Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings?

The social and family evaluation (SAFE) scale for caregivers of individuals with disorders of consciousness: preliminary results

BACKGROUND

Caregivers' involvement in the diagnostic and monitoring processes of the level of consciousness of patients with Disorders of Consciousness (DoC) is strongly encouraged by international guidelines, as current literature suggests a better chance to detect behavioural responses when caregivers are involved in clinical assessments. Since caregivers' involvement during clinical assessments can be difficult, the Social And Family Evaluation (SAFE) scale has been recently proposed as a standardised tool that caregivers can autonomously use to collect their opinions about the level of consciousness of patients with DoC, based on the behaviours manifested by the patients in a given time-window.

OBJECTIVE

Providing preliminary results concerning SAFE adoption.

METHODS

22 patients with DoC were assessed through the Coma Recovery Scale-revised (CRS-r), while their caregivers filled-in the SAFE.

RESULTS

The SAFE showed a very high internal consistency, very high test-retest reliability, and high criterion validity when correlated to the CRS-r total score. Moreover, in line with the literature, the SAFE allowed the detection of some behaviours indicative of a higher level of consciousness than those detected by clinicians through the CRS-r in more than half of the sample.

CONCLUSION

Overall, these preliminary data are promising for the adoption of the SAFE to collect the opinions of the caregivers about the level of consciousness of patients with DoC, especially in those settings where it would be otherwise difficult to monitor the patients, such as long-term care structures and at home, as a tool for telemedicine allowing the monitoring of patients in remote settings.

Perception of diagnosis by family caregivers in severe brain injury patients in China

OBJECTIVES

Surrogate decision-making by family caregivers for patients with severe brain injury is influenced by the availability and understanding of relevant information and expectations for future rehabilitation. We aimed to compare the consistency of family caregivers' perceptions with clinical diagnoses and to inform their expectation of prognosis in the future.

METHODS

The Coma Recovery Scale-Revised was used to assess the diagnosis of inpatients with severe brain injury between February 2019 and February 2020. A main family caregiver was included per patient. The family caregiver's perception of the patient's consciousness and expectations of future recovery were collected through questionnaires and compared consistently with the clinical diagnosis.

RESULTS

The final sample included 101 main family caregivers of patients (57 UWS, unresponsive wakefulness syndrome, 37 MCS, minimally conscious state, 7 EMCS, emergence from MCS) with severe brain injury. Only 57 family caregivers correctly assessed the level of consciousness as indicated by the CRS-R, showing weak consistency (Kappa = 0.217, P = 0.002). Family caregivers' demographic characteristics and CRS-R diagnosis influenced the consistency between perception and clinical diagnosis. Family caregivers who provided hands-on care to patients showed higher levels of consistent perception (AOR = 12.24, 95% CI = 2.06-73.00, P = 0.006). Compared to UWS, the family caregivers of MCS patients were more likely to have a correct perception (OR = 7.68, 95% CI = 1.34-44.06). Family caregivers had positive expectations for patients' recovery in terms of both communication and returning to normal life.

CONCLUSION

Nearly half of family caregivers have inadequate understanding of their relative's level of consciousness, and most of them report overly optimistic expectations that do not align with clinical diagnosis. Providing more medical information to family caregivers to support their surrogate decision-making process is essential.

Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation

BACKGROUND

Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs.

AIM

The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC.

DESIGN

Cross-sectional study.

SETTING

Post-acute Unit of Neurorehabilitation.

POPULATION

DOC due to severe brain injury.

METHODS

Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence).

RESULTS

Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious).

CONCLUSIONS

Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach.

CLINICAL REHABILITATION IMPACT

In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.

Behavioral scales variability in patients with prolonged disorders of consciousness

BACKGROUND

The principal conditions differentiating disorders of consciousness (DOC) patients are the unresponsive wakefulness syndrome/vegetative state (UWS/VS) and the minimally conscious state (MCS). Many individuals who suffer from sudden-onset severe brain injury move through stages of UWS/VS and MCS before regaining full awareness. In some patients, the DOC condition is protracted for years (PDOC). In this study, we observed PDOC patients for 6 months to assess possible changes in their level of consciousness.

