Multidimensional Assessment of Acute Confusion After Traumatic Brain Injury

Past Studies

Past Studies have reported disturbed consciousness (confusion) as a consequence of TBI. The degree of disturbance individuals with brain injury may experience can range from coma to temporary confusion. For the majority of people, disturbed consciousness improves over time. For a small percentage of comatose patients, recovery may be only to a vegetative state (inability to follow commands) or to a minimally conscious state (inconsistent command following). Survivors of a moderate or severe injury almost always have a period of recovery during which they are responsive, but confused. During this acute confusion patients may be agitated and disoriented and have impaired memory, language impairment, impaired perception (understanding of what is happening), disinhibition (inappropriate behaviors), decreased judgment, lower level of arousal, and inappropriate mood. This state of altered consciousness has been called impaired consciousness, acute psychosis, or more commonly posttraumatic amnesia (PTA). The term PTA suggests that the memory disturbance is the key symptom of patients in this stage. Agitation is another common symptom seen during recovery from TBI, and one that can pose safety concerns for the patient, staff and family. It is important to assess the level of agitation and develop treatment plans to address this behavior.In the psychiatric literature, delirium is identified as a disturbance in consciousness, perception or cognition with a rapid onset (hours-days) that is caused by a medical condition, substance intoxication or withdrawal, or a variety of other causes. Disturbed ability to focus and shift attention is a key aspect in this early period of recovery. Persons in early recovery from TBI may be diagnosed as being delirium.

Recently, researchers have proposed a new term, posttraumatic confusional state (PTCS), to replace PTA or delirium for describing the early period of recovery from TBI during which patients are acutely confused. This investigation provided an initial comparison of PTCS, PTA, and delirium in persons with TBI.

This Study

This Study has three primary goals: (1) to develop a process for assessing PTCS by using elements of existing instruments to assess orientation and cognitive functioning, combining data with clinician-ratings of other symptoms of confusion; (2) to develop a brief procedure called the Confusion Assessment Protocol (CAP) to detect patterns of confusion symptoms and different rates of recovery of the various symptoms of confusion; and (3) to provide preliminary validity data for this new procedure.Two consecutive groups of patients (62 in the first study; 93 in the second) in inpatient rehabilitation in the TBI Model Systems research program, were studied. The groups for study 1 and study 2 were comparable in age and years of education. For study 1, a number of tests were administered 3 days after admission to rehabilitation., and 7 key symptoms for PTCS were noted.

In the second study, designed to validate the CAP instrument, the CAP was given to a new group of patients with TBI. The goals of this study were to (1) provide descriptive data using the CAP for patients classified in PTCS, (2) compare PTCS classification with the clinical diagnosis of delirium using DSM IV criteria and with PTA status, to determine the agreement between diagnoses of PTA, PTCS, and delirium and (3) determine if there was an association between PTCS status and early outcome TBI. This study involved 93 individuals with TBI who were admitted to inpatient rehabilitation between June 2002 and October 2003. CAP data was collected on all participants, analyzed and evaluated for agreement between PTCS classifications and delirium diagnosis and agreement between PTCS and PTA. Of the 93 participants in this study, 71 (76%) of the participants met diagnostic criteria for delirium.

Overall findings indicate that acute confusion is a common symptom for individuals with TBI. Such acute confusion contributes to management and safety issues, and to poorer functioning at discharge.

Who May Be Affected By These Findings

Individuals who have sustained a traumatic brain injury, their families, caregivers, community providers, health professional dealing with the TBI population, and researchers.

Caveats

This study points to the need for an assessment tool that improves diagnosis of confusion and detects clinical progress in confused patients and a measurement tool that assesses multi-aspects of confusional state to be used in other trials. Additional investigation of the validity, reliability, and utility of the CAP is needed.

Bottom Line

The CAP, a brief, structured, repeatable measure of numerous neurobehavioral aspects of PTCS, was developed to address the needs mentioned in the overall findings regarding acute confusion in people with TBI. This tool measures 7 key symptoms of confusion and is a collection of items taken or adapted from existing measurement tools. This study found that there were symptoms of PTCS and delirium. It further found that patients diagnosed with confused sustained more severe injuries and required a longer rehabilitation program than those who were not confused. Being confused was also associated with poorer functional status at rehabilitation discharge for people sustaining TBI.

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