; TBI Risk Factors for TBI
Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

TBI Risk Factors for TBI

VIEWS: 94 PAGES: 34

  • pg 1
									                                                          Fred R. Maue, M.D.
                                                       Chief of Clinical Services
                                                Pennsylvania Department of Corrections

              EVALUATION AND TREATMENT OF INMATES/PATIENTS WITH TBI
                            (TRAUMATIC BRAIN INJURY)
                                                      Alaska Screening Tool (Attachment A) – Psychology

                                                      Identification of Risk Factors (Attachment B) – Psychology

                                                      Clinical Assessment – Comprehensive – Psychiatrist


History                  Drug and                     Neuropsychological Testing Referral (if indicated referral to Psychology)
 and                      Alcohol
 MSE                     Screening



           Review of type of brain injury and time since injury
           Identification of psychiatric-behavioral symptoms

      (1)        (2)                              (3)           (4)      (7)           (4)                   (8)                     (5)
      Depression Anxiety                         Mood        Psychoses   PTSD        Delirium            Lability and               Chronic
                                               Instability                            Acute               Emotional                Aggression
                                                                                     Agitation           Incontinence
   (6)                                                                                                                                              (9)
Sleep Disorders                                                                                                                              Impaired Cognitive
                                                                                                                                            Function and Arousal
           (1)                                                                            (6)
               See MDD Clinical Guidelines (Appendix 1)                                       See Sleep Disorder Protocols and Attachment C-Sleep Disorders and TBI
           (2)                                                                            (7)
               See Anxiety Disorder Guidelines (Appendix 2)                                   See PTSD Guidelines from Aner Psychological Association – Attachment D
           (3)                                                                            (8)
               See Mood Instability, Mania Guidelines (Appendix 3)                            See Treatment of Lability of Mood and Affect – Attachment E
           (4)                                                                            (9)
               See Psychotic Disorder Guidelines (Appendix 4)                                 See Treatment of Impaired Cognitive and Function – Attachment F
           (5)
               See Management of Chronic Aggression Guidelines (Appendix 5)
 File (Evaluation of TBI Guidelines-5-11-05)
TBI - Neuroanatomy of TBA
 Primary Effects:
 • Diffuse Axonal Injury
 • Contusions
 Secondary Effects:
  • Hematomas
  • Cerebral Edema
  • Hydrocephatus
  • Infections
  • Neurotoxicity
  • ↑ ICP
  • Hypoxic or anoxic event
 Prediction of Outcome
        after TBI
Injury severity
Duration of Post-Traumatic Amnesia
Type of damage (contusion vs. DAI)
Premorbid intelligence
Alcohol intoxication at time of injury
Premorbid OBS or history of substance
abuse
Premorbid psychiatric/behavioral history
TBI - Risk Factors for TBI
Men 2:1
15-24 Years Old
Alcohol
Trauma
TBI - Personality Changes
        – Common
Worsening of premorbid behavioral traits
Childishness
Disinhibition
Social inappropriateness
Restlessness
Emotional lability
Decreased social contact
Less spontaneity/poverty of interest
Decreased social interaction
 TBI – Executive Function
Changes – Decreased Mental
        Flexibility
 Decreased capacity to:
 • Concentrate
 • Use language
 • Abstract calculate
 • Reason remember
 • Plan
 • Access information
Post Concussion Syndrome
         and TBI

Criteria:
• Any period of LOC
• Any loss of memory
• Any alteration in mental status
• Mild focal neurological deficits
     Post Concussion and
        TBI Syndrome
Somatic: HA, dizziness, fatigue, insomnia
Cognitive: memory deficits, impaired
concentration
Perceptual: tinnitus, noise sensitivity, light
sensitivity
Emotional: depression, anxiety, irritability
Other: decreased reasoning, information
processing, verbal learning, attention
Alaska TBI Screening
SECTION III – Please circle and fill in your answer to the following questions based on
events in your lifetime.

1.    Have you ever had a blow to the head that was severe enough to make you lose
      consciousness? Circle one: Yes     No    When did it occur?_______________
      If “Yes”, how long were you unconscious?