METHODS

We enrolled 40 PDOC patients, 23 UWS/VS and 17 MCS hosted in a dedicated unit for long-term brain injury care. The time from injury was 472 ± 533 days for UWS/VS and 1090 ± 1079 days for MCS. The Wessex Head Injury Matrix (WHIM), Coma Recovery Scale-R (CRS-R), and Nociception Coma Scale were administered monthly for 6 months.

RESULTS

During the period of assessment, the percentage of UWS/VS shifted from 58 to 45%, while for the MCS, from 42 to 55%. A positive correlation was found for the UWS/VS patients between the months of observation with the CRS-R total score and WHIM total numbers of behaviors (TNB). In the UWS/VS group, the CRS-R auditive and visual subscales correlated positively with the observation time. During the whole period of observation, 8 patients had constant CRS-R total scores while the WHIM TNB changed in 7 of them.

CONCLUSION

Our findings demonstrated that the monthly assessment of PDOC by means of the CRS-R and WHIM was able to detect also subtle changes in consciousness level.

Study protocol: Developing telephone follow-up scale for patients with disorders of consciousness

Background

The significant lack of rehabilitation prognostic data is the main reason that affects the treatment decision-making and ethical issues of patients with disorders of consciousness (DoC). Currently, the clinic's consciousness assessment tools cannot satisfy DoC patients' follow-up needs.

Objective

The purpose of this study is to construct a sensitive, professional, and simple telephone follow-up scale for DoC patients to follow up on the prognosis, especially the recovery of consciousness, of prolonged DoC patients transferred to community hospitals or at home.

Methods

This study is to adopt expert consultation to construct and to verify the validity and feasibility of the scale on-site.

Conclusion

At present, there is a strong demand for portable, accurate, and easily operated scales. It is helpful to improve the rehabilitation data of prolonged DoC patients and provide more basis for their treatment and rehabilitation.

Quantitative evaluation of the consciousness level of patients in a vegetative state using virtual reality and an eye-tracking system: A single-case experimental design study

ABSTRACTIt is important to distinguish patients in a minimally conscious state (MCS) from patients in a vegetative state (VS) when assessing disorders of consciousness (DOC) as prognosis, selection of therapy, and drug treatment could differ accordingly. Clinical evaluation of a patient's eye movements, such as visual startle, visual fixation, and visual pursuit, provides valuable evidence but is often subject to misdiagnosis. To minimize such misdiagnosis caused by human judgment, a virtual reality (VR) technology-based quantitative assessment method with an eye-tracking system is proposed in this study. The new VR system presented 3 stimuli to 20 healthy participants, and visual response data were recorded to define valid responses to each stimulus. Further, the newly defined stimuli were presented to five chronic patients in VS, and the system classified three of them as showing visual fixations that could not be verified through clinical assessment beforehand. The proposed system, as verified through such experimentation, suggests quantitative and objective evaluation methods for examining three visual functions of patients with DOC.

Validity of the Early Functional Ability scale (EFA) among critically ill patients undergoing early neurological rehabilitation

Background

A reliable assessment of the functional abilities of patients after severe brain damage is crucial for valid prognostication and treatment decisions, but most clinical scales are of limited use among this specific group of patients.

Aim

The present study investigates the usefulness of the Early Functional Ability (EFA) scale, which determines the functional abilities of severely impaired patients.

Methods

Critically ill patients consecutively admitted to early neurological rehabilitation were screened for eligibility. We assessed the correlation between the EFA scale and (i) the Early Rehabilitation Barthel Index (ERBI), and (ii) the Coma Recovery Scale-Revised (CRS-R). The 1-year outcome on the Glasgow Outcome Scale-extended (GOSE) was used to examine the predictive validity. Demographical and medical variables were entered into univariate and multivariate binary regression models to identify independent predictors of 1-year outcome.

Results

Two hundred fifty-seven patients (168 men) with a median age of 62 years (IQR = 51–75) were enrolled. The correlation of the EFA scale with the CRS-R was high but low with the ERBI upon admission. Multivariate regression analysis yielded the vegetative subscale of the EFA scale as the only independent predictor for the 1-year outcome of patients admitted to early neurological rehabilitation.

