Many Faces of the Hidden Souls: Medical and Neurological Complications and Comorbidities in Disorders of Consciousness

Abstract

Early and goal-directed management of complications and comorbidities is imperative to facilitate neurorecovery and to optimize outcomes of disorders of consciousness (DoC). This is the first large retrospective cohort study on the primary medical and neurological complications and comorbidities in persons with DoC. A total of 146 patients admitted to a specialized inpatient DoC rehabilitation program from 1 January 2014 to 31 October 2018 were included. The incidences of those conditions since their initial brain injuries were reviewed per documentation. They were categorized into reversible causes of DoC, confounders and mimics, and other medical/neurological conditions. The common complications and comorbidities included pneumonia (73.3%), pain (75.3%), pressure ulcers (70.5%), oral and limb apraxia (67.1%), urinary tract infection (69.2%), and 4-limb spasticity (52.7%). Reversible causes of DoC occurred very commonly. Conditions that may confound the diagnosis of DoC occurred at surprisingly high rates. Conditions that may be a source of pain occurred not infrequently. Among those that may diminish or confound the level of consciousness, 4.8 ± 2.0 conditions were identified per patient. In conclusion, high rates of various complications and comorbidities occurred in persons with DoC. Correcting reversible causes, identifying confounders and mimics, and managing general consequences need to be seriously considered in clinical practice.

Frequency and Characteristics of Medical Complications in Rehabilitation Settings: A Scoping Review

“…The most commonly reported complications were infections, and non-infectious neurological alterations. Infectious complications were identified in 26 studies, with UTIs, pneumonia and cellulitis reported as the most common ( 17 , 26 – 28 , 31 , 34 – 36 , 38 , 41 , 46 – 48 , 51 – 53 , 55 , 57 – 59 , 61 , 64 , 66 – 69 ). Six studies noted infection to have occurred in over half of the study population ( 26 , 51 , 53 , 55 , 59 , 68 ).…”

“…Six studies noted infection to have occurred in over half of the study population ( 26 , 51 , 53 , 55 , 59 , 68 ). Neurological alterations were reported in 20 studies, with a variety of complications reported, including alterations in cognition, challenging behaviours, hydrocephalus, stroke progression, epilepsy, seizure and seizure-like activity ( 17 , 26 , 28 , 29 , 31 , 34 – 36 , 43 , 46 , 47 , 51 , 52 , 57 , 59 , 61 , 64 , 67 – 69 ).…”

“…Studies were conducted across a variety of international healthcare settings, including North America (n = 22) (17, 27, 31, 33, 36-38, 40, 42, 44-46, 50, 51, 54, 59, 60, 62-66), Europe (n = 9) (26,29,34,35,43,49,52,55,69), Asia (n = 11) (28, 41, 47, 48, 53, 56-58, 61, 67, 68) and Oceania (n = 5) (2,25,30,32,39). Study cohorts included general rehabilitation (2,25,44,47,51,56,60,65) and rehabilitation following: cerebrovascular accident (CVA) (17,26,28,30,35,36,38,52,57,58,61,67,68), acquired brain injury (32,34,43,49,54,64,66), spinal cord injury (37,41,48,…”

Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from disorders of consciousness

“…The admission criteria and screening process have previously been described in detail ( 17 ). In brief, pre-admission screening was performed to determine the appropriateness of admission to the specialized DoC program (i.e., to triage potential misdiagnosis of DoC).…”

“…While the field has seen major advancements in the detection of consciousness and in standardization of assessments ( 2 , 15 ), we hope to contribute by providing guidance for effective clinical rehabilitation and advocating for increased rehabilitative access for these patients. Recently, we summarized and proposed clinical approaches in the assessment of reversible causes, confounders, and mimics of DoC ( 17 ), spasticity management ( 18 ), and the application of GABAergic medication trials ( 19 ). It is notable that meaningful improvements can be observed out of the scope of commonly used scales, such as achievement of decannulation and initiation of oral diet, thereby facilitating remaining voluntary motor control, etc.…”