5.3 Neuro-palliative care and disorders of consciousness

Question 1

Disturbances in a patient’s level of arousal and awareness and ability to perceive aspects of the world and themselves are termed disorders of consciousness. What are three recognized disorders of consciousness?

Answer 1

coma

persistent and permanent vegetative state

Minimally conscious state

Question 2

Describe 4 features of a patient who is in a coma

Answer 2

eyes closed

no wakefulness

no response to stimuli

remain in state for 2 weeks before progressing

Question 3

A patient is seen by the palliative care team and is reported as being in a coma. What aspect of the brain injury is important when considering prognosis? For patients that experience cardiac arrest, what intervention has been shown to improve neurologic outcomes?

Answer 3

A. mechanism of injury - traumatic vs anoxic vs vascular (traumatic better prognosis then anoxic)

B. treatment with therapeutic hypothermia

Question 4

Describe four features of a patient in a vegetative state

Answer 4

• brainstem function is preserved but higher cortical functions are not
  1. eyes open state
  2. signs of arousal present
  3. no responsiveness
  4. open eyes in response to external stimuli
  5. exhibit reflexive but unintentional movements
  6. regain autonomic functions (resp and cardiac activity, sleep/wake cycles)
• persistent lasts at least one month
• permanent greater than three months after anoxic brain injury and greater than 12 months after traumatic brain injury
• life expectancy after permanent is mixed with 33% dying in first, pulmonary and urinary infections are most frequent cause of death
• length of time pt is in minimally conscious state inversely correlates with recovery

Question 5

Describe four features of a patient in minimally conscious state

Answer 5

definite evidence of consciousness by their behaviours - intention, attention, memory, awareness of self, others, or the environment

may track objects in visual field, say a word or phrase, hold a ball

do above actions intermittently in episodic fashion

do not reliably follow commands

Question 6

Longitudinal evaluation of a patient with a disorder of consciousness is needed to accurately determine their LOC. What is the most reliable tool for assessing this? Why is it important to differentiate a vegetative state from a minimally conscious state?

Answer 6

coma recovery scale - revised (CRS-R)

MCS - has widely dispersed brain wide neural networks

vegetative state - non-integrated, dis-integrated organization of neural networks

important to distinguish MCS and vegetative state for prognostication and because to experience pain requires integrated neural networks

MCS has potential to emerge and regain function regardless of time they are in state; permanent vegetative state length of time inversely correlates with recovery

Question 7

List five complications of prolonged disorder of consciousness

Answer 7

deconditioning 
muscle wasting 
osteopenia
contractures 
bedsores
aspiration pneumonia 
poor GI motility 
GERD
constipation 
hypercalcemia due to bone resorption 
weight loss/obesity 
illnessness related to age earlier than expected (ie heart disease)

Question 8

List three types of drugs that may improve arousal and awareness for those in minimally conscious states

Answer 8

amantadine
zolpidem
SSRIs
psychostimulants
dopamine agonists
TCAs