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 UK 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 as a result of overactivity; an early symptom occurring as a feature of post-traumatic delirium/confusional 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
• Seventy percent of adults experience agitation during inpatient TBI rehab
• Agitation has been show 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 (see COM – Adult – Analgesia (Non-Intubated) order-set) Management

I. FIRST LINE THERAPY: Environmental Modifications (High-Quality Evidence)

• Promote sleep hygiene, reduce noise, reduce interruptions 
• Reduce stimuli and optimize sleep wake cycle:
• Consider fatigue and allow patient down time
• Limit number of visitors at one time
• Use orientation / memory strategies
• Ensure the management of anxiety and reassuring [Non-Violent Crisis Intervention training program, for example]
• Recommended involving family members on the way to react in order 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
• Optimize pain control
• Address GI distress, reflux, constipation

• Manage drug withdrawal
• Identify and address seizures (subclinical epilepsy may present as aggression)
• Limit polypharmacy
• Eliminate unnecessary medications
• Medication sassociated with agitation should be used based on risk/benefit analysis (amantadine, levetiracetam, stimulants, benzodiazepines, antihistamines, etc.)
• Consult PM&R as they could potentially shorten length of stay if agitation is only issue keeping
  patient from discharge

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), and PM&R input should be strongly considered.

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.
8. Noe E, Ferri J, Trenor c, Chirivella J. Efficacy of ziprasidone in controlling agitation during post- traumatic amnesia. Behav Neurol 2007;18:7-11.

Published February 25, 2020 (S Priest, Dina Ali, S Fryman, A Bernard)