Welcome to the TBI-HELP Live Chat

Today's topic is: "Behavioral Assessment Regarding Psychoactive Medications"

Our Guests are: Louis Zimmer, Ph.D., United Cerebral Palsy

[19:12:25] Mod: Good evening and welcome all! Tonight we are very happy to have Dr. Louis Zimmer from United Cerebral Palsy. Dr. Zimmer will be discussing "Behavioral Assessment Regarding Psychoactive Medications. Welcome Dr. Zimmer!
[19:13:35] Mod: Rail: Under what situations should psychoactive medications be prescribed in TBI?
[19:15:02] louzimmer: That's a big question. It kind of encompasses the whole topic. would you be a bit more specific.
[19:15:47] Mod: The purpose of tonight's chat is to help educate the audience on the use of psychoactive medications after a brain injury or stroke. Please consult your physician prior making any changes regarding medication usage.
[19:16:38] Mod: K: What are the top three meds for controlling agitation in the TBI pt recently emerged from coma?
[19:16:52] louzimmer: Agitation can be controlled using antiseizure medications such as tegretol,  the others are antidepressants and sometimes even stimulants such as ritalin. In the past antipsychotics were and are still used.
[19:19:19] Mod: Why give medications which affect behavior after a brain injury or stroke? Wouldn't they just further interfere with the recovery process?
[19:20:00] louzimmer: Some medications such as haldol have been shown to interfere with recovery. However , in order to control behaviors such as outbursts, confusion and even under arousal,  mediactions help the person respond to Rehab.
[19:21:31] Mod: Rail: What are the Behavioral Assessment indicators for some Psychoactive Intervention?
[19:22:29] louzimmer: Most often the assessments are behavioral observations by the staff and sometimes the family. There are some special tests for agitation and for level of awareness or coma
[19:22:53] Mod: Susan: How would one determine if its really agitation or is it extreme curiosity or exuberance? How can you decide if agitation is caused by the TBI or by the environment?
[19:23:44] louzimmer: Agitation right after an injury is usually a result of confusion and over stimulation.  At that time the person is trying to cope with everything and the world is a bit much as well as being told they must do this and that. This gets them angry and confused, so they may lash out. This is self protection.
[19:25:26] Mod: What about addiction? Can't someone become addicted or dependent on drugs that affect the brain?
[19:26:30] louzimmer: Most of the drugs used do not cause addiction with at least two important exceptions. Amphetamines are addictive and could be used to improve arousal. Some anti-anxiety medications such as valium can also be addictive. These are generally not used for prolonged periods, if at all, so addiction is not usually a problem
[19:28:10] Mod: Susan: What do you think of the use of artificial rewards as tokens in a behavior mod program? Since there are no tokens in "real life" would that help in community integration techniques?
[19:28:33] louzimmer: Sometimes it works but not always. There are two factors to consider: One is the status and cognitive level of the patient and the other is the staff. If the staff have little training, it will not likely work. The patient has to be at a cognitive level where they are aware that there is a reward, that it is valuable to them and that they can remember what they are working on. Sometimes a medication can help the cognitive level.
[19:31:27] Mod: Rail: What behaviors are responsive to drugs?
[19:31:59] louzimmer: The behavior that I have seen the most dramatic response is early agitation. Others are attention and alertness, also problems such as anxiety and depression. There is a lot of evidence in the literature that memory, and language problems are also benefited.
[19:33:47] Mod: Susan: What drugs would be good for incrasing cognitive level?
[19:34:47] louzimmer: There is some evidence that cholinergic drugs suvh as cholinee, aricept and tacrine are effective for memory. But the evidence shows the effects are limited. Amphetamine ar similar stimulants have also been show to be effective. My sense is that these drugs have limited effects because they improve the function of remaining cells to some extent. Furthermore these drugs show limited effects in the so-called normal brain so there is only so much tweaking we can do with drugs
[19:38:12] Mod: Susan: After starting a med and seeing good results would another neuropsych eval help in making a determination if there has been cognitive growth?
[19:38:13] louzimmer: This is a maybe answer. These evals take a long time and do not always test the behaviors that are improved. On the other hand, neuropsychs definitely document effects and help therapists begin working on the next level.
[19:39:49] Mod: Rail: What about Ginkgo and other circulation stimulants for the brain-can these help cognitive function as is observed in the normal brain?
[19:40:35] louzimmer: The research that I have seen on Ginkgo Biloba has not been very useful. Mostly the effects are very small if any at all. On the other hand it does not seem to hurt either. There are other drugs that improve circulation or blood flow such as nimodipine which has had some positive results.
[19:42:28] Mod: Rail: Are there psychoactive drugs that should be avoided in TBI?
[19:43:08] louzimmer: Some professionals argue that we should try to avoid them all. We should try less invasive methods such as behavioral ones to see if they work first. However there are a couple that are generally avoided unless absolutely necessary. Some research has shown that haldol can interfere with further recovery. Another report I saw recently pointed out that clonidine may interfere with early recovery. Clonidine is a type of stimulant.
[19:45:58] Mod: Rail: Can Behavior Modification be assisted by some Medications?
[19:47:17] louzimmer: I would guess that medications which "take the edge off" of agitation, or which can iprove atttention would help improve the effectiveness of behavior modification
[19:47:53] Mod: What medication is useful for paranoia and other bizarre thoughts?
[19:49:25] louzimmer: Some of the newer antipsychotic drugs are effective for paranoia. The trick is to pick those that have the leas side effects, especially drowsiness.
[19:49:57] Mod: Can antipsychotic drugs be used to help reduce severe agitation and aggression as well?
[19:50:47] louzimmer: There might be some times when the antipsychotics help but the Dr. usually looks for some bizarre though patterns.
[19:53:12] louzimmer: In reference to the previous question about antipsychtis used for tbi, some of the more commonly used ones are risperidal and zyprexia. The Zyprexia is often used for those suffering from dementia
[19:55:32] Mod: How does antipsychotic work with TBI patients when their thought patterns are bizarre normally at times?
[19:55:49] louzimmer: The antipsychotics probably work the same way they do in people without the TBI. there are neurotransmitters systems that seem to be malfunctioning in non-tbi people and these medications appear to work by moderating those systems
[19:57:49] Mod: buddie: I have son 18 he is TBI 8 years post injury and I need someone who can help me find out about his vision?
[19:59:16] louzimmer: Specialists that may be able to help are neuro-ophthalmologists and some ophthalmologists that specialize in neurological problems related to vision. That is they look beyond the eye itself. Is your son able to communicate?
[20:00:15] Mod: Susan: What type of dr. would be best for these. A neurologist, rehab or psychiatrist?
[20:02:43] louzimmer: Any one of these specialists, neurologist, psychiatrist or physiatrist can prescribe these medication. The Dr's experience and training are the most important factors in this area.
[20:03:00] Mod: Our time is just about up. I would like to thank the audience for participating in our chat tonight. I would also like to thank Dr. Zimmer very much for providing us with a very informative chat session. Good night all and hope to hear from you all soon!