Agitation Predictors in Acute Traumatic Brain Injury

Transcription

1 Agitation Predictors in Acute Traumatic Brain Injury Dr Jehane H Dagher, MD, BScPT, FRCPC, FABPMR Physiatre Chef de Programme Trauma Cranio-Cerebral Professeure agrégée - Physiatrie Universite de Montreal Institut de Readaptation de Montreal Physical Medecine & Rehab McGill University Montreal General Hospital

2 NO CONFLICT OF INTEREST

3 In press Post Traumatic Agitation Predictors in Acute Traumatic Brain Injury Submitted to Brain Injury Journal

4 Authors Jehane H. Dagher MD, FRCPC, FABPMR, Jennifer Massad MD FRCPC, Julie Lamoureux DMD, M.Sc., Elaine de Guise PhD, Mitra Feyz MSc Ps. Physical Medicine Rehabilitation Service, McGill University Health Centre-Montreal General Hospital Physical Medicine and Rehabilitation Department, University of Montreal. Social and Preventive Medicine Department, University of Montreal. Traumatic Brain Injury Programme, McGill University Health Centre-Montreal General Hospital Psychology Department, University of Montreal, Montreal, Quebec, Canada

5 Post traumatic agitation The agitation crisis in the awakening phase after TBI is one of the most difficult behavioural disorders to alleviate

6 Definition of post-traumatic agitation Post TBI & during post-traumatic amnesia Occurs in the absence of other medical or psychiatric causes Continuous or intermittent verbal or physical behavior Inability to maintain or shift attention Perceptual disorders disorganized thinking Explosive anger Impulsivity Increased psychomotor activity / Akathisia Nott et al. Brain Inj Oct; 20 (11):

7 Definition of post-traumatic agitation Inappropriate vocalization Intolerance to the constraints of medical treatment Direct or diffuse combativity Hostility, disinhibition and emotional lability Described as a variant of delirium unique to TBI Lombard et al. Am J Phys Med Rehabil ;

8 When? During post traumatic amnesia (PTA) Transitory phase 1 to 4 weeks for symptom resolution Resolves when patient comes out of PTA

9 Pathophysiology Factors Structural lesions Frontal & limbic lesions External factors premorbid aggressivity & substance abuse Biochemical disbalance dopamine and catecholamine serotonin

10 Agitated Behavior Scale

11 Agitated Behavior Scale (ABS)

12 Objectives of our study To determine if socio-demographic & medical variables have an impact on the risk of developing post-traumatic agitation in patients with mild complex to severe TBI To determine prognosis using the Extended Glasgow Outcome Scale (GOS-E), length of stay (LOS) and orientation at discharge of agitated patients with TBI

13 Methods Retrospective observational study of all 778 patients Admitted to the Montreal General Hospital, a tertiary specialized trauma centre Following a TBI between 2013 and 2015 Database: Quebec trauma registry and TBI program data Independent variables socio-demographic Clinical neurological Dependent variables LOS non-pharmacological treatment GOS-E at discharge Galveston Orientation and Amnesia Test (GOAT) discharge destination

14 Results 55/778 patients (7.1%) suffered from post-traumatic agitation

15 Demographic and medical characteristics Variable No agitation Agitation Stat Sign Age (average) 61 ±21 57 ±23 p = Sex (n, % female) % 9 16% p = 0.018* Marital status (n, %) p = Single 197 (30%) 18 (36%) Couples 306 (46%) 19 (38%) Divorced /Separated 74 (11%) 4 (8%) Widow 94 (14%) 9 (18%) Education (n, %) No formal education Primary High school College University Post grad 4 (1%) 73 (13%) 297 (51%) 71 (12%) 137 (23%) 3 (1%) 2 (4%) 4 (9%) 28 (62%) 4 (9%) 7 (16%) 0 (0.) p = 0.093

16 Demographic and medical characteristics Variable No agitation Agitation Stat Sign Drugs or alcohol misuse (n, %) 176 (23%) 19 (35%) p = Psych History (n, %) 112 (15%) 23 (42%) p < 0.001* History of previous TBI (n, %) 67 (9%) 5 (9%) p = Neurological History (n, %) 158 (22%) 10 (18%) p = Homelessness (n, %) 15 (2%) 3 (6)% p = Legal History (n, %) 11 (2%) 2 (4%) p = 0.238

