Accepted Abstracts from the International Brain Injury Association’s 13th World Congress on Brain Injury

Abstract

Case Description: A 64-year-old gentleman sustained a traumatic brain injury (TBI) after an attack by an inmate while he was working as a prison guard, where he hit his head on a brick wall resulting in loss of consciousness (LOC). He then developed paroxysmal spells characterized by sudden falls with resultant LOC. Electroencephalograms (EEG) were negative for seizure activity. He sustained a subsequent head injury when he had a syncopal episode and fell backward, resulting in acute subdural hemorrhage (SDH). He was started on various medications after the initial injury to treat the neurobeha-vioral and medical sequelae of his TBI, including olanzapine, imipramine, clarithromycin, levetiracetam, lamotrigine, gaba-pentin, modafinil, and zolpidem on admission to the inpatient rehabilitation hospital. After both injuries, he was taken to a skilled nursing facility (SNF) instead of acute inpatient rehabilitation. He continued to suffer from multiple falls related to an unsteady gait and a progressive decline in mentation. He was admitted to a tertiary hospital on two separate occasions for restlessness, confusion, and refusal to eat or take medications. The patient was admitted to the Brain Injury Program in an acute inpatient rehabilitation facility (IRF) approximately six months post-injury, after he was admitted to acute care for pneumonia. Upon admission to the IRF, he was initially para-noid, delusional, and had developed trismus and rigidity, contributing to his falls; he was unsafe to walk, confabulatory and perseverative, with severe memory deficits and cognitive rigidity. Throughout his inpatient rehabilitation admission, all of the medications listed above were discontinued with the exception of clarithromycin and lamotrigine. Setting: Acute Inpatient Rehabilitation Facility Results: After discontinuation of multiple medications, he improved rapidly with physical, occupational, and speech therapy. In particular, the patient's cognitive status, as indicated by comprehensive formal neuropsychiatric testing, rapidly improved, and he was noted to have significant improvement in overall arousal/alertness, following commands , complex yes/no questions, verbal fluency, convergent naming, and orientation. Discussion: Sequelae from acquired brain injury, including cognitive impairments, are often targeted with pharmacologic interventions prior to admission to inpatient rehabilitation, leading to an increased potential of drug-drug and drug-disease interactions from polypharmacy. This case illustrates how discontinuation of various medications, particularly psy-chotropic, used to treat TBI sequelae may improve functional recovery and cognitive status. Conclusion: Polypharmacy should be addressed immediately upon admission to inpatient rehabilitation, if not in the acute care setting, as adverse events and drug-drug interactions could have deleterious effects on a patient's rehabilitation potential, both physically and cognitively. Improved awareness of polypharmacy in the setting of TBI may Level of Evidence: Level V