Using the Agitated Behavior Scale to Evaluate Restlessness/ Agitation Following TrauDlatic Brain Injury A Case Example Restlessness and agitation following traumatic brain injury are potential barriers to successful rehabilitation. Although there are several ways to address the problem, including environmental management, physical restraint, and medication, the type of treatment which would be most appropriate under particular circumstances has not been established. Existing treatment stwlies often suffer from an emphasis on anecdotal information rather than measurement of restlessness/agitation. Use of the Agitated Behavior Scale would help remedy this situation by allowing more consistent decisions about beginning and altering treatment and providing a measurement device to clarify research results, particularly with respect to the use of medications.
The authors wish to thank C. Clendaniel, L. Thompson, S. Guerdat, L. Bishop. and S. Caldwell for their help in data collection.
Thomas A. NovaCk, PhD Department of Physical Medicine and Rehabilitation University of Alabama at Birmingham Birmingham, AL
louis Penrod, MD Department of Orthopaedic Surgery University of Pittsburgh Pittsburgh, PA
Among traumatically brain-injured (TBI) individuals undergoing acute rehabilitation, restlessness and agitation may interfere with participation in therapies and thus slow recovery, in addition to the potential for injury to the patient and others. Restlessness (defined as incessant, often repetitive, motor action) has been described as a stage of recovery after TBI,1 although it is unclear what percentage of TBI patients experience restlessness. The physiological basis for restlessness has not been established, but it appears likely that difficulties with focusing and maintaining attention playa part. Agitation may be viewed as a more extreme form of restlessness in which there are persistent attempts to reach a goal, such as leaving an area or attempting to arise from a wheelchair when restrained. There may be an emotional component to agitation, such as hostility and anger, which can be directed at staff if there are attempts to intervene. Environmental and behavioral management strategies have been employed successfully to decrease restlessness/agitation. 2•3 Decreasing extraneous stimulation, such as noise, while behaving in a calm, soothing manner, is often beneficial. Various types of physical restraint are available, although these devices may carry risks. 4 The use NeuroRehabill993; 3(3):79-82
Copyright © 1993 by Andover Medical.
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NEUROREHABILITATION / SUMMER 1993
of medications as a final alternative has been explored in greater depth recently. The effectiveness of the psychostimulants, tricyclic antidepressants, and dopamine agonists have been described, while the use of major tranquilizers has been discouraged. 5- 7 Unfortunately, it has yet to be established which medications are most effective under specific circumstances. Comparative effectiveness of medications is difficult to establish due to the anecdotal nature of most published reports; subject behavior is described, but not measured. To improve on this situation, use of a behaviorally oriented scale, such as the Agitated Behavior Scale, 8 would be appropriate. 1be scale was developed for use with traumatically brain-injured individuals and exhibits adequate reliability and validity 8 as shown by the progression in scores as individuals improve with respect to cognition.! At our center the ABS is employed daily in all therapies for patients exhibiting restlessness/agitation. At the same time each day the therapist working with the patient fills out the 14-item scale based on contact with the patient during the therapy appointments. Scores are reported to the neuropsychologist who then derives an average for the day. Averaging is necessary because the patient sometimes misses a particular therapy session and also because restlessness/agitation may vary based on: the type of therapy. Scores tend to be higher for physical and occupational therapy where physical contact and stamina are necessary, as opposed to speech therapy and psychology sessions where excess stimulation can be more easily controlled through environmental behavioral management. The average ABS scores can be graphed with notation of when medications are initiated or discontinued. The ABS does not interfere with use of behavioral management strategies or monitoring of specific behaviors, such as yelling episodes or striking out at others. An experienced therapist can complete the scale in two to three minutes. For consistency across therapies, the rating scale from one to four for each of the 14 items has been defined as follows: (1) absent, meaning that the behavior is not seen at all; (2) present to a slight degree, meaning that the behavior is present but does not interfere with completion of therapy tasks; (3) present to a moderate degree, meaning that the therapist has to modify treatment due to
the behavior but still can accomplish some tasks; and (4) present to an extreme degree, meaning that therapy tasks cannot be accomplished at all due to the behavior.
CASE REPORT Figure 1 presents the average ABS scores for a 38-year-old female who sustained a severe TBI with right subdural hematoma as well as multiple fractures nine weeks prior to admission for acute rehabilitation. Initially, her communication was limited, she exhibited no recall from day to day, and she was anxious. Participation in therapies was hampered by an inability to attend and restlessness. Decreasing extraneous stimulation did not have a significant impact, and restraints were required for safety. On admission the patient was receiving haloperidol 1 mg hs, which was discontinued on the seventh day of rehabilitation. She was started on alprazolam .25 mg tid, which was later increased to .5 mg without apparent effect on ABS scores. Lorazepam up to 1 mg qid was prescribed and seemed to have some effect initially, but the response was inconsistent. Eventually, amantadine 200 bid was added on the twentyeighth rehabilitation day and lorazepam discontinued two days later. Subsequently, there was a noticeable drop in ABS scores over the next two weeks. Significant improvement in cognition was also evident during this period 13 weeks postonset of her injury. The patient was discharged home where amatadine was later discontinued without apparent difficulty.
DISCUSSION The case example is not intended as a recommendation for particular medications, but as an example of use of the ABS to evaluate the effectiveness of intervention for restlessness/agitation. Objectivity in the measurement of restlessness/agitation is a necessity to establish which interventions, particularly medications, are the most effective under specific circumstances. For instance, it is possible that one type of medication would be appropriate for individuals having average ABS scores of 40 or
Using the Agitated Behavior Scale Following TBI
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The authors wish to thank C. Clendaniel, L. Thompson, S. Guerdat, L. Bishop. and S. Caldwell for their help in data collection.
Thomas A. NovaCk, PhD Department of Physical Medicine and Rehabilitation University of Alabama at Birmingham Birmingham, AL
louis Penrod, MD Department of Orthopaedic Surgery University of Pittsburgh Pittsburgh, PA
Among traumatically brain-injured (TBI) individuals undergoing acute rehabilitation, restlessness and agitation may interfere with participation in therapies and thus slow recovery, in addition to the potential for injury to the patient and others. Restlessness (defined as incessant, often repetitive, motor action) has been described as a stage of recovery after TBI,1 although it is unclear what percentage of TBI patients experience restlessness. The physiological basis for restlessness has not been established, but it appears likely that difficulties with focusing and maintaining attention playa part. Agitation may be viewed as a more extreme form of restlessness in which there are persistent attempts to reach a goal, such as leaving an area or attempting to arise from a wheelchair when restrained. There may be an emotional component to agitation, such as hostility and anger, which can be directed at staff if there are attempts to intervene. Environmental and behavioral management strategies have been employed successfully to decrease restlessness/agitation. 2•3 Decreasing extraneous stimulation, such as noise, while behaving in a calm, soothing manner, is often beneficial. Various types of physical restraint are available, although these devices may carry risks. 4 The use NeuroRehabill993; 3(3):79-82
Copyright © 1993 by Andover Medical.
80
NEUROREHABILITATION / SUMMER 1993
of medications as a final alternative has been explored in greater depth recently. The effectiveness of the psychostimulants, tricyclic antidepressants, and dopamine agonists have been described, while the use of major tranquilizers has been discouraged. 5- 7 Unfortunately, it has yet to be established which medications are most effective under specific circumstances. Comparative effectiveness of medications is difficult to establish due to the anecdotal nature of most published reports; subject behavior is described, but not measured. To improve on this situation, use of a behaviorally oriented scale, such as the Agitated Behavior Scale, 8 would be appropriate. 1be scale was developed for use with traumatically brain-injured individuals and exhibits adequate reliability and validity 8 as shown by the progression in scores as individuals improve with respect to cognition.! At our center the ABS is employed daily in all therapies for patients exhibiting restlessness/agitation. At the same time each day the therapist working with the patient fills out the 14-item scale based on contact with the patient during the therapy appointments. Scores are reported to the neuropsychologist who then derives an average for the day. Averaging is necessary because the patient sometimes misses a particular therapy session and also because restlessness/agitation may vary based on: the type of therapy. Scores tend to be higher for physical and occupational therapy where physical contact and stamina are necessary, as opposed to speech therapy and psychology sessions where excess stimulation can be more easily controlled through environmental behavioral management. The average ABS scores can be graphed with notation of when medications are initiated or discontinued. The ABS does not interfere with use of behavioral management strategies or monitoring of specific behaviors, such as yelling episodes or striking out at others. An experienced therapist can complete the scale in two to three minutes. For consistency across therapies, the rating scale from one to four for each of the 14 items has been defined as follows: (1) absent, meaning that the behavior is not seen at all; (2) present to a slight degree, meaning that the behavior is present but does not interfere with completion of therapy tasks; (3) present to a moderate degree, meaning that the therapist has to modify treatment due to
the behavior but still can accomplish some tasks; and (4) present to an extreme degree, meaning that therapy tasks cannot be accomplished at all due to the behavior.
CASE REPORT Figure 1 presents the average ABS scores for a 38-year-old female who sustained a severe TBI with right subdural hematoma as well as multiple fractures nine weeks prior to admission for acute rehabilitation. Initially, her communication was limited, she exhibited no recall from day to day, and she was anxious. Participation in therapies was hampered by an inability to attend and restlessness. Decreasing extraneous stimulation did not have a significant impact, and restraints were required for safety. On admission the patient was receiving haloperidol 1 mg hs, which was discontinued on the seventh day of rehabilitation. She was started on alprazolam .25 mg tid, which was later increased to .5 mg without apparent effect on ABS scores. Lorazepam up to 1 mg qid was prescribed and seemed to have some effect initially, but the response was inconsistent. Eventually, amantadine 200 bid was added on the twentyeighth rehabilitation day and lorazepam discontinued two days later. Subsequently, there was a noticeable drop in ABS scores over the next two weeks. Significant improvement in cognition was also evident during this period 13 weeks postonset of her injury. The patient was discharged home where amatadine was later discontinued without apparent difficulty.
DISCUSSION The case example is not intended as a recommendation for particular medications, but as an example of use of the ABS to evaluate the effectiveness of intervention for restlessness/agitation. Objectivity in the measurement of restlessness/agitation is a necessity to establish which interventions, particularly medications, are the most effective under specific circumstances. For instance, it is possible that one type of medication would be appropriate for individuals having average ABS scores of 40 or
Using the Agitated Behavior Scale Following TBI
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