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Overbeek BUH, van Erp WS, Eilander HJ, Koopmans RTCM, Lavrijsen JCM. Prevalence of the Minimally Conscious State Among Institutionalized Patients in the Netherlands: A Nationwide Study. Neurology 2023; 101:e2005-e2013. [PMID: 37857492 PMCID: PMC10662977 DOI: 10.1212/wnl.0000000000207820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/03/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The minimally conscious state (MCS) is a prolonged disorder of consciousness (pDoC) and one of the most severe outcomes of acquired brain injury. Prevalence data are scarce. The aim of this study was to establish the nationwide point prevalence of institutionalized patients in MCS in the Netherlands. METHODS This was a descriptive cross-sectional study in which all 86 Dutch hospitals, all 5 specialized pDoC rehabilitation facilities, and all 274 nursing homes were asked whether they were treating patients with a pDoC on the point prevalence date of September 15, 2021. Each patient's legal representative provided informed consent for their inclusion. Patient level of consciousness was verified using the Coma Recovery Scale-Revised (CRS-R) in a single assessment session performed in the facility of residence by an experienced physician. Data on patient demographics, etiology, level of consciousness, facility of residence, and clinical status were collected from a questionnaire by the treating physician. The prevalence of institutionalized patients in MCS of per 100,000 members of the Dutch population was calculated, based on actual census data. RESULTS Seventy patients were reported to have a pDoC, of whom 6 were excluded. The level of consciousness was verified for 49 patients while for 15, it could not be verified. Of the patients verified, 38 had a pDoC, of whom 32 were in MCS (mean age 44.8 years, 68.8% male). The prevalence of institutionalized patients in MCS is 0.2-0.3 per 100,000 Dutch inhabitants. Traumatic brain injury was present in 21 of 32 patients (65.6%). Specialized pDoC rehabilitation was received by 17 of 32 patients (53%), with the rest admitted to nursing homes. The most frequent signs of consciousness on the CRS-R were visual pursuit, reproducible movement to command, and automatic motor response. DISCUSSION This nationwide study revealed a low prevalence of institutionalized patients in MCS in the Netherlands. These findings are now being used to organize pDoC care in this country.
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Affiliation(s)
- Berno U H Overbeek
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands.
| | - Willemijn S van Erp
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Henk J Eilander
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Raymond T C M Koopmans
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Jan C M Lavrijsen
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
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Nekrasova JY, Kanarsky MM, Borisov IV, Pradhan P, Yankevich DS, Roshka SF, Petrova MV, Grechko AV. Post-Discharge Plight Of Patients With Chronic Disorders Of Consciousness: A Systematic Review Of Socioeconomic And Health Aspects. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective — the presented study aims to systematize and structure significant information regarding the problems of patients with disorders of consciousness (DOC) and their families after discharge from the hospital, and to search for possible solutions. Material and Methods — to identify eligible studies, we searched the Medline database (via PubMed) for studies on socioeconomic and medical issues of patients with chronic DOC at the post-hospital stage of rehabilitation for the last 20 years. Results — we included 28 studies with 21 cohorts of patients from 7 different countries in our study. The components of informal caregiver burden and their impact on the quality of life were identified and systematized. These components include high physical load, high economic costs, vast time expenditures, strong emotional involvement, and a top level of expertise in caregiving, all of which are required from the relatives. Conclusion — It was affirmed, that the lack of healthcare system support was a major contributing factor to the overall burden. Our research also showed that delivering care without receiving information, advice, and training is extremely painful for family caregivers.
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Affiliation(s)
- Julia Yu. Nekrasova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Mikhail M. Kanarsky
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Ilya V. Borisov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Pranil Pradhan
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Dmitry S. Yankevich
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Stanislav F. Roshka
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Marina V. Petrova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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Boegle K, Bassi M, Comanducci A, Kuehlmeyer K, Oehl P, Raiser T, Rosenfelder M, Sitt JD, Valota C, Willacker L, Bender A, Grill E. Informal Caregivers of Patients with Disorders of Consciousness: a Qualitative Study of Communication Experiences and Information Needs with Physicians. NEUROETHICS-NETH 2022; 15:24. [PMID: 35912377 PMCID: PMC9307713 DOI: 10.1007/s12152-022-09503-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/11/2022] [Indexed: 10/27/2022]
Abstract
AbstractDue to improvements in medicine, the figures of patients with disorders of consciousness (DoC) are increasing. Diagnostics of DoC and prognostication of rehabilitation outcome is challenging but necessary to evaluate recovery potential and to decide on treatment options. Such decisions should be made by doctors and patients’ surrogates based on medico-ethical principles. Meeting information needs and communicating effectively with caregivers as the patients´ most common surrogate-decision makers is crucial, and challenging when novel tech-nologies are introduced. This qualitative study aims to explore information needs of informal DoC caregivers, how they manage the obtained information and their perceptions and experiences with caregiver-physician communication in facilities that implemented innovative neurodiagnostics studies. In 2021, we conducted semi-structured interviews with nine caregivers of clinically stable DoC patients in two rehabilitation centers in Italy and Germany. Participants were selected based on consecutive purposeful sampling. Caregivers were recruited at the facilities after written informed consent. All interviews were recorded, transcribed verbatim and translated. For analysis, we used reflexive thematic analysis according to Braun & Clarke (2006). Caregivers experienced the conversations emotionally, generally based on the value of the information provided. They reported to seek positive information, comfort and empathy with-in the communication of results of examinations. They needed detailed information to gain a deep understanding and a clear picture of their loved-one’s condition. The results suggest a mismatch between the perspectives of caregivers and the perspectives of medical profession-als, and stress the need for more elaborate approaches to the communication of results of neu-rodiagnostics studies.
