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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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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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3
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Cataford G, Monton LA, Karzon S, Livernoche-Leduc C, Saavedra-Mitjans M, Potvin MJ, Bernard F, Burry L, Arbour C, Williamson DR. Cognitive and Motor Function Effects of Antipsychotics in Traumatic Brain Injury: A Systematic Review of Pre-Clinical Studies. Neurotrauma Rep 2024; 5:181-193. [PMID: 38463417 PMCID: PMC10924062 DOI: 10.1089/neur.2023.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Traumatic brain injury (TBI) survivors often suffer from agitated behaviors and will most likely receive pharmacological treatments. Choosing an optimal and safe treatment that will not interfere with neurological recovery remains controversial. By interfering with dopaminergic circuits, antipsychotics may impede processes important to cognitive recovery. Despite their frequent use, there have been no large randomized controlled studies of antipsychotics for the management of agitated behaviors during the acute TBI recovery period. We conducted a systematic review and meta-analysis of pre-clinical studies evaluating the effects of antipsychotics post-TBI on both cognitive and motor recovery. MEDLINE and Embase databases were searched up to August 2, 2023. Pre-clinical studies evaluating the effects of antipsychotics on cognitive and motor functions post-TBI were considered. Risk of bias was evaluated with the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) tool. We identified 15 studies including a total of 1188 rodents, mostly conducted in male Sprague-Dawley rats using cortical impact injury. The analysis revealed no consistent effect of haloperidol on motor functions, but risperidone was associated with a significant impairment in motor function on day 5 post-injury (7.05 sec; 95% confidence interval [CI]: 1.47, 12.62; I2 = 92%). Other atypical antipsychotics did not result in impaired motor function. When evaluating cognitive function, haloperidol- (23.00 sec; 95% CI: 17.42-28.59; I2 = 7%) and risperidone-treated rats (24.27 sec; 95% CI: 16.18-32.36; I2 = 0%) were consistently impaired when compared to controls. In studies evaluating atypical antipsychotics, no impairments were observed. Clinicians should avoid the regular use of haloperidol and risperidone, and future human studies should be conducted with atypical antipsychotics.
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Affiliation(s)
| | | | - Stephanie Karzon
- Faculté de Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Camille Livernoche-Leduc
- Départment de psychologie, Université du Québec à Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Mar Saavedra-Mitjans
- Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Marie-Julie Potvin
- Départment de psychologie, Université du Québec à Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Francis Bernard
- Faculté de Médecine, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
| | - Lisa Burry
- Pharmacy Department, Mount Sinai Hospital. Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Arbour
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
- Faculté de sciences infirmières, Université de Montréal, Montreal, Quebec, Canada
| | - David R Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research center, CIUSSS-Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Cœur de Montréal. Montreal, Quebec, Canada
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4
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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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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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6
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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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7
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Carrier SL, Ponsford J, Phyland RK, Hicks AJ, McKay A. Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review. Neuropsychol Rev 2022. [DOI: https://doi:10.1007/s11065-022-09544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractAgitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.
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Abstract
OBJECTIVES Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.
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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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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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11
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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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12
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Roberson SW, Patel MB, Dabrowski W, Ely EW, Pakulski C, Kotfis K. Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice. Curr Neuropharmacol 2021; 19:1519-1544. [PMID: 33463474 PMCID: PMC8762177 DOI: 10.2174/1570159x19666210119153839] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.
