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Carrier SL, Ponsford J, McKay A. Family experiences of supporting a relative with agitation during early recovery after traumatic brain injury. Neuropsychol Rehabil 2024; 34:510-534. [PMID: 37332244 DOI: 10.1080/09602011.2023.2219064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
During the early recovery period after traumatic brain injury (TBI), referred to as post-traumatic amnesia (PTA), approximately 44% of individuals may exhibit agitated behaviours. Agitation can impede recovery and poses a significant management challenge for healthcare services. As families provide significant support for their injured relatives during this time, this study aimed to explore the family's experience during PTA to better understand their role in agitation management. There were 20 qualitative semi-structured interviews conducted with 24 family members of patients exhibiting agitation during early TBI recovery (75% female, aged 30-71 years), predominantly parents (n = 12), spouses (n = 7) and children (n = 3). The interviews explored the family's experience of supporting their relative exhibiting agitation during PTA. The interviews were analyzed using reflexive thematic analysis, which revealed three key themes: family contributions to patient care, expectations of the health care service and supporting families to support patients. This study emphasized the significant role of families in managing agitation during early TBI recovery and highlighted that families who are well-informed and well-supported have the potential to minimize their relative's agitation during PTA, which may reduce the burden on healthcare staff and promote patient recovery.
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Affiliation(s)
- Sarah L Carrier
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, 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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Saavedra-Mitjans M, Van der Maren S, Gosselin N, Duclos C, Frenette AJ, Arbour C, Burry L, Williams V, Bernard F, Williamson DR. Use of actigraphy for monitoring agitation and rest-activity cycles in patients with acute traumatic brain injury in the ICU. Brain Inj 2024:1-7. [PMID: 38635547 DOI: 10.1080/02699052.2024.2341323] [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: 11/10/2023] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND In traumatic brain injury patients (TBI) admitted to the intensive care unit (ICU), agitation can lead to accidental removal of catheters, devices as well as self-extubation and falls. Actigraphy could be a potential tool to continuously monitor agitation. The objectives of this study were to assess the feasibility of monitoring agitation with actigraphs and to compare activity levels in agitated and non-agitated critically ill TBI patients. METHODS Actigraphs were placed on patients' wrists; 24-hour monitoring was continued until ICU discharge or limitation of therapeutic efforts. Feasibility was assessed by actigraphy recording duration and missing activity count per day. RESULTS Data from 25 patients were analyzed. The mean number of completed day of actigraphy per patient was 6.5 ± 5.1. The mean missing activity count was 20.3 minutes (±81.7) per day. The mean level of activity measured by raw actigraphy counts per minute over 24 hours was higher in participants with agitation than without agitation. CONCLUSIONS This study supports the feasibility of actigraphy use in TBI patients in the ICU. In the acute phase of TBI, agitated patients have higher levels of activity, confirming the potential of actigraphy to monitor agitation.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
| | - Solenne Van der Maren
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Département de Psychologie, Université de Montréal, Montréal (Québec), Canada
| | - Nadia Gosselin
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Département de Psychologie, Université de Montréal, Montréal (Québec), Canada
| | - Catherine Duclos
- Center for Advanced Research in Sleep Medicine, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Department of Anesthesiology and Pain Medicine, Department of Neuroscience, Faculté de médecine, Université de Montréal, Montréal (Québec), Canada
- CIFAR Azrieli Global Scholars Program, Toronto, Canada
| | - Anne Julie Frenette
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
- Pharmacy Department, Centre intégré universitaire de santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
| | - Caroline Arbour
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Faculté de Sciences Infirmières, Université de Montréal, Montréal (Québec), Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Virginie Williams
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
| | - Francis Bernard
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Faculté de Médecine, Université de Montréal, Montréal (Québec), Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal (Québec), Canada
- Research Centre, Centre intégré universitaire de Santé et de Services sociaux du Nord-de-l'île-de-Montréal, Montreal, Canada
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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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Block H, Bellon M, Hunter SC, George S. Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study. BMC Health Serv Res 2023; 23:1266. [PMID: 37974214 PMCID: PMC10655469 DOI: 10.1186/s12913-023-10279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
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.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia.
- Division of Allied Health, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia.
