Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings?
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Differential diagnosis between Vegetative State and Minimally Conscious State is a challenging task that requires specific assessment scales, involvement of expert neuropsychologists or physicians and use of tailored stimuli for eliciting behavioural responses. Although misdiagnosis rate as high as 40 % has been reported, no clear guidelines are available in literature on the optimal setting for assessment. The present study aims to analyse score differences in behavioural assessments of persons with disorders of consciousness (DOC) with or without family members and to determine whether the presence of caregivers could improve clinical accuracy in diagnostic evaluation. The research was conducted on 92 adults with DOC among 153 consecutive patients enrolled in the Coma Research Centre of the Neurological Institute C. Besta of Milan between January 2011 and May 2013. The results indicate that in almost half of the sample the scoring, thus the performance, observed with caregivers was better than without them. Furthermore, in 16 % of the sample, when assessment was performed with caregivers there was a change in diagnosis, from Vegetative to Minimally Conscious State or from that to Severe Disability. Finally, statistical differences were found in relation to diagnosis between mean scores in the “visual function” Coma Recovery Scale revised’s subscale obtained by raters plus caregiver and rates only assessment. This study demonstrates how the presence of caregivers can positively affect behavioural assessments of persons with DOC, thus contributing to the definition of the optimal setting for behavioural evaluation of patients, to decrease misdiagnosis rates.
KeywordsConsciousness disorders Caregivers Outcome and process assessment Diagnostic techniques and procedures Diagnostic errors Persistent vegetative state
The present paper was submitted on behalf of the Coma Research Centre (CRC) multidisciplinary team. The authors would like to acknowledge the contributions of the following other members: A. Andronache, R. Benti, D. Caldiroli, P. Fazio, S. Franceschetti, G. Marotta, F. Molteni, M. Pagani, F. Panzica, B. Reggiori, C. Rosazza, G. Varotto, J. Vela Gomez, and E. Visani. The study was conducted in collaboration with the European Biomedical Research Federation (FERB).
The authors are grateful to all the caregivers who participated in the study and to Anna Moiana for her help with language editing.
Conflicts of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest. The project CRC, “Coma Research Centre” was supported by Grant No. IX/000407—05/08/2010 awarded by Regione Lombardia.
The study was approved by the Ethics Committee of C. Besta Neurological Institute in Milan, Italy, and was performed in accordance with the Declaration of Helsinki.
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