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Spataro R, La Bella V. The role of ethical attitudes on mortality of patients with disorders of consciousness. Eur J Neurol 2022; 29:3473-3474. [DOI: 10.1111/ene.15510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 06/18/2022] [Accepted: 07/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rossella Spataro
- IRCCS Centro Neurolesi Bonino Pulejo Palermo Italy
- ALS Clinical Research Center University of Palermo Palermo Italy
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Kohnen RF, Lavrijsen J, Akkermans R, Gerritsen D, Koopmans R. The prevalence and determinants of inappropriate sexual behaviour in people with acquired brain injury in nursing homes. J Adv Nurs 2021; 77:3058-3072. [PMID: 33634494 PMCID: PMC8248184 DOI: 10.1111/jan.14817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/18/2021] [Accepted: 02/05/2021] [Indexed: 11/29/2022]
Abstract
AIMS Establishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes. DESIGN Cross-sectional, observational study in acquired brain injury special care units spreads throughout the country. METHODS Nursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory-Nursing Home Version and the Cohen-Mansfield Agitation Inventory, cognition with the Mini-Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019. RESULTS Of the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non-contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour. CONCLUSION Inappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes. IMPACT Inappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs.
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Affiliation(s)
- Roy F. Kohnen
- Vivent, Rosmalen and LivioEnschedethe Netherlands
- Department of Primary and Community CareRadboud University Medical CenterRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Jan Lavrijsen
- Department of Primary and Community CareRadboud University Medical CenterRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Reinier Akkermans
- Radboud University Medical CenterRadboud Institute for Health SciencesScientific Institute for Quality of CareNijmegenthe Netherlands
| | - Debby Gerritsen
- Department of Primary and Community CareRadboud University Medical CenterRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Raymond Koopmans
- Department of Primary and Community CareRadboud University Medical CenterDe Waalboog“Joachim and Anna”Centre for Specialized Geriatric CareNijmegenthe Netherlands
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Sharma-Virk M, van Erp WS, Lavrijsen JCM, Koopmans RTCM. Intensive neurorehabilitation for patients with prolonged disorders of consciousness: protocol of a mixed-methods study focusing on outcomes, ethics and impact. BMC Neurol 2021; 21:133. [PMID: 33752631 PMCID: PMC7983203 DOI: 10.1186/s12883-021-02158-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals. METHODS Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups. DISCUSSION To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.
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Affiliation(s)
- Manju Sharma-Virk
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands. .,PZC Dordrecht, Dordrecht, The Netherlands.
| | - Willemijn S van Erp
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.,Accolade Zorg, Bosch en Duin, The Netherlands.,Libra Revalidatie & Audiologie, Tilburg, The Netherlands
| | - Jan C M Lavrijsen
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.,Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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7
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Chadasch C, Kotchoubey B. Life satisfaction in families with a child in an Unresponsive Wakefulness Syndrome. BMC Pediatr 2021; 21:116. [PMID: 33685445 PMCID: PMC7938537 DOI: 10.1186/s12887-021-02549-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background The article examines life conditions in families living together with a child in an Unresponsive Wakefulness Syndrome (UWS). Such families experience severe stress at financial, logistical, and existential level. Methods We investigated a large sample of families living with a UWS child (comprising 13% of the total population) and compared these families with families without a chronically ill child. A set of four questionnaires aimed to evaluate life conditions entails a total of 204 items. One of the questionnaires was developed by the corresponding author specifically for this study. The questionnaires were positively accepted by the persons concerned and permitted us to test six specific hypotheses. Results Life satisfaction (LS) in families with a UWS child was significantly lower than in control families. LS was significantly affected by external situational factors (everyday support, home visits, support by a doctor, nursing service, health insurance, etc.). Self-management skills were on average lower in families with a UWS child than in controls. These skills strongly and directly correlated with LS. Further, LS was not significantly related to the acceptance of feelings and negatively correlated with the floods of emotions. The relationship with the own child was equally satisfactory in families with and without a UWS child indicating that the families regard their UWS child as a full family member. Conclusions The data show that happy life is possible in families living together with a UWS child. They further specify conditions for satisfactory life under multiple highly severe challenges. Personal self-management skills, coping strategies, and resilience, as well as outside social support, appear to be critical factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02549-8.
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Affiliation(s)
- Christiane Chadasch
- Management Psychology, Coping, Resilience & Ethics, Meiersheide 8a, 53773, Hennef, Germany.
| | - Boris Kotchoubey
- Institute of Medical Psychology and Behavioral Neurobiology, Eberhardt Karls University of Tübingen, Silcherstr. 5, 72076, Tübingen, Germany
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Driessen DMF, Utens CMA, Ribbers GM, van Erp WS, Heijenbrok-Kal MH. Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study. BMC Neurol 2021; 21:69. [PMID: 33579219 PMCID: PMC7879405 DOI: 10.1186/s12883-021-02099-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/05/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN. METHODS Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers' strain and cost-effectiveness of the programme. DISCUSSION The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families. TRIAL REGISTRATION Netherlands Trial Register, NL 8138 . Retrospectively registered 6 November 2019.
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Affiliation(s)
- Danielle M F Driessen
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands. .,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.
| | - Cecile M A Utens
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
| | - Willemijn S van Erp
- Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.,Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands.,Accolade Zorg, Zeist, the Netherlands
| | - Majanka H Heijenbrok-Kal
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
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EEG Assessment in a 2-Year-Old Child with Prolonged Disorders of Consciousness: 3 Years' Follow-up. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2020; 2020:8826238. [PMID: 33293944 PMCID: PMC7718066 DOI: 10.1155/2020/8826238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/21/2020] [Accepted: 10/31/2020] [Indexed: 11/25/2022]
Abstract
A 2-year-old girl, diagnosed with traumatic brain injury and epilepsy following car trauma, was followed up for 3 years (a total of 15 recordings taken at 0, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 14, 19, 26, and 35 months). There is still no clear guidance on the diagnosis, treatment, and prognosis of children with disorders of consciousness. At each appointment, recordings included the child's height, weight, pediatric Glasgow Coma Scale (pGCS), Coma Recovery Scale-Revised (CRS-R), Gesell Developmental Schedule, computed tomography or magnetic resonance imaging, electroencephalogram, frequency of seizures, oral antiepileptic drugs, stimulation with subject's own name (SON), and median nerve electrical stimulation (MNS). Growth and development were deemed appropriate for the age of the child. The pGCS and Gesell Developmental Schedule provided a comprehensive assessment of consciousness and mental development; the weighted Phase Lag Index (wPLI ) in the β-band (13–25 Hz) can distinguish unresponsive wakefulness syndrome from minimally conscious state and confirm that the SON and MNS were effective. The continuous increase of delta-band power indicates a poor prognosis. Interictal epileptiform discharges (IEDs) have a cumulative effect and seizures seriously affect the prognosis.
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Kohnen RF, Lavrijsen JCM, Akkermans RP, Gerritsen DL, Koopmans RTCM. The Prevalence and Determinants of Neuropsychiatric Symptoms in People With Acquired Brain Injury in Nursing Homes. J Am Med Dir Assoc 2020; 21:1643-1650. [PMID: 32859514 DOI: 10.1016/j.jamda.2020.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Establishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes. DESIGN Cross-sectional, observational study. SETTING AND PARTICIPANTS Patients 18-65 years old with ABI in special care units in Dutch nursing homes. METHODS Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models. RESULTS In a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score. CONCLUSIONS AND IMPLICATIONS NPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.
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Affiliation(s)
- Roy F Kohnen
- Vivent, Rosmalen and Livio, Enschede, the Netherlands; Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Scientific Institute for Quality of Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, De Waalboog, "Joachim and Anna", Centre for Specialized Geriatric Care, Radboud University Medical Center, Nijmegen, the Netherlands
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Kwiatkowska A, Lech M, Odya P, Czyżewski A. Post-comatose patients with minimal consciousness tend to preserve reading comprehension skills but neglect syntax and spelling. Sci Rep 2019; 9:19929. [PMID: 31882697 PMCID: PMC6934549 DOI: 10.1038/s41598-019-56443-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/09/2019] [Indexed: 11/08/2022] Open
Abstract
Modern eye tracking technology provides a means for communication with patients suffering from disorders of consciousness (DoC) or remaining in locked-in-state. However, being able to use an eye tracker for controlling text-based contents by such patients requires preserved reading ability in the first place. To our knowledge, this aspect, although of great social importance, so far has seemed to be neglected. In the paper, we presented the possibility of using an eye-tracking technology for assessing reading comprehension skills in post-comatose patients with minimal consciousness. We prepared various syllable-, word- and sentence-based tasks, controlled by gaze, used for assessing the reading comprehension skills. The obtained results showed that people with minimal consciousness preserved the reading comprehension skills, in most cases to a high extent, but had difficulties with recognizing errors in the written text. The ability to maintain attention during performing the tasks was in statistically significant correlation with motivation, and that one was in a statistically significant correlation with the reading ability. The results indicate that post-comatose patients with minimal consciousness can read words and sentences, hence some useful hints may be provided for the development of gaze tracking-based human-computer interfaces for these people.
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Affiliation(s)
- Agnieszka Kwiatkowska
- Department of Multimedia Systems, Faculty of Electronics, Telecommunication and Informatics, Gdansk University of Technology, Gdańsk, Poland
| | - Michał Lech
- Department of Multimedia Systems, Faculty of Electronics, Telecommunication and Informatics, Gdansk University of Technology, Gdańsk, Poland.
| | - Piotr Odya
- Department of Multimedia Systems, Faculty of Electronics, Telecommunication and Informatics, Gdansk University of Technology, Gdańsk, Poland
| | - Andrzej Czyżewski
- Department of Multimedia Systems, Faculty of Electronics, Telecommunication and Informatics, Gdansk University of Technology, Gdańsk, Poland
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12
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van Erp WS, Lavrijsen JCM, Vos PE, Laureys S, Koopmans RTCM. Unresponsive wakefulness syndrome: Outcomes from a vicious circle. Ann Neurol 2019; 87:12-18. [PMID: 31675139 PMCID: PMC6972677 DOI: 10.1002/ana.25624] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Willemijn S van Erp
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.,Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Pieter E Vos
- Department of Neurology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, and Joachim en Anna Center for Specialized Geriatric Care, Nijmegen, the Netherlands
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13
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Kohnen R, Lavrijsen J, Smals O, Gerritsen D, Koopmans R. Prevalence and characteristics of neuropsychiatric symptoms, quality of life and psychotropics in people with acquired brain injury in long-term care. J Adv Nurs 2019; 75:3715-3725. [PMID: 31318085 PMCID: PMC6900174 DOI: 10.1111/jan.14156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/28/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022]
Abstract
Aim Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes. Design Cross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes. Methods According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020. Discussion Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS. Impact Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.
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Affiliation(s)
- Roy Kohnen
- Vivent, Rosmalen and Livio, Enschede, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jan Lavrijsen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Odile Smals
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Vivent, Rosmalen, The Netherlands
| | - Debby Gerritsen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Raymond Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, De Waalboog, "Joachim and Anna", Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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14
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Kohnen RF, Gerritsen DL, Smals OM, Lavrijsen JCM, Koopmans RTCM. Prevalence of neuropsychiatric symptoms and psychotropic drug use in patients with acquired brain injury in long-term care: a systematic review. Brain Inj 2018; 32:1591-1600. [PMID: 30373405 DOI: 10.1080/02699052.2018.1538537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Little is known about the prevalence of neuropsychiatric symptoms (NPS) and psychotropic drug use (PDU) in patients below the age of 65 years with acquired brain injury (ABI) in long-term care. The objective of this study was to review the literature about the prevalence of NPS and PDU. METHODS A systematic literature search of English, Dutch and German articles in Pubmed, EMBASE, PsycINFO and CINAHL was performed with the use of MeSH and free-text terms. RESULTS Six articles met the inclusion criteria. The place of residence was mainly a nursing home and most studies were conducted in a population of patients with traumatic brain injury. Sample sizes varied from 40 to 26,472 residents and NPS were assessed with different assessment instruments. Depressive symptoms were most common with a prevalence ranging from 13.9% to 39.3%. Two studies reported PDU in which tranquillizers (59%) were the most prevalent psychotropic drugs followed by anticonvulsants (35%) and antidepressants (26-34%). CONCLUSIONS Patients with ABI experience lifelong consequences, regardless the cause of ABI, that have a high impact on them and their surroundings. More insight into the magnitude of NPS and PDU, through prevalence studies, is necessary to achieve suitable provision of care for these patients.
