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Agitation in patients recovering from traumatic brain injury: nursing management.

ABSTRACT

This article reviews clinical and research literature regarding the nursing management of agitation after severe traumatic brain injury. Neuroscience nurses in acute rehabilitation settings use an evidence-based approach to perform multifaceted assessments and implement effective individualized plans of care. These essential efforts minimize the effects of agitation and help patients achieve optimal outcomes.

Keywords: acute rehabilitation, agitation, traumatic brain injury

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Posttraumatic agitation is a near-inevitable component of rehabilitation after severe traumatic brain injury (TBI) (Bogner et al., 2015). This manuscript, an applied review of clinical and research literature regarding the nursing management of agitation after severe TBI, informs readers about this common but complicated issue.

Neuroscience nursing management of agitation after TBI includes careful assessment and skillful interdisciplinary collaboration (Sandel & Mysiw, 1996). Nurses cultivate therapeutic environments, provide beneficial nonpharmacologic treatments, educate family members, and administer appropriate pharmacologic agents (Mysiw & Sandel, 1997). These crucial interventions both maintain safety during the agitation period (Janzen, McIntyre, Meyer, Sequeira, & Teasell, 2014) and optimize overall rehabilitation outcomes (McNett, Sarver, & Wilczewski, 2012).

Overview of Agitation

Agitation, a subtype of delirium, encompasses a continuum of behavioral disturbances. Agitation is characterized by inattention, disinhibition, emotional liability. impulsivity, motor restlessness, and aggression. These behaviors are especially problematic because they tend to be present in excess (Rosenthal & Mortimer, 2013).

Agitated behaviors are exhibited during the discrete stage of TBI recovery that is associated with acute confusion, posttraumatic amnesia, and lack of consistent orientation (Corrigan, Mysiw, Gribble, & Chock, 1992). This stage, classified as Ranchos Los Amigos Scale level IV, generally lasts from days to weeks, with extensive variability among individual patients (Hagen, Malkmus, & Durham, 1979). Isolated agitated behaviors can be observed after emergence into an oriented state, but the full range of excessive agitated behaviors generally occurs while orientation is still deficient (Corrigan & Mysiw, 1988).

Prevalence of Agitation

Agitation is quite prevalent in patients recovering from severe TBI. Approximately 20 000 people are admitted to acute rehabilitation facilities with severe TBI every year (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2015). Between 30% and 70% of these patients demonstrate agitation during their course. Although this wide range can be explained by differences in measurement methods, the data clearly indicate that agitation is a common problem (Kim, 2002).

Pathophysiology of Agitation

The pathophysiology of agitation is uncertain. Some clues can be found in the factors that seem to put patients at a greater risk. Agitation is more likely to occur with more severe injuries, injuries to particular brain regions, and neurotransmitter dysfunction (Mysiw & Sandel, 1997). Lower cognitive function, which is related to injury severity, has been shown to be a predictor for subsequent agitation (Bockbrader et al., 2015). Infection, which can be related to severity of the injury or its sequelae, has also been associated with the occurrence of agitation (Bogner et al., 2015).

Injuries to certain areas of the brain seem to predispose patients to agitation. Damage to the fronto-parietal cortex, subcortical regions, and brainstem, areas responsible for arousal, attention, memory, and emotional regulation (Kim, 2002), are associated with the development of behavioral changes including agitation (Riggio, 2010).

Neurochemical dysregulation involving the brain's neurotransmitters is also associated with agitation. Dysfunction in the dopaminergic and noradrenergic pathways, with subsequent abnormal amounts or concentrations of dopamine, epinephrine, and norepinephrine, can translate into problems with arousal and attention (Lombard & Zafonte, 2005). Acetylcholine deficiency can lead to impaired memory functioning. Serotonin imbalance is associated with aggression. These neurotransmitter abnormalities, either alone or in combination, can trigger disinhibition and emotional liability (Kim, 2002).

Agitation's Effects

Agitated behaviors, which are highly disruptive and potentially unsafe, can impede rehabilitation and significantly affect progress (Bockbrader et al., 2015; Bogner, Corrigan, Fugate, Mysiw, & Clinchot, 2001). Agitation is associated with decreased engagement and participation in therapy, difficulty achieving functional goals (Lequerica et al., 2007), and longer rehabilitation stays (Singh, Vankateshwara, Nair, Khan, & Saad, 2014).

Agitation can be distressing to caregivers and family members. Problematic behaviors can obstruct relationships between recovering patients and their families. Agitation can also strain families' ability to cope with and adapt to an already challenging and potentially overwhelming situation (Norup, Siert, & Lykke Mortensen, 2010).

Agitated behaviors, including verbal belligerence, wandering, and physical aggression, pose safety risks for patients, staff, and family members. Loud voices or yelling can be disruptive to other patients. Agitated patients with decreased safety awareness may fall. They may elope from the unit or care area. Patients may attempt to hit, kick, grab, bite, or, otherwise, injure caregivers. These behaviors can result in harm (Becker, 2012).

In addition, agitation can affect prognosis. Patients who exhibit agitation during acute rehabilitation have higher rates of institutionalization after discharge (McNett et al., 2012). Agitation has been linked to poorer cognitive function at discharge (Bogner et al., 2001), residual behavioral disturbance, and worse overall functional outcomes after discharge (Singh et al., 2014). Patients who are agitated in acute rehabilitation tend to subsequently have more difficulties with psychological recovery, community reintegration, and work reentry than patients without agitation (Kim, 2002).

Notably, there is some ambiguity in the studies that link agitation to poorer outcomes. Agitation tends to occur in the setting of impaired cognition (Bogner et al., 2015). It is quite possible that the reduced cognitive functioning underlying agitation, and not the actual presence of agitation, can explain the worse outcomes (Bockbrader et al., 2015). Either way, the presence of agitation can be an important negative prognostic factor (Bogner et al., 2001).

Nursing Management Assessment: Agitated Behavior Scale

Agitation can be evaluated and quantitatively described using the Agitated Behavior Scale (ABS). The ABS is a well-studied tool with demonstrated validity and reliability for the assessment of agitation in patients with traumatic brain injuries. Agitated Behavior Scale scores have been found to correlate with other measures of agitation, such as the need for constant observation. It has high interrater reliability among nurses (Amato, Resan, & Mion, 2012) and other TBI providers (Bogner, Corrigan, Stange, & Rabold, 1999). On psychometric testing, the ABS has high internal consistency and concurrent validity (Corrigan. 1989). Confirmatory factor analysis has also demonstrated that the ABS is highly valid for the detection of agitation (Bogner, Corrigan, Bode, & Heinemann, 2000; Corrigan & Bogner, 1994).

Behaviors are divided into categories of aggression, disinhibition, and liability. Fourteen items within each category are rated from 1 (absent) to 4 (present to an extreme degree). Ratings are summed to obtain total scores, which range from 14 to 56. Agitated Behavior Scale scores of 21 or higher are consistent with agitation (Bogner et al., 1999). For a copy of the ABS, the reader is referred to the Center for Outcome Measurement in Brain Injury's Web site (Bogner, 2000).

The ABS provides objective and quantifiable data that help clinicians characterize troublesome behaviors when the behaviors are present. The ABS also allows staff members to measure and track agitation's extent and duration throughout the rehabilitation course (Amato et al., 2012).

Knowing ABS scores can help clinicians manage agitation. It can be especially helpful to identify a particular time of day or night when a patient's agitation generally occurs (Amato et al., 2012). Agitated Behavior Scale scores can also be used to detect potential triggers for agitation episodes (Duraski, 2011). Furthermore, correlating ABS scores with medication changes and other interventions can help appraise the effects of treatment (Sherer, Nakase-Thompson, Yablon, & Gontkovsky, 2005).

Additional Assessment

Neuroscience nurses strive to understand, and then address, agitation's potential underlying causes or exacerbating factors. Nearly any physiologic derangement can be associated with altered mental status and agitation after TBI. Neuroscience nurses collaborate with other providers to identify and reverse such abnormalities. Underlying factors can include pain, infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities (Lombard & Zafonte, 2005).

One frequent culprit is pain. Pain can be related to spasticity, heterotopic ossification, posttraumatic headaches, neuropathic pain, or musculoskeletal pain in the setting of healing fractures or injuries (Mysiw & Sandel, 1997). The pain, and subsequent agitation, can improve with measures such as positioning, resting, stretching, heat, ice, massage, or pain medications (Duraski, 2011).

Sequelae of bowel and bladder dysfunction can also commonly incite agitation. Neuroscience nurses implement appropriate bowel and bladder care. This often involves a regimen that facilitates regular voids and attempts to avoid fullness, urgency, or incontinence (Duraski, 2011).

Agitation and cognition are closely related. If cognition can be optimized, agitation can improve. It follows that, if agitated behaviors can be minimized, then cognitive function may also be improved. Nurses and other rehabilitation team members aim to create milieus that facilitate cognitive recovery (Bogner et al., 2015).

Promoting and Maintaining a Therapeutic Environment

The rehabilitation environment is designed to allow individuals to engage with the team and participate in therapies in a beneficial way. Nurses and other team members implement milieus that are at once calm and therapeutic. For some patients, however, the level of stimulation may be either too much or too little. Either situation can potentially exacerbate agitation (Lombard & Zafonte, 2005).

Quiet rooms with individualized visiting schedules can be beneficial. Patients may become stressed by multiple visitors and prolonged visits. Patients may become overwhelmed by seeing loved ones. There may be even a lower threshold for stress with unfamiliar visitors and when visitors try to engage patients beyond the current ability to communicate (Dvorkin, Pacini, Hsu, & Larson, 2013).

Environmental modifications aimed at optimizing the sleep-wake cycle can minimize agitation. At night, nurses decrease stimulation by turning off televisions, radios, and lights. Patients should not have caffeine or other stimulants after midafternoon (Lombard & Zafonte, 2005).

Disoriented and restless states can be ameliorated by verbal reminders and strategically placed calendars, clocks, or signs. A consistent schedule and treatment team provides important reassurance and reinforcement. Restless patients often respond positively to engaging in therapeutic activities such as games, reading, movies, and supervised ambulation. Planned rest breaks can also be helpful (Janzen et al., 2014).

Caring for the Whole Patient

Neuroscience nurses design and implement individualized interventions to prevent, treat, and minimize the negative effects of agitation. These actions can be divided into those aimed at maintenance and those that are useful in specific situations. Maintenance level interventions are geared toward maintaining a constant level of patient safety and comfort. Proper positioning, for example, is a basic but potentially very potent intervention. Thoughtful and appropriate use of pillows and positioning devices helps facilitate comfort and skin integrity, particularly for patients with altered mobility (Kreitzer & Koithan, 2012). Similar actions can impede agitation.

Situational interventions are implemented when a patient is agitated. Nurses work toward de-escalating the patient, thus minimizing the potential for harm or injury during the acute agitation period. Strategies include assessing for the presence of noxious or unpleasant stimuli. These can include discomfort related to perspiration or chills, overstimulation or understimulation, hunger, thirst, and fatigue (Sherer et al., 2005). Nurses can often remove or address the offending source and help the patient regain calm (Montgomery, Kitten, & Niemiec, 1997).

Integrative therapies can be an important part of both maintenance and situational strategies. Individualized use of integrative therapies, including aromatherapy, massage therapy, and music, can beget stress reduction, overall calm, and decreased subsequent agitation. Although these interventions have not been extensively studied in agitation after TBI, there is ample evidence for their safety and efficacy in other situations (Kreitzer & Koithan, 2012).

Aromatherapy has been shown to decrease pain and anxiety in hospitalized patients with cancer and other ailments (Rivard, Crespin, Finch, Johnson, & Dusek, 2014). Nurses can assess the effect of an essential oil such as lavender on a patient's agitation. If the patient seems to tolerate the oil, a few drops can be put on a cotton ball, and the ball can be left near the patient. The oil can then be part of an overall plan to promote and maintain an environment that is antagonistic to agitation (Kreitzer & Koithan, 2012).

Massage therapy, one of the most commonly used integrative therapies, has been shown to improve anxiety, mood, and pain. It has been postulated that moderate pressure massage can help improve regulation of both emotions and the autonomic nervous system (Field, 2014). Nurses can provide therapeutic touch interventions to try to achieve similar benefits in patients with agitation (Kreitzer & Koithan, 2012).

Music can have a calming effect. Music can be appreciated despite brain injuries that cause impairments with language, orientation, and judgment. Music should generally be soft but should be from a genre that would predictably be pleasant and calming to the individual patient. Notably, patients can quickly become overstimulated or tired and then agitated. Interventions should be continually evaluated and tailored to the patient and the situation (Tabloski, McKinnon-Howe, & Remington, 1995).

Rehabilitation Issues

Nurses and therapy team members use a targeted approach to facilitate progress with activities of daily living and other functional goals despite the presence of agitation. This process can involve implementing specific strategies directed at a single behavior. For example, if the patient becomes agitated while showering in a bathroom, that activity can be modified in a way that causes less distress. The patient could undergo sponge baths in bed until an improvement occurs. Other activities can be similarly modified (Becker, 2012).