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
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Block H, George S, Hunter SC, Bellon M. Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting. Disabil Rehabil 2023:1-10. [PMID: 37970816 DOI: 10.1080/09638288.2023.2280081] [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: 06/12/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, 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
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Carrier SL, Ponsford J, McKay A. Managing agitation during early recovery following traumatic brain injury: qualitative interviews with clinicians. Disabil Rehabil 2023; 45:3686-3695. [PMID: 36282105 DOI: 10.1080/09638288.2022.2135771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 10/02/2022] [Accepted: 10/09/2022] [Indexed: 11/03/2022]
Abstract
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.
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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
| | - 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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Race NS, Moschonas EH, Cheng JP, Bondi CO, Kline AE. Antipsychotic Drugs: The Antithesis to Neurorehabilitation in Models of Pre-Clinical Traumatic Brain Injury. Neurotrauma Rep 2023; 4:724-735. [PMID: 37928134 PMCID: PMC10621671 DOI: 10.1089/neur.2023.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Sixty-nine million traumatic brain injuries (TBIs) are reported worldwide each year, and, of those, close to 3 million occur in the United States. In addition to neurobehavioral and cognitive deficits, TBI induces other maladaptive behaviors, such as agitation and aggression, which must be managed for safe, accurate assessment and effective treatment of the patient. The use of antipsychotic drugs (APDs) in TBI is supported by some expert guidelines, which suggests that they are an important part of the pharmacological armamentarium to be used in the management of agitation. Despite the advantages of APDs after TBI, there are significant disadvantages that may not be fully appreciated clinically during decision making because of the lack of a readily available updated compendium. Hence, the aim of this review is to integrate the existing findings and present the current state of APD use in pre-clinical models of TBI. The studies discussed were identified through PubMed and the University of Pittsburgh Library System search strategies and reveal that APDs, particularly those with dopamine2 (D2) receptor antagonism, generally impair the recovery process in rodents of both sexes and, in some instances, attenuate the potential benefits of neurorehabilitation. We believe that the compilation of findings represented by this exhaustive review of pre-clinical TBI + APD models can serve as a convenient source for guiding informed decisions by critical care clinicians and physiatrists contemplating APD use for patients exhibiting agitation.
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Affiliation(s)
- Nicholas S. Race
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Association of Academic Physiatrists Rehabilitation Medicine Scientist Training Program, Owings Mills, Maryland, USA
| | - Eleni H. Moschonas
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P. Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Corina O. Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony E. Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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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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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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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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Kalra ID, Watanabe TK. Enhancing management of agitation after traumatic brain injury: Psychiatric perspectives and quantitative assessments. NeuroRehabilitation 2023; 53:177-185. [PMID: 37694312 DOI: 10.3233/nre-230009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Post-traumatic agitation is a common and problematic complication after traumatic brain injury. It may present with features consistent with psychiatric disorders, which may provide clues as to management. OBJECTIVE This is a narrative review of pertinent literature and a description of a collaborative clinical approach utilizing psychiatric and brain injury rehabilitation strategies to optimize outcomes in the management of post-traumatic agitation. METHODS Describe and provide evidence for a transdisciplinary clinical approach supported by existing literature and clinical experience. RESULTS Given the heterogeneity of the problem and limitations in the current literature there is no standardized approach to manage post-traumatic agitation; nevertheless, a strategy is proposed that clinicians may utilize to guide treatment and assess efficacy of the chosen intervention(s). CONCLUSION A clinical approach that uses quantitative assessment of targeted behavior to objectively evaluate pharmacological interventions that are generated by a collaborative approach may yield improved outcomes for managing post-traumatic agitation.
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Affiliation(s)
- Inder D Kalra
- Department of Psychiatry, Einstein Healthcare Network, Elkins Park, PA, USA
| | - Thomas K Watanabe
- Department of Physical Medicine and Rehabilitation, MossRehab at Elkins Park, Einstein Healthcare Network, Elkins Park, PA, USA
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12
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Ponsford M, Ponsford JL. Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials. J Neurotrauma 2023; 40:33-51. [PMID: 35833454 DOI: 10.1089/neu.2022.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, Melbourne, Australia
| | - Michael Ponsford
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
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13
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Garrote-Cámara ME, Gea-Caballero V, Sufrate-Sorzano T, Rubinat-Arnaldo E, Santos-Sánchez JÁ, Cobos-Rincón A, Santolalla-Arnedo I, Juárez-Vela R. Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15972. [PMID: 36498042 PMCID: PMC9735933 DOI: 10.3390/ijerph192315972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.
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Affiliation(s)
- María Elena Garrote-Cámara
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Vicente Gea-Caballero
- Research Group on Community Health and Care, Faculty of Health Science, Valencia International University, 46002 Valencia, Spain
| | - Teresa Sufrate-Sorzano
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Esther Rubinat-Arnaldo
- Society, Health, Education and Culture Study Group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, 25003 Lleida, Spain
| | | | - Ana Cobos-Rincón
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Iván Santolalla-Arnedo
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Raúl Juárez-Vela
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
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14
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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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15
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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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16
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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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17
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Spiteri C, Williams G, Kahn M, Ponsford J, McKay A. Factors Associated With Physical Therapy Engagement During the Period of Posttraumatic Amnesia. J Neurol Phys Ther 2022; 46:41-49. [PMID: 34628437 DOI: 10.1097/npt.0000000000000380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue. SUMMARY OF KEY POINTS The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions. RECOMMENDATIONS FOR CLINICAL PRACTICE Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).
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Affiliation(s)
- Courtney Spiteri
- Monash University, Clayton, Victoria, Australia (C.S., J.P., A.M.); Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Victoria, Australia (C.S., J.P., A.M.); Epworth Healthcare, Richmond, Victoria, Australia (G.W., M.K.); and University of Melbourne, Parkville, Victoria, Australia (G.W.)
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18
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Garrote-Cámara ME, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Gea-Caballero V, Sufrate-Sorzano T, del Pozo-Herce P, Garrido-García R, Rubinat-Arnaldo E, Juárez Vela R. Psychometric Characteristics and Sociodemographic Adaptation of the Corrigan Agitated Behavior Scale in Patients With Severe Mental Disorders. Front Psychol 2021; 12:779277. [PMID: 34955998 PMCID: PMC8693627 DOI: 10.3389/fpsyg.2021.779277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Severe mental disorder (SMD) is understood in a first approximation as a disorder of thought, emotion, or behavior of long duration, which entails a variable degree of disability and social dysfunction. One of the most widely used assessment scales for agitated behavior, in its English version, is the Corrigan Agitated Behavior Scale (ABS); several studies have demonstrated solid psychometric properties of the English version, with adequate internal consistency. Objective: The objective of this study was to evaluate the psychometric properties of the Spanish version of the ABS Corrigan scale, in a sample of patients with severe mental disorders. The psychometric analyses of the Spanish version of the ABS Corrigan included tests of the reliability and validity of its internal structure. Results: The structure of the factorial loads of the analyzed elements is consistent with the hypothesized three-dimensional construction referred to in the original ABS. The results suggest that the reliability and validity of the three dimensions are acceptable (First 0.8, Second 0.8, and Third 0.7). The internal consistency of the Spanish version of the complete ABS and of each of the three domains that compose it is high, with values very close to those found in the original version, with approximate figures of 0.9. Conclusion: In our study, the three domains aim to explain 64.1% of the total variance of the scale, which exceeds the 50% found in the original version.
