Transcript TBI Risk Factors for TBI - abin

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
and
MSE
Drug and
Alcohol
Screening
Neuropsychological Testing Referral (if indicated referral to Psychology)
Review of type of brain injury and time since injury
Identification of psychiatric-behavioral symptoms
(1)
(2)
Depression Anxiety
(3)
Mood
Instability
(4)
Psychoses
(7)
PTSD
(4)
Delirium
Acute
Agitation
(6)
Sleep Disorders
(6)
(2)
(7)
File (Evaluation of TBI Guidelines-5-11-05)
(5)
Chronic
Aggression
(9)
Impaired Cognitive
Function and Arousal
(1)
See MDD Clinical Guidelines (Appendix 1)
See Anxiety Disorder Guidelines (Appendix 2)
(3)
See Mood Instability, Mania Guidelines (Appendix 3)
(4)
See Psychotic Disorder Guidelines (Appendix 4)
(5)
See Management of Chronic Aggression Guidelines (Appendix 5)
(8)
Lability and
Emotional
Incontinence
See Sleep Disorder Protocols and Attachment C-Sleep Disorders and TBI
See PTSD Guidelines from Aner Psychological Association – Attachment D
(8)
See Treatment of Lability of Mood and Affect – Attachment E
(9)
See Treatment of Impaired Cognitive and Function – Attachment F
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
2.
Seconds
Minutes
Hours
Days
Weeks
Months
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
3.
Did you receive treatment for the head injury? Circle One: N/A
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
Ability to care for yourself
Speech
Hearing, vision, or other senses
Memory
Ability to concentrate
Mood
Temper
Relationships with others
Ability to work, or do school work
Use of alcohol or other drugs
Headaches
Dizziness
Sleep Problems
Memory Loss
5.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Months
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
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
of
TBI
• Depression
• 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
and
MSE
Drug and
Alcohol
Screening
Neuropsychological Testing Referral (if indicated referral to Psychology)
Review of type of brain injury and time since injury
Identification of psychiatric-behavioral symptoms
(1)
(2)
Depression Anxiety
(3)
Mood
Instability
(4)
Psychoses
(7)
PTSD
(4)
Delirium
Acute
Agitation
(6)
Sleep Disorders
(6)
(2)
(7)
File (Evaluation of TBI Guidelines-5-11-05)
(5)
Chronic
Aggression
(9)
Impaired Cognitive
Function and Arousal
(1)
See MDD Clinical Guidelines (Appendix 1)
See Anxiety Disorder Guidelines (Appendix 2)
(3)
See Mood Instability, Mania Guidelines (Appendix 3)
(4)
See Psychotic Disorder Guidelines (Appendix 4)
(5)
See Management of Chronic Aggression Guidelines (Appendix 5)
(8)
Lability and
Emotional
Incontinence
See Sleep Disorder Protocols and Attachment C-Sleep Disorders and TBI
See PTSD Guidelines from Aner Psychological Association – Attachment D
(8)
See Treatment of Lability of Mood and Affect – Attachment E
(9)
See Treatment of Impaired Cognitive and Function – Attachment F
TBI - Treatment of
Depression
See Depression Guidelines for MDD and
Bipolar Depression
Tricyclic anticholinergic effects may
impair cognition
Acute/Major Depression
PA DOC
Clinical
Guidelines
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
Stage 2a
Stage 3
Stage 3a
Does patient have a clear
history of depression?
NO
Treat underlying disorder
Referral to Psychology
Proceed to Stage 3
Assessment after 4 week trial:
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
SSRI-Fluoxetine/TCA #2 or
Lexapro
(4-6 week trial)
Assessment after 4 week trial:
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 5
Stage 5
Stage 5a
YES
Monotherapy: TCA #1/SSRI-Fluoxetine (4-6 week trial)
Psychotic Features: Use low does of Antipsychotic
Stage 4
Stage 4a
Physicians may vary
from guidelines based
upon
clinical
need
and
with
adequate
supportive
documentation.
Comprehensive Psychiatric Evaluation Completed?
Does inmate meet DSM-IV Criteria for active Depression?
Stage 1
Stage 2
Attachment 1
Bupropion/Venlafaxine/Mirtazapine
(4-6 week trial)
Assessment after 4 week trial:
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 6
Partial Response or No Response
Response
Stage 6
Stage 6a
Combination antidepressants:
TCA + SSRI
BUPsr + SSRI
Wellbutrin + SSRI
SSRI + Lithium
TCA + Lithium
ECT
Refer to SCI Waymart
TCA – Amitriptyline, Doxepin
SSRI-Prozac, Lexapro
Physicians are instructed to follow Formulary, Non-Formulary Process
File (PA DOC Clinical Guidelines-9-30-03)
1. Continue Therapy
2. Reassess for 14-28
days
Clinical judgment may warrant altering steps if necessary.
Attachment 2
Bipolar Major Depressive Episode
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
Patient Referral
PA DOC
Clinical
Guidelines
*Comprehensive Assessment
Stage 1
Add AD-1to Mood Stabilizer or AD-2
No Response 4 Weeks
Stage 2
Stage 3
Stage 4
No Response 4 Weeks
Stage 5
Physicians may vary
from guidelines based
upon clinical need
and with adequate
supportive
documentation.
Stable Continue
Mood Stabilizer Switch
to AD-2 or AD-1
Stable Continue
No Response 4 Weeks
Mood Stabilizer Switch
to AD-3 or AD-4
Stable Continue
Mood Stabilizer Switch
to AD-4 or AD-3
Stable Continue
Mood Stabilizer
Plus AD 1-4
Plus Atypical Antipsychotic
Buspar, Lithium, Lamotragine,
Cytomel Augmentation
Stable Continue
No Response 4 Weeks
Stage 6
Zyprexa
Stage 7
AD-1
AD-2
AD-3
AD-4
ECT
Refer to SCIWaymart FTC
[(Tricyclic-norepinephrine specific (Imipramine, Desipramine)]
(SSRI-Prozac)
(Wellbutrin)
(Effexor)
Atypical Antipsychotics Preferred:
These agents should have a 4-6 week trial
period before changing to a new agent.
TBI - Treatment of Mood
Instability – Mania,
Hypomania, Mixed
See Treatment Guidelines.
Lithium levels – keep level less than 1.0
Manic, Hypomanic, Mixed or
Rapid Cycling Bipolar Episodes
Attachment 3
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
PA DOC
Clinical
Guidelines
Physicians may vary
from guidelines based
upon
clinical
need
and with adequate
supportive
documentation.
Patient Referral
*Comprehensive Assessment
All med trials for 2-4 weeks
Mixed Episode or Cycling
Euphoria
Mania or Hypomania
Stable
Continue
Stage 1
CBZ or DVP
DVP or Lithium
Unstable
Unstable
Stage 2
2 Mood Stabilizers
CBZ, DVP or Lithium
Stable
Continue
Unstable
Stage 3
2 Mood Stabilizers
Add SSRI or Buspar
2 Mood StabilizersStable Continue
Add low dose Atypical
Antipsychotic
Stable
Continue
Stage 6
1 Mood Stabilizer +
1 New Generation Mood
Stabilizer
(Lamotrigene Topamax)
Stable
Continue
DVP + CBZ
Stable
Continue
Unstable
Mood Stabilizer +
Atypical
Antipsychotic #1
Unstable
ECT-Referral to SCI-Waymart FTC
Physicians are instructed to follow Formulary, Non-Formulary Process.
File (PA DOC Clinical Guidelines-2.12.03)
Stable
Continue
CBZ +
Lithium
Unstable
Unstable
Stage 5
Stable
Continue
DVP +
Lithium
Unstable
Unstable
Stage 4
Stable
Continue
Mood Stabilizer +
Atypical
Antipsychotic #2
Stable
Continue
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
Evaluation for
Psychoses (3)
or Previous
Medicine
Trials
CLINICAL GUIDELINES FOR
TREATMENT OF PSYCHOTIC DISORDERS
Typical Antipsychotic Agent
plus Benzodiazepine (1)
(IM or PO)
Evaluate for Psychoses(3)
Psychiatric Emergency
YES
Clear History of Psychotic Disorder
Unclear
History
Atypical Agent - 1 Line(2)
(8-12 week trial) (5)
Mental Health Commitments
st
Drug Free Trial
Positive
Symptoms
Reemerge
TMAP 1
No Response
Evaluate for other causes
Bipolar Personality
Disorder
Substance Induced
Dementia
Atypical Agent - 2
nd
line(5)
TMAP 2
EPS treatment
guidelines
switch to
atypical agent
Stabilized on Antipsychotic Med
(typical)
Comprehensive Psychiatric Evaluation
No Response
TMAP 4
Typical (full dose) - 3 line(4)
No side effects (EPS)
rd
No positive symptoms
No treatment indicated
st
nd
rd
Maximize dose of 1 , 2 & 3 line(5)
Or
Augment with Loxitane (25-50 mg.)(6)
EPS Side
Effects
TMAP
Stage
6, 5a
Monitor monthly for signs of
recurrence of psychotic
symptoms
Continue Typical Agent
Patient has history of good
response to typical agents
Good Compliance
th
Clozapine trial - full dose - 5 line (7)
NO
5. New
TMAP 3
Consider Typical
Agents in “Depot”
Formulation
(1)
(2)
(3)
Typical Antipsychotics (Haldol or Loxitane).
Atypical Antipsychotic Agents (Risperdal or Seroquel).
Evaluate for smoking history.
(4)
(5)
Dosing - Haldol 5-20 mg/day
Loxitane 150-200 mg
Dosing - Risperdal 4-6 mg
Seroquel 300-600 mg
(6)
(7)
YES
Continue Typical
Agents PO
Augmentation - Haloperidol 1-4 mg
Loxipine 25-50 mg
Dosing - Clozopine 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
NO
Institutional Management/Living
problem observed by staff (note
housing location)
Management
plan not needed
YES
Dangerous or Assaultive Behavior
Toward Self or Others
Interventions (*See Table 1)
NO
Outpatient
observation in present
housing location
Consider
Psychology
Referral
DC-97
YES
Transfer to
POC(3)
See Guidelines for
Psychoses-Psychiatric
Emergencies
(Attachment 5)
YES
Psychiatric
Emergency
Consider MHU/FTC Admission
PRT Develops Treatment Plan
Treatable – Accepts Treatment
Plan (*See Table 4)
YES
201 Vol.
Admission
NO
302, 304
Invol. Admission
Brief Psychiatric Assessment
(*See Table 2)
Serious Mental Illness
Level of social withdrawal
SIB-medical attention
Assault history-injuries
Suicide potential
YES
NO
Psychiatric
Emergency
Initial Treatment/Management
Plan (1) PRT – (2) PRC Input
(*See Table 4)
NO
Medical Condition
Substance Intox or WD
YES
Comprehensive
Psychiatric
Assessment
(*See Table 2)
Medical evaluation with
Medical Director
(*See Table 3)
Psychology MH
Evaluation
(*See BPRS-F, Table 8)
(*See PEACHS, Table 9)
Go to 2
nd
Page
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
Disorders
(Attachment 5)
MDD
with
rage
attacks
See MDD
Guidelines
(Attachments 1
and 2)
BPD
Affective
Instability
See APA
Guidelines
(Attachment 4)
See Bipolar
Hypermania,
Mania, Mixed
Guidelines
(Attachment 3)
Refer for
Dialectical
Behavior
Therapy
Impulse Control
Disorder
Organic Head
Injury
Lower Arousal
Level and
Impulsiveness
Reduce Arousal
Improve Cognition
DVP
CPZ
Li
SSRI
Buspar
Clonidine
Propranolol
DVP
CPZ
Li
Clonidine
Propranolol
SSRI’s
PTSD
See
APA
Guidelines for
BPD
(Attachment 4)
ADHD
Assess Level
of Functional
Impairment
NO
Psychiatric
Symptoms
Refer to FTC
if Significantly
Impaired
Wellbutrin
Stimulants
See Clinical
Guidelines
for Psychoses
Management of
Dementia with
Atypical
Antipsychotic
Agents
(Attachment 5)
Diagnostic Specific
Treatment/Management
Plan Developed
by PRT/PRC
Axis II
only
ASPD
See
ASPD
Guidelines
(*See
Table
7)
YES
(4)SAU-Special Asessment Unit – SCI-Waymart
(5)SMU-Special Management Unit – SCI-Camp
Hill and SCI-Greene
SAU(4),
SMU(5)
Referral
Page 3
DIAGNOSTIC SPECIFIC MANAGEMENT PLAN (CONTINUED)
Inmates
Refuse Plan
Inmate refuses
medication recommended
in management plan
Inmate
Accepts Plan
Accepts
Refuses
Inmate
Accepts
Medication
and
Management
Plan
Patient signs DC-462
Refusal of Medical Treatment
Psychoeducation provided by
nursing staff
Management
Plan is
Monitored
Monthly by
PRT - PRC
Management Plan Team
PRT – PRC
Notified of Refusal
Psychology
Referral for
Psychotherapy
if Indicated
Psychiatry Referral
for Medication
Counseling and
Education
Compliant Inmate
(*See Table 7)
Inmate Accepts
Management Plan
Unit Management
Staff Provide
Counseling Per
Refusal of Medical
Procedures(6)
Inmate Continues to Refuse
PRT-PRC Management Plan Monitoring Provided Monthly
(6)Policy Reference – 13.1.1 – Medical-Legal Procedures
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
behavior
therapy
(Usually an SSRI, titrated to a therapeutic
dose. If the agent is not tolerated, a
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
Partial response
Augment antidepressant
or
add cognitive
behavior therapy
Cognitive behavior therapy
No response
Partial response
No response
Cognitive behavior
therapy
or
Different
antidepressant type
Augment cognitive behavior
therapy (additional sessions)
or
add first-line antidepressant
Augment cognitive
behavior therapy
or
add first-line
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