In cases of severe agitation with a high potential for injury, behavioral and mobility controls help maintain safety (Janzen et al., 2014). Continuous supervision can be accomplished using video cameras or bedside one-to-one monitoring (Dvorkin et al., 2013). Devices such as seatbelts, vests, mitts, enclosed beds, low beds, and padded floors can minimize injury related to falls, unplanned tube removal, wandering, and physical aggression. On the other hand, physical restraints can be associated with more agitation in some patients. Careful monitoring is needed to minimize the risk of restraint-related injury. Behavioral and mobility controls, which are implemented in accordance with facility and national regulations, are used for the shortest amount of time possible (Becker, 2012).

Nurses and other team members adjust interventions based on patient responses. Careful monitoring helps patients avoid developing adverse effects such as worsening agitation, skin issues, and other injury. Behaviors and responses to interventions frequently change as individuals progress. The rehabilitation plan of care is adjusted accordingly (Beaulieu et al., 2008).

Family and Caregiver Education

Continued family and caregiver education and support are needed throughout the complicated journey toward recovery. Nurses provide crucial supportive education about the patient's current status, factors that seem to exacerbate or minimize agitation, and the fact that this stage of TBI recovery will likely resolve. Nurses explain that a patient's behavior, which can include uncharacteristic verbal and physical aggression directed at his or her own loved ones, is not unexpected during the present phase of recovery. Family members can then try to engage the patient in an appropriate way, provide compassion and affection, and help pave the way toward eventual healing (Norup et al., 2010).

Pharmacologic Interventions

Medications play an important role in the treatment of agitation after TBI. Although no true best practices have yet been established, at least 2 large systematic reviews provide some empiric evidence for medication choices (Chew & Zafonte, 2009; Fleminger, Greenwood, & Oliver, 2008). The reader is referred to those articles for additional information about specific medications.

Effective collaboration among team members is an essential part of the successful use of pharmacological agents. Providers individualize approaches while considering factors such as patients' overall status, comorbid conditions, and metabolic function. Medications' potential benefits are weighed against likely risks. Changes in therapeutic regimens are discussed with interdisciplinary team members. Families also participate in conversations about plans for care (Lombard & Zafonte, 2005).

Neuroscience nurses are well versed in medication indications, administration techniques, and adverse effects. Creative and patient-centered strategies can optimize medication adherence despite common barriers such as confusion and swallowing disorders. Nurses may administer medications with pudding or another food that is safe and pleasurable (Becker, 2012). Nurses also help develop and implement therapeutic medication schedules. For example, pain medications may be more appropriate before or after therapies, depending on the patient. The resulting decrease in pain can help prevent agitation and facilitate calm (Duraski, 2011).

Future Research

Many important questions remain unanswered. More knowledge about the pathophysiology behind agitation could yield better prevention and treatment strategies (Rosenthal & Mortimer, 2013). Additional information about the effects of therapeutic interventions, both nonpharmacologic and pharmacologic, could guide care planning (Lombard & Zafonte, 2005). Future technological advances, including potential use of virtual reality and semiautomated monitoring devices, may help facilitate safety during this necessary but potentially dangerous period of TBI recovery (Dvorkin et al., 2013). Neuroscience nurses will likely play instrumental roles in these upcoming research efforts.

Conclusion

Agitation is a highly prevalent and clinically significant problem in patients recovering from severe TBI. Neuroscience nursing management includes adept assessment and expert family education. Nurses collaborate with other rehabilitation team members to develop and implement individualized, holistic, and effective nonpharmacological interventions throughout the rehabilitation course. These measures, in conjunction with appropriate medical management, allow neuroscience nurses to minimize the deleterious effects of agitation and improve overall outcomes for these vulnerable patients.

Questions or comments about this article may be directed to Diane Schretzman Mortimer, MD MSN, at diane.mortimer67@ gmail.com. She is a Traumatic Brain Injury/Polytrauma Staff Physician, Department of Physical Medicine and Rehabilitation, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN.

Wesley Berg, RN BA, is Rehabilitation Nurse Case Manager, Department of Physical Medicine and Rehabilitation, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0000000000000253

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Author:Mortimer, Diane Schretzman; Berg, Wesley
Publication:Journal of Neuroscience Nursing
Article Type:Report
Date:Feb 1, 2017
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