Domain 11 of 12·PRIORITY-ELIGIBLE

Altered States of Consciousness

Seizures, loss of consciousness, delirium, fluctuating awareness, clinical risk.

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What this domain measures

The Altered States of Consciousness domain captures seizures, loss of consciousness, delirium, and other fluctuations in awareness that create clinical risk. It is one of four Priority-eligible domains and is unusual in skipping the Severe level — the DST descriptor table jumps from High to Priority. A single Priority score here can secure CHC eligibility on this domain alone, typically in status epilepticus risk or prolonged unresponsive episodes.

How it's scored (Annex C wording)

DST scoring levels for the Altered States of Consciousness domain, with verbatim Annex C descriptors.
Level	DST descriptor
No needs	No evidence of altered states of consciousness (ASC).
Low	History of ASC but it is effectively managed and there is a low risk of harm.
Moderate	Occasional (monthly or less frequently) episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm.
High	Frequent episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm. OR Occasional ASCs that require skilled intervention to reduce the risk of harm.
Priority	Coma. OR ASC that occur on most days, do not respond to preventative treatment, and result in a severe risk of harm.

Evidence that moves the score up

Seizure log with dates, duration, type (tonic-clonic, focal, absence), and post-ictal recovery time
Buccal midazolam / rectal diazepam emergency-medication administration records
Neurology consultant letters and any EEG or MRI findings
Delirium screening tools (e.g. 4AT, CAM) and recorded episodes
Care plan section on individual seizure-management protocol and trained-staff response
Ambulance call-out and A&E attendance records for prolonged or atypical episodes
Risk assessment showing the level of supervision required (1:1, line-of-sight, monitored)
Status epilepticus protocol if one is in place

How ICBs commonly under-score this domain

Pattern: Assessor scored Low because seizures are 'controlled' by anti-epileptic medication.

Rebuttal: Controlled-by-medication is the well-managed need pattern. Per paras 162–166, the level must reflect the present-day risk if medication were withdrawn or efficacy lapsed — which in epilepsy is typically rapid return of seizure activity and risk of status epilepticus.

Source: para 162-166 + DST user notes para 31

Pattern: Assessor scored Moderate because emergency medication is 'rarely used'.

Rebuttal: Frequency of emergency-medication administration is not the threshold — availability and trained-staff capability are. The High descriptor turns on frequent ASC episodes requiring trained-staff response; the Priority descriptor turns on need for skilled professional response when episodes occur on most days.

Source: DST Annex C ASC High and Priority descriptors

Pattern: Assessor scored High instead of Priority because the person 'recovers' between episodes.

Rebuttal: Recovery between episodes is not a Priority disqualifier. The Priority descriptor turns on whether episodes occur on most days and result in severe risk of harm — not on the inter-episode baseline. Daily episodes + severe-risk-of-harm = Priority.

Source: DST Annex C ASC Priority descriptor

4-line rebuttal template

I disagree with the [LEVEL] score for Altered States of Consciousness. The evidence shows [SPECIFIC PATTERN — seizure frequency / status risk / delirium episode] which meets the [HIGHER LEVEL] descriptor. On [DATE/PERIOD], the recorded episodes were [DESCRIBE: number, type, duration, emergency medication required, trained-staff response, time to recovery]. Per the well-managed needs principle (National Framework paras 162–166), [the anti-epileptic regime / supervision level / 1:1 staffing] is the intervention, not the absence of need. If [SUPPORT] were withdrawn, the present-day risk would be [DESCRIBE: status epilepticus / injury / aspiration]. I therefore request the Altered States of Consciousness domain be re-scored to [HIGHER LEVEL] with reference to the [SPECIFIC EVIDENCE: seizure log / emergency medication chart / neurology letter / A&E records].

Altered States of Consciousness is one of four Priority-eligible domains

A single Priority score in Altered States of Consciousness can secure CHC eligibility on this domain alone. The MDT Preparation Pack (£799) walks through exactly how to prepare your Altered States of Consciousness evidence for the MDT.

View MDT Preparation Pack →