Thanks to years of watching their favorite TV characters miraculously wake up from a coma with no discernible aftereffects, people might have a skewed perception of what “altered states of mind” really means. There are actually several states of altered consciousness, each one a point on a spectrum of decreased cognitive and motor function caused by traumatic injury, physical causes such as a stroke or tumor, metabolic causes, slow degenerative processes or neurodegenerative disorders.
“There’s not a lot of agreement on what consciousness is,” said Dr. Chris Zacko, assistant professor of neurosurgery and co-director of Penn State Milton S. Hershey Medical Center’s neurotrauma and neurocritical care department. “Some of the terms are starting to blend together and there’s evolving thought that they are all sort of along a spectrum of what might be wrong.”
In general, a state of altered consciousness is diagnosed using simple criteria: alertness, awareness and attention span; eyes open or closed; and the presence or absence of motor function, Zacko said.
The word “coma” comes from the Greek word “koma,” for deep sleep. “To get someone in a coma, you either need dysfunction of both hemispheres or a dysfunction of the brain stem itself,” Zacko said. For a patient to be diagnosed as comatose, his or her eyes must remain closed and there are no periods of arousal. The patient is unable to respond to stimulants, such as noise or pain, and they have no response to commands.
Stupor, Obtunded, Lethargic, Delirious
These are nonspecific terms that describe short-term states of altered consciousness. They can be quickly reversible, or they can be early symptoms of a more serious problem, which could lead to coma, Zacko said.
- A lethargic state indicates the patient has problems staying awake and alert, though they can usually stay awake with verbal stimuli.
- A stupor implies the patient needs a physical nudge to get them to stay awake and be aroused.
- When a patient is obtunded, he or she is not aroused with shaking or yelling and they may be starting to enter a coma.
- Delirium is a severe confusional state in which the patient is unaware of their environment.
Often when the underlying cause of the state is treated, the patient’s mental state begins to show improvement, usually within a few days to a week.
Minimally conscious state
In a minimally conscious state the patient’s eyes are open and he or she occasionally shows awareness. The patient does retain some cognitive ability and may be able to track objects with their eyes and respond to commands. “Every now and again you can say ‘wiggle your thumb,’ and they’ll wiggle their thumb, but they don’t do it consistently,” Zacko said. Another technique used to determine functional communication skills is a series of questions. Patients are asked to correctly answer six simple questions — usually with yes or no responses.
Vegetative state/Persistent vegetative state
A vegetative state means that the patient’s eyes are open but the patient is not aware. “People in vegetative state and minimally conscious state have sleep-wake cycles. People in coma do not,” Zacko said. Doctors do not have a set time in which a vegetative state becomes a persistent vegetative state. According to Jane Brody’s book “Guide to the Great Beyond,” “When a person remains in a vegetative state for more than a month, the condition is described as persistent.” However, some doctors do not diagnose until one year.
Locked-in syndrome is not a disorder of consciousness. “Your cognition is fully preserved in a locked-in state. You have an intact patient with intact brain, but no motor function at all,” Zacko said. Eye movement is usually the only way locked-in syndrome is diagnosed. “Often times people can move their eyes up and down, but not left and right. If you find damage in this area, you have to think locked-in syndrome,” he said. With this state, damage occurs to a specific spot in the brain.
“There is one area in the brain stem that everything passes through. All of those signals still get made in the brain, but they don’t get passed through the spinal cord,” he said.
Locked-in syndrome was made famous by the book “The Diving Bell and the Butterfly” by Jean-Dominique Bauby, former journalist and editor in chief of Elle magazine, who suffered a stroke that left him physically paralyzed. He wrote the book, about his daily experiences as a locked-in syndrome patient, through a translator with whom he communicated by blinking his eye.
Brain death is a complete lack of electrical activity and is synonymous with physical death, according to Brody’s book. “It is now the universally accepted definition of death used, for example, in determining when it is appropriate to disconnect a patient from life support and retrieve organs for transplantation.” Doctors diagnose this state with two confirmatory apnea tests performed six hours apart, during which the ventilator is turned off for 10 minutes. If no breathing occurs during this 10 minutes, the patient is considered brain dead. “People will have a heart rate, they will have a blood pressure, but they will be dead,” Zacko said.
Treatment and Recovery
There are no hard and fast rules when it comes to the treatment and recovery of patients in altered states of consciousness. Much is dependent on the severity of the injury, the duration of the altered state and the patient’s age. “The cutoff for how people do after head injury is age 40. Your chances of doing well are decreased statistically,” Zacko said. He also said, “the longer you’re in the state, the more likely you’re going to stay there.”
Treatment for altered states of consciousness takes many forms. “Once we’ve reversed the problem that caused (the trauma) or treated it the best that we can, we’re more aggressive with our treatment,” Zacko said. Cocktails of medications are used to target neurotransmitter function in the brain. Some drugs used include Ritalin, most commonly used to treat symptoms of attention deficit hyperactivity disorder; Amantadine, a Parkinson’s disease drug; and NUVIGIL, a treatment for narcolepsy.
Dr. Nicholas Schiff, director of the Laboratory of Cognitive Neuromodulation at Weill Cornell Medical Center, addressed recent treatment findings in a 2010 lecture at Stony Brook University. He highlighted a case where a man in a minimally conscious state was given Ambien as a sleep aide and instead became dramatically more alert. The patient is now treated with three doses of Ambien a day to improve his alertness.
Another area of study is deep brain stimulation, when an electrode is placed in the portion of the brain that is out of balance. Rather than shocking the brain, “it is sort of overriding the circuitry,” Zacko explained. Some studies have seen limited success with brain stimulation. Hershey Medical Center plans to perform a study with minimally conscious patients, he said.
Patients are also treated with supportive care including proper nutrition, health monitoring and diagnostic testing.
“People always ask ‘What can we expect for the recovery?’ There is no typical recovery,” Zacko said. He notes that some people who wake up need to relearn everything while others have remarkably intact memory and cognition. But one consistency is that recovery will always include some element of retraining, including physical and speech therapy.
SOURCES: Dr. Chris Zacko, assistant professor of neurosurgery and co-director of Penn State Milton S. Hershey Medical Center’s neurotrauma and neurocritical care department; Dr. Nicholas Schiff’s 2010 lecture “Understanding the Recovery of Consciousness,” available on YouTube and recommended by Zacko; Jane Brody’s book “Guide to the Great Beyond: A practical primer to help you and your loved ones prepare medically, legally and emotionally for the end of life”; www.traumaticbraininjury.com