Management of Behavioral Issues in Traumatic Brain Injury
Behavioral issues following TBI require early identification of at-risk patients, structured assessment using validated tools, and a stepwise approach prioritizing non-pharmacological interventions before considering medications, with mandatory specialist referral for persistent symptoms beyond 3 weeks.
Risk Stratification and Early Identification
Identify high-risk patients at initial ED presentation using the following predictors of persistent behavioral problems 1:
- Female gender (consistently associated with worse behavioral outcomes) 1
- Pre-existing psychiatric history (depression, anxiety, PTSD) 1
- Elevated anxiety scores on Hospital Anxiety and Depression Scale (HADS) 1
- Loss of consciousness during injury 1
- Assault as mechanism of injury 1
- Alcohol intoxication at presentation 1
- No recall of receiving ED discharge information 1
These patients warrant closer follow-up and earlier intervention, as they have significantly higher rates of persistent postconcussive symptoms at 3-6 months 1.
Initial Assessment and Documentation
Screen for specific behavioral symptoms at the time of ED assessment 1:
- Chronic headaches
- Depression or mood swings
- Anxiety
- Irritability
- Memory problems
- Difficulty concentrating or paying attention
- Sleep difficulties
- Abnormal behavior 1
Provide written and verbal education about these symptoms to both patient and immediate caregiver, using sixth- to seventh-grade reading level materials with type font ≥12 points 1.
Discharge Instructions and Return Precautions
Instruct patients to return immediately for 1:
- Repeated vomiting
- Worsening headache
- Confusion
- Abnormal behavior
- Increased sleepiness or passing out
- Seizures 1
Mandate 2-3 days off work or school for patients experiencing postconcussive symptoms, with strict avoidance of strenuous mental or physical activity until symptom-free 1.
Follow-Up and Specialist Referral
Refer to a traumatic brain injury specialist when 1:
- Symptoms persist beyond 3 weeks
- Earlier referral if planning return to sports
- Any patient with identified risk factors above 1
This is critical because 18.7% of mTBI patients report 3 or more postconcussive symptoms, with fatigue (17.2%) and forgetfulness (14.6%) being most common 1.
Social Support Needs
Assess and arrange for social assistance including 1:
- Driving support
- Employment accommodations
- Financial assistance during recovery 1
These needs persist for at least 6 months and significantly impact quality of life, yet are frequently overlooked in acute management 1.
Behavioral Management Approach for Moderate-Severe TBI
For patients with moderate-severe TBI requiring rehabilitation, follow a stepwise algorithm 2:
Comprehensive behavioral assessment using validated tools to identify specific problem behaviors (agitation, aggression, apathy, inappropriate sexual behavior) 2
Non-pharmacological interventions first 2:
Pharmacological interventions only after non-pharmacological approaches have been optimized 2
Ongoing monitoring with data collection to track outcomes and adjust interventions 4
Common Pitfalls to Avoid
Do not rely on home observation protocols (frequent waking, pupil checks) for patients with negative CT or low-risk features—this is not supported by evidence 1.
Do not dismiss anxiety symptoms as they are the strongest predictor of persistent postconcussive syndrome at 3 months, even more than initial injury severity 1.
Do not delay specialist referral beyond 3 weeks of persistent symptoms, as early intervention improves outcomes 1.
Recognize that behavioral changes have 25-88% prevalence in moderate-severe TBI and typically stabilize after 1-2 years, but the first 6 months are critical for intervention 5.