4.6 Management of Agitation and Aggression

4.6.1  Non-Pharmacological Treatment of Agitated and Aggressive Behaviour

Describe the principles of non-pharmacological measures for agitated and aggressive behaviour?

  1. Reduce the level of stimulation in the environment;
     
  2. Protect the patient from harming himself or others;
     
  3. Reduce the patient’s cognitive confusion;
     
  4. Tolerate restlessness when possible (i.e. limit physical restraints).
  • Post ABI individuals should be maintained in a safe, well structured environment with low stimulus.
     
  • Agitation can often be managed by making changes to their environment, or to their staffing compliment.
     
  • Physical restraints are only recommended if absolutely necessary; that is the patient is a danger to themselves or others 23.

Environmental Management of Agitation

1.    Reduce Level of Stimulation in the Environment

  • Place patient in quiet private room
  • Remove noxious stimuli if possible, tubes, catheters, restraints, traction
  • Limit unnecessary sounds, television, radio, background conversations
  • Limit number of visitors
  • Staff to behave in a calm and reassuring manner
  • Limit number of length of therapy sessions
  • Provide therapies in patient room

2.    Protect Patient from Harming Self and Others

  •  Place patient in a floor bed with padded side panels (Craig bed)
  • Assign 1:1 or 1:2 sitter to observe patient and ensure safety
  • Avoid taking patient off the unit
  • Place patient in a locked ward

3.    Reduce Patient’s Cognitive Confusion

  • One person speaking to patient at a time
  • Maintain staff to work with patient
  • Minimize contact with unfamiliar staff
  • Communicate to patient briefly and simple, one idea at a time

4.     Tolerate restlessness when possible

  • Allow patient to thrash about in floor bed
  • Allow patient to pace around the unit with 1:1 supervision
  • Allow confused patient to be verbally inappropriate (table 49-8) 24

4.6.2  Pharmacological Treatment of Agitated and Aggressive Behiavour

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
  •  Neuropharmacologic agents given early in the treatment of posttraumatic brain injury agitation may be an effective therapeutic intervention for both behavioral and cognitive problems.  
     
  • Anticonvulsants and beta-blockers are the two classes of drugs most often recommended to treat agitation or aggression post injury.
     
  • The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers 25.
     
  • Although several other medication may be usedsuch asAmantidine, Ritalin, Trazadone and Dexedrine more research is needed to determine their effectiveness and efficacy 26.
     
  • Despite the lack of research evidence, clinically, atypical anti-psychotic medications are frequently used early on because they act so quickly.
     

For a more detailed discussion of the various medications used to treat agitation and aggression post ABI please see ERABI/Mental Health Issues Post ABI.

According to ABIKUS Guidelines 27

  1. “Thereshould be careful considerations of the sensitivity of people with traumatic brain injury to psychotropic medication before trial use. Psychotropic medications should be used with caution. Where medications are clinically indicated ‘start low and go slow’, keep under direct clinical monitoring to ensure that the drug is tolerated and producing the expected improvement and used with caution where indicated. (pg 18)
  2. Perform a detailed physical exam prior to commencing any trial of medications. People with traumatic brain injury and their caregiver should be asked about any prescribed medications, over the counter remedies, herbs or supplements they are taking to check for potential interactions and adverse effects. (pg 18)
  3. Appropriateinvestigations should be completed prior to medication trials to rule out and minimize metabolic abnormalities including evaluation of: plasma blood sugar, electrolytes, hormones, hemoglobin, oxygenation and infection. (pg 18)
  4. Clinicians should also consider the possibility of brain injury related sleep disorders as a cause of cognitive and other behavioural changes. (pg 18)
  5. Any trial of medication for a person with traumatic brain injury should be preceded by a clear explanation to the person with traumatic brain injury and their caregivers, and a caution that effects of medications are less predictable in people with traumatic brain injury. (pg 18)
  6. Minimize use of Benzodiazepines and Neuroleptic antipsychotic medications as animal studies suggest these medications may slow recovery after brain injury. (pg 18)
  7. Beta Blockers are recommended; a guideline for the treatment of aggression after TBI. Studies reported the efficacy of both Propranolol (maximum dose 420-520 mg/day) and Pindolol (maximum dose 40-100 mg/day) in the treatment of aggression in this population. (pg 19)
  8. Anticonvulsants: Carbamazepine and/or Valproic Acid may be used to decrease the incidence of aggressive behaviours. (pg 19)
  9. Valproic Acid may be preferred over Phenytoin post brain injury as it does not have any significant neuropsychological side effects, and is effective for controlling established seizures and stabilizing mood. (pg 19)”          

4.6.3  Evidence for Pharmacological Measures Used to Treat Aggressive Behaviors Post TBI


What medications are used to treat aggressive behaviours post ABI?
 

 

Medications to treat aggressive behavior post ABI

 

Medication

Recommended Doses

Level of Evidence

Divalproex

 

Level 4

Carbazepine

400 mg -800 mg per day for 8 weeks

Level 4

Lamotrigine 

25 mg daily

Level 5

Pindolol

60 mg -100mg/day

Level 1

Propranolol

520 mg/day

60 mg -420 mg/day

Level 1

Methotrimeprazine

2-50 mg. 2-4 times per day

Level 4

Droperidol

2.5-5 mg IM

Level 4

Haloperidol

1-6 mg

Level 4

Quetiapine

25 to 300mg

Level 4

Sertraline HCH

50 mg- 200 mg per day

Level 4

Amantadine

100-300 mg per day

Level 4

Trazadone

150 to 400 mg per day, for seniors start at 75 mg day

Level 4

Lithium carbonate

150 to 300 mg TID, (monitor serum levels, should be drawn every 2 months)

Level 5

The ABIKUS 28was a consensus driven document; the ERABI 29dealt with the published research.  A comparison of the two is shown in the table below:

Medication to treat Aggression Post ABI: A comparison of the findings from ABIKUS and ERABI

Medication

ABIKUS

ERABI

Valproic Acid and Divalproex

Recommended

Level 4 evidence for Divalproex

Methylphenidate

Recommended

No evidence

SSRIs

Recommended

No evidence

Beta-Blockers

Recommended

No evidence

Tricyclic antidepressants

Recommended

Level 4 evidence for Trazadone

Amantadine

No comment

Evidence is uncertain

Methotrimeprazine

No comment

Level 4 evidence

Other Anticonvulsants

No comment

Level 4 evidence for Carbamazepine

Lithium carbonate

No comment

Level 4 evidence