Agitation Duration, Density and Intensity during Acute Inpatient Rehabilitation Predict Length of Stay in Acute Inpatient Rehabilitation and Motor FIMsTM at Discharge for Patients with Traumatic Brain Injury MA Bockbrader, A Nielsen, C Kudron, L Worthen-Chaudhari, J Rosenthal, D Mortimer, WJ Mysiw, J Bogner, J Corrigan

Disclosures Research supported by NIDRR TBI Model Systems grant to J Bogner and J Corrigan Marcie Bockbrader has nothing to disclose

Objective To examine the relationship between Traumatic Brain Injury (TBI) outcomes and duration, density and intensity of agitation during inpatient rehabilitation (IPR).

AGITATION DFN: excessive behaviors occurring during an altered state of consciousness (Bogner, Corrigan, 1995); for TBI, the altered state of consciousness is post-traumatic amnesia (PTA). E.g., aggressive, labile, or disinhibited behaviors Interferes with functional activity Can affect therapy participation Hypothesis: Agitation affects recovery and outcomes after TBI

Agitated Behavior Scale (Corrigan 1989) Each item rated 1 (none) – 4 (extreme) per 8h shift Total score range: 14 – 56 Cutoff for agitation: total score > 21 14 Items

Background Bogner et al. 2001 n= 340 TBI patients in IPR Agitation as categorical variable Presence of agitation Severity of agitation Duration of agitation Agitated: at least one 48-hr period during IPR with 3 ABS scores > 21 Mean of 3 high ABS scores Mild: 22-28 Moderate: 29-35 Severe: >36 Days (first agitated shift in 48-hr period containing 3 ABS scores > 21) to (last shift with ABS >21) 4 groups: 0d, (1-10d), (11-25d), >26d

Presence of agitation “Cognitive functioning at admission to IPR mediates the relationship between the presence of agitation and LOS in IPR, as well as between agitation and cognitive functioning at discharge.” Agitated: at least one 48-hr period during inpatient stay contained 3 ABS total scores > 21 Patients with agitation had Longer LOS in IPR Less frequent discharge home Lower motor and cognitive FIMsTM at discharge 36% of 340 TBI patients were agitated using this definition.

Severity of agitation No significant differences based on severity for Agitation severity: Mean 3 high ABS None <22 Mild 22 - 28 Moderate 29 - 35 Severe 36 - 56 Bogner et al. 2001 No significant differences based on severity for LOS in IPR FIMTM motor at discharge Mild and moderate groups had lower FIMTM cog at discharge than nonagitated group (difference 2.3) Severe group did not differ from nonagitated group for FIMTM cog at discharge

Duration of agitation LOS in IPR Equivalent for 0d, 1-10d agitation Days (first agitated shift in 48-hr period containing 3 ABS scores > 21) to (last shift with ABS >21) 4 groups: 0d, (1-10d), (11-25d), >26d Bogner et al. 2001 LOS in IPR Equivalent for 0d, 1-10d agitation ~LOS +12d for 11-25d agitation ~LOS +41d for >26d agitation (& not dc to home) FIMsTM at discharge Motor & Cog equivalent for 0d, 1-10d, 11-25d groups FIMTM cog –3.6 for >26d agitation FIMTM motor –8.9 for >26d agitation

Revisit effects of agitation intensity, duration and density New sample of 284 patients Characterize agitation as continuous variable Agitation intensity = Bogner’s severity Agitation duration = 3 alternative definitions Agitation density = 4 alternative definitions Agitated Bout = Time period over which 6 consecutive shifts had at least 3 ABS scores >21

Agitation Intensity Mean of 3 highest ABS scores Intensity.1 Range: 14 – 56 Intensity ~ peak agitation http://www.peakfreaks.com/everestclimbphotos.htm

Agitation Duration Number of shifts in longest bout Duration.1 Range: 0 – 3*LOS in IPR shortest Number of shifts from first agitated shift of first bout to last agitated shift of last bout Range: 0 – 3*LOS in IPR Number of agitated shifts from first agitated shift of first bout to last agitated shift during IPR Range: 0 – 3*LOS in IPR longest

Agitation Density Number of bouts Density.1 Density.2 Range: 0 – LOS in IPR/2 shortest Number of agitated shifts within all bouts Range: 0 – 3*LOS in IPR Number of agitated shifts during IPR Range: 0 – 3*LOS in IPR longest Normalized density: Avg number of agitated shifts per day = Density.3/LOS in IPR Range: 0 – 3

Methods Design: Prospective, observational Setting: Multidisciplinary acute inpatient rehab Participants: 284 consecutively admitted patients meeting criteria for participation in the NIDRR-funded TBI Model Systems National Database (10 excluded) Instruments: Agitated behavior scale (ABS) scores during each shift of IPR. Computed agitation Density, Duration and Intensity constructs Demographic variables: Age, Gender, Race, Education level, Admission GCS, LOS acute, FIMTM Motor and Cognitive scores at IPR admission Outcomes: LOS in acute IPR, FIMTM Motor and FIMTM Cognitive scores at discharge from IPR

Sample Characteristics MA Bockbrader1, D Mortimer2, L Worthen-Chaudhari1, J Rosenthal1, JD Corrigan1, WJ Mysiw1, JA Bogner1 1Physical Medicine & Rehabiitation, The Ohio State University – Columbus, OH; 2Physical Medicine & Rehabilitation, Hennepin County Medical Center - Minneapolis, MN TBI severity, based on initial GCS 207 67 Gender Mild (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8) Uncategorizable (GCS 3T) Race Outcome Means (SD) LOS IPR 20.4 (13.9) days FIMTM Cog discharge 25.2 (4.2) FIMTM Motor discharge 70.7 (14.2) 41% of TBI patients (n=112) had at least one agitated shift. One-third (n=85) had at least one agitated bout. Education

Agitation Construct Definition Demographic variables Results + correlation - correlation Agitated Behavior Scale Constructs & Regression Analyses Clinical bout of agitation - “time period over which any 6 consecutive shifts had 3 or more ABS total scores > 21” *p<0.05 % variance accounted for (R2) by Significant* Univariate Predictors of: Significant* Multivariate Predictors of: Duration Agitation Construct Definition Mean (SD) FIMTM Cog discharge FIMTM Motor discharge LOS IPR (days) Duration.1 # shifts in longest bout 6.8 (15.5) 7% 2% 21% - Duration.2 # shifts from first agitated shift of first bout to last agitated shift of last bout 11.1 (26.8) 14% 8% 33% Duration.3 # shifts from first agitated shift of first bout to last agitated shift 14.6 (31.1) 16% 9% 37% 10% Density Density.1 # bouts of agitation 0.5 (0.8) 13% 28% Density.2 # agitated shifts within all bouts 4.6 (10.5) 24% Density.3 # agitated shifts during IPR 5.8 (11.3) 12% 5% 31% Density.4 average # agitated shifts per day, calculated as Density.3/LOS IPR 0.2 (0.3) 11% NS 3% Intensity Intensity.1 mean of 3 highest shift scores 22.3 (8.7) 1% 22% Demographic variables Age 37.2 (16.7) 4% Gender Race (white, nonwhite) Education level Admission GCS group FIMTM Cog admission 16.4 (6.8) 44% 43% FIMTM Motor admission 39.4 (18.1) 17% 38% 53% LOS acute care 16.4 (14.5) 20% 29%

Discussion In univariate regression analyses, Agitation Density, Duration and Intensity were significant predictors of rehab LOS and discharge FIMsTM. As has been shown previously (Bogner et al. 2001), the relationship between agitation and discharge Cognitive FIMTM was mediated by admission Cognitive FIMTM. Agitation Intensity & Duration were significant independent predictors of discharge Motor FIMTM (even after accounting for patient age, acute hospital LOS, and admission Motor FIMTM). Agitation Duration and Density were significant independent predictors of rehab LOS (even after accounting for admission Motor and Cognitive FIMsTM and acute hospital LOS). Agitation Duration accounted for 10% of the variability in rehab LOS  

Conclusions Constructs that take into account ABS scores over shifts yield Duration, Density and Intensity measures of agitation. Some of these provide additional predictive power (over admission FIMsTM and demographics) for TBI outcomes. Agitation Duration, Density, and Intensity may be important targets for intervention and relevant adjustments to case-mix groups to more accurately characterize the resources needed to achieve optimal rehabilitation outcomes.

References Bogner JA, Corrigan JD, Fugate L, Mysiw WJ, Clinchot D. Role of agitation in prediction of outcomes after traumatic brain injury. Am J Phys Med Rehabil 2001;80:636-44. Bogner JA, Corrigan JD. Epidemiology of agitation following brain injury. NeuroRehabilitation 1995;5(4):293-7. Corrigan JD. Development of a scale for assessment of agitation following traumatic brain injury. J Clin Exp Neuropsychol 1989;11:262-77. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehab 1993;74(5):531-6.