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Affiliation(s)
| | | | | | | | | | - Katarzyna Kotfis
- Address correspondence to this author at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland; E-mail:
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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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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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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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Cheng JP, Leary JB, O'Neil DA, Meyer EA, Free KE, Bondi CO, Kline AE. Spontaneous recovery of traumatic brain injury-induced functional deficits is not hindered by daily administration of lorazepam. Behav Brain Res 2017; 339:215-221. [PMID: 29203336 DOI: 10.1016/j.bbr.2017.11.039] [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: 08/29/2017] [Revised: 11/02/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
Agitation and aggression are common sequelae of traumatic brain injury (TBI) and pose a challenge to physicians and other health providers during acute patient care and subsequent neurorehabilitation. Antipsychotic drugs (APDs) are routinely administered to manage TBI patients displaying such maladaptive behaviors despite several clinical and preclinical studies demonstrating that they hinder recovery. A potentially viable alternative to APDs may be the benzodiazepines, which have differing mechanisms of action. Hence, the aim of the study was to test the hypothesis that lorazepam (LOR) would not impede recovery after TBI. Anesthetized adult male rats received a cortical impact or sham injury and then were intraperitoneally administered LOR (0.1mg/kg, 1.0mg/kg, or 2.0mg/kg) or vehicle (VEH; 1mL/kg) commencing 24-h after surgery and once daily for 19days. Motor and cognitive outcomes were assessed on post-operative days 1-5 and 14-19, respectively. No differences were revealed among the four sham control groups and thus they were pooled into one inclusive SHAM group. The SHAMs performed better than all TBI groups on all assessments (p<0.05). Regarding TBI, the 2.0mg/kg LOR group performed better than the VEH and 0.1mg/kg or 1.0mg/kg LOR groups on every task (p<0.05); no differences were observed among the latter three groups on any endpoint (p>0.05). Overall, these preclinical behavioral data support the hypothesis and reveal a therapeutic benefit with the higher dose of LOR. The findings suggest that LOR may be an alternative, to APDs, for controlling agitation without compromising spontaneous recovery and perhaps could afford a dual benefit by also promoting therapeutic efficacy.
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Affiliation(s)
- Jeffrey P Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Jacob B Leary
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Darik A O'Neil
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Elizabeth A Meyer
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Kristin E Free
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Corina O Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Neurobiology, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Anthony E Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Psychology, University of Pittsburgh, PA, 15213, United States.
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Hicks AJ, Clay FJ, Hopwood M, Jayaram M, Batty R, Ponsford JL. Efficacy and harms of pharmacological interventions for neurobehavioral symptoms in post traumatic amnesia after traumatic brain injury: a systematic review and meta-analysis protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:2890-2912. [PMID: 29219873 DOI: 10.11124/jbisrir-2017-003430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
REVIEW OBJECTIVE/QUESTION The objective of this systematic review is to synthesize the best available evidence on the effectiveness and harms of pharmacotherapy as compared to all types of comparators for the management of neurobehavioral symptoms in post-traumatic amnesia in adults aged 16 years and over who have sustained a traumatic brain injury. This review forms part of a larger project which aims to gather the evidence for the pharmacological treatment of neurobehavioral symptoms post traumatic brain injury as a prelude to the development of a clinical guideline.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Forensic Medicine, Monash University, Southbank, Australia
- The Australian Centre for Evidence-Based Primary Health Care, Community Care: a Joanna Briggs Institute Centre of Excellence, Adelaide, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
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Management of Medical Complications During the Rehabilitation of Moderate-Severe Traumatic Brain Injury. Phys Med Rehabil Clin N Am 2017; 28:259-270. [DOI: 10.1016/j.pmr.2016.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Phelps TI, Bondi CO, Mattiola VV, Kline AE. Relative to Typical Antipsychotic Drugs, Aripiprazole Is a Safer Alternative for Alleviating Behavioral Disturbances After Experimental Brain Trauma. Neurorehabil Neural Repair 2016; 31:25-33. [PMID: 27225976 DOI: 10.1177/1545968316650281] [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: 11/15/2022]
Abstract
BACKGROUND Antipsychotic drugs (APDs) are used to manage traumatic brain injury (TBI)-induced behavioral disturbances, such as agitation and aggression. However, APDs exhibiting D2 receptor antagonism impede cognitive recovery after experimental TBI. Hence, empirical evaluation of APDs with different mechanistic actions is warranted. Aripiprazole (ARIP) is a D2 and 5-hydroxytryptamine1A (5-HT1A) receptor agonist; pharmacotherapies with these properties enhance cognition after TBI. OBJECTIVE To test the hypothesis that ARIP would increase behavioral performance and decrease histopathology after TBI. METHODS Adult male rats were subjected to either a controlled cortical impact (CCI) or sham injury and then randomly assigned to ARIP (0.1 or 1.0 mg/kg) or VEH (1.0 mL/kg, saline vehicle) groups. Treatments began 24 hours after surgery and were administered once daily for 19 days. Motor (beam-balance/beam-walk) and cognitive (Morris water maze) performance was assessed on postoperative days 1 to 5 and 14 to 19, respectively, followed by quantification of hippocampal CA1,3 neuron survival and cortical lesion volume. RESULTS Beam-balance was significantly improved in the CCI + ARIP (1.0 mg/kg) group versus CCI + ARIP (0.1 mg/kg) and CCI + VEH (P < .05). Spatial learning and memory retention were significantly improved in the CCI + ARIP (0.1 mg/kg) group versus the CCI + ARIP (1.0 mg/kg) and CCI + VEH groups (P < .05). Both doses of ARIP reduced lesion size and CA3 cell loss versus VEH (P < .05). Importantly, neither dose of ARIP impeded functional recovery as previously reported with other APDs. CONCLUSION These findings support the hypothesis and endorse ARIP as a safer APD for alleviating behavioral disturbances after TBI.
