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Early in her rehabilitative course, following a traumatic brain injury, "JD" demonstrated significant restlessness. She would impulsively attempt to get out of bed, and  was observed to have poor sleep initiation with fragmented sleep at night. JD became agitated and fatigued following visits from multiple family members and friends. She was physically aggressive and easily distracted during her therapies. Vital signs showed a consistent tachycardia and mild hypertension without any fever or evidence of infection. What treatment approach would you recommend?

Educational objectives:

Upon completion of this activity, participants should be able to:

  • Determine a patient’s level of recovery from a history and physical examination
  • Develop a differential diagnosis for agitation after TBI and identify potential causes
  • Understand the role nonpharmacologic methods of treating individuals with TBI and agitation
  • Understand the role of pharmacologic management in posttraumatic agitation and be able to identify medications that should be avoided

Reading Resources:

  1. Faul, M., Xu, L., Wald, M., & Coronado, V. (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
  2. Selassie, A., Zaloshnja, E., Langlois, J., Miler, T., Jones, P., & Steiner, C. (2008). Incidence of Long-Term Disability Following Traumatic Brain Injury Hospitalization, United States, 2003. J Head Trauma Rehabil, 23 (2), 123-131.
  3. Centers for Disease Control and Prevention. (2011). Injury Prevention & Control: Traumatic Brain Injury. Retrieved 2011 from Centers for Disease Control and Prevention: http://www.cdc.gov/TraumaticBrainInjury/severe.html.
  4. Ciurli, P., Formisano, R., Umberto, B., Cantagallo, A., & Angelelli, P. (2011). Neuropsychiatric Disorders in Persons With Severe Traumatic Brain Injury: Prevalence, Phenomenology, and Relationship With Demographic, Clinical, and Functional Features. J Head Trauma Rehabil, 26 (2), 116-126.
  5. Lequerica, A., Rapport, L., Loeher, K., Axelrod, B., Vangel, S., & Hanks, R. (2007). Agitation in Acquired Brain Injury: Impact on Acute Rehabilitation Therapies. J Head Trauma Rehabil, 22 (3), 177-83.
  6. Bogner, J., Corrigan, J., Fugate, L., Mysiw, J., & Clinchot, D. (2001). Role of Agitation in Prediction of Outcomes After Traumatic Brain Injury. J Phys Med Rehabil, 80, 636-44.
  7. Fugate, L., Spacek, L., Kresty, L., Levy, C., Johnson, J., & Mysiw, J. (1997). Definition of Agitation Following Traumatic Brain Injury: I. A Survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation. Arch Phys Med Rehabil , 78 (11), 261-77.
  8. Lombard, L., & Zafonte, R. (2005). Agitation After Traumatic Brain Injury: Considerations and Treatment Options. American Journal of Physical Medicine & Rehabilitation, 84 (10), 797–812.
  9. Brooke, M., Questad, K., Patterson, D., & Bashak, K. (1992). Agitation and Restlessness After Closed Head Injury: A Prospective Study of 100 Consecutive Admissions. Arch Phys Med Rehabil, 73 (4), 320-23.
  10. Nott, M., Chapparo, C., & Baguley, I. (2006). Agitation Following Traumatic Brain Injury: An Australian Sample. Brain Injury, 20 (11), 1175-82.
  11. Kadyan, V., Mysiw, W., Bogner, J., Corrigan, J., Fugate, L., & Clinchot, D. (2004). Gender Differences in Agitation after Traumatic Brain Injury. Am J Phys Med Rehabil, 83, 747-52.
  12. Hagen, C. (March 2011). The Rancho Levels of Cognitive Functioning. Retrieved November 2011 from The Rancho Los Amigos National Rehabilitation Center: http://www.rancho.org/research/cognitive_levels.pdf.
  13. Nott, M., Chapparo, C., Heard, R., & Baguley, I. (2010). Patterns of Agitated Behaviour During Acute Brain Injury Rehabilitation. Brain Injury, 24 (10), 1214-21.
  14. Desai, A., Nierenberg, W., Duhaime, A. (2010). Akathisia After Mild Traumatic Head Injury. J Neurosurg Pediatrics, (5) 460-64.
  15. Andriessen, T., Jacobs, B., & Vos, P. (2010). Clinical Characteristics and Pathophysiological Mechanisms of Focal and Diffuse Traumatic Brain Injury. J. Cell. Mol. Med, 14 (10), 2381-92.
  16. Grafman, J., Schwab, K., Warden, D., Pridgen, A., Brown, H., & Salazar, A. (1996). Frontal Lobe Injuries, Violence, and Aggression: A Report of the Vietnam Head Injury Study. Neurology, 46 (5), 1231-38.
  17. Siever, L. (2008). Neurobiology of Aggression and Violence. Am J Psychiatry, 165 (4), 429-42.
  18. Coccaro, E., Lee, E., & Kavoussi, R. (2009). A Double-Blind, Randomized, Placebo-Controlled Trial of Fluoxetine in Patients With Intermittent Explosive Disorder. J Clin Psychiatry, 70 (5), 653-62.
  19. De Almeida, R., Ferrari, P., Parmigiani, S., & Miczek, K. (2005). Escalated Aggressive Behavior: Dopamine, Serotonin and GABA. Eur J Pharmacol, 526, 51-65. Desai, A., Nierenberg, D., & Duhaime, A. (2010). Akathisia After Mild Traumatic Head Injury. J Neurosurg Pediatrics, 5, 460-64.
  20. Corrigan, J. (1989). Development of a Scale for Assessment of Agitation Following Traumatic Brain Injury. Journal of Clinical and Experimental Neuropsychology, 11: 261-277.
  21. Bogner, J., Corrigan, J., Stange, M., & Rabold, D. (1999). Reliability of the Agitated Behavior Scale. J. Head Trauma Rehabil, 14 (1): 91-96.
  22. Rindlisbacher, P., & Hopkins, R. (1991). The Sundowning Syndrome: A Conceptual Analysis and Review. The American Journal of Alzheimer’s Care and Related Disorders & Research, 6 (4): 2-9.
  23. Corrigan, J. (1995). Substance Abuse as a Mediating Factor in Outcome From Traumatic Brain Injury. Arch Phys Med Rehabil, 76: 302-309.
  24. Levy, M., Berson, A., Cook, T., Bollegala, N., Seto, E., Tursanski, S., Kim, J., Sockalingam, S., Rajput, A., Krishnadev, N., Feng, C., & Bhalerao, S. (2005). Treatment of Agitation Following Traumatic Brain Injury: A Review of the Literature. Neurorehabilitation 20 (4): 279-306.
  25. Warden, D., Gordon, B., McAllister, T., Silver, J., Barth, J., Bruns, J., Drake, A., Gentry, T., Jagoda, A., Katz, D., Krauz, J., Labbate, L., Ryan, L., Sparling, M., Walters, B., Whyte, J., Zapata, A., & Zitnay, G. (2006). Guidelines for the Pharmacologic Treatment of Neurobehavioral Sequelae of Traumatic Brain Injury. Journal of Neurotrauma, 23 (10): 1468-1501.
  26. Chew, E., & Zafonte, R. (2009). Pharmacological Management of Neurobehavioral Disorders Following Traumatic Brain Injury – A State-of-the-Art Review. Journal of Rehabilitation Research & Development, 46 (6): 851-878.
  27. Feeney, D., Gonzalez, A., & Law, W. (1982). Amphetamine, Haloperidol, and Experience Interact to Affect Rate of Recovery After Motor Cortex Injury. Science, 217 (4562): 855-857.
  28. Goldstein, L. (2003). Neuropharmacology of TBI-induced Plasticity. Brain Inj, 17 (8): 685-694.

Disclosures:

Dr. Reddy, Dr. Hong and Dr. Huie have no relevant relationships with any entities producing healthcare goods or services. Dr. Munin receives grant/research support from Allergan, Inc.

Accreditation Statement:
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Pittsburgh School of Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditsTM. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.1) continuing education units (CEU) which are equivalent to 1 contact hours.

For your credit transcript, please access our website 4 weeks post-completion at http://ccehs.upmc.edu and follow the link to the Credit Transcript page. If you do not provide the last 5 digits of your SSN on the next page you will not be able to access a CME credit transcript. Providing your SSN is voluntary.

Release Date: 2/21/2012 | Last Modified On: 2/21/2012 | Expires: 2/20/2013

This course has been expired.