Conclusions

This study shows a high correlation of the EFA scale with the CRS-R but a weak correlation with the ERBI in patients with low functional abilities. With improving patient abilities, these correlations were partly reversed. Thus, the EFA scale is a useful tool to assess the functional abilities and the prognosis of critically ill patients adequately and may be more feasible than other scales.

Entropy Metrics Correlating with Higher Residual Functioning in Patients with Chronic Disorders of Consciousness

To test the ability of different entropy measures to classify patients with different conditions of chronic disorder of consciousness, we applied the Lempel–Ziv complexity, the amplitude coalition entropy (ACE), and the synchrony coalition entropy (SCE) to the EEG signals recorded in 32 patients, clinically evaluated using the coma recovery scale revised (CRS-R). All the entropy measures indicated that differences found in the theta and alpha bands can distinguish patients in a minimal consciousness state (MCS) with respect to those in a vegetative state/unresponsive wakefulness state (VS/UWS). These differences were significant comparing the entropy measure performed on the anterior region of the left hemisphere and midline region. The values of theta-alpha entropy positively correlated with those of the CRS-R scores. Among the entropy measures, ACE most often highlighted significant differences. The higher values found in MCS were for the less impaired patients, according to their CRS-R, suggest that the preservation of signal entropy on the anterior region of the dominant hemisphere correlates with better preservation of consciousness, even in chronic conditions.

Towards a New Assessment Tool for Caregivers of Patients with Disorders of Consciousness: The Social and Family Evaluation Scale (SAFE)

Monitoring the level of responsiveness of patients with Disorders of Consciousness (DoCs) represents an issue in all the settings where there is not the daily presence of clinicians, such as long-term and domestic settings. The involvement of patients’ informal caregivers (i.e., patients’ family) in such a monitoring process is thus fundamental. However, to date, no standardized tailored-made instruments exist that informal caregivers can use without the presence of clinicians, despite evidence illustrating the good accuracy of caregivers when expressing their opinions about the level of responsiveness of DoC patients. The present work aims to set the foundational knowledge, to create a standardized instrument that is able to assess the level of responsiveness of patients with DoCs by their informal caregivers. After selecting and modifying the items to be included in the new scale from the gold standard to diagnose DoCs (i.e., the Coma Recovery Scale-revised), and following a consensus process, we created the Social and Family Evaluation (SAFE) scale for caregivers of patients with DoCs. Although the SAFE needs a validation process, with the present work we provided its preliminary description along with insights into its clinical utility.

COVID-19 and hospital restrictions: physical disconnection and digital re-connection in disorders of consciousness

Purpose: The coronavirus disease 2019 (COVID-19) pandemic forced hospitals to adopt tighter restrictions, the most impacting is no access to visitors. Disorder of consciousness (DOC) due to severe acquired brain injury is a condition needing neurorehabilitation and the role of relatives is essential, hence besides physical "disconnection" digital "re-connection" is crucial. We aimed to assess whether digital communication benefits in patients with DOC, considering the sensorial and emotional deprivation due to the COVID-19 emergency lock-down.Methods: For eleven consecutive patients with DOC admitted to our Intensive Neurorehabilitation Care (mean age: 45; females: 9), two observers registered neurobehavioral changes during a video-calls with their relatives. Heart-rate variability was measured before and during the calls. The video-call was performed by using two displays of different sizes: tablet (T-video-call) and large screen (LS-Video-call).Results: The video-calls impacted on the patients' vigilance and in the relationship with relatives. Moreover, positively impacted on their relatives. The current results showed significant greater impact on patients during the LS-video-call than when they are exposed to T-video-call.Conclusions: During the COVID-19 pandemic, besides the physical disconnection to stop the contagion spread, a "digital re-connection" is needed for all and especially for fragile population groups as patients with DOC.

