Efficacy and Harms of Pharmacological Interventions for Neurobehavioral Symptoms in Post-Traumatic Amnesia after Traumatic Brain Injury: A Systematic Review

Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting

PURPOSE

This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members.

MATERIALS AND METHODS

A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice.

RESULTS

Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information.

CONCLUSIONS

This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.

Cognition and Behavior in the Aging Brain Following TBI: Surveying the Preclinical Evidence

Elderly individuals (65 years and older) represent the fastest-growing demographic of new clinical traumatic brain injury (TBI) cases, yet there is a paucity of preclinical research in aged animals. The limited preclinical work available aligns with the clinical literature in that there appear to be significant differences in pathophysiology, recovery potential, and response to medications between animals at different points across the age spectrum. The aim of this review is to discuss the limited studies and highlight critical age-related differences in affective, cognitive, and neurobehavioral deficits, to discuss factors that influence functional outcomes, and to identify targets for future research. The consensus is that aged rodents face challenges related to dysregulated inflammation, reduced neuroplasticity, and age-related cellular changes, which hinder their recovery after TBI. The most successful intervention studies in animal models to date, of the limited array available, have explored interventions targeting inflammatory downregulation. Current standards of neuropsychopharmacology for post-TBI neurocognitive recovery have not been investigated in a significant capacity. In addition, currently available animal models do not sufficiently account for important age-related comorbidities, dual insults, or differences in TBI mechanism of injury in elderly individuals. TBI in the aged population is more likely to lead to additional neurodegenerative diseases that further complicate recovery. The findings underscore the need for tailored therapeutic interventions to improve outcomes in both adult and elderly populations.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms

BACKGROUND

Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk.

METHODS

Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias.

RESULTS

Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed.

CONCLUSIONS

Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias.

AIMS

This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study

BACKGROUND

Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings.

METHODS

Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting.

RESULTS

Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams.

CONCLUSION

These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Managing agitation during early recovery following traumatic brain injury: qualitative interviews with clinicians

PURPOSE

Agitated behaviours pose a significant challenge during early recovery following traumatic brain injury (TBI). This study aimed to gain a deeper understanding of how clinicians worldwide manage post-TBI agitation. Understanding the factors that influence how clinicians manage agitation can help inform the use of consistent and effective management strategies for reducing agitation in TBI care.

METHODS

Using a qualitative design, semi-structured interviews were conducted with 33 clinicians (58% female, aged 23-71 years) from 16 countries who had experience working with agitated patients. The interviews explored the approaches used to manage agitation during early TBI recovery.

RESULTS

Interviews were analysed using thematic analysis. The central theme of the interviews was the effective management of agitation, consisting of three sub-themes: managing the safety of staff and patients, reducing triggers for agitation, and implementing behavioural principles for managing agitation. Two overarching themes influenced the effective management of agitation: clinician-related factors and systemic factors.

CONCLUSIONS

This study highlighted key approaches for effective agitation management during early TBI recovery, as described by clinicians working with these patients worldwide. There were similarities in the strategies described, although there were many challenges that impeded the consistent implementation of such strategies in TBI care settings.

IMPLICATIONS FOR REHABILITATIONEffective management of agitation during early traumatic brain injury (TBI) recovery continues to pose a significant challenge for clinicians worldwide.Healthcare services may improve the management of agitation by involving the patient's family in care delivery and implementing low-cost less-restrictive non-pharmacological interventions to reduce reliance on pharmacological interventions.Proactively addressing and removing potential sources of agitation (patient-related and environmental) may help reduce the risk of agitation occurring.The use of simple behaviour management strategies may be effective for reducing agitation, but strategies need to be implemented consistently and the approach should be flexible and tailored to the patient.Clinicians should develop an understanding of a patient's premorbid behaviours and interests to best inform the management approach.Management of agitation may be improved by increasing clinicians' agency in responding to agitated behaviours, through the provision of information and resources, ongoing training and skill development, supervision and support.

Rehabilitation Care of the Child with an Acute Severe Traumatic Brain Injury

Children with traumatic brain injury (TBI) represent a unique and evolving population. Recovery and long-term prognosis are variable given the heterogeneity of ages, developmental stages, and types of injuries. This article summarizes important information regarding severe TBI epidemiology, pathophysiology, classification, and acute management. Early and longitudinal involvement of rehabilitation experts, such as pediatric physiatrists, is critical in managing complications and optimizing outcomes.

Adamantanes for the treatment of neurodegenerative diseases in the presence of SARS-CoV-2

Advent of the acute respiratory coronavirus SARS-CoV-2 has resulted in the search for novel antiviral agents and in the repurposing of existing agents with demonstrated efficacy against other known coronaviruses in the search for an agent with antiviral activity for use during the COVID-19 pandemic. Adamantanes including amantadine, rimantadine, and memantine have well-established benefit in the treatment of neurodegenerative diseases including Parkinson's disease (PD), Alzheimer's disease (AD) and fatigue related to Multiple sclerosis (MS) all of which are known comorbidities related to COVID-19 Moreover, results of basic pharmacological studies both in vitro and in vivo reveal that amantadine has the potential to inhibit SARS-CoV-2 via down-regulation of host-cell proteases resulting in impaired viral genome release into the host cell and via amantadine's property as an NMDA receptor antagonist resulting in the prevention of the acute lung injury and respiratory distress that is characteristic of COVID-19. Cases suggestive of COVID-19 prophylaxis have been reported in patients with PD or MS or severe cognitive impairment treated in all cases for several months with an adamantane [amantadine or memantine] who were subsequently infected with SARS-CoV-2 confirmed by RT-PCR, and, in all cases, no signs of infectious disease were encountered. Amantadine is effective for the treatment of fatigue in MS and for the neurological complications of Traumatic Brain Injury (TBI).

Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials

Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles

INTRODUCTION

Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI.

METHODS

The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices.

RESULTS

In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.

CONCLUSIONS

Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.

Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury

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.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

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.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

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.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

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

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.

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury

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.

Managing agitation during early recovery in adults with traumatic brain injury: An international survey

BACKGROUND

Managing agitation is a significant challenge in the early stages of recovery after traumatic brain injury (TBI), and research investigating current practice during this period is lacking.

OBJECTIVES

This study examined how clinicians worldwide conceptualise, measure and manage agitation during early TBI recovery.

METHODS

A cross-sectional anonymous online survey was distributed via email, newsletters, conferences and social media to clinicians involved in early TBI care worldwide. Respondents were 331 clinicians (66% female) from 34 countries worldwide who worked in inpatient and outpatient settings in disciplines including medicine, nursing and allied health. Participants had an average of 13 years' clinical experience working specifically with an adult TBI population.

RESULTS

Agitated behaviour was commonly defined as aggression and restlessness. Three quarters of clinicians reported that their services measure agitation, and clinicians in North America more frequently use standardised assessment tools. Common non-pharmacological approaches used across all regions surveyed included providing familiarising information (85%) and environmental cues (82%), managing patients in single rooms (81%) and reducing noise levels (80%). Most clinicians (90%) reported pharmacology use, particularly atypical antipsychotic agents. Clinicians' mean rating of confidence in managing agitation was 7 out of 10 (10 being excellent) and was higher for services that provided staff with written guidelines for agitation management. Only half of clinicians reported sufficient training for managing agitation and 52% were satisfied with current agitation management practices.

CONCLUSIONS

Despite high rates of agitation measurement and management, many clinicians reported dissatisfaction with current agitation management and insufficient training. This study supports the development of international guidelines and training to ensure consistent and effective agitation management in early TBI care.

Assessment and Management of Patients in the Acute Stages of Recovery after Traumatic Brain Injury in Adults: A Worldwide Survey

Most individuals with traumatic brain injury (TBI) experience a period of confusion after emergence from coma, termed post-traumatic amnesia, post-traumatic confusional state, or delirium. Recent guidelines suggest the importance of assessment and consistent management during this phase, but current practice worldwide remains unknown. This survey aimed to elucidate current international practice in assessment and treatment of patients in the acute stages of recovery after TBI. The web-based survey was distributed to clinicians working with patients with acute TBI. There were 400 participants (68.8% females), from 41 countries, mostly neuropsychologists, rehabilitation physicians, and occupational therapists (OTs), with an average 12.8 years of experience. Of those working with adults (n = 376, 94%), most described this acute period as post-traumatic amnesia and used its duration to indicate injury severity. More than 85% used a tool to assess patients; in order of frequency, the Glasgow Coma Scale (GCS), Westmead PTA Scale (WPTAS), Galveston Orientation and Amnesia Test, Rancho Los Amigos Scale, and O-Log. Meeting criteria on the assessment tool or clinical judgment determined emergence from this phase, indicated by recovery of orientation, day-to-day memories, and ability to follow commands or participate in rehabilitation. Most patients had physiotherapy, OT, speech therapy, and environmental changes, with a third of participants indicating sedating medication was prescribed during this phase. Findings suggest that, consistent with guidelines, PTA is a widely recognized and measured TBI recovery phase, used to determine injury severity and readiness for therapy.

Effectiveness of non-pharmacological interventions for managing agitation during post-traumatic amnesia following traumatic brain injury: a systematic review protocol

OBJECTIVE

To synthesize current evidence on the effects and harms of non-pharmacological interventions for managing agitation during post-traumatic amnesia in adults who have sustained a traumatic brain injury.

INTRODUCTION

Agitation is one of the most disruptive and clinically significant sequelae observed during post-traumatic amnesia. Patients who experience agitation during this period demonstrate reduced engagement in rehabilitation and poorer long-term functional outcomes. Agitation also poses a risk to staff and patient safety. Research for the effects of pharmacological intervention for managing agitation during this period is inconclusive. Thus, synthesis of the research for non-pharmacological interventions for reducing agitation during post-traumatic amnesia is essential for improving long-term outcomes for survivors of traumatic brain injury.

INCLUSION CRITERIA

Studies will be considered if they include participants aged 16 years and older who exhibit agitated behaviors during post-traumatic amnesia after sustaining a traumatic brain injury (irrespective of severity or mechanism). Studies will be considered if they evaluate any non-pharmacological intervention for reducing agitation, with all types of comparators accepted. Primary outcomes of interest include a change in agitation severity and any adverse effects.

METHODS

Key information sources include MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO, and Cochrane CENTRAL. Studies published in English will be included, irrespective of publication year. Two independent reviewers will be involved in study selection and data extraction. Eligible studies will be critically appraised for methodological quality. Studies will be pooled with statistical meta-analysis where possible; otherwise findings will be reported in narrative form.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020186802.

Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial

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

Evidence for the management of challenging behaviours in patients with acute traumatic brain injury or post-traumatic amnesia: An Umbrella Review

Objective:

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.