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Huang YQ, Weiss S, Gros P, Wong E, Piché PP, Vyas MV, Tam AKH, Watt JA. Prevention and treatment of traumatic brain injury-related delirium: a systematic review. J Neurol 2023; 270:5966-5987. [PMID: 37634162 DOI: 10.1007/s00415-023-11889-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Our systematic review examines the effectiveness and safety of non-pharmacologic and pharmacologic interventions in preventing or treating traumatic brain injury (TBI)-related delirium in acute care. METHODS We searched four electronic databases (MEDLINE, EMBASE, CENTRAL/CDSR, and PsycINFO) to identify randomized controlled trials (RCTs), quasi-experimental, and observational studies. Eligible studies included adults with TBI, at least one comparator group, delirium as an outcome and took place in acute care. Two reviewers independently completed all study screening, data abstraction, and risk of bias assessment using the Cochrane risk of bias 2 tool for RCTs or risk of bias in non-randomized studies-of interventions tool for observational studies. We implemented the PROGRESS-Plus framework to describe social determinants of health (SDoH) reporting. RESULTS We identified 20,022 citations, reviewed 301 in full text, and included eight studies in the descriptive synthesis. The mean age of study participants ranged from 32 to 62 years. 12.5% of included studies reported SDoH. Included studies had moderate-to-high risk of bias. Studies compared reorientation programs and an intervention bundle to usual care, but these interventions were not better than usual care in treating TBI-related delirium. Individual studies found that rosuvastatin and aripiprazole were more efficacious than placebo, and dexmedetomidine was more efficacious than propofol and haloperidol for preventing TBI-related delirium. No studies reported safety as the primary outcome. CONCLUSIONS We identified efficacious pharmacologic interventions for preventing TBI-related delirium, but these studies were at moderate-to-high risk of bias, which limits our confidence in these findings. Future studies should incorporate safety outcomes, and a diverse study population, including older adults.
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Affiliation(s)
- Yu Qing Huang
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, ON, M5G 2C4, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada
| | - Sophie Weiss
- Temerty Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Priti Gros
- Division of Neurology, Department of Medicine, University of Toronto, 6th Floor, Stroke and Neurology Clinic, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Edwin Wong
- Temerty Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Pierre-Philippe Piché
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Manav V Vyas
- Division of Neurology, Department of Medicine, University of Toronto, 6th Floor, Stroke and Neurology Clinic, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Alan Ka Ho Tam
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, M5G 2C4, Canada
| | - Jennifer Ann Watt
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, ON, M5G 2C4, Canada.
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada.
- St. Michael's Hospital, 36 Queen St East, Toronto, ON, M5B 1W8, Canada.
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Lannin NA, Galea C, Coulter M, Gruen R, Jolliffe L, Ownsworth T, Schmidt J, Unsworth C. Feasibility of modifying the hospital environment to reduce the length of amnesia after traumatic brain injury: a pilot randomized controlled trial. Int J Qual Health Care 2021; 33:6162463. [PMID: 33693639 DOI: 10.1093/intqhc/mzab044] [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: 09/20/2020] [Revised: 12/21/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Reorientation programmes have been an important component of neurotrauma rehabilitation for adults who suffer from post-traumatic amnesia (PTA) after traumatic brain injury (TBI); however, research testing the efficacy of acute programmes is limited. OBJECTIVE This study aimed to determine if it is feasible to provide a standardized environmental reorientation programme to adults suffering from PTA after TBI in an acute care hospital setting, and whether it is likely to be beneficial. METHODS We conducted a randomized controlled trial with concealed allocation and intention-to-treat analysis. A total of 40 participants suffering from PTA after TBI were included. The control group received usual care; the experimental group received usual care plus a standardized orientation programme inclusive of environmental cues. The primary outcome measure was time to emergence from PTA measured by the Westmead PTA Scale, assessed daily from hospital admission or on regaining consciousness. RESULTS Adherence to the orientation programme was high, and there were no study-related adverse responses to the environmental orientation programme. Although there were no statistically significant between-group differences in time to emergence, the median time to emergence was shorter for those who received the standardized reorientation programme (9.0 (6.4-11.6) versus 13.0 (4.5-21.5) days). Multivariate analysis showed that the Glasgow Coma Scale (GCS) at scene (P = 0.041) and GCS at arrival at hospital (P = 0.0001) were significant factors contributing to the longer length of PTA. CONCLUSION Providing an orientation programme in acute care is feasible for adults suffering from PTA after TBI. A future efficacy trial would require 216 participants to detect a between-group difference of 5 days with an alpha of 0.05 and a power of 80%.