Preservation of Language Processing and Auditory Performance in Patients With Disorders of Consciousness: A Multimodal Assessment

The impact of language impairment on the clinical assessment of patients suffering from disorders of consciousness (DOC) is unknown or underestimated and may mask the presence of conscious behavior. In a group of DOC patients (n = 11; time post-injury range: 5–252 months), we investigated the main neural functional and structural underpinnings of linguistic processing, and their relationship with the behavioral measures of the auditory function using the Coma Recovery Scale-Revised (CRS-R). We assessed the integrity of the brainstem auditory pathways, of the left superior temporal gyrus and arcuate fasciculus, the neural activity elicited by passive listening of an auditory language task, and the mean hemispheric glucose metabolism. Our results support the hypothesis of a relationship between the level of preservation of the investigated structures/functions and the CRS-R auditory subscale scores. Moreover, our findings indicate that patients in minimally conscious state minus (MCS−): (1) when presenting the auditory startle (at the CRS-R auditory subscale) might be aphasic in the receptive domain, being severely impaired in the core language structures/functions; (2) when presenting the localization to sound might retain language processing, being almost intact or intact in the core language structures/functions. Despite the small group of investigated patients, our findings provide a grounding of the clinical measures of the CRS-R auditory subscale in the integrity of the underlying auditory structures/functions. Future studies are needed to confirm our results that might have important consequences for the clinical practice.

Assessing emergence from a prolonged disorder of consciousness: Current opinion and practice in the UK

BACKGROUND

A patient in PDOC must demonstrate functional object use or functional communication to confirm they have emerged from this state. A range of tasks and stimuli are used and patients must achieve 100% accuracy. As consciousness occurs along a continuum, determining emergence is not straightforward.

OBJECTIVE

To establish the opinions of expert clinicians on how emergence is determined in practice.

METHODS

An online survey was completed by clinicians working in specialist rehabilitation settings across the UK. Questions were asked about diagnosis and confidence, informal assessment, formal assessment, and family involvement. Descriptive statistics were used to analyse responses to closed questions. Responses to open questions were analysed using thematic analysis.

RESULTS

Seventy-five surveys were analysed. Approximately a third (30.4 %) used tasks other than those recommended to determine emergence. A lack of confidence in tasks to detect the return of functional communication was reported by 46.4%. The majority (78.6%) reported they worked with patients who they felt had emerged, but could not demonstrate it based on the current criteria. A range of stimuli were employed, but 30.6% of respondents were not confident they could choose stimuli appropriately. Respondents reported a range of benefits and challenges when involving family in assessment.

European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness

BACKGROUND AND PURPOSE

Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG).

METHODS

Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN.

RESULTS

Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside.

CONCLUSIONS

Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.

Coma Recovery Scale-Revised With and Without the Emotional Stimulation of Caregivers

The Coma Recovery Scale-Revised (CRS-R) is the gold standard of responsiveness assessment in patients with disorder of consciousness. The purpose of this study is to search for the efficacy of the caregivers’ involvement in the evaluation of responsiveness in these patients. Responsiveness assessment was performed in 15 patients with CRS-R. The CRS-R was administered with and without the emotional stimulation of the primary caregiver at different times. Our preliminary findings seem to suggest that, including also the caregivers during CRS-R assessment, may obtain better responsiveness scoring than that obtained by professionals and might reduce the misdiagnosis rate.

Conscious While Being Considered in an Unresponsive Wakefulness Syndrome for 20 Years

Despite recent advances in our understanding of consciousness disorders, accurate diagnosis of severely brain-damaged patients is still a major clinical challenge. We here present the case of a patient who was considered in an unresponsive wakefulness syndrome/vegetative state for 20 years. Repeated standardized behavioral examinations combined to neuroimaging assessments allowed us to show that this patient was in fact fully conscious and was able to functionally communicate. We thus revised the diagnosis into an incomplete locked-in syndrome, notably because the main brain lesion was located in the brainstem. Clinical examinations of severe brain injured patients suffering from serious motor impairment should systematically include repeated standardized behavioral assessments and, when possible, neuroimaging evaluations encompassing magnetic resonance imaging and ¹⁸F-fluorodeoxyglucose positron emission tomography.

