Agitation and Traumatic Brain Injury (TBI): how to manage

If you work with patients recovering from a Traumatic Brain Injury (TBI), you know that on occasion they may need a bit of behavior modification for- agitation.  TBI symptoms can have quite a wide range, including physical impairments, cognitive impairments, and social/emotional challenges.  Usually at some point in the rehab process with TBI, you will see unwanted and disruptive behaviors come and go.  Knowing how to approach the agitated patient and de-escalate the situation is key in order to be able to move forward with your goals for their care.

Why agitation happens in Traumatic Brain Injury:

One reason that agitation happens in the Traumatic Brain Injury population is that it can be part of the recovery process.  When someone sustains a TBI, they will start to go through stages of recovery that are characterized by the Rancho Levels of Cognitive Functioning

Per the Rancho Scale- if someone is at a Cognitive Level I (no response), they do not respond to any outside stimuli.  They are essentially in a coma.  When they move into Cognitive Level II (generalized response), they will start to slowly and inconsistently respond to stimuli.  Cognitive Level III (localized response) is characterized by the person’s ability to react more specifically to what they see, hear, and feel; they may begin to be awake on and off throughout the day; start to recognize family and friends and start to follow simple commands.  And Cognitive Level IV (agitated and confused) is where most clinicians run into trouble. 

brain injury

At Cognitive Level IV, the person will appear very frightened and confused; they may not understand how they feel or what is going on around them; they will have a hard time following instructions and may overreact by hitting and screaming; and they will be very focused on their basic needs.  This stage seems to last forever when you’re helping them through it, but in reality, will run its course and they will move into the next stage within a relatively short time period. 

There are four more Cognitive Levels the person can move through, with the last one being Cognitive Level VIII (purposeful and appropriate).  This person may still have some lingering difficulties but will be aware of them and be able to apply compensatory strategies to function in day to day life.  For a great description of all the levels as well as what family and friends can do to help at each level, check out this great resource.

If you would like to find out about the benefits and the process of becoming a Certified Brain Injury Specialist, download the CBIS Power Pack HERE!

Outside of the natural healing process, another reason someone with a traumatic brain injury experiences agitation- could be the same reason that we may also become agitated. They’ve been triggered! 

Now, this may look much different than your average trigger and people who have not sustained a TBI may have the ability to effectively use coping strategies and work through it.  Your patient will not be able to self-regulate very well at this point and they may not even be able to communicate that something is bothering them. Some triggers for a person with TBI may be:


There are several reasons a person with TBI could be experiencing pain.  A likely culprit could be persistent headache.  We know that even mild TBI symptoms consist of headache, so in someone that has sustained a severe TBI, this could be exacerbated further. 

There may also be other orthopedic sources of pain depending on the mechanism of their injury.  Fractures, surgical incisions, and other wounds could be causing ongoing pain for your patient.

Some non-verbal signs and symptoms of pain include restlessness, moaning, labored breathing, and agitation.  Since this person may not be able to communicate this specifically, it’s important to speak with the patient’s physician to find out if any medical interventions would be appropriate to include for pain management.   

Medical Appliances

Some patients in this stage of recovery have a few add-ons that can be rather uncomfortable – such as helmets, PEG tubes, trachs, IVs, oxygen, etc.  These are not things that they likely had prior to sustaining a TBI and these types of medical devices are usually uncomfortable to deal with for anyone – with or without a TBI!  These patients are going to feel this discomfort… not be able to communicate the discomfort… and most likely be confused as to what it is and why it is there to begin with.  Understandable that this may cause a bit of agitation for someone post brain injury!

