NeuroRehabilitation ELSEVIER
NeuroRehabilitation 5 (1995) 205-210
Assessment of agitation following brain injury John D. Corrigan*, Jennifer A. Bogner Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA Accepted 17 April 1995
Abstract Advances in clinical interventions for agitation, as well as progress in research toward better understanding of the construct, have been limited by the lack of a reliable and valid measure. This article provides a practical overview of the measurement characteristics of the Agitated Behavior Scale (ABS) (Corrigan, J. Clin Exp Neuropsychol1989; 11: 261-277) [1]. This 14-item scale has shown significant inter-rater reliability for all items; Total Score inter-rater correlations exceeding 0.70; and internal consistencies based on Cronbach's alphas have consistently exceeded 0.80. The original development of the ABS emphasized the content validity of items and demonstrated the concurrent validity of the Total Score. Subsequent studies have shown the ABS to be predictive of change in cognitive status, and able to differentiate confusion and inattention from agitation. Construct validity has been further substantiated by the identification of underlying factors that have proven stable over multiple samples.
Keywords: Brain injury; Agitation; Assessment; Disinhibition; Aggression; Lability
1. Introduction We have previously observed that agitation during the acute phase of recovery from brain injury is ' ... often observed, usually treated, but rarely measured' (p. 386) [2]. Other articles in this volume underscore the importance of agitation in brain injury rehabilitation. However, advancements in the refinement of clinical interventions,
* Corresponding author, Dodd Hall, 480 W. 9th Avenue, Columbus, OH 43210, USA.
as well as progress in research toward better understanding of the construct, have been limited by the lack of a reliable and valid measure of agitation. Most researchers, including DennyBrown [3], Levin and Grossman [4], Reyes and colleagues [5], and Brooke and colleagues [6], have used simple presence/absence determinations in their studies of agitation. While such determinations can be made reliably, presence / absence falls short when treatments require feedback as to subtle variations in agitation, or research questions demand more sensitive measurement. Work at Ohio State University be-
1053-8135/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI 1053-8135(95)00118-R
206
J.D. Corrigan, lA. Bogner / NeuroRehabilitation5 (J995) 205-210
gan in the mid-1980s to develop such a measure. The Agitated Behavior Scale (ABS) [1] was the outgrowth of these early efforts. In this article, we will provide a practical overview of the measurement characteristics of the ABS. The interested reader is directed to other sources for more technical descriptions of scale development [1], validation [7-9] and factor structure [2]. 1.1. Development of the ABS
To construct the ABS, a preliminary pool of 39 items was generated using multiple methods, including review of the literature and use of Kelly's
[10] construct elicitation methodology with interdisciplinary staff experienced in brain injury rehabilitation. A pilot study reduced the 39-item pool to 14 based on inter-rater reliability, ability to differentiate agitation, frequency of occurrence, and retention of factors present in the original item pool. The final 14-item scale, shown in Fig. 1, was then validated on an independent sample and was found to have appropriate levels of inter-rater reliability, internal consistency and concurrent validity [1]. Subsequent studies have provided support for the construct validity of the ABS [7-11]. More
AGITATED BEHAVIOR SCALE Patient _ _ _ _ _ _ _ __ Observ. Environ . _ _ _ _ __ RateriDisc. _ _ _ _ _ _ __
Period of Observation: a.m. From:_ _ p.m._ _I----1_ _ a.m. To:_ _ _p.m.-----.l----1_ _
At the end of the observation period indicate whether the behavior described in each item was present and, if so, to what degree: slight, moderate or extreme. Use the following nwnerical values and criteria for your ratings. 1 =absent: the behavior is not present. 2 =present to a slight degree: the behavior is present but does not prevent· the conduct of other, contextually appropriate behavior. (The individual may redirect spontaneously, or the continuation of the agitated behavior does not disrupt appropriate behavior. ) 3 =present to a moderate degree: the individual needs to be redirected from an agitated to an appropriate behavior, but benefits from such cueing. 4 =present to an extreme degree: the individual is not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided.
DO NOT LEAVE BLANKS.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. _ _ 14.
Short attention span, easy distractibility, inability to concentrate. Impulsive, impatient, low tolerance for pain or frustration. Uncooperative, resistant to care, demanding. Violent and or threatening violence toward people or property. Explosive and/ or unpredictable anger. Rocking, rubbing, moaning or other self-stimulating behavior. Pulling at tubes, restraints, etc. Wandering from treatment areas. Restlessness, pacing, excessive movement. Repetitive behaviors, motor and/or verbal. Rapid, loud or excessive talking. Sudden changes of mood. Easily initiated or excessive crying and/ or laughter. Self-abusiveness, physical and/or verbal.
