Epilepsy and its management

Epilepsy and its management

1. EPILEPSY AND ITS MANAGEMENT

2. INTRODUCTION • The word “epilepsy” is derived from the Greek word which means to be taken, seized or attacked. • A seizure is a result of excessive nerve-cell discharges in the brain. It is seen as a sudden abnormal function of the body, often with loss of consciousness, an excess or loss of muscular activity, or an abnormal sensation. • Seizure is also referred to as a convulsion, fit, or attack. However, the words “convulsion” or “fit” are usually used to refer to seizures with tonic- clonic muscle movements.

3. • According to the International League Against Epilepsy (ILAE), epilepsy is defined by at least two unprovoked seizures occurring more than 24 hours apart or a single unprovoked seizure with a recurrence risk of at least 60% over the next 10 years or an identifiable epileptic syndrome. • Every year, International Epilepsy Day is celebrated on the second Monday of February.

4. EPIDEMIOLOGY • Epilepsy is a chronic non-communicable neurological disorder that can affect individuals of any age irrespective of gender. • About 50 million people are affected with epilepsy all over world. Around 7.6 per 1000 persons have epilepsy during their lifetime. • The estimated proportion of the general population with active epilepsy at a given period of time is between 4 to 10 per 1000 people. • Nearly 10–12 million people with epilepsy are living in India, which contributes to almost one-sixth of the disease burden. The incidence of epilepsy in India is 0.2 - 0.6/1000/year and prevalence range from 3.0 - 11.9/1000 population.

5. AURA An aura precedes the seizure by seconds or a few minutes. It is the beginning of the seizure. The feelings of the aura are often vague and indescribable, leading to extreme fear. Strange epigastric sensations, dreamlike experiences, unpleasant smells, etc. may occur. The patient remembers the aura very well, and although he/she will not always be able to recount it, he/she can affirm the presence of it, as it happens before consciousness is lost.

6. SEIZURE (ICTUS) In most seizures there is a loss of consciousness, and the patient is therefore not able to give any information about the actual ictus. For this, information is taken from witnesses who have seen the actual seizure.

7. Seizures Onset – At what age was the first seizure? – Was it in association with a particular event, accident or illness? – Was there fever with the first seizure? – Is there always fever with the seizures? Pre-ictal phase – Does the patient know of any precipitating factors such as hunger (pointing to hypoglycaemia ), lack of sleep, emotion, alcohol, flashing lights, etc ? – Are there any prodromal symptoms? – Is there an aura? What does it consist of?

8. Ictal phase (description of seizure itself) – Does the patient get flushed or become pale? Does he scream? – Where and how does it start, turning face to one side, or in one hand? – Does he jerk? If so, with both arms and both legs, or only one side? – Is the patient unconscious? Does he fall down? – Does he fumble with his clothes, smack his lips, mumble or make any other noises? Duration – How long does the seizure last? Post-ictal phase – What is the patient’s behaviour like after the seizure—sleepy, aggressive, continues what he was doing?

9. Time – Is it always in the day time, always when he is asleep, or on awakening? Frequency – How often does it happen? Family history – Is there any similar disease in any of the siblings, the parents, or the parents’ families? Perinatal history How was the pregnancy: – Any diseases or complaints? – Were medicines or alcohol used, was the mother a chain smoker? – Was it of normal duration?

10. How was the delivery: – Normal, vacuum, forceps, or Caesarean section? – Was it of normal duration, prolonged, or precipitate? – Did the baby cry immediately after birth, or had he to be resuscitated? – Did the baby have a low birth weight? – Did he look yellow? – Did the baby suck well? – Was there any disease after birth? – Did he get the usual vaccinations?

11. Development – Were the milestones normal? – Does or did he go to school and how is/was he performing there? – If of school-age and not attending school, why not? – What is his behaviour like? – Does he sleep well? What has been done up till now about the seizures? – Has he been admitted to a hospital for his seizures or for any other disease or accident? – What kind of treatment has he had in the past? – Is he on treatment now? – Which medicines, what dosage? – If his drugs were changed what was the reason—allergy or ineffectiveness? – Is he treated by a traditional healer? If so, what treatment has been prescribed?

