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MANAGING AT RISK BEHAVIORS AFTER BRAIN INJURY Darryl L Kaelin MD Medical Director Frazier Rehab Institute Slide 2 BEHAVIORAL CHANGES Arousal / Attention Affect / Depression Psychosis Delirium / Agitation Slide 3 AGITATION A heightened state of (cortical) activity marked by a complex of deficits in Cognition (Attn., Memory) Behavior (Aggressive, Impulsive, Restless) Affect (Emotionally Labile) Slide 4 DELIRIUM AFTER ABI Difficulty in focusing, shifting, and sustaining attention Agitation Disturbed Sleep Wake Cycle Memory Impairment Always happens during period of Post- Traumatic Amnesia Slide 5 Agitation after TBI: Impact Adults 3x more likely in first 6 months after head injury to show aggression than those with multiple traumatic injuries without head injury 25% of adults showed aggressive behavior 60 months after discharge from inpatient rehabilitation unit for TBI 70% of adults during inpatient TBI rehabilitation experience agitation Agitation has been shown to negatively affect rate of recovery in acute inpatient rehabilitation Slide 6 INCIDENCE Levin / Grossman (1978) 30% Reyes (1981) 50% Brooke (1992) 11-35% Keyser / Kreutzer 9% Slide 7 QUANTIFICATION Neurobehavioral Scale Overt Aggression Scale Agitation Behavior Scale Behavior Log Sleep Charting Slide 8 AGITATION BEHAVIOR SCALE Slide 9 THE CALL Johnny is screaming out that he wants to go home now. He is very confused and restless. Can I have some Ativan or Seroquel to calm him down please. How do you respond? Slide 10 MANAGEMENT R/O visual, hearing, and communication deficits R/O medical causes (pain, metabolic, neurologic) R/O pharmacological causes R/O environmental causes Slide 11 CAUSES OF AGITATION Identify and address possible cause/contributors including: Sleep disruption / alteration of sleep wake cycle Sources for discomfort Lines/catheters Unidentified injury (fracture, etc) Inadequate pain control Gastrointestinal distress (reflux, constipation, ileus) Seizures subclinical epilepsy can present as intermittent aggression Slide 12 CAUSES OF AGITATION Electrolyte abnormality Na+, Glucose, Calcium Infection UTI, Pneumonia, wound Neuroendocrine dysfunction Post-traumatic hydrocephalus Drug withdrawal (pain medications, other meds from ICU) Polypharmacy Slide 13 Environmental Management Slide 14 ENVIRONMENTAL MODIFICATION Goal: Provide the least restrictive environment c/w safety of the patient Adequate staff : patient ratio Adequate Behavior Modification Training Means of Implementation Physical environment needs Slide 15 PHYSICAL ENVIRONMENT Locked unit Alarm system Enclosure beds Minimize stimulus Room / Roommate assignment Sitter for supervision Restraints if necessary Slide 16 RESTRAINTS Team determined Physician prescribed Documentation / Weaning Type Reason Goals for use Reevaluation daily Slide 17 BEHAVIOR MODIFICATION PROGRAM Interdisciplinary approach Documentation Cause of behavior Purpose of program (Goal) + or Reinforcement Examples of responses to appropriate and inappropriate behavior Slide 18 NEUROTRANSMITTER THEORY Noradrenergic Serotonergic Dopaminergic Cholinergic Gabaminergic Peptidinergic Slide 19 PHARMACOLOGIC AGENTS Neurostimulants Anticonvulsants Anticholinergics B lockers (sympatholytic) SSRI Atypical Antipsychotics Lithium Slide 20 Fugate Et al. Study of 129 physicians divided into brain injury experts or nonexperts surveyed. Experts either had published two or greater articles on pharmacological interventions for TBI in the last 5 years, or had > or = 70% of their practice devoted to treating TBI Experts most frequently prescribed carbamazepine, beta blockers, TCAs Nonexperts chose Haldol four times more frequently than experts Slide 21 Pharmacologic Tx Cochrane review last updated 2008 6 studies met criteria (RCTs) for meta- analysis Propranolol (2) Pindolol (2) Methylphenidate (1) Amantadine (1) Research supports use of -Blockers Effect seen within 2-6 weeks Response similar in both subacute and chronic timeframe Slide 22 HOW DO YOU DECIDE? Observation Theory Trial and error Slide 23 BENZODIAZIPINES Work on GABA molecule to create: Anxiolytic, sedative, antispasticity, anticonvulsant and AMNESTIC effects Effect duration varies based on medication Short (1-8 hour half life) e.g. midazolam, alprazolam Intermediate (8-40 hour half life) e.g. lorazepam Long (>40 hours) e.g. Diazepam, clonazepam Slide 24 BENZO: Side Effects Side effects include the following: Amnesia/memory loss Increased daytime fatigue Decreased concentration Decreased alertness TBI causes the above effects as well Repeated use of benzodiazepines may slow/impair neuronal recovery after focal injury Slide 