17 Demographic and medical characteristics Variable No agitation Agitation Stat Sign Age (average) 61 ±21 57 ±23 p = Sex (n, % female) % 9 16% p = 0.018* Marital status (n, %) p = Single 197 (30%) 18 (36%) Couples 306 (46%) 19 (38%) Divorced /Separated 74 (11%) 4 (8%) Widow 94 (14%) 9 (18%) Education (n, %) No formal education Primary High school College University Post grad 4 (1%) 73 (13%) 297 (51%) 71 (12%) 137 (23%) 3 (1%) 2 (4%) 4 (9%) 28 (62%) 4 (9%) 7 (16%) 0 (0.) p = 0.093

18 Demographic and medical characteristics Variable No agitation Agitation Stat Sign Drugs or alcohol misuse (n, %) 176 (23%) 19 (35%) p = Psych History (n, %) 112 (15%) 23 (42%) p < 0.001* History of previous TBI (n, %) 67 (9%) 5 (9%) p = Neurological History (n, %) 158 (22%) 10 (18%) p = Homelessness (n, %) 15 (2%) 3 (6)% p = Legal History (n, %) 11 (2%) 2 (4%) p = 0.238

19 Agitation and TBI severity Table 2. Agitation and Severity of TBI Agitation severity No Yes Total Mild Mild complex Moderate Severe Total Pts with agitation suffered a greater proportion a moderate TBI (47% v. 35%) and less of a mild complex TBI than those without agitation (32% v. 50%) (p = 0.042)

20 Agitation & GCS Table 3. Agitation in TBI and GCS Agitation N mean sd p50 p25 p No Yes Total P50: median, p25: 1st quarter, p75: 3d quarter, sd : standard deviation Median GCS was significantly lower in subjects with agitation than those without (p = 0.021)

21 Table 4. Agitation in TBI and length of PTA Length of Agitation PTA No Yes Total Agitation & PTA < hours days days Total Pts with agitation had proportionally longer PTA 65% pts with agitation have a PTA of 7-14 days + as compared to 39% without agitation

22 Agitation & GOS-E Table 5. Agitation in TBI and GOS-E Agitation N mean sd p50 p25 p No Yes GOS-E median score was similar for both groups Total

23 Agitation & Discharge destination Table 6. Agitation in TBI and orientation at discharge Agitation Discharge destination No Yes Total Home In-patient Rehab Out-patient Rehab LTC Death Other Total A smaller % of pts with agitation were discharged home 11% vs 25% without agitation A higher % of pts with agitation were transferred to LTC 27% vs 14% without agitation

24 Agitation & length of hospitalization Length of stay for pts with agitation was 11 vs 3 days in the nonagitated Bedside supervision was sign* much higher in pts with agitation (p < 0.001) Duration of sitters use for agitated pts was 24 vs 0 hours for nonagitated pts Cost of sitters was significantly more expensive in the agitated group Median cost of sitters for agitated pts was 374$ CDN vs 0$ for nonagitated (p < 0.001)

25 Results Pts with agitation: significantly higher proportion Men Psychiatric history Suffered a moderate TBI Lower GCS Longer PTA Median length of stay 3 x longer Required more direct care More transfer to long-term care

26 Of interest From logistic regressions Men have 2x more probability of developing agitation Psychiatric history 4 x more chances of agitation Long PTA (7-14 days +) 2 x more agitation severe TBI has a higher risk of agitation vs Mild complex TBI

27 Conclusion Our study specifically addresses risk factors for post-traumatic agitation Prognosis of agitated patients is less favourable Our study support previous results demonstrating a relationship between post-traumatic agitation and increased PTA duration, longer hospital stays and reduced functional independence at discharge, leading in this case to more transfers to LTC Identification of these factors is a key element in prevention, care & orientation By identifying early on the risk factors, appropriate treatment plans can be instated and positively alter the course of patients' stay This could also lead to less medical and hospitalization expenses

28 Treatment plan of post-traumatic agitation Environment modifications and medication management Non-pharmacological methods stimulation reduced environment minimizing physical discomfort: reducing tubes and catheters physical restraints Restoring sleep-wake cycle Medication has a central role

29 Recommendations for agitation crisis Search for an underlying factor that should be treated Pain Acute sepsis Drug adverse effect (expert opinion) Neuroleptic agent used for quick sedation to protect patient from himself but the duration should be as short as possible (expert opinion) Beta-blockers and antiepileptics Antidepressants, benzodiazepines are considered second-line treatments (expert opinion) Luauté J, Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations Ann Phys Rehabil Med Feb;59(1):58-67

30 Luauté J, Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations Ann Phys Rehabil Med Feb;59(1):58-67

31 A special thanks to Jennifer Massad MD FRCPC Mitra Feyz MSc Ps Elaine de Guise PhD

32 Thank you!