but when present are associated with poor outcome at one year after injury. In the early phase after a severe traumatic brain injury agitated behaviour in need of interventions from staff occur in a substantial proportion of patients.

Pain issues in disorders of consciousness

BACKGROUND

The assessment of pain and nociception in non-communicative patients with disorders of consciousness (DOC) is a real challenge for clinicians. It is, therefore, important to develop sensitive standardized tools usable at the bedside.

OBJECTIVES

This review aims to provide an overview of the current knowledge about pain processing and assessment in patients with DOC.

METHODS

A search was performed on PubMed using MeSH terms including vegetative state, unresponsive wakefulness syndrome, minimally conscious state, consciousness disorders, pain, nociception, neuroimaging and pain assessment.

RESULTS

Neuroimaging studies investigating pain processing in patients with DOC and their implication for clinicians are reviewed. Current works on the development of standardized and sensitive tools for assessing nociception are described.

CONCLUSION

The suggested pain perception capacity highlighted by neuroimaging studies in patients in a MCS and in some patients in a VS/UWS supports the idea that these patients need analgesic treatment and monitoring. The first tool which has been developed to assess nociception and pain in patients with DOC is the NCS. Its revised version represents a rapid, standardized and sensitive scale which can be easily implemented in a clinical setting. Complementary pain assessments are also under validation in order to offer more options to clinicians.

Monitoring Agitated Behavior After acquired Brain Injury: Onset, Duration, Intensity, and Nursing Shift Variation

PURPOSE

To describe the onset, duration, intensity, and nursing shift variation of agitated behavior in patients with acquired brain injury (ABI) at a rehabilitation hospital.

DESIGN

Prospective descriptive study.

METHODS

A total of 11 patients with agitated behavior were included. Agitated behavior was registered with the Agitated Behavior Scale (ABS). The nurse or therapist allocated the individual patient assessed ABS during each shift. Intensity of agitated behavior was tested using exact test. A within-subject shift effect was analyzed with repeated-measure ANOVA.

FINDINGS

The onset of agitated behavior was at a median of 14 (1-28) days from admission. Seven patients remained agitated beyond 3 weeks from onset. Severe intensity of agitation was observed in 86 of 453 nursing shifts. Differences in agitated behavior between day, evening, and night shifts were found, F(2.20) = 7.90, p = .008, with tendencies of increased agitated behavior in day and evening shifts compared to night shifts.

CONCLUSION

Agitated behavior had a late onset, was severe, and long-lasting in the present sample of patients.

CLINICAL RELEVANCE

The study increases awareness on the potential challenge of agitated behavior in patients with ABI.

Effect of Preferred Music on Agitation After Traumatic Brain Injury

Agitation is a common behavioral problem after traumatic brain injury (TBI), which threatens the safety of patients and caregivers and disrupts the rehabilitation process. This study aimed to evaluate the effects of a preferred music intervention on the reduction of agitation in TBI patients and to compare the effects of preferred music with those of classical “relaxation” music. A single group, within-subjects, randomized crossover trial design was formed, consisting of 14 agitated patients with cognitive impairment after severe TBI. Patients listened to preferred music and classical “relaxation” music, with a wash-out period in between. Patients listening to the preferred music reported a significantly greater reduction in agitation compared with the effect seen during the classical “relaxation” music intervention ( p = .046). These findings provide preliminary evidence that the preferred music intervention may be effective as an environmental therapeutic approach for reducing agitation after TBI.

Clinical and neuropsychological correlates of major depression following post-traumatic brain injury, a prospective study

OBJECTIVES

Major depression disorder (MDD) is the most frequent psychiatric complication after traumatic brain injury (TBI), with a prevalence of 14-77%. The aim of this study was to analyse the psychiatric sequelae of TBI, and to identify the neuropsychological and psychopathological correlates of post-TBI MDD in order to highlight their differences from those of primary MDD.

METHODS

This was a longitudinal, prospective, case-control study. Sixteen patients with closed brain injury, and a lesion revealed by computed tomography (CT), were recruited and were evaluated one (T1), three (T3) and six (T6) months after discharge from Neurosurgery Department; the controls were six patients with MDD. The psychiatric symptoms were evaluated using brief psychiatric rating scale (BPRS), Hamilton depression rating scale (HRSD), Beck depression inventory scale (BDI), Hamilton anxiety rating scale (HRSA), global assessment of functioning (GAF) and instrumental activity of daily living (IADL). Neuropsychological profiles were assessed by using neuropsychological tests, focused on memory and frontal-executive functioning.

