Pharmacological management for agitation and aggression in people with acquired brain injury

  • Review
  • Intervention

Authors


Abstract

Background

Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management.

Objectives

To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI).

Search methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006.

Selection criteria

Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age.

Data collection and analysis

We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused.

Main results

Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking.

Authors' conclusions

Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.

摘要

背景

藥物處理後天性腦損傷所導致的躁動和侵略行為

起因於大腦損傷的精神病學的症狀中,躁動和/或侵略行為經常是最難以處理的。評估使用抗精神藥物療法的效果是重要的。

目標

評估藥物處理後天性腦損傷所導致的躁動和侵略行為的效果

搜尋策略

我們搜尋Cochrane Central Register of Controlled Trials, MEDLINE, EMSASE和其他的電子資料庫。我們也搜尋參考表包括最近的研究和回顧文獻,也手動搜尋journals Brain Injury and the Journal of Head Trauma Rehabilitation。沒有語言限制,最後一次搜尋是在2006年6月。

選擇標準

隨機控制試驗評估中樞神經系統藥物控制導因於後天性腦損傷之躁動和侵略行為的效果,參加試驗者超過10歲。

資料收集與分析

我們獨立選出數據並且評估試驗品質。在大腦損傷後和/或處於混亂狀態6個月內病患的研究,與大腦損傷超過6個月或無混亂狀態的病患作比較。

主要結論

包括6篇隨機控制試驗,4篇評估betablockers, propranolol and pindolol, 1篇評估神經系統興奮劑methylphenidate,1篇評估amantadine,一種通常使用在帕金森症和有關疾病的藥物。最有效治療後天性腦損傷所導致的躁動和侵略行為是betablockers。2篇隨機控制試驗發現propranolol有效(1篇研究是早期大腦損傷,1篇研究是在損傷後期)。但是,這些研究樣本數相對較小,不能複製,使用大劑量,並且沒有使用整體性結果測量或長期的追蹤。比較早期的躁動與後期侵略行為,沒有不同藥物反應的證據。缺乏堅定的證據證明carbamazepine或者valproate治療躁動和/或侵略行為是有效果的。

作者結論

許多藥物被試驗用來治療後天性腦損傷的侵略行為,但是沒有堅定的證據證明是有效力的。選擇很少副作用的藥物並且監控他們的效果是重要的。βblockers證明是有效力的,應當受到更多的重視。由於缺乏證據,因而突顯出藥物需被好好評估的重要問題。

翻譯人

本摘要由高雄榮民總醫院葉宣德翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

被增加。

Plain language summary

Prescription drug use for managing agitation and aggression in people with acquired brain injury

This review found no firm evidence that drug management of agitation and aggression in adults with acquired brain injury is effective. There was weak evidence, based on a few small randomized controlled trials, that beta-blockers can improve aggression after acquired brain injury, but very large doses were used which would have been likely to produce significant adverse effects. For other classes of medication, reasonable size randomized controlled trials have not been published.

Based on the lack of evidence, the review comes to no conclusion on the effectiveness of drugs. There is reasonable anecdotal evidence, for example in published cases series, that antipsychotics, mood stabilizers and antidepressants may be effective in the management of this situation.

Ancillary