Total Score
Fig. 1. The Agitated Behavior Scale.
J.D. Corrigan, J.A. Bogner / NeuroRehabilitation 5 (1995) 205-210
recently, Corrigan and Bogner [2] delineated the factor structure of the ABS. In their sample of 212 patients with recently acquired brain injury who exhibited agitation during acute rehabilitation, confirmatory factor analyses revealed that agitation is represented by one general construct with three underlying, correlated factors: aggression, disinhibition, and lability. They concluded that the Total Score remains the best measure of agitation, but subscale scores may provide important additional clinical and research data.
rating of '1' is ascribed when the behavior in the item is not present. Ratings of '2,' '3,' and '4' indicate the behavior is present and differentiate the degree or severity. Raters should be instructed that the basis for establishing degree is the extent to which the occurrence of the behavior described in the item interferes with functional behavior that would be appropriate to the situation: •
2. Measurement characteristics of the ABS The ABS was developed to assess the nature and extent of agitation during the acute phase of recovery from acquired brain injury. Its primary purpose is to allow serial assessment of agitation by treatment professionals who want objective feedback about the course of a patient's agitation. Serial assessments are particularly important when treatment interventions are being attempted. This instrument may be useful with populations other than patients recovering from acquired brain injury. Tabloski, McKinnon-Howe and Remington [12] demonstrated the utility of the ABS for measuring agitation in nursing home residents with progressive dementias, primarily Alzheimer's disease. 2.1. Raters and observational units
The ABS is an observational (as opposed to a self-report) measure. Original validation studies showed nursing staff, physical therapists and occupational therapists can use the scale reliably and validly. At Ohio State University, the ABS is completed by the primary nurse at the end of each shift. Novack and Penrod [11] report its use at the end of each session by therapy staff. The ABS has been shown to be reliable and valid when based on therapists' 30-min observation periods, or primary nurses' perceptions based on an 8-h shift.
•
•
A rating of '2' or 'slight' should be ascribed when the behavior is present but does not prevent the conduct of other, contextually appropriate behavior. Patients may redirect themselves spontaneously or the continuation of the agitated behavior does not preclude the conduct of the appropriate behavior. A rating of '3' or 'moderate' indicates the individual may need to be redirected from an agitated to an appropriate behavior, but is able to benefit from such cueing. A rating of '4' or 'extreme' is ascribed when the individual is not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided.
2.3. Scoring
The Total Score is calculated by adding the ratings (from one to four) on each of the 14 items. Raters are instructed to leave no blanks; but, if a blank is left, the median rating for the other 14 items should be inserted such that the Total Score reflects the appropriate possible range of values. The Total Score is the best overall measure of the course of agitation [1,2]. Subscale scores are calculated by adding ratings from the component items, as follows: •
Disinhibition is the sum of items 1,2,3,6, 7, 8,
•
Aggression is the sum of items 3, 4, 5 and 14
•
(it is not an error that item 3 is in both scores); and Lability is the sum of items 11, 12 and 13.
9 and 10;
2.2. Administration
Observers make a rating of one to four for each of the 14 items. In validation, nurses and therapists were trained by sharing impressions and asking feedback during a trial-use period. A
207
In order to allow subscale scores to be compared to each other and to the Total Score, it is
J.D. Corrigan, lA. Bogner / NeuroRehabilitation 5 (1995) 205-210
208
NAME: Line Chart Split By: SHIFT
Example
TOTAL AGITATION -0- day -0- eve -b-
night
55 50
45
~ 40
~ 35~~~----~~H+++~~~~------------------------------------+ CJ cC 30 ~
e ~
t-------.--~~~~-----4~~-+~----------------------------~
25 20
t-----------~~----------~~-b~Ft~~~~--~~~D_~~----
15
~
'"o
DATE
AGGRESSION Line Chart Split By: SHIFT
-0- day -0- eve -b- night
55 50
45
z
040
in ffi35+-~~~~-£r-~+r~~~------------------------*-------------+ a::
CJ CJ 30 cC +-~hH--~--~~~4r~o--b~~---------------4+------------+
25 20 15
DATE
209
J.D. Corrigan, JA. Bogner / NeuroRehabilitation5 (1995) 205-210
NAME:
Example Continued
DISINHIBITION
Une Chart Split By: SHIFT
-0- day -Q-- eve
night
~
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040
E
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sa 30 Q 25 20 15 10
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LABILITY
Line Chart Split By: SHIFT
-0- day -Q-- eve
60
~
night
55 50 45
~ 40
;;;!
III
NeuroRehabilitation 5 (1995) 205-210
Assessment of agitation following brain injury John D. Corrigan*, Jennifer A. Bogner Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA Accepted 17 April 1995
Abstract Advances in clinical interventions for agitation, as well as progress in research toward better understanding of the construct, have been limited by the lack of a reliable and valid measure. This article provides a practical overview of the measurement characteristics of the Agitated Behavior Scale (ABS) (Corrigan, J. Clin Exp Neuropsychol1989; 11: 261-277) [1]. This 14-item scale has shown significant inter-rater reliability for all items; Total Score inter-rater correlations exceeding 0.70; and internal consistencies based on Cronbach's alphas have consistently exceeded 0.80. The original development of the ABS emphasized the content validity of items and demonstrated the concurrent validity of the Total Score. Subsequent studies have shown the ABS to be predictive of change in cognitive status, and able to differentiate confusion and inattention from agitation. Construct validity has been further substantiated by the identification of underlying factors that have proven stable over multiple samples.
Keywords: Brain injury; Agitation; Assessment; Disinhibition; Aggression; Lability
1. Introduction We have previously observed that agitation during the acute phase of recovery from brain injury is ' ... often observed, usually treated, but rarely measured' (p. 386) [2]. Other articles in this volume underscore the importance of agitation in brain injury rehabilitation. However, advancements in the refinement of clinical interventions,
* Corresponding author, Dodd Hall, 480 W. 9th Avenue, Columbus, OH 43210, USA.
as well as progress in research toward better understanding of the construct, have been limited by the lack of a reliable and valid measure of agitation. Most researchers, including DennyBrown [3], Levin and Grossman [4], Reyes and colleagues [5], and Brooke and colleagues [6], have used simple presence/absence determinations in their studies of agitation. While such determinations can be made reliably, presence / absence falls short when treatments require feedback as to subtle variations in agitation, or research questions demand more sensitive measurement. Work at Ohio State University be-
1053-8135/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI 1053-8135(95)00118-R
206
J.D. Corrigan, lA. Bogner / NeuroRehabilitation5 (J995) 205-210
gan in the mid-1980s to develop such a measure. The Agitated Behavior Scale (ABS) [1] was the outgrowth of these early efforts. In this article, we will provide a practical overview of the measurement characteristics of the ABS. The interested reader is directed to other sources for more technical descriptions of scale development [1], validation [7-9] and factor structure [2]. 1.1. Development of the ABS
To construct the ABS, a preliminary pool of 39 items was generated using multiple methods, including review of the literature and use of Kelly's
[10] construct elicitation methodology with interdisciplinary staff experienced in brain injury rehabilitation. A pilot study reduced the 39-item pool to 14 based on inter-rater reliability, ability to differentiate agitation, frequency of occurrence, and retention of factors present in the original item pool. The final 14-item scale, shown in Fig. 1, was then validated on an independent sample and was found to have appropriate levels of inter-rater reliability, internal consistency and concurrent validity [1]. Subsequent studies have provided support for the construct validity of the ABS [7-11]. More
AGITATED BEHAVIOR SCALE Patient _ _ _ _ _ _ _ __ Observ. Environ . _ _ _ _ __ RateriDisc. _ _ _ _ _ _ __
Period of Observation: a.m. From:_ _ p.m._ _I----1_ _ a.m. To:_ _ _p.m.-----.l----1_ _
At the end of the observation period indicate whether the behavior described in each item was present and, if so, to what degree: slight, moderate or extreme. Use the following nwnerical values and criteria for your ratings. 1 =absent: the behavior is not present. 2 =present to a slight degree: the behavior is present but does not prevent· the conduct of other, contextually appropriate behavior. (The individual may redirect spontaneously, or the continuation of the agitated behavior does not disrupt appropriate behavior. ) 3 =present to a moderate degree: the individual needs to be redirected from an agitated to an appropriate behavior, but benefits from such cueing. 4 =present to an extreme degree: the individual is not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided.
DO NOT LEAVE BLANKS.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. _ _ 14.
Short attention span, easy distractibility, inability to concentrate. Impulsive, impatient, low tolerance for pain or frustration. Uncooperative, resistant to care, demanding. Violent and or threatening violence toward people or property. Explosive and/ or unpredictable anger. Rocking, rubbing, moaning or other self-stimulating behavior. Pulling at tubes, restraints, etc. Wandering from treatment areas. Restlessness, pacing, excessive movement. Repetitive behaviors, motor and/or verbal. Rapid, loud or excessive talking. Sudden changes of mood. Easily initiated or excessive crying and/ or laughter. Self-abusiveness, physical and/or verbal.
Total Score
Fig. 1. The Agitated Behavior Scale.
J.D. Corrigan, J.A. Bogner / NeuroRehabilitation 5 (1995) 205-210
recently, Corrigan and Bogner [2] delineated the factor structure of the ABS. In their sample of 212 patients with recently acquired brain injury who exhibited agitation during acute rehabilitation, confirmatory factor analyses revealed that agitation is represented by one general construct with three underlying, correlated factors: aggression, disinhibition, and lability. They concluded that the Total Score remains the best measure of agitation, but subscale scores may provide important additional clinical and research data.
rating of '1' is ascribed when the behavior in the item is not present. Ratings of '2,' '3,' and '4' indicate the behavior is present and differentiate the degree or severity. Raters should be instructed that the basis for establishing degree is the extent to which the occurrence of the behavior described in the item interferes with functional behavior that would be appropriate to the situation: •
2. Measurement characteristics of the ABS The ABS was developed to assess the nature and extent of agitation during the acute phase of recovery from acquired brain injury. Its primary purpose is to allow serial assessment of agitation by treatment professionals who want objective feedback about the course of a patient's agitation. Serial assessments are particularly important when treatment interventions are being attempted. This instrument may be useful with populations other than patients recovering from acquired brain injury. Tabloski, McKinnon-Howe and Remington [12] demonstrated the utility of the ABS for measuring agitation in nursing home residents with progressive dementias, primarily Alzheimer's disease. 2.1. Raters and observational units
The ABS is an observational (as opposed to a self-report) measure. Original validation studies showed nursing staff, physical therapists and occupational therapists can use the scale reliably and validly. At Ohio State University, the ABS is completed by the primary nurse at the end of each shift. Novack and Penrod [11] report its use at the end of each session by therapy staff. The ABS has been shown to be reliable and valid when based on therapists' 30-min observation periods, or primary nurses' perceptions based on an 8-h shift.
•
•
A rating of '2' or 'slight' should be ascribed when the behavior is present but does not prevent the conduct of other, contextually appropriate behavior. Patients may redirect themselves spontaneously or the continuation of the agitated behavior does not preclude the conduct of the appropriate behavior. A rating of '3' or 'moderate' indicates the individual may need to be redirected from an agitated to an appropriate behavior, but is able to benefit from such cueing. A rating of '4' or 'extreme' is ascribed when the individual is not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided.
2.3. Scoring
The Total Score is calculated by adding the ratings (from one to four) on each of the 14 items. Raters are instructed to leave no blanks; but, if a blank is left, the median rating for the other 14 items should be inserted such that the Total Score reflects the appropriate possible range of values. The Total Score is the best overall measure of the course of agitation [1,2]. Subscale scores are calculated by adding ratings from the component items, as follows: •
Disinhibition is the sum of items 1,2,3,6, 7, 8,
•
Aggression is the sum of items 3, 4, 5 and 14
•
(it is not an error that item 3 is in both scores); and Lability is the sum of items 11, 12 and 13.
9 and 10;
2.2. Administration
Observers make a rating of one to four for each of the 14 items. In validation, nurses and therapists were trained by sharing impressions and asking feedback during a trial-use period. A
207
In order to allow subscale scores to be compared to each other and to the Total Score, it is
J.D. Corrigan, lA. Bogner / NeuroRehabilitation 5 (1995) 205-210
208
NAME: Line Chart Split By: SHIFT
Example
TOTAL AGITATION -0- day -0- eve -b-
night
55 50
45
~ 40
~ 35~~~----~~H+++~~~~------------------------------------+ CJ cC 30 ~
e ~
t-------.--~~~~-----4~~-+~----------------------------~
25 20
t-----------~~----------~~-b~Ft~~~~--~~~D_~~----
15
~
'"o
DATE
AGGRESSION Line Chart Split By: SHIFT
-0- day -0- eve -b- night
55 50
45
z
040
in ffi35+-~~~~-£r-~+r~~~------------------------*-------------+ a::
CJ CJ 30 cC +-~hH--~--~~~4r~o--b~~---------------4+------------+
25 20 15
DATE
209
J.D. Corrigan, JA. Bogner / NeuroRehabilitation5 (1995) 205-210
NAME:
Example Continued
DISINHIBITION
Une Chart Split By: SHIFT
-0- day -Q-- eve
night
~
60 55 50 45 Z
040
E
!a ::c 35 Z
sa 30 Q 25 20 15 10
'" '"
~
j\)
'"
~
~
-oJ
~
'"
~
(X)
.10-
j\)
'"
~
0
DATE
!I:!
'"
~ ~
~
-oJ
~
N
LABILITY
Line Chart Split By: SHIFT
-0- day -Q-- eve
60
~
night
55 50 45
~ 40
;;;!
III