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Affiliation(s)
- Thomas I Phelps
- University of Pittsburgh, Pittsburgh, PA, USA.,Case Western/MetroHealth Medical Center, Cleveland OH, USA
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Stéfan A, Mathé JF. What are the disruptive symptoms of behavioral disorders after traumatic brain injury? A systematic review leading to recommendations for good practices. Ann Phys Rehabil Med 2016; 59:5-17. [DOI: 10.1016/j.rehab.2015.11.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 12/01/2022]
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Plantier D, Luauté J. Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice. Ann Phys Rehabil Med 2016; 59:42-57. [PMID: 26797170 DOI: 10.1016/j.rehab.2015.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/12/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There are no handbook or recommendations for the use of pharmacological agents to treat neurobehavioral disorders after traumatic brain injury (TBI). This work proposes a systematic review of the literature and a user guide on neuroleptics, antidepressants, beta-blockers, mood stabilizers and other medications for irritability, aggressiveness, agitation, impulsivity, depression, apathy… METHOD Steering, working and reading groups (62 people) were formed under the control of the French High Authority for Health (HAS) in collaboration with the SOFMER scientific society (French Society of Physical and Rehabilitation Medicine). Articles were searched by HAS officers in the Medline database from 1990 to 2012, crossing TBI and pharmacological agents. The HAS method to select, read and analyze papers is close to the PRISMA statements. RESULTS Out of 772 references, 89 were analyzed, covering a total of 1306 people with TBI. There is insufficient evidence to standardize drug treatments for these disorders. There are however some elements to establish consensus recommendations for good clinical practice. Propranolol can improve aggression (B grade). Carbamazepine and valproate seem effective on agitation and aggression and are recommended as first line treatment (Expert Consensus [EC]). There is no evidence of efficacy for neuroleptics. Their prescription is based on emergency situation for a crisis (loxapine) but not for long-term use (EC). Antidepressants are recommended to treat depression (EC) with a higher standard of proof for Selective Serotonin Reuptake Inhibitors (SSRI, grade B). Other products are described. CONCLUSION The choice of treatment depends on the level of evidence, target symptoms, custom objectives, clinical experience and caution strategies.
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Affiliation(s)
- D Plantier
- Department of Physical Medicine and Rehabilitation (PM&R), Neurological Rehabilitation, Renée-Sabran Hospital, University Hospital of Lyon, boulevard Édouard-Herriot, 83400 Hyères, France.
| | - J Luauté
- Physical Medicine and Rehabilitation, Neurological Rehabilitation, Henry-Gabrielle Hospital, University Hospital of Lyon, 69230 Saint-Genis-Laval, France; Neuroscience Research Center of Lyon (CRNL) IMPACT team, Inserm U1028, CNRS, UMR5292, 69500 Bron, France
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Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations. Ann Phys Rehabil Med 2015; 59:58-67. [PMID: 26700025 DOI: 10.1016/j.rehab.2015.11.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 11/21/2022]
Abstract
UNLABELLED The agitation crisis in the awakening phase after traumatic brain injury (TBI) is one of the most difficult behavioral disorders to alleviate. Current treatment options are heterogeneous and may involve excessive sedation. Practice guidelines are required by professionals in charge of TBI patients. Few reviews were published but those are old and based on expert opinions. The purpose of this work is to propose evidence-based guidelines to treat the agitation crisis. METHODS The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. Guidelines were elaborated on the basis of a systematic and critical review of the literature. RESULTS Twenty-eight articles concerning 376 patients were analyzed. Recommendations are: when faced with an agitation crisis, the management strategy implies to search for an underlying factor that should be treated such as pain, acute sepsis, and drug adverse effect (expert opinion). Physical restraints should be discarded when possible (expert opinion). Neuroleptic agent with a marketing authorization can be used in order to obtain a quick sedation so as to protect the patient from himself, closed ones or the healthcare team but the duration should be as short as possible (expert opinion). The efficacy of beta-blockers and antiepileptics with mood regulation effects like carbamazepine and valproate yield the most compelling evidence and should be preferably used when a background regimen is envisioned (grade B for beta-blocker and C for antiepileptics). Neuroleptics, antidepressants, benzodiazepines, buspirone may be prescribed but are considered second-line treatments (expert opinion). CONCLUSION This study provides a strategy for treating the agitation crisis based on scientific data and expert opinion. The level of evidence remains low and published data are often old. New studies are essential to validate results from previous studies and test new drugs and non-pharmaceutical therapies.
