Agitation After TBI in a Shared Room
Marcus is a 34-year-old man six weeks after a severe traumatic brain injury (initial Glasgow Coma Scale 6). He is in inpatient rehabilitation and is described as Rancho Los Amigos level IV: confused, agitated, and inconsistently oriented. He attends 30-minute music therapy sessions in a shared four-bed room; no quiet room is available during your scheduled time. Nursing reports that he becomes agitated during loud hallway noise and whenever two or more people speak at once. The referral says “music therapy for agitation.” He can follow one-step directions on good days, uses a wheelchair, and has a healing right clavicle fracture. He has no reported musical training but hums along to familiar country songs. Your session starts in ten minutes.
1. Before the first session, what assessment information do you prioritize, and what will you deliberately defer? Explain your reasoning.
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Prioritize medical stability and pain, especially the healing clavicle fracture, recent TBI, fatigue, seizure risk, and medications. Assess sensory and environmental triggers: noise, crowding, light, and the number of people speaking. Check communication and orientation: one-step commands, reliability of yes/no responses, hearing, and vision. Assess current safety: agitation intensity, fall risk, exit-seeking, and use of restraints. Ask about music responses and preferences, including familiar country songs, humming, and volume tolerance. Obtain consent or assent and identify family involvement.
Defer standardized music therapy assessment, complex instrument tasks, and long verbal interviews until agitation is better managed. Rancho IV means responses are inconsistent, so a single session is not a stable baseline. Ask nursing about pain, bowel and bladder function, sleep, infection, and recent medication changes, because agitation after TBI is not automatically a psychological target. Brief, repeated observation is more valid than one long assessment.
2. Design the first 15 minutes of the session. Specify musical elements, instruments, and environmental modifications, and justify each choice against Marcus’s profile.
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Before starting, close the door, reduce hallway traffic, dim light if possible, sit at eye level, and keep one therapist speaking. Have water and the call bell within reach.
0–2 minutes: sing a greeting song at 60–65 bpm with guitar, simple I–IV–V harmony, 4/4 meter, and a repeated two-bar phrase. Use one short phrase at a time.
2–5 minutes: offer two choices-hum or tap a padded drum with the left hand. Avoid the right arm because of the clavicle fracture.
5–10 minutes: play a familiar country song at a slower tempo and lower key, with a repetitive chorus and 2–3 seconds of silence between phrases. Allow humming; do not demand lyric recall.
10–15 minutes: continue only if calm; add a single sustained chord or silence, then end with the same goodbye song.
Justification: predictable form, low harmonic rhythm, and familiar material reduce processing load. Low volume and one stimulus reduce sensory overload. Choice supports autonomy. Avoid cymbals, sudden tempo changes, complex lyrics, and multiple instruments. Stop if he covers his ears, shouts, or shows two signs of escalation.
3. Five minutes in, Marcus covers his ears and shouts “too many.” What do you do in the next 60 seconds, and how do you document and adjust the plan?
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Stop all music immediately. Do not ask more than one short question. Lower your voice, move back slightly, and say, “I’m stopping. You’re safe.” Reduce stimuli: ask staff to close the door, turn off the television, and limit the number of people nearby. Offer one choice: “Quiet, or one song?” Do not touch him without permission, and make sure the wheelchair brakes are set. If agitation escalates, call nursing according to protocol. Do not continue music in order to “calm” him.
Document the time, antecedent (music, hallway noise, multiple speakers), behavior (covered ears, shouted “too many”), intervention (stopped music, reduced stimuli), response, staff notified, and plan change. Adjust to 10–15 minute individual sessions in the quietest available space, same time daily, with a pre-session sensory check and an agreed stop signal. Reassess whether the referral target is overstimulation rather than “agitation.”