Agitation, cognition and attention during post-traumatic amnesia

Post-traumatic amnesia: a scoping review & content analysis of behavioral disturbances

OBJECTIVE

The aim of this scoping review was to identify behavioral disturbances exhibited by patients in post-traumatic amnesia (PTA). While behavioral disturbances are common in PTA, research into their presentation and standardized measures for their assessment are limited.

DESIGN

The study protocol was registered with PROSPERO (CRD42021268275). A scoping review of databases was performed according to pre-determined criteria on 29 July 2021 and updated on 13 July 2022. A conventional content analysis was used to examine and categorize behavioral disturbances.

RESULTS

Thirty papers met the inclusion criteria, of which 27 reported observations and/or scores obtained on behavioral scales, and 3 on clinician interviews and surveys. None focused exclusively on children. Agitation was the most frequently assessed behavior, and Agitated Behavior Scale was the most used instrument. Content analysis, however, bore eight broad behavioral categories: disinhibition, agitation, aggression, lability, lethargy/low mood, perceptual disturbances/psychotic symptoms, personality change and sleep disturbances.

CONCLUSION

Our study revealed that while standardized assessments of behavior of patients in PTA are often limited to agitation, clinical descriptions include a range of behavioral disturbances. Our study highlights a significant gap in the systematic assessment of a wide range of behavioral disturbances observed in PTA.

Predictors for quality of life in older adults: network analysis on cognitive and neuropsychiatric symptoms

BACKGROUND

Quality of life (QoL) of older adults has become a pivotal concern of the public and health system. Previous studies found that both cognitive decline and neuropsychiatric symptoms (NPS) can affect QoL in older adults. However, it remains unclear how these symptoms are related to each other and impact on QoL. Our aim is to investigate the complex network relationship between cognitive and NPS symptoms in older adults, and to further explore their association with QoL.

METHODS

A cross-sectional study was conducted in a sample of 389 older individuals with complaints of memory decline. The instruments included the Neuropsychiatric Inventory, the Mini Mental State Examination, and the 36-item Short Form Health Survey. Data was analyzed using network analysis and mediation analysis.

RESULTS

We found that attention and agitation were the variables with the highest centrality in cognitive and NPS symptoms, respectively. In an exploratory mediation analysis, agitation was significantly associated with poor attention (β = -0.214, P < 0.001) and reduced QoL (β = -0.137, P = 0.005). The indirect effect of agitation on the QoL through attention was significant (95% confidence interval (CI) [-0.119, -0.035]). Furthermore, attention served as a mediator between agitation and QoL, accounting for 35.09% of the total effect.

CONCLUSIONS

By elucidating the NPS-cognition-QoL relationship, the current study provides insights for developing rehabilitation programs among older adults to ensure their QoL.

Cross-cultural adaptation, translation, and validation of a Spanish version of the Westmead Post-traumatic Amnesia Scale for use following a traumatic brain injury

Health professionals need linguistically and culturally correct tools with proven validity to effectively assess people in their native language. This study aimed to translate and validate the Westmead Post-traumatic Amnesia Scale (WPTAS) into a Spanish version to measure the progression and duration of post-traumatic amnesia (PTA) in Spanish-speaking populations. Seven native Spanish and English translators, 11 therapists and 15 people with a traumatic brain injury (TBI) and nine people with non-traumatic acquired brain injury participated in the forward-backward translation method to adapt the WPTAS. Participants with a TBI in PTA (n = 20), out of PTA (n = 21), and controls without cognitive impairment (n = 21) participated in the validation test phase by completing the WPTAS, Selective Reminding Test, Short Portable Metal Status Questionnaire, Digit Span, and Agitated Behaviour Scale. The translated version of the WPTAS produced consistent responses and appropriate errors (2%) among all pre-test participants. Results from the validation phase showed that participants in PTA scored significantly lower in all tests (p < .05) when compared with those out of PTA and controls. The Spanish version of the WPTAS created and tested in this study is culturally and linguistically appropriate as well as valid for use with Spanish speakers.

Exploring physical activity during the discharge transition phase in people with acquired brain injury – an observational study

Objective

To explore physical activity trajectories during the discharge transition phase after in-hospital rehabilitation after acquired brain injury (ABI).

Design

A cross-sectional observational study.

Setting

Transition from an in-hospital rehabilitation center to community-based living.

Participants

Independently walking patients with ABI (n=10) who were ready for discharge.

Interventions

Not applicable.

Main Outcome Measures

Two weeks of physically active time continuously monitored with an accelerometer and classified by a machine learning algorithm summed as daily average and total active time for each participant and classified into standing, walking, running, bike riding, stair climbing, ambulation, and sedentary time. Physical activity trajectories showing the total daily active time for all participants were inspected before and after discharge, and the average active time per participant was plotted against self-reported scores of potentially explanatory factors.

Results

Average total physically active time was 5:49 hours (range 4:26-7:13 hours). Average daily physically active time for participants appeared to be related to functional independence measure sub scores, fatigue, and pre-morbid physical activity level. Individual physical activity trajectories showed a decreased walking activity after discharge, which increased again after 1-2 days.

Conclusions

Daily total physically active time among participants was higher than expected. Factors expectedly related to physical activity trajectories in the discharge transition phase were explored and showed some relation to functional scores.

Aspects of Cognitive Impairment Associated with Agitated Behaviour during Post-traumatic Amnesia

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.

Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behavior Type

Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages of recovery is unknown. The aim of this systematic review and meta-analysis was to evaluate the prevalence of agitation in TBI patients undergoing inpatient care, and whether this prevalence differed by post-traumatic amnesia (PTA) status and setting (acute and rehabilitation). We also aimed to describe the prevalence of sub-types of agitated behavior (disinhibited, aggressive, and emotionally labile). We searched five databases and one clinical trials register, with additional review of websites and key journals to identify any relevant records up to July 2020. We included studies describing the proportion of hospitalized TBI patients age 16 years or older demonstrating agitated behavior. We included comparative studies with and without concurrent controls, randomized controlled trials, pseudo-randomized controlled trials, and case series. Methodological quality was critically appraised using a Joanna Briggs Institute checklist. Sixteen studies met eligibility criteria, with a total of 5592 participants. The pooled prevalence of agitation was 31.73% (95% confidence interval [CI], 25.25%-39.00%) during inpatient care (acute and rehabilitation), 32.23% (95% CI, 27.13%-37.80%) during rehabilitative care and 44.06% (95% CI, 36.15%-52.28%) for inpatients in PTA specifically. Disinhibited behaviors were the most common. There was substantial heterogeneity between studies. Additional high-quality research featuring large samples, frequent and long-term measurement of agitation, use of validated scales, and consideration of variables such as PTA status will further improve estimates of agitation prevalence following TBI.

Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial

Background

Agitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management.

Methods

Fifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured.

Discussion

This trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population.

Trial registration

ANZCTR ACTRN12619000284167. Registered on 25 February 2019

Retrograde Personal Semantic Memory During Post-Traumatic Amnesia and Following Emergence

OBJECTIVES

Anecdotal reports suggest that following traumatic brain injury (TBI) retrograde memories are initially impaired and recover in order of remoteness. However, there has been limited empirical research investigating whether a negative gradient in retrograde amnesia-relative preservation of remote over recent memory-exists during post-traumatic amnesia (PTA) compared with the acute phase post-emergence. This study used a repeated-measures design to examine the pattern of personal semantic (PS) memory performance during PTA and within two weeks of emergence to improve understanding of the nature of the memory deficit during PTA and its relationship with recovery.

METHODS

Twenty patients with moderate-severe TBI and 20 healthy controls (HCs) were administered the Personal Semantic Schedule of the Autobiographical Memory Interview. The TBI group was assessed once during PTA and post-emergence. Analysis of variance was used to compare the gradient across lifetime periods during PTA relative to post-emergence, and between groups.

RESULTS

PS memory was significantly lower during PTA than post-emergence from PTA, with no relative preservation of remote memories. The TBI group was still impaired relative to HCs following emergence from PTA. Lower overall PS memory scores during PTA were associated with increased days to emerge from PTA post-interview.

CONCLUSIONS

These results suggest a global impairment in PS memory across lifetime periods particularly during PTA, but still present within 2 weeks of emergence from PTA. PS memory performance may be sensitive to the diffuse nature of TBI and may, therefore, function as a clinically valuable indicator of the likely time to emerge from PTA. (JINS, 2018, 24, 1064-1072).

