Agitation Duration, Density and Intensity during Acute Inpatient Rehabilitation

Predict Length of Stay in Acute Inpatient Rehabilitation

and Motor FIMsTM at Discharge

for Patients with Traumatic Brain Injury

MA Bockbrader, A Nielsen, C Kudron, L Worthen-Chaudhari, J Rosenthal, D Mortimer, WJ Mysiw, J Bogner, J Corrigan

Objective

To examine the relationship between Traumatic Brain Injury (TBI) outcomes and duration, density and intensity of agitation during inpatient rehabilitation (IPR).

2

3

Disclosures

Research supported by NIDRR TBI Model Systems grant to J Bogner and J Corrigan

Marcie Bockbrader has nothing to disclose

4

AGITATION

DFN: excessive behaviors occurring during an altered state of consciousness (Bogner, Corrigan, 1995); for TBI, the altered state of consciousness is post-traumatic amnesia (PTA).

E.g., aggressive, labile, or disinhibited behaviors

Interferes with functional activity Can affect therapy participation

Hypothesis:

Agitation affects recovery and outcomes after TBI

5

Agitated Behavior Scale (Corrigan 1989)

Each item rated 1 (none) – 4 (extreme) per 8h shift Total score range: 14 – 56 Cutoff for agitation: total score > 21

14Items

6

Background Bogner et al. 2001

n= 340 TBI patients in IPR

Agitation as categorical variable

1. Presence of agitation

2. Severity of agitation

3. Duration of agitation

Agitated: at least one 48-hr period during IPR with 3 ABS scores > 21

Mean of 3 high ABS scoresMild: 22-28Moderate: 29-35Severe: >36

Days (first agitated shift in 48-hr period containing 3 ABS scores > 21) to (last shift with ABS >21)4 groups: 0d, (1-10d), (11-25d), >26d

7

Presence of agitation

Patients with agitation had Longer LOS in IPR Less frequent discharge home Lower motor and cognitive

FIMsTM at discharge

Agitated: at least one 48-hr period during inpatient stay contained 3

ABS total scores > 21

“Cognitive functioning at admission to IPR mediates the relationship between the presence of agitation and LOS in IPR, as well as between agitation and cognitive functioning at discharge.”

36% of 340 TBI patients were agitated using this definition.

8

Severity of agitationAgitation severity: Mean 3 high ABS• None <22• Mild 22 - 28• Moderate 29 - 35 • Severe 36 - 56

No significant differences based on severity for • LOS in IPR• FIMTM motor at discharge

Mild and moderate groups had lower FIMTM cog at discharge than nonagitated group (difference 2.3)

Severe group did not differ from nonagitated group for FIMTM cog at discharge

Bogner et al. 2001

9

Duration of agitation

LOS in IPR • Equivalent for 0d, 1-10d agitation• ~LOS +12d for 11-25d agitation• ~LOS +41d for >26d agitation (& not dc to home)

FIMsTMs at discharge• Motor & Cog equivalent for 0d, 1-10d, 11-25d groups• FIMTM cog –3.6 for >26d agitation• FIMTM motor –8.9 for >26d agitation

Days (first agitated shift in 48-hr period containing 3 ABS scores > 21) to (last shift with ABS >21)4 groups: 0d, (1-10d), (11-25d), >26d

Bogner et al. 2001

10

Revisit effects of agitation intensity, duration and density New sample of 284 patients Characterize agitation as continuous variable

Agitation intensity = Bogner’s severity Agitation duration = 3 alternative definitions Agitation density = 4 alternative definitions

Agitated Bout = Time period over which 6 consecutive shifts had at least 3 ABS scores >21

11

Agitation Intensity

Intensity.1 Mean of 3 highest ABS scoresRange: 14 – 56

Intensity ~ peak agitation

http://www.peakfreaks.com/everestclimbphotos.htm

12

Agitation Duration

Duration.1

Duration.2

Duration.3

Number of shifts in longest boutRange: 0 – 3*LOS in IPR

Number of shifts from first agitated shift of first bout to last agitated shift of last boutRange: 0 – 3*LOS in IPR

Number of agitated shifts from first agitated shift of first bout to last agitated shift during IPRRange: 0 – 3*LOS in IPR

shortest

longest

13

Agitation Density

Density.1

Density.2

Density.3

Density.4

Number of boutsRange: 0 – LOS in IPR/2

Number of agitated shifts within all boutsRange: 0 – 3*LOS in IPR

Number of agitated shifts during IPRRange: 0 – 3*LOS in IPR

Normalized density: Avg number of agitated shifts per day =Density.3/LOS in IPRRange: 0 – 3

shortest

longest

14

Methods Design: Prospective, observational Setting: Multidisciplinary acute inpatient rehab Participants: 284 consecutively admitted patients

meeting criteria for participation in the NIDRR-funded TBI Model Systems National Database (10 excluded)

Instruments: Agitated behavior scale (ABS) scores during each shift of IPR. Computed agitation Density, Duration and Intensity constructs

Demographic variables: Age, Gender, Race, Education level, Admission GCS, LOS acute, FIM Motor and Cognitive scores at IPR admission

Outcomes: LOS in acute IPR, FIM Motor and FIM Cognitive scores at discharge from IPR

MA Bockbrader1, D Mortimer2, L Worthen-Chaudhari1, J Rosenthal1, JD Corrigan1, WJ Mysiw1, JA Bogner1

1Physical Medicine & Rehabiitation, The Ohio State University – Columbus, OH; 2Physical Medicine & Rehabilitation, Hennepin County Medical Center - Minneapolis, MN

Mild (GCS 13-15)Moderate (GCS 9-12)Severe (GCS 3-8)Uncategorizable (GCS 3T)

TBI severity, based on initial GCS

Outcome Means (SD)LOS IPR 20.4 (13.9) daysFIMTM Cog discharge 25.2 (4.2) FIMTM Motor discharge 70.7 (14.2)

•41% of TBI patients (n=112) had at least one agitated shift.•One-third (n=85) had at least one agitated bout.

207 67

Gender

WhiteBlackAsian/PINative AmerHispanic

Race

<HSHS grad>HS

Education

Sample Characteristics

Agitated Behavior Scale Constructs & Regression Analyses

Clinical bout of agitation - “time period over which any 6 consecutive shifts had 3 or more ABS total scores > 21”

% variance accounted for (R2) bySignificant* Univariate Predictors of:

% variance accounted for (R2) bySignificant* Multivariate Predictors of:

Duration Agitation Construct Definition Mean (SD) FIMTM Cog discharge

FIMTM Motor discharge

LOS IPR (days)

FIMTM Cog discharge

FIMTM Motor discharge

LOS IPR (days)

Duration.1 # shifts in longest bout 6.8 (15.5) 7% 2% 21% - - -

Duration.2 # shifts from first agitated shift of first bout to last agitated shift of last bout

11.1 (26.8) 14% 8% 33% - 2% -

Duration.3 # shifts from first agitated shift of first bout to last agitated shift

14.6 (31.1) 16% 9% 37% - - 10%

Density Agitation Construct Definition Mean (SD)

Density.1 # bouts of agitation 0.5 (0.8) 13% 7% 28% - - -

Density.2 # agitated shifts within all bouts 4.6 (10.5) 8% 2% 24% - - -

Density.3 # agitated shifts during IPR 5.8 (11.3) 12% 5% 31% - - -

Density.4 average # agitated shifts per day, calculated as Density.3/LOS IPR

0.2 (0.3) 11% NS 12% - - 3%

Intensity Agitation Construct Definition Mean (SD)

Intensity.1 mean of 3 highest shift scores 22.3 (8.7) 11% 1% 22% - 3% -

Demographic variables Mean (SD)

Age 37.2 (16.7) NS 4% NS 3% 5% -

Gender - 2% NS NS 1% - -

Race (white, nonwhite) - NS NS NS - - -

Education level - NS NS NS - - -

Admission GCS group - NS NS NS - - -

FIMTM Cog admission 16.4 (6.8) 44% 9% 43% 44% - 2%

FIMTM Motor admission 39.4 (18.1) 17% 38% 53% - 38% 53%

LOS acute care 16.4 (14.5) 5% 20% 29% - 5% 5%

*p<0.05

Results+ correlation - correlation

• In univariate regression analyses, Agitation Density, Duration and Intensity were significant predictors of rehab LOS and discharge FIMsTM.

•As has been shown previously (Bogner et al. 2001), the relationship between agitation and discharge Cognitive FIMTM was mediated by admission Cognitive FIMTM.

•Agitation Intensity & Duration were significant independent predictors of discharge Motor FIMTM (even after accounting for patient age, acute hospital LOS, and admission Motor FIMTM).

•Agitation Duration and Density were significant independent predictors of rehab LOS (even after accounting for admission Motor and Cognitive FIMsTM and acute hospital LOS).

•Agitation Duration accounted for 10% of the variability in rehab LOS 

Discussion

18

Conclusions

1. Constructs that take into account ABS scores over shifts yield Duration, Density and Intensity measures of agitation. Some of these provide additional predictive power (over admission FIMsTM and demographics) for TBI outcomes.

2. Agitation Duration, Density, and Intensity may be important targets for intervention and relevant adjustments to case-mix groups to more accurately characterize the resources needed to achieve optimal rehabilitation outcomes.

19

References

Bogner JA, Corrigan JD, Fugate L, Mysiw WJ, Clinchot D. Role of agitation in prediction of outcomes after traumatic brain injury. Am J Phys Med Rehabil 2001;80:636-44.

Bogner JA, Corrigan JD. Epidemiology of agitation following brain injury. NeuroRehabilitation 1995;5(4):293-7.

Corrigan JD. Development of a scale for assessment of agitation following traumatic brain injury. J Clin Exp Neuropsychol 1989;11:262-77.

Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehab 1993;74(5):531-6.