Can We Meet the Challenge?Raymond Tallis FRCP FMedSci

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CommonDifferentUnder-researchedService challenges

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Unpleasant experience

Physical consequences

Psychosocial consequences

Underlying cause

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CommonDifferentUnder-researchedService challenges

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456,000 people have epilepsy (based on 2003 census population)

This is equivalent to 1 in 131 people or 7.5 per thousand

People over 65, one in 91 (compared with 1 in 279 in children under 16)

Source: ONS 2003

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CommonDifferentUnder-researchedService challenges

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Presentation

Type of seizure

Differential diagnosis

Aetiology

Co-morbidity

Functional consequences

Clinical pharmacology

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Pre-stroke seizures

Post-stroke seizures

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At any point in time, the relative risk of stroke in the control group is approximately one third of that in the seizure cohort (RR 0.346; 95% CI 0.294–0.408)

•Cleary, Tallis, Shorvon Lancet 2004

p <0.0001 

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Approximately 10% of patients with

ischaemic stroke will have developed post-

stroke seizures by 5 years

(Burn, et al. 1997, Oxford Community Stroke

Project)

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CommonDifferentUnder-researchedService challenges

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Percentage of patients remaining in the trial over time (52 weeks).

Rowan et al. Neurology 2005; 64:1868-1873.

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When to start? Which drug? What dose? Adverse reactions? Interactions? Monitoring? Compliance? Withdrawal?

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The drug you choose may be less important than how you and the patient use it.

Be prepared to modify the dose in response to actual but unexpected responses

Be prepared to fine tune with small incremental changes

This has implications for provision of services!

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CommonDifferentUnder-researchedService challenges

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Accurate diagnosis

Comprehensive management

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Epilepsy often only part of the problem Diagnostic challenges Multiple medical problems Disability Who should care: neurologists (who might

get the epilepsy right) or geriatricians (who might get everything else right)

Role of ESNA

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Muddling non-seizures with seizure

Muddling seizures with non-seizure

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Syncope Hypoglycaemia Transient ischaemic attack Recurrent paroxysmal behavioural

disturbances in organic brain disease Drop attacks and other non-epileptic

causes of falls Transient global amnesia Sleep phenomena: hypnic jerks;

obstructive sleep apnoea [Non-epileptic attack disorder]

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Epileptic event

Partial motor status

Sensory seizures

Complex partial seizures

Epileptic vertigo (due to temporal lobe attacks)

Todd’s Palsy

Any kind of seizures

Possible misdiagnosis

Extra pyramidal movement disorder

Transient ischaemic attack

Organic or functional psychosis

Brain stem vestibular disease/non-specific dizziness

Stroke/TIAs

’Falls’

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Need comprehensive, thoughtful, expert assessment AND reassessment

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To make epilepsy the least important thing in

the patient’s life

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Need to have expertise in epilepsyNeed to have expertise in special aspects of epilepsy in older people

Need to have expertise in other problems that older people may have

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Shared care Role of GPSIs The annual review Hospital-based epilepsy service Specialist epilepsy nurse

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Highly qualified general nurse Very experienced Training in epilepsy Working closely with the rest of the clinical

team under the supervision of a consultant May be a ‘nurse prescriber’ ESNA as trainer

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Building good relationships/rapportEducation, support and advice Act as resource of informationMonitoring of medicationTelephone helplineLink between primary and secondary care

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Research study conducted for Epilepsy Action

April – May 2005

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9 out 10 geriatricians see elderly people with seizures

Most geriatricians think the prevalence of seizures is lower than it in fact is

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Only ⅔ of geriatricians are aware that NICE guidelines are available

Only 1 in 10 identify that under these guidelines a patient reporting a suspected seizure should be seen by a specialist medical practitioner with training and expertise in epilepsy within 2 weeks

Only 13% of geriatricians have been on an epilepsy related course

Of the 87% that had never been on an epilepsy related course, 85% see patients with epilepsy

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Referral to a specialist centre if: Epilepsy not controlled with medication

within 2 years Not controlled after two drugs have been

tried There are unacceptable side effects from

medication There is doubt over the diagnosis of

seizures

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Training and education (geriatricians, neurologists) [NB National Meeting 2nd March]

Professional bodies: Special Interest Groups

Flag up nationally: DoH (New Commissioning arrangements?)

Voluntary Bodies

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Accurate diagnosis Full information Appropriate drug treatment Ready access to review of diagnosis and

treatment Ready access to further information and

advice

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Do not settle for second class care.

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Epilepsy in older adults is:

More common More important More to gain Much to be done

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