Agitation/Aggression/Apathy After Brain Injury

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Condition: Agitation, aggression, and apathy (lack of motivation) are seen in many people who have had a traumatic brain injury (TBI), an acquired brain injury (including stroke, brain tumor, or anoxic), or who have other brain disorders, such as dementia.

Background: Between a quarter and half of patients with TBI or dementia become agitated or aggressive. Apathy is seen in about a third of stroke patients and most patients with Alzheimer’s disease. The symptoms seem to be caused by damage to certain parts of the brain.

Risk Factors: Agitation and aggression are more common in people with a history of substance abuse, depression, or other problem behaviors.  Agitation is very common after a TBI, and an expected part of a patient’s recovery.  As patients start to recovery, they transition through the Rancho Los Amigos stages of TBI recovery.

History and Symptoms: Brain injured patients usually become less agitated as they recover from their injury. With dementia, agitation and aggression may increase as the disease gets worse

Physical Exam: The doctor will take a detailed health history and check all systems in the body to rule out other problems that could be causing agitation or aggression. Testing how well the patient can do certain tasks may also help the doctor understand what is causing the behaviors.  

Diagnostic Process: Blood tests, and sometimes tests of the spinal fluid, will be done to look for infections or chemical changes in the body that might be causing agitation or aggression. Brain imaging may also be ordered. Rating scales are often used to describe the severity.   Neuropsychology testing, or psychology counseling, may also be indicated.

Rehab Management: Some symptoms will improve by keeping the patient in a quiet, relaxed place and limiting contact with others. This is why it is important to limit the number of visitors during the immediate period of a patient’s recovery.  Physical medicine and rehabilitation (PM&R) physician specialists lead a team which usually includes occupational therapists (OTs), physical therapists (PTs), speech therapists (or speech-language pathologists, SLPs), counselors/psychologists, recreational therapists, and social workers. In some cases, medications are also used to treat symptoms. PM&R physicians have special expertise in prescribing medications to control aggressive behavior, as well as discontinuing other medications which may exacerbate the situation.

Other Resources for Patients and Families: Education helps families understand what is happening, and how to appropriately respond, and possibly reduce, these behaviors.  Furthermore, some nurses, therapists, and social workers have taken the American Congress of Rehabilitation Medicine training and are considered certified brain injury specialists.