Dixie  Eastridge  Clinical  Director/Behavior  Analyst  

Learning  Services  Neurobehavioral  Ins>tute-­‐West  Lakewood,  Colorado  

Return on Investment Medications in Patient

Services

Behavior    •  The  ability  to  respond,  use  previously  acquired  skill  sets,  and  to  learn  new  skills  may  be  impacted  

•  Do  not  assume  that  a  person  can  perform  a  skill  because  they  did  so  in  the  past  

•  A  person  with  a  brain  injury  oJen  shows  poor  insight  and  judgment  

Antecedents  •  Typical stimuli conditions may affect behavior and function

as aversive stimuli •  Responses to the perceived aversive situation may include

attempts to escape and avoid the unpleasant stimuli or situations. –  There may be an over sensitivity to sounds, lights, aromas, tastes,

and touch. This may affect the way stimuli affect behavior 1.  Impacting accuracy in executing responses 2.  Timing and precision based on cues 3.  Reducing generalization of behavior 4.  Application of skills to new situations 5.  Reducing contextual control 6.  How situations are interpreted

•  Reduce  intensity  of  sounds,  lights,  temperature  •  Be  aware  of  your  nonverbal  communica>on,  facial  expressions  and  tone  of  voice    

•  Model  calmness  and  confidence    •  Use  structure  and  consistency  to  ensure  events  are  more  predictable    

•  Provide  concise  instruc>ons  and  offer  choices    –  Avoid  using  ques>ons.  i.e.  Are  you  ready  to  get  your  shower?  

–  State  as  choice-­‐  Do  you  want  to  use  a  wash  cloth  or  a  puff  for  your  shower?    

Antecedent  Interven>ons  

Consequences  

•  Changes in brain activity resulting from a brain injury and the disruption of previous learned behavior - reinforcer relationships may cause behavior to become unstable, agitated, and unpredictable

•  Treatment approaches are aimed at reducing agitated depression, anxiety, personality changes and environmental changes

Consequence  Interven>ons  •  Reinforce  quick  responses  to  requests    •  Performance  and  mee>ng  goals    •  Use  posi>ve  statements  at  a  4:1  ra>o  •  Factors  affec>ng  the  effect  of  reinforcers    

•  Magnitude,    •  Dura>on,    •  Frequency  •  Delay    •  Schedule  

–  Variable-­‐ra)o  schedules  (VR):  reinforcing  the  target  behavior  aJer  an  unpredictable  number  of  responses.  e.g.,  VR:10  

•  Rapid  and  steady  responding.  

Brain  Injury  and  Frustra>on  •  Frustra>on  may  occur  because-­‐        

–  Physical  ac>vi>es  are  harder  to  do      –  Daily  ac>vi>es  previously  taken  for  granted  are  difficult  or  impossible  to  accomplish  

–  Lack  of  compensatory  strategies  for  physical/cogni>ve  deficits  

–  Difficulty  remembering  or  using  new  ways  of  doing  common  ac>vi>es  such  as  dressing,  ea>ng,  ge\ng  around,  handling  money,  etc.      

–  Emo>onal  reac>ons  may  come  more  easily  

Brain injury and aggression Can we get some help? 1. Tony M. Wong, PhD

+SHOW AFFILIATIONS 1. From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY.

2. Address correspondence and reprint requests to Dr. Tony M. Wong, Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org

3. doi: 10.1212/WNL.0b013e318211c3fd Neurology March 22, 2011 vol. 76 no. 12 1032-1033

• » Excerpt

• Full Text • Full Text (PDF)

For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,

1 and are often associated with damage to the prefrontal regions of the brain.

2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.

5

Brain injury and aggression Can we get some help? 1. Tony M. Wong, PhD

+SHOW AFFILIATIONS 1. From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY.

2. Address correspondence and reprint requests to Dr. Tony M. Wong, Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org

3. doi: 10.1212/WNL.0b013e318211c3fd Neurology March 22, 2011 vol. 76 no. 12 1032-1033

• » Excerpt

• Full Text • Full Text (PDF)

For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,

1 and are often associated with damage to the prefrontal regions of the brain.

2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.

5

Brain injury and aggression Can we get some hel

p? 1.Tony M. Wong, PhD +SHOW AFFILIATIONS 1.From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY. 2.Address correspondence and reprint requests to Dr. Tony M. Wong,

Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org 3.doi: 10.1212/WNL.0b013e318211c3fd Neurology

March 22, 2011 vol. 76 no. 12 1032-1033 •» Excerpt •Full Text •Full Text (PDF) For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,1 and are often associated with damage to the prefrontal regions of the brain.2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.5

Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.5

Agitation occurs commonly in the delirious subacute phase of recovery. Chronic irritability and aggression are seen in ~40 to 70% of patients with TBI. Aggression in patients with TBI is generally reactive without premeditation, and is nonpurposeful, explosive, periodic, and egodystonic

Agita>on  and  Aggression  

A  Bit  of  Frustra>on      •  People  need  to  struggle    

–  Difficult  tasks  are  necessary  to  learn  how    

 to  do  them  and  to  learn  how  to  handle  frustra>on    –  Too  much  help  can  prevent  this  process      –  Brain  imaging  experts  with  Baycrest’s  Rotman  Research  Ins>tute  in  Toronto  found  a  dis>nct  “brain  signature”  in  pa>ents  who  have  recovered  from  head  injuries  that  shows  their  brains  may  have  to  work  harder  than  the  brains  of  healthy  people  to  perform  at  the  same  level.    

But….Not  TOO  Much  Frustra>on    

•  The  best  help  will  allow  the  person  to  calm  down  enough  to  work  through  how  to  do  the  task,  rather  than  have  the  task  done  for  them  

 •  Too  much  help  can  lead  to  learned  helplessness  

Management  of  Frustra>on  •  Increase  rest  >me  

–  People  with  TBI  may  fa>gue  easily,  which  may  contribute  to  behavioral  issues  

•  Keep  the  environment  simple    –  People  with  a  brain  injury  may  be  easily  over-­‐  s>mulated  by  the  surroundings  

•  Keep  instruc>ons  simple    –   Instruc>ons,  prompts,  and  cues  should  be  kept  as  concrete  and  simple  as  possible  

Management  of  Frustra>on  •  Give  feedback  and  set  goals    

– Due  to  diminished  self-­‐monitoring  skills  feedback  is  impera>ve  un>l  the  ability  is  relearned.  Se\ng  goals  gives  direc>on  and  incen>ve    

•  Be  calm  and  redirect  to  task  – People  who  cannot  control  their  own  behavior  need  others  to  model  calm,  stable,  non-­‐threatening  behavior  

Management  of  Frustra>on  

•  Offer  Choices  –  Can  reduce  serious  behavior  problems  –  Allows  an  element  of  freedom  and  a  measure  of  control  over  the  environment  

•   Decrease  the  chance  of  failure    – Work  slightly  above  the  individual's  level  of  ability.  

•  Try  to  keep  the  success  rate  above  80%      •  Vary  the  ac>vi>es  to  maintain  interest  and  increase  success.    

•  Errorless  learning  

•  Damage  to  the  limbic  system,  orbitofrontal  cortex,  leJ  anteromedial  frontal  lobe,  and  anterior  cingulate  have  been  par>cularly  associated  with  aggressive  behavior.[61]  Studies  have  found  increased  amounts  of  CSF  norepinephrine[62]  and  decreased  amounts  of  serotonin  in  violent  pa>ents.[63]  

 •  Behavior  modifica>on  is  probably  the  most  effec>ve  treatment  for  

these  pa>ents.  Careful  observa>on  and  documenta>on  of  the  pa>ent's  aggressive  outbursts  may  reveal  triggers  of  and  secondary  gains  from  this  behavior.  

Causes  of  Anger  

•  Extreme  Anger  – Experienced  by  failing  to  get  what  we  think  we  need  or  must  have  

•  An  emo>onal  response  to  a  frustrated  demand  

•  Results  from  how  people  view  what  happens  to  them  (Ellis,  1997;  Novaco,  1975)  

 

Task  analysis  

•  Break  tasks  down  into  smaller  steps  –  For  example  

•  pu\ng  on  clothing  can  be  broken  down  into  several,  smaller  and  more  manageable  steps  that  may  be  easier  to  prompt  through  

•  Reinforce quick responses to requests •  Performance and meeting goals •  Use positive statements at a 4:1 ratio •  Factors affecting the effect of reinforcers •  Magnitude, •  Duration, •  Frequency •  Delay •  Schedule •  Variable-ratio schedules (VR): reinforcing the target behavior

after an unpredictable number of responses. e.g., VR:10 •  Rapid and steady responding.

Reinforcement Interventions

Drug  Trend  Defini>on      

The  annual  increase  in  pharmacy  spending-­‐  

 the  combined  effect  of  changing  drug  

prices  and  u6liza6on      

From Kupfer, Eastridge, Buzan, & Castro, 2012

SUMMARY OF MEDICATIONS

From Kupfer, Eastridge, Buzan, & Castro, 2012

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6

8

10

12

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8/17

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Resident 4 Verbal/Physical Aggression

Verbal Aggression Physical Aggression

8/21 Depakote Seroquel to HS  

8/25 Depakote

9/8 Orap DC Abilify Depakote DC  

9/27 Lexapro  

10/7 Lexapro Valium taper   11/3

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11/9 Valium DC  

11/7 Abilify

12/1 Valium add Mirapax  

12/8 Mirapax DC Valium  

12/23 Valium

1/6 Seroquel

1/12 Seroquel

1/19 Seroquel

1/26 Seroquel

2/2 Seroquel

2/9 Seroquel  

2/16 Seroquel

2/23 Seroquel

 

Green=  Add/Increase  Red=  Decrease/Discharge  

From Kupfer, Eastridge, Buzan, & Castro, 2012

0

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Freq

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Date

Resident 4 Cumulative Verbal/Physical Aggression

Verbal Aggression Physical Aggression

8/25 Depakote

 8/21 Depakote Seroquel HS  

9/8 Depakote DC Orap

9/9 Abilify  

9/27 Lexapro  

10/7 Lexapro Valium  

11/9 Valium DC  

12/1 Valium  

12/8 Mirapax  

12/23 Valium  

1/6 Seroquel  

1/12 Seroquel  

1/19 Seroquel

 

1/26 Seroquel

 

2/2 Seroquel

 

2/9 Seroquel

 

2/16 Seroquel

 

2/23 Seroquel

 

11/7 Abilify  

Green=  Add/Increase  Red=  Decrease/Discharge  

From Kupfer, Eastridge, Buzan, & Castro, 2012

From Kupfer, Eastridge, Buzan, & Castro, 2012

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Orang e=  DecreaseGreen=  Increase/A dd

Resident 1 Cumulative Verbal/Physical Aggression

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In

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5/4 6/86/22 Seroquel

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1/6 SeroquelClozaril

1/29 Clozaril Seroquel

3/10 Seroquel

3/15Klonopin

3/24 Seroquel

5/5 Seroquel

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11/2 Risperdal

5/26Paxil

7/1 Klonopin

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From Kupfer, Eastridge, Buzan, & Castro, 2012

From Kupfer, Eastridge, Buzan, & Castro, 2012

SUMMARY OF MEDICATIONS