Efficacy and Harms of Pharmacological Interventions for Neurobehavioral Symptoms in Post-Traumatic Amnesia after Traumatic Brain Injury: A Systematic Review

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.

Efficacy and harms of pharmacological interventions for neurobehavioral symptoms in post traumatic amnesia after traumatic brain injury: a systematic review and meta-analysis protocol

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.

Pharmacological interventions for agitation in patients with traumatic brain injury: protocol for a systematic review and meta-analysis

BACKGROUND

Traumatic brain injury (TBI) is a worldwide leading cause of mortality and disability. Among TBI complications, agitation is a frequent behavioural problem. Agitation causes potential harm to patients and caregivers, interferes with treatments, leads to unnecessary chemical and physical restraints, increases hospital length of stay, delays rehabilitation, and impedes functional independence. Pharmacological treatments are often considered for agitation management following TBI. Several types of agents have been proposed for the treatment of agitation. However, the benefit and safety of these agents in TBI patients as well as their differential effects and interactions are uncertain. In addition, animal studies and observational studies have suggested impaired cognitive function with the use of certain antipsychotics and benzodiazepines. Hence, a safe and effective treatment for agitation, which does not interfere with neurological recovery, remains to be identified.

METHODS/DESIGN

With the help of Health Sciences librarian, we will design a search strategy in the following databases: PubMed, Ovid MEDLINE®, EMBASE, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science, and Prospero. A grey literature search will be performed using the resources suggested in CADTH's Grey Matters. We will include all randomized controlled, quasi-experimental, and observational studies with control groups. The population of interest is all patients, including children and adults, who have suffered a TBI. We will include studies in which agitation, not further defined, was the presenting symptom or one of the presenting symptoms. We will also include studies where agitation was not the presenting symptom but was measured as an outcome variable and studies assessing the safety of these pharmacological interventions in TBI patients. We will include studies evaluating all pharmacological interventions including beta-adrenergic blockers, typical and atypical antipsychotics, anticonvulsants, dopamine agonists, psychostimulants, antidepressants, alpha-2-adrenergic agonists, hypnotics, and anxiolytics.

DISCUSSION

Although agitation is frequent following TBI and pharmacological agents that are often used, there is no consensus on the most efficacious and safest strategy to treat these complications. There is a need for an updated systematic review to summarize the evidence in order to inform practice and future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033140.

Effect of Preferred Music on Agitation After Traumatic Brain Injury

Agitation is a common behavioral problem after traumatic brain injury (TBI), which threatens the safety of patients and caregivers and disrupts the rehabilitation process. This study aimed to evaluate the effects of a preferred music intervention on the reduction of agitation in TBI patients and to compare the effects of preferred music with those of classical “relaxation” music. A single group, within-subjects, randomized crossover trial design was formed, consisting of 14 agitated patients with cognitive impairment after severe TBI. Patients listened to preferred music and classical “relaxation” music, with a wash-out period in between. Patients listening to the preferred music reported a significantly greater reduction in agitation compared with the effect seen during the classical “relaxation” music intervention ( p = .046). These findings provide preliminary evidence that the preferred music intervention may be effective as an environmental therapeutic approach for reducing agitation after TBI.

Problems and Pitfalls in the Assessment of Posttraumatic Amnesia

In the early stages of recovery after a traumatic brain injury, patients usually experience a period of posttraumatic amnesia (PTA) in which they are confused, amnesic for ongoing events, and frequently behaviourally agitated. Although a variety of procedures and instruments are available to measure the duration of PTA, their applications in clinical practice are far from ideal. This review paper describes retrospective and prospective measures of PTA and critically examines variations in item content and scoring procedures. In particular, methods currently available to measure the amnesia component of PTA are especially problematic. The limitations of PTA scales give rise to a number of difficulties that impact upon clinical practice. These include determining precisely when a patient has emerged from PTA, and distinguishing between patients in PTA and those with chronic amnesia. It is concluded that there is a need to revisit basic constructs comprising PTA, and develop an instrument with greater specificity. More focus should be placed on examining the confusional component of PTA, and validity of PTA tests would be improved by measuring attention and behaviour, in addition to orientation and memory.