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Hammond FM, Barrett RS, Shea T, Seel RT, McAlister TW, Kaelin D, Ryser DK, Corrigan JD, Cullen N, Horn SD. Psychotropic Medication Use During Inpatient Rehabilitation for Traumatic Brain Injury. Arch Phys Med Rehabil 2015. [PMID: 26212402 DOI: 10.1016/j.apmr.2015.01.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. DESIGN Prospective observational cohort. SETTING Multiple acute inpatient rehabilitation units or hospitals. PARTICIPANTS Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. CONCLUSIONS Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.
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Affiliation(s)
- Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University School of Medicine, Indianapolis, IN.
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, Salt Lake City, UT
| | | | - Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA
| | | | - Darryl Kaelin
- University of Louisville School of Medicine and Frazier Rehabilitation Institute, Louisville, KY
| | | | | | - Nora Cullen
- Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT
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Under arrest: the use of amantadine for treatment-refractory mood lability and aggression in a patient with traumatic brain injury. J Clin Psychopharmacol 2015; 35:102-4. [PMID: 25478939 DOI: 10.1097/jcp.0000000000000248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bower J, Catroppa C, Grocke D, Shoemark H. Music therapy for early cognitive rehabilitation post-childhood TBI: an intrinsic mixed methods case study. Dev Neurorehabil 2014; 17:339-46. [PMID: 23815784 DOI: 10.3109/17518423.2013.778910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The primary aim of this case study was to explore the behavioural changes of a paediatric patient in post-traumatic amnesia (PTA) during a music therapy session. A secondary objective was to measure the effect of the music therapy intervention on agitation. METHOD Video data from pre, during and post-music therapy sessions were collected and analysed using video micro-analysis and the Agitated Behaviour Scale. RESULTS The participant displayed four discrete categories of behaviours: Neutral, Acceptance, Recruitment and Rejection. Further analysis revealed brief but consistent and repeated periods of awareness and responsiveness to the live singing of familiar songs, which were classified as Islands of Awareness. Song offered an Environment of Potential to maximise these periods of emerging consciousness. The quantitative data analysis yielded inconclusive results in determining if music therapy was effective in reducing agitation during and immediately post the music therapy sessions. CONCLUSION The process of micro-analysis illuminated four discrete participant behaviours not apparent in the immediate clinical setting. The results of this case suggest that the use of familiar song as a music therapy intervention may harness early patient responsiveness to foster cognitive rehabilitation in the early acute phase post-TBI.
