VEGETATIVE STATE -

1

• VEGETATIVE STATE -
• Evaluation, Management Prognosis
• Dr Keith Andrews
• Royal Hospital for Neuro-disability,
• London, UK

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Vegetative State Nomenclature/Definitions

• Prolonged coma
• Coma vigile
• Parasomnia
• Akinetic mutism
• Apallic syndrome
• Decerebrate dementia

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Recovery Continuum
Coma
.
Vegetative State
Minimal Conscious State
Cognitive Impaired States
Normal
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DIAGNOSISThe (Persistent) Vegetative State
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Clinical Features of VS

• Breathing spontaneously
• Sleep-awake pattern
• Reflex responses to stimulation
• No meaningful response

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Problematic Presentations

• Grasp Reflex
• Swallowing
• Chewing Tongue Pumping/Thrusting
• Bruxism
• Grunts Groans
• Smiles Frowns
• Relaxation Response

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Minimally Conscious State
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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

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MCS - Reproducibility

• Consistency of Response
• Complexity of Response

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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.

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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.

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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

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Other Conditions

• Coma
• (Brain Stem Death)
• Locked-in- Syndrome

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Differential Diagnosis (1)
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Differential Diagnosis (2)
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Differential Diagnosis (3)
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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.

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Outcome - Referrered as VS
(n40)
43
33
25
N40
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Misdiagnosis - Outcome
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Misdiagnosis - Characterisitics
100
65
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Causes of Misdiagnosis

• Too ill
• Fatigue
• Missed windows of opportunity
• Physical disability/Poor positioning
• Blind
• Inexperience of observer
• Too short an assessment period

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THE VEGETATIVE PATIENT

• Management

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Disability Management
Recovery
Deterioration
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Inter-disciplinary Team
OT
Physio
SALT
Music Therapist
Nurse
Social Worker
Patient
Family
Doctor
Psychol
Oral Hygienist
Dietician
Clinical Engin
Dentist
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Principles of Rehabilitation

• Prevent secondary complications
• Provide environment for recovery
• Treatment
• Modify the patient
• Modify the environment
• Support the family
• Change Society

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The Vegetative Patient

• Physically dependent
• Complex neurological complications
• Cognitively impaired
• Medically vulnerable
• Family in crisis

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Medical Needs

• Epilepsy
• Fluid electrolyte balance
• Infections (UTI RTI)
• Respiratory function
• Drug control of spasticity
• Stimulants
• Systems control - e.g. diabetes

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Health Management

• Nutrition
• Posture positioning
• Spasticity
• Bowel function
• Bladder function
• Tracheostomy

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Recovery - Opportunities

• Nutritional state
• Good positioning
• General health
• Control of medication
• Sensory regulation

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COGNITIVE ASSESSMENT
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Sensory Regulation

• Controllable environment
• Staff awareness
• Family awareness
• Specialist knowledge
• Equipment

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Sensory Assessment
.

• Vision
• Hearing
• Smell
• Taste
• Touch
• Arousal

• None
• Reflex
• Withdrawal
• Localisation
• Differentiating

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Method of Showing Awareness

• Eye blink
• Move finger
• Hand thrust
• Knee or foot movement
• Shrug shoulder
• Head turn

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Assessment - Basic Requirements

• Good nutritional state
• Good health
• Seated with good posture
• At least some muscle movement

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Communication - Optimal Conditions

• After rest period
• Windows of opportunity
• Short sessions
• Repeated
• Over period of time

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Factors Affecting Assessment

• Physical ability to respond
• Desire/willingness to respond
• Ability to observe accurately
• Time available for observation/assessment
• Reliable assessment tools

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• FAMILIES ,
• CARERS
• OR
• SIGNIFICANT OTHERS

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Support Patient/Family

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

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Family effect on outcome?

• Anxiety
• Guilt
• Wishful thinking
• Anger
• Expectations v Reality

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Expectations v Reality
Reality
Expectations
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Expectations v Reality
Expectations
Reality
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Expectations v Reality
Expectations
Reality
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Expectations v Reality
Expectations
Reality
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• What is reality?

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WHY BOTHER?
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Why Bother?

• Diagnosis and Misdiagnosis
• Recovery v optimal maintenance
• Long term requirements/ benefits
• Cost to state
• Cost to family

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VEGETATIVE STATE The
End

• (or The Beginning?)