Disorders of consciousness: practice guideline update recommendations

Practice guideline update recommendations summary: Disorders of consciousness. 

Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

Giacino JT, Katz DI, Schiff ND, Whyte J, Ashman EJ, Ashwal S, Barbano R, Hammond FM, Laureys S, Ling GSF, Nakase-Richardson R, Seel RT, Yablon S, Getchius TSD, Gronseth GS, Armstrong MJ Neurology 2018; 91: 450–460

 

Introduction

Severe injuries can result in prolonged (28 days or more) disorders of consciousness (DoC), including vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious state (MCS).  The lifetime care costs for a patient with prolonged DoC may total over $1,000,000,1 yet very few practice guidelines exist for these patients.  The American Academy of Neurology (AAN), the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research conducted a systematic review to provide updated evidence-based recommendations for the diagnosis, prognosis, care and treatment of patients with prolonged DoC.

very few practice guidelines exist for these patients

Methodology

The updated practice guidelines and recommendations were based on systematic review evidence, related evidence, care principles and inferences using a modified Delphi consensus process according to the AAN 2011 process manual.  Recommendations were subjected to three rounds of modified Delphi voting consensus to determine the strength of each recommendation (Table 1).

Table 1. Recommendation strength levels

Level

Strength of recommendation

A

Strong

B

Moderate

C

Weak

Recommendations for diagnosis and overall care

Use of serial standardised neurobehavioural assessment measures is recommended to improve diagnostic accuracy

Misdiagnosis and medical complications are common in the management of patients suffering from prolonged DoC, interfering with treatment and hindering recovery.2  In light of recent studies,3 it is recommended that once medically stable, patients with prolonged DoC be referred to a specialised setting for care by a team of multidisciplinary rehabilitation specialists (Level B).  Use of serial standardised neurobehavioural assessment measures, such as those endorsed by the ACRM, is recommended to improve diagnostic accuracy (Level B).  Prior to performing these assessments, it is recommended to attempt to increase arousal (Level B).  Any confounding conditions should be identified and treated before establishing a diagnosis (Level B).  When diagnostic ambiguity remains, specialised functional neuroimaging or electrophysiological procedures may differentiate MCS from VS/UWS (Level C).

Recommendations for prognosis

“chronic VS” should replace “permanent VS”, along with a description of the current duration of VS/UWS

Given that some patients with prolonged DoC can achieve significant late functional recovery,4,5 it is recommended that clinicians avoid using language that suggests an overall poor prognosis (Level A) and that the term “permanent VS” no longer be used (Level B).  It is recommended that the term “chronic VS” should replace “permanent VS”, along with a description of the current duration of VS/UWS.  Use of serial standardised behavioural assessments is recommended to improve diagnosis and prognosis (Level B), while structural MRI, SPECT and CRS-R, as recommended, can help determine prognosis (Level B).  Family counselling should also highlight that MCS (versus VS/UWS) and injury of a traumatic (versus non-traumatic) aetiology are associated with more favourable outcomes and that prognosis is not universally poor (Level B).  Once a prognosis is determined, counselling should also encourage family members to establish goals of care and plan for a prolonged recovery (Level A), and should encompass the need for and type of long-term supportive care (Level B).

Recommendations for treatment and care

administration of an antiviral, antiparkinson drug between 4 and 16 weeks after injury is recommended to reduce time to recovery and the level of disability

Early identification of patient and family preferences is recommended to help guide the decision-making process; these preferences should also be considered throughout the care of the patient (Level A).  Given the high rates of medical complications for patients with prolonged DoC, particularly in the first few months, it is recommended that clinicians remain vigilant and use a systematic approach to the diagnosis and treatment of these (Level B).  Regardless of the level of consciousness, pain should be assessed and treated when it is suspected that a patient is suffering (Level B).  Based on the results of a randomised controlled trial,6,7 administration of an antiviral, antiparkinson drug between 4 and 16 weeks after injury is recommended to reduce time to recovery and the level of disability (Level B).  Families should be counselled about the limitations of proposed new treatment options, as many carry significant risks and often lack sufficient evidence to support their effectiveness (Level B).

Recommendations for care for children

the natural history and prognosis of children with prolonged DoC is not well defined

As for adults, recommendations for the care of children with prolonged DoC advocate for the treatment of confounding conditions and increasing arousal before performing diagnostic assessments, and for the use of serial standardised behavioural assessment (Level B). Families should be counselled that the natural history and prognosis of children with prolonged DoC is not well defined (Level B), that there are no current established evaluations to improve prognostic accuracy and there are no recognised therapies (Level B).

Referencias
  1. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury.  JAMA 1999; 282: 974–983.
  2. Whyte J et al.  Arch Phys Med Rehabil 2013; 94: 1877–1883.
  3. Davidson GH et al.  JAMA 2011; 305: 1001–1007.
  4. Nakase-Richardson R et al.  J Neurotrauma 2012; 29: 59–65.
  5. Katz DI et al.  Prog Brain Res 2009; 177: 73–88.
  6. Giacino JT et al.  N Engl J Med 2012; 366: 819–826.
  7. Krewer C et al.  PLoS One 2015; 10: e0143180.
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