RESULTS

At T1, MDD was observed in 10 cases (62.5%), a manic episode in 12.5%, and post-traumatic stress disorder in 6.5%. At T3 and T6, MDD was diagnosed in, respectively, eight (50%) and six cases (37.5%). Post TBI MDD had less severe depressive symptoms, showed greater social isolation and hostility and more cognitive deficits in comparison with the control group.

CONCLUSIONS

MDD is a frequent TBI complication. Patients with post-TBI MDD have a specific psychopathological profile characterised by a less severe depressive symptomatology and a neuropsychological pattern that is significantly associated with greater deficits in cognitive functions than those with primary MDD.

Dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study

BACKGROUND AND PURPOSE

Attentional impairments following severe traumatic brain injury (TBI) are common and can lead to decreased functional mobility and balance, as well as deficits in previously automatic movements such as walking and stair climbing. The purpose of this case study was to determine the feasibility and potential value of incorporating a cognitive-motor dual-task training program into physical therapy for a patient with a severe TBI.

CASE DESCRIPTION

The patient was a 26-year-old woman who sustained a severe TBI during a motor vehicle accident 46 days prior to physical therapy evaluation. On the 8-level Rancho Los Amigos Cognitive Function Scale, her functioning was classified as level IV. She had impairments in attention, functional mobility, and balance, all of which limited her ability to participate in activities of daily living.

INTERVENTION

: Physical therapy was provided over 26 days within the inpatient rehabilitation setting. Interventions included mobility tasks such as walking, balancing, and stair climbing. Mobility training was paired with specific secondary cognitive and motor tasks.

OUTCOMES

Dual-task training may have contributed to improvements on outcome measures designed to test divided attention including the Walking While Talking Test and Trail Making Test and a greater rate of improvement in walking speed and time to descend stairs when compared to the baseline phase.

DISCUSSION

Addition of cognitive-motor dual-task training to standard physical therapy in the inpatient rehabilitation setting appears to be feasible and may have value for improving function in individuals with severe TBI.

VIDEO ABSTRACT AVAILABLE

(see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A41) for more insights from the authors.

The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units

PURPOSE

Agitation occurs in 70% of patients hospitalized with traumatic brain injury (TBI) and has adverse effects on length of stay and functional outcomes. Treatment involves pharmacological and behavioural interventions. Much research on TBI agitation has been conducted in intensive care or rehabilitation settings. This study aimed to identify agitation prevalence, treatment and outcomes among patients with TBI on acute care wards.

METHODS

Data abstracted from the trauma registry and medical records of adult patients with TBI admitted to an acute care ward within a Level I trauma centre over 12 months.

FINDINGS

From 219 patients, at least one agitation behaviour was present in 41% (n = 90) of patients. Clinically significant agitation was present in 8% (n = 18) of patients. Agitation behaviours included impulsiveness (30%), pulling at devices (21%) and decreased attention span (16%). Common interventions were reorientation (33%), constant supervision (32%) and benzodiazepines (30%). Agitated patients had longer length of stay (p < 0.001) and were less likely to be discharged home. Physical restraints, constant supervision, redirection, reorientation and environmental modifications were associated with agitation (p < 0.001).

IMPLICATIONS

Management of agitation among patients with TBI on acute care wards can present challenges to healthcare staff. Innovative approaches are needed to promote outcomes using available resources.

Patterns of agitated behaviour during acute brain injury rehabilitation

OBJECTIVE

To monitor daily shift-by-shift changes in agitated behaviour during adult brain injury rehabilitation.

DESIGN

A prospective, descriptive study.

METHODS

Eight participants were monitored daily for up to 28 days. The Agitated Behaviour Scale (ABS) evaluated behaviour during three nursing shifts (morning, afternoon, night). Severity of agitation, peak intensity and concomitant behaviours were calculated. Shift differences and patterns of behavioural changes were analysed.

RESULTS

Four hundred and seven recordings were taken with the ABS. All participants demonstrated multiple agitated behaviours (between 3-13 concomitant behaviours per person); the most common behaviours were representative of the ABS Disinhibition sub-scale. Weekly peak intensity ranged from 14-55 on the ABS. Mean ABS scores were highest during the afternoon shift and lowest at night. Improved cognition was associated with resolving agitated behaviour; while persistent agitated behaviour was associated with low levels of cognition. Minimal agitated behaviour was observed in participants who emerged from post-traumatic amnesia.