Basic needs


Eating, sleeping, and using the bathroom are often things that a patient after TBI needs assistance with.  If they are NPO, they may still have a feeling of hunger and want nothing more than to be given something to eat.  And when they can’t have it, this could cause agitation.  If they are on a PO diet, they may not like the texture or not like the food choices and this will cause agitation as well.  The person with TBI may not be sleeping well or may have their days and nights mixed up.  So, when you are trying to do any kind of treatment with them, they end up being too tired… and end up agitated.  They also may now have difficulty with continence.  They have an uncomfortable feeling in their body, but they are not quite sure what it means or how to communicate it or they have an accident and become uncomfortable due to being soiled.  They are not able to anticipate these types of issues or problem solve their way through them… so they become agitated!


Loud noises, bright lights, crowded areas, temperature changes, among other things can overwhelm a patient’s system and cause them to go into an agitated state.  This could be easily identified by tracking the circumstances that are present when agitation occurs and seeing what sets them off.  This could even include people that are in their environment – sometimes there are certain personalities that clash or even the tone of a person’s voice could be too loud or is perceived as noxious by the patient after TBI.    


As the title of Cognitive Level IV states, these patients will be confused and agitated.  They often require frequent reorientation to place, time, and situation and often perseverate on wanting to leave or go home.  They don’t remember who you are, where they are, why they are there… and this can be scary!  They want to leave and when they are not permitted to do so, this could escalate the situation.  

To learn more about resources available to the patients and families affected by TBI, check out the Brain Injury Association of America.

There are many other things that could cause agitation in someone recovering from a Traumatic Brain Injury, and the most important thing is to pay attention and recognize patterns of behavior that may be occurring, so you can put an appropriate behavior modification in place and help them through the recovery process.  It’s important to respond to brain injury-related agitation consistently and professionally. 

Try these 3 tried-and-true strategies to help you and your patients through this challenging stage!

Strategy 1: Stay present, stay calm, and don’t argue

Ok, so that may sound like three separate strategies… but they are all related to building rapport, building trust, and teaching your patient what your expectations are.  Staying present means that you don’t leave and end the session simply because your patient is agitated and is yelling at you.  They may be trying to refuse therapy and yelling for you to get out of their room… but however counterintuitive it may seem at the time – the best thing to do is stay with them and “ride the storm.” 

Here is an example of how the same scenario can be handled different ways and why staying present and calm will be the best choice in the long run. 

Imagine the simple scenario described above.  You go into your patient’s room at their scheduled time and they start yelling, refusing, maybe even threatening to throw something at you. 

  • If you…Leave and mark that session as missed, you have taught the patient that they are not expected to participate in your plan of care for them.  They simply have to act out a bit and they will be able to get out of participating.  Even when they move past the confused and agitated stage and progress with their recovery, they will be less likely to want to participate with you as this has now become a learned behavior and they may not feel that you expect much from them.
  • If you… Start to argue and correct the inappropriate behavior, you have taught the patient that you are a source of anxiety for them.  You are not someone they can be vulnerable with and they will not tend to trust you.  It doesn’t matter in that moment if what they are saying is completely wrong – in their mind, they are right and if you try to correct them by arguing with them you will only heighten their level of agitation.  It’s very much worth doing a self-assessment when we speak to any of our patients, as we may not always come across how we intend to.
  • BUT: If you… Stay present, stay calm, and don’t argue you will get the best result by far!  This requires extreme patience and is very difficult to do at times.  But if you remain calm and continually reorient them and redirect them to the situation and what your purpose is, they will eventually learn that you can be trusted and they will learn that you expect them to participate in your session during the scheduled time.  This may not happen during the first attempt, this may not happen during the second attempt… but if you ride it out with them, they will come around!  Some examples of things you may say are as follows:

“Mr. Smith, I see you’re upset.  You are in rehab because you have a brain injury.  This is your therapy time.  I’m going to stay here with you.  Let me know when you’re ready.”

agitation brain injury

This allows you to show empathy by acknowledging that something is wrong.  You are reorienting them to the situation by reminding them why they are there and what time it is.  You are reassuring them that this time with them is important to you and that you are going to follow through.  And you hand them a small amount of control back – they will tell you when they are ready instead of you telling them to do something now.