      Circle One: N/A     Seconds      Minutes     Hours   Days    Weeks      Months

2.    Have you ever had a blow to the head that was severe enough to cause a
      concussion? Circle One: Yes       No    When did it occur?__________________
      If “Yes”, how long did the concussion last?

      Circle One: N/A     Seconds      Minutes     Hours   Days    Weeks      Months

3.    Did you receive treatment for the head injury? Circle One: N/A    Yes    No

4.    If you had a blow to the head that caused unconsciousness or a concussion, was
      there a permanent change in any of the following?

      Circle all that apply:
      N/A (Did not have head injury)
      Physical Abilities                         Yes        No
      Ability to care for yourself               Yes        No
      Speech                                     Yes        No
      Hearing, vision, or other senses           Yes        No
      Memory                                     Yes        No
      Ability to concentrate                     Yes        No
      Mood                                       Yes        No
      Temper                                     Yes        No
      Relationships with others                  Yes        No
      Ability to work, or do school work         Yes        No
      Use of alcohol or other drugs              Yes        No
      Headaches                                  Yes        No
      Dizziness                                  Yes        No
      Sleep Problems                             Yes        No
      Memory Loss                                Yes        No

5.    Did you receive treatment for any of the things that changed after the head
      injury?

      Circle One: N/A     Yes    No
        TBI - Assessment
Neuropsychological Testing:
•   Attention
•   Concentration
•   Memory
•   Verbal Capacity
•   Executive Functions:
     • Problem Solving
     • Reasoning Abilities
     • Abstract Thinking
     • Planning
Psychiatric Complications
 • Depression
              of TBI
• Mania and mood instability
• Delirium:
     •   Restlessness
     •   Agitation
     •   Confusion
     •   Disorientation
     •   Delusions – hallucinations
     •   Usual during coma emergence
•   Sleep Disturbance
•   Psychoses
•   Anxiety
•   Personality Changes
•   Emotional Instability
•   Chronic Aggression and Violence
   Post Concussion and
       TBI Workup
Comprehensive assessment
Validate cognitive and emotional
problems
Treat both cognitive and emotional
difficulties
Treat underlying anxiety and
psychological symptoms
   General Principles of
       Treatment
Review all current meds – indications
Examine current or potential side
effects
OBS patients: increased sensitivity to
side effects
Start low – go slow
Allow sufficient time to work
Reassessness medication need
                                                          Fred R. Maue, M.D.
                                                       Chief of Clinical Services
                                                Pennsylvania Department of Corrections

              EVALUATION AND TREATMENT OF INMATES/PATIENTS WITH TBI
                            (TRAUMATIC BRAIN INJURY)
                                                      Alaska Screening Tool (Attachment A) – Psychology

                                                      Identification of Risk Factors (Attachment B) – Psychology

                                                      Clinical Assessment – Comprehensive – Psychiatrist


History                  Drug and                     Neuropsychological Testing Referral (if indicated referral to Psychology)
 and                      Alcohol
 MSE                     Screening



           Review of type of brain injury and time since injury
           Identification of psychiatric-behavioral symptoms

      (1)        (2)                              (3)           (4)      (7)           (4)                   (8)                     (5)
      Depression Anxiety                         Mood        Psychoses   PTSD        Delirium            Lability and               Chronic
                                               Instability                            Acute               Emotional                Aggression
                                                                                     Agitation           Incontinence
   (6)                                                                                                                                              (9)
Sleep Disorders                                                                                                                              Impaired Cognitive
                                                                                                                                            Function and Arousal
           (1)                                                                            (6)
               See MDD Clinical Guidelines (Appendix 1)                                       See Sleep Disorder Protocols and Attachment C-Sleep Disorders and TBI
           (2)                                                                            (7)
               See Anxiety Disorder Guidelines (Appendix 2)                                   See PTSD Guidelines from Aner Psychological Association – Attachment D
           (3)                                                                            (8)
               See Mood Instability, Mania Guidelines (Appendix 3)                            See Treatment of Lability of Mood and Affect – Attachment E
           (4)                                                                            (9)
               See Psychotic Disorder Guidelines (Appendix 4)                                 See Treatment of Impaired Cognitive and Function – Attachment F
           (5)
               See Management of Chronic Aggression Guidelines (Appendix 5)
 File (Evaluation of TBI Guidelines-5-11-05)
      TBI - Treatment of
         Depression
See Depression Guidelines for MDD and
Bipolar Depression

