Agitation after traumatic brain injury (TBI) is a clinical manifestation of the natural recovery process and is often associated with posttraumatic amnesia (PTA). Most definitions denote an excess of behaviors (motor or verbal) that interfere with patient care, pose a risk to persons or property, or require action from staff. , These include some combination of aggression, restlessness, disinhibition, akathisia, inappropriate vocalizing, and emotional liability. These behaviors must be present in the absence of other physical, medical, or psychiatric causes.
The incidence among patients varies widely, between 11% and 70%. Studies have shown agitation duration varies from a few days to several weeks, although it typically resolves within 4 weeks. The most consistent predictors of agitation are impaired cognition, ongoing PTA, and lower functional status. Other variables associated with worse agitation behaviors include more severe injury, premorbid history of substance abuse, and presence of infection. The pathology underlying posttraumatic agitation is likely multifactorial, involving a complicated combination of cerebral structural lesions, biochemical abnormalities, and external factors including damage to the frontal and temporal lobes, injury to the prefrontal cortex, damage to the thalamus and limbic system, and impaired regulation of serotonin, norepinephrine, and dopamine. ,
Diagnosis
A detailed history of present illness and medical comorbidities and an in-depth social history should be obtained. A comprehensive physical examination should be performed next, including vital signs, neurological examination, cardiopulmonary evaluation, and musculoskeletal examination. Evaluation should include assessment for secondary conditions common in TBI that may contribute to agitation, such as expressive aphasia leading to behavioral outbursts as the individual becomes frustrated with the inability to communicate.
Agitation is a diagnosis of exclusion after other conditions have been ruled out. ,
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Medical
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Medication side effects: Many drugs may exacerbate agitation including: opioids, benzodiazepines, dopamine agonists (e.g., metoclopramide), H 2 -receptor antagonists (e.g., omeprazole), and anticholinergic medications (e.g., oxybutynin)
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Pain (headache, polytrauma, postop, heterotopic ossification, spasticity, shoulder subluxation, occult fracture, skin lesion, etc.)
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Infection
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Metabolic disturbance (electrolytes, thyroid, hypoglycemia)
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Hypoxemia (pulmonary embolism)
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Urinary retention/incontinence
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Nausea, constipation
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Neurological
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Hydrocephalus
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Seizures
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Intracranial mass lesions
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Psychiatric
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Personality disorders/psychosis/anxiety/mood disorders
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Sundowning in patients with dementia
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Substance use/acute intoxication
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Workup/laboratory tests
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Complete blood count with differential
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Complete metabolic panel
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Thyroid function tests
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Urinalysis with urine culture
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Urine toxicology screen
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Cerebrospinal fluid analysis
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Computed tomography head/magnetic resonance imaging brain
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Electroencephalogram
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X-ray
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Assessment
In practice, agitation is typically assessed clinically. In fact, one study showed fewer than half the brain injury specialists use objective measures of agitation in their practice. Objective measures of agitation can be used to determine the effectiveness of treatment.
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Agitated Behavior Scale (ABS) , ,
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Only measure of agitation developed specifically for and validated in the TBI population
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Helpful for monitoring patient’s recovery progression and assessing effectiveness of interventions
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High interrater reliability
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Can be completed in 5 to 10 minutes of observation
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See Table 36.1
TABLE 36.1
Agitated Behavior Scale
= Absent: The behavior is not present.
= Present to a slight degree: The behavior is present but does not disrupt appropriate behavior. The individual may redirect spontaneously.
= Present to a moderate degree: The individual needs to be redirected from an agitated to an appropriate behavior but benefits from such cueing.
= Present to an extreme degree: The individual is not able to engage in appropriate behavior because of the interference of the agitated behavior, even when external cueing or redirection is provided.
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Short attention span, easy distractibility, inability to concentrate
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Impulsive, impatient, low tolerance for pain or frustration
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Uncooperative, resistant to care, demanding
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Violent and/or threatening violence toward people or property
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Explosive and/or unpredictable anger
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Rocking, rubbing, moaning, or other self-stimulating behavior
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Pulling at tubes, restraints, etc.
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Wandering from treatment areas
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Restlessness, pacing, excessive movement
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Repetitive behaviors—motor and/or verbal
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Rapid, loud, or excessive talking
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Sudden changes of mood
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Easily initiated or excessive crying and/or laughter
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Self-abusiveness—physical and/or verbal
Total Score
<21
Normal
22–28
Low agitation
29–35
Moderate agitation
>35
Severe agitation
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Overt Aggression Scale (OAS) ,
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Observational scale that requires training to administer
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Can be completed in 3 to 5 minutes
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Allows recording of type, severity, and frequency of different aggressive behaviors such as verbal, physical against objects, physical against self, and physical against others
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There are additional items that register the intervention applied by the staff
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Management and treatment recommendations
Agitated behavior has been associated with longer lengths of stay in both hospital and acute rehabilitation settings, increased cost of care, and increased amount of support needed after hospitalization. Agitation can also impede community reintegration, including alienation from family, loss of employment, and potential legal issues. Thus, management is essential to ensure safety, ease caregiver burden, and maximize cooperation in therapies.
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First line: Environmental modification , ,
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Reduce stimuli:
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Minimize light, noise, and distractions—low-level lighting, draw curtains, turn off television, etc.
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Limit number of visitors at one time
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Staff and family should speak in low volume, slowly, one at a time
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Implement rest periods throughout the day to minimize impact of fatigue.
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Avoid/minimize restraints: Use noncontact restraints if able (e.g., safety net beds), padded hand mittens, one-to-one staff supervision
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Minimize tubes and lines: Cover them if essential for patient care (e.g., place abdominal binder)
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Frequent reorientation by staff and family
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Consistent schedule and staff
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Timed toileting
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Create a familiar environment: Allow family to bring in personal possessions
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Ensure good sleep cycle regulation and sleep quality
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Encourage good sleep hygiene
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Consider use of trazodone, melatonin
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Behavior modification ,
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Allow patient to express feelings of restlessness by allowing them to pace (if safe) or be walked/wheeled around by staff
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Mobile patients may require a closed unit or sensors for safety
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Deescalation techniques
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Structured behavioral programs
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May have limited application given cognitive and impaired safety awareness. Anosognosia (lack of awareness of deficits) is also a challenge.
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Pharmacological management
For patients who exhibit agitated behaviors despite environmental and behavioral modification, addition of a pharmacological agent may be considered. Every TBI is different, thus the choice of therapy should be based on clinical presentation and medical comorbidities. The ideal agent is nonsedating, would not affect cognitive recovery, and has a low side effect profile. Agents that slow cognition may prolong/exacerbate agitation. As with most medications, the general principle for administration is “start low, go slow,” beginning with the lowest dose available and slowly increasing for effectiveness. Frequent reassessment is essential to determine the need for continuation of the pharmacological agents ( Table 36.2 ).
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