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Affiliation(s)
- Janeen Bower
- Music Therapy Department, The Royal Children's Hospital Melbourne , Flemington Rd, Parkville, VIC , Australia
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Janzen S, McIntyre A, Meyer M, Sequeira K, Teasell R. The management of agitation among inpatients in a brain injury rehabilitation unit. Brain Inj 2014; 28:318-22. [DOI: 10.3109/02699052.2013.860478] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nejad SH, Chuang K, Hirschberg R, Aquino PR, Fricchione GL. The Use of Antiepileptic Drugs in Acute Neuropsychiatric Conditions: Focus on Traumatic Brain Injury, Pain, and Alcohol Withdrawal. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.512099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kinnaman KA, Mannix RC, Dawn Comstock R, Meehan WP. Management strategies and medication use for treating paediatric patients with concussions. Acta Paediatr 2013; 102:e424-8. [PMID: 23750873 DOI: 10.1111/apa.12315] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 06/01/2013] [Accepted: 06/05/2013] [Indexed: 11/30/2022]
Abstract
AIM To assess management strategies for paediatric patients suffering from concussions. METHODS A 17-item questionnaire was distributed to 1305 section members of the American Academy of Pediatrics Sections on Adolescent Health, Sports Medicine and Fitness, Community Pediatrics and School Health. The use of medications, neuropsychological testing, neuroimaging and published guidelines in concussion management was queried. RESULTS Two hundred and twenty respondents (17%) completed the questionnaire, of which 64% had been an attending for greater than 10 years. A majority of respondents (92%) managed patients with concussions, with 26% treating more than 24 patients per year. Most paediatricians (84%) reported using a published guideline. The majority of respondents (89%) manage the symptoms of concussed patients with medications, most commonly acetaminophen (62%) or nonsteroidal anti-inflammatory medications (54%). The use of prescriptions medications such as tricyclic antidepressants (23%), amantadine (10%) and methylphenidate (8%) was also commonly reported. Paediatricians treating >16 patients per year with concussion were more likely to prescribe tricyclic antidepressants, stimulants and agents used for sleep disturbance. CONCLUSION Paediatricians nationwide routinely use medications when managing patients with concussions. The pharmacological agents used differ according to number of patients treated per year. In addition, most paediatricians use published guidelines in concussion management.
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Affiliation(s)
- Karen A Kinnaman
- Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA USA
| | - Rebekah C Mannix
- Division of Emergency Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA USA
- Brain Injury Center; Boston Children's Hospital; Harvard Medical School; Boston MA USA
| | - R Dawn Comstock
- Department of Epidemiology; Colorado School of Public Health; Aurora CO USA
| | - William P Meehan
- Division of Emergency Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA USA
- Division of Sports Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA USA
- Sports Concussion Clinic; Boston Children's Hospital; Harvard Medical School; Boston MA USA
- Micheli Center for Sports; Injury and Prevention; Waltham MA USA
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Neuroleptic malignant syndrome associated with haloperidol treatment in a patient with head injury. FORMOSAN JOURNAL OF SURGERY 2013. [DOI: 10.1016/j.fjs.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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McNett M, Sarver W, Wilczewski P. The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units. Brain Inj 2012; 26:1155-62. [PMID: 22642404 DOI: 10.3109/02699052.2012.667587] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Agitation occurs in 70% of patients hospitalized with traumatic brain injury (TBI) and has adverse effects on length of stay and functional outcomes. Treatment involves pharmacological and behavioural interventions. Much research on TBI agitation has been conducted in intensive care or rehabilitation settings. This study aimed to identify agitation prevalence, treatment and outcomes among patients with TBI on acute care wards. METHODS Data abstracted from the trauma registry and medical records of adult patients with TBI admitted to an acute care ward within a Level I trauma centre over 12 months. FINDINGS From 219 patients, at least one agitation behaviour was present in 41% (n = 90) of patients. Clinically significant agitation was present in 8% (n = 18) of patients. Agitation behaviours included impulsiveness (30%), pulling at devices (21%) and decreased attention span (16%). Common interventions were reorientation (33%), constant supervision (32%) and benzodiazepines (30%). Agitated patients had longer length of stay (p < 0.001) and were less likely to be discharged home. Physical restraints, constant supervision, redirection, reorientation and environmental modifications were associated with agitation (p < 0.001). IMPLICATIONS Management of agitation among patients with TBI on acute care wards can present challenges to healthcare staff. Innovative approaches are needed to promote outcomes using available resources.
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Affiliation(s)
- Molly McNett
- MetroHealth Medical Centre, Cleveland, OH 44109, USA.
