A minimally conscious state (MCS) should not be confused with a waking coma, although the two conditions are very similar. Affected individuals appear temporarily awake because their eyes are open and movements as well as facial expression are present. A minimal state of consciousness can be temporary as well as permanent.
What is a minimally conscious state?
A minimally conscious state (MCS)-also referred to as a minimal conscious state-is a twilight state that is very similar to that of persistent vegetative state. Unlike the waking coma, however, those affected occasionally respond to external stimuli, such as touch, sound, or light effects. The minimally conscious state is controlled by the autonomic nervous system, which functions independently of the cerebrum, so a sleep-wake rhythm is still present. A minimally conscious state can develop from a coma or even a waking coma. It can be temporary, but after about 12 months, the likelihood that the person will reawaken from the minimally conscious state decreases and it becomes a permanent state.
Causes
There are several causes of a minimally conscious state. In an MCS, there is a disturbance in cerebral function. This is often triggered as a result of disease or injury. The following diseases or disorders in the brain can lead to a minimally conscious state: Apoplexy (stroke), traumatic brain injury, epilepsy, meningitis, encephalitis, tumors, cerebral hemorrhage. However, metabolic diseases such as diabetes mellitus, liver dysfunction, thyroid disease and kidney disease can also be a trigger for the minimal state of consciousness. In addition to cardiovascular disease, alcohol and drug abuse can also trigger a minimally conscious state. An MCS does not occur immediately. If the above causes take a severe course and patients fall into a coma, a minimally conscious state may develop from this.
Symptoms, complaints, and signs
Physicians bear a heavy responsibility in correctly differentiating between the syndrome of unresponsive wakefulness (SRW or waking coma) and the state of minimal consciousness (MCS). Misdiagnosis often occurs, and the rate of misdiagnosis is extremely high at approximately 37 to 43 percent. In classic waking coma, there is no evidence of the patient’s ability to make contact, although periods of wakefulness with open eyes are present. In minimally conscious state (MCS), patients exhibit behaviors that suggest conscious awareness of the environment. Whereas in the syndrome of unresponsive wakefulness, sufferers show no reactions to external stimuli, individuals with MCS sometimes respond to touch, sound, or visual impressions. Among other things, they may move their hand, foot, or other body part when prompted. Some affected individuals may follow a moving object via eye contact or perform certain agreed-upon gestures in response to questions that require a yes or no answer. MCS is always preceded by a waking coma. It is a transitional state between coma and full consciousness. The patient may remain in this state for years or even forever. However, this state may also prove to be the initial state for a full recovery. The margin of error in making the correct distinction is so high because there are also patients with MCS who can experience the environment consciously but, for various reasons, lack the ability to show responses.
Diagnosis and course
The minimally conscious state is diagnosed by neurologists. Diagnosis is extremely difficult because MCS and persistent vegetative state are confusingly similar. Imaging techniques are used to diagnose a minimally conscious state. In addition to a regular MRI and CT, a so-called functional magnetic resonance imaging (fMRI) is also used. Colloquially, the fMRI is also referred to as a brain scanner. With the help of this examination method, brain activity in the various regions of the brain can be measured. The outcome in a minimally conscious state is not promising. The probability of affected persons waking up from MCS is higher than waking up from a waking coma. In the first weeks and months, the affected person is still most likely to wake up.However, if more than 12 months have passed since the onset of MCS, it becomes increasingly unlikely that the affected person will awaken. The minimal state of consciousness becomes a permanent state. If an affected person awakens from the MCS, severe damage usually remains. The longer the MCS has lasted, the more pronounced the physical and psychological disabilities will be. A minimal state of consciousness may last for many years before the affected person eventually dies.
Complications
The minimally conscious state has a very negative impact on the sufferer’s quality of life and can lead to very severe psychological distress or depression. In this case, the affected person is in a waking coma and can no longer eat or drink on their own. As a rule, they are always dependent on the help of other people. Furthermore, the eyes are also open, so that the patients always notice events from the outside world, but cannot actively participate. Speaking is also usually not possible. Furthermore, the patient also suffers from incontinence. Not infrequently, the parents, children or relatives of the affected person are also significantly affected by the minimal state of consciousness and suffer from severe psychological restrictions and depressive moods. It cannot generally be predicted whether the disease will progress positively or whether the affected person will spend his entire life in this state. Also a specific treatment of the minimal state of consciousness is usually not possible. Various therapies can be used to support the joints so that they do not stiffen. However, life expectancy itself is not reduced or affected by this condition in most cases.
When should you see a doctor?