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Affiliation(s)
- Roy F Kohnen
- a Vivent , Mariaoord , Rosmalen , the Netherlands.,b Department of Primary and Community Care , Radboud University, Medical Centre , Nijmegen , the Netherlands
| | - Debby L Gerritsen
- b Department of Primary and Community Care , Radboud University, Medical Centre , Nijmegen , the Netherlands
| | - Odile M Smals
- a Vivent , Mariaoord , Rosmalen , the Netherlands.,b Department of Primary and Community Care , Radboud University, Medical Centre , Nijmegen , the Netherlands
| | - Jan C M Lavrijsen
- b Department of Primary and Community Care , Radboud University, Medical Centre , Nijmegen , the Netherlands
| | - Raymond T C M Koopmans
- b Department of Primary and Community Care , Radboud University, Medical Centre , Nijmegen , the Netherlands.,c De Waalboog , Centre for Specialized Geriatric Care"Joachim en Anna" , Nijmegen , the Netherlands
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15
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Wade DT. How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding? Clin Rehabil 2018; 32:1551-1564. [PMID: 29779405 DOI: 10.1177/0269215518777285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE: To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country. METHOD: Identification of studies on people with a PDOC giving information about incidence, and/or prevalence, and/or cause, and/or location of long-term care. Sources included systematic reviews, a new search of MEDLINE (April 2018), and a personal collection of papers. Validating information was sought from existing data on services. RESULTS: There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term care in nursing homes, but a significant proportion (10%-15%) may be cared for at home. CONCLUSION: Each year, about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time, there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater.
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Affiliation(s)
- Derick T Wade
- 1 OxINMAHR, and Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
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16
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Wang PY, Hung YN, Smith R, Lin CC. Changes in the Use of Intensive and Supportive Procedures for Patients With Stroke in Taiwan in the Last Month of Life Between 2000 and 2010. J Pain Symptom Manage 2018; 55:835-842. [PMID: 29191721 DOI: 10.1016/j.jpainsymman.2017.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 11/22/2022]
Abstract
CONTEXT Stroke is the second leading cause of death and the primary cause of disability worldwide. It is uncertain what care patients with stroke receive in their end of life and what trends in care are in recent years. OBJECTIVES The objective of this study was to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010. METHODS Analysis of claims data of 55,930 patients with stroke obtained from the National Health Insurance Research Database was performed to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010. RESULTS Over the whole study period, 25.4% of patients with stroke were admitted to intensive care units in their last month of life. The percentages of patients receiving mechanical ventilation (77.4%-67.9%), cardiopulmonary resuscitation (53.8%-35.8%), and inotropic agents (73.5%-64.3%) decreased over time. The percentages of patients receiving artificial hydration and nutrition (65.9%-73.3%) and sedative or analgesic agents (34.7%-38.6%) increased over time. Patients under 85 years old were more likely to be admitted to intensive care units. Men were more likely to receive mechanical ventilation and cardiopulmonary resuscitation than women. CONCLUSION Over time, the use of supportive procedures increased, and the use of intensive procedures decreased in patients with stroke in the last month of life. This study highlights a need for research, guidelines, and training in how to provide palliative care for end-stage patients with stroke.
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Affiliation(s)
- Pei-Yi Wang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Surgical Intensive Care Unit, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Robert Smith
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong; Alice Ho Miu Ling Nethersole Charity Foundation, Hong Kong.
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17
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Span-Sluyter CAMFH, Lavrijsen JCM, van Leeuwen E, Koopmans RTCM. Moral dilemmas and conflicts concerning patients in a vegetative state/unresponsive wakefulness syndrome: shared or non-shared decision making? A qualitative study of the professional perspective in two moral case deliberations. BMC Med Ethics 2018; 19:10. [PMID: 29471814 PMCID: PMC5824545 DOI: 10.1186/s12910-018-0247-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts in long-term care of patients in VS/UWS. Methods A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Results Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Conclusions Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making.
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Affiliation(s)
- Conny A M F H Span-Sluyter
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands. .,Novicare, Professionals in Elderly Care, Best, the Netherlands.
| | - Jan C M Lavrijsen
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands
| | | | - Raymond T C M Koopmans
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands.,Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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18
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Morrissey AM, Gill-Thwaites H, Wilson B, Leonard R, McLellan L, Pundole A, Shiel A. The role of the SMART and WHIM in behavioural assessment of disorders of consciousness: clinical utility and scope for a symbiotic relationship. Neuropsychol Rehabil 2017; 28:1254-1265. [PMID: 28762872 DOI: 10.1080/09602011.2017.1354769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As the prevalence and incidence of disorders of consciousness (DoC) increase, researchers and clinicians are tasked with developing best practice assessment techniques. Neurobehavioural assessment remains the most clinically available method of measuring consciousness. Neuroimaging and other physiological measurements are demonstrating promise in supporting this assessment but many of these techniques require further research and are not widely available in sub-acute and long-term care settings. No study to date has explored in-depth complementary use of multiple neurobehavioural assessments in aiding beside assessment of consciousness. This paper describes and proposes complementary use of two commonly used standardised neurobehavioural assessments. The Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Wessex Head Injury Matrix (WHIM) both have specific aims and play an important role in behavioural assessment across the care continuum. This paper proposes that when used together appropriately these two assessments promote best practice and strengthen behavioural assessment of consciousness by providing increased opportunities to capture awareness. Further research into use of more than one neurobehavioural tool is highlighted as an important area of inquiry for this heterogeneous population not only in clinical practice but also in research.