CONCLUSIONS

Agitated behaviour during acute brain injury rehabilitation has a complex clinical presentation. High levels of agitation observed during the afternoon shift may be associated with low levels of structured activities available at that time, higher levels of environmental stimuli during visiting times and increased cognitive fatigue. Lower cognitive ability was related to consistently higher levels of agitated behaviour and vice-versa.

The impact of acute care medications on rehabilitation outcome after traumatic brain injury

OBJECTIVES

To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation.

DESIGN

Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors.

METHODS

The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)).

MAIN OUTCOME AND RESULTS

The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant.

CONCLUSIONS

The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.

Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies

OBJECTIVE

To systematically review prospective cohort studies that investigated prognostic factors associated with long-term activity limitations or participation restrictions and productivity after a traumatic brain injury.

DATA SOURCES

PubMed and Psychinfo were searched from 1995 to April 2005, and references were checked.

REVIEW METHODS

Publications were selected if the study assessed prognostic factors for activity limitations or participation restrictions at least one year post injury; outcome was measured with another or additional measure besides the Glasgow Outcome Scale; the design was a prospective cohort study of adult traumatic brain injury patients; the article was a full-text article written in English, French, German or Dutch. Two reviewers independently assessed methodological quality. A study was considered as 'high quality' if it satisfied at least half of the maximum available quality score.

RESULTS

Thirty-five articles reporting on 14 cohorts were included. Due to heterogeneity in prognostic factors and outcome measures, a best-evidence synthesis was performed. All cohorts were of high quality. Strong evidence for predicting disability was found for older age, pre-injury unemployment, pre-injury substance abuse, and more disability at rehabilitation discharge. Strong prognostic factors for being non-productive were pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission, and pre-injury substance abuse.

CONCLUSION

Older age, pre-injury unemployment, pre-injury substance abuse and more disability at rehabilitation discharge are important predictors of long-term disability. Pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission and pre-injury substance abuse are important predictors of being non-productive.

Agitation following traumatic brain injury: an Australian sample

PURPOSE

Agitation following traumatic brain injury (TBI) is perceived to limit the achievement of rehabilitation goals. The aims of this study were: (1) To examine the nature and incidence of agitation during TBI rehabilitation in an Australian sample; and (2) To explore the relationship between agitation and functional outcomes after TBI.

METHOD

Retrospective medical record review of 80 participants admitted for rehabilitation following TBI. Outcome data collected at discharge, 6 and 24 months post-discharge, included length of stay, duration of post-traumatic amnesia (PTA), community integration, functional independence and life satisfaction.

RESULTS

Seventy per cent of patients demonstrated agitation during rehabilitation for an average of 32 days. Agitated patients experienced longer PTA duration, increased length of stay and reduced functional independence, specifically cognitive function, at discharge. These differences between agitated and non-agitated participants did not appear to persist and were not evident at follow-up 6 and 24 months post-discharge. Longer duration of agitation was associated with delayed PTA emergence, longer rehabilitation stay and reduced functional independence at discharge and follow-up.

CONCLUSIONS

A large proportion of patients with TBI experience agitation. Presence of agitation seems to limit rehabilitation gains at discharge. Longer duration of agitation is associated with persisting limitations to functional independence.

Agitation in Acquired Brain Injury

OBJECTIVE

To examine the nature of agitation in patients with brain injury and quantify the relation between agitation and patient progress in rehabilitation.

DESIGN

Cross-sectional, correlational.

SETTING

Urban, inpatient rehabilitation facility in the midwestern United States.

PARTICIPANTS

Sixty-nine patients with acquired brain injury admitted to an acute rehabilitation hospital.

MAIN OUTCOME MEASURES

Therapy Engagement using the Rehabilitation Therapy Engagement Scale; Functional Status using the Functional Independence Measure.

RESULTS

Agitated behavior was inversely associated with engagement in rehabilitation therapy even after controlling for injury severity. Engagement in therapy mediated the relation between agitated behavior and progress in rehabilitation as assessed using a Functional Independence Measure efficiency ratio.