Are visual functions diagnostic signs of the minimally conscious state? an integrative review

Visual pursuit (VP) and visual fixation (VF) have been recognized as the first signs of emerging consciousness and, therefore, are considered indicative of the minimally conscious state (MCS). However, debate exists about their status as they are considered either conscious reactions or reflexes. The aim of this study is to review the evidence of the definition, operationalization, and assessment of VP and VF in unconscious patients. PubMed and EMBASE were searched for relevant papers between May 26, 1994 and October 1, 2016. In addition, an internet search was done to identify other relevant papers, reports and manuals of assessment methods. Papers were included if the definition, operationalization, or assessment method of VP and VF was discussed in patients with disorders of consciousness. We identified 2364 articles, of which 38 were included. No uniform definitions of VP and VF were found. VP and VF were operationalized differently, depending on which scale was used. The Coma Recovery Scale-revised and the Sensory Tool to Assess Responsiveness were the only diagnostic scales found; the other scales were developed to monitor DOC patients. The use of a mirror was the most sensitive method for detecting VP and VF. The literature about the importance VP and VF in relation with consciousness is controversial. This integrative review shows a lack of consensus regarding the definition, operationalization, and assessment of VP and VF. International consensus development about the definition, operationalization, and assessment of VP and VF is recommended.

SMART - Recognising the value of existing practice and introducing recent developments: leaving no stone unturned in the assessment and treatment of the PDOC patient

Over the last 25 years there have been a number of papers highlighting the issues of high rates of misdiagnosis in prolonged disorders of consciousness (PDOC) (Andrews, K., Murphy, L., Munday, R., & Littlewood, C. (1996). Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit. BMJ, 313(7048), 13-16; Childs, N. L., Mercer, W. N., & Childs, H. W. (1993). Accuracy of diagnosis of persistent vegetative state. Neurology, 43(8), 1465-1467). Surprisingly, these rates still remain at the same level despite defined criteria for diagnosis (Schnakers, C., Vanhaudenhuyse, A., Giacino, J., Ventura, M., Boly, M., Majerus, S.,…Laureys, S. (2009). Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology, 9(35), 1-5; Van Erp, W., Larvrijsen, J., Vos, P., Bor, H., Laureys, S., & Koopmans, R. (2015). The vegetative state: Prevalence, misdiagnosis and treatment limitations. JAMDA, 85, e9-85.e14. doi: 10.1016/j.jamda.2014.10.014 ). This indicates the continued need for careful standardised assessment by skilled assessors to identify all potential meaningful responses and to establish a correct and incontrovertible diagnosis. The Sensory Modality Assessment and Rehabilitation Technique (SMART) is one of three assessments identified for the assessment of PDOC in the Royal College of Physician guidelines (Royal College of Physicians, 2013). The RCP guidelines and recent publications have highlighted and substantiated the value of some of the existing practices and unique features of the SMART. In recognition of the need to keep SMART current, SMART Version 3 is being developed and will be launched shortly. The interim SMART developments will be introduced in this paper and applied to practice through the illustration of a case study. Evidence suggests that SMART is a current and invaluable tool for the clinical and medico-legal assessment and treatment of the PDOC patient.

A comparative study on assessment procedures and metric properties of two scoring systems of the Coma Recovery Scale-Revised items: standard and modified scores

Objective:

The study compared the metric characteristics (discriminant capacity and factorial structure) of two different methods for scoring the items of the Coma Recovery Scale-Revised and it analysed scale scores collected using the standard assessment procedure and a new proposed method.

Design:

Cross sectional design/methodological study.

Setting:

Inpatient, neurological unit.

Participants:

A total of 153 patients with disorders of consciousness were consecutively enrolled between 2011 and 2013.

Intervention:

All patients were assessed with the Coma Recovery Scale-Revised using standard (rater 1) and inverted (rater 2) procedures.

Main outcome measures:

Coma Recovery Scale-Revised score, number of cognitive and reflex behaviours and diagnosis.

