Minimally Conscious State
Minimally Conscious State
The minimally conscious state is a defined as severely altered consciousness in which minimal but definite, sustained and/or reproducible behavioral evidence of awareness of self or environment is demonstrated.
The person may have periods where they can communicate or respond to commands, such as moving a finger when asked.
A person may enter a minimally conscious state after being in a coma or vegetative state. In some cases a minimally conscious state is a stage on the route to recovery, but in others it's permanent.
A continuing minimally conscious state means it has lasted longer than four weeks. However, it's more difficult to diagnose a permanent minimally conscious state because it depends on things such as:
- the type of brain injury
- how severe the injury is
- how responsive the person is
In most cases, a minimally conscious state isn't usually considered to be permanent until it's lasted several years.
To make the diagnosis of MCS, limited but clearly discernible evidence of self or of environmental awareness must be demonstrated on a reproducible or sustained basis by one or more of the following behaviors:
- Follow simple commands (eg touch your nose, look up).
- Gestural or verbal yes/no responses (regardless of accuracy).
- Intelligible verbalization.
- Purposeful behavior that is not due to reflexive activity. Eg appropriate smiling or crying in response to emotional but not to neutral topics or stimuli – reaching for objects demonstrating a clear relationship between object location and direction of reach – touching or holding objects appropriately in relation to the size and shape of the object – pursuit eye movement or sustained fixation that occurs in direct response to moving or salient stimuli.
Treatment can't ensure recovery from a state of impaired consciousness, however supportive treatment is used to give the best chance of natural improvement. This can involve:
- providing nutrition through a feeding tube
- making sure the person is moved regularly so they don't develop pressure ulcers
- gently exercising their joints to prevent them becoming tight
- keeping their skin clean
- managing their bowel and bladder – for example, using a catheter to drain the bladder
- keeping their teeth and mouth clean
- efforts should be made to establish functional communication and environmental interaction when possible. Offering opportunities for periods of meaningful activity – such as listening to music or watching television, being shown pictures or hearing family members talking
- visual – showing photos of friends and family, or a favourite film
- hearing – talking or playing a favourite song
- smell – putting flowers in the room or spraying a favourite perfume
- touch – holding their hand or stroking their skin with different fabrics
In all circumstances, the patient should be treated with dignity, and caregivers should be cognisant of the patient’s potential for understanding and perception of pain. In early MCS, prevention of complications and maintenance of bodily integrity should be emphasised because of the likelihood of further improvement. While not empirically validated, families have reported benefits from arousal regimes, such as those implemented by Dr Ted Freeman (eg Coma Arousal Therapy). The therapy involves family members taking the coma patient through a regimen of controlled auditory, visual and physical stimulation for up to six hours a day every day.
A person with experience in neurologic assessment of patients with impaired consciousness should be primarily responsible for establishing the diagnosis and prognosis and for coordinating clinical management. An additional opinion of a physician or other professional with particular expertise in the evaluation, diagnosis, and prognosis of patients in MCS is recommended when the assessment will impact critical management decisions.
Prognosis (outlook for recovery)
To date, the natural history and long-term outcome of MCS has not been adequately investigated. MCS may occur in a variety of neurologic conditions, such as traumatic brain injury, stroke, progressive degenerative disorders, tumours, neurometabolic diseases, and congenital or developmental disorders. Following an acute injury, MCS can be a transitional or permanent state. Although it is not known how many patients will emerge from MCS twelve months or more after injury, most patients in MCS for this length of time remain severely disabled. The likelihood of significant functional improvement for MCS patients diminishes over time.
Further Information and Support
For information about Coma Arousal Therapy, which has been found to be beneficial in patients in Minimally Conscious State, see Dr Edward (Ted) Freeman (1987) The Catastrophe of Coma. Publisher: David Bateman
Coma Science Group
Brain Injury Australia
National Institute of Neurological Disorders and Stroke
Brain Injury Resource Center
Reviewed February 2017 by:Shannan Keen, MBMSc, Brain and Mind Research Institute, University of Sydney