The American Academy of Neurology (AAN) has released updated practice guidelines for managing prolonged disorders of consciousness (DoC) (≥28 days).
Joseph T. Giacino, the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School, and colleagues drafted the guidelines to update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).
The recommendations, published in the journal Neurology, were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.
- Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged disorders of consciousness (DoC).
- Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes.
- When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor.
- Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children.
- Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed.
- Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B).
- Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established.
- Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with the duration specified.
“If its recommendations are heeded, the Guideline will be viewed as a historic work that helped transform the care of patients with DoC and deepened society’s appreciation of the ethical mandate to work towards this laudable goal.” commented experts in an accompanying essay.
For further information follow the link: https://doi.org/10.1212/WNL.0000000000005926