Agitation assessment in severe traumatic brain injury: methodological and clinical issues

Overview and inter-rater reliability of an incident-based rating scale for aggressive behaviour following traumatic brain injury: The Overt Aggression Scale–Modified for Neurorehabiltation–Extended (OAS-MNR-E)

PRIMARY OBJECTIVE

The presentation and evaluation of the Overt Aggression Scale-Modified for Neurorehabilitation-Extended (OAS-MNR-E).

RESEARCH DESIGN

Inter-rater reliability study using data collection procedures mirroring clinical practice.

METHODS AND PROCEDURES

Fifteen clinical staff representing five different disciplines received a 30-minute orientation to the study and a 30-minute overview of the OAS-MNR-E. There were 34 patients who engaged in a rateable behaviour and were observed by two raters. There were 199 observed aggressive behaviours during the 6-week study period.

MAIN OUTCOMES AND RESULTS

All sub-scales of the OAS-MNR-E had high percentage agreement (>92%) and the kappa statistic was uniformly excellent (>0.77). Multiple ratings within a sub-scale resulted in lower reliabilities. Incidents with multiple interventions were of longer duration. Interventions were on average more intrusive when used in combination than when used singly.

CONCLUSIONS

The OAS-MNR-E can be easily incorporated into facility routines and is reliable. The rating tool reported here can provide data that assists in programme design, evaluation and treatment planning.

Agitation After Traumatic Brain Injury

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.