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Affiliation(s)
- Natasha A Lannin
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia.,Occupational Therapy Department, Alfred Health, Melbourne, VIC, Australia
| | - Claire Galea
- Melanoma Institute Australia, Sydney, NSW, Australia
| | - Megan Coulter
- Occupational Therapy Department, Alfred Health, Melbourne, VIC, Australia
| | - Russell Gruen
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - Laura Jolliffe
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia.,Occupational Therapy Department, Alfred Health, Melbourne, VIC, Australia
| | - Tamara Ownsworth
- Menzies Health Institute Queensland, Griffith University, Mount Gravatt, QLD, Australia
| | - Julia Schmidt
- University of British Columbia, Vancouver, BC, Canada
| | - Carolyn Unsworth
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia.,Federation University, Mount Helen, VIC, Australia
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Quach NT, Ehsanian R, Dirlikov B, Sechrist S, Mohole J, McKenna S, Isaac L, Duong TT. Burden of Care Implications and Association of Intracranial Hypertension With Extremely Severe Post-traumatic Amnesia After Traumatic Brain Injury: A 5-Year Retrospective Longitudinal Study. Front Neurol 2019; 10:34. [PMID: 30761071 PMCID: PMC6361805 DOI: 10.3389/fneur.2019.00034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/10/2019] [Indexed: 11/30/2022] Open
Abstract
Post-traumatic amnesia (PTA) is characterized by a state of disorientation and confusion following traumatic brain injury (TBI). Few studies have looked at the effect of prolonged PTA on the functional outcomes beyond 1 year post-injury. This study aims to evaluate the burden of care in individuals with extremely severe PTA (esPTA; PTA >28 days) from acute inpatient rehabilitation admission to 5 years post-injury as well as the association between intracranial hypertension (ICH; Intracranial pressure (ICP) ≥20 mmHg) and esPTA status. Three hundred and forty-two individuals with moderate to severe TBI enrolled in the Northern California TBI Model System (TBIMS) of Care were included in this study. The FIM® instrument was chosen as the outcome measurement as it is a widely used functional assessment in the rehabilitation community. Repeated measure ANOVA revealed greater burden of care based on FIM® total scores (p < 0.001) from admission to 5-year follow-up for the esPTA group compared to the non-esPTA group (PTA ≤ 28 days). Unlike the non-esPTA group where FIM® total score plateaued 1 year post-injury, FIM® total score continued to improve up to 2 years post-injury for the esPTA group. The odds of developing esPTA was ~3 times higher for individuals with ICH vs. individuals without ICH (p < 0.001). In conclusion, individuals with esPTA have increased short- and long-term burden of care and the presence of ICH during hospitalization increased the odds of experiencing esPTA. These results may help the rehabilitation team and family in planning care post rehabilitation discharge.