12. SOCIAL HISTORY – Where does the patient live? With parents? With sibs? With wife/husband or child? – What are the parents’ occupations? If he is married, who earns a living? – What is the educational level of the parents/the household member? – Are the parents together? – Who is looking after the patient, in case of need? – How many siblings are there? /How many children are there? – Are they all well/normal? If not, what is wrong? – How is the patient doing at school/in his job? Is he coping? – Are there any others in the class, the school, the workplace, or the neighbourhood with the same problem? – Are there any problems with his teachers, superiors or colleagues, neighbourhood , (extended) family because of the epilepsy?

13. Physical examination This starts with: Observation – From the moment the patient enters the consulting room notice whether he walks normally, or is there weakness or spasticity on one or both sides? – Does he act appropriately to the new surroundings or is he too quiet, or too active? – Is he able to communicate? – Is the speech normal for his age?

14. Measurements – Weight – Height – Head circumference General physical examination – Scars, bruises, change in pigmentation, adenoma sebaceum , haemangioma – Asymmetry, congenital anomalies – In acutely ill children note: fever, bulging fontanels, neck stiffness, rash, level of consciousness

15. Neurological examination – Eyes—size and reaction of pupils, visual fields, nystagmus, fundoscopy if possible – Other cranial nerves – Muscle power and tone—hyper- or hypotonic – Reflexes – Is there any difference between right and left – Are there any signs of drug toxicity, e.g., ataxia, drowsiness, sleepiness, nystagmus – Finger-nose test – Dysdiadochokinesis (slowing or overshooting when alternating pronation and supination of the hands)

16. Laboratory investigations – Haemoglobin , WBC count and differentiation, blood platelets, ESR, blood film, urinalysis, and stool examination – Specific tests are sometimes indicated to find the basic cause of the convulsions (blood glucose, electrolytes, parasites, etc.) – HIV/ syphylis serology in suspected cases – Liver-function tests are indicated in the first months after starting an antiepileptic drug – Lumbar puncture is indicated when there is an acute illness with fever, convulsions and signs of meningitis (neck stiffness, in infants bulging fontanels) or, in the absence of these signs, in a very ill patient with no other obvious disease – Exceptionally it may be necessary to measure the level of AED in Serum.

17. DRUG THERAPY The aim is to try and prevent further seizures, either completely or to reduce their frequency and severity as much as possible with the least possible side-effects. The medication should be given daily for many years, sometimes life-long, sometimes less. After a seizure-free period with medication for at least two years in idiopathic, and at least three years in symptomatic epilepsy, the dosage might be reduced very gradually over many months, and, if no relapse has occurred, discontinued.

18. • Dose frequency is determined by the elimination half-life time and the need to avoid toxic peak levels. • A sudden discontinuation may lead to a dangerous status epilepticus. • The treatment should be started with one drug only. Ideally, the choice of the drug depends on the type of epilepsy and the seizure type. • The most common seizures are the generalized tonic- clonic seizures (GTCS). The main four AEDs—phenobarbitone, phenytoin, carbamazepine and valproate—are almost equally effective for these seizures.

19. SURGERY In some cases, surgery could be indicated. Required conditions are: – Long-term appropriate anticonvulsant therapy has not controlled the seizures. – A clearly defined focal lesion has been demonstrated. Lesions in the frontal part of a temporal lobe are especially suitable for surgery. – Surgery of this focal lesion should not introduce other neurological problems such as aphasia, or paralysis.

20. Temporal lobectomy

21. Situational low self-esteem related to stigma associated with the condition. Non-compliance related to Financial limitation. Risk for trauma or suffocation related to loss of large or small muscle coordination. Risk for ineffective airway clearance related to neuromuscular impairment. Deficient knowledge related to information misinterpretation.

22. Seizure prevention: some precipitating factors and possible preventive measures • Flashing lights- wear sunglasses when travelling by car or bus, sit as far as possible from a TV screen. • Alcohol - avoid becoming drunk (an occasional drink is not harmful) • Hypoglycaemia - do not skip meals, eat at regular times. • Physical stress- find out how far you can go, what is your limit. • Mental stress- stress cannot always be avoided; for very limited time periods such as sitting for an examination, a mild tranquillizer may be added. • Sleep deprivation- keep regular hours. If working shifts, a sleeping tablet may be necessary when changing shift duties. • Physical systemic illness- to be treated promptly.

23. Patient education and rehabilitation The following instructions to be given to the patient and family members: 1. To take tablets regularly, not missing even a single dose. 2. Patient may feel drowsy in the beginning. This should not lead to any change in drug dosage. 3. Missing dose can result in a fit. Always keep stock of tablets ready for at least two weeks. 4. Never take the missed dose or doses cumulatively. 5. Keep them in a safe plastic container to avoid misuse of accidental use by other especially children. 6. Keep a small book and record the fits.

24. 7. Regular follow-up is essential for adjustment of doses and assessment of any side effects. 8. Visit the doctor in the beginning once a fortnight, later once a month. 9. Till fits are fully under control do not work near fire, water, moving wheels, do not climb trees, and do not drive vehicles. 10. There is no food restrictions as part of treatment. 11. Continue all routine work, like going to school or work etc. 12. Patient should not be kept idle; he should be given a work to do and earn his livelihood, proper support and encouragement to be given so that he can live with pride and dignity.

25. Health-related quality of life and associated factors among patients with epilepsy at the University of Gondar comprehensive specialized hospital, northwest Ethiopia Addis B, Minyihun A, Aschalew AY (2020) conducted a cross-sectional study to measure Health related Quality of Life (HRQOL) on 370 patients with epilepsy. The Quality of Life in Epilepsy Inventory-31 (QOLIE-31) was used. 55.81 was the mean overall HRQOL score. The range of scale scores was from 46.50 to 64.98. The energy scale score was the lowest among the seven scales. Significant positive association was found for social support whereas frequency of seizure, depression, anxiety, perceived stigma and adverse drug event were negatively associated with quality of life. The study concluded that the HRQOL of patients was low and mostly affected by energy and emotional aspects. Presence of depression, anxiety and stigma adversely affected quality of life. Interventions should be aimed at reducing psychosocial problems and stigmatization to improve the quality of life.

26. Determinants of quality of life in adults living with epilepsy Ayanda KA, Sulyman D (2020) conducted a descriptive cross-sectional study to determine the sociodemographic and clinical factors that predict poor quality of life in epilepsy patients on 74 patients. The mental health of patients and quality of life were assessed using the Mini-International Neuropsychiatric Interview and the short form of the World Health Organization QOL instrument, respectively. 33 (44.6%) of the respondents had psychiatric disorder which showed poor score on the overall quality of life. Longer duration of epilepsy and being single were predictive of a poor score on the health satisfaction item and social relationship domain respectively. The study concluded that presence of psychiatric disorder, long duration of epilepsy, and being single were predictive of poor quality of life.

27. CONCLUSION As discussed throughout the presentation, learning about epilepsy and its management will help nurses to care for an epilepsy patient. Nurses can do assessment of an epilepsy patient, classify the type of seizure, observe the sign and symptoms, provide the necessary nursing care and support the patient psychologically. Nurses can also counsel the patients and their family for various options available in treatment for epilepsy.

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29. 6.World Health Organization. Epilepsy: A manual for Medical and clinical officers in Africa. Available from https://www.who.int/mental_health/media/en/639.pdf?ua=1 [cited 27 Nov 2020] 7. Garg D. Specific considerations for epilepsy in India. Curr Med Issues [serial online] 2020 [cited 2020 Nov 27];18:105-10. Available from: https://www.cmijournal.org/text.asp?2020/18/2/105/282783 8. Medical News Today. [cited 11 jan 2020] Available from https://www.medicalnewstoday.com/articles/8947.php#treatment 9. Addis B, Minyihun A, Aschalew AY. Health-related quality of life and associated factors among patients with epilepsy at the University of Gondar comprehensive specialized hospital, northwest Ethiopia. Qual Life Res. 2020 Oct 18. [cited 5 Nov 2020] doi : 10.1007/s11136-020-02666-4. Epub ahead of print. PMID: 33070287. 10. Ayanda KA, Sulyman D. Determinants of quality of life in adults living with epilepsy. Ann Afr Med. 2020 Jul-Sep;19(3):164-169. [cited 5 Nov 2020] doi : 10.4103/aam.aam_20_18. PMID: 32820727.