Patterns of agitated behaviour during acute brain injury rehabilitation

OBJECTIVE

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

DESIGN

A prospective, descriptive study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of acute care medications on rehabilitation outcome after traumatic brain injury

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.

Objective and behavioural assessment of the emergence from post-traumatic amnesia (PTA)

PRIMARY OBJECTIVE

To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA.

RESEARCH DESIGN

Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis.

METHODS AND PROCEDURES

Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics.

MAIN OUTCOMES AND RESULTS

Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA.

CONCLUSIONS

It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.

Acetylcholine and choline dynamics provide early and late markers of traumatic brain injury

We assessed acetylcholine (ACh) and choline (Ch) dynamics 2.5 h, 1, 4 and 14 days after cerebral cortex impact injury or craniotomy only in adult male Sprague-Dawley rats. Cortical endogenous ACh (D0ACh), endogenous free Ch (D0Ch), deuterium-labeled Ch (D4Ch), and ACh synthesized from D4Ch (D4ACh) were measured by gas-chromatography mass-spectrometry after intravenous injection of D4Ch followed in 1 min by microwave fixation of the brain. D0Ch increased in and around the impact up to 700% of control within 1 day after trauma. Smaller D0Ch increases were found in the cortex contralateral to the impact and in both hemispheres after craniotomy only. D4Ch contents increased to 200% in the impact and surrounding regions 4-14 days post-trauma, with lower increases 2.5 h post-trauma. D0ACh decreased at all times post-trauma in the impact center, and initially in the periphery and adjacent regions with a recovery at 14 days. Similar D0ACh decreases, although of lesser extent and magnitude were present in the craniotomy only group. D4ACh showed a peak at one day post-trauma in all regions studied in the impact and craniotomy groups. In conclusion, D0Ch tissue level was an early marker of trauma, while 14 days after trauma Ch uptake from blood was enhanced in and around the traumatized cortex. Craniotomy by itself induced a generalized increase in ACh turnover 1 day after this minimal trauma. Choline acetyltransferase activity was reduced in the impact center region but not affected in the adjacent and contralateral regions or by craniotomy.

A multicentre, randomised trial examining the effect of test procedures measuring emergence from post-traumatic amnesia

BACKGROUND

Post-traumatic amnesia (PTA) tests that record different PTA durations in the same patient, thereby raising measurement accuracy issues, have been reported previously. A major problem lies in determining the end point of PTA.

AIMS

To delineate areas of discrepancy in PTA tests and to provide independent verification for a criterion signalling emergence from PTA.

METHODS

In a randomised design, two related PTA procedures were compared, one purportedly more difficult (Westmead PTA Scale, WPTAS) than the other (Modified Oxford PTA Scale, MOPTAS). Eighty two patients in the early stages of PTA were examined daily until emergence, by using the Galveston Orientation and Amnesia Test (GOAT) and the WPTAS/MOPTAS. A short battery of cognitive and behavioural measurements was made on three occasions: at the early stage of PTA (time 1), towards the end of PTA when the maximum score (12/12) was first obtained (time 2) and at the traditional criterion for emergence (scoring 12/12 for 3 consecutive days; time 3).

RESULTS

No significant difference was recorded in PTA duration between the MOPTAS and WPTAS. Both scales recorded longer PTA durations than the GOAT. By using Kaplan-Meier survival analyses, the WPTAS was found to show a more protracted pattern of emergence at the end stage of PTA than the MOPTAS. A time lag of > or = 1 week in the resolution of disorientation as compared with amnesia was observed in 59% cases. Significant improvements occurred on all independent measurements between time 1 and time 2, but on only 2 of 5 cognitive measurements between time 2 and time 3.

CONCLUSIONS

Although no significant differences in the duration of PTA on the MOPTAS/WPTAS were recorded, emergence from the late stages of PTA occurred more promptly with the MOPTAS. The need for inclusion of both orientation and memory items in PTA tests is highlighted by the frequency of disorientation-amnesia dissociations. The patterns of results on the independent measures suggest that patients who are in PTA for > 4 weeks have probably emerged from PTA when they first score 12/12 on the MOPTAS/WPTAS, and this criterion can replace the traditional criterion.

Aggressive behavior following traumatic brain injury: how common is common?

OBJECTIVE

To assess the prevalence and predictors of aggressive behavior among traumatic brain injury (TBI) survivors at 6, 24, and 60 months postdischarge.

DESIGN

Mixed cross-sectional and longitudinal data from a 5-year follow-up study of discharged TBI patients analyzed retrospectively.

SETTING

A specialized Brain Injury Rehabilitation Service of a tertiary referral hospital.

PATIENTS

Two hundred twenty-eight (228) patients with moderate to severe TBI.

MAIN OUTCOME MEASURES

The Overt Aggression Scale; injury-related variables (in particular, Glasgow Coma and Outcome scales and posttraumatic amnesia duration); and a battery of postdischarge questionnaires (Beck Depression Inventory, Trauma Complaints List, General Health Questionnaire, etc).

RESULTS

At any given follow-up period, 25% of the participants were classified as aggressive. Aggression, where present, was consistently associated with depression, concurrent traumatic complaints, younger age at injury, and low satisfaction with life rather than with injury, demographic, or premorbid characteristics. Depression was the factor that was most significantly associated with aggressive behavior at all times postinjury, followed by a younger age at the time of injury.

CONCLUSIONS

Aggression is a common, fluctuating, and long-term problem following TBI. The underlying association between aggression and psychosocial variables lends support to the provision of ongoing outreach services and psychological and behavioral interventions for all affected TBI survivors.

Gender Differences in Agitation After Traumatic Brain Injury

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.

Positive behavioural disturbances in the rehabilitation phase after severe traumatic brain injury: an historic cohort study

PRIMARY OBJECTIVE

To investigate the association of post-traumatic amnesia (PTA) with positive behavioural disturbances (PBD) in an historic cohort of patients with severe traumatic brain injury (TBI) and to evaluate the use and effects of neuroleptic drugs in this cohort.

RESEARCH DESIGN

Historic cohort study.

METHODS

The medical files of 60 patients with severe TBI, selected for inpatient rehabilitation during a period of 5.5 years, were independently examined for the presence of PTA and PBD at admission in the rehabilitation centre as well as for the concomitant use of neuroleptic drugs. All TBI patients with PBD at admission were subjected to special nursing measures consisting of a structured and safe environment, a minimum number of caregivers and provision of simple and consistent feedback. As a basic policy, the use of neuroleptic medication was minimized or stopped.

RESULTS

Of the 28 patients suffering from PTA at admission, 16 demonstrated PBD (positive predictive value 0.57 (95% CI 0.45-0.70)). In contrast, all the 32 patients without PTA but one did not show PBD (negative predictive value 0.97 (95% CI 0.93-1.00)). Seven of the 17 patients with PBD (41%) had been prescribed neuroleptic medication, of whom five patients (81%) experienced undesired side effects. Because of the special nursing measures, these drugs could be stopped or substituted by non-neuroleptic behaviour-modifying drugs in all patients within 3 weeks, without aggravation of their PBD.

CONCLUSIONS

These results suggest that impaired attention and memory may play a critical role in the development of PBD in patients with severe TBI. From this perspective, maximum effort must be made to improve TBI patients' level of attention, memory and orientation instead of using mechanical or chemical restraints.

Predicting duration of posttraumatic amnesia (PTA) from early PTA measurements

OBJECTIVES

To determine a set of variables that would reliably predict duration of posttraumatic amnesia (PTA) in patients with traumatic brain injury and to test the efficacy of the model.

DESIGN

Simultaneous standard multiple regression analyses.

PARTICIPANTS

Two independent samples of patients with traumatic brain injury who were in the early stages of PTA: a test sample (n = 61) and a cross-validation sample (n = 25).

MAIN OUTCOME MEASURE

The Modified Oxford PTA Scale (MOPTAS) is a 12-item test measuring orientation (8 items) and anterograde memory (4 items). The Galveston Orientation and Amnesia Test (GOAT) was also used on a subset of the test sample.

PROCEDURE

Patients were examined daily until they emerged from PTA.

RESULTS

A statistically significant model, using three predictor variables, was derived that reliably predicted duration of PTA, accounting for 89% of the variance. A second model, using two predictor variables readily available to the clinician (day posttrauma on which PTA testing began and aggregate PTA scores over the first 5 days of testing) had comparable predictive accuracy. A third model, using GOAT data, was also statistically significant and successfully accounted for 72% of the variance. The MOPTAS model showed excellent application to an independent (validation) sample, with an intraclass correlation coefficient between observed and predicted durations of PTA of 0.95. Regression equations for all three models are provided to enable calculation of the predicted duration of PTA.

CONCLUSIONS

These models can be readily applied in clinical practice and will provide clinically useful estimates of the duration of PTA within the first week of testing after admission to rehabilitation. This information will be important in terms of family counseling and planning of rehabilitation programs.

A comparison of acute and postdischarge predictors of employment 2 years after traumatic brain injury

OBJECTIVE

To examine whether adding postdischarge psychosocial predictors to premorbid and injury-related variables improved the capacity to predict employment 2 years after rehabilitation for traumatic brain injury (TBI).

DESIGN

Data were collected prospectively at 6 and 24 months after discharge from rehabilitation. Logistic regression analyses examined predictors of employment status.

SETTING

Inpatient and community TBI rehabilitation service attached to a major Australian teaching hospital.

PARTICIPANTS

Fifty-five patients with TBI, aged 16 or older, who were consecutively admitted to a brain injury unit with complete longitudinal data and who agreed to participate in the study.

INTERVENTION

Measured injury severity (Glasgow Coma Scale scores, posttraumatic amnesia); functional independence (Functional Assessment Measure cognitive subscale) at admission and discharge from rehabilitation; self-report of employment (premorbid, postdischarge); postdischarge psychosocial status at 6 months and 2 years (Community Integration Questionnaire, General Health Questionnaire, Trauma Complaints List, Overt Aggression Scale, Alcohol Use Disorders Inventory Test, Satisfaction with Life Scale).

MAIN OUTCOME MEASURES

Employment status (employed, unemployed) was used to reflect vocational outcome. Predictor variables comprised premorbid work status, injury-related variables (age, injury severity), and postdischarge variables (employment, community integration, psychologic, cognitive status).

RESULTS

Adding postdischarge predictors to premorbid and acute variables significantly improved the ability to predict work status 2 years after rehabilitation. Age at the time of injury, premorbid employment status, work status, and psychologic distress 6 months postdischarge were significant predictors of employment.

CONCLUSIONS

It is important to consider postdischarge psychologic well-being, in conjunction with premorbid and acute factors, in vocational interventions after TBI.

Acute behavioural disturbances related to imaging studies and outcome in mild-to-moderate head injury

The frequency of behavioural disturbances early after injury in relation to outcome was prospectively investigated in a series of 67 patients with mild-to-moderate head injury (as defined by GCS on admission). In more than half of the patients, behavioural disturbances were observed. Restlessness occurred in 40% of patients, whereas agitation was seen in 19% of patients. In all patients, restlessness and agitation disappeared before resolution of PTA. In multiple regression analysis, restlessness and PTA were found to be separate factors in predicting outcome. On imaging studies, twice as many lesions were seen in patients with restlessness and agitation (81% compared to 39%), mainly localized in the frontotemporal region. In two thirds of patients with early behavioural disturbances, residual emotional and cognitive impairments were seen 1 year after injury. This study suggests that behavioural disturbances in the early phase after injury are related to frontotemporal lesions and lends support for the view of the existence of a separate profile of patient behaviour in mild-to-moderate head injury.

Rating scale analysis of the Agitated Behavior Scale

OBJECTIVE

Evaluate the measurement properties of the Agitated Behavior Scale (ABS) using rating scale analysis.

SAMPLES

Sample 1: 900 observations of 100 individuals with traumatic brain injury; Sample 2: 204 observations of 102 persons with dementia; Sample 3: 241 observations of 6 individuals with anoxia.

RESULTS

The calibration indicated that the rating scale was used as intended. The hierarchies of item difficulty were similar across samples. Person and item separation values were within the acceptable range for the TBI sample. Generally, the items work well together, however 3 items misfit the measurement model moderately.

CONCLUSIONS

Agitation as measured by the ABS is best represented as a unitary construct. Results provide additional support for the reliability and validity of the ABS.

The acute period of recovery from traumatic brain injury: posttraumatic amnesia or posttraumatic confusional state?

OBJECT

The goal of this study was to characterize more fully the cognitive changes that occur during the period of acute recovery after traumatic brain injury (TBI).