  Tricyclic anticholinergic effects may
  impair cognition
                                            Acute/Major Depression                                       Attachment 1
 PA DOC                The pathways do not replace sound clinical judgment.
 Clinical                                                                                               Physicians may vary
                       Nor are they intended to strictly apply to all patients.                         from guidelines based
Guidelines
                                                                                                        upon   clinical  need
                                                                                                        and   with   adequate
                              Comprehensive Psychiatric Evaluation Completed?                          supportive
 Stage 1                    Does inmate meet DSM-IV Criteria for active Depression?                    documentation.



 Stage 2                                        Does patient have a clear
                       NO                        history of depression?                     YES




 Stage 2a          Treat underlying disorder                               Proceed to Stage 3
                   Referral to Psychology



 Stage 3                          Monotherapy: TCA #1/SSRI-Fluoxetine (4-6 week trial)
                                  Psychotic Features: Use low does of Antipsychotic



                                              Assessment after 4 week trial:
 Stage 3a                                         Is patient responding?
                         Improvement evidenced by self report, rating scales, and collaborative data.
                    If Yes, continue therapy and reassess for 14-28 days. If No, proceed to Stage 4


 Stage 4                                                  SSRI-Fluoxetine/TCA #2 or          (4-6 week trial)
                                                                  Lexapro

                                              Assessment after 4 week trial:
                                                  Is patient responding?
 Stage 4a                Improvement evidenced by self report, rating scales, and collaborative data.
                    If Yes, continue therapy and reassess for 14-28 days. If No, proceed to Stage 5


 Stage 5
                                                       Bupropion/Venlafaxine/Mirtazapine         (4-6 week trial)


                                              Assessment after 4 week trial:
                                                  Is patient responding?
 Stage 5a                Improvement evidenced by self report, rating scales, and collaborative data.
                    If Yes, continue therapy and reassess for 14-28 days. If No, proceed to Stage 6
                     Partial Response or No Response                                             Response


                                                             Combination antidepressants:
 Stage 6                                         TCA + SSRI      BUPsr + SSRI      Wellbutrin + SSRI
                                                 SSRI + Lithium  TCA + Lithium




Stage 6a
                                                        ECT                     1. Continue Therapy
                                                                                2. Reassess for 14-28
                                              Refer to SCI Waymart              days
TCA – Amitriptyline, Doxepin
SSRI-Prozac, Lexapro
Physicians are instructed to follow Formulary, Non-Formulary Process         Clinical judgment may warrant altering steps if necessary.
File (PA DOC Clinical Guidelines-9-30-03)
                                                                                                 Attachment 2

                             Bipolar Major Depressive Episode
                              The pathways do not replace sound clinical judgment.
                              Nor are they intended to strictly apply to all patients.

                                                                                          Physicians may vary
                                                                                          from guidelines based
                                              Patient Referral
        PA DOC                                                                            upon clinical need
        Clinical                                                                          and with adequate
       Guidelines                                                                         supportive
                                                                                          documentation.
                                       *Comprehensive Assessment



         Stage 1                 Add AD-1to Mood Stabilizer or AD-2
                                                                             Stable Continue



No Response 4 Weeks
       Stage 2                            Mood Stabilizer Switch
                                            to AD-2 or AD-1                  Stable Continue



                                       No Response 4 Weeks
         Stage 3                          Mood Stabilizer Switch
                                             to AD-3 or AD-4                 Stable Continue



                                                                             No Response 4 Weeks
         Stage 4                          Mood Stabilizer Switch
                                            to AD-4 or AD-3                  Stable Continue




No Response 4 Weeks                          Mood Stabilizer
                                                Plus AD 1-4
       Stage 5
                                        Plus Atypical Antipsychotic          Stable Continue
                                       Buspar, Lithium, Lamotragine,
                                          Cytomel Augmentation


