Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria

doi:10.1016/j.apmr.2020.06.021

Archives of Physical Medicine and Rehabilitation

Volume 101, Issue 11, November 2020, Pages 2041-2050

https://doi.org/10.1016/j.apmr.2020.06.021 Get rights and content

Abstract

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

Section snippets

Evidence review

The Confusion Workgroup consisted of all authors of the case definition. The Workgroup included 7 neuropsychologists, 6 physiatrists, 2 behavioral neurologists/neuropsychiatrists, 2 neuroscientists, and 2 speech language pathologists. These members met in person and via teleconference from 2012-2019. Key in-person meetings were held at American Congress of Rehabilitation Medicine annual conferences from 2013 through 2017 and at the Galveston Brain Injury Conference in 2017 and 2018.

Evidence review

During the first round of abstract and article reviews (published through 2013), the literature search yielded 1757 abstracts, from which 154 were retained for full-article review. Of these 154, a total of 53 articles met all inclusion criteria. The second literature search for 2013-2017 identified 649 additional abstracts. We reviewed 14 articles and retained 6 that met all inclusion criteria. During the final round of review (ie, abstracts identified during the review of publication

Discussion

PTCS commonly occurs after TBI of all severity levels. This condition often follows emergence from lower levels of consciousness but also occurs with other patterns of recovery, including those without a period of unconsciousness. While historically, the term PTA has been used by some to label this phase of recovery, PTA is better used to indicate the clinical impairments of anterograde amnesia and disorientation following TBI. As defined by this Workgroup, PTCS encompasses multiple domains,

Conclusions

A primary goal for future research is the development of a new instrument for assessing degree and pattern of confusion, with sufficient precision that natural history studies are more feasible and accurate. Accordingly, new measurement tools that assess all features of the PTCS should be validated, including cutoffs for the lower and upper boundaries. The lack of a reference standard or biomarker for PTCS will make it challenging to validate new tools. Research on functional abilities that

Acknowledgments

We give special acknowledgment to coauthor Donald T. Stuss, PhD, OC, OOnt, FRSC, FCAHS, 1941-2019, for his contribution, wisdom and guidance on this article. His previous work served as a foundation for research on PTCS and he was such an important inspiration and mentor to so many in neuroscience and neuropsychology. Drs. Sherer, Katz, and Bodien were joint first authors for this article.

This case definition was written by Mark Sherer, PhD, Douglas I. Katz, MD, Yelena G. Bodien, PhD, David B.

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Citation Excerpt :
We graded the level of consciousness as coma, vegetative state (VS), minimally conscious state with/without language function (MCS+/-) or emerged from the minimally conscious state (EMCS). We used the Confusion Assessment Protocol (CAP) (Sherer, Nakase-Thompson, Yablon, & Gontkovsky, 2005) (https://www.tbims.org/combi/cap/caprat.html) to confirm whether patients who emerged from MCS were in a post-traumatic confusional state (PTCS) or recovered from PTCS (R-PTCS) (Sherer et al., 2020). A single investigator (B.L.E.) conducted all CRS-R and CAP assessments, blinded to the EEG data.
Tools assaying the neural networks that modulate consciousness may facilitate tracking of recovery after acute severe brain injury. The ABCD framework classifies resting-state EEG into categories reflecting levels of thalamocortical network function that correlate with outcome in post-cardiac arrest coma. In this longitudinal cohort study, we applied the ABCD framework to 20 patients with acute severe traumatic brain injury requiring intensive care (12 of whom were also studied at ≥6-months post-injury) and 16 healthy controls. We tested four hypotheses: 1) EEG ABCD classifications are spatially heterogeneous and temporally variable; 2) ABCD classifications improve longitudinally, commensurate with the degree of behavioral recovery; 3) ABCD classifications correlate with behavioral level of consciousness; and 4) the Coma Recovery Scale-Revised arousal facilitation protocol yields improved ABCD classifications. Channel-level EEG power spectra were classified based on spectral peaks within pre-defined frequency bands: ‘A’ = no peaks above delta (<4 Hz) range (complete thalamocortical disruption); ‘B’ = theta (4–8 Hz) peak (severe thalamocortical disruption); ‘C’ = theta and beta (13–24 Hz) peaks (moderate thalamocortical disruption); or ‘D’ = alpha (8–13 Hz) and beta peaks (normal thalamocortical function). Acutely, 95% of patients demonstrated ‘D’ signals in at least one channel but exhibited within-session temporal variability and spatial heterogeneity in the proportion of different channel-level ABCD classifications. By contrast, healthy participants and patients at follow-up consistently demonstrated signals corresponding to intact thalamocortical network function. Patients demonstrated longitudinal improvement in ABCD classifications (p < .05) and ABCD classification distinguished patients with and without command-following in the subacute-to-chronic phase of recovery (p < .01). In patients studied acutely, ABCD classifications improved after the Coma Recovery Scale-Revised arousal facilitation protocol (p < .05) but did not correspond with behavioral level of consciousness. These findings support the use of the ABCD framework to characterize channel-level EEG dynamics and track fluctuations in functional thalamocortical network integrity in spatial detail.

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: Presented to the ACRM (2015-2019) and the 4th Federal Interagency Conference on Traumatic Brain Injury (2018). This special article was approved by the ACRM EPC on June 19, 2020, and by the American Congress of Rehabilitation Medicine Board of Governors on July 2, 2020, and was published in the Archives of Physical Medical Rehabilitation. The Archives of Physical Medicine and Rehabilitation was responsible for the peer review of this article.

: This case definition was developed under the ACRM Evidence and Practice Committee (ACRM EPC), which is supported by unrestricted grants from CARF International and Paradigm. Neither CARF International nor Paradigm were involved in any phase of the development of this case definition. Preparation of this article was partially supported by National Institute of Disability, Independent Living, and Rehabilitation Research grant no. 90DPTB0016. NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this publication do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government. This Case Definition is in the public domain: it may be copied, published, or shared without permission from ACRM.

: Disclosures: none.

^†: Deceased.

View full text

ACRM endorsed case definitionPost-traumatic Confusional State: A Case Definition and Diagnostic Criteria

Abstract

Section snippets

Evidence review

Evidence review

Discussion

Conclusions

Acknowledgments

Lancet

Psychosomatics

Prog Brain Res

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Mental disorder following head injury: (section of psychiatry)

Proc R Soc Med

Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome

BMC Med

The minimally conscious state: definition and diagnostic criteria

Neurology

Disorders of consciousness after acquired brain injury: the state of the science

Nat Rev Neurol

The acute period of recovery from traumatic brain injury: posttraumatic amnesia or posttraumatic confusional state?

J Neurosurg

Update of neuropathology and neurological recovery after traumatic brain injury

J Head Trauma Rehabil

Stages of recovery during post-traumatic amnesia and subsequent everyday memory deficits

Neuroreport

Cognitive impairment, clinical symptoms and functional disability in patients emerging from the minimally conscious state

NeuroRehabilitation

The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early identification of cognitive impairment in patients with mild traumatic brain injury

J Neurol Neurosurg Psychiatry

The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury

J Nerv Ment Dis

Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log

Arch Phys Med Rehabil

Using the Delphi expert consensus method in mental health research

Aust N Z J Psychiatry

ACRM endorsed case definition
Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria