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Pauli E, Debecker I, Hund-Georgiadis M. Functional independence and agitation outcomes following inpatient rehabilitation after structural brain injury: A retrospective cohort study. Neuropsychol Rehabil 2024:1-18. [PMID: 38502714 DOI: 10.1080/09602011.2024.2328871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 02/23/2024] [Indexed: 03/21/2024]
Abstract
The study's purpose was to analyze outcomes of patients with severe behavioural disturbances after acquired brain injury (ABI) in order to identify predictors of discharge destination from a specialized unit (SU) of a Swiss neurorehabilitation facility. Retrospective analysis of 85 patients. Potential predictors of the main outcome discharge destination were assessed with a correlation analysis. The Agitation Behaviour Scale (ABS), Functional Independence Measure (FIM), length of stay (LOS) and pre-living situation were tested in a logistic regression analysis. Twenty-nine patients were institutionalized and 56 patients went home. Discharge destination was significantly correlated to ABS score at discharge from SU (rs = -.33, p = .002), total FIM score on admission to the SU (rs = .25, p = .022), total FIM score at discharge from the SU (rs = .37, p < .001), LOS at the SU (rs = -.36, p = .001), and LOS after discharge of the SU (rs = .36, p = .001). Multivariate analysis showed that FIM scores at discharge (OR = 1.03, p = .008), and LOS at SU (OR = 0.98, p = .017) predicted discharge destination significantly. FIM or LOS may be important predictors in planning discharge destination in patients with severe behavioural disturbances. Further prospective studies are critically needed to better understand the complexity of interactions amongst important predictive factors.
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Affiliation(s)
- Elena Pauli
- REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, Basel, Switzerland
| | - Isabelle Debecker
- REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, Basel, Switzerland
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2
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Hoover GL, Whitehair VC. Agitation after traumatic brain injury: a review of current and future concepts in diagnosis and management. Neurol Res 2023; 45:884-892. [PMID: 32706643 DOI: 10.1080/01616412.2020.1797374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Agitation and aggression are common following traumatic brain injury. The challenges related to these disorders affect all stages of recovery, from the acute hospital to the community setting. The aim of this literature review is to provide an updated overview of the current state of post-traumatic agitation research. METHODS We performed a PubMed literature review which included recent confirmatory and novel research as well as classic and historical studies to integrate past and future concepts. RESULTS Areas explored include the personal and societal effects of post-traumatic agitation, methods for defining and diagnosing several neurobehavioral disorders, and pathophysiology and management of agitation and aggression. Target areas for future study are identified and discussed. DISCUSSION While much progress has been made in understanding post-traumatic agitation, there remain several key areas that require further elucidation to support the care and treatment for people with traumatic brain injury.
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Affiliation(s)
- Gary L Hoover
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
| | - Victoria C Whitehair
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
- Cleveland FES Center, Cleveland, OH, USA
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3
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Hon E, Case A. The Effect of Amantadine on Agitation in the Pediatric Traumatic Brain Injury Population: A Case Series. Cureus 2023; 15:e42892. [PMID: 37664300 PMCID: PMC10474794 DOI: 10.7759/cureus.42892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
In this report, we present a case series involving four pediatric patients who sustained a traumatic brain injury (TBI) and required intensive care unit admission immediately after the injury. In each of the four cases, amantadine was started during the acute care hospital admission to address agitation. Cases were retrieved from the electronic medical record at the Children's Hospital of Philadelphia between July 1, 2020, and October 31, 2022. This case series describes clinical data on TBI presentation, amantadine administration, patient behavior, and hospital course relating to agitation. This is the first publication that reports the effect of amantadine on agitation in the acute phase of recovery in the pediatric TBI population. Improvement in agitation was observed within 48 hours of amantadine initiation in all four cases based on the primary team progress notes, as well as the quantity of pro re nata medications given for agitation. Resolution of agitation was also observed in all cases, though the time scale varied. No adverse events were reported in relation to amantadine use, supporting other reports that the medication may be well tolerated in the pediatric population. More research is needed to determine the optimal dose of amantadine for the pediatric population and whether amantadine hastens agitation resolution compared to the current standard of care.
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Affiliation(s)
- Emily Hon
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Abigail Case
- Division of Rehabilitative Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, USA
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4
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Bonin EAC, Lejeune N, Szymkowicz E, Bonhomme V, Martial C, Gosseries O, Laureys S, Thibaut A. Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review. Front Syst Neurosci 2023; 17:1112206. [PMID: 37021037 PMCID: PMC10067681 DOI: 10.3389/fnsys.2023.1112206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.
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Affiliation(s)
- Estelle A. C. Bonin
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre Hospitalier Neurologique (CHN) William Lennox, Saint-Luc Hospital Group, Ottignies-Louvain-la-Neuve, Belgium
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Emilie Szymkowicz
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liège University Hospital, Liège, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSS), University Laval, Québec City, QC, Canada
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness Thematic Unit, GIGA-Research, Liège, Belgium
- Centre du Cerveau, Liège University Hospital, Liège, Belgium
- *Correspondence: Aurore Thibaut,
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5
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Factor Structure of the Agitated Behavior Scale in Traumatic Brain Injury During Posttraumatic Amnesia. J Head Trauma Rehabil 2023; 38:E56-E64. [PMID: 36594864 DOI: 10.1097/htr.0000000000000787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA). SETTING Inpatient TBI rehabilitation ward in Victoria, Australia. PARTICIPANTS A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020. DESIGN Retrospective cohort study utilizing electronic medical record data. MAIN MEASURES The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS). RESULTS Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (β = -.14, P < .001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (β = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures. CONCLUSION This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.
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Block H, Hunter SC, Bellon M, George S. Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury. Brain Inj 2022; 36:1176-1186. [PMID: 35996950 DOI: 10.1080/02699052.2022.2110941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PRIMARY OBJECTIVE This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation. RESEARCH DESIGN This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74). METHOD AND PROCEDURES The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia. MAIN OUTCOMES AND RESULTS Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded. CONCLUSIONS These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.,Division of Allied Health, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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7
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Carrier SL, Ponsford J, Phyland RK, Hicks AJ, McKay A. Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review. Neuropsychol Rev 2022; 33:374-392. [PMID: 35687261 PMCID: PMC10148768 DOI: 10.1007/s11065-022-09544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 05/15/2022] [Indexed: 02/03/2023]
Abstract
Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia. .,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.
| | - Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Ruby K Phyland
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Amelia J Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
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8
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Carrier SL, Ponsford J, Phyland RK, Hicks AJ, McKay A. Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review. Neuropsychol Rev 2022. [DOI: https://doi:10.1007/s11065-022-09544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractAgitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.
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Abstract
OBJECTIVES Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.
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10
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Phyland RK, Ponsford JL, Carrier SL, Hicks AJ, McKay A. Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behavior Type. J Neurotrauma 2021; 38:3047-3067. [PMID: 34435884 DOI: 10.1089/neu.2021.0257] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages of recovery is unknown. The aim of this systematic review and meta-analysis was to evaluate the prevalence of agitation in TBI patients undergoing inpatient care, and whether this prevalence differed by post-traumatic amnesia (PTA) status and setting (acute and rehabilitation). We also aimed to describe the prevalence of sub-types of agitated behavior (disinhibited, aggressive, and emotionally labile). We searched five databases and one clinical trials register, with additional review of websites and key journals to identify any relevant records up to July 2020. We included studies describing the proportion of hospitalized TBI patients age 16 years or older demonstrating agitated behavior. We included comparative studies with and without concurrent controls, randomized controlled trials, pseudo-randomized controlled trials, and case series. Methodological quality was critically appraised using a Joanna Briggs Institute checklist. Sixteen studies met eligibility criteria, with a total of 5592 participants. The pooled prevalence of agitation was 31.73% (95% confidence interval [CI], 25.25%-39.00%) during inpatient care (acute and rehabilitation), 32.23% (95% CI, 27.13%-37.80%) during rehabilitative care and 44.06% (95% CI, 36.15%-52.28%) for inpatients in PTA specifically. Disinhibited behaviors were the most common. There was substantial heterogeneity between studies. Additional high-quality research featuring large samples, frequent and long-term measurement of agitation, use of validated scales, and consideration of variables such as PTA status will further improve estimates of agitation prevalence following TBI.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sarah L Carrier
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Victoria, Australia
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11
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The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:149-155. [PMID: 32898031 DOI: 10.1097/htr.0000000000000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. DESIGN Observational prospective study with correlational design. SETTING Inpatient rehabilitation hospital for TBI. PARTICIPANTS A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. MEASURES Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). RESULTS Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. CONCLUSIONS Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.
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12
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Bilodeau V, Saavedra-Mitjans M, Frenette AJ, Burry L, Albert M, Bernard F, Williamson DR. Safety of dexmedetomidine for the control of agitation in critically ill traumatic brain injury patients: a descriptive study. J Clin Pharm Ther 2021; 46:1020-1026. [PMID: 33606290 DOI: 10.1111/jcpt.13389] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/25/2021] [Accepted: 02/08/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Behavioural disturbances such as agitation are common following traumatic brain injury and can interfere with treatments, cause self-harm and delay rehabilitation. As there is a lack of evidence on the optimal approach to manage agitation in recovering TBI patients, various pharmacological agents are used including antipsychotics, anticonvulsants and sedative agents. Among sedatives, the safety and efficacy of dexmedetomidine to control agitation in traumatic brain injury patients is not well documented. OBJECTIVE To describe the safety, use and efficacy of dexmedetomidine for the management of agitation following traumatic brain injury in the intensive care unit. METHODS Medical records of all patients admitted to the intensive care unit of the Hôpital Sacré-Coeur de Montréal for a traumatic brain injury who received dexmedetomidine for agitation between 1 January 2017 and 31 December 2017 were reviewed. Patients who received dexmedetomidine for indications other than agitation were excluded. Data on dexmedetomidine prescription practices and safety were extracted. Frequency of agitation and concomitant psychoactive medication use was explored over a period starting two days prior to the initiation of dexmedetomidine to six days after or discontinuation, whichever came first. RESULTS We identified 41 patients in whom dexmedetomidine was initiated. Dexmedetomidine was started on median ICU day 3 (25th -75th percentiles: 2-7) and had a median treatment duration of 3 days (25th -75th percentiles: 3-6) and a mean average rate of 0.62 mcg/kg/h (SD 0.25). Although hypotension (76%) and bradycardia (54%) were common, only one patient required intervention. The proportion of patients with at least one episode of agitation decreased from 100% on day 0, to 88%, 69% and 63% on days 1, 2 and 3 of dexmedetomidine, respectively. The decrease was statistically significant difference between days 0 and 2 as well as between days 0 and 3. Concomitant use of propofol and benzodiazepines also decreased over the course of dexmedetomidine treatment. CONCLUSION Dexmedetomidine use was safe and associated with a reduction in agitation in traumatic brain injury patients in the 96 hours following its initiation.
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Affiliation(s)
| | - Mar Saavedra-Mitjans
- Faculté de pharmacie, Université de Montréal, Montreal, Canada.,Research center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Canada
| | - Anne Julie Frenette
- Faculté de pharmacie, Université de Montréal, Montreal, Canada.,Research center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Canada
| | - Lisa Burry
- Pharmacy Department, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Martin Albert
- Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada.,Department of Medicine, Faculté de médecine, Université de Montréal, Montreal, Canada
| | - Francis Bernard
- Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada.,Department of Medicine, Faculté de médecine, Université de Montréal, Montreal, Canada
| | - David R Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, Canada.,Research center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Canada
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13
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Williamson DR, Cherifa SI, Frenette AJ, Saavedra Mitjans M, Charbonney E, Cataford G, Williams V, Lainer Palacios J, Burry L, Mehta S, Arbour C, Bernard F. Agitation, confusion, and aggression in critically ill traumatic brain injury-a pilot cohort study (ACACIA-PILOT). Pilot Feasibility Stud 2020; 6:193. [PMID: 33308318 PMCID: PMC7729148 DOI: 10.1186/s40814-020-00736-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/30/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Agitated behaviors are problematic in intensive care unit (ICU) patients recovering from traumatic brain injury (TBI) as they create substantial risks and challenges for healthcare providers. To date, there have been no studies evaluating their epidemiology and impact in the ICU. Prior to planning a multicenter study, assessment of recruitment, feasibility, and pilot study procedures is needed. In this pilot study, we aimed to evaluate the feasibility of conducting a large multicenter prospective cohort study. METHODS This feasibility study recruited adult patients admitted to the ICU with TBI and an abnormal cerebral CT scan. In all patients, we documented Richmond Agitation Sedation Score (RASS) and agitated behaviors every 8-h nursing shift using a dedicated tool documenting 14 behaviors. Our feasibility objectives were to obtain consent from at least 2 patients per month; completion of screening logs for agitated behaviors by bedside nurses for more than 90% of 8-h shifts; completion of data collection in an average of 6 h or less; and obtain 6-month follow-up for surviving patients. The main clinical outcome was the incidence of agitation and individual agitated behaviors. RESULTS In total, 47 eligible patients were approached for inclusion and 30 (64% consent rate) were recruited over a 10-month period (3 patients/month). In total, 794 out of 827 (96%) possible 8-h periods of agitated behavior logs were completed by bedside nurses, with a median of 24 observations (IQR 28.0) per patient. During the ICU stay, 17 of 30 patients developed agitation (56.7%; 95% CI 0.37-0.75) defined as RASS ≥ 2 during at least one observation period and for a median of 4 days (IQR 5.5). At 6 months post-TBI, among the 24 available patients, an unfavorable score (GOS-E < 5 including death) was reported in 12 patients (50%). In the 14 patients who were alive and available at 6 months, the median QOLIBRI score was 74.5 (IQR 18.5). CONCLUSIONS This study demonstrates the feasibility of conducting a larger cohort study to evaluate the epidemiology and impact of agitated behaviors in critically ill TBI patients. This study also shows that agitated behaviors are frequent and are associated with adverse events.
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Affiliation(s)
- David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada. .,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada. .,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.
| | - Sofia Ihsenne Cherifa
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Mar Saavedra Mitjans
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Emmanuel Charbonney
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Gabrielle Cataford
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Virginie Williams
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Julia Lainer Palacios
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Pharmacy Department, Mount Sinai Hospital, Toronto, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Arbour
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de sciences infirmières, Université de Montréal, Montréal, Canada
| | - Francis Bernard
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
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Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia. Arch Phys Med Rehabil 2020; 102:378-385. [PMID: 32745545 DOI: 10.1016/j.apmr.2020.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). DESIGN Prospective longitudinal study. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. RESULTS Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. CONCLUSIONS The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Hicks AJ, Mortimer D, Ponsford JL. Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial. Trials 2020; 21:662. [PMID: 32690072 PMCID: PMC7370410 DOI: 10.1186/s13063-020-04553-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Agitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management. Methods Fifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured. Discussion This trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population. Trial registration ANZCTR ACTRN12619000284167. Registered on 25 February 2019
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia. .,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia. .,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.
| | - Adam McKay
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.,Department of Psychology, Epworth HealthCare, 29 Erin Street, Richmond, Victoria, 3121, Australia
| | - John Olver
- Rehabilitation Medicine, Epworth HealthCare, 89 Bridge Rd, Richmond, Victoria, 3121, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade, Parkville, Victoria, 3052, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, 31 Albert Rd, Melbourne, Victoria, 3004, Australia
| | - Amelia J Hicks
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Building H, Level 5, Caulfield Campus, Clayton, Victoria, 3145, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
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Evidence for the management of challenging behaviours in patients with acute traumatic brain injury or post-traumatic amnesia: An Umbrella Review. BRAIN IMPAIR 2020. [DOI: 10.1017/brimp.2020.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractObjective:To synthesise the current best evidence on both pharmacological and non-pharmacological behaviour management interventions for adult patients in the acute hospital setting with traumatic brain injury (TBI) or post-traumatic amnesia (PTA).Data Sources:A comprehensive search of 10 electronic databases was completed.Study Selection:Systematic reviews (SRs) published in English before September 2018 were included. Initial search resulted in 4604 citations, 2916 for title and abstract screening with duplicates removed, and 2909 articles failed to meet the inclusion criteria leaving seven reviews for inclusion. Five reporting pharmacological management approaches, two reporting non-pharmacological management approaches, and one reporting both pharmacological and non-pharmacological management approaches.Data Extraction:Methodological quality was assessed independently by two reviewers using the Critical Appraisal Skills Programme Tool for SRs. Data were extracted from the studies based on the recommendations of the Joanna Briggs Institute (JBI) Methodology for JBI Umbrella Reviews.Data Synthesis:The SRs were of low-to-moderate quality overall. High-quality SRs were characterised by low numbers of studies and significant biases. The evidence relating to pharmacological interventions demonstrates low level and variable quality. The evidence relating to non-pharmacological interventions was limited and of low quality.Conclusions:The current evidence for the management of challenging behaviours in patients with acute TBI/PTA is generally equivocal, potentially reflecting the heterogeneity of patients with TBI and their clinical behaviours. More studies with rigorous methodologies are required to investigate the most suitable pharmacological and non-pharmacological behavioural interventions for the acute phase of TBI or PTA.
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Abstract
OBJECTIVES Severe brain injury is often accompanied by painful comorbidities and by concurrent limitations in the ability to report pain. Assessment of nociception aids diagnosis and helps balance reduction in suffering with avoidance of sedating medications. Existing assessment methods confound patients' level of consciousness with the intensity of nociception, complicating pain assessment as consciousness evolves. We sought to develop a measure of nociception that is independent of the level of consciousness. MATERIALS AND METHODS We identified 15 behavioral and physiological items likely to be sensitive to nociception. We rated noncommunicative patients with traumatic brain injury in 4 different activities predicted to modulate nociception, on each of 2 days, one randomly chosen for acetaminophen administration. The level of consciousness and level of agitation were also measured. RASCH ANALYSIS Rasch analysis was used to assess item fit to an underlying dimension of nociception. RESULTS Five items that demonstrated poor fit to the dimension were removed. The 10 remaining items demonstrated acceptable fit. Scores were significantly influenced by activity and analgesic treatment and were largely independent of measures of consciousness and agitation. Accurate scores could be obtained in about 10 minutes and were robust to missing data. DISCUSSION The results provide evidence that the Brain Injury Nociception Assessment Measure (BINAM) is reliable and feasible to administer. It can assess the intensity of nociception largely independent of the level of consciousness. Further research is warranted on the impact of BINAM use on the care of patients with severe traumatic brain injury.
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Reznik ME, Mahta A, Schmidt JM, Frey HP, Park S, Roh DJ, Agarwal S, Claassen J. Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2019; 29:33-39. [PMID: 29313314 DOI: 10.1007/s12028-017-0491-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Agitation is common after subarachnoid hemorrhage (SAH) and may be independently associated with outcomes. We sought to determine whether the duration of agitation and fluctuating consciousness were also associated with outcomes in patients with SAH. METHODS We identified all patients with positive Richmond Agitation Sedation Scale (RASS) scores from a prospective observational cohort of patients with SAH from 2011 to 2015. Total duration of agitation was extrapolated for each patient using available RASS scores, and 24-h mean and standard deviation (SD) of RASS scores were calculated for each patient. We also calculated each patient's duration of substantial fluctuation of consciousness, defined as the number of days with 24-h RASS SD > 1. Patients were stratified by 3-month outcome using the modified Rankin scale, and associations with outcome were assessed via logistic regression. RESULTS There were 98 patients with at least one positive RASS score, with median total duration of agitation 8 h (interquartile range [IQR] 4-18), and median duration of substantially fluctuating consciousness 2 days (IQR 1-3). Unfavorable 3-month outcome was significantly associated with a longer duration of fluctuating consciousness (odds ratio [OR] per day, 1.51; 95% confidence interval [CI], 1.04-2.20; p = 0.031), but a briefer duration of agitation (OR per hour, 0.94; 95% CI, 0.89-0.99; p = 0.031). CONCLUSION Though a longer duration of fluctuating consciousness was associated with worse outcomes in our cohort, total duration of agitation was not, and may have had the opposite effect. Our findings should therefore challenge the intensity with which agitation is often treated in SAH patients.
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Affiliation(s)
- Michael E Reznik
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - J Michael Schmidt
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Hans-Peter Frey
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - David J Roh
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA.
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Williamson D, Frenette AJ, Burry LD, Perreault M, Charbonney E, Lamontagne F, Potvin MJ, Giguère JF, Mehta S, Bernard F. Pharmacological interventions for agitated behaviours in patients with traumatic brain injury: a systematic review. BMJ Open 2019; 9:e029604. [PMID: 31289093 PMCID: PMC6615826 DOI: 10.1136/bmjopen-2019-029604] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI). METHODS We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured. RESULTS Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits. CONCLUSIONS Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed. PROSPERO REGISTRATION NUMBER CRD42016033140.
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Affiliation(s)
- David Williamson
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | - Lisa D Burry
- Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, Ontario, Canada
| | - Marc Perreault
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Marie-Julie Potvin
- Psychology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Jean-Francois Giguère
- Neurosurgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
- Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francis Bernard
- Médecine, Université de Montréal, Montreal, Quebec, Canada
- Critical Care, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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Armstrong M, Champagne J, Mortimer DS. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Inpatient Rehabilitation Management of Combat-Related Polytrauma. Phys Med Rehabil Clin N Am 2018; 30:13-27. [PMID: 30470417 DOI: 10.1016/j.pmr.2018.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Traumatic brain injury (TBI) is one of the signature injuries of Operation Iraqi Freedom and Operation Enduring Freedom. To ensure that rehabilitation care needs of veterans and active duty servicemembers with TBI and polytrauma injuries were met, the Department of Veterans Affairs (VA) established the Polytrauma System of Care (PSC) in 2005. The 5 VA Polytrauma Rehabilitation Centers provide tertiary, acute inpatient rehabilitation for the PSC. Interdisciplinary treatment teams of multiple rehabilitation disciplines provide the complex, patient-centered care to achieve maximum benefit. After discharge, veterans and servicemembers with TBI and polytrauma receive lifelong support and care through the PSC.
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Affiliation(s)
- Michael Armstrong
- Department of Physical Medicine and Rehabilitation, Minneapolis VA Health Care System, University of Minnesota, 1 Veterans Drive (117), Minneapolis, MN 55417, USA.
| | - Julie Champagne
- Polytrauma Transitional Rehabilitation, Minneapolis VA Health Care System, 1 Veterans Drive (117), Minneapolis, MN 55417, USA
| | - Diane Schretzman Mortimer
- Department of Physical Medicine and Rehabilitation, Polytrauma Network Site, Minneapolis VA Health Care System, 1 Veterans Drive (117), Minneapolis, MN 55417, USA
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Agitated Behavior and Activities of Daily Living Retraining During Posttraumatic Amnesia. J Head Trauma Rehabil 2018; 33:317-325. [DOI: 10.1097/htr.0000000000000363] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hicks AJ, Clay FJ, Hopwood M, James AC, Jayaram M, Batty R, Perry LA, Ponsford JL. Efficacy and Harms of Pharmacological Interventions for Neurobehavioral Symptoms in Post-Traumatic Amnesia after Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2018; 35:2755-2775. [PMID: 29969935 DOI: 10.1089/neu.2018.5738] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Many individuals in post-traumatic amnesia (PTA) following traumatic brain injury (TBI) experience neurobehavioral symptoms (NBS) in addition to disorientation and amnesia. These symptoms are associated with low rehabilitation engagement, self-inflicted harm, and risk of violence. The aim of this systematic review was to evaluate the efficacy and harms of pharmacological interventions for NBS in PTA following TBI in adults. Studies in English published before December 2017 were reviewed. Six databases were searched, with additional hand searching of key journals, clinical trials registries, and international drug regulators. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Thirteen studies were identified: three randomized controlled trials (RCTs), three cohort studies, and seven case series. In the RCTs, neither amantadine nor sertraline reduced NBS. Less rigorous studies reported reduced NBS in patients administered haloperidol, ziprasidone, carbamazepine, amitriptyline, desipramine, and varied neuroleptics. There is a paucity of well-designed, adequately powered and controlled studies of pharmacological interventions for NBS in PTA. More research is needed to provide evidence-based treatment recommendations and improve care.
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Affiliation(s)
- Amelia J Hicks
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Fiona J Clay
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia .,3 Department of Forensic Medicine, Monash University, Southbank, Melbourne, Australia .,4 Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia .,4 Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Amelia C James
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Mahesh Jayaram
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Luke A Perry
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
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Sauvigny T, Mohme M, Grensemann J, Dührsen L, Regelsberger J, Kluge S, Schmidt NO, Westphal M, Czorlich P. Rate and risk factors for a hyperactivity delirium in patients with aneurysmal subarachnoid haemorrhage. Neurosurg Rev 2018; 42:481-488. [DOI: 10.1007/s10143-018-0990-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 05/30/2018] [Indexed: 11/30/2022]
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McKay A, Love J, Trevena-Peters J, Gracey J, Ponsford J. The relationship between agitation and impairments of orientation and memory during the PTA period after traumatic brain injury. Neuropsychol Rehabil 2018; 30:579-590. [DOI: 10.1080/09602011.2018.1479276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Adam McKay
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
- Department of Psychology, Epworth HealthCare, Melbourne, Australia
| | - Jasmine Love
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jessica Trevena-Peters
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
| | - Jacinta Gracey
- Department of Psychology, Epworth HealthCare, Melbourne, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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Reznik ME, Schmidt JM, Mahta A, Agarwal S, Roh DJ, Park S, Frey HP, Claassen J. Agitation After Subarachnoid Hemorrhage: A Frequent Omen of Hospital Complications Associated with Worse Outcomes. Neurocrit Care 2018; 26:428-435. [PMID: 28008563 DOI: 10.1007/s12028-016-0331-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Agitated delirium is frequent following acute brain injury, but data are limited in patients with subarachnoid hemorrhage (SAH). We examined incidence, risk factors, and consequences of agitation in these patients in a single-center retrospective study. METHODS We identified all patients treated with antipsychotics or dexmedetomidine from a prospective observational cohort of patients with spontaneous SAH. Agitation was confirmed by chart review. Outcomes were assessed at 12 months using the modified Rankin Scale (mRS), Telephone Interview for Cognitive Status (TICS), and Lawton IADL (Instrumental Activities of Daily Living) scores. Independent predictors were identified using logistic regression. RESULTS From 309 SAH patients admitted between January 2011 and December 2015, 52 (17 %) developed agitation, frequently in the first 72 h (50 %) and in patients with Hunt-Hess grades 3-4 (12 % of grades 1-2, 28 % of grades 3-4, 8 % of grade 5). There was also a significant association between agitation and a history of cocaine use or prior psychiatric diagnosis. Agitated patients were more likely to develop multiple hospital complications; and in half of these patients, complications were diagnosed within 24 h of agitation onset. Agitation was associated with IADL impairment at 12 months (Lawton >8; p = 0.03, OR 2.7, 95 % CI, 1.1-6.8) in non-comatose patients (Hunt-Hess 1-4), but not with functional outcome (mRS >3), cognitive impairment (TICS ≤30), or ICU/hospital length of stay after controlling for other predictors. CONCLUSION Agitation occurs frequently after SAH, especially in non-comatose patients with higher clinical grades. It is associated with the development of multiple hospital complications and may have an independent impact on long-term outcomes.
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Affiliation(s)
- Michael E Reznik
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - J Michael Schmidt
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - Ali Mahta
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - David J Roh
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - Hans Peter Frey
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA
| | - Jan Claassen
- Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA.
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Williamson DR, Frenette AJ, Burry L, Perreault MM, Charbonney E, Lamontagne F, Potvin MJ, Giguère JF, Mehta S, Bernard F. Pharmacological interventions for agitation in patients with traumatic brain injury: protocol for a systematic review and meta-analysis. Syst Rev 2016; 5:193. [PMID: 27855720 PMCID: PMC5114826 DOI: 10.1186/s13643-016-0374-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a worldwide leading cause of mortality and disability. Among TBI complications, agitation is a frequent behavioural problem. Agitation causes potential harm to patients and caregivers, interferes with treatments, leads to unnecessary chemical and physical restraints, increases hospital length of stay, delays rehabilitation, and impedes functional independence. Pharmacological treatments are often considered for agitation management following TBI. Several types of agents have been proposed for the treatment of agitation. However, the benefit and safety of these agents in TBI patients as well as their differential effects and interactions are uncertain. In addition, animal studies and observational studies have suggested impaired cognitive function with the use of certain antipsychotics and benzodiazepines. Hence, a safe and effective treatment for agitation, which does not interfere with neurological recovery, remains to be identified. METHODS/DESIGN With the help of Health Sciences librarian, we will design a search strategy in the following databases: PubMed, Ovid MEDLINE®, EMBASE, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science, and Prospero. A grey literature search will be performed using the resources suggested in CADTH's Grey Matters. We will include all randomized controlled, quasi-experimental, and observational studies with control groups. The population of interest is all patients, including children and adults, who have suffered a TBI. We will include studies in which agitation, not further defined, was the presenting symptom or one of the presenting symptoms. We will also include studies where agitation was not the presenting symptom but was measured as an outcome variable and studies assessing the safety of these pharmacological interventions in TBI patients. We will include studies evaluating all pharmacological interventions including beta-adrenergic blockers, typical and atypical antipsychotics, anticonvulsants, dopamine agonists, psychostimulants, antidepressants, alpha-2-adrenergic agonists, hypnotics, and anxiolytics. DISCUSSION Although agitation is frequent following TBI and pharmacological agents that are often used, there is no consensus on the most efficacious and safest strategy to treat these complications. There is a need for an updated systematic review to summarize the evidence in order to inform practice and future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016033140.
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Affiliation(s)
- David R Williamson
- Pharmacy Department and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, Quebec, H4J 1C5, Canada. .,Faculté de pharmacie, Université de Montréal, Montréal, Canada.
| | - Anne Julie Frenette
- Pharmacy Department and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, Quebec, H4J 1C5, Canada.,Faculté de pharmacie, Université de Montréal, Montréal, Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Marc M Perreault
- Faculté de pharmacie, Université de Montréal, Montréal, Canada.,Department of Pharmacy, McGill University Health Center, Montréal, Canada
| | - Emmanuel Charbonney
- Department of Critical Care and Research Center, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada
| | - François Lamontagne
- Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada.,Faculté de Médecine, Université de Sherbrooke, Sherbrooke, Canada
| | - Marie-Julie Potvin
- Department of Psychology, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Department of Psychology, Université du Québec à Montréal, Montréal, Canada
| | - Jean-François Giguère
- Faculté de Médecine, Université de Montréal, Montréal, Canada.,Department of Neurosurgery, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Francis Bernard
- Department of Critical Care and Research Center, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada
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28
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Hellweg S, Schuster-Amft C. German version, inter- and intrarater reliability and internal consistency of the "Agitated Behavior Scale" (ABS-G) in patients with moderate to severe traumatic brain injury. Health Qual Life Outcomes 2016; 14:106. [PMID: 27431448 PMCID: PMC4950165 DOI: 10.1186/s12955-016-0511-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 07/13/2016] [Indexed: 11/17/2022] Open
Abstract
Background Agitation is frequently observed during early recovery after traumatic brain injury (TBI). Agitated behaviour often interferes with a goal-orientated rehabilitation and can be a substantial hindrance to therapy. Despite the relatively high occurance of agitation in TBI population there is no objective assessement in German (G) available. An existing scale with excellent psychometric properties is the “Agitated Behavior Scale (ABS)” developed by Corrigan in 1989. The aim of the study was to translate the Agitated Behavior Scale (ABS) into German (ABS-G) and investigate the inter- and intrarater reliability and internal consistency in patients with moderate to severe TBI. Methods A formal nine-step translation and cross-cultural adaptation procedure (TCCA) was applied. Subsequently a prospective observational patient study was conducted. To examine the interrater reliability and internal consistency, two therapists rated 20 patients independently after a therapy session. This procedure was repeated twice on a weekly basis. The intrarater reliability was assessed through video recordings from three patients. Nine raters scored the demonstrated behaviour on the videotape with the ABS-G independently twice within one month. The inter- and intrarater reliability were evaluated with the Spearman rank correlation coefficient and the quadratic weighted kappa. The internal consistency was tested with Cronbach’s alpha. Results Behaviour of 20 patients (18 males; mean age 41 ± 20.7; mean Functional Independence Measure (FIM) cognitive score on admission 7.1 ± 4.04; mean ABS-G score at first observation 17.3 ± 2.83) was assessed threefold. Interrater reliability yielded a correlation coefficient for ABS-G total score of all 60 paired observations of rs 0.845 and a weighted Kappa of 0.738. Intrarater reliability for ABS-G total score ranged between rs 0.719 and 0.953 and showed a weighted Kappa between 0.871 and 0.953. Cronbach’s alpha indicated moderate internal consistency with 0.661. Conclusion This study demonstrates that the ABS-G is a reliable instrument for evaluating agitation in patients with moderate to severe TBI. Hereby it would be possible to monitor agitation objectively and optimise the management of agitated patients according to international recommendations.