25 ANTIPSYCHOTICS Mechanism of Action Typical antipsychotics block D2-dopamine receptor Atypical antipsychotics have less D2 receptor activity Atypicals likely act on other neurotransmitter pathways, including serotonin, dopamine, 1-adrenergic, muscarinic, and histamine pathways Slide 26 Side Effects Movement disorders Akathisia one of more common movement disorders seen a subjective sense of restlessness often accompanied by involuntary movements of the limbs or trunk Confusion Extrapyramidal Symptoms Tardive Dyskinesia choreoathetotic or other involuntary repetitive movement Weight gain / Metabolic Syndrome Neuroleptic Malignant Syndrome (NMS) Seizures Prolonged QT Slide 27 COGNITION Cognitive impact of Antipsychotics Multiple animal studies have demonstrated either slowed cognitive improvement or reduced cognitive return with use of antipsychotic medications (both typical and atypical) One human study demonstrated negative cognitive impact with use of antipsychotics after TBI that improved with discontinuation of medication (Stanislav et al, 1997) Slide 28 TAKE HOME Though atypicals may be relatively safer, likely all antipsychotic medications have detrimental effects with long term use (NMS, Tardive Dyskinesia, etc) May be appropriate to use atypical antipsychotics for short-term limited (PRN) use in agitation after TBI during the acute period when sedation is not a barrier Slide 29 Timing of Drug Slide 30 Beta-Blockers Proposed mechanism of reducing hyperadrenergic activity Commonly used for periodic autonomic instability and dystonia (Storming) In retrospective studies shown to improve survival when used acutely after ABI Current prospective placebo study looking at effect of adrenergic blockade acutely after brain injury on survival and functional outcomes (clonidine and propranolol) Slide 31 B-Blockers: Research 2 randomized placebo- controlled trials (Brooke 1992, Greendyke 1986) show benefit with propranolol for agitation in the weeks after injury (Brooke) and for aggressive behavior months and years after injury (Greendyke). Slide 32 ANTICONVULSANTS Various mechanisms based on medication: Decrease excitatory neurotransmitter activity Increase inhibitor neurotransmitter activity Reduce sub-clinical epileptic activity Seizures can be a source for aggression/confusion/disorientation Provide mood stabilization Slide 33 ANTICONVULSANTS Adult Research (all studies without controls) Valproic Acid Retrospective study of 28 patients with age range 13-89 demonstrated reduction of agitation symptoms with valproic acid in 26 (90%) patients Authors concluded it may be appropriate for alert, labile, impulsive, and disinhibited patients (Chatham Showalter et al, 2000) Slide 34 ANTICONVULSANTS Carbamazepime Prospective open trial in 8 patients (400-800 mg daily) had improved Agitated Behavior Scale (Azouvi et al, 1999) 7 patients showed reduction in combativeness within 4 days (Chatham Showalter et al, 1996) Slide 35 ANTIDEPRESSANTS Proposed mechanism for decreasing agitation: Treatment of depression/anxiety that contribute to agitation/irritability Mood stabilization Slide 36 ANTIDEPRESSANTS Very few studies looking at use of antidepressants with primary outcome of reduction of agitation Multiple studies (including one prospective RCT) in adults addressing post-TBI depression noted reduction in symptoms of depression as well as reduction in agitation with treatment A pilot study demonstrated improved mood, and improved attention and working memory with fluoxetine Slide 37 Kaelins Theory of Agitation Two distinct foci of Agitation Internal Restless and more agitated when left alone and quiet External Aggressive and more agitated when stimulated or challenged Slide 38 Kaelins Theory of Agitation Treatments Internal cause of Agitation may be better treated with membrane stabilizing agents like anticonvulsants CBZ, V. Acid External causes of Agitation may be better treated with stimulants to improve attention and cognitive processing Some may need both Slide 39 Kaelins Theory of Agitation Beta-Blockers may be most beneficial when there appears to be sympathetic overdrive (HR, BP, sweating, outbursts) SSRIs may be most beneficial when there is a clear emotional component ( depression, anxiety). Slide 40 Summary: Little evidence to guide us so: Identify and treat contributors to agitation when possible Treatment should include non- pharmacologic environmental and behavioral management Monitor response to intervention Agitated Behavior Scale (may be most appropriate for adult patients) Avoid Polypharmacy if something doesnt work, stop it before adding more Slide 41 Questions ? Darryl Kaelin, MD 502-584-3377 THANK YOU !!