        Stage 6


                                                  Zyprexa



        Stage 7                                  ECT
                                             Refer to SCI-
                                             Waymart FTC


AD-1   [(Tricyclic-norepinephrine specific (Imipramine, Desipramine)]
AD-2   (SSRI-Prozac)                                                    These agents should have a 4-6 week trial
AD-3   (Wellbutrin)                                                     period before changing to a new agent.
AD-4   (Effexor)

Atypical Antipsychotics Preferred:
 TBI - Treatment of Mood
   Instability – Mania,
    Hypomania, Mixed
See Treatment Guidelines.

 Lithium levels – keep level less than 1.0
                                    Manic, Hypomanic, Mixed or                                                  Attachment 3
                                   Rapid Cycling Bipolar Episodes
                               The pathways do not replace sound clinical judgment.
                               Nor are they intended to strictly apply to all patients.

                                                                                                               Physicians may vary
       PA DOC                                                                                                  from guidelines based
       Clinical                                              Patient Referral                                  upon   clinical  need
      Guidelines                                                                                               and with adequate
                                                                                                               supportive
                                                       *Comprehensive Assessment                               documentation.
                                                        All med trials for 2-4 weeks




                              Mixed Episode or Cycling                               Euphoria
                                                                                Mania or Hypomania


  Stage 1                                                 Stable                                             Stable
                                CBZ or DVP                Continue               DVP or Lithium              Continue

                                                                                                  Unstable
                                               Unstable
                                                                                                             Stable
                            2 Mood Stabilizers                  Stable                 DVP +                 Continue
  Stage 2                  CBZ, DVP or Lithium                  Continue               Lithium



                                         Unstable                                                Unstable


                                                                 Stable
                              2 Mood Stabilizers                                                              Stable
  Stage 3                                                        Continue               CBZ +
                             Add SSRI or Buspar                                                               Continue
                                                                                        Lithium

                                               Unstable                                           Unstable


  Stage 4                       2 Mood Stabilizers-                  Stable            DVP + CBZ                Stable
                                  Stable Continue                    Continue                                   Continue
                               Add low dose Atypical
                                   Antipsychotic

                                                                                                  Unstable
                                               Unstable


                                  1 Mood Stabilizer +                                  Mood Stabilizer +                Stable
                                1 New Generation Mood                                      Atypical                     Continue
   Stage 5                            Stabilizer                                       Antipsychotic #1
                                (Lamotrigene Topamax)
                                                                   Unstable




   Stage 6                ECT-Referral to SCI-Waymart FTC                              Mood Stabilizer +
                                                                                           Atypical
                                                                                       Antipsychotic #2
Physicians are instructed to follow Formulary, Non-Formulary Process.


   File (PA DOC Clinical Guidelines-2.12.03)
TBI - Treatment of Psychoses
 See Clinical Guidelines for Treatment of
 Psychoses.

   Increased sensitivity to EPS
   Atypicals – less EPS potential, greater
   metabolic side effects, OHD, CVA
   Risperdal – higher EPS
                                                                                                                                                               ATTACHMENT 5
Comprehensive Psychiatric Evaluation
                                               NO
                                                            CLINICAL GUIDELINES FOR
                                                     TREATMENT OF PSYCHOTIC DISORDERS
           Evaluation for
                                                                                                                                             Typical Antipsychotic Agent
           Psychoses (3)
            or Previous                                                                                                                       plus Benzodiazepine (1)
             Medicine                                                                                                                                 (IM or PO)
               Trials                                             Psychiatric Emergency                                                       Evaluate for Psychoses(3)
                                                                                                                 YES

