NeuroRehabilitation

Posttraumatic agitation is perhaps the most dramatic behavioral consequence of severe traumatic brain injury. The mechanism for this behavior remains to be determined. The development of effective management strategies has been hampered at least in part by the lack of a consensus definition for posttraumatic agitation. The diagnosis of posttraumatic agitation is a diagnosis of exclusion. Concurrent neurologic or medical decline during the recovery from an acute traumatic brain injury may precipitate delirium, which has many clinical features that overlap with posttraumatic agitation. Hence, the differential diagnosis of posttraumatic agitation includes all medical and neurologic etiologies for transient declines in consciousness and cognition.

Advances in clinical interventions for agitation, as well as progress in research toward better understanding of the construct, have been limited by the lack of a reliable and valid measure. This article provides a practical overview of the measurement characteristics of the Agitated Behavior Scale (ABS) (Corrigan, J. Clin Exp Neuropsychol 1989; 11: 261–277) [1]. This 14-item scale has shown significant inter-rater reliability for all items; Total Score inter-rater correlations exceeding 0.70; and internal consistencies based on Cronbach's alphas have consistently exceeded 0.80. The original development of the ABS emphasized the content validity of items and demonstrated the concurrent validity of the Total Score. Subsequent studies have shown the ABS to be predictive of change in cognitive status, and able to differentiate confusion and inattention from agitation. Construct validity has been further substantiated by the identification of underlying factors that have proven stable over multiple samples.

Though agitation frequently occurs following brain injury, allied health professionals on brain injury teams may not possess sufficient clinical competency to manage the manifestations of agitation. Traditional therapy approaches are inadequate for patients experiencing agitation. This paper reviews practical strategies the authors have found effective when treating agitated patients.

Agitation following brain injury is a significant and difficult problem; severe agitiation is most effectively treated by concurrent environmental, behavioral, and pharmacologic interventions. Delirium and agitation are briefly compared, however, a more thorough discussion of this topic appears in other articles within this issue. This article reviews the current literature in regard to practical pharmacologic interventions for agitation following brain injury and outlines short-term and long-term strategies. Common and serious side effects, as well as unique characteristics for each medication are highlighted.

The treatment of agitation and aggression in the TBI patient continues to be a challenge in both the immediate period following injury and later, in the community setting. While there are few studies of non-traditional pharmacologic compounds in TBI subjects, studies of other patient populations with related disorders have been referenced for information on new and experimental compounds. In this article, medications such as the serotonergic system enhancers, atypical neuroleptics, central nervous system stimulants, hormonal agents, and opioid antagonists are reviewed at a basic science and clinical level. Possible directions for their use in the brain-injured patient are discussed.

Improvements in medical care and health have resulted in an increase in life expectancy and with it a steady increase in the number of older adults, which has resulted in an increasing number of brain-injured older adults. There is limited information available however, which specifically defines the incidence, management and outcome of behavioral sequelae, specifically agitation, in the older adult with TBI. The vast majority of the available literature addressing interventions in the agitated older adult, focuses on the individual with a psychiatric or dementing process who is a resident of a long-term care facility. Agitated behavior in the older adult with acute brain injury differs from this patient population and therefore management must also differ. Management includes behavioral strategies, environmental modifications, structured therapy sessions, appropriate medical management and neuropharmacologic interventions. There are no controlled studies which utilize standardized measures and examine the efficacy of these behavioral, environmental, therapeutical and pharmacological interventions for agitation in the older adult following TBI. In general, considerable care must be taken when using medications in the older adult. Alterations in absorption, pharmacokinetics, liver and renal metabolism, receptor sensitivity, side-effect tolerance, and compliance must all be considered. This article aims to present available information and provide a practical and clinically effective guide for the management of agitation in the older adult with brain injury.

Outcome of 295 rehabilitation patients with mild, moderate, and severe brain injury was investigated prospectively at five regional medical centers using the Neurobehavioral Rating Scale. Mean factor scale scores were generally low. with the cognition mean highest and the excitement mean lowest. Regardless of scale, the most significant neurobehavioral difficulties were related to memory, insight, attention, alertness, fatigue, and blunted affect. Conversely, problems rated as least severe included hallucinations, guilt, excitement and lability of mood. Approximately 9% of the sample had at least a moderate problem with agitation, an item on the excitement scale. The general pattern of mean factor scale elevations was consistent with other studies. No relationship was found between injury severity and neurobehavioral characteristics. The relatively low incidence of neurobehavioral problems may reflect recovery and effective interdisciplinary management.

Head trauma is a leading cause of disability and death in young adults in the United States and elsewhere [1–4]. It has been estimated that 422000 patients are hospitalized annually in the United States for head injury [5]. Closed (non-penetrating) head injury accounts for the vast majority of civilian head injuries [6], the major causes of which are motor vehicle accidents (50%) and domestic accidents or falls (33%) [3,5,7]. The majority of victims of head injury will survive, but a large number suffer from significant medical, psychological and neurological sequelae, including seizures. In this chapter we review the literature concerning the relationship of posttraumatic seizures and posttraumatic epilepsy to rehabilitation outcomes following closed head injury.

Antiepileptic drugs (AEDs) are used in rehabilitation patients with injury to the nervous system for control of clinical seizures, prophylaxis against the development of a seizure disorder, and treatment of secondary mania. Although most AEDs can produce mild cognitive side effects, the benefits of treatment with AEDs in rehabilitation patients with seizure disorders typically outweigh these minor risks, Bromide, phenobarbital, and benzodiazepines may have more severe cognitive side effects than other AEDs. However, there is no convincing evidence of clinically significant differences in cognitive adverse effects among the other established AEDs. Furthermore, cognitive side effects are usually modest with mono therapy and anticonvulsant blood levels within standard therapeutic ranges. With regard to prophylaxis against future seizures, there is no significant data indicating that AED administration can prevent or retard the process of epileptogenesis, Therefore, the use of AEDs to prevent the development of a seizure disorder is not warranted at this time. Finally, although there is little information about the behavioral effects of anticonvulsants in neurological rehabilitation patients, the efficacy of carbamazepine, and perhaps valproate, in the treatment of primary mania suggests that these AEDs may be beneficial in mania secondary to brain injury. The role of AEDs in the treatment of other psychiatric disorders, such as post-traumatic stress disorder and episodic dyscontrol, remains unclear.