METHODS

The pattern of performance recovery on attention and memory tests was compared with the results of the Galveston Orientation and Amnesia Test (GOAT). Tests of memory and attention were administered serially to a hospitalized group of patients with TBI of varying severity. The tests differed in their level of complexity and/or requirement for more effortful or strategic processing. The authors found a regular pattern to recovery. As expected, ability to perform on simpler tests was recovered before performance on more effortful ones. The ability to recall three words freely after a 24-hour delay (the operational definition in this study of return to continuous memory) was recovered last, later than normal performance on the GOAT. Ability to perform simple attentional tasks was recovered before the less demanding memory task (recognition); ability to perform more complex attentional tasks was recovered before the free recall of three words after a 24-hour delay. This recovery of attention before memory was most notable and distinct in the group with mild TBI.

CONCLUSIONS

The period of recovery after TBI, which is currently termed posttraumatic amnesia, appears to be primarily a confusional state and should be labeled as such. The authors propose a new definition for this acute recovery period and argue that the term posttraumatic confusional state should be used, because it more appropriately and completely characterizes the early period of recovery after TBI.

Reliability of the Agitated Behavior Scale

OBJECTIVE

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

DESIGN

Ratings made by research assistants and nursing staff were compared.

PARTICIPANTS AND SETTING

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

RESULTS

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

CONCLUSION

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

The agitated brain injured patient. Part 1: Definitions, differential diagnosis, and assessment

This two-part review provides a critical analysis of the scientific and clinical literature on the agitated brain injured patient. Part 1 reviews nomenclature and classification issues, differential diagnosis, and assessment instruments designed for evaluation of the patient. Pathophysiology and treatment approaches will be discussed in Part 2 in a subsequent issue of the Archives. The review was unfortunately hampered by a lack of consistency in definitions, little scientific study of the neuroanatomic and neurochemical basis for the disorder, few outcome studies, and no randomized controlled treatment trials. Part 1 sets forth an interdisciplinary definition of agitation, establishes a differential diagnostic approach, and describes and critiques the assessment instruments available for clinical evaluation of the agitated patient. Part 2 will address treatment interventions including pharmacological, environmental, and behavioral approaches to this patient population.

Factor structure of the Agitated Behavior Scale

The Agitated Behavior Scale (ABS; Corrigan, 1989) is a 14-item scale developed to monitor agitation during the acute phase of recovery from acquired brain injury. While previous studies have supported the reliability, internal consistency, and concurrent validity of the ABS, the current study was designed to investigate its underlying factor structure, as well as to determine systematic effects of time-of-day on the occurrence of agitation. Subjects were 212 patients with traumatic or other recently acquired brain injury who exhibited agitation during their treatment on a specialized brain-injury unit of an acute rehabilitation hospital. Confirmatory factor analysis revealed that agitation is best represented by one general construct with three underlying factors: Aggression, Disinhibition, and Lability. Analysis of agitation by nursing shift in which ratings were made confirmed that overall level was lowest during the night shift; however, the relationship between time-of-day and underlying factors deviated from this pattern. Results are discussed in terms of the necessity for objective measurement, definition of the construct of agitation, and time-of-day issues in sampling agitated behavior.

A survey of accredited and other rehabilitation facilities: education, training and cognitive rehabilitation in brain-injury programmes

Although it is routinely acknowledged that cognitive rehabilitation therapy comprises a major part of the services provided to survivors of brain injury, there continues to be no general consensus regarding the methods and training of those who provide cognitive rehabilitation services. This survey of 398 head-injury rehabilitation facilities includes information on which disciplines are providing and supervising cognitive rehabilitation therapy, which therapy formats are used, and a first attempt to define the costs and providers for cognitive therapy staff training in Commission on Accreditation of Rehabilitation Facilities (CARF) approved and other (non-CARF) facilities. The education and training of junior and senior staff members is compared, and respondents suggest changes in the education and training of those who provide cognitive rehabilitation therapy. The results of this survey suggest no significant differences in the organization and delivery of cognitive rehabilitation therapy in CARF and non-CARF programmes. They indicate that cognitive rehabilitation therapy and the education and training of providers deserve further study and definition, given the widespread provision of cognitive rehabilitative services.