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Management of Agitation Following Aneurysmal Subarachnoid Hemorrhage: Is There a Role for Beta-Blockers? Case Rep Psychiatry 2012; 2012:753934. [PMID: 22937415 PMCID: PMC3420481 DOI: 10.1155/2012/753934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 03/21/2012] [Indexed: 11/30/2022] Open
Abstract
Introduction. Stroke is a leading cause of mortality and morbidity in the United States. About 20% of the stroke is hemorrhagic and about 50% of these is due to aneurysmal subarachnoid hemorrhage. A troublesome neuropsychiatric complication of subarachnoid hemorrhage is agitation/aggression. Case Presentation. A 45-year-old man with no prior psychiatric history, sustained subarachnoid hemorrhage. After initial stabilization for 2 days, he underwent craniotomy and clipping of anterior cerebral communicating artery aneurysm. Treatment was continued with labetalol, nimodipine, and levetiracetam. Beginning postoperative day 4, patient developed episodes of confusion and agitation/aggression. Switching of Levetiracetam to valproate did not show any improvement. Psychiatry team tried to manage him with intense nursing intervention and different medications like olanzapine, valproate, lorazepam, and haloperidol. However, patient continued to be agitated and aggressive. Switching from labetalol to metoprolol resulted in dramatic improvement within 3 days. Discussion. Antipsychotics and benzodiazepines are often not sufficiently effective in the control of agitation/aggression in patients with traumatic brain injury and similar conditions. Our case report and the literature review including a cochrane review suggests that beta-blockers may be helpful in this situation.
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Abstract
Adolescent aggressive behavior is a frequently encountered problem for clinicians and society as a whole. Better understanding of biological, social, and familial risk factors for maladaptive aggressive behavior may lead to more effective interventions. The social information processing problems characteristic of this group interfere with treatment and outcome. Although further studies are needed, evidence for the effectiveness of psychopharmacologic treatments is increasing. There is also evidence for several effective psychotherapeutic interventions, especially for those with affective/impulsive aggression. Knowledge of risk factors, psychosocial strategies, and psychopharmacologic treatments can enhance the clinician's ability to intervene with this difficult group.
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Affiliation(s)
- John Peterson
- Department of Behavioral Health, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA.
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Saoût V, Gambart G, Leguay D, Ferrapie AL, Launay C, Richard I. Agressive behavior after traumatic brain injury. Ann Phys Rehabil Med 2011; 54:259-69. [DOI: 10.1016/j.rehab.2011.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 04/07/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
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Pangilinan PH, Giacoletti-Argento A, Shellhaas R, Hurvitz EA, Hornyak JE. Neuropharmacology in Pediatric Brain Injury: A Review. PM R 2010; 2:1127-40. [DOI: 10.1016/j.pmrj.2010.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 06/16/2010] [Accepted: 07/05/2010] [Indexed: 11/28/2022]
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Antiepileptic Medications in the Treatment of Neuropsychiatric Symptoms Associated with Traumatic Brain Injury. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/9780849382666.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Mysiw WJ, Bogner JA, Corrigan JD, Fugate LP, Clinchot DM, Kadyan V. The impact of acute care medications on rehabilitation outcome after traumatic brain injury. Brain Inj 2009; 20:905-11. [PMID: 17062422 DOI: 10.1080/02699050600743972] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation. DESIGN Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors. METHODS The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)). MAIN OUTCOME AND RESULTS The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant. CONCLUSIONS The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.
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Affiliation(s)
- W Jerry Mysiw
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH 43210, USA.
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Neuroleptic malignant syndrome in traumatic brain injury patients treated with haloperidol. ACTA ACUST UNITED AC 2009; 66:954-8. [PMID: 19276778 DOI: 10.1097/ta.0b013e31818e90ed] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Haloperidol, which is commonly used to treat agitation in critically ill patients, has been associated with the development of neuroleptic malignant syndrome (NMS). The purpose of this manuscript was to review the literature describing NMS and haloperidol use in patients sustaining a traumatic brain injury (TBI) since these patients may be at greater risk for NMS. METHODS A computerized search of MEDLINE was conducted (1966-May 2008) to identify all publications in which haloperidol was related to NMS in patients with a TBI. The references of these manuscripts were reviewed for additional literature. RESULTS Nine case reports describe the development of NMS in patients with TBI treated with haloperidol for agitation. Cumulative haloperidol doses before the onset of NMS ranged from 10 mg to at least 210 mg. Most of these patients received high dose (> or =30 mg) haloperidol. Four patients received haloperidol parenterally. On diagnosis, of NMS, haloperidol was discontinued in five cases, and all were given supportive care and pharmacologic treatment. Patients were discharged with improved, but diminished functional capacity. CONCLUSION Development of NMS in TBI patients treated with haloperidol should be a concern for clinicians since these patients may be at greater risk for this adverse event; especially if the patient is receiving haloperidol at high doses parenterally. Future studies are needed to evaluate the incidence and increased risk of adverse events in patients sustaining a TBI and receiving haloperidol especially since haloperidol is being used more frequently in the critically ill patients.