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Affiliation(s)
- Ann-Marie Morrissey
- a Discipline of Occupational Therapy , Trinity College Dublin, The University of Dublin , Dublin, Ireland.,b College of Medicine, Nursing and Health Sciences , National University of Ireland Galway , Galway , Ireland
| | | | - Barbara Wilson
- d Department of Neuropsychology, Raphael Medical Centre , Tonbridge , Kent , UK.,e Department of Neuropsychology, Oliver Zangwill Centre , Ely , Cambridgeshire , UK
| | - Rachel Leonard
- f Department of Speech and Language Therapy , Mayo General Hospital , Castlebar, Mayo , Ireland
| | - Lindsay McLellan
- g Rehabilitation Research Unit , University of Southampton , Southampton , UK
| | - Amy Pundole
- c Royal Hospital for Neuro-Disability Putney , London , UK
| | - Agnes Shiel
- b College of Medicine, Nursing and Health Sciences , National University of Ireland Galway , Galway , Ireland
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19
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Sattin D, Morganti L, De Torres L, Dolce G, Arcuri F, Estraneo A, Cardinale V, Piperno R, Zavatta E, Formisano R, D'Ippolito M, Vassallo C, Dessi B, Lamberti G, Antoniono E, Lanzillotti C, Navarro J, Bramanti P, Corallo F, Zampolini M, Scarponi F, Avesani R, Salvi L, Ferro S, Mazza L, Fogar P, Feller S, De Nigris F, Martinuzzi A, Buffoni M, Pessina A, Corsico P, Leonardi M. Care pathways models and clinical outcomes in Disorders of consciousness. Brain Behav 2017; 7:e00740. [PMID: 28828206 PMCID: PMC5561306 DOI: 10.1002/brb3.740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 04/20/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Patients with Disorders of consciousness, are persons with extremely low functioning levels and represent a challenge for health care systems due to their high needs of facilitating environmental factors. Despite a common Italian health care pathway for these patients, no studies have analyzed information on how each region have implemented it in its welfare system correlating data with patients' clinical outcomes. MATERIALS AND METHODS A multicenter observational pilot study was realized. Clinicians collected data on the care pathways of patients with Disorder of consciousness by asking 90 patients' caregivers to complete an ad hoc questionnaire through a structured phone interview. Questionnaire consisted of three sections: sociodemographic data, description of the care pathway done by the patient, and caregiver evaluation of health services and information received. RESULTS Seventy-three patients were analyzed. Length of hospital stay was different across the health care models and it was associated with improvement in clinical diagnosis. In long-term care units, the diagnosis at admission and the number of caregivers available for each patient (median value = 3) showed an indirect relationship with worsening probability in clinical outcome. Caregivers reported that communication with professionals (42%) and the answer to the need of information were the most critical points in the acute phase, whereas presence of Non-Governmental Organizations (25%) and availability of psychologists for caregivers (21%) were often missing during long-term care. The 65% of caregivers reported they did not know the UN Convention on the Rights of Persons with Disabilities. CONCLUSION This study highlights relevant differences in analyzed models, despite a recommended national pathway of care. Future public health considerations and actions are needed to guarantee equity and standardization of the care process in all European countries.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit - Scientific Department Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Laura Morganti
- Neurology, Public Health, Disability Unit - Scientific Department Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Laura De Torres
- Neurology, Public Health, Disability Unit - Scientific Department Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Giuliano Dolce
- RAN (Research in Advanced Neurorehabilitation) - Istituto S. Anna Crotone Italy
| | - Francesco Arcuri
- RAN (Research in Advanced Neurorehabilitation) - Istituto S. Anna Crotone Italy
| | - Anna Estraneo
- Disorders of Consciousness Laboratory Salvatore Maugeri Foundation IRCCS Scientific Institute of Telese Terme Telese Terme Italy
| | - Viviana Cardinale
- Disorders of Consciousness Laboratory Salvatore Maugeri Foundation IRCCS Scientific Institute of Telese Terme Telese Terme Italy
| | - Roberto Piperno
- Neurorehabilitation Unit Emergency Department AUSL of Bologna Bologna Italy
| | - Elena Zavatta
- Centro Studi per la Ricerca sul Coma - "Gli Amici di Luca" ONLUSCasa dei Risvegli Luca De Nigris Bologna Italy
| | | | - Mariagrazia D'Ippolito
- Unità Post-ComaI RCCS Fondazione Santa Lucia Roma Italy.,Dipartimento di Psicologia Università "La Sapienza" Roma Italy
| | - Claudio Vassallo
- Centro di Riabilitazione Ambulatoriale Associazione Rinascita Vita ONLUS Genova Italy
| | - Barbara Dessi
- Centro di Riabilitazione Ambulatoriale Associazione Rinascita Vita ONLUS Genova Italy
| | - Gianfranco Lamberti
- S.C. Neuroriabilitazione ASL CN1 Ospedale "SS. Trinità" - Fossano Fossano Italy
| | - Elena Antoniono
- S.C. Neuroriabilitazione ASL CN1 Ospedale "SS. Trinità" - Fossano Fossano Italy
| | - Crocifissa Lanzillotti
- Fondazione San Raffaele - Presidio Ospedaliero di Ceglie Messapica Ceglie Messapica Italy
| | - Jorge Navarro
- Fondazione San Raffaele - Presidio Ospedaliero di Ceglie Messapica Ceglie Messapica Italy
| | | | | | - Mauro Zampolini
- Neurorehabilitation Unit "S.Giovanni Battista" Hospital Foligno Italy
| | - Federico Scarponi
- Neurorehabilitation Unit "S.Giovanni Battista" Hospital Foligno Italy
| | - Renato Avesani
- Dipartimento di Riabilitazione Ospedale Sacro Cuore Don Calabria Verona Italy