Results:

Regarding patient assessment, rater 1 using standard and rater 2 using inverted procedures obtained the same best scores for each subscale of the Coma Recovery Scale-Revised for all patients, so no clinical (and statistical) difference was found between the two procedures. In 11 patients (7.7%), rater 2 noted that some Coma Recovery Scale-Revised codified behavioural responses were not found during assessment, although higher response categories were present. A total of 51 (36%) patients presented the same Coma Recovery Scale-Revised scores of 7 or 8 using a standard score, whereas no overlap was found using the modified score. Unidimensionality was confirmed for both score systems.

Conclusion:

The Coma Recovery Scale Modified Score showed a higher discriminant capacity than the standard score and a monofactorial structure was also supported. The inverted assessment procedure could be a useful evaluation method for the assessment of patients with disorder of consciousness diagnosis.

Caregivers of patients with disorder of consciousness: burden, quality of life and social support

OBJECTIVE

To evaluate quality of life (QoL) and its predictors, psychological burden and level of perceived social support in caregivers of patients with disorder of consciousness.

MATERIALS & METHODS

World Health Organization Quality of Life-Bref (WHOQOL-BREF), State Trait Anxiety Inventory-Y (STAI-Y), Beck Depression Inventory (BDI-II), Prolonged Grief Disorder Questionnaire, Coping Orientations to Problem Experiences, State-Trait Anger Expression Inventory-2 (STAXI-2), and the Medical Outcome Study Social Support Survey (MOS-SSS) were administered. One-sample t-tests were performed to compare WHOQOL-BREF, STAI-Y and STAXI-2 mean scores to the respective normative sample (NS). Pearson correlation was calculated between time dedicated to patient's care, WHOQOL-BREF, BDI-II, STAI-Y and MOS-SSS scores. Hierarchical multiple regression analyses were performed to evaluate which variables have predictive power on QoL.

RESULTS

A total of 129 caregivers, 68.2% female, mean age 52.8 years, were enrolled. Three WHOQOL-BREF domains were significantly lower. Anxiety and anger were in line with NS. 28.7% of the sample reported high level of depressive symptoms; 20.9% satisfied the prolonged grief disorder criteria. No differences emerged between caregivers and chronic ill patients' scores at MOS-SSS. STAI-Y, BDI-II and WHOQOL-BREF scores positively correlated. MOS-SSS domains inversely correlate with BDI-II scores. BDI-II results the most relevant predictor of QoL.

CONCLUSIONS

Study results provided innovative information about caregivers' poor QoL, difficulties in social support and high levels of burden. Time dedicated to care is not strictly related to burden, while social support perceived is highly associated with caregivers' depressive symptoms that are strong predictor of poor QoL. Supportive intervention able to integrate psychological, social and environmental levels is needed.

Is Period3 Genotype Associated With Sleep and Recovery in Patients With Disorders of Consciousness?

Background Sleep evaluation is increasingly being used as prognostic tool in patients with disorders of consciousness, but, surprisingly, the role of Period3 (Per3) gene polymorphism has never been evaluated. Objective The aim of this study was to investigate the contribution of Per3 genotype on sleep quantity and consciousness recovery level in patients with disorders of consciousness (DOC). Methods In this observational study, we evaluated 71 patients with DOC classified as vegetative state/unresponsive wakefulness syndrome or minimally conscious state. Demographic and clinical data were collected and a standardised diagnostic workup, including a polysomnographic record, was applied. After informed consent provided by proxy, genomic DNA was obtained and Per3 polymorphism was analysed by polymerase chain reaction to identify 5/5, 4/5, or 4/4 genotype. Results Per3(5/5) genotype was found in 12.7% of our DOC patients. The median total Coma Recovery Scale-revised score in Per3(5/5) carriers was significantly higher than 4/4 genotype (10, range 5-16 vs 7, range 4-11; post hoc P = .036). Moreover, total sleep time seemed to be higher in 5/5 genotype (5/5, 221 minutes, range 88-515 minutes; 4/4, 151.5 minutes, range 36-477 minutes; and 4/5, 188 minutes, range 44-422 minutes). Conclusion For the first time we have shown a possible association between Per3 polymorphism and consciousness recovery level in DOC patients. Even though the exact molecular mechanism has not been defined, we speculate that its effect is mediated by higher total sleep time and slow wave sleep, which would improve the preservation of main cerebral connections.