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Assessment and Communication for People with Disorders of Consciousness
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Consensus on covert awareness: a Delphi study.

Caroline Schnakers1, Berno Overbeek2,3, Niko Fullmer1

  • 1Research Institute,Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA.

Brain Communications
|December 4, 2025
PubMed
Summary
This summary is machine-generated.

Experts reached consensus on "Covert Awareness" as the preferred term for patients with disorders of consciousness who show brain activity but no behavioral signs. This advances research and clinical care for these individuals.

Keywords:
consciousnesscovert awarenessminimally conscious stateunresponsive wakefulness syndromevegetative state

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Area of Science:

  • Neuroscience
  • Clinical Neurology
  • Rehabilitation Medicine

Background:

  • Identifying covert awareness in disorders of consciousness is crucial for patient care and research.
  • Lack of standardized terminology hinders progress in understanding and managing patients with disorders of consciousness.
  • Existing terms like 'cognitive motor dissociation' and 'functional locked-in syndrome' lack consensus.

Purpose of the Study:

  • To achieve expert consensus on terminology and definitions for patients with disorders of consciousness exhibiting covert awareness.
  • To evaluate agreement on terms such as covert awareness, cognitive motor dissociation, functional locked-in syndrome, and non-behavioral minimally conscious state.

Main Methods:

  • A Delphi study involving 96 international experts in disorders of consciousness.
  • Utilized REDCap for evaluating expert agreement on terminology and definitions over two rounds.
  • Consensus defined as median score of 5, interquartile range ≤1, and ≥75% agreement.

Main Results:

  • Consensus was achieved for over two-thirds of statements within two rounds.
  • The term 'Covert Awareness' and its definition were identified as the preferred terminology by the expert panel.
  • Over 75% of experts agreed on 'Covert Awareness' as the standardized term.

Conclusions:

  • The international expert panel recommends 'Covert Awareness' for patients with disorders of consciousness who lack behavioral signs but show brain activity.
  • This consensus provides a foundation for future research and clinical standardization in disorders of consciousness.
  • The findings support improved diagnostic accuracy and understanding of covert awareness, with further research needed for clinical application.