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Poster 4 Memantine as a Treatment for Agitation in an Adult With Severe Traumatic Brain Injury: A Case Report
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Disclosures: J. Martinez-Barrizonte, none. Patients or Programs: Subjects who sustained a traumatic brain injury (TBI) during 2008-2009 and had continued in outpatient follow-up after discharge from acute inpatient rehabilitation for at least 1 year. Program Description: 4 subjects who had been injured and observed for more than a 12-month period. Setting: An outpatient TBI rehabilitation clinic. Results: Data of 4 subjects were collected over a 12-month period. All the subjects had sustained a severe TBI with frontoparietal or bifrontal injury. On discharge from the inpatient facility, all the subjects were at supervision level with mobility. At 12-month follow-up, body mass index (BMI) for all the subjects was in the overweight to obese range (27.6, 25.6, 37.3, 35). Thyroid levels were evaluated on all subjects and were in normal range. Discussion: Obesity continues to be a growing epidemic in our society. There has been scarce medical literature of studies that looked at obesity in TBI, although this subject has been mentioned as far back as 1948. Obesity after TBI can be multifactorial. Changes in one’s mobility and socialization may contribute. The area of the brain affected may contribute to impulsive behavior, including that of excessive food intake or decrease inhibitory signaling of satiety. Medications also may be responsible for some of the excessive weight gain. Hypopituitarism also is a common complication of TBI. The patients at greatest risk include those who have had moderateto-severe trauma, although mild intensity trauma may precede hypopituitarism. Hypopituitarism is also a common complication of TBI and may be partial or complete. This is diagnosed only by biochemical means. Patients at greatest risk include those who have had moderate to severe trauma. Conclusions: As obesity continues to grow in our society and with TBI considered by the World Health Organization to be the “silent epidemic,” more research needs to be conducted in this area. Few studies have attempted to estimate the prevalence and predictive factors of hypopituitarism after TBI. Of these, the prevalence was estimated to be approximately 16%. Neuroendocrine evaluation, therefore, should also be considered in this patient population.
Poster 4 Memantine as a Treatment for Agitation in an Adult With Severe Traumatic Brain Injury: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Deborah N. Kimmel, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 56-year-old man status post motor vehicle accident with severe traumatic brain injury, with resulting bilateral frontal subdural hematomas, temporal parietal skull fractures, and seizures. Program Description: The patient was treated conservatively at the acute hospital. He was initially placed on phenytoin and subsequently was transitioned to levetiracetam for seizure control. Haloperidol with lorazepam was used for acute agitation control. The averaged Agitated Behavior Scale (ABS) was used to assess clinical improvement in his agitation and the Rancho Los Amigos Cognitive Scale (Rancho) was used to assess cognition. On day 4 post-admission (second IRF trial), he was Rancho 4, with an ABS of 45, and was started on valproic acid 250 mg 3 times a day. On day 5, valproic acid was increased to 375 mg every 8 hours. On day 8, his ABS was 37, and levetiracetam was decreased to 250 mg daily. On day 9,
PRESENTATIONS
valproic acid was increased to 375 mg at 8 AM and 500 mg at 2 PM and 10 PM. On day 11, memantine 5 mg daily was initiated, titrated up 5 mg weekly until 20 mg per day was reached. By day 14 and 15, the ABS score was 24 and 20, respectively. The patient was Rancho 5 at the time of discharge. Setting: Acute inpatient rehabilitation facility (IRF) (traumatic brain injury unit). Results: The patient demonstrated marked improvement without signs of agitation. He is integrating well into society, with improved alertness, attention, and cognitive functioning. Four weeks after IRF, he is a Rancho 7. Discussion: Randomized controlled trials on pharmacologic options for treating agitation and improving cognitive functions in patients with traumatic brain injury are limited. There appears to be a correlation between the use of memantine and improvements in agitation as well as cognitive function. Conclusions: The relationship of memantine and agitation and cognitive improvement in TBI populations may be further explored.
Poster 5 Determinants of Exercise Participation in Veterans of the Wars in Iraq and Afghanistan. Kun Yan, MD (Veterans Affairs Boston Healthcare System, Boston, MA, United States); Melissa Amick, PhD, Pradeep Suri, MD. Disclosures: K. Yan, none. Objective: Exercise confers major benefits in mood, sleep, and pain management, functions that frequently affect veterans of the wars in Iraq and Afghanistan. We examined which patient characteristics were associated with exercise participation in veterans from these current wars. Design: A cross-sectional study with retrospective data collection. Demographic factors and medical history, including participant age, marital status, gender, predeployment education, current employment, history of mild traumatic brain injury (mTBI), and posttraumatic stress disorder (PTSD) were abstracted from the medical record. Patients self-rated current symptoms of insomnia, pain, and depression by using the Neurobehavioral Symptom Inventory. Setting: A Veterans Affairs polytrauma network site. Participants: 113 veterans referred for a traumatic brain injury evaluation. Interventions: Not applicable. Main Outcome Measures: At least biweekly current exercise participation. Results: Age in years (odds ratio [OR], 0.92 [95% confidence interval {CI}, 0.86-0.99]), having at least some predeployment college education (OR, 2.5 [95% CI, 1.1-6.0]), and current employment (OR, 4.6 [95% CI, 2.0-11.0]) were independently associated with exercise participation. Other participant characteristics, including a diagnosis of mild traumatic brain injury or posttraumatic stress disorder, were not associated with exercise participation. Although current symptom ratings of insomnia, depression, and pain were each associated with exercise participation when added to a multivariate model, including demographic factors, depression alone remained associated with exercise participation in our final model. Conclusions: Higher predeployment educational level, current employment, and younger age were associated with regular exercise participation in this sample. Greater self-reported depression sever-