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Affiliation(s)
- María Elena Garrote-Cámara
- Mental Health Center of Albelda de Iregua, Riojan Health Service, Government of La Rioja, La Rioja, Spain
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
| | - Iván Santolalla-Arnedo
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | - Regina Ruiz de Viñaspre-Hernández
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | | | - Teresa Sufrate-Sorzano
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | - Pablo del Pozo-Herce
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
- Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Rebeca Garrido-García
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
- Najera Health Center, Riojan Health Service, Government of La Rioja, La Rioja, Spain
| | - Esther Rubinat-Arnaldo
- Research Group of Health Care (GRECS) - IRBLleida, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Research Group Society, Health, Education and Culture (GESEC), University of Lleida, Lleida, Spain
- Center for Biomedical Research Network on Diabetes and Associated Metabolic Diseases (CIBERDEM), Carlos III Health Institute, Barcelona, Spain
| | - Raúl Juárez Vela
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
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19
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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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20
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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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21
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Egerod I, Poulsen I, Langhorn L, Aadal L. Inclusion, delivery, assessment, and outcomes in longitudinal research on sleep disturbance and agitation in TBI-rehabilitation: lessons learned and future considerations. Brain Inj 2021; 35:1616-1623. [PMID: 34550819 DOI: 10.1080/02699052.2021.1978546] [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: 10/20/2022]
Abstract
PURPOSE This article presents some issues for consideration before scaling from a pilot study to a larger investigation in longitudinal observational studies of traumatic brain injury (TBI) rehabilitation. MATERIALS AND METHODS We present a case to discuss protocol improvements in longitudinal TBI-rehabilitation studies. The case was a pilot study conducted at two university hospitals in Denmark investigating 1-year outcomes related to sleep disturbance and agitation during neurointensive care. We included patients with moderate and severe TBI determined by the Glasgow Coma Scale, sleep disturbance was assessed using actigraphy, and agitation was assessed using the Agitated Behavior Scale. RESULTS Patients (n = 29) were more severely ill and had poorer six-month outcomes in Eastern vs. Western Denmark. Recovery was similar at one-year follow-up. Protocol improvements were needed in relation to inclusion criteria, intervention delivery, patient assessment, and follow-up outcomes. CONCLUSION In TBI-rehabilitation studies, we suggest adding the severity of disease score to the initial GCS score and a delirium detection score to the ABS score. Actigraphy should not be used during deep sedation. Established procedures should be in place along all stages of the study protocol, including preparation and periodic assessment of study nurses to optimize data quality.
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Affiliation(s)
- Ingrid Egerod
- University of Copenhagen, Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark
| | - Ingrid Poulsen
- Copenhagen University Hospital, Rigshospitalet, Department of Neurorehabilitation, Hvidovre, Denmark
| | - Leanne Langhorn
- Aarhus University Hospital, Department of Anesthesiology and Intensive Care, Aarhus, Denmark
| | - Lena Aadal
- Hammel Neurorehabilitation and Research Center, Hammel, Denmark
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22
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Carrier SL, Hicks AJ, Ponsford J, McKay A. Managing agitation during early recovery in adults with traumatic brain injury: An international survey. Ann Phys Rehabil Med 2021; 64:101532. [PMID: 33933690 DOI: 10.1016/j.rehab.2021.101532] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
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.
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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.
| | - 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
| | - 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
| | - 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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23
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Rahmani E, Lemelle TM, Samarbafzadeh E, Kablinger AS. Pharmacological Treatment of Agitation and/or Aggression in Patients With Traumatic Brain Injury: A Systematic Review of Reviews. J Head Trauma Rehabil 2021; 36:E262-E283. [PMID: 33656478 DOI: 10.1097/htr.0000000000000656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To systematically review the available literature on the pharmacological management of agitation and/or aggression in patients with traumatic brain injury (TBI), synthesize the available data, and provide guidelines. DESIGN Systematic review of systematic reviews. MAIN MEASURES A literature review of the following websites was performed looking for systematic reviews on the treatment of agitation and/or aggression among patients with TBI: PubMed, CINAHL, DynaMed, Health Business Elite, and EBSCO (Psychology and behavioral sciences collection). Two researchers independently assessed articles for meeting inclusion/exclusion criteria. Data were extracted on year of publication, reviewed databases, dates of coverage, search limitations, pharmacological agents of interest, and a list of all controlled studies included. The included controlled studies were then examined to determine potential reasons for any difference in recommendations. RESULTS The literature review led to 187 citations and 67 unique publications after removing the duplicates. Following review of the title/abstracts and full texts, a total of 11 systematic reviews were included. The systematic reviews evaluated the evidence for safety and efficacy of the following medications: amantadine, amphetamines, methylphenidate, antiepileptics, atypical and typical antipsychotics, benzodiazepines, β-blockers, and sertraline. CONCLUSIONS On the basis of the results of this literature review, the authors recommend avoiding benzodiazepines and haloperidol for treating agitation and/or aggression in the context of TBI. Atypical antipsychotics (olanzapine in particular) can be considered as practical alternatives for the as-needed management of agitation and/or aggression in lieu of benzodiazepines and haloperidol. Amantadine, β-blockers (propranolol and pindolol), antiepileptics, and methylphenidate can be considered for scheduled treatment of agitation and/or aggression in patients with TBI.
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Affiliation(s)
- Elham Rahmani
- Department of Psychiatry and Behavioral Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina (Dr Rahmani); Georgetown University Hospital, Washington, District of Columbia (Dr Lemelle); Department of Psychiatry and Behavioral Medicine, Carilion Clinic-Virginia Tech Carilion School of Medicine, Raonoke, Virginia (Drs Kablinger and Samarbafzadeh)
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24
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Carrarini C, Russo M, Dono F, Barbone F, Rispoli MG, Ferri L, Di Pietro M, Digiovanni A, Ajdinaj P, Speranza R, Granzotto A, Frazzini V, Thomas A, Pilotto A, Padovani A, Onofrj M, Sensi SL, Bonanni L. Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions. Front Neurol 2021; 12:644317. [PMID: 33935943 PMCID: PMC8085397 DOI: 10.3389/fneur.2021.644317] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/12/2021] [Indexed: 01/11/2023] Open
Abstract
Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Rino Speranza
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Alberto Granzotto
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institute for Mind Impairments and Neurological Disorders-iMIND, University of California, Irvine, Irvine, CA, United States
| | - Valerio Frazzini
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié Salpêtrière Hospital, Paris, France.,AP-HP, GH Pitie-Salpêtrière-Charles Foix, Epilepsy Unit and Neurophysiology Department, Paris, France
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Parkinson's Disease Rehabilitation Centre, FERB ONLUS-S. Isidoro Hospital, Trescore Balneario, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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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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Ponsford J, Carrier S, Hicks A, McKay A. Assessment and Management of Patients in the Acute Stages of Recovery after Traumatic Brain Injury in Adults: A Worldwide Survey. J Neurotrauma 2020; 38:1060-1067. [PMID: 33121375 DOI: 10.1089/neu.2020.7299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - Sarah Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Amelia Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
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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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Carrier SL, Hicks AJ, Ponsford JL, McKay A. Effectiveness of non-pharmacological interventions for managing agitation during post-traumatic amnesia following traumatic brain injury: a systematic review protocol. JBI Evid Synth 2020; 19:499-512. [PMID: 33165180 DOI: 10.11124/jbies-20-00216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia
| | - Amelia J Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia
| | - Jennie L Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Vic, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Vic, Australia
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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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Prediction of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation. Int J Rehabil Res 2019; 42:256-262. [PMID: 31033582 DOI: 10.1097/mrr.0000000000000353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the survival rate of traumatic brain injury increases, the burden of care for patients with traumatic brain injury is emerging as a socioeconomic issue and the discharge destination is one of the important outcome measures in the post-acute rehabilitation unit. To investigate the predictors of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation. A retrospective review was performed on 86 patients who were admitted to the rehabilitation unit between January 2010 and June 2017. Multiple regression analysis was used as a statistical method to identify the factors affecting Modified Barthel Index and discharge destination. The number of days from traumatic brain injury onset to rehabilitation unit admission (odds ratio = 0.959, P = 0.049), brain surgery for traumatic brain injury management (odds ratio = 0.160, P = 0.021), initial Glasgow Coma Scale score (odds ratio = 1.269, P = 0.022) and Mini-Mental State Examination score at admission (odds ratio = 1.245, P < 0.001) were the predictive factors for higher Modified Barthel Index after rehabilitation. Underlying vascular risk factors (odds ratio = 0.138, P = 0.015), Modified Barthel Index score after rehabilitation (odds ratio = 1.085, P < 0.001) and deductible-free insurance (odds ratio = 0.211, P = 0.032) were the predictive factors of home discharge. The functional outcome of patients with traumatic brain injury after rehabilitation was related to the severity of initial injury, cognitive function at admission and rehabilitation timing. The discharge destination after rehabilitation was related to functional outcome, insurance issues and underlying vascular risk factors.