                                        Clear History of Psychotic Disorder

   Unclear
   History

                                                              Atypical Agent - 1 Line(2)
                                                                                    st                                                       Mental Health Commitments
                                  Positive
                                                                                                          TMAP 1
 Drug Free Trial                 Symptoms                        (8-12 week trial) (5)
                                 Reemerge
                                                                                No Response                     EPS treatment                Stabilized on Antipsychotic Med
                                                                                                                  guidelines                             (typical)
                                                                                                                   switch to
       Evaluate for other causes                                                                                atypical agent
                                                                                         line(5)
                                                                                    nd
                                                             Atypical Agent - 2                       TMAP 2
          Bipolar Personality
               Disorder                                                                                                                  Comprehensive Psychiatric Evaluation
         Substance Induced                                                     No Response
              Dementia                                                                                  TMAP 4
                                                                                                                                                 No side effects (EPS)
                                                           Typical (full dose) - 3 line(4)
                                                                                     rd
                                                                                                                           EPS Side
                                                                                                                            Effects              Continue Typical Agent
                                                                                                                                               Patient has history of good
       No positive symptoms                                                                                 TMAP                               response to typical agents
       No treatment indicated                                                                               Stage
                                                      Maximize dose of 1 , 2 & 3 line(5)
                                                                         st nd   rd
                                                                                                            6, 5a
                                                                      Or
                                                      Augment with Loxitane (25-50 mg.)(6)
  Monitor monthly for signs of                                                                                                                   Good Compliance
   recurrence of psychotic
          symptoms
                                                                                                               5. New                          NO               YES
                                                        Clozapine trial - full dose - 5 line (7)
                                                                                       th
                                                                                                               TMAP 3

                                                                                                                                      Consider Typical          Continue Typical
                                                                                                                                      Agents in “Depot”           Agents PO
                                                                                                                                        Formulation




 (1)       Typical Antipsychotics (Haldol or Loxitane).                       (4)           Dosing - Haldol 5-20 mg/day       (6)        Augmentation - Haloperidol 1-4 mg
 (2)       Atypical Antipsychotic Agents (Risperdal or Seroquel).                                    Loxitane 150-200 mg                                Loxipine 25-50 mg
 (3)       Evaluate for smoking history.                                      (5)           Dosing - Risperdal 4-6 mg         (7)        Dosing - Clozopine 300-600 mg
                                                                                                     Seroquel 300-600 mg
TBI -Treatment of Chronic
  Aggression – Episodic
        Dyscontrol
See Management of Chronic Aggression
Guidelines.
            PA Department of Corrections’ Guidelines for Management of
              Inmates/Patients with Chronic Aggression and Violence

                                              Institutional Management/Living          NO               Management
                                              problem observed by staff (note                          plan not needed
                                                       housing location)

                                                                YES                                                                                    Consider
                                                                                      NO                    Outpatient
                                        Dangerous or Assaultive Behavior                                                                              Psychology
                                                                                                       observation in present
                                             Toward Self or Others                                                                                     Referral
                                                                                                         housing location
                                          Interventions (*See Table 1)                                                                                  DC-97
                                                                YES

                                                        Transfer to
                                                          POC(3)




    See Guidelines for                         Brief Psychiatric Assessment
   Psychoses-Psychiatric                               (*See Table 2)
                                  YES              Serious Mental Illness                            Initial Treatment/Management
       Emergencies
      (Attachment 5)                            Level of social withdrawal                            Plan (1) PRT – (2) PRC Input
                                Psychiatric        SIB-medical attention        NO                             (*See Table 4)
                                Emergency         Assault history-injuries      Psychiatric
                                                      Suicide potential         Emergency
Consider MHU/FTC Admission
PRT Develops Treatment Plan                             YES                       NO
                                                    Medical Condition                    Comprehensive                            Psychology MH
                                                  Substance Intox or WD                    Psychiatric                              Evaluation
Treatable – Accepts Treatment                                                             Assessment                          (*See BPRS-F, Table 8)
     Plan (*See Table 4)                                        YES                      (*See Table 2)                      (*See PEACHS, Table 9)
                                                  Medical evaluation with
                                                    Medical Director
      YES        NO
                                                     (*See Table 3)                                                              nd
                                                                                                                       Go to 2        Page
 201 Vol.          302, 304
Admission      Invol. Admission                                                                  Comprehensive Management Plan
                                                                      (1)PRT = Psychiatric Review Team – Treatment
                                                                      (2)PRC = Program Review Committee – Security
                                                                      (3)POC = Psychiatric Observation Cell located in SCI infirmary or special housing locations
                                                                                                                                                           Page 2