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Slifer KJ, Amari A. Behavior management for children and adolescents with acquired brain injury. ACTA ACUST UNITED AC 2009; 15:144-51. [DOI: 10.1002/ddrr.60] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Francisco GE, Walker WC, Zasler ND, Bouffard MH. Pharmacological management of neurobehavioural sequelae of traumatic brain injury: a survey of current physiatric practice. Brain Inj 2008; 21:1007-14. [PMID: 17891562 DOI: 10.1080/02699050701559558] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe pharmacological preference for the treatment of neurobehavioural sequela of traumatic brain injury (TBI). DESIGN Survey. PARTICIPANTS TBI physiatrists were divided into specialists (completed a TBI fellowship or commit >70% of clinical practice time to TBI) and non-specialists. OUTCOME MEASURES Participants were asked to list the drugs most frequently prescribed for each of 15 neurobehavioural symptoms commonly encountered during TBI rehabilitation and enumerate neurobehavioural symptom for which they prescribed each listed drug or drug class. RESULTS There was no clear consensus on drug of choice for each target symptom. There were differences in drug choice patterns between specialists and non-specialists, especially for agitation. CONCLUSION There is limited uniformity in drug selection for various TBI neurobehavioural sequela. Potential explanations include the availability of various medications with similar clinical effect, the variability of clinical presentation and severity of neurobehavioural symptoms and the lack of clinical practice guidelines.
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Affiliation(s)
- Gerard E Francisco
- Physical Medicine and Rehabilitation Alliance, Baylor College of Medicine and University of Texas Health Science Center, Houston, TX, USA.
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Wusthoff CJ, Shellhaas RA, Licht DJ. Management of common neurologic symptoms in pediatric palliative care: seizures, agitation, and spasticity. Pediatr Clin North Am 2007; 54:709-33, xi. [PMID: 17933619 DOI: 10.1016/j.pcl.2007.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Palliative care for children is complex and focuses on patients' comfort. Some of the most troublesome symptoms as patients approach the end of life are seizures, agitation, and spasticity. Many doctors caring for children at the end of life are uncomfortable or untrained in managing these symptoms in children. Our goal is to help physicians recognize and treat these neurologic symptoms optimally.
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Affiliation(s)
- Courtney J Wusthoff
- Division of Child Neurology, The Children's Hospital of Philadelphia, 6th Floor Wood Building, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
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Gaber TAZK. Medico-legal and ethical aspects in the management of wandering patients following brain injury: questionnaire survey. Disabil Rehabil 2006; 28:1413-6. [PMID: 17071573 DOI: 10.1080/09638280600638208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Different methods are often used to deter head injury patients, who have a tendency to wander, from leaving the rehabilitation wards. The extent to which these patients could be restrained is controversial. Despite the fact that the majority of these patients lack mental capacity, Mental Health Act sections are rarely invoked. Under common law, informal patients should have the right to refuse treatment and to leave the hospital whenever they like. OBJECTIVE To examine the current practice in the management of wandering patients following brain injury in rehabilitation units in the UK and to formulate practical guidelines based on this common practice. METHODS A postal survey in the form of a structured questionnaire was sent to 58 consultants in Rehabilitation Medicine and Neuropsychologists based at different neurological rehabilitation units in the UK. RESULTS A total of 30 clinicians (52%) completed the questionnaire. One-to-one supervision was the method most commonly used to manage wandering patients (83%) followed by implementation of a structured daily routine (73%) and the use of different medications (70%). Only 17% would lock the door without giving the patient lock combination/key and another 17% would physically restrain the patient without invoking mental health act (MHA) section; 60% would consider MHA section with great variability in the mental health team response time and the place where patient is managed once under MHA section. CONCLUSIONS The questionnaire showed great variations in the methods and the medico-legal framework used in the management of wandering patients. There was, however, a tendency to avoid physical restraint which may reflect the recognition of the unlawfulness of detaining informal patients.
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Fleminger S, Greenwood RJ, Oliver DL. Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database Syst Rev 2006:CD003299. [PMID: 17054165 DOI: 10.1002/14651858.cd003299.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006. SELECTION CRITERIA Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. DATA COLLECTION AND ANALYSIS We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. AUTHORS' CONCLUSIONS Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.
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Affiliation(s)
- S Fleminger
- Maudsley Hospital, Lishman Brain Injury Unit, Denmark Hill, London, UK.
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Abstract
Posttraumatic agitation is a challenging problem for acute and rehabilitation staff, persons with traumatic brain injury, and their families. Specific variables for evaluation and care remain elusive. Clinical trials have not yielded a strong foundation for evidence-based practice in this arena. This review seeks to evaluate the present literature (with a focus on the decade 1995-2005) and employ previous clinical experience to deliver a review of the topic. We will discuss definitions, pathophysiology, evaluation techniques, and treatment regimens. A recommended approach to the evaluation and treatment of the person with posttraumatic agitation will be presented. The authors hope that this review will spur discussion and assist in facilitating clinical care paradigms and research programs.
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Affiliation(s)
- Lisa A Lombard
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Sherer M, Nakase-Thompson R, Yablon SA, Gontkovsky ST. Multidimensional assessment of acute confusion after traumatic brain injury. Arch Phys Med Rehabil 2005; 86:896-904. [PMID: 15895334 DOI: 10.1016/j.apmr.2004.09.029] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the phenomenology of posttraumatic confusional state (PTCS) and to provide preliminary validation of a new procedure, the Confusion Assessment Protocol (CAP), for assessing PTCS. DESIGN Criterion standard investigation. SETTING Inpatient traumatic brain injury (TBI) rehabilitation program. PARTICIPANTS Two consecutive series of patients (n=62, n=93) with TBI admitted for inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Clinical diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, classification of posttraumatic amnesia (PTA) based on the Galveston Orientation and Amnesia Test (GOAT), and Disability Rating Scale score at time of rehabilitation hospital discharge. Results Agreement between the diagnosis of PTCS with the CAP and DSM-IV classification of delirium was 87%, and agreement between PTCS and PTA using GOAT criteria was 90%. Patients classified as in PTCS sustained more severe injuries and required longer rehabilitation stays. Confusion status was associated with poorer functional status at rehabilitation discharge. CONCLUSIONS The CAP is a brief, structured, repeatable measure of multiple neurobehavioral aspects of PTCS. Confusion status as determined by CAP assessment contributed to prediction of outcome at rehabilitation discharge after adjustment for other potential predictors.
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Affiliation(s)
- Mark Sherer
- Methodist Rehabilitation Center, Jackson, MS, USA.
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Affiliation(s)
- Mary E Braine
- Greater Manchester Neuroscience Centre, Hope Hospital, Stott Lane, Salford M6 8HG
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Kadyan V, Mysiw WJ, Bogner JA, Corrigan JD, Fugate LP, Clinchot DM. Gender Differences in Agitation After Traumatic Brain Injury. Am J Phys Med Rehabil 2004; 83:747-52. [PMID: 15385782 DOI: 10.1097/01.phm.0000140790.30468.f4] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine sex differences in extent and type of posttraumatic agitation during acute rehabilitation. DESIGN This prospective, observational study was performed at a Midwest, regional, university-based acute rehabilitation center. RESULTS In a total of 158 subjects, comprising 120 men (76%) and 38 women (24%), there were no significant differences between male and female subjects for age, Glasgow Coma Scale score, Rancho Los Amigos Level of Cognitive Functioning Scale, Mini Mental State Exam, days in acute hospital, and days in rehabilitation. No difference in incidence was observed between sexes based on the criterion of agitation as three or more abnormal total Agitated Behavior Scale scores in 48 hrs (P = 0.890). Also, no difference in posttraumatic agitation between the two sexes (P = 0.396) was observed with the criterion of agitation as two or more abnormal total Agitated Behavior Scale scores in 2 days. There were no differences observed between the sexes for peak intensity and average intensity for the total score or each of the factor scores of the Agitated Behavior Scale. CONCLUSION Posttraumatic agitation is seen in approximately 50% of patients after traumatic brain injury and usually lasts for <10 days. There are no significant sex differences in the frequency, duration, presentation, or extent of posttraumatic agitation. These data imply that both sexes, despite any predetermined notions, should be treated equally with respect to posttraumatic agitation management.
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Affiliation(s)
- Vivek Kadyan
- Department of Physical Medicine and Rehabilitation, The Ohio State University, College of Medicine, Columbus, Ohio 43210, USA
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