VS - Evaluation, Management, Prognosis VEGETATIVE STATE - Evaluation, Management & Prognosis Dr...

VS - Evaluation, Management, Prognosis

VEGETATIVE STATE -

Evaluation, Management & Prognosis

Dr Keith AndrewsRoyal Hospital for Neuro-disability,

London, UK


Vegetative State Nomenclature/Definitions

• Prolonged coma

• Coma vigile

• Parasomnia

• Akinetic mutism

• Apallic syndrome

• Decerebrate dementia


Recovery Continuum

Coma

Vegetative State

Minimal Conscious State

‘Cognitive Impaired States’‘Norma

l’

.


DIAGNOSIS

The (Persistent) Vegetative State


•Breathing spontaneously

•Sleep-awake pattern

•Reflex responses to stimulation

•No ‘meaningful’ response

Clinical Features of VS


Problematic Presentations

• Grasp Reflex

• Swallowing

• Chewing & Tongue Pumping/Thrusting

• Bruxism

• Grunts & Groans

• Smiles & Frowns

• Relaxation Response


Minimally Conscious State


Minimally Conscious State

“Severely altered consciousness in

which the patient does not meet

the criteria for coma or the

vegetative state because there is

inconsistent but reproducible or

sustained behavioural evidence

of self or environmental

awareness”

Aspen WP 2001


MCS - Reproducibility

•Consistency of Response

•Complexity of Response


MCS- Complexity v Consistency

• The simpler the response (e.g. eye blink, finger movement) the higher the frequency required.

• The more complex the response (e.g. saying a few words) the lower the frequency required.


MCS - Diagnostic Responses

• Simple command following

• Gestural or verbal ‘yes’/’no’ responses (regardless of accuracy)

• Purposeful behaviour including movements or affective behaviours contingent to relevant stimulation.


MCS - Purposeful Behaviour

• Appropriate smiling/crying to linguistic/ visual emotional but not neutral topics.

• Vocalisation/gestures in direct response to content of question

• Reaching for object - demonstrating location and direction of reach

• Touching/holding objects -recognition of size and shape

• Eye pursuit/sustained fixation


Other Conditions

• Coma

• (Brain [Stem] Death)

• Locked-in- Syndrome


Differential Diagnosis (1)Condition Coma Veg. State Min. Cons

State Locked-in Syndrome

Self Awareness

- - Partial Full

Cyclical Eye Opening

- + + +

Motor function

Reflex & Postural

Postures or

withdraws. Occasional

non-purpose

Localises. Reach for objects.

Automatic movements

Quadriplegic.

Vertical eye movement

Experience pain

No No ? Yes

Respiratory Function

Depressed or varied

Normal Normal Normal


Differential Diagnosis (2)

Condition Coma Veg. State Min. Cons State

Locked-in Syndrome

Auditory Function

None Startle. Brief

orientation

Localise. Inconsist

commands-following

Preserved

Visual Function

None Startle. Brief

orientation

Sustained visual fix. Sustained pursuit.

Preserved.


Differential Diagnosis (3)

Condition Coma Veg. State Min. Cons State

Locked-in Syndrome

Communication None None Contingent vocalisat/n. Inconsist

verbal/n or gesture

Aphonic/ anarthric. Verical eye movement

and blinking

Emotion None None or reflex

smiling crying

Contingent smiling or

crying

Preserved


Misdiagnosis of VS

• Tresch et al (1991) 18% of long term patients diagnosed as PVS

• Childs et al (1993) 37% admitted to rehabilitation unit.

• Andrews et al (1996) 43% admitted with a diagnosis of VS for longer than 6 months.


Outcome - Referrered as VS

0

2

46

8

10

12

1416

18

No

. of

Ptn

ts

Remained VS Emerge Misdiag

25%

33%

43%

(n=40)

N=40


Misdiagnosis - Outcome

0 20 40 60 80 100

% of Misdiagnosed Patients

Spell message

Make choices

Simple Maths

Orientated TPP

Write messages


Misdiagnosis - Characterisitics

0% 20% 40% 60% 80% 100%

Misdiagnosed Patients

Blind orVisuallyImpaired

Physicallydisabled

100%

65%


Causes of Misdiagnosis

• Too ill

• Fatigue

• Missed windows of opportunity

• Physical disability/Poor positioning

• Blind

• Inexperience of observer

• Too short an assessment period


THE VEGETATIVE PATIENT

Management


Disability Management

Recovery

Deterioration


Inter-disciplinary Team

Patient FamilyDoctor

Nurse

Physio OT SALT

Music Therapist

SocialWorker

Psychol

Dietician

OralHygienist

ClinicalEngin Dentist


Principles of Rehabilitation Prevent secondary

complications

Provide environment for

recovery

Treatment

Modify the patient

Modify the environment

Support the family Change Society


The Vegetative Patient

• Physically dependent

• Complex neurological complications

• Cognitively impaired

• Medically vulnerable

• Family in crisis


Medical Needs

• Epilepsy

• Fluid & electrolyte balance

• Infections (UTI & RTI)

• Respiratory function

• Drug control of spasticity

• Stimulants

• Systems control - e.g. diabetes


Health Management

• Nutrition

• Posture & positioning

• Spasticity

• Bowel function

• Bladder function

• Tracheostomy


Recovery - Opportunities

•Nutritional state

•Good positioning

•General health

•Control of medication

•Sensory regulation


COGNITIVE ASSESSMENT


Sensory Regulation

• Controllable environment

• Staff awareness

• Family awareness

• Specialist knowledge

• Equipment


Sensory Assessment

Vision

Hearing

Smell

Taste

Touch

+

Arousal

None

Reflex

Withdrawal

Localisation

Differentiating

.


Method of Showing Awareness

•Eye blink

•Move finger

•Hand thrust

•Knee or foot movement

•Shrug shoulder

•Head turn


Assessment - Basic Requirements

• Good nutritional state

• Good health

• Seated with good posture

• At least some muscle movement


Communication - Optimal Conditions

• After rest period

• Windows of opportunity

• Short sessions

• Repeated

• Over period of time


Factors Affecting Assessment

• Physical ability to respond

• Desire/willingness to respond

• Ability to observe accurately

• Time available for observation/assessment

• Reliable assessment tools


FAMILIES ,

CARERS

OR

SIGNIFICANT OTHERS


Support Patient/Family

Information Involvement Counselling Welfare information Ward based support groups Peer support National groups


Family effect on outcome?

Anxiety Guilt Wishful thinking Anger Expectations v Reality


Expectations v Reality

RealityExpectations


Expectations v Reality

Reality

Expectations


What is reality?


WHY BOTHER?


Why Bother?

• Diagnosis and Misdiagnosis

• Recovery v optimal maintenance

• Long term requirements/ benefits

• Cost to state

• Cost to family


VEGETATIVE STATE The End

(or The Beginning?)

VS - Evaluation, Management, Prognosis VEGETATIVE STATE - Evaluation, Management & Prognosis Dr...

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