Ch 2 - TBI: Posttraumatic Agitation Flashcards
What is posttraumatic agitation?
Subtype of delirium occurring during the state of posttraumatic amnesia
What are characteristics of posttraumatic agitation?
Aggression
Akathisia
Disinhibition
Emotional lability
How long does posttraumatic agitation typically last?
1 to 14 days but can last longer
What types of lesions MC have posttraumatic agitation?
Frontotemporal lesions, which coordinate arousal, attention, executive control, memory, and limbic behavioral functions
What are ways to quantify agitation?
Agitated Behavior Scale (ABS) or Overt Aggression Scale
What is the Agitated Behavior Scale (ABS)?
Serial assessments of agitated patients based on observation during an 8 hour nursing shift or after therapy treatment
How is the patient rated in Agitated Behavior Scale (ABS)?
14 items or behaviors rated b/w 1 (absent) to 4 (present to an extreme)
What is the total scoring in Agitated Behavior Scale (ABS)?
Below 21: normal
22 to 28: mild agitation
29 to 35: moderate agitation
35 to 54: severe agitation
Describe ways to reduce the level of stimulation in the environment for an agitated patient
Quiet private room Remove noxious stim Staff to behave calm Limit sounds/visitors Limit # and length of therapy sessions Do therapy in pts room
Describe ways to protect patient from harming self or others.
Sitter for safety
Place in locked ward
Avoiding taking patient off floor
Craig bed (floor bed with padded walls)
Describe ways to reduce patient’s cognitive confusion.
One person speak to pt at a time
Maintain similar staff
Communicate briefly and simply with one idea at a time
Describe ways to tolerate restlessness.
Allow patient to thrash on floor bed
Allow pacing around with supervision
Allow confused patient to be verbally inappropriate
What complication can antipsychotic medications cause?
Neuroleptic malignant syndrome (fever, leukocytosis, muscle stiffness)
How is neuroleptic malignant syndrome treated?
Dantrolene and beta-blockers
What is the MOA of typical antipsychotic agents?
Block D2-receptors, histaminic, alpha-1-adrenergic and cholinergic receptors
What do antipsychotic agents with more anticholinergic properties do to the nigrostriatal pathway?
Inc dopamine lessening extrapyramidal symptoms (EPS)
What has been shown in animal models and humans with the use of haloperidol?
Animals: slow motor recovery
Humans: prolong PTA
What are types of typical antipsychotics?
Haldoperidol
Chlorpromazine
Thiothixene
What is the MOA of atypical antipsychotic agents?
Less blockage of dopamine D2-receptors with more serotonin blockade at 5HT2-receptor
What are atypical antipsychotics less likely to cause?
Tardive dyskinesia
Parkinsonism
Dystonia
Akasthisia
What are side effects of atypical antipsychotics?
Hyperglycemia/DM Weight gain HLD Stroke QT prolongation
What types of atypical antipsychotics?
Risperidone (Risperdal) Ziprasidone (Geodon) Quetiapine (Seroquel) Olanzapine (Zyprexa) Clozapine (Clozaril) Aripiprazole (Abilify)
Which medication is the most “typical” of the atypical antipsychotics?
Risperidone (Risperdal) at higher doses, higher incidence of EPS than other atypicals
What are side effects of Risperidone (Risperdal)?
Stimulating Insomnia Agitation Hypotension Inc prolactin levels
What is the MC side effect of Ziprasidone (Geodon)?
Most known for QT prolongation; otherwise, favorable side-effects profile
What is the MC side effect of Quetiapine (Seroquel)?
Very sedating
What are side effects of Olanzapine (Zyprexa)?
Somnolence
Gait disturbances
High rate of metabolic SE and weight gain
Dose related EPS (>7.5 mg)
What are side effects of Clozapine (Clozaril)?
Agranulocytosis
Cardiac effects
Lowered seizure threshold
Most anticholinergic activity and weight gain of all atypicals
What are side effects of Aripiprazole (Abilify)?
Least sedating
Fewest EPS
Low propensity for metabolic adverse reaction
What are side effects of benzodiazepines?
Paradoxal agitation in elderly Inc confusion in emerging PTA Respiratory depression Disinhibition Impaired coordination
What can benzodiazepines be used to treat in TBI patients?
Mutism
Which agents have the best evidence for efficacy in treating posttraumatic agitation?
Beta-blockers
Which beta-blockers are the most effective for posttraumatic agitation?
Lipophilic agents (propranolol, metoprolol)
What can Valproic acid (Depakote, Depakene) be helpful for in post-traumatic agitation?
Reduce behavioral outbursts and agitation
What can Carbamazepine (Tegretol), oxcarbazepine (Trileptal) be helpful for post-traumatic agitation?
Can improve irritability, disinhibition, and aggression
What have been found to be reduced in CSF of agitated anoxic brain injury (ABI) patients?
Metabolites of norepinephrine and serotonin
What have Amitriptyline and desipramine been shown to reduce in post-traumatic agitation?
Reduce agitation and aggressive behaviors possibly due to sedative effects.
What has Sertraline been shown to reduce in post-traumatic agitation?
Reduce irritability and aggressive behavior
What has Trazodone been shown to reduce in post-traumatic agitation?
Reduce agitation and aggressive behaviors in dementia patients
What has Buspirone been shown to reduce in post-traumatic agitation?
Reduced aggressive behavior
What has Buproprion been shown to reduce in post-traumatic agitation?
Restlessness
When can Lithium be useful in TBI?
Aggression is related to manic effects and irritability is related to cyclic mood disorders
What is Medroxyprogesterone acetate (Depo-Provera) used for in TBI?
For aggressive hypersexual behavior—lowers testosterone