“Mr. Smith, this is your therapy session.  I’m here with you until 1:30. We need to work on [x, y, and z] during this session.  What would you like to work on first?”

Here you are telling them what to expect while you are there.  They now have an end time, which makes your purpose and presence more concrete.  They don’t have to wonder how long they have to work.  You let them know what your goals for the session are, which again makes the session feel more concrete.  And you allow them to have a choice.  You are there for a specific reason, but you are not going to run things – you are allowing them to direct how the session goes as long as you accomplish [x, y, and z].

“Mr. Smith, please don’t speak to me that way.  I am being polite to you, please be polite to me.  I am your therapist.  You are in rehab because you had a brain injury.  I’m here to help you get better so you can go home.”

Now, you may see how this could come across as argumentative given that you’re telling them not to do something.  However, if delivered in a calm and even tone this is quite effective in pointing out the inappropriateness of how they are acting.  There is nothing wrong with calling them out on what they’re doing as long as it’s approached the right way.  This type of cueing may even take a few practice runs in the mirror or some role playing with co-workers.  This will also reorient them to why they are there and what the “end game” is… going home – which may be motivating to some patients. 

You will know what the exact wording needs to be based on the needs of your patient.  The main thing to remember is to stay present and calm and work to build the trust and rapport you need to help them stay calm and be present in their own recovery.  While you are using these strategies, there may be some down time and “waiting it out” when not much “therapy” is going on.  But this is well worth the time spent in the beginning in order to get the outcomes you’re looking for in the end.  You will gradually teach the patient how to treat you by remaining consistent and continually reorienting and redirecting them.

Strategy 2: Provide Structure

When someone sustains a TBI and is going through the cognitive stages of recovery, they are confused at times, disoriented to time and place, don’t always remember who their caregivers are or what they’ve done throughout the day.  Since they are unable to organize and process all of this information, it can be useful to provide structure to them in a few different ways.  Helping them keep track of things will give them a sense of comfort and security and may help prevent agitation before it occurs.

  • Calendar – Having a monthly calendar readily available is going to provide an easy and consistent way to reorient the patient to time and also keep track of activities and appointments that are coming up.  Often times, if unexpected things happen to or around a person with a TBI… this could send them into a tailspin!  They usually have very little flexibility of thinking due their injury (and depending on what stage of recovery they are in) and the more concrete you make their day, the information you present to them, their environment… the more chance you have of holding back the anxiety and agitation.   Giving them the ability to anticipate things that fall outside the realm of a “normal day” will be a life saver!
  • Daily Schedule – You don’t want to leave the day to chance.  Your patient has lost so much control over their bodies and their lives, that a simple thing like knowing what to expect throughout the day will help them feel more settled and less anxious.  They will know what to expect and have more time to process the information and complete whatever preparation they may need to.  A great place to start is their therapy schedule.  Coordinate with all the therapists and with nursing to see when each therapy would fit best in the day for that particular patient.  Write it down and provide it to the patient, so they always know when to expect you.  And if this has to change for any reason, make sure to tell them ahead of time!  As they start to recover and are able to participate in more high-level activities, you can add other things to their daily routine.  These things may be a wake up and bed time, morning and evening routine, making a call to a family member, going on a community outing, going to an appointment, etc.  The more they know in regards to how the day will unfold, the better.  And since it is written down, they won’t have the pressure of trying to remember what is next.  They can look at it as many times as they need to.
  • The Care Team – As much as possible, try to have the same therapists, nurses, aides, etc. work with the patient on an ongoing basis.  As mentioned previously, these patients (especially if they are at a Cognitive Level IV) will be confused and disoriented and will be fairly untrusting at first of the people trying to care for them.  Seeing the same faces day in and day out, building trust, and establishing expectations will be key in preventing and de-escalating episodes of agitation.  And on the clinician side of this factor, it is much easier for us to know how to approach someone, how to anticipate needs, what strategies work (and which ones don’t) if we are the ones seeing them each day.  If the patient with a TBI has to get to know a different clinician each day for their whole recovery period and those clinicians have to try their best to get to know everything that is going to make the session or treatment go as efficiently as possible… progress is going to be rather slow, if not non-existent.  Consistency and structure in the care team is what you want to strive for.

The three examples above are some of the more natural ways you can incorporate structure when you’re starting to formulate your plan.  They are a good place to start, but any type of structure you can provide will be helpful in decreasing brain injury-related agitation and helping your patient with TBI feel more confident in themselves, and with what they see around them.  Try to always give instructions in a concrete way, so nothing is left to chance and provide information in writing (if they are able to read and comprehend) so they can review it at will.  

Strategy 3: Make a Plan & Meet their needs

So, this may seem oversimplified.  Meet their needs.  As healthcare professionals, we want to make a difference and help people… we always strive to meet the needs of the patients we work with.  However, when you’re working with the TBI population and you are at the point where behavior modification is needed – it may not be so obvious what their needs are!

Step 1: Identify triggers – When your patient with a Traumatic Brain Injury starts to have episodes of agitation, you want to carefully track what preceded the episode, what is in and around their environment, who is caring for them, etc.  By paying close attention to these sorts of things, you can easily identify what undoubtedly sets them off.  There will still be times that the agitation seems to be insidious, but for the most part you will be able to find out what circumstances are troublesome for that specific patient.  This type of tracking is best done with input from the interdisciplinary team.  So, if your facility has a daily huddle or a daily clinical meeting – this type of information should be brought up then so everyone has the opportunity to ask questions that are relevant to them and that others may not have thought about.  Sample questions that should be explored are:

  • Were they found to be incontinent?  Were they wet or soiled?
  • Were they in the same position for a long time?  Could they have been uncomfortable?
  • Did they feel too hot or too cold?
  • Were there any loud noises?  Or other environmental irritants?
  • Was someone trying to work with them when the behavior started to escalate?  Or were they alone?
  • When was the last time they ate? (if not NPO)

There are a whole host of other questions to ask depending on the needs and circumstances of the patient and the episode of agitation.  But having a quick discussion as a team will be the fastest way to identify what is triggering them.

Step 2: Identify needs – Once the triggers are identified, you can more easily identify what the patient needs.  If the patient seems to always be found as incontinent when the agitation ramps up, they may need to be toileted more often.  If the patient seems to get restless after a certain amount of time in their chair, they may need rest breaks in bed.  If they seem calm in their room but hate being in the therapy gym with other people, they may need a quiet space to start treatment in.  If light seems to bother them, sunglasses may be in order!  If they are constantly asking for something to eat, maybe giving them double portions at their meals would be appropriate. 

These patients will have needs, just like all the other patients that we work with.  Unfortunately, agitation is the person with brain injury ‘s way of saying they need something, or something is wrong.  Once we identify why they are acting out, we will know what to do!

Step 3: Make a plan – All the information discussed above will go into a behavior modification plan.  This plan should be easily accessible to all clinicians caring for the patient and should be initiated as soon as possible.  You can include things like:

  • Names of people on their care team
  • Names of caregivers or contacts
  • Therapy schedule and/or out of bed schedule
  • Toileting schedule
  • Environmental modifications
  • Triggers of agitation
  • Strategies for de-escalation
  • What types of external memory aides are being used
  • Any other special instructions

As your patient with a TBI moves through recovery, there are going to be times that are challenging and there are going to be behaviors you observe that are irrational and sometimes quite explosive!  Agitation in brain injury is not uncommon… however no one (you or the patient) has to simply suffer through this time.  If we take a step back and make sure we are building trust and rapport, providing structure, and meeting their needs… we can all experience a smoother transition through the Rancho Levels of Cognitive Function.

If you are interested in learning more about assessment and treatment of Mild TBI, check out ‘Practical Approaches to Concussion Management‘! This powerful seminar provides skills and tools to be able to assess, treat and manage concussion and the complications that may arise from it.

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