Early Signs Of Improvement

Patients who had poor functionality before their illness may improve but typically never beyond their baseline levels. And for some their functioning may become much worse. For the most part, comatose patients who awaken quickly generally do well. Outcomes are often worse among individuals who remain comatose for longer periods. Outcomes may include limited resilience, cognitive deficits and lack of physical reserves. Given the mixed picture and many variables, physicians often are forced to consider what defines quality of life and whether to recommend aggressive treatment. For sure, recovery in patients who are comatose often is K shaped. At a certain point the paths of the individuals diverge, like the arms of the letter K, with some on a relentlessly downward trajectory and others going up and improving daily. In individuals with histories of poor health, recovery may occur, but these individuals may have much less functionality over the long term. However, over time, comatose patients often provide indications that they are improving or when things are likely to turn around, as shown in the shaded boxes below. For example, a patient who exhibited only reflex movements, such as stiffening up or bending at the elbow, now knows where on the body he or she is being touched and may move an arm up to the area that’s being pinched. This action shows a sense of purpose, indicating a relatively high degree of active brain function.

It's Not The Way

After purposeful localization of a pinch, fine finger movements may occur, and an individual may be able to squeeze a hand and, eventually, give a sign. At this stage, the individual often can’t make sounds or speak intelligibly. A patient emerging from a coma sometimes displays verbalization. Often, the next step is for the individual to hold an object, such as a ball. Eventually, the individual will be able to imitate the proper use of objects, such as using a comb for grooming and using a toothbrush for cleaning teeth. At this point, the person becomes very aware of his or her surroundings and is on a trajectory of further improvement. The person may proceed from having the ability to move from the bed to a chair, to standing, and eventually, walking with assistance. Unfortunately, awakening and becoming more aware often are associated with loss of some intellectual function, skills, strength and dexterity. In addition, individuals may have vision difficulties, such as seeing only part of the visual field or seeing double. Some vision issues can be corrected with surgery or prism glasses, but these issues tend to be overlooked. Surprisingly, they’re not included in scales for rating outcomes of recovered comatose patients. A severe brain injury increases the potential for depression and apathy, which may be interrupted by episodes of aggressive behavior and panic attacks.

Just In Time

A patient’s response to other people may be significantly impaired. The patient might forget easily, have a very low tolerance for stressful situations and be unable to multitask. Among older adults who may already have been challenged in the digital world, electronic devices can rapidly become overwhelming. Given all this frustration, patients emerging from coma may be less able to control their behaviors or keep up with the rapidly changing digital world, increasing their risks of social isolation, loneliness and helplessness. People seldom appreciate how much we rely on our emotions to function in the world. Emotions give us powerful and critical feedback. People who survive severe comas caused by traumatic brain injuries are at risk of addiction. Many addiction experts now operate on the assumption that addiction isn’t a moral or discipline failure, but rather a brain disorder that may carry a genetic predisposition. Indeed, a patient who makes it out of the hospital may look much different a year later. These individuals may have major memory problems, such as the inability to complete familiar tasks. Traumatic brain injuries, some individuals experience ongoing seizures. This is more common in those who’ve undergone brain surgery to remove a clot or part of the skull to accommodate swelling.

Everything in its Right Place

Surgical scars may be the source of the seizures, and in many cases, several medications are needed to control them. Unfortunately, remembering to take medication every day can be a formidable task for an individual with memory difficulties or with a lower level of functioning. If medication isn’t taken on a regular basis, the seizures may reappear. They may spend a year in a rehabilitation center and reemerge similar mentally and physically to how they were before the injury, with only minor adjustments in their daily functioning. It’s extremely encouraging and, often, quite emotional when our patients return to see us and we see how much progress they’ve made. The patients may not remember much, but we all immediately remember them and continue to be surprised by the resilience of youth. In these people, recovery is largely determined by their brain injuries. The patient may be disoriented for several days, to the extent of having hallucinations and delirium, but should soon be back to the prior mental baseline. Individuals on ventilators for a week or more often lose considerable muscle mass and may have very significant muscle injuries. Reversing muscle deterioration requires a comprehensive physical therapy program with weekly goals for improvement. The process can take several months, but many individuals fully recover their muscle strength. Delayed awakening from a comatose state can occur if an individual’s illness has resulted in organ shutdown, and it takes longer for sedative medications to be cleared from the body. Marked obesity, heart failure and other organ dysfunction also can contribute to prolonged clearance of the medications and their active breakdown products. Some of the data were from patients who had better outcomes because they received inpatient rehabilitation. Factors such as an individual’s age, the involvement of a rehabilitation physician and the proximity of the hospital to an inpatient rehabilitation facility play a role in whether an individual who’s emerged from a coma is referred for inpatient rehabilitation. We need recovery from a major stroke.