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Introduction   

Traumatic Brain Injuries (TBI) affect millions of individuals every year, as they manifest differently in every individual, and impact their loved ones. Beyond the immediate physical changes, there are emotional, cognitive, and behavioral fluctuations that occur, with aggression and impulsion being the most common concerns. 

Definition/Types of Brain Injuries  

There are two main classifications regarding brain injuries: traumatic and acquired. A traumatic brain injury (TBI) is defined as an alteration in brain function or any change to the pathology of the brain due to an external force (1).  

An acquired brain injury relates to any change or damage to brain functioning within the brain itself, resulting from incidences such as illness, hypoxia, aneurysms, strokes, and cardiac arrests (1). This injury is not induced, degenerative, hereditary, or congenital. 

It is important to note that what differentiates a TBI from a non-traumatic brain injury is that TBIs include trauma to the head, while medical conditions, including strokes, tumors, and cancers, qualify as non-traumatic brain injuries. 

Another way to classify types of head injuries is penetrating and non-penetrating. Penetrating trauma involves an object penetrating the skull and entering the brain such as gunshot wounds or other sharp objects (3,4,6). The severity depends on the trajectory and characteristics of the penetrating object. Typically, penetrating TBIs damage only a specific segment of the brain.  

Non-penetrating TBIs, or closed head injuries, are characterized by a momentary disruption to normal brain function (6). This is often due to car accidents, falls, concussions (a blow to the head or sudden acceleration/deceleration force), contusions (bruising of brain tissue) or diffuse axonal injury (DAI) which are non-penetrating injuries that produce shearing forces that impair the brain’s axons (4,6). 

  Etiology/Causes of TBI  

TBI is the chief cause of death and disability, affecting people of all age groups, and can have numerous causes (3,4). The etiology may vary due to the nature and severity of the injury.  

Below are common causes of TBI: 

• Falls are the leading cause of TBI, including ground-level falls and falls from heights that result in head injuries (4,6) 
• Motor Vehicle Accidents (MVAs), including motorcycle crashes, car accidents, and pedestrian accidents (4,5,6) 
• Penetrating injuries, including gunshot wounds, stabbings or being struck by an object (3,4,6) 
• Workplace injuries, especially in industries with a higher risk of injuries (4) 
• Assaults, including intentional acts of physical violence (5) 
• Blast injuries, including incidents occurring in combat zones, especially in military personnel (7) 
• Recreational Activities, such as biking, skiing, and football, especially when not following proper safety precautions (5,8) 

Neurological Changes after TBI  

Several complex factors cause individuals with TBI to exhibit aggression and impulsive behaviors. There are physical and neuropsychological changes that occur (2). When there is TBI in the brain, normal functioning is disrupted and areas that are responsible for impulse control, emotional regulation, behavior, and cognitive function are affected (2). There is damage to the brain tissue, resulting in neural connection and neurotransmitter imbalance (key for mood regulation).  

Due to these pathways being disrupted, emotional responses are changed, which leads to aggression and irritability (13). Damage to specific areas of the brain will also disrupt those specific executive functions. For example, the responsibility of the frontal lobe is to regulate emotions, impulses, social behavior, language, and speech production (9). Should there be damage to this area, it would be understandable if there was a personality change with impaired judgment (9).  

Pain and discomfort, cognitive impairment (like memory loss or difficulty processing information), and sensory overload (such as overwhelming stimulus), due to injuries could be very frustrating and lead to agitation. Pre-existing factors such as mental health issues or a challenging social environment can also contribute to an individual’s frustration.  

Signs and Symptoms of TBI 

TBIs can reveal themselves in a variety of signs and symptoms, depending on the severity of the injury. Below are common signs and symptoms most often displayed: 

Physical  

• Seizures/convulsions 
• Headache 
• Unequal eye pupil size or dilation 
• Blurred or double vision 
• Clear nasal/ear drainage 
• New neurological deficit (including slurred speech, loss of balance, weakness of face/extremities) 

(6,8,13) 

Cognitive/Behavioral  

• Decreased level of consciousness 
• Loss or change in consciousness 
• Confusion/disorientation 
• Difficulty with memory, concentration or decision making 
• Coordination problems 
• Disruption in sleep pattern 
• Social withdrawal or isolation 
• Frustration, irritability 
• Loss of skills affecting activities of daily living 

(6,8,13) 

Perception/Sensation  

• Anxiety, depression 
• Lack of energy or motivation  
• Changes in mood  
• Unusual behavior 
• Sensitivity to stimuli, including light or sound 
• Loss of balance or coordination 
• Blurred vision 
• Hearing problems 
• Changes in taste or smell 

(6,8,13) 

Recovery Stages of TBI  

Patient Recovery Course  

After a TBI, initial care includes emergency treatment in stabilizing the patient and running diagnostic exams such as imaging tests to identify the severity and location of the injury (10). For critical cases, intensive care stays may be required for close monitoring and medical interventions.  

Rehabilitation is the next step. Not only are there physical treatments, but also mental adjustments and coping. This is the time when patients adapt to their ‘new normal’ and accept residual challenges. Inpatient rehabilitation, potentially at a specialized facility, may be needed for intensive therapy (10).  

Rehabilitation will include physical therapy (improving balance, coordination, and strength), occupational therapy (developing daily living skills and fine motor coordination), and speech-language therapy (enhancing communication and addressing swallowing concerns) (6,10). There may be a transition to outpatient rehabilitation for continued monitoring (6). There will be a return to daily activities with continued community support, through community reintegration.  

Recovery from a TBI is a dynamic and unending process, so long-term rehabilitation for maintenance and lifelong management is required (6,10). Timelines and outcomes also vary amongst individuals as no two individuals have the same injuries. Lifestyle adjustments will be made to maintain overall health and well-being. Because of its unpredictability, emotional symptoms such as irritability, and frustration tend to develop during recovery (10).  

Additionally, it is vital to consider the involvement of family and friends as part of the rehabilitation and they are often needed to support the patient in the transition back into their new “normal.” 

Rancho Los Amigos Scale – Cognitive Functioning Scale 

The comprehensive ten-level Rancho Los Amigos Scale depicts the stages most commonly seen after a TBI as they recover from injury (11). Some individuals advance through each of the ten levels while others might reach a particular level and be unable to progress further (11). 

Early Stages (Total Assistance) (11): 

• Level 1: No response to external stimuli 
• Level 2: Generalized response  
• Inconsistent responses 
• Non-purposeful external stimuli 
• Awake, but not aware 
• Level 3: Localized response  
• Inconsistent responses, responses are directly related to stimuli 
• Responds to familiarity 
• Awake and aware 
•  

Mid Stages (Moderate to Maximum Assistance) (11) 

• Level 4: Confused/Agitated  
• Hyperactive state with non-purposeful behavior 
• Agitated behavior originates from internal confusion rather than external stimuli 
• Level 5: Confused, Inappropriate Non-Agitated  
• Short-term memory loss 
• Behavior and verbalization can be inappropriate 
• Increased consistency in following simple commands 
• Responses are non-purposeful to complex commands 
• Can show agitation to unpleasant external stimuli 
• Level 6: Confused but appropriate 
• Increased consistency in following simple commands 
• Able to retain familiar tasks learned pre-injury, but still has difficulty remembering newly learned tasks.  
• Demonstrates self-awareness, situational awareness, and environmental awareness, but is oblivious to specific impairments, especially safety concerns. 
• Goal-directed behavior but with dependence on external involvement 

Late Stages (Independent to Minimal Assistance) (11) 

• Level 7: Automatic and appropriate 
• Exhibits robot-like, habitual behavior in performing daily routine 
• Able to learn and retain new skills 
• Shows involvement in social and recreational activities in structured settings 
• Level 8: Purposeful and appropriate 
• Consistently oriented  
• Beginning to show awareness of specific impairments but requires standby assistance.  
• Acknowledges the emotional needs of others, with minimal assistance to appropriately respond. 
• Level 9: Purposeful and appropriate  
• Able to transition between and complete tasks independently 
• When impairments interfere with tasks, can use compensatory strategies  
• Able to anticipate consequences to actions, with assistance 
• Level 10: Purposeful and appropriate 
• Goal-directed and purposeful behavior. 
• Shows a higher level of cognitive functioning by recalling and integrating past and present events. 
• Able to foresee obstacles and take corrective action. 

Common Triggers  

Individuals with TBIs may experience aggressive and impulsive behaviors. Although it may seem like the onset of this behavior is sudden, it is often triggered by emotional or physical stimuli (12,13).  

Here are the most common triggers that lead to aggression or impulsive behavior in TBI (12,13,14): 

• Frustration  
• Depression 
• Emotional dysregulation 
• Hunger/low blood glucose levels 
• Fatigue or disrupted sleep patterns 
• Lack of independence or control 
• Changes in environment or routine 
• Physical discomfort or pain 
• Cognitive overload/overstimulation 
• Social stressors 
• Challenges with communication  
• Struggles with activities of daily living 
• To escape or avoid  

Consider these seven reasons as the overarching triggers that may lead to unwanted behavior: change (in routine, schedule, or environment), mood (in pain, sensitivity, mental health concern), social (situations, interactions), situation (task disruption or frustration), memory (altered state), medication (changes, missed doses, side effects), or unmet needs (desired attention or avoidance) (14). 

Creating a safe, therapeutic environment  

Creating a safe and therapeutic environment for individuals with TBIs is crucial to their rehabilitation and continued well-being. Interventions need to concentrate on patient-centered outcomes and consider not only the individuals with TBI but also their caregivers(s) (14). Mitigating stressors and managing symptoms is the preventative goal. Addressing modifiable factors such as pain, sleep, mental health, and nutrition, are good ways to create a stable environment (16).  

Effectively managing pain to promote comfort, either through therapy exercises or medication management, is essential. Good sleep hygiene can include treatments to address sleep apnea, the use of medications for insomnia, and therapeutic interventions such as sound machines or noise/stimulus control (14). In terms of mobility and accessibility, making certain that the environment is wheelchair accessible and necessary daily items are within reach (16).  

Other strategies include modifying the individual’s environment to their functioning level and effecting cognitive strategies, such as memory exercises, to help stimulate the individual’s brain, if appropriate. Clear communication with the individual, especially based on the level they are functioning at. Therapeutic activities such as music or recreational activities will stimulate emotional well-being.  

A structured routine makes life more predictable and stable (16). Writing schedules down on a whiteboard or poster can act as a reminder for the individual.  

Strategies for Behavior De-escalation  

Behavior is a way to express oneself; every behavior is often preceded by a trigger, emotion, or unmet need (16). Dealing with aggression and impulsive behaviors in patients with TBI can require a sensitive and observant approach. 

Sometimes doing nothing or disregarding unwanted behavior will show the individual that this is unacceptable behavior (16). Avoid using expressions such as “calm down,” or repeating such phrases. Avoid speaking all at once, too quickly, or asking for multiple steps at once (16). Touching or crowding the individual without permission may overwhelm him/her.  

Remaining calm and composed while evaluating the situation for potential stressors or triggers is an effective starting approach (16). The use of a calm and clear tone of voice can help influence the individual to mirror emotions while using open and friendly body language (16).  Maintaining personal space and refraining from physical contact (unless necessary for safety concerns), can help the individual avoid feeling threatened (16).  

Personal space can extend to their belongings, gender, hygiene, culture, age, situation, and environment. Acknowledging the individual’s feelings (not necessarily meaning that their behavior is acceptable or agreeing with their thoughts) can help them feel seen (16). Then, redirect their attention and present simple choices to help them regain control. Once the potential stressors and triggers are identified then eliminated, if possible, work on establishing a predictable routine (16).  

De-escalation tips from the crisis prevention intervention are: 

• Empathy and nonjudgmental behavior 
• Respecting personal space 
• Non-threatening non-verbal behavior 
• Rational detachment 
• Reading between the line 
• Ignoring challenging questions 
• Setting reasonable limits 
• Offering options but not ultimatums 
• Silence 
• Time for reflection 

This supports a sense of stability and safety. Ultimately, it is essential for every person interacting with the individual to answer with the same techniques as this also provides consistency and creates a rhythm for the individual’s response. 

Family Education  

Family and caretakers are often called the ‘hidden heroes’ as they are often overlooked. Strong family engagement is associated with better patient outcomes, per Bogner and colleagues (2019). It is the heart of the care that helps transition the individual back into society (14). Caretakers need to understand and emphasize that same plan (14).  

Caregivers should be given education on the signs and symptoms, triggers, and stages of TBI. In anticipation of providing a stable environment, addressing modifiable factors, and reframing the home tailored specifically to the individual will afford the best chance of success.  

However, the individual should be allowed choices and control, so long as it is safe (16). Should aggression or impulsive behaviors occur, caretakers will be equipped with effective strategies to de-escalate (16). Most importantly, seek to praise good behavior (16). 

Caretaker burnout can be severe. Caretakers should also take heed to prioritizing their health and needs as well (16). Rotating caretakers, taking time for personal needs, and enjoying their time away from the individual would allow for long-term success.  

Resources  

It is so important to reach out to providers, therapists, nursing staff, or whoever is needed, to support the individual and the caretakers. This is a community effort. There are peer learning groups available and a vast number of resources online for individuals with brain injury as well as for caretakers.  

Some of these include: 

• National Brain Injury information is available for individuals living with TBI and for their caregivers here: https://www.biausa.org/  or call 1-800-444-6443. To find a Brain Injury Association support group in your state: https://www.biausa.org/find-bia  
• For facts sheets, videos and other resources, refer to the Model Systems Knowledge Translation Center: https://msktc.org/ The material is also available in Spanish: https://msktc.org/tbi-resources-spanish  
• Military Health System’s Traumatic Brain Injury Center of Excellence 
• Refer to the National Association of State Head Injury Administrators for Medicaid waiver programs and brain injury programs: https://www.nashia.org/state-program-directory  
• Suicide Prevention Hotline: 1-800-273-TALK (8255) or chat at SuicidePreventionLifeline.org  

Conclusion

TBIs are complicated and multifaceted, as there is an intricate interplay between the neurological and psychosocial factors. There are generalized concepts and strategies to assist but there are no two individuals with TBIs that are cared for in the same way. Although TBIs can manifest themselves in challenging ways, understanding each individual with TBI’s specific diagnosis and area of injury will help tailor their care and promote success.  

Appreciating a holistic perception of caring for these individuals is crucial. Ultimately, by addressing the complexities of TBIs, individuals can lead an enhanced quality of life through valuable support from their caregivers. 

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