CONCLUSIONS

Progress in acute brain injury rehabilitation appears to be meaningfully influenced by the complex interplay among injury severity, agitation, and engagement. The findings are consistent with a theoretical model, suggesting that agitated patients make less progress in rehabilitation not only because of greater injury severity but also because agitation disrupts engagement in rehabilitation therapies. Multiple clinical purposes may be better served by measuring behavioral excess on a continuum than in a dichotomous fashion.

Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury

There is currently a lack of evidence-based guidelines to guide the pharmacological treatment of neurobehavioral problems that commonly occur after traumatic brain injury (TBI). It was our objective to review the current literature on the pharmacological treatment of neurobehavioral problems after traumatic brain injury in three key areas: aggression, cognitive disorders, and affective disorders/anxiety/ psychosis. Three panels of leading researchers in the field of brain injury were formed to review the current literature on pharmacological treatment for TBI sequelae in the topic areas of affective/anxiety/ psychotic disorders, cognitive disorders, and aggression. A comprehensive Medline literature search was performed by each group to establish the groups of pertinent articles. Additional articles were obtained from bibliography searches of the primary articles. Group members then independently reviewed the articles and established a consensus rating. Despite reviewing a significant number of studies on drug treatment of neurobehavioral sequelae after TBI, the quality of evidence did not support any treatment standards and few guidelines due to a number of recurrent methodological problems. Guidelines were established for the use of methylphenidate in the treatment of deficits in attention and speed of information processing, as well as for the use of beta-blockers for the treatment of aggression following TBI. Options were recommended in the treatment of depression, bipolar disorder/mania, psychosis, aggression, general cognitive functions, and deficits in attention, speed of processing, and memory after TBI. The evidence-based guidelines and options established by this working group may help to guide the pharmacological treatment of the person experiencing neurobehavioral sequelae following TBI. There is a clear need for well-designed randomized controlled trials in the treatment of these common problems after TBI in order to establish definitive treatment standards for this patient population.

Aggressive behavior following traumatic brain injury: how common is common?

OBJECTIVE

To assess the prevalence and predictors of aggressive behavior among traumatic brain injury (TBI) survivors at 6, 24, and 60 months postdischarge.

DESIGN

Mixed cross-sectional and longitudinal data from a 5-year follow-up study of discharged TBI patients analyzed retrospectively.

SETTING

A specialized Brain Injury Rehabilitation Service of a tertiary referral hospital.

PATIENTS

Two hundred twenty-eight (228) patients with moderate to severe TBI.

MAIN OUTCOME MEASURES

The Overt Aggression Scale; injury-related variables (in particular, Glasgow Coma and Outcome scales and posttraumatic amnesia duration); and a battery of postdischarge questionnaires (Beck Depression Inventory, Trauma Complaints List, General Health Questionnaire, etc).

RESULTS

At any given follow-up period, 25% of the participants were classified as aggressive. Aggression, where present, was consistently associated with depression, concurrent traumatic complaints, younger age at injury, and low satisfaction with life rather than with injury, demographic, or premorbid characteristics. Depression was the factor that was most significantly associated with aggressive behavior at all times postinjury, followed by a younger age at the time of injury.

CONCLUSIONS

Aggression is a common, fluctuating, and long-term problem following TBI. The underlying association between aggression and psychosocial variables lends support to the provision of ongoing outreach services and psychological and behavioral interventions for all affected TBI survivors.

Transient versus prolonged hyperlocomotion following lateral fluid percussion injury in mongolian gerbils

Posttraumatic hyperactivity is a neurobehavioral symptom commonly seen in patients after traumatic brain injury (TBI). No useful animal model has yet been established for evaluation of this important symptom. We induced either mild (MILD, 0.7-0.9 atm) or moderate (MOD, 1.3-1.6 atm) lateral fluid percussion injury (LFPI) in Mongolian gerbils. Open-field and T-maze tests were used during a 7-day period after the trauma. All animals were perfusion fixed for histopathological examinations. Transient locomotor hyperactivity was found with a peak at 6 hr after injury in the MILD animals, whereas MOD animals showed prolonged and severe hyperlocomotion throughout the 7-day posttrauma period (P < 0.0001). Interestingly, the temporal profile of the posttraumatic hyperactivity was similar to that of the working memory deficit in both injury groups. Histological examination revealed significant neural tissue damages, including cortical necrosis, white matter rarefaction, and neuronal loss in the hippocampus in the ipsilateral hemisphere of the MOD animals, vs. only negligible changes in the MILD animals. Correlation analysis revealed that the volume of white matter lesions was significantly correlated with both posttraumatic hyperactivity (r = 0.591, P < 0.01) and working memory deficit (r = -0.859, P < 0.0001). Taken together, our findings confirm the successful reproduction of posttraumatic hyperactivity following experimental TBI. The posttraumatic hyperlocomotion probably shared pathomechanisms common to those of cognitive dysfunction caused by LFPI, supporting the speculation from previous studies that some neurobehavioral abnormities intimately correlate with TBI-induced cognitive dysfunction. Histopathologically, significant involvement of white matter damage in the posttraumatic functional deficits was indicated.