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Affiliation(s)
- Nhung T Quach
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Reza Ehsanian
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States.,Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Benjamin Dirlikov
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Samantha Sechrist
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Jyodi Mohole
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Stephen McKenna
- Department of Neurosurgery, Stanford University, Stanford, CA, United States.,Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, United States.,Department of Orthopedic Surgery, Stanford University, Stanford, CA, United States
| | - Linda Isaac
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, United States
| | - Thao T Duong
- Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, United States.,Department of Orthopedic Surgery, Stanford University, Stanford, CA, United States
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Steel J, Ferguson A, Spencer E, Togher L. Language and cognitive communication during post-traumatic amnesia: A critical synthesis. NeuroRehabilitation 2015; 37:221-34. [DOI: 10.3233/nre-151255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joanne Steel
- Speech Pathology, The University of Newcastle, Newcastle, NSW, Australia
- NHMRC Clinical Centre of Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia
| | - Alison Ferguson
- Speech Pathology, The University of Newcastle, Newcastle, NSW, Australia
- NHMRC Clinical Centre of Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia
| | - Elizabeth Spencer
- Speech Pathology, The University of Newcastle, Newcastle, NSW, Australia
| | - Leanne Togher
- Speech Pathology, The University of Sydney, Sydney, NSW, Australia
- NHMRC Clinical Centre of Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia
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Ponsford J, Janzen S, McIntyre A, Bayley M, Velikonja D, Tate R. INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part I. J Head Trauma Rehabil 2014; 29:307-20. [DOI: 10.1097/htr.0000000000000074] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Silva SCFE, Settervall CHC, Sousa RMCD. Amnésia pós-traumática e qualidade de vida pós-trauma. Rev Esc Enferm USP 2012; 46 Spec No:30-7. [DOI: 10.1590/s0080-62342012000700005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 07/04/2012] [Indexed: 11/22/2022] Open
Abstract
Este estudo compara a qualidade de vida das vítimas que apresentaram amnésia pós-traumática de longa duração com as demais e analisa a relação entre qualidade de vida e duração da amnésia pós-traumática, computando ou não o período de coma. Estudo de coorte prospectivo, com coleta de dados durante a internação hospitalar e avaliação da qualidade de vida no período de estabilidade da recuperação pós-traumática. Participaram desta investigação vítimas de trauma crânio-encefálico contuso, maiores de 14 anos, sem antecedentes de demência ou trauma crânio-encefálico, internadas em hospital de referência para atendimento de trauma nas primeiras 12 horas pós-evento. Os resultados referentes à qualidade de vida foram mais desfavoráveis em três domínios do grupo com amnésia de longa duração. Correlações entre duração da amnésia e domínios de qualidade de vida foram mais expressivas quando excluído o período de coma, indicando que este tempo não deve ser computado na duração da amnésia pós-traumática.
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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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Langhorn L, Sorensen JC, Pedersen PU. A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care. J Clin Nurs 2011; 19:2959-69. [PMID: 21040002 DOI: 10.1111/j.1365-2702.2010.03330.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To identify the effect of early rehabilitation of patients with post-traumatic amnesia in patients with traumatic brain injury, to review and critically assess evidence related to the timing of intervention and to identify the effect on outcome of a specific neurological rehabilitation in acute care. BACKGROUND Up to 70% of patients with traumatic brain injury will experience post-traumatic amnesia. Although duration of post-traumatic amnesia is correlated negatively with outcome for patients with traumatic brain injury, there is limited evidence relating to what influence timing and effect may have on enhancing early rehabilitation patient outcomes. DESIGN A critical literature review. METHODS Searches for systematic reviews were undertaken in Medline, CINAHL, Cochrane, PSYC INFO and Neurotraume databases. The efficacy of intervention and timing was classified based on a hierarchy of study designs for questions about health care interventions based on soundness of design. RESULTS Six reviews and 11 original studies were included and comprised the review. Many studies used weak designs and small sample size, thus limiting their ability to control confusing variables and outcomes. Few studies included papers with the information about timing and effect of early post-traumatic amnesia intervention. Only one study showed an effect of a reality orientation programme in acute care. Although there was no significant detail reported on the possibility of reducing the post-traumatic amnesia period, the study showed clinical relevance. CONCLUSION This review highlights the limited evidence of the effect of early rehabilitation of patients with post-traumatic amnesia. Future research should be conducted to identify the effectiveness of early intervention. RELEVANCE TO CLINICAL PRACTICE Although nurses are treating patients with post-traumatic amnesia without systematic assessment, the limited evidence available does little to direct nurses as to the best approach to start early rehabilitation of post-traumatic amnesia to promote good outcomes.
