6.3 Treatments for Agitation and Aggression Post-TBI

6.3.1  Non-Pharmacological Measures for Agitated and Aggressive Behaviour

What non-pharmacological methods for 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

6.3.2   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 has 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;
     
  2. 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.
  • 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 (ERABI 6.
     
  • The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers 7.
     
  • 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 asAmantidine, Ritalin, Trazadone and Dexedrine 8.