                                                 Comprehensive Management
                                                    Plan (*See Table 6)
                                                        PRT + PRC




                                                  Assess Level of Aggression
                                                    Diagnostic Categories
                                                    (*See Tables 5 and 6)




Psychotic      MDD         Affective            BPD             Impulse Control       Organic Head           PTSD              ADHD                   Axis II
Disorders       with      Instability                              Disorder              Injury                                                        only
 (Attach-      rage                                                                                                                                   ASPD
 ment 5)      attacks                         See APA                                                          See            Assess Level
                                              Guidelines        Lower Arousal                                  APA            of Functional
                          See Bipolar                                                Reduce Arousal          Guide-
                                               (Attach-           Level and                                                    Impairment         Psychiatric
                         Hypermania,                                                Improve Cognition       lines for
                         Mania, Mixed          ment 4)          Impulsiveness                                                                     Symptoms
            See MDD                                                                                            BPD
              Guide-      Guidelines                                                                        (Attach-
                                                                                                                           Refer to FTC
               lines    (Attachment 3)                                                    DVP               ment 4)
                                              Refer for                                                                   if Significantly
             (Attach-                                               DVP                   CPZ
                                              Dialectical                                                                     Impaired
             ments 1                                                CPZ                    Li
              and 2)                          Behavior               Li                 Clonidine
                                               Therapy              SSRI                                                                        See             SAU(4),
                                                                                       Propranolol                            Wellbutrin
                                                                   Buspar                                                                     ASPD              SMU(5)
                                                                                         SSRI’s                               Stimulants
                                                                  Clonidine                                                                   Guide-            Referral
                                                                 Propranolol                                                                   lines
                                                                                                                                              (*See
                                                                                       See Clinical                                           Table
                                                                                        Guidelines                                               7)
                                                                                      for Psychoses
                                                                                      Management of
                                                                                      Dementia with
                                                                                          Atypical
                                                                                       Antipsychotic
                                                                                          Agents
                                                                                      (Attachment 5)



                                                              Diagnostic Specific
                                                            Treatment/Management
                                                                Plan Developed         YES
                                         NO                      by PRT/PRC                             (4)SAU-Special Asessment Unit – SCI-Waymart
                                                                                                        (5)SMU-Special Management Unit – SCI-Camp
                                                                                                        Hill and SCI-Greene
         DIAGNOSTIC SPECIFIC MANAGEMENT PLAN (CONTINUED)                                                  Page 3




               Inmates                                Inmate
              Refuse Plan                           Accepts Plan



             Inmate refuses           Accepts         Inmate
        medication recommended                        Accepts
          in management plan                         Medication
                                                        and
                        Refuses                     Management
                                                       Plan
          Patient signs DC-462
       Refusal of Medical Treatment

                                                    Management
                                                      Plan is                          Compliant Inmate
                                                     Monitored                          (*See Table 7)
       Psychoeducation provided by                   Monthly by
              nursing staff                          PRT - PRC



         Management Plan Team
              PRT – PRC
           Notified of Refusal                                           Inmate Accepts
                                                                        Management Plan

  Psychology       Psychiatry Referral     Unit Management
  Referral for       for Medication          Staff Provide
 Psychotherapy      Counseling and          Counseling Per
  if Indicated         Education           Refusal of Medical
                                             Procedures(6)




