Recovery measures after a coma

Dementia is a pathology that develops against the background of organic brain damage and is manifested by impaired intellectual activity and personality disorder. According to statistics, older people are more susceptible to the disease, although the onset of dementia at an early age cannot be ruled out. The pathology is characterized by progression and a gradual increase in severity; the patient does not immediately lose acquired skills, knowledge and abilities. At the Yusupov Hospital, a personal nutritionist will develop an individual menu according to the recommendations of the attending physician.

Dementia is divided into atrophic (degenerative), vascular and mixed; it appears due to the death of brain cells or their atrophy with subsequent loss of functional activity. Therefore, the main goals of any treatment program are to prevent further destruction of brain tissue, strengthening neural connections, returning lost functions, normalizing blood supply and metabolism in brain tissue. This can be achieved not only with the help of medications and rehabilitation measures, but also with proper nutrition for dementia, so maintaining a proper diet is very important.

Causes of coma

Coma itself is not a disease; it is divided into several types, depending on the reasons that gave rise to it:

1. Cerebral. Occurs with brain damage caused by traumatic brain injury (traumatic) or stroke (apoplectic).
2. Endocrine. It is observed in case of hormonal disorders or overdose of drugs containing hormones (diabetic, thyrotoxic, etc.).
3. Toxic. Occurs when poisoned by poisons, as well as intoxication due to renal or liver failure (alcoholic, barbituric, uremic, etc.).
4. Hypoxic. Occurs from respiratory dysfunction.
5. Hungry - from a large lack of water, energy, electrolytes.
6. Thermal – from prolonged exposure to high temperatures.

Important!
The duration of a coma and its consequences are difficult to predict, so subsequent recovery of the body is not easy. To protect the brain from irreversible effects, doctors artificially put the patient into a coma. This is achieved in two ways - with medications and lowering body temperature. The duration of an induced coma is rarely long, and the consequences are often severe. Therefore, this procedure is used infrequently.

Proper and healthy nutrition for dementia

A balanced and nutritious diet plays an important role in the treatment of dementia, since brain cells have an increased metabolism, so even a slight deficiency of any elements can lead to serious consequences. For this reason, it is worth taking foods seriously, as they can not only help improve the condition of patients with dementia, but also help prevent the onset of pathology.

According to statistics, residents of eastern countries, in particular India, rarely suffer from diseases that cause mental impairment, as they attach great importance to the quality of food and its composition. For example, daily use of seasonings contained in oriental dishes (curry, turmeric, cinnamon and others), according to research, can prevent the formation and accumulation of amyloid plaques in the brain, which cause damage to neurons and lead to the formation of Alzheimer's disease, accompanied by dementia. Based on these observations, it is worth concluding that for therapeutic and preventive purposes it is necessary to formulate a diet in such a way as to reduce the degree of manifestations and the likelihood of the formation of diseases leading to dementia.

The cause of atrophic dementia is often the accumulation of large amounts of free radicals in brain cells, which enhance the aging process and destruction of neurons. Therefore, nutrition for dementia should include foods that neutralize these harmful substances in the body and prevent their formation - natural antioxidants. The most effective components are vitamin E, C, A, lycopene, carotene, coenzyme, which are found in nuts (sesame, pistachios), citrus fruits, vegetables, herbs, and seafood.

Atrophic processes can be caused by insufficient intake of vitamins and minerals. Patients with dementia especially need vitamins C and E, since their levels rapidly decrease in old age, which causes hormonal imbalance, metabolic disorders and vascular disorders, worsening the general condition of patients. Therefore, it is recommended to include citrus fruits in your daily diet.

Vascular dementia often develops against the background of atherosclerosis, which is formed due to elevated cholesterol levels, which leads to the appearance of plaques and blockage of blood vessels. As a result, the brain experiences oxygen starvation, which ends in the destruction of neurons. For this reason, it is worth monitoring your cholesterol levels, in particular, avoiding foods with high cholesterol content and eating those that lead to a decrease in its levels.

Foods that lower cholesterol:

• dry red wine;
• almond;
• beans;
• blueberry;
• avocado;
• vegetable oils;
• barley, etc.

Also, if you have dementia, you need to drink enough water, and your diet should include dishes that improve the functional activity of the brain, which contain:

• fish;
• seafood;
• nuts;
• seeds;
• dairy products;
• dietary meat;
• seasonings (cinnamon, sage, saffron, lemon balm, etc.);
• vegetables;
• sauerkraut;
• fruits

Degrees of coma

Coma can last from several hours to many years. In this case, the fall into a coma can be instantaneous or gradual, lasting hours and even days. Each stage is characterized by its own characteristics.

1. Prekoma. The condition that precedes coma is confusion, excessive excitement or apathy, impaired coordination, all reflexes are present.
2. Stage I. Slowing reactions to stimuli (pain or sounds), increased muscle tone, stupor. The patient is able to make some movements - swallow food, turn around. Monitoring the reaction of the pupils to light exposure can show blurred vision, and the eyeballs make erratic movements.
3. Stage II. Loss of contact with the patient, greater weakening of reactions, intense breathing, fibrillation, muscle spasms, practically no reaction of the pupils when exposed to light.
4. Stage III. Atonic coma. Lack of consciousness and reflexes. Arrhythmic breathing, low blood pressure, involuntary bowel movements, decreased body temperature.
5. Stage IV. Extreme coma. The pupils dilate, breathing stops, pressure and temperature drop sharply.

Consequences of coma

The consequences of being in a coma depend on the state of the body, the severity of the diseases that led the patient to this situation. The second factor is the degree of coma. Particularly unfavorable prognoses are associated with aortic aneurysm, strokes and traumatic brain injuries. A person who has gone through a coma may experience the following complications and consequences:

1. Disturbances in the functioning of the heart, kidneys, and gastrointestinal tract.
2. Weakening of the immune system.
3. Respiratory diseases. Since artificial ventilation of the lungs is used, bronchial obstruction, pneumonia, formation of adhesions, tracheal bedsores, and stenosis may occur.
4. Neurological disorders. They are expressed in the loss of certain skills, changes in behavioral reactions, memory deterioration, and amnesia.

Important! Staying a patient in a coma for more than a month leads to irreversible changes in the brain.

Nutrition in the terminal stage, with dementia or in a state of awake coma

We present a fragment of the book by Jean Domenico Borasio “On Death. What do we know? What we can do. How can we prepare for it,” published with the participation of the Vera charity foundation. The book, which became a bestseller in Switzerland, is addressed to specialists, as well as relatives of seriously ill patients.

The issue of feeding and providing the patient with sufficient fluid in the terminal stage is a very painful, emotionally difficult topic. The reason can be considered that for a person, satisfying hunger and thirst belongs to one of the very first experiences of attachment (to the mother - approx.), so that the very topic of nutrition refers to the archetypes of human life. What terrible words these are - “hunger” and “thirst”! They are “painted” like the proverbial devil, they frighten us from childhood - as a result, it is very, very difficult for all of us to calmly perceive information about the advantages and disadvantages of artificial nutrition and hydration in the terminal phase. Already in 2004, the German Federal Medical Association introduced and in 2011 approved the following of its main provisions regarding palliative care: “Care consists of palliative care and, accordingly, caring for the patient and providing basic care. This care does not always include feeding and hydration in the terminal stage, as this can be a burden for the patient. However, if the patient has subjective sensations of hunger or thirst, then thirst and hunger should be quenched”[1].

Insufficient food and fluid: what does this mean for a healthy person and for a dying person?

We believe that death occurs when we stop eating and drinking because the thought of it immediately brings to mind images and news from areas of the world where food is scarce. The consequences of malnutrition and dehydration for a healthy person are reflected in table. 5.1.

Table 5.1. Effects of malnutrition and dehydration on a healthy person

This daunting list of symptoms, however, has no significance for the stage of dying. Rather, the question that arises here is: do dying people suffer from painful feelings of hunger or thirst if they can no longer take food and liquid? And is artificial nutrition and hydration necessary in the terminal phase to prevent this suffering? The answer in both cases is: no.

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In the terminal phase, especially in older people, the body consumes more energy than it can take in (the so-called catabolic metabolic state) because the body can no longer process even normal amounts of food. A high-calorie diet will no longer help here, so weight loss cannot be avoided at the end of life. To quench hunger and thirst, an insignificant amount of food and liquid is already enough. During the dying process, patients usually do not experience hunger.

The feeling of thirst at the end of life occurs due to dryness of the oral mucosa, and not due to a lack of fluid. Dry mouth can be caused by medications, fungal infections, local radiation, oxygen, or mouth breathing. Therefore, it is possible to prevent and eliminate the patient's feeling of thirst in the terminal phase by eliminating dry mouth (and not by artificial hydration).

How to prevent and eliminate dry mouth:

• Avoid medications with side effects such as drying of the oral mucosa (for example, anticholinergics).
• Regularly care for the patient's mouth and lips.
• Use artificial saliva.
• Avoid lemons/glycerin.
• Avoid oxygen supply.
• Give small ice cubes.
• Give a small amount of liquid (drop by drop).

Reducing the patient's hydration at the end of life has a number of benefits: less vomiting, less cough and mucus, less water accumulation (edema) in the tissues, lungs and abdomen, and less pain (for example, in cancer patients as a result of reduced swelling around the tumor and metastases and the associated reduction in pressure on surrounding tissues).

In addition, as a result of a reduction in the amount of fluid injected into the brain, there is an increased release of endorphins (autogenic mediators), which have an analgesic and mood-lifting effect. In general, dying in a state of mild dehydration appears to be the least burdensome form of the dying process from a physiological point of view. In contrast, terminal hydration, especially when combined with unnecessary oxygen supply, can lead to significantly increased suffering.

Interesting in this regard are the results of a study conducted in a nursing home in the Netherlands. The study involved patients with progressive dementia. As part of the experiment, it was decided to abandon artificial nutrition and hydration of patients[2].

Outcomes were assessed using a scale specifically designed for patients with dementia, which indicated increases or decreases in suffering. Due to the lack of possibility of communication with patients, the results of observation of them were used. After the decision was made to stop artificial nutrition and hydration, the scale showed a long-term, sustained decrease in the intensity of suffering. There was a clear feeling that after making this decision, the patient felt much more comfortable until the moment of death.

Another source of information is a publication from The New England Journal of Medicine about the experiences of hospice nurses working with patients who consciously refused to consume food and fluids[3].

It must be borne in mind that here we are talking about a fundamentally different situation than the situation at the dying stage: these patients, being seriously ill, were not dying and made a conscious decision to shorten their remaining life span by stopping the consumption of fluids and food. 102 out of 307 caregivers had experienced this situation at least once (in informal conversations with speakers at nursing conventions, the author of this book found that 50% of caregivers had such an experience). This means, obviously, we are talking about a frequently encountered but insufficiently taken into account phenomenon. A US study found that 85% of such patients died within 15 days. Health care providers subsequently rated these patients' dying experiences on a scale of 0 to 9 (where 0 = the worst death imaginable; 9 = the most peaceful death imaginable). The mean was 8, meaning that the patients' dying process was generally very peaceful.

Of course, in medicine, no rule is without exceptions, but each of these exceptions should be considered separately. Indications for artificial hydration and the amount of fluid administered always depend on the patient's condition at the moment. The following example illustrates this.

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An elderly, frail lady aged 88 years was admitted to the emergency department of a large clinic with a femoral neck fracture. By that time, she had already been diagnosed with heart valve disease. After the operation, the condition worsened due to a microinfarction. She complained of suffocation and her general condition was so poor that it was decided that death was imminent and it was time to involve palliative care physicians. The X-rays showed fluid in the lung very clearly. That is why the first question was: how much fluid did the patient receive? Answer: She received 1000 ml of fluid per day through intravenous infusions, which, given her heart condition and low body weight, was a little more than required, but still within the norm. However, after reviewing the medical record, it turned out that the patient, who could not swallow on her own after the operation, received another 1500 ml of nutritional formula in addition to the indicated 1000 ml.

In addition, since the patient could not swallow on her own, all medications were also administered intravenously, each in a specific small amount (the so-called short infusion, usually 300 ml). And this was a fairly large number of medications, including antibiotics, painkillers, medications that prevent the formation of mucus, anti-nausea medications, as well as medications to improve the removal of fluid from the body. The latter seemed very appropriate, because if we add all the volumes of liquid required to administer these medications to the amount of nutritional mixture consumed by the patient, we get another 3050 ml. As a result, the patient was given more than 4 liters of fluid per day, which explained the reason for her serious condition. After reducing the amount of fluid she received by less than a quarter, she felt significantly better, the suffocation went away, and she was transferred to the rehabilitation department.

[1] Bundesärztekammer: Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Deutsches Ärzteblatt 2004, Jg. 101, S. A1298, sowie 2011, Jg. 108, S. A346.

[2] Pasman HR, Onwuteaka-Philipsen BD, Kriegsman DM et al. Discomfort in nursing home patients with severe dementia in whom artificial nutrition and hydration is forgone. Archives of Internal Medicine 2005, Bd. 165, Heft 15, S. 1729–1735.

[3] Ganzini L, Goy ER, Miller LL et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. New England Journal of Medicine 2003, Bd. 349, Heft 4, pp. 359–365.

Recovery after a coma

Not all comatose states are extremely severe. They recover from a diabetic coma relatively quickly; alcoholic and drug comas will last until toxic substances are removed from the body. But even in the first stage of coma severity, rehabilitation measures are mandatory.

This is especially true for restoring brain activity. Amnesia does not always occur, but memory deteriorates and attention is impaired. Sometimes patients lose the ability to sit and walk independently. Confused consciousness and loss of orientation in the surrounding space are often observed. In this case, rehabilitation measures will include restoration of memory and speech activity. The patient should be dealt with:

• neurologist with special training;
• a psychologist who helps the patient find motivation for rehabilitation and re-realize his place in the world;
• an occupational therapist who sets various tasks to improve motor skills;
• physiotherapist and neurologist.

For example, in Petrozavodsk the second clinic has a good rehabilitation and physiotherapy department, many patients note the effectiveness of the classes.

Important! The first step is examination and treatment of the disease that caused the coma. At the same time, you need to do rehabilitation.

The patient attitude of others is of great importance, since often recovery from a coma is accompanied by an aggressive state. It is even necessary to fix the arms and legs with a special device in order to prevent the patient from injuring himself.

When in a coma for more than a month, the patient remains in a vegetative state. He is able to open his eyes and move slightly, but cannot otherwise contact the outside world. Some patients gradually recover from this state. They need to ensure an increase in the flow of information - turn on music, talk, take them for a walk, a balcony. If after 3 months nothing has changed, the prognosis for rehabilitation after a coma is poor.