OK... Sam had already posted essentially the same as I just did.... This is getting a little scary. But sorry for the repetition.
Dana On Wed, 26 Jan 2005 13:03:41 -0800, Sam <[EMAIL PROTECTED]> wrote: > You left out the most important part: > > http://pmj.bmjjournals.com/cgi/content/full/75/884/321 > > Difficulty in diagnosis > The International Working Party on Vegetative State13 recognised that > deciding the cognitive awareness of this type of patient, especially > when at a very low level, was an educated guess since there are, as > yet, no tests which can confirm whether the patient has any `inner > awareness'. They pointed out that the assessments in general use are > based on a series of behavioural patterns. The clinician is, > therefore, dependent on overt responses which depend on: > > the physical ability of the patient to respond > the desire or willingness (if the patient is aware) of the patient to respond > the abilities of the observer to make rapport with the patient > the ability to observe accurately > the time available for observation and assessment > the lack of available and reliable assessment tools. > > It is essential to understand that the diagnosis is based on the > presentation of clinical features since it is basically a behavioural > model. There are three prime features of the vegetative state. The > first is that the patient has sleep-awake patterns; this > differentiates the condition from coma. This is a feature which can be > easily detected by the lay person. There is the theoretical > possibility that a patient with bilateral third nerve palsy could be > aware but have no eye opening. I have only come across one case (in > America) where this has been shown to have happened. The second > feature is that all responses can be identified as reflex patterns. > This requires considerable neurological knowledge of reflex patterns. > The third element, the other side of the coin to reflex patterns, is > that the patient makes no meaningful responses and has no awareness. > This is much more difficult since the only way anyone can demonstrate > their awareness is through a motor function, ie, speech, facial > expression, or physical gesture. In the presence of severe spasticity, > muscle inactivity and dysphasia it is extremely difficult for even an > aware person to demonstrate their awareness. > > This difficulty has been seen in several studies. Childs et al20 > report that 37% of patients admitted more than one month post injury > with a diagnosis of coma or persistent vegetative state had some level > of awareness. In a group of longer term patients in a nursing home, > Tresch et al21 found that 18% of those diagnosed as being in the > persistent vegetative state were aware of themselves or their > environment. > > The study by Andrews et al15 highlights some of the major problems in > making a diagnosis of the vegetative state. They reviewed the records > of 40 consecutive patients admitted to their specialist profound brain > injury unit at least 6 months following their brain injury (a period > after which spontaneous recovery is generally regards as limited) with > a referral diagnosis of vegetative state. They found that whilst 25% > remained vegetative, 33% emerged during the rehabilitation programme, > and 43% had been misdiagnosed (41% of these for more than a year > including three for more than 5 years). The level of cognitive > functioning present in this misdiagnosed group at the time of > discharge was considerable: 60% were orientated in time, place and > person, 75% were able to recall a name after 15 minutes delay, 69% > were able to carry out simple mental arithmetic, 75% were able to > generate words to communicate their needs and 86% were able to make > choices about their daily social activities. > > The predominant features which seem to have lead to misdiagnosis were > that all the patients were profoundly physically disabled and 60% were > blind or severely visually impaired. Since clinicians use visual > tracking as an important sign that the patient is emerging from the > vegetative state, and this sign was usually absent because of the > damage to the visual tracts, the patients were mistakenly assumed to > be vegetative. > > There are several prerequisites for the accurate assessment of the > person thought to be in the vegetative state: > > The patient should be healthy. Even simple conditions such as > constipation, chronic urinary tract infection (usually associated with > long term catheterisation) or chest infections can prevent optimal > responses from being obtained. > The patient should be in a good nutritional state. Until recently as > many as 80% patients admitted to our specialist unit were suffering > from undernutrition. The earlier use of gastrostomy feeding has > altered this pattern but still about 30% of patients admitted have a > low Body Mass Index, emphasising the difficulty in managing people > with complex medical and physical disabilities. > As many sedating drugs as possible should be withdrawn, or at least > decreased to the lowest effective dose; this includes antispasticity > and anti-epileptic drugs. In the case of anti-epileptic drugs which > are still required to control fitting, drugs with the least sedative > effect should be used. > Complications and consequences of neurological imbalance should be > prevented; this includes high muscle tone and contractures by the > provision of special seating, good bed and sitting posture to control > abnormal muscle tone. These complications in the long term increase > the amount of nursing care required which, since the patient may live > for many years, increases the cost of care considerably. > Controlled posture is important. Most doctors have been trained to > examine patients on the bed. Experience suggests that patients are > more likely to be alert when sitting up (presumably due to greater > stimulation of the reticular activating system). A well supporting > seating system is essential to reduce sufficient muscle tone to allow > movement of limbs which can be used for communication purposes, eg, to > press a touch-sensitive switch. > Providing a controlled environment of sensory regulation to avoid > sensory overload of the severely damaged brain. Since it is likely > that profoundly brain-damaged patients have a problems with selective > attention, sensory input should be simple and interspersed with > periods of rest. It is, therefore, logical to assess for cognitive > responses after a period of rest rather than after a period of > activity, such as being washed and dressed, or after a period of > physiotherapy. This requires staff and family to understand the > importance of avoiding overstimulation prior to the assessment. > Assessments should be short (to avoid tiring the patient), repeated > (to identify windows of opportunity) and carried out over a period of > time (to accommodate the learning process of both the patient and the > assessor). A short, one-off, assessment of the patient who is lying in > bed is likely to result in a missed diagnosis, even by very experience > clinicians. > The ability to generate a behavioural response fluctuates from day to > day and hour to hour, and even minute to minute, depending on fatigue > factors, general health of the patient and the underlying neurological > condition. > Observation needs to take into account delayed responses. Assimilation > of even basic information is often slow and therefore response time > may be delayed. Because of this, information provided at any one time > should be simple, consistent, repeated after a period of rest and > allow for a delayed response. > Communication requires skilled techniques and a sensitivity for the > method by which the patient wants to communicate. > Families and other carers have a very important role in identifying > the best responses and the optimal conditions for assessment. Whilst > there are some relatives who interpret reflex responses as being > meaningful, there is no doubt that members of the family are often > more sensitive to early changes than even experienced clinical staff. > > ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~| Discover CFTicket - The leading ColdFusion Help Desk and Trouble Ticket application http://www.houseoffusion.com/banners/view.cfm?bannerid=48 Message: http://www.houseoffusion.com/lists.cfm/link=i:5:144778 Archives: http://www.houseoffusion.com/cf_lists/threads.cfm/5 Subscription: http://www.houseoffusion.com/lists.cfm/link=s:5 Unsubscribe: http://www.houseoffusion.com/cf_lists/unsubscribe.cfm?user=11502.10531.5 Donations & Support: http://www.houseoffusion.com/tiny.cfm/54
