2. TBI - Neuroanatomy of TBA Primary Effects: Diffuse Axonal Injury Contusions Secondary Effects: Hematomas Cerebral Edema Hydrocephatus Infections Neurotoxicity ↑ ICP Hypoxic or anoxic event

3. 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

4. Men 2:1 15-24 Years Old Alcohol Trauma TBI - Risk Factors for TBI

5. 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

6. TBI – Executive Function Changes – Decreased Mental Flexibility Decreased capacity to: Concentrate Use language Abstract calculate Reason remember Plan Access information

7. Post Concussion Syndrome and TBI Criteria: Any period of LOC Any loss of memory Any alteration in mental status Mild focal neurological deficits

8. 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

9. Alaska TBI Screening

10. TBI - Assessment Neuropsychological Testing: Attention Concentration Memory Verbal Capacity Executive Functions: Problem Solving Reasoning Abilities Abstract Thinking Planning

11. 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

12. Post Concussion and TBI Workup Comprehensive assessment Validate cognitive and emotional problems Treat both cognitive and emotional difficulties Treat underlying anxiety and psychological symptoms

13. 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

15. TBI - Treatment of Depression See Depression Guidelines for MDD and Bipolar Depression Tricyclic anticholinergic effects may impair cognition

18. TBI - Treatment of Mood Instability – Mania, Hypomania, Mixed See Treatment Guidelines. Lithium levels – keep level less than 1.0

20. 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

22. TBI -Treatment of Chronic Aggression – Episodic Dyscontrol See Management of Chronic Aggression Guidelines.

26. 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 Lability of Mood and Affect

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Medication Treatment (Usually an SSRI, titrated to a therapeutic dose. If the agent is not tolerated, a second SSRI may be tried.) Step 1 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 Step 3 Medication treatmentCognitive behavior therapy Partial response Augment anti- depressant or add cognitive behavior therapy No response Cognitive behavior therapy or Different antidepressant type Partial response Augment cognitive behavior therapy (additional sessions) 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. 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 Stepped Algorithm for the Treatment of Anxiety Disorders No response Augment cognitive behavior therapy or add first-line antidepressant

34. Alcohol TCU Screening Clinical Assessment CAGE