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Affiliation(s)
- Stephanie Hellweg
- Department of Neurological Rehabilitation, Rehaklinik Bellikon, Bellikon, 5454, Switzerland. .,Institute of Physiotherapy, School of Health Professions, Zurich University of Applied Sciences, Winterthur, 8400, Switzerland.
| | - Corina Schuster-Amft
- Research Department, Reha Rheinfelden, Salinenstrasse 98, Rheinfelden, 4310, Switzerland.,Institute for Rehabilitation and Performance Technology, Bern University of Applied Sciences, Pestalozzistrasse 20, Burgdorf, 3400, Switzerland
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29
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Lamontagne ME, Gagnon C, Allaire AS, Noreau L. A Scoping Review of Clinical Practice Improvement Methodology Use in Rehabilitation. Rehabil Process Outcome 2016. [DOI: 10.4137/rpo.s20360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Context The Clinical Practice Improvement (CPI) approach is a methodological and quality improvement approach that has emerged and is gaining in popularity. However, there is no systematic description of its use or the determinants of its practice in rehabilitation settings. Method We performed a scoping review of the use of CPI methodology in rehabilitation settings. Results A total of 103 articles were reviewed. We found evidence of 13 initiatives involving CPI with six different populations. A total of 335 citations of determinants were found, with 68.7% related to CPI itself. Little information was found about what type of external and internal environment, individual characteristics and implementation process might facilitate or hinder the use of CPI. Conclusion Given the growing popularity of this methodological approach, CPI initiatives would gain from increasing knowledge of the determinants of its success and incorporating them in future implementation.
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Affiliation(s)
- Marie-Eve Lamontagne
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, L'Institut de réadaptation en déficience physique de Québec, Québec, QC, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Cynthia Gagnon
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Groupe de recherche interdisciplinaire sur les maladies neuromusculaires (GRIMN), Neuromuscular Clinic, Centre de réadaptation en déficience physique de Jonquière, Centre de santé et de services sociaux de Jonquière, Jonquière, QC, Canada
| | - Anne-Sophie Allaire
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, L'Institut de réadaptation en déficience physique de Québec, Québec, QC, Canada
| | - Luc Noreau
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, L'Institut de réadaptation en déficience physique de Québec, Québec, QC, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, QC, Canada
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30
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Osier ND, Dixon CE. Catecholaminergic based therapies for functional recovery after TBI. Brain Res 2015; 1640:15-35. [PMID: 26711850 DOI: 10.1016/j.brainres.2015.12.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/15/2022]
Abstract
Among the many pathophysiologic consequences of traumatic brain injury are changes in catecholamines, including dopamine, epinephrine, and norepinephrine. In the context of TBI, dopamine is the one most extensively studied, though some research exploring epinephrine and norepinephrine have also been published. The purpose of this review is to summarize the evidence surrounding use of drugs that target the catecholaminergic system on pathophysiological and functional outcomes of TBI using published evidence from pre-clinical and clinical brain injury studies. Evidence of the effects of specific drugs that target catecholamines as agonists or antagonists will be discussed. Taken together, available evidence suggests that therapies targeting the catecholaminergic system may attenuate functional deficits after TBI. Notably, it is fairly common for TBI patients to be treated with catecholamine agonists for either physiological symptoms of TBI (e.g. altered cerebral perfusion pressures) or a co-occuring condition (e.g. shock), or cognitive symptoms (e.g. attentional and arousal deficits). Previous clinical trials are limited by methodological limitations, failure to replicate findings, challenges translating therapies to clinical practice, the complexity or lack of specificity of catecholamine receptors, as well as potentially counfounding effects of personal and genetic factors. Overall, there is a need for additional research evidence, along with a need for systematic dissemination of important study details and results as outlined in the common data elements published by the National Institute of Neurological Diseases and Stroke. Ultimately, a better understanding of catecholamines in the context of TBI may lead to therapeutic advancements. This article is part of a Special Issue entitled SI:Brain injury and recovery.
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Affiliation(s)
- Nicole D Osier
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, USA; School of Nursing, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - C Edward Dixon
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; V.A. Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
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31
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Hammond FM, Barrett RS, Shea T, Seel RT, McAlister TW, Kaelin D, Ryser DK, Corrigan JD, Cullen N, Horn SD. Psychotropic Medication Use During Inpatient Rehabilitation for Traumatic Brain Injury. Arch Phys Med Rehabil 2015. [PMID: 26212402 DOI: 10.1016/j.apmr.2015.01.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. DESIGN Prospective observational cohort. SETTING Multiple acute inpatient rehabilitation units or hospitals. PARTICIPANTS Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. CONCLUSIONS Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.
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Affiliation(s)
- Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University School of Medicine, Indianapolis, IN.
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, Salt Lake City, UT
| | | | - Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA
| | | | - Darryl Kaelin
- University of Louisville School of Medicine and Frazier Rehabilitation Institute, Louisville, KY
| | | | | | - Nora Cullen
- Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT
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