Disclosures: J. Martinez-Barrizonte, none. Patients or Programs: Subjects who sustained a traumatic brain injury (TBI) during 2008-2009 and had continued in outpatient follow-up after discharge from acute inpatient rehabilitation for at least 1 year. Program Description: 4 subjects who had been injured and observed for more than a 12-month period. Setting: An outpatient TBI rehabilitation clinic. Results: Data of 4 subjects were collected over a 12-month period. All the subjects had sustained a severe TBI with frontoparietal or bifrontal injury. On discharge from the inpatient facility, all the subjects were at supervision level with mobility. At 12-month follow-up, body mass index (BMI) for all the subjects was in the overweight to obese range (27.6, 25.6, 37.3, 35). Thyroid levels were evaluated on all subjects and were in normal range. Discussion: Obesity continues to be a growing epidemic in our society. There has been scarce medical literature of studies that looked at obesity in TBI, although this subject has been mentioned as far back as 1948. Obesity after TBI can be multifactorial. Changes in one’s mobility and socialization may contribute. The area of the brain affected may contribute to impulsive behavior, including that of excessive food intake or decrease inhibitory signaling of satiety. Medications also may be responsible for some of the excessive weight gain. Hypopituitarism also is a common complication of TBI. The patients at greatest risk include those who have had moderateto-severe trauma, although mild intensity trauma may precede hypopituitarism. Hypopituitarism is also a common complication of TBI and may be partial or complete. This is diagnosed only by biochemical means. Patients at greatest risk include those who have had moderate to severe trauma. Conclusions: As obesity continues to grow in our society and with TBI considered by the World Health Organization to be the “silent epidemic,” more research needs to be conducted in this area. Few studies have attempted to estimate the prevalence and predictive factors of hypopituitarism after TBI. Of these, the prevalence was estimated to be approximately 16%. Neuroendocrine evaluation, therefore, should also be considered in this patient population.
Poster 4 Memantine as a Treatment for Agitation in an Adult With Severe Traumatic Brain Injury: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Deborah N. Kimmel, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 56-year-old man status post motor vehicle accident with severe traumatic brain injury, with resulting bilateral frontal subdural hematomas, temporal parietal skull fractures, and seizures. Program Description: The patient was treated conservatively at the acute hospital. He was initially placed on phenytoin and subsequently was transitioned to levetiracetam for seizure control. Haloperidol with lorazepam was used for acute agitation control. The averaged Agitated Behavior Scale (ABS) was used to assess clinical improvement in his agitation and the Rancho Los Amigos Cognitive Scale (Rancho) was used to assess cognition. On day 4 post-admission (second IRF trial), he was Rancho 4, with an ABS of 45, and was started on valproic acid 250 mg 3 times a day. On day 5, valproic acid was increased to 375 mg every 8 hours. On day 8, his ABS was 37, and levetiracetam was decreased to 250 mg daily. On day 9,
PRESENTATIONS
valproic acid was increased to 375 mg at 8 AM and 500 mg at 2 PM and 10 PM. On day 11, memantine 5 mg daily was initiated, titrated up 5 mg weekly until 20 mg per day was reached. By day 14 and 15, the ABS score was 24 and 20, respectively. The patient was Rancho 5 at the time of discharge. Setting: Acute inpatient rehabilitation facility (IRF) (traumatic brain injury unit). Results: The patient demonstrated marked improvement without signs of agitation. He is integrating well into society, with improved alertness, attention, and cognitive functioning. Four weeks after IRF, he is a Rancho 7. Discussion: Randomized controlled trials on pharmacologic options for treating agitation and improving cognitive functions in patients with traumatic brain injury are limited. There appears to be a correlation between the use of memantine and improvements in agitation as well as cognitive function. Conclusions: The relationship of memantine and agitation and cognitive improvement in TBI populations may be further explored.
Poster 5 Determinants of Exercise Participation in Veterans of the Wars in Iraq and Afghanistan. Kun Yan, MD (Veterans Affairs Boston Healthcare System, Boston, MA, United States); Melissa Amick, PhD, Pradeep Suri, MD. Disclosures: K. Yan, none. Objective: Exercise confers major benefits in mood, sleep, and pain management, functions that frequently affect veterans of the wars in Iraq and Afghanistan. We examined which patient characteristics were associated with exercise participation in veterans from these current wars. Design: A cross-sectional study with retrospective data collection. Demographic factors and medical history, including participant age, marital status, gender, predeployment education, current employment, history of mild traumatic brain injury (mTBI), and posttraumatic stress disorder (PTSD) were abstracted from the medical record. Patients self-rated current symptoms of insomnia, pain, and depression by using the Neurobehavioral Symptom Inventory. Setting: A Veterans Affairs polytrauma network site. Participants: 113 veterans referred for a traumatic brain injury evaluation. Interventions: Not applicable. Main Outcome Measures: At least biweekly current exercise participation. Results: Age in years (odds ratio [OR], 0.92 [95% confidence interval {CI}, 0.86-0.99]), having at least some predeployment college education (OR, 2.5 [95% CI, 1.1-6.0]), and current employment (OR, 4.6 [95% CI, 2.0-11.0]) were independently associated with exercise participation. Other participant characteristics, including a diagnosis of mild traumatic brain injury or posttraumatic stress disorder, were not associated with exercise participation. Although current symptom ratings of insomnia, depression, and pain were each associated with exercise participation when added to a multivariate model, including demographic factors, depression alone remained associated with exercise participation in our final model. Conclusions: Higher predeployment educational level, current employment, and younger age were associated with regular exercise participation in this sample. Greater self-reported depression sever-