| | - Luca Salvi
- Dipartimento di Riabilitazione Ospedale Sacro Cuore Don Calabria Verona Italy
| | - Salvatore Ferro
- Emilia Romagna Region Direzione Generale Cura della Persona, Salute e Welfare Bologna Italy
| | - Luigi Mazza
- Emilia Romagna Region Servizio Integrazione Sociosanitaria e politiche per la Non Autosufficienza Bologna Italy
| | - Paolo Fogar
- Federazione Nazionale Associazioni Trauma cranico Carnago Italy
| | - Sandro Feller
- Federazione Nazionale Associazioni Trauma cranico Carnago Italy
| | | | | | - Mara Buffoni
- IRCCS Medea Conegliano Research Centre Conegliano Italy
| | - Adriano Pessina
- Bioethics University Centre Università Cattolica del Sacro Cuore Milan Italy
| | - Paolo Corsico
- Bioethics University Centre Università Cattolica del Sacro Cuore Milan Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit - Scientific Department Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
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20
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Eilander HJ, Wijnen VJM, Schouten EJ, Lavrijsen JCM. Ten-to-twelve years after specialized neurorehabilitation of young patients with severe disorders of consciousness: A follow-up study. Brain Inj 2016; 30:1302-1310. [PMID: 27589011 DOI: 10.3109/02699052.2016.1170881] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To explore the long-term outcome of young patients with disorders of consciousness who had received intensive neurorehabilitation. METHODS A cross-sectional cohort study, in which the survival, level of consciousness, functional independence, mobility, communication and living situation were determined by means of a structured questionnaire. The cohort consisted of 44 children and young adults, originally either in a prolonged Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS, n = 33) or a Minimally Conscious State (MCS, n = 11) who had received a specialized neurorehabilitation programme 10-12 years earlier. RESULTS Response rate was 72% (34/44). Eleven patients were deceased, 10 of whom were in VS/UWS or MCS at discharge from the programme. Of the remaining 23 patients, 19 were conscious. Twelve lived independently, of whom six required some household support. One conscious patient lived permanently in a long-term care facility. All other patients lived either independently or with their parents. None of the VS/UWS or MCS patients showed any functional recovery. CONCLUSION Two main long-term outcome scenarios can be recognized. Two-thirds of the participating patients who were conscious at programme discharge were able to live independently, whereas almost two-thirds of the participating patients who were in VS/UWS or MCS at discharge subsequently died.
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Affiliation(s)
- Henk J Eilander
- a Libra Rehabilitation Medicine and Audiology , Tilburg , The Netherlands.,b Radboud University Nijmegen Medical Centre , Department of Primary and Community Care , Nijmegen , The Netherlands
| | - Viona J M Wijnen
- a Libra Rehabilitation Medicine and Audiology , Tilburg , The Netherlands.,b Radboud University Nijmegen Medical Centre , Department of Primary and Community Care , Nijmegen , The Netherlands
| | - Evert J Schouten
- a Libra Rehabilitation Medicine and Audiology , Tilburg , The Netherlands
| | - Jan C M Lavrijsen
- b Radboud University Nijmegen Medical Centre , Department of Primary and Community Care , Nijmegen , The Netherlands
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21
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van Erp WS, Lavrijsen JCM, Vos PE, Bor H, Laureys S, Koopmans RTCM. The vegetative state: prevalence, misdiagnosis, and treatment limitations. J Am Med Dir Assoc 2016; 16:85.e9-85.e14. [PMID: 25528282 DOI: 10.1016/j.jamda.2014.10.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) open their eyes spontaneously, but show only reflexive behavior. Although VS/UWS is one of the worst possible outcomes of acquired brain injury, its prevalence is largely unknown. This study's objective was to map the total population of hospitalized and institutionalized patients in VS/UWS in the Netherlands: prevalence, clinical characteristics, and treatment limitations. METHODS Nationwide point prevalence study on patients in VS/UWS at least 1 month after acute brain injury in hospitals, rehabilitation centers, nursing homes, institutions for people with intellectual disability, and hospices; diagnosis verification by a researcher using the Coma Recovery Scale-revised (CRS-r); gathering of demographics, clinical characteristics, and treatment limitations. RESULTS We identified 33 patients in VS/UWS, 24 of whose diagnoses could be verified. Patients were on average 51 years old with a mean duration of VS/UWS of 5 years. The main etiology was hypoxia sustained during cardiac arrest and resuscitation. More than 50% of patients had not received rehabilitation services. Most were given life-sustaining treatment beyond internationally accepted prognostic boundaries regarding recovery of consciousness. Seventeen (39%) of 41 patients presumed to be in VS/UWS were found to be at least minimally conscious. CONCLUSIONS Results translate to a prevalence of 0.1 to 0.2 hospitalized and institutionalized VS/UWS patients per 100,000 members of the general population. This small figure may be related to the legal option to withhold or withdraw life-sustaining treatment, including artificial nutrition and hydration. On the other hand, this study shows that in certain cases, physicians continue life-prolonging treatment for up to 25 years. Patients have poor access to rehabilitation and are at substantial risk for misdiagnosis.
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Affiliation(s)
- Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium.
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pieter E Vos
- Department of Neurology, Singeland Ziekenhuis, Doetinchem, The Netherlands
| | - Hans Bor
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium; University Hospital of Liège, Liège, Belgium; Belgian Funds for Scientific Research, Belgium
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Waalboog Foundation, Joachim and Anna, Centre for Specialised Geriatric Care, Nijmegen, The Netherlands
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Prevalence Differences of Patients in Vegetative State in the Netherlands and Vienna, Austria. J Head Trauma Rehabil 2015; 30:E57-60. [DOI: 10.1097/htr.0000000000000058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Erp WS, Lavrijsen JCM, van de Laar FA, Vos PE, Laureys S, Koopmans RTCM. The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies. Eur J Neurol 2014; 21:1361-8. [PMID: 25039901 DOI: 10.1111/ene.12483] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 05/05/2014] [Indexed: 12/21/2022]
Abstract
One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.
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Affiliation(s)
- W S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Cyclotron Research Center & Neurology Department, Coma Science Group, University of Liège, Liège, Belgium
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de la Morena MJE, Cruzado JA. Caregivers of patients with disorders of consciousness: coping and prolonged grief. Acta Neurol Scand 2013; 127:413-8. [PMID: 23311319 DOI: 10.1111/ane.12061] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To study the relationship between coping strategies and prolonged grief disorder (PGD) in caregivers of patients with disorders of consciousness: vegetative state (VS) or minimally conscious state (MCS). MATERIALS AND METHODS Fifty-three caregivers of 43 patients with VS or MCS were assessed using PG-12 and Brief COPE-28. Mean differences for each coping strategy between caregivers of patients with/without PGD were compared using Bonferroni-adjusted t-tests, and the size effect was calculated (Cohen's d). RESULTS The frequency of PGD was very high (n = 32; 60.40%). The most common coping strategies were problem-focused: active coping (mean = 6.41; SD = 1.02), Instrumental support (mean = 6.41; SD = 1.06), Planning (mean = 6.32; SD = 1.01) and Acceptance (mean = 6.20; SD = 1.29). Acceptance predicted a lower presence of PGD (P = 0.001; Cohen's d = 1.02), while Denial (P = 0.003; Cohen's d = 0.98) and Self-blame (P = 0.004, Cohen's d = 0.91) increased the presence of PGD. CONCLUSIONS The caregivers of patients with VS or MCS show a high risk of PGD. Problem-focused coping strategies are the most used. Acceptance is highly protective of PGD, and Denial and Self-blame are associated with an increased presence of PGD. PGD in caregivers of patients in VS or MCS should be evaluated, Acceptance and problem-focused strategies should be promoted, and Denial and Self-blame should be diminished.
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Affiliation(s)
| | - J. A. Cruzado
- Facultad de Psicología; Universidad de Complutense de Madrid; Madrid; Spain
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Cruzado JA, Elvira de la Morena MJ. Coping and distress in caregivers of patients with disorders of consciousness. Brain Inj 2013; 27:793-8. [DOI: 10.3109/02699052.2013.793402] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kohnen RF, Lavrijsen JCM, Bor JHJ, Koopmans RTCM. The prevalence and characteristics of patients with classic locked-in syndrome in Dutch nursing homes. J Neurol 2013; 260:1527-34. [DOI: 10.1007/s00415-012-6821-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/20/2012] [Accepted: 12/22/2012] [Indexed: 10/27/2022]
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Donis J, Kräftner B. The prevalence of patients in a vegetative state and minimally conscious state in nursing homes in Austria. Brain Inj 2011; 25:1101-7. [DOI: 10.3109/02699052.2011.577047] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Laureys S, Celesia GG, Cohadon F, Lavrijsen J, León-Carrión J, Sannita WG, Sazbon L, Schmutzhard E, von Wild KR, Zeman A, Dolce G. Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Med 2010; 8:68. [PMID: 21040571 PMCID: PMC2987895 DOI: 10.1186/1741-7015-8-68] [Citation(s) in RCA: 688] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/01/2010] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Some patients awaken from coma (that is, open the eyes) but remain unresponsive (that is, only showing reflex movements without response to command). This syndrome has been coined vegetative state. We here present a new name for this challenging neurological condition: unresponsive wakefulness syndrome (abbreviated UWS). DISCUSSION Many clinicians feel uncomfortable when referring to patients as vegetative. Indeed, to most of the lay public and media vegetative state has a pejorative connotation and seems inappropriately to refer to these patients as being vegetable-like. Some political and religious groups have hence felt the need to emphasize these vulnerable patients' rights as human beings. Moreover, since its first description over 35 years ago, an increasing number of functional neuroimaging and cognitive evoked potential studies have shown that physicians should be cautious to make strong claims about awareness in some patients without behavioral responses to command. Given these concerns regarding the negative associations intrinsic to the term vegetative state as well as the diagnostic errors and their potential effect on the treatment and care for these patients (who sometimes never recover behavioral signs of consciousness but often recover to what was recently coined a minimally conscious state) we here propose to replace the name. CONCLUSION Since after 35 years the medical community has been unsuccessful in changing the pejorative image associated with the words vegetative state, we think it would be better to change the term itself. We here offer physicians the possibility to refer to this condition as unresponsive wakefulness syndrome or UWS. As this neutral descriptive term indicates, it refers to patients showing a number of clinical signs (hence syndrome) of unresponsiveness (that is, without response to commands) in the presence of wakefulness (that is, eye opening).
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Affiliation(s)
- Steven Laureys
- Dept of Neurology, Cyclotron Research Centre, University Hospital and University of Liège, Belgium.
