Epidemiology of agitation following brain injury

Patterns of agitated behaviour during acute brain injury rehabilitation

OBJECTIVE

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

DESIGN

A prospective, descriptive study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Agitation in dementia: concept clarification

AIM

The aim of this paper is to clarify the concept of agitation in dementia through analysing definitions, critical attributes, components, boundaries, antecedents and consequences of agitation.

BACKGROUND

The concept of agitation is not well defined. In addition, there exists much confusion about the characteristics and boundaries of agitation, as well as the distinction between agitation and related concepts. Recently developed theoretical models for agitation in dementia require new interpretation and conceptualization of agitation.

METHODS

Morse's method of critical appraisal of the literature was used. In addition, some parts of Rodgers' evolutionary method were employed. Data were selected using six electronic databases and the key words 'agitation', 'agitated', 'dementia', 'demented' and 'Alzheimer'. The analysis included 86 empirical or theoretical papers and one book.

RESULTS

A transition from the observer's perspective to the patient's perspective in the interpretation of agitation was found. Five critical attributes of agitation in dementia were identified: excessive, inappropriate, repetitive, non-specific and observable. Patient factors, interpersonal factors, environmental factors and restraint were identified as precipitating antecedents. Mediating antecedents included discomfort, unmet need and misinterpretation. Consequences of agitation were identified at the levels of patient, caregiver and others.

CONCLUSIONS

This transition in perspectives has important implications as it can change health providers' attitudes and responses to agitation and lead to patient-focused and individualized care. Researchers and clinicians are encouraged to avoid labelling agitated behaviour as 'disturbing behaviour'.

Hong Kong family caregivers' stress and coping for people with brain injury

Chinese families,in caring for their members with a brain injury have faced longterm burdens for which they were usually ill prepared. The complicated. Intertwined disability- and family-related factors appeared to be affecting their effective family coping especially in the context of Chinese families. The present study examined the impact of brain injury, which was based on analysing individual families' differences, and conceptualized through an empowerment framework for possible guidance in designing appropriate, indigenous family intervention. A total of 50 families with a brain injured members were successfully recruited by convenient sampling to attend an individual interview. Discussion was guided by open-ended questions. All the families' responses to questions, and the verbatim transcripts of long interviews of four randomly selected families, were used to construct themes of coping strategies. They were found to show the typical coping strategies of people facing stress, including shock and uncertainty, which were suggested to be related closely to the nature of brain injury, especially if the injury was traumatic in nature, and their difficulties in managing problems that were novel, unpredictable and global in nature (affecting physical and cognitive functions, personality change and social integration). The physical and psychological burdens involved in day-to-day caring for members with brain injury were unanimously reflected in the interviews. Further content analysis of the long interviews of four selected families showed that some families coped well and some did not. For those successful coping situations, families reported that they became empowered after the onset of their members' brain injury. They expressed possible factors leading to better adjustment, which included setting clear personal expectations, the flexibility to adjust life goals, a desire to master the situation, strong motivation, awareness of their own powerless state and willingness to ask for help from different sources. The results indicated that families cope with a brain-injured member differently, depending on the family's structure, and this should be explored further for the development of intervention guidelines.

Role of agitation in prediction of outcomes after traumatic brain injury

OBJECTIVE

To determine the role of agitation in the prediction of traumatic brain injury rehabilitation outcomes.

DESIGN

A longitudinal study of 340 consecutive patients admitted to an acute traumatic brain injury rehabilitation unit was conducted. Outcomes under study included rehabilitation length of stay, discharge destination, functional independence at discharge (FIM instrument), productivity at 1-yr follow-up, and life satisfaction at 1-yr follow-up (Satisfaction with Life Scale).

RESULTS

Univariate analyses suggested that the presence of agitation in rehabilitation is predictive of a longer length of stay and decreased functional independence in the cognitive realm at discharge. In addition, individuals who exhibit agitation at any time during rehabilitation are less likely to be discharged to a private residence. However, multivariate analyses indicated that cognitive functioning at admission to rehabilitation (FIM cognitive) mediates the relationship between the presence of agitation and length of rehabilitation, as well as between agitation and FIM cognitive at discharge. Similar results were found when discharge residence was the dependent variable; however, agitation also contributed some unique variance to the prediction. Lower cognitive functioning at admission to rehabilitation was associated with the occurrence of agitation during rehabilitation, longer length of stay, lower cognitive functioning at discharge, and a decreased likelihood that an individual would be discharged to a private residence.

CONCLUSIONS

The results of the multivariate analyses support the contention that agitation and cognition are intimately related, with the long-term effects of the former being at least partially driven by the latter. These findings support the importance of systematically monitoring both agitation and cognition when applying interventions to reduce agitation.

Reliability of the Agitated Behavior Scale

OBJECTIVE

The objective of this study was to investigate the interrater reliability of the Agitated Behavior Scale.

DESIGN

Ratings made by research assistants and nursing staff were compared.

PARTICIPANTS AND SETTING

Forty-five persons with brain injury and 23 persons with progressive dementia were studied at an acute rehabilitation unit and a long-term-care facility.

RESULTS

Ratings of persons with brain injury by research assistants yielded a correlation coefficient for the Total score of.920. The correlation coefficients for the factors Disinhibition, Aggression, and Lability were.902,.909, and.726, respectively. Lower coefficients were obtained when the ratings of the research assistants and nursing staff were correlated; these ranged from.364 to.604. The ratings by research assistants of long-term-care facility residents yielded coefficients ranging from.860 to.906 for the Total and factor scores.

CONCLUSION

This study shows that the Agitated Behavior Scale is a reliable instrument for measuring agitation in persons with traumatic brain injury, as well as with long-term-care facility residents experiencing dementia.