             Inmate Continues to Refuse


                                                                (6)Policy Reference – 13.1.1 – Medical-Legal Procedures
PRT-PRC Management Plan Monitoring Provided Monthly
TBI - Treatment of Lability
    of Mood and Affect
 Emotional incontinence
 Antidepressants are best choice:
  • Fluoxetine (20-80 mg/d) – Prozac
  • Sertraline (25-150 mg/d) – Zoloft
  • Nortriptyline (50-150 mg/d) – Pamelor
  • Effexor (150-450 mg/day) – higher
    doses needed to get NE effect
  TBI - Treatment of Acute
         Aggression
Antipsychotic meds: Haldol, Geodan
• Problems: EPS, Akathisia, Retardation of
  neuronal recovery
Benzodiazepines:
• Disinihibition, hostility, ataxia confusion,
  sedation, decreased memory
Treatment of choice:
• Haldol plus Ativan – lowest dose needed
 TBI -Treatment of Impaired
Cognitive Function and Arousal
   Psychostimulants:
   • Dexedrine
   • Ritalin
   Indications for stimulants:
   •   ADD or ADHD
   •   Anergy/Apathy
   •   Rage outbursts
   •   Emotional incontinence
   •   Emotional irritability
   •   Frontal Lobe Syndrome – left sided
TBI – Treatment of Cognitive
  Dysfunction and Arousal
  Psychostimulants:
  • May increase neuronal recovery
  • Side effects: paranoia, dysphoria,
    anorexia, irritability, agitation, insomnia
  • Wellbutrin – alternative to stimulants, no
    lower seizer threshold on SL formulation
  • Cylert – no proven help
  • Concerta – liver toxicity
  • Provigil (modafinil):
     • Awake, alert, but no cognitive improvement
     • Used for narcolepsy
TBI – Treatment of Cognitive
  Dysfunction and Arousal
Dopamine agonist:
• Symmetrel (Amantadine hcl) – dose 100-400
  mg/d
   • Improves: arousal, attention, initiation, processing
     speed, and agitation
   • Drug of choice for management of agitation post TBI
   • Side Effects: Hallucinations, GI upset, low blood
     pressure, lower seizure threshold
   • Action: NMDA antagonism, release Dopamine to
     stimulate interaction of neurons
 Sleep Disorders and TBI
50% of TBI patients with pain
27-56% of all patients with TBI
Common symptom of co-existing depression
Acute phase of TBI – diffuse disruption of cerebral
functioning, direct physical damage to brain, secondary
neuropathological events
Decreased REM and slow wave sleep
Increase awakening at night
Shortening of total sleep time:
 • Decrease or disappearance of deep sleep
DIMS – common in recent injury
   Treatment of Sleep
Disorders in TBI Patients
Melatonin – 3.0 to 7.5 mg at bedtime
Ambien (5 to 20 mgs.) – shorter
activity, preserves REM sleep,
decreased daytime effects
Chloral Hydrate – rapid sleep induction,
increases total sleep time, potential for
tolerance, narrow therapeutic window
Trazadone (Desyrel) – useful in
depressed-TBI patients with insomnia
                                         Stepped Algorithm for the Treatment of Anxiety Disorders

Step 1                        Medication Treatment
                                                                                                                        Cognitive
                    (Usually an SSRI, titrated to a therapeutic
                                                                                                                        behavior
                      dose. If the agent is not tolerated, a
                                                                                                                         therapy
                           second SSRI may be tried.)


                                                   Evaluate response to treatment in step 1.
                                                   Patients who have a full response to either
                                                    treatment go to maintenance treatment.
                                                              Others go to step 2.



Step 2                Medication treatment                                                        Cognitive behavior therapy

               Partial response                   No response                           Partial response                         No response

                  Augment anti-                Cognitive behavior                  Augment cognitive behavior               Augment cognitive
                   depressant                        therapy                      therapy (additional sessions)              behavior therapy
                        or                              or                                        or                                or
                  add cognitive                      Different                     add first-line antidepressant               add first-line
                 behavior therapy              antidepressant type                                                            antidepressant

                                                       Evaluate response to step 2 treatments.
                                                    Patients with full response go to maintenance
                                                     treatment. Others are considered for step 3.


Step 3   Consider:
         •Trial of second or third type of antidepressant (e.g., SNRI, venlafaxine, nefazadone, mirtazapine, and clomipramine)
         Intensive cognitive behavior therapy (several times a week)
         Other augmentation of antidepressants (if patient had a partial response to an antidepressant in step 2)
         Referral to specialty mental health care for more ongoing treatment if more complex problems are present (e.g., childhood abuse and
         PTSD
             Alcohol
TCU Screening
Clinical Assessment
CAGE

								
To top