It takes extensive testing to assess levels of wakefulness and awareness before a disorder of consciousness can be confirmed.
This may involve tests such as brain scans, but is largely based on the specific features a person displays, such as whether they can respond to commands.
The Glasgow Coma Scale
Doctors can score a person's level of consciousness using a tool called the Glasgow Coma Scale. This assesses three things:
- eye opening – a score of 1 means the eyes don't open at all, and 4 means opens eyes spontaneously
- verbal response to a command – 1 means no response, and 5 means a person is alert and talking
- voluntary movements in response to a command – 1 means no response, and 6 means a person can follow commands
A lower score indicates a more severely impaired consciousness, such as a coma, although this level will be monitored regularly to look for any changes.
The brain injury association Headway has more detailed information about the Glasgow Coma Scale.
Other scoring systems
There are also more specific scoring systems, which are based on more detailed observations of a person's behaviour.
One example is known as the JFK Coma Recovery Scale-Revised (CRS-R). This system uses 23 different items, each with individual scales to assess how a person is responding.
You can read more detailed information about the CRS-R on The Center for Outcome Measurement in Brain Injury (COMBI) website.
Brain scans are used to help assess the level of brain damage in someone with impaired consciousness. They can also check for signs of any complications, such as hydrocephalus, a build-up of fluid on the brain.
There are several types of scans that can assess brain structure. A CT scan or MRI scan are used if the person is able to tolerate it.
Research brain scans
There are separate scans that can show areas of brain activity as well as brain damage. These are only used in research settings at the moment, but may be useful if a person can't move or speak.
One example is a functional magnetic resonance (fMRI) scan. A fMRI scan is able to show changes if the brain is responding to lights and sound.
However, they don't necessarily show awareness because the brain is able to respond to stimulation even without the person actually being aware of it. Research is being carried out into ways brain scans can be used to show true awareness.
Criteria for a vegetative state
A vegetative state is when a person is awake but showing no signs of awareness. Doctors are particularly careful when diagnosing a permanent vegetative state, as there's a risk of misdiagnosis.
A confident diagnosis can only be made if the following criteria have been met:
- the cause of the brain injury has been established – for example, if a case of meningitis is suspected, a diagnosis can be confirmed by testing the fluid that surrounds the brain for infection
- it's been confirmed drugs or medication aren't responsible for the symptoms
- it's been confirmed treatable problems with the body's chemistry (a metabolic disorder) aren't responsible for the symptoms of loss of awareness – an example of a metabolic disorder is a diabetic coma, where people lose consciousness because their blood sugar levels are either dangerously high or dangerously low
- the possibility of a treatable cause in the brain, such as a brain tumour, has been ruled out by brain imaging scans
- examinations have been carried out by a trained assessor experienced in prolonged disorders of consciousness
For a permanent vegetative state to be confirmed, the above criteria must apply and either:
- six months must have passed since the start of symptoms after a non-traumatic brain injury
- 12 months must have passed since the start of symptoms after a traumatic brain injury