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INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part I: Posttraumatic Amnesia/Delirium

Ponsford, Jennie PhD; Janzen, Shannon MSc; McIntyre, Amanda MSc; Bayley, Mark MD, FRCPC; Velikonja, Diana PhD; Tate, Robyn PhD

Section Editor(s): Bayley, Mark Theodore MD; Bragge, Peter PhD; Ponsford, Jennie PhD

The Journal of Head Trauma Rehabilitation: July/August 2014 - Volume 29 - Issue 4 - p 307–320
doi: 10.1097/HTR.0000000000000074
Original Articles

Introduction: After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA.

Methods: The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations.

Results: Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study.

Conclusions: The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

NHMRC Centre of Research Excellence in Traumatic Brain Injury Psychosocial Rehabilitation, Australia (Drs Ponsford and Tate); School of Psychological Sciences, Monash University and Epworth Hospital, Melbourne, Australia (Dr Ponsford); National Trauma Research Institute, Monash University and the Alfred Hospital (Dr Ponsford); Lawson Health Research Institute, St Joseph's Parkwood Hospital, London, Ontario, Canada (Mss Janzen and McIntyre); Neuro Rehabilitation Program, Toronto Rehabilitation Institute, University of Toronto, Toronto, Canada (Dr Bayley); Neuropsychology, Acquired Brain Injury Program, Hamilton Health Sciences, Hamilton, Ontario, Canada (Dr Velikonja); Department of Psychiatry and Behavioural Neurosciences, DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada (Dr Velikonja); Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School - Northern, University of Sydney, Australia (Dr Tate); and Royal Rehabilitation Centre Sydney, Australia (Dr Velikonja).

Corresponding Author: Jennie Ponsford, PhD, School of Psychological Sciences, Monash University, Clayton, 3800, Victoria, Australia, Australia (

We gratefully acknowledge the support of the Victorian Transport Accident Commission (TAC) through its Victorian Neurotrauma Initiative (VNI), Monash University, and the Ontario Neurotrauma Foundation (ONF) for their support of this project.

The authors declare no conflicts of interest.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins