This paper reviews the current state of bedside behavioral assessment in brain-damaged patients with impaired consciousness (coma, vegetative state, minimally conscious state). As misdiagnosis in this field is unfortunately very frequent, we first discuss a number of fundamental principles of clinical evaluation that should guide the assessment of consciousness in brain-damaged patients in order to avoid confusion between vegetative state and minimally conscious state. The role of standardized behavioral assessment tools is particularly stressed. The second part of this paper reviews existing behavioral assessment techniques of consciousness, showing that there are actually a large number of these scales. After a discussion of the most widely used scale, the Glasgow Coma Scale, we present several new promising tools that show higher sensitivity and reliability for detecting subtle signs of recovery of consciousness in the post-acute setting.
Many factors contribute to the alarmingly high rates of misdiagnosis in the Vegetative State (VS) patient. These include the differential diagnosis and definitions, inconsistencies in the assessors' knowledge, expertise and their approaches to the assessment of awareness. Variability in the patient's medical and physical management adds to this confusion, leading to the potential to misdiagnose an aware patient in Minimally Conscious State (MCS) as being in VS. Subsequently, this range of variables leads to inconsistencies in the assessment, clinical diagnosis and management of this patient group. This concept is clearly of great importance in terms of the patient's future management and life or death decisions when considering withdrawal of nutrition and hydration. Further exploration of the frequency and causes of misdiagnosis and a review of current guidelines will illustrate the potential loopholes in diagnosis and reveal possible solutions to this modern-day dilemma.
An analysis of data from 30 subjects diagnosed as being in vegetative state (VS) on admission to a specialized Brain Injury Unit was carried out. Rancho Level ratings given by the referring physician were compared with those of the units occupational therapists (OT). Scores were obtained from the Sensory Modality Assessment Technique (SMART) and the Western Neuro Sensory Stimulation Profile (WNSSP) on admission and at 2 monthly intervals and converted to Rancho Level ratings to allow comparison. The comparison of the assessments within one week of admission showed agreement between Rancho Level scores derived from the WNSSP and those from the referring physicians. The Rancho scores derived from the SMART were significantly different from the physicians' and the WNSSP (P < 0.01), with the SMART rating the patient at a higher level of cognitive functioning. Although all 30 subjects were diagnosed as VS on admission, the SMART assessed six subjects not to be in VS within 2 to 4 months from admission and this was established at least 6 weeks earlier than the comparable conclusion from the WNSSP in four subjects. This initial validation study shows that the SMART is a useful tool in discriminating awareness and more sensitive at detecting the higher cognitive functions than both the WNSPP and referring physician, thus indicating the need to conduct a specifically designed prospective study to validate and further evaluate the SMART.
The assessment of the vegetative and minimally responsive patient requires a comprehensive programme of assessment and intervention. The Sensory Modality Assessment and Rehabilitation Technique (SMART) is a unique protocol that requires the SMART assessor, the team, and the family and friends of the patient to work as a collaborative team to observe response to sensory and environmental stimulation.This paper identifies the two formal and two informal components of the SMART protocol. The formal assessment programme is conducted by the SMART assessor and includes the structured assessment of the patient's behaviour and observation of response to a sensory stimulatio n programme. The informal component relies on the team, friends, and relatives to make observations of the patient's response to day-to-day activities and environmental stimulation. The features of existing assessment tools will be discussed to allow comparison to the SMART, and research-based practice is described. This paper proposes the SMART protocol as an effective and unique tool for accurate assessment and diagnosis of the vegetative state and minimally responsive patient.
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