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?
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Do not leave alone;
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Keep noise and traffic in room to a minimum;
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Familiarize with basic information;
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Physical reassurance through talking or touching patient;
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Accomodation in a highly-structured setting;
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Establish desired behaviour;
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Remove patient from group or change activity if agitation increases;
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Freedom of movement to control outbursts;
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Stimulating simple self-care tasks and participation;
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Assess for treatable pathology;
- 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?
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Pharmacological agents should only be used as a last resort (ABS > 28).
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Careful considerations of the sensitivity of people with TBI to psychotropic medications which should be used with caution.
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With medications “start low and go slow” and titrate to an optimal dose; but get to a therapeutic dosing before abandoning use.
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Develop clear cut goals and metrics to assist in determining when to stop treatment (i.e. consider weaning off medication when ABS < 21).
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Be alert to side effects and undesired effects.
- 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
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Atypical antipsychotics prn – Risperidone up to 3 gm daily;
- Alternative Seroquel or Olanzepine
Later
If ABS > 28 then provide scheduled dose medications
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Beta-blockers;
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Anticonvulsants (i.e Valproic Acid);
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SSRI (Sertraline);
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Tricyclic antidepressants (Amtriptyline titrated up to 75 mg/day);
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Methylphenidate;
- Avoid the use of antipsychotic drugs such as Haldol.
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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.
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The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers 7.
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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.