Traumatic Brain Injury and Agitation: CPCP

This is a companion post about traumatic brain injury (TBI) and it’s also another Clinical Problems in Consultation Psychiatry (CPCP) educational presentation. The resident psychiatrist, Dr. Fatma Simsek-Duran presented the paper for the topic, which is all about how consultation psychiatrists are often asked to help neurosurgeons manage agitation in patients who’ve suffered acute traumatic brain injury and who are on the acute neurosurgery ward [1]. This seemed to be an excellent followup CPCP to the previous one given by Dr. Ki Won Nam on traumatic brain injury, Traumatic Brain Injury and Sleep Disturbance CPCP « The Practical Psychosomaticist: James Amos, M.D.

The question begging began early in the discussion of the paper on agitation in traumatic brain injury. The results seemed obvious to all the participants, which is that agitation is common in patients who’ve been brain-injured. The wonder is that there are no controlled studies out there which guide clinicians on how to manage it. Agitation occurs in up to 70% of patients hospitalized for TBI. We thought it was laudable that the investigators used a scale for measuring agitation, because the word could cover a multitude of behaviors. However, the study about the Agitation Behaviour Scale (ABS) cited in the reference list was published in 1989 and the paper was not immediately available. However, there is a more recent reference indicating the instrument is reliable and useful as part of routine rehabilitation nursing assessment [2].

Another paper described a survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation. This paper was published back in 1997 and sparked a dim memory of something I read several years ago regarding cautions against using Haloperidol to manage agitation in patients who’ve suffered TBI. The authors sought to determine the most common pharmacologic interventions for agitation due to TBI. Unfortunately, most respondents to the survey did not use a validated, standardized rating scale for agitation. They were divided into “experts” and “nonexperts”, meaning that the “experts” had postgraduate training specifically in the assessment and management of patients with TBI. The five most common drugs prescribed by experts were Carbamazepine, tricyclic antidepressants, Trazodone, Amantadine, and beta-blockers. Nonexperts were more likely to recommend or use Haloperidol, benzodiazepines as well as the drugs just mentioned. And experts chose Haloperidol much less frequently than the nonexperts did. Again, it was tough to conclude much and the dearth of rigorous research was highlighted [3].

Another paper mentioned was a Cochrane Database review of pharmacologic management of agitation and aggression in TBI patients [4]. Although this review concludes that the best evidence for efficacy is for beta blockers, the authors again highlight the absence of good studies to support the use of any psychoactive drug in the management of agitation in TBI patients. It’s notable that large doses of beta blockers had to be used which begs the question of whether the drop in blood pressure led to simply slowing the patients down because this leads to a sensation of fatigue.

Benzodiazepines are probably a poor choice because of the often anecdotal observation that they lead to disinhibited behavior with potential worsening of agitation. They also tend to have an amnestic effect as well, potentially contributing to post-traumatic amnesia. We just don’t know enough, so it’s good to remember–“First, do no harm.”

Still, our group could have told anyone the conclusions reached by the study. There are no prospective, placebo-controlled drug trials or comparison studies between behavioral interventions and medications that could guide doctors and nurses on how to help patients who’ve suffered TBI be less agitated, uncomfortable, miserable, and confused. And there didn’t seem to be any distinction amongst different etiologies for “agitation”, such as delirium, which is, by the way, an extremely common early complication of acute TBI. Delirium was not even mentioned.

Why? Add this study to the long list of those in which the abstract’s bottom line is “MORE STUDIES ARE DESPERATELY NEEDED.” I know that one of our residents is now fired up to talk to mentors in both clinical practice and research to find out what it would take to devise a proposal to study the questions raised in this paper. We need to both care deeply for our patients and we need to spend the money and effort on groundbreaking research to learn more about how to help them. Have a heart and do the science–go back to the start.

By way of review of the CPCP purpose and structure:

Clinical Problems in Consultation Psychiatry (CPCP):

A weekly case conference held Wednesdays from 8:00 a.m. to approximately 8:45 a.m. Each week, a case is selected from the Daily Review Rounds Records to illustrate a clinical problem for the next week’s meeting. The residents are assigned dates when they rotate. The medical students are welcome and even encouraged to participate as well.

This is a practical way to approach teaching the Practice-Based Learning & Improvement Core Competency. This helps develop the habit of reflecting on and analyzing one’s practice performance; locating and applying scientific evidence to the care of patients; critically appraising the medical literature; using the computer to support learning and patient care; facilitating the education of other health care professionals. This is applying principles of evidence-based medicine (EBM) to clinical practice.

  • Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine
  • Skills are needed to integrate the available evidence with clinical experience and patient concerns
  • Application and evaluation of EBM skills will provide a frame-work for life-long learning.

Self-evaluation is vital to the successful practice of EBM:

  • Am I asking answerable clinical questions?
  • Am I searching the literature?
  • Am I becoming more efficient in my searches?
  • Am I integrating my critical appraisals into my practice?

The assigned resident is responsible for searching the literature and selecting one or two teaching papers for the conference. Presentations will begin with a review of the case, followed by a summary of the references with subsequent round table discussion.

Circulate copies of 2-4 pertinent articles to team members including psychiatric nurses and faculty. A copy machine is available in the departmental administration office. Consult staff can also assist with obtaining copies.

Presentations begin with a 5-minute summary of the case with discussion of both psychiatric and medical aspects of evaluation and management. The remaining time is spent summarizing the pertinent data in the articles. Residents and medical students are encouraged to use the case conference material as preparation for submitting a case report or letter to the editor.

1. McNett, M., W. Sarver, et al. (2012). “The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units.” Brain injury : [BI] 26(9): 1155-1162.
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.

2. Amato, S., M. Resan, et al. (2012). “The feasibility, reliability, and clinical utility of the agitated behavior scale in brain-injured rehabilitation patients.” Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses 37(1): 19-24.
Patients with traumatic brain injury often experience physical and cognitive impairments as well as agitation requiring additional care to maintain a safe and therapeutic environment. PURPOSE: The aim of this study was to determine the feasibility, reliability and clinical utility of the Agitated Behavior Scale (ABS) as part of routine rehabilitation nursing assessment. METHOD: A prospective descriptive study was conducted on a brain injury rehabilitation unit consisting of a sample of 51 patients who were consecutively admitted over 4 months to a rehabilitation unit. FINDINGS: Results showed that the tool was completed on the majority of nursing shifts, had high interrater agreement, and distinguished patients who were on constant observation or physically restrained. CONCLUSION AND CLINICAL RELEVANCE: The ABS can be used as an objective measure for nurses to guide the initiation and evaluate the effectiveness of various care strategies.

3. Fugate, L. P., L. A. Spacek, et al. (1997). “Measurement and treatment of agitation following traumatic brain injury: II. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation.” Arch Phys Med Rehabil 78(9): 924-928.

OBJECTIVE: Determine national patterns of measuring and treating agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors. DESIGN: A 70% random sample of members of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation was surveyed by telephone. MAIN OUTCOME MEASURE: The survey instrument was designed to determine the most common pharmacologic interventions for agitation and, where possible, match each drug with the target behavioral and cognitive characteristics for which it is prescribed. Data were also collected on the manner in which participants measured agitation and judged treatment efficacy. RESULTS: One hundred twenty-nine of 157 responded, yielding an 82% response rate. The majority of respondents were not measuring agitation in a standard fashion. The five most frequently prescribed drugs by the expert stratum were carbamazepine, tricyclic antidepressants (TCAs), trazodone, amantadine, and beta-blockers. In comparison, the nonexperts most often reported prescribing carbamazepine, beta-blockers, haloperidol, TCAs, and benzodiazepines. Desyrel (p = .06) and amantadine (p = .001) were significantly more likely to be chosen by experts than by nonexperts. Experts chose haloperidol significantly less often than nonexperts (p = .01). Prescription of sedating drugs such as haloperidol or benzodiazepines was not found to be associated with the acuity of injury of TBI patients in the respondent’s practice, practice setting, or years of practice since completing residency. Choice of haloperidol to treat agitation was not significantly associated with the degree to which explosive anger, verbal aggression, or physical aggression were considered important to the respondent’s definition of agitation. CONCLUSIONS: The majority of physiatrists surveyed did not formally measure agitation. Treatment strategies differ significantly between general physiatrists and those who specialize in the treatment of patients with TBI. The breadth of pharmacologic agents and strategies identified in this survey probably reflects the lack of research specific to the pathophysiology of the disorder of posttraumatic agitation.

4. Fleminger, S., R. J. Greenwood, et al. (2006). “Pharmacological management for agitation and aggression in people with acquired brain injury.” Cochrane Database Syst Rev(4): CD003299.

BACKGROUND: Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES: To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006. SELECTION CRITERIA: Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. DATA COLLECTION AND ANALYSIS: We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS: Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. AUTHORS’ CONCLUSIONS: Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.