Managing Agitation and Aggression after TBI
VBMC TRAUMA CARE SERVICES GUIDELINE
Managing Agitation and Aggression after Traumatic Brain Injury (TBI)
Background
Definitions
The objective of this guideline is to assist providers in managing acute
agitation and aggression in TBI patients admitted to VBMC by providing
therapies, both environmental/non-pharmacologic and pharmacologic, to consider
based on current level of evidence available. This guideline is not meant to replace
clinical judgement. It does not address chronic TBI/rehab management. Where
applicable, recommendations have been graded to note quality of available
evidence for described therapies.
Agitation – disturbed behavior because of overactivity; an early symptom
occurring as a feature of post-traumatic delirium/confused state
Aggression – verbal and physical aggression against self, objects, and other
people; more likely to be seen late after injury and is often part of a
personality change
Impact
·
In the first 6 months after TBI,
adults are 3x more likely to show aggression compared to those with multiple
traumatic injuries but without TBI
·
70% of adults experience agitation
during inpatient TBI rehab
·
Agitation has been shown to negatively
affect rate of recovery in acute inpatient rehabilitation
Symptoms
·
Akathisia
·
Disorientation
·
Explosive anger
·
Irritability
·
Maladaptive behavior
·
Mood lability
·
Physical and verbal
aggression
General Principles
·
Continue pre-TBI medication therapies
such as antidepressants/psychoactive medications, as abrupt withdrawal may negatively
contribute to agitation
·
Limit use of new medication therapy
that may contribute to CNS depression (e.g. methocarbamol, gabapentin, etc.),
unless clear benefit outweighs risk
·
Optimize pain control
I. FIRST LINE
THERAPY: Environmental Modifications (High-Quality Evidence)
·
Promote sleep hygiene, reduce noise,
reduce interruptions
o
Reduce stimuli and optimize sleep wake
cycle:
o
Consider fatigue and allow patient
down time
o
Limit number of visitors at one time
·
Use orientation / memory strategies
o
Ensure the management of anxiety and
reassuring [Non-Violent Crisis Intervention training program, for example]
o
Recommended involving family members
on the way to react to avoid escalation of aggression, how to adopt calming
attitudes toward patient
·
Discard all non-essential physical
constraints
·
Remove lines/catheters as soon as
possible
·
Minimize sources of discomfort
o
Optimize pain control
o
Address GI distress, reflux,
constipation
·
Manage drug withdrawal
·
Identify and address seizures
(subclinical epilepsy may present as aggression)
·
Limit polypharmacy
o
Eliminate unnecessary medications
o
Medication associated with agitation
should be used based on risk/benefit analysis (amantadine, levetiracetam,
stimulants, benzodiazepines, antihistamines, etc.)
II. PHARMACOLOGIC
MANAGEMENT:
Despite the prevalence of agitation following TBI, a limited number of studies
have evaluated pharmacological interventions for the management of acute
agitation/aggression. Furthermore, even within the limited number of studies
evaluated, each study was limited by sample size, heterogeneous patient
populations, and an unclear risk of bias. For this reason, this guideline
strongly urges the routine use of a comprehensive risk/benefit evaluation when
deciding to initiate any pharmacological treatment given limited and/or low-quality evidence.
Recommendations provided in this section are not all inclusive, and alternative
therapies may be appropriate. A multi-disciplinary approach, with assistance
from clinical pharmacist, consult services (neurology and neurosurgery).
References
1.
Luaute J, Plantier D, Wiart L, et al.
Care management of the agitation or aggressiveness crisis in patients with TBI.
Systematic review of the literature and practice recommendations. Ann
Phys Rehabil Med 2016; 59:58-67.
2.
Lombard LA, Zafonte RD. Agitation
after traumatic brain injury: considerations and treatment options. Am
J Phys Rehabil 2005;84:797-812.
3.
Brooke MM, Patterson DR, Questad KA,
Cardenas D, Farrel-Roberts L: The treatment of agitation during initial
hospitalization after traumatic brain injury. Arch Phys Med
Rehabil 1992; 73:917– 921.
4.
Fleminger S, Greenwood RJ, Oliver DL:
Pharmacological management for agitation and aggression in people with acquired
brain injury. Cochrane Database Syst Rev 2006; 1:CD003299
5.
Mousavi SG, Amini M, Mousavi SH:
Prevention of more complications in patients with head trauma. Int J
Preventive Med 2013; 4:1210–1212.
6.
Kim E, Bijlani M. A pilot study of
quetiapine treatment of aggression due to traumatic brain injury. J
Neuropsychiatry Clin Neurosci 2006;18:547–9.
7. Mysiw WJ, Bogner JA, Corrigan JD, et al. The impact of acute care medications on rehabilitation outcome after traumatic brain injury. Brain Inj 2006;20:905–11.