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Affiliation(s)
- Leanne Langhorn
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.
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Abstract
O trauma crânio-encefálico contuso (TCEC) é freqüentemente seguido pela amnésia pós-traumática (APT), caracterizada como um estado transitório de confusão e desorientação. Sua duração tem sido utilizada para quantificar a gravidade do TCEC e prever distúrbios nas funções cognitivas, assim como para antever as alterações na capacidade funcional das vítimas pós-trauma. O Galveston Orientation Amnesia Test (GOAT) é o primeiro instrumento sistematizado criado e o mais amplamente utilizado para avaliar a APT. Este artigo apresenta esse instrumento, as bases conceituais para seu desenvolvimento e a adaptação e validação do GOAT para cultura brasileira. Além disso, descreve sua aplicação e comenta as restrições do seu uso. Resultados de pesquisas realizadas em nosso meio contribuíram para as evidências sobre a validade do GOAT. Também apontaram os indicadores do momento pós-trauma em que o GOAT deve ser aplicado e destacaram as dificuldades no uso desse instrumento.
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10
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De Guise E, Leblanc J, Dagher J, Lamoureux J, Jishi AA, Maleki M, Marcoux J, Feyz M. Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of injury. Brain Inj 2009; 23:853-65. [DOI: 10.1080/02699050903283221] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Silva SCFE, Sousa RMCD. Galveston Orientation and Amnesia Test: applicability and relation with the Glasgow Coma Scale. Rev Lat Am Enfermagem 2007; 15:651-7. [DOI: 10.1590/s0104-11692007000400020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 05/10/2007] [Indexed: 11/22/2022] Open
Abstract
Restrictions in the application of the Galveston Orientation and Amnesia Test and questionings about the relationship between conscience and post-traumatic amnesia motivated this study, which aims to identify, through the Glasgow Coma Scale scores, when to initiate the application of this amnesia test, as well to verify the relationship between the results of these two indicators. The longitudinal prospective study was carried at a referral center for trauma care in São Paulo - Brazil. The sample consisted of 73 victims of blunt traumatic brain injury, admitted at this institution between January 03rd and May 03rd 2001. Regarding the applicability, the test could be applied in patients with a Glasgow Coma Scale score > 12; however, the end of post traumatic amnesia was verified in patients who scored > 14 on the scale. A significant relationship (r s = 0.65) was verified between these measures, although different kinds of relationship between the end of the amnesia and changes in consciousness were observed.
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Abstract
OBJETIVO: Traduzir e validar o Galveston Orientation and Amnesia Test para uso em nosso meio. MÉTODOS: Esse teste foi traduzido para o português e retro-traduzido para o inglês por diferentes especialistas na língua e por fim, feita a avaliação da equivalência entre o instrumento original e a versão retro-traduzida. Sua aplicação em 73 vítimas de trauma crânio-encefálico contuso e a indicação da gravidade dessa lesão, estabelecida pela Escala de Coma de Glasgow, permitiram verificar as propriedades de medida do instrumento. RESULTADOS: A confiabilidade verificada pelo Alfa de Cronbach resultou em 0,76. Houve indicação de validade convergente e discriminante do instrumento quando os resultados de aplicação do Galveston Orientation and Amnésia Test foram analisados perante a gravidade do trauma crânio-encefálico. CONCLUSÃO: Os resultados observados dão suporte para a aplicação do Galveston Orientation and Amnesia Test em nosso meio como indicador do término da amnésia pós-traumática.
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