1.7 Management of Agitation and Aggressive Behaviour

The staff on the unit are becoming increasingly concerned about the patient’s aggressive and agitated behavior – it is disruptive on the unit and there are concerns about staff getting hurt.  They ask if the patient should not be medicated to improve his behavior.

1.7.1 Assessment of Agitation and Aggressive Behaviour

What test is available to assess for agitated and aggressive behavior? 

Agitated Behaviour Scale, designed to assess agitation in patients by those working with them.  14 item scale, with each item scoring 1-4 (total range 14-56)

  • To measure agitation post-injury the Agitated Behavior Scale was developed 33.
     
  • According to Levy et al. 34, despite the availability of the scale, agitation remains unmeasured by most who work with the TBI population.  
     
  • The scale, which began as a 39 item scale, was reduced to 14 items, with each item scoring 1 to 4, (from absent to present to an extreme degree). The scale which was originally tested by nurses, occupational therapists (OT), physiotherapists (PT) and other hospital staff, was designed to be used by allied health professionals 35.

What are the strengths and weaknesses of the ABI?

Strengths

  • The Length of the scale (14 questions);
     
  • The amount of time to complete it (< 30 minutes);
     
  • Its availability makes the scale very practical.

Weakness

  • Risk of over diagnosis of agitiation2.

What are some of the practical advantages of using an objective scale for assessing agitation?

  1. Assess pattern of agitation;
     
  2. Assess the level of agitation, which then can dictate treatment;
     
  3. Assess the response of agitation to interventions;
     
  4. Numbers mean something; ABS >21 = agitation, <23 unlikely to be violent, >28 = treatment with pharmacological agents.

1.7.2 Treatments for Agitation and Agression Post-TBI

1.7.2.1 Non-Pharmacological Measures

What non-pharmacological methods of managing agitation and aggressive behavior are available in a case such as this?

  1. Do not leave alone;
     
  2. Keep noise and traffic in room to a minimum;
     
  3. Familiarize with basic information;
     
  4. Physical reassurance through talking or touching patient;
     
  5. Accomodation in a highly-structured setting;
     
  6. Establish desired behaviour;
     
  7. Remove patient from group or change activity if agitation increases;
     
  8. Freedom of movement to control outbursts;
     
  9. Stimulating simple self-care tasks and participation;
     
  10. Assess for treatable pathology;
     
  11. Assess for sleep/wake cycle

1.7.2.2 Pharmacological Measures for Aggressive and Agitated Behaviour

What are some principles for using Pharmacological Measures in the treatment of aggressive and agitated behaviour?

  1. Pharmacological agents should only be used as a last resort (ABS > 28).
     
  2. Careful considerations of the sensitivity of people with TBI to psychotropic medications which should be used with caution.
     
  3. With medications “start low and go slow” and titrate to an optimal dose; but get to a therapeutic dosing before abandoning use.
     
  4. Develop clear cut goals and metrics to assist in determining when to stop treatment (i.e. consider weaning off medication when ABS < 21).
     
  5. Be alert to side effects and undesired effects.
     
  6. Minimize use of Benzodiazepines and neuroleptic antipsychotic medications such as Haldol as animal studies suggest these medications may slow brain recovery.

When non-pharmacological measures are unsuccessful which medications are recommended to decrease aggressive and agitated behaviours?

Initially

  1. Atypical antipsychotics prn – Risperidone up to 3 gm daily; alternative Seroquel or Olanzepine

Later (if ABS > 28 then provide scheduled dose medications         

  1. Beta-blockers
     
  2. Anticonvulsants (i.e Valproic Acid)
     
  3. SSRI (Sertraline)
     
  4. Tricyclic antidepressants (Amtriptyline titrated up to 75 mg/day)
     
  5. Methylphenidate
     
  6. Avoid the use of antipsychotic drugs such as Haldol
  • According to the newest version of ERABI 36
     
  • The use of multiple neuropharmacologic agents early in the treatment of posttraumatic brain injury agitation may be an effective therapeutic intervention for both behavioral and cognitive problems.
     
  • The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers 37 and anticonvulsants and beta-blockers are the two classes of drugs most often recommended.
     
  • More research is needed to assess the role of other medications and medication   combinations such as Amantidine, Ritalin, Trazadone and Dexedrine 38.
     

Appendix: ABIKUS Guidelines