New AAN Guidelines for the Management of Disorders of Consciousness

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The new guidelines place a substantial emphasis on the importance of introducing high-quality rehabilitation early in these patients.
The new guidelines place a substantial emphasis on the importance of introducing high-quality rehabilitation early in these patients.

In a new report published in Neurology by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living, and Rehabilitation Research provided updated guidelines on the treatment of patients with prolonged disorders of consciousness (DoC).1

Based on a systematic review, the committee recommends that clinicians identify and treat confounding conditions, optimize arousal, and routinely perform standardized evaluations for improvement of diagnostic accuracy for prolonged DoC. Patient care may benefit from a multidisciplinary approach to care, comprised of neurologists, neuropsychologists, physical therapists, and speech pathologists. Additionally, prognostication in adults with DoC is highlighted, with tools such as structural magnetic resonance imaging, single photon emission-computed tomography, and Coma Recovery Scale-Revised emphasized in the new guidelines. In addition, the new guidelines emphasize the importance of introducing high-quality rehabilitation early in these patients. However, these systems of care are not readily available in some circumstances and are also costly.

The committee also recommends changes to terminology, including modifying the term “permanent” vegetative state to now officially be referred to as “chronic” vegetative state. This change was primarily driven by the increased frequency of late improvements in these patients. Although “unaware wakefulness syndrome” is suggested to replace “vegetative state,” authors Joseph J. Fins, MD, MACP, and James L. Bernat, MD, suggest these terms are no different in “expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation.”2

In a separate systematic review update,3 the authors also discuss research that supports the use of amantadine for 4 weeks in hastening functional recovery, particularly in patients with minimally conscious state or vegetative state/unresponsive wakefulness syndrome caused by severe traumatic brain injury. “Faster recovery reduces the burden of disability, lessens health care costs, and minimizes psychosocial stressors in patients and caregivers,” the authors wrote.

Reference

  1. Giacino JT, Katz DI, Schiff ND, et al. Practice guideline update recommendations summary: disorders of consciousness: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018;91:450-460.
  2. Fins JJ, Bernat JL. Ethical, palliative, and policy considerations in disorders of consciousness. Neurology. 2018;91:471-475.
  3. Giacino JT, Katz DI, Schiff ND, et al. Comprehensive systematic review update summary: disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018;91:461-470.
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