Measuring High-Level Mobility After Traumatic Brain Injury

High-level mobility is important for participation in many pre-accident activities after traumatic brain injury (TBI). This review examined which measures are used to quantify physical status and mobility after TBI to determine their appropriateness for measuring high-level mobility. Electronic databases, hand searching of several TBI journals, and citation tracking from retrieved articles were used to identify all TBI outcome studies from 1990 through to May 2004. Preliminary screening identified articles that either reported on physical outcome or mobility after TBI or utilized measurement tools with a physical component. Studies were selected for detailed analysis if they reported on mobility or physical outcomes after TBI. The search identified 175 studies that met the inclusion criteria for further analysis. The FIM instrument is the most frequently used outcome measure, highlighting a trend toward using inpatient measures to evaluate long-term outcomes. Only one study used a measurement tool that incorporated a mobility item beyond independent walking and stairs. High-level mobility is seldom measured using standardized outcome measures after TBI, despite independent mobility being one of the major goals of rehabilitation. A high-level mobility scale is needed to address the ceiling effect of outcome scales currently used in TBI rehabilitation and to extend mobility to age-appropriate levels for return to leisure and sporting activities.

Gender Differences in Agitation After Traumatic Brain Injury

OBJECTIVE

To determine sex differences in extent and type of posttraumatic agitation during acute rehabilitation.

DESIGN

This prospective, observational study was performed at a Midwest, regional, university-based acute rehabilitation center.

RESULTS

In a total of 158 subjects, comprising 120 men (76%) and 38 women (24%), there were no significant differences between male and female subjects for age, Glasgow Coma Scale score, Rancho Los Amigos Level of Cognitive Functioning Scale, Mini Mental State Exam, days in acute hospital, and days in rehabilitation. No difference in incidence was observed between sexes based on the criterion of agitation as three or more abnormal total Agitated Behavior Scale scores in 48 hrs (P = 0.890). Also, no difference in posttraumatic agitation between the two sexes (P = 0.396) was observed with the criterion of agitation as two or more abnormal total Agitated Behavior Scale scores in 2 days. There were no differences observed between the sexes for peak intensity and average intensity for the total score or each of the factor scores of the Agitated Behavior Scale.

CONCLUSION

Posttraumatic agitation is seen in approximately 50% of patients after traumatic brain injury and usually lasts for <10 days. There are no significant sex differences in the frequency, duration, presentation, or extent of posttraumatic agitation. These data imply that both sexes, despite any predetermined notions, should be treated equally with respect to posttraumatic agitation management.

Activity-related quality of life in rehabilitation and traumatic brain injury

OBJECTIVES

To review approaches to assessment of quality of life (QOL) outcomes in rehabilitation, focusing particularly on traumatic brain injury (TBI), and to introduce the concept of activity-related QOL.

DATA SOURCES

A conceptual review, based on extensive searches of MEDLINE, PsychInfo, and other information sources.

STUDY SELECTION

Studies indexed under QOL and brain injury.

DATA EXTRACTION

Literature search on key words quality of life and traumatic brain injury.

DATA SYNTHESIS

Past research in rehabilitation and TBI has concentrated largely on assessment of function or activity. Although research on QOL after TBI remains limited, many studies have made inferences about QOL without actually assessing it. Persons with TBI experience serious long-enduring problems with QOL. Progress has been made in measurement of QOL and understanding of predictors of QOL after TBI.

CONCLUSIONS

Future research in rehabilitation would do well to consider not only activity outcomes but also the affective quality of everyday life, and the connections between the two. Measures of activity-related QOL may provide a more sensitive, valid, and useful evaluation of rehabilitative therapies than other approaches. Further research is needed to improve measurement and interpretation of QOL assessments. By assessing both objective and subjective features of outcomes, outcomes assessment becomes more complete and potentially more useful.