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Classification of epileptic seizures in adults
1. Partial seizures
A. Simple partial (no alteration of consciousness)
Results from focal epileptic discharge in a localised part of the brain. A simple partial motor seizure begins in the motor cortex. When it spreads sequentially through the motor strip, it is called a Jacksonian march.
B. Complex partial (with alteration of consciousness)
A prodrome is common and automatisms are seen in 90% of patients, with post ictal drowsiness in 75% of patients.
C. Partial becoming secondarily generalised (secondary generalised tonic-clonic seizures)
A partial seizure which spreads to the entire brain to produce a convulsