With traumatic brain injury (TBI), the first question we often ask is, Will the patient recover? Beyond concerns about cognitive function and disability, little is generally known about the milestones and setbacks patients encounter while recovering from a TBI.
Most don't realize that neurobehavioral problems are the most debilitating sequelae in individuals attempting to reestablish family and work relationships after a TBI. New evidence-based guidelines, published in October's Journal of Neurotrauma, offer treatment recommendations for several neurobehavioral disorders associated with TBIs, such as mood and anxiety disorders, psychotic syndromes, aggression, and problems with attention and speed of information processing. "TBI may result in a complex mixture of mental impairment and psychiatric disorders for which pharmacotherapy ... should be a mainstay of treatment," asserted Tamira Mullarkey, R.Ph., M.S., clinical pharmacist at Clara Maass Medical Center in N.J.
As a general consideration, the report noted that patients with TBIs are more refractory to treatment, more prone to the various side effects of psychotropic agents, and may not respond to traditional psychotropic therapy. A number of clinicians are said to feel strongly that some standard agents are ineffective or may be associated with excess toxicity in brain-injured patients. And at this point, it would be difficult to agree or disagree with this statement since the three panels of experts who developed the guidelines concluded that, with some exceptions, "the quality of evidence was insufficient to support specific therapeutic standards." The guidelines should, therefore, be used only to "guide pharmacologic treatment recommendations."
Despite the absence of concrete evidence, many therapeutic recommendations in the guidelines appear to follow a rationale similar to that for non-brain-injured patients. "You want to use agents with the best tolerability profiles—especially in complicated patients such as those with TBI," noted Mullarkey. And "since these patients will require numerous medications, it's important to closely monitor for response to therapy and adverse effects."
For depression, a common occurrence in patients with TBI, the guidelines recommend the tricyclic antidepressants amitriptyline and desipramine but contend that side effects may limit their utility. Thus, selective serotonin reuptake inhibitors (SSRIs) may also be considered. In patients with TBI, however, fluoxetine has been associated with dysarthria and speech blocking, and both sertraline and fluoxetine have reportedly caused severe akathisia. For patients with psychosis, the atypical antipsychotic olanzapine (Zyprexa, Lilly) is recommended, while clozapine is associated with significant sedation, weight gain, and seizures.
In treating various cognitive disorders, the guidelines recommend methylphenidate and the cholinesterase inhibitor donepezil (Aricept, Eisai) for patients with moderate to severe TBI who have deficits in attention and speed of cognitive processing. Donepezil is also used to improve memory function, and bromocriptine may enhance aspects of executive functioning (e.g., tasks involving initiation and mental flexibility). Side effects of concern include tachycardia and reduced appetite from methylphenidate; nausea, vomiting, diarrhea, and insomnia from donepezil; and nausea, dizziness, and insomnia from bromocriptine. The guidelines warn against using phenytoin in patients with TBI, since anticonvulsants may impair cognitive function at one month post-event.
In treating aggression, the guidelines recommend the beta-blockers pindolol or propranolol but caution about their propensity to cause hypotension and bradycardia. Other options with less supporting evidence include methylphenidate, SSRIs, valproate, lithium, tricyclic antidepressants, and buspirone.
In managing patients with TBI and neurobehavioral disorders, Michael L. Gallagher, M.S., R.Ph., assistant director of pharmacy and clinical coordinator at Union Hospital in Union, N.J., emphasized the importance of standard tools to assess neurologic-psychiatric disease (Abnormal Involuntary Movement Scale) in the general population. "Perhaps some of these individuals with TBI should be considered psychiatric patients [as opposed to simply trauma patients] and treated according to psychiatric guidelines to allow them to regain activities of daily living, with less emphasis on the precipitating event."
THE AUTHOR is a writer and hospital pharmacist based in New Jersey.