1. 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

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

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

4. 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

5. 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

6. 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:
Moderate:
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

7. 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.

8. Severity of agitation No significant differences based on severity for
Agitation severity: Mean 3 high ABS
None <22
Mild
Moderate
Severe
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

9. 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

10. 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

11. Agitation Intensity Mean of 3 highest ABS scores Intensity.1
Range: 14 – 56
Intensity ~ peak agitation

12. 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

13. 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

14. 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

15. 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
Gender
Mild (GCS 13-15)
Moderate (GCS 9-12)
Severe (GCS 3-8)
Uncategorizable (GCS 3T)
Race
Outcome Means (SD)
LOS IPR (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

16. 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%

17. 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

18. 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.

19. 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:
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:
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.