With a minimal state of consciousness, many patients are already under medical care. They normally need help and support only in the event of a deterioration or sudden abnormalities in their state of health. If the patient notices an impairment of his state of consciousness in everyday life without a diagnosed illness, he should consult a doctor. If the condition persists for a longer period of time or if further reductions in consciousness occur, there is cause for concern. Since in some cases a serious illness is present, a visit to the doctor is advisable as soon as possible. If members of the social environment notice minimal consciousness, they are encouraged to seek help. Often, the ill person is not in the health condition to notice the existing irregularities. Signs are the open eyes of the affected person with simultaneous inability of social interaction appropriate to the situation. If communication with people in the immediate environment is not possible, a doctor should be called. Behavioral abnormalities such as apathy, drowsiness, or persistent mental absence must be presented to a physician. If incontinence of urine or stool occurs, a doctor should be consulted. If the affected person is unable to control his or her sphincter, medical assistance is needed. If daily life cannot be managed independently, a visit to the doctor is necessary.
Treatment and therapy
At the onset of a minimally conscious state, intensive medical care is provided. Thereafter, the affected person may be transferred to the hospital’s nursing wards or to special nursing facilities. Furthermore, it is also possible for relatives to provide care at home. In addition to general medical care and professional nursing, physiotherapeutic, ergotherapeutic and logopedic measures are particularly useful. With the help of physiotherapy, as well as occupational therapy, the various limbs are moved so that the joints do not stiffen. Furthermore, various stimuli are used to stimulate hearing as well as vision. There are special music therapies for this purpose and the so-called basal stimulation, in which sensory stimuli are used to try to cause a reaction in the affected person.
Outlook and prognosis
The prognosis regarding the overcoming of a minimally conscious state (MCS) depends on the cause and the particular patient. For example, it should first be noted that a younger age increases the chance of surviving brain injury and resulting alterations in state of consciousness.At the same time, the prognosis for non-traumatic brain injuries leading to MCS is worse than for traumatic brain injuries. Thus, conditions affecting all or large parts of the brain (infections, tumors, etc.) are worse for prognosis than, say, a violent injury resulting from an accident. In addition, patients in the minimally conscious state have a significantly better prognosis than those in the vegetative state. However, because the two states are not always properly distinguished, MCS patients are sometimes treated as patients in the vegetative stage. This leads to a worse prognosis because the treatment is usually purely palliative and does not work toward a possible improvement in the state of consciousness. In addition, as time passes, it becomes less likely that affected individuals will outgrow their condition. Most who do mature within the first three months, while this is considered extremely unlikely after twelve months. Permanent damage in the form of impaired brain function and associated problems remains in almost all people who have been in a minimally conscious state. Some impairments can be compensated for by appropriate therapies.
Prevention
A minimally conscious state cannot be prevented. Only general prophylactic measures can be taken, in terms of accident prevention at home, at work, and in road traffic. Furthermore, a healthy diet and sufficient physical exercise are good measures for a healthy and long life. In order to prevent illnesses or to detect them in time, it makes sense to regularly participate in preventive and health examinations. If you really fall ill, you will have a good starting point to defeat the disease, so that no minimal consciousness state (MCS) can develop from it.
Follow-up
Aftercare plays an exceedingly important role in sufferers of minimal consciousness syndrome. For example, patients continue to require care after discharge from the hospital, depending on the extent of their activity limitations. This is equally true when independence is regained. Rehabilitation aftercare takes place on an outpatient basis and extends over a longer period of time, the duration of which cannot always be determined. Since patients are no longer able to live alone, it is recommended that they be placed in a shared apartment where out-of-hospital intensive care is provided. However, 24-hour care is also possible in a familiar environment. In mild cases, assisted living can also be implemented. Some affected persons are even able to work in a special workshop for disabled people. Severely ill patients, on the other hand, require permanent care in a day care center or a practice for outpatient neurorehabilitation. Numerous patients are able to recover from apallic syndrome even after years in their familiar environment. Consultations are available through long-term care insurance companies. For example, they have the task of providing individual advice to those affected on care within their own homes. Special care support points are also available in numerous regions. An important component of aftercare is early rehabilitation. It continues the acute treatment from the hospital and includes therapeutic nursing, physiotherapeutic measures, speech and swallowing therapy, occupational therapy and neuropsychological treatments. The aim is to improve the patient’s state of consciousness. Whether complete recovery is possible depends on the individual.
What you can do yourself
Patients who are in a minimally conscious state can do little for themselves or to improve their situation. As a result, relatives or nursing staff have the primary responsibility to optimize the patient’s environment. In particular, hygiene and sleeping conditions are important to avoid triggering additional discomfort. The patient’s body must be moved regularly and thoroughly cleaned. Since the patient is not able to do this himself, helping hands should take over these tasks. The sleeping place should also be cleaned and equipped with clean sleeping utensils. It is important to minimize the risk for the development of bacteria or other pathogens, as the patient’s health condition makes him very susceptible to further illnesses. The supply of fresh air should not be forgotten.This has a beneficial effect on the patient’s airway. Several studies suggest that the proximity and voice of relatives can have a positive influence on the course of the disease. It is therefore advisable to talk to the patient or read him stories, even if he is unable to respond. At the same time, relatives should pay attention to their own well-being. To strengthen their mental power in dealing with the disease, psychotherapies or even relaxation procedures help.
