1. Agitation Duration, Density and Intensity during Acute Inpatient Rehabilitation Predict Length of Stay in Acute Inpatient Rehabilitation and Motor FIMs TM 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. Objective  To examine the relationship between Traumatic Brain Injury (TBI) outcomes and duration, density and intensity of agitation during inpatient rehabilitation (IPR). 2

3. Disclosures  Research supported by NIDRR TBI Model Systems grant to J Bogner and J Corrigan  Marcie Bockbrader has nothing to disclose 3

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 4

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 5 14 Items

6. Background  Bogner et al. 2001  n= 340 TBI patients in IPR  Agitation as categorical variable 1.Presence of agitation 1.Severity of agitation 1.Duration of agitation 6 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

7. Presence of agitation  Patients with agitation had  Longer LOS in IPR  Less frequent discharge home  Lower motor and cognitive FIMs TM at discharge 7 Agitated: at least one 48-hr period during inpatient stay contained 3 ABS total scores > 21 “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.” 36% of 340 TBI patients were agitated using this definition.

8. Severity of agitation 8 Agitation severity: Mean 3 high ABS None <22 Mild22 - 28 Moderate29 - 35 Severe36 - 56 No significant differences based on severity for LOS in IPR FIM TM motor at discharge Mild and moderate groups had lower FIM TM cog at discharge than nonagitated group (difference 2.3) Severe group did not differ from nonagitated group for FIM TM cog at discharge Bogner et al. 2001

9. Duration of agitation 9 LOS in IPR Equivalent for 0d, 1-10d agitation ~LOS +12d for 11-25d agitation ~LOS +41d for >26d agitation (& not dc to home) FIMs TMs at discharge Motor & Cog equivalent for 0d, 1-10d, 11-25d groups FIM TM cog –3.6 for >26d agitation FIM TM motor –8.9 for >26d 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

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 10

11. Agitation Intensity  Intensity.1 11 Mean of 3 highest ABS scores Range: 14 – 56 Intensity ~ peak agitation http://www.peakfreaks.com/everestclimbphotos.htm

12. Agitation Duration  Duration.1  Duration.2  Duration.3 12 Number of shifts in longest bout Range: 0 – 3*LOS in IPR 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 shortest longest

13. Agitation Density  Density.1  Density.2  Density.3  Density.4 13 Number of bouts Range: 0 – LOS in IPR/2 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 Normalized density: Avg number of agitated shifts per day = Density.3/LOS in IPR Range: 0 – 3 shortest longest

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, FIM Motor and Cognitive scores at IPR admission  Outcomes: LOS in acute IPR, FIM Motor and FIM Cognitive scores at discharge from IPR 14

15.  MA Bockbrader 1, D Mortimer 2, L Worthen-Chaudhari 1, J Rosenthal 1, JD Corrigan 1, WJ Mysiw 1, JA Bogner 1  1 Physical Medicine & Rehabiitation, The Ohio State University – Columbus, OH; 2 Physical Medicine & Rehabilitation, Hennepin County Medical Center - Minneapolis, MN Mild (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8) Uncategorizable (GCS 3T) TBI severity, based on initial GCS Outcome Means (SD) LOS IPR20.4 (13.9) days FIM TM Cog discharge25.2 (4.2) FIM TM Motor discharge70.7 (14.2) 41% of TBI patients (n=112) had at least one agitated shift. One-third (n=85) had at least one agitated bout. 207 67 Gender Race Education Sample Characteristics

16. 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” % variance accounted for (R 2 ) by Significant* Univariate Predictors of: % variance accounted for (R 2 ) by Significant* Multivariate Predictors of: DurationAgitation Construct DefinitionMean (SD)FIM TM Cog discharge FIM TM Motor discharge LOS IPR (days) FIM TM Cog discharge FIM TM Motor discharge LOS IPR (days) Duration.1# shifts in longest bout6.8 (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%-2%- Duration.3# shifts from first agitated shift of first bout to last agitated shift 14.6 (31.1)16%9%37%--10% DensityAgitation Construct DefinitionMean (SD) Density.1# bouts of agitation0.5 (0.8)13%7%28%--- Density.2# agitated shifts within all bouts4.6 (10.5)8%2%24%--- Density.3# agitated shifts during IPR5.8 (11.3)12%5%31%--- Density.4average # agitated shifts per day, calculated as Density.3/LOS IPR 0.2 (0.3)11%NS12%--3% IntensityAgitation Construct DefinitionMean (SD) Intensity.1mean of 3 highest shift scores22.3 (8.7)11%1%22%-3%- Demographic variablesMean (SD) Age37.2 (16.7)NS4%NS3%5%- Gender-2%NS 1%-- Race (white, nonwhite)-NS --- Education level-NS --- Admission GCS group-NS --- FIM TM Cog admission16.4 (6.8)44%9%43%44%-2% FIM TM Motor admission39.4 (18.1)17%38%53%-38%53% LOS acute care16.4 (14.5)5%20%29%-5% *p<0.05 Results + correlation - correlation

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

18. Conclusions 18 1. 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 FIMs TM and demographics) for TBI outcomes. 1. 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 19  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.