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Patients in a permanent vegetative state or minimally conscious state in the Maine-et-Loire county of France: A cross-sectional, descriptive study. Ann Phys Rehabil Med 2010; 53:96-104. [DOI: 10.1016/j.rehab.2010.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 11/12/2009] [Indexed: 11/24/2022]
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Abstract
Although philosophers and cognitive neuroscientists have struggled to define human consciousness, physicians can identify and assess its two clinical dimensions: wakefulness and awareness. A comatose patient has neither wakefulness nor awareness; a patient in a vegetative state has wakefulness without awareness; and a minimally conscious patient has both, but awareness is impaired. Syndromes of unconsciousness have established diagnostic criteria, but they encompass a spectrum of severity of brain damage and have indistinct boundaries. Functional neuroimaging using PET and fMRI have provided a new and complementary way to assess consciousness. Several recent provocative studies suggest that fMRI in unresponsive patients may detect evidence of conscious awareness when a careful neurological examination cannot. If these findings are verified by future studies, functional neuroimaging technologies will alter clinical practices concerning the diagnosis, classification, and prognosis of unconscious patients, and will lead to a greater understanding of the biology of human consciousness.
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Affiliation(s)
- James L Bernat
- Neurology Section, Dartmouth Medical School, Hanover, New Hampshire 03756, USA.
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Lavrijsen J, van den Bosch H, Vegter J. Bone fractures in the long-term care of a patient in a vegetative state: A risk to conflicts. Brain Inj 2009; 21:993-6. [PMID: 17729051 DOI: 10.1080/02699050701528447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE This case report shows how recurrent bone fractures can increase the tension in the relationship between family and caregivers in the long-term care of a patient in a vegetative state (VS). The aim of this report is to prevent conflict situations elsewhere by informing the family in time about the risk of fractures in a situation of severe osteoporosis. RESULTS A second opinion and a density test of the bone contributed to the acceptance of the family of that risk in the daily nursing care, after all adjustments to prevent fractures and to adapt the environment were undertaken. CONCLUSIONS The registration of immobility and the risk of fractures in the problem list is recommended, particularly in the emotional context of the long-term care of a vegetative state. This should be part of the multidisciplinary care plan, in which regular evaluations and communication with family are essential.
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Affiliation(s)
- Jan Lavrijsen
- Nursing Home Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Beis JM, Seyer JL, Brugerolle B, Le Chapelain L, Thisse MO, Mainard D, Paysant J, André JM. Care protocol for persistent vegetative states (PVS) and minimally conscious state (MSC) in Lorraine: retrospective study over an 18-year period. Ann Phys Rehabil Med 2009; 52:374-81. [PMID: 19541559 DOI: 10.1016/j.rehab.2009.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 05/18/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine. MATERIAL AND METHOD Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies). RESULTS Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases. CONCLUSION The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.
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Affiliation(s)
- J-M Beis
- Centre de médecine physique et de réadaptation, institut régional de médecine physique et de réadaptation, Lay-Saint-Christophe, France.
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Eilander HJ, van de Wiel M, Wijers M, van Heugten CM, Buljevac D, Lavrijsen JCM, Hoenderdaal PL, de Letter-van der Heide L, Wijnen VJM, Scheirs JGM, de Kort PLM, Prevo AJH. The reliability and validity of the PALOC-s: a post-acute level of consciousness scale for assessment of young patients with prolonged disturbed consciousness after brain injury. Neuropsychol Rehabil 2009; 19:1-27. [PMID: 18609020 DOI: 10.1080/09602010701694822] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The objective of the study was the validation of the Post-Acute Level of Consciousness scale (PALOC-s) for use in assessing levels of consciousness of severe brain injured patients in a vegetative state or in a minimally conscious state. A cohort of 44 successively admitted patients (between 2 and 25 years of age), who were treated in an early intensive neurorehabilitation programme, were included in the study. Each patient was examined, using the Western Neuro Sensory Stimulation Profile (WNSSP) and the Disability Rating Scale (DRS), once every two weeks resulting in 327 examinations (all videotaped). To determine the reliability of the PALOC-s, six observers rated one videotape of each patient. One of the observers rated the same tapes a second time, 3-4 months later. Validity was determined by correlating 100 ratings of one observer with the scores on the WNSSP and the DRS. To determine the responsiveness of the PALOC-s, the size of change between the scores of the first and last examinations was calculated. The inter-observer correlations and agreement scores varied between .82 and .95. The intra-observer correlation and agreement scores varied between .94 and .96. Correlations with the WNSSP varied between .88 and .93, and with the DRS between .75 and .88. The responsiveness was significantly high (t=8.2), with a standardised effect size of 1.30. It is concluded that the PALOC-s is a reliable, valid, and responsive observation instrument provided it is administered after a structured assessment by an experienced and trained clinician. The PALOC-s is feasible for use in clinical management, as well as in outcome research.
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Affiliation(s)
- H J Eilander
- Rehabilitation Centre Leijpark, Division Research, Tilburg, The Netherlands.
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Abstract
BACKGROUND Very few studies have approached the issue of persistent vegetative state (PVS) within the elderly population. This study aims to assess the prevalence, determinants and prognosis of elderly patients with PVS admitted to a long-term geriatric facility. METHODS We conducted a cohort study in the setting of a Skilled Geriatric Nursing Department. All patients admitted during a 17-month period (N = 88) were included and tested for a diagnosis of PVS according to the Disability Rating Scale (DRS). RESULTS A clinical diagnosis of PVS was given to 15% of patients upon admission, whereas the DRS diagnosed 30.5% of patients as having PVS. During the study period, 12 out of 31 patients with PVS died, with a median survival of 127 days (range: 1-517 days). CONCLUSION Our study suggests that PVS is an advanced stage in the natural history of dementia in the elderly. The low proportion of patients with PVS recognized as having this disorder upon admission suggests a low awareness among hospital personnel. Further studies of the prevalence and determinants of PVS in the severely disabled elderly population are warranted.
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Affiliation(s)
- Efraim Jaul
- Skilled Geriatric Nursing Department, Herzog Hospital, Jerusalem, Israel.
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Latour JM. Caring for children in a persistent vegetative state: complex but manageable. Pediatr Crit Care Med 2007; 8:497-8. [PMID: 17873785 DOI: 10.1097/01.pcc.0000282166.84021.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.
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