4.5 Assessment of Agitation and Aggressive Behaviours

Case Study (continued)

The patient was admitted and noted to be restless, aggressive, and argumentative and experiencing sleep disturbance, in that he would often be wandering about in the middle of the night. A 24 hour sleep record was ordered and maintained for the next 7 days to allow for staff to assess the patient’s sleep patterns. Behaviour logs were ordered to assess what behaviours were being seen and what might have been triggering them. He was constantly wanting to go home. When told he could not go home he would become very anxious and would then suffer sudden unpredictable outbursts of anger characterized by loud verbal arguing and making threatening gestures. Other times he would just lie curled up in his bed and would refuse to participate in his therapies.

What is agitation and why is it important?

  1. Agitation is often displayed as physical or verbal aggressiveness, explosive anger, increased psychomotor activity, impulsivity, restlessness, etc.
     
  2. High levels of agitation associated with poorer recovery and a delay in return to work.
  • Agitation, one behavior that is often seen post ABI, can be difficult to define as it is variable, subjective and often dependent on context and the observer. 
     
  • Agitation itself has been described as a single construct but is often displayed as physical or verbal aggressiveness, explosive anger, increased psychomotor activity, impulsivity, restlessness etc.17;18.  
     
  • Therefore, agitation may be associated with behavoural observations of dysphoria (mood disorder), anxiety, restlessness, frustration, mood lability/irritability, physical violence and threats/acts of self-harm.
     
  • Poorer recovery and a delay in the return to work have been associated with higher levels of agitation in the early recovery periodspost ABI/TBI, and are typically seen in those who have sustained an ABI. 

What would be involved in assessing the patient who appears agitated?

  1. Behavioural assessment: Longitudinal assessement with behavioural mapping and specific descriptions of behaviours (situation, precipitant, behavior, response, effectiveness).
     
  2. Psychiatric assessment to rule in/out psychiatric or cognitive sequelae of the TBI.
     
  3. Rule out other physical causes through physical assessment and diagnostic testing.
  • Approximately one-third of TBI patients have agitation or aggression in the first year post-injury.19
     
  • Associated features include:
  • frontal lobe injury;
  • premorbid substance use and aggressive behavior;
  • possibly associated with cognitive impairment. 

4.5.1   Causes of Agitation

In chronic TBI, agitation could be due to a number of “psychiatric” causes.  List them.

Agitation following chronic TBI could be due to the following “psychiatric causes:

  • Depression
     
  • Mania
     
  • Anxiety “free-floating” or specific symptoms (obsessions/compulsions, panic disorders, PTSD
     
  • Psychosis
     
  • Cognitive impairment
     
  • Frontal lobe syndromes
     
  • Substance/Medication-induced (antipsychotics, benzodiazepines, ongoing substance abuse)

In chronic TBI, agitation could be due to a number of “non-psychiatric” causes.  List them.

Agitation following TBI could be due to the following “non-psychiatric” causes:

  • Uncontrolled seizures
     
  • Endocrine (anterior pituitary) dysfunction
     
  • Pain
     
  • Dental problems
     
  • Uncontrolled/disinhibited appetite/sexual behavior
     
  • Incontinence, constipation, retention, UTI
     
  • Skin breakdown
     
  • Can be complicated by difficulty communicating, vision or hearing impairment

It is not unusual for multiple factors (psychiatric and non-psychiatric) to co-exist.

What assessment tool could be used to assess his agitated behavior?

  1. The Agitated Behavior Scale (ABS)

Click here to view the Agitated Behavior Scale: http://www.tbims.org/combi/abs/absrat.html

4.5.2  The Agitated Behavior Scale (ABS)

Describe the Agitated Behaviour Scale (ABS) including advantages and disadvantages

  1. 14 item scale, with each item scored from 1(absent) to 4 (present to an extreme degree).
     
  2.  Designed to be done by those working with agitated patients.
     
  3. Advantages including the length of the scale (14 questions), amount of time to complete it (<30 minutes) and its availability makes the scale very practical.
     
  4. Limitations include the risk of overdiagnosis of agitation.20
  • To measure agitation post-injury the Agitated Behavior Scale was developed 17
     
  • The ABS was designed to assess agitation in patients by those working with them.
     
  • 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 21
     
  • According to Levi et al.22, despite the availability of the scale, agitation remains unmeasured by most who work with the TBI population.

What are some key threshold scores for the Agitated Behavioural Scale (ABS)?

1.    ABS >21 = agitation, <23 unlikely to be violent, >28 = treatment with pharmacological agents.