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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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Sharma R, Shultz SR, Robinson MJ, Belli A, Hibbs ML, O'Brien TJ, Semple BD. Infections after a traumatic brain injury: The complex interplay between the immune and neurological systems. Brain Behav Immun 2019; 79:63-74. [PMID: 31029794 DOI: 10.1016/j.bbi.2019.04.034] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/29/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a serious global health issue, being the leading cause of death and disability for individuals under the age of 45, and one of the largest causes of global neurological disability. In addition to the brain injury itself, it is increasingly appreciated that a TBI may also alter the systemic immune response in a way that renders TBI patients more vulnerable to infections in the acute post-injury period. Such infections pose an additional challenge to the patient, increasing rates of mortality and morbidity, and worsening neurological outcomes. Hospitalization, surgical interventions, and a state of immunosuppression induced by injury to the central nervous system (CNS), may all contribute to the high rate of infections seen in the population with TBI. Ongoing research to better understand the immunomodulators that underlie TBI-induced immunosuppression may aid in the development of effective therapeutic strategies to improve the recovery trajectory for patients. This review first describes the clinical scenario, posing the question of whether TBI patients are more susceptible to infections such as pneumonia, and if so, why? We then consider how cross-talk between the injured brain and the systemic immune system occurs, and further, how the additional immune challenge of an acquired infection can contribute to ongoing neuroinflammation and neurodegeneration after a TBI. Experimental models combining TBI with infection are discussed, as well as current treatment options available for this double-barreled insult. The aims of this review are to summarize current understanding of the bidirectional relationship between the CNS and the immune system when faced with a mechanical trauma combined with a concomitant infection, and to highlight key outstanding questions that remain in the field.
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Affiliation(s)
- Rishabh Sharma
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia
| | - Marcus J Robinson
- Department of Immunology and Pathology, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Antonio Belli
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Margaret L Hibbs
- Department of Immunology and Pathology, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia.
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36
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Oyesanya TO, Thomas MA. Strategies nurses use when caring for patients with moderate-to-severe traumatic brain injury who have cognitive impairments. J Clin Nurs 2019; 28:4098-4109. [PMID: 31190340 DOI: 10.1111/jocn.14958] [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] [Received: 01/31/2019] [Revised: 03/16/2019] [Accepted: 05/26/2019] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES Adults with moderate-to-severe traumatic brain injury (TBI) may have immediate and chronic cognitive impairments that require use of specific nursing strategies. Nurses must be knowledgeable about strategies to use to accommodate these impairments. However, available clinical guidelines and research lack information to direct nonacute nursing management of cognition, limiting guidance for nurses when developing their care plans. The purpose of this study was to investigate strategies nurses use when caring for patients with moderate-to-severe TBI who have cognitive impairments. DESIGN Cross-sectional, exploratory study. METHODS A total of 692 nurses from three hospitals answered the following open-ended question via electronic survey: "Imagine you are caring for a patient with moderate-to-severe TBI who has problems with cognition (e.g., issues with memory, attention, and executive function). Please state your typical nursing routine to care for this type of patient." Data were analysed using summative content analysis. Methods are reported using COREQ guidelines (See File S1). RESULTS Most respondents were female (89%), middle-aged (40.3 years), staff registered nurses (77%) practicing on an inpatient unit (51%) with prior experience caring for patients with moderate-to-severe TBI (95%). Nurses described 189 strategies used in their care plan when caring for patients with TBI who have cognitive impairments, including the following: (a) cognitive techniques; (b) communication techniques; (c) patient safety techniques; (d) agitation and behaviour management techniques; and (e) education techniques. CONCLUSIONS Findings have implications for education and training of nurses, direction for future research aimed at determining the effectiveness of nursing strategies with this patient population, and for development of clinical guidelines for nonacute nursing management of patients with moderate-to-severe TBI who have cognitive impairments. RELEVANCE TO CLINICAL PRACTICE Findings provide foundational knowledge on strategies nurses use when caring for patients with TBI who have cognitive impairments, which could be used to direct evidence-based nursing care of this patient population.
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Affiliation(s)
| | - Mitchell A Thomas
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, Wisconsin
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Nowicki M, Pearlman L, Campbell C, Hicks R, Fraser DD, Hutchison J. Agitated behavior scale in pediatric traumatic brain injury. Brain Inj 2019; 33:916-921. [PMID: 30696278 DOI: 10.1080/02699052.2019.1565893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Agitation following TBI commonly occurs during the acute recovery phase. The ABS is a valid measure of agitation in adults following TBI. The objective of the study was to determine if ABS scores accurately measure acute agitation in pediatric patients recovering from TBI. The ABS was completed twice daily for 4 days and mean ABS scores were calculated. Physicians assessed patients' agitation daily using a VAS. In addition, interventions for agitation were recorded. The association between ABS and VAS scores was assessed using Spearman's correlation. The relationship between the number of medication classes taken for agitation (0, 1-2, or ≥3) and ABS scores was assessed using one-way analysis of variance. Finally, the association between the use of hand restraints and ABS scores was examined using an unpaired two-sample t-test. Twenty-six pediatric patients with acute TBI were included. ABS scores significantly associated with VAS scores. Patients that required interventions for agitation (hand restraints or ≥3 medication classes) had higher ABS scores than patients that did not receive any intervention. The study supports the use of ABS scoring to measure agitation in pediatric patients with TBI. However, additional studies are warranted to further support the validity of this scale. Abbreviations: TBI: Traumatic brain injury; ABS: Agitated Behaviour Scale; VAS: visual analog scale; PCCU: Pediatric Critical Care Unit.
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Affiliation(s)
- Magda Nowicki
- a Schulich School of Medicine & Dentistry , Western University , London , ON , Canada
| | - Lisa Pearlman
- b Children's Hospital , London Health Sciences Centre , London , ON , Canada
| | - Craig Campbell
- a Schulich School of Medicine & Dentistry , Western University , London , ON , Canada.,c Department of Pediatrics, Division of Neurology and Neurosurgery , Children's Hospital, London Health Sciences Centre , London , ON , Canada.,d Faculty of Clinical Neurological Sciences and Epidemiology , Western University , London , ON , Canada
| | - Rhiannon Hicks
- c Department of Pediatrics, Division of Neurology and Neurosurgery , Children's Hospital, London Health Sciences Centre , London , ON , Canada
| | - Douglas D Fraser
- e Department of Pediatrics , Western University , Ontario , Canada
| | - Jamie Hutchison
- f Department of Critical Care Medicine , Hospital for Sick Children , Toronto , ON , Canada
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38
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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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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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Descriptive Findings of the VA Polytrauma Rehabilitation Centers TBI Model Systems National Database. Arch Phys Med Rehabil 2018; 99:952-959. [DOI: 10.1016/j.apmr.2017.12.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/22/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022]
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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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Trevena-Peters J, McKay A, Spitz G, Suda R, Renison B, Ponsford J. Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial. Arch Phys Med Rehabil 2018; 99:329-337.e2. [DOI: 10.1016/j.apmr.2017.08.486] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 08/15/2017] [Accepted: 08/23/2017] [Indexed: 10/18/2022]
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Mahmood S, Mahmood O, El-Menyar A, Asim M, Al-Thani H. Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit. World J Emerg Med 2018; 9:105-112. [PMID: 29576822 DOI: 10.5847/wjem.j.1920-8642.2018.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Agitation occurs frequently among critically ill patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS A total of 102 intubated patients were enrolled; of which 46 (45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95% CI=1.35-18.27), subarachnoid hemorrhage (OR=5.11; 95% CI=1.38-18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95% CI=1.16-15.35) were independent predictors for agitation (P<0.01). CONCLUSION Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.
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Affiliation(s)
- Saeed Mahmood
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
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Waszynski CM, Milner KA, Staff I, Molony SL. Using simulated family presence to decrease agitation in older hospitalized delirious patients: A randomized controlled trial. Int J Nurs Stud 2017; 77:154-161. [PMID: 29100197 DOI: 10.1016/j.ijnurstu.2017.09.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 08/26/2017] [Accepted: 09/29/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed. OBJECTIVES To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients. DESIGN Single site randomized control trial, 3 groups×4 time points mixed factorial design conducted from July 2015 to March 2016. SETTING Acute care level one trauma center in an inner city of the state of Connecticut, USA. PARTICIPANTS Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n=126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia. METHODS Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30min following the intervention. RESULTS Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p<0.001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p<0.001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p<0.001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p=0.001) between family video(60%) and usual care (35.1%) immediately following the intervention CONCLUSION: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia.
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Affiliation(s)
- Christine M Waszynski
- Department of Geriatric Medicine and Department of Nursing, Hartford Hospital, 80 Seymour Street, Hartford, CT 06012, USA.
| | - Kerry A Milner
- College of Nursing, Sacred Heart University, 5151 Park Ave, Fairfield, CT 06825, USA.
| | - Ilene Staff
- Department of Research, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
| | - Sheila L Molony
- School of Nursing, Quinnipiac University, 275 Mt Carmel Ave, Hamden, CT 06518, 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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Moessner A, Malec JF, Beveridge S, Reddy CC, Huffman T, Marton J, Schmerzler AJ. Preliminary evaluation of a measure for reliable assessment of need for constant visual observation in adults with traumatic brain injury. Brain Inj 2016; 30:1343-1349. [PMID: 27715319 DOI: 10.1080/02699052.2016.1193629] [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: 10/21/2022]
Abstract
PRIMARY OBJECTIVE To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation. RESEARCH DESIGN Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity. METHODS AND PROCEDURES One hundred and thirty-four individuals with moderate-severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2-3, Days 5-6 and Days 8-9. OUTCOMES AND RESULTS After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85-0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29-56%). CONCLUSIONS The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.
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Affiliation(s)
- Anne Moessner
- a Mayo Clinic Department of Physical Medicine & Rehabilitation , Rochester , MN , USA
| | - James F Malec
- b Physical Medicine and Rehabilitation , Indiana University School of Medicine and Rehabilitation Hospital of Indiana , Indianapolis , IN , USA
| | - Scott Beveridge
- c UPMC Mercy Hospital Rehabilitation Institute , Pittsburgh , PA , USA
| | | | - Tracy Huffman
- d The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - Julia Marton
- e Department of Rehabilitation , Baylor Institute for Rehabilitation-Dallas Campus , Dallas , TX , USA
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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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Nygren DeBoussard C, Lannsjö M, Stenberg M, Stålnacke BM, Godbolt AK. Behavioural problems in the first year after Severe traumatic brain injury: a prospective multicentre study. Clin Rehabil 2016; 31:555-566. [PMID: 27277217 DOI: 10.1177/0269215516652184] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the occurrence of behavioural problems in patients with severe traumatic brain injury during the first year after injury and potential associations with outcome. An additional post hoc objective was to analyse the frequency of behaviours with need for intervention from staff. DESIGN AND SETTING In a prospective population based cohort study 114 patients with severe traumatic brain injury were assessed at three weeks, three months and one year after injury. MAIN MEASURES Assessments included clinical examination and standardised instruments. Agitation was assessed with the Agitated Behaviour Scale, the course of recovery by the Rancho Los Amigo Scale and outcome by Glasgow Outcome Scale Extended. RESULTS Agitation were most common at 3 weeks post injury and 28% ( n=68) of the patients showed at least one agitated behaviour requiring intervention from staff. Presence of significant agitation at 3 weeks after injury was not associated with poor outcome. At 3 months agitation was present in 11% ( n=90) and apathy in 26 out of 81 assessed patients. At 3 months agitation and apathy were associated with poor outcome at one year. CONCLUSIONS Most agitated behaviours in the early phase are transient and are not associated with poor outcome. Agitation and apathy are uncommon at three months but when present are associated with poor outcome at one year after injury. In the early phase after a severe traumatic brain injury agitated behaviour in need of interventions from staff occur in a substantial proportion of patients.
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Affiliation(s)
- Catharina Nygren DeBoussard
- 1 Department of Clinical Sciences, Karolinska Institutet, and University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Marianne Lannsjö
- 2 Sandviken Hospital and Uppsala University, Sweden.,3 Centre for Research and Development, Uppsala University/County Council of Gävleborg Gävle, Sweden
| | - Maud Stenberg
- 4 Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Britt-Marie Stålnacke
- 4 Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Alison K Godbolt
- 1 Department of Clinical Sciences, Karolinska Institutet, and University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital, SE-182 88 Stockholm, Sweden.,5 Formerly of Department of Rehabilitation Medicine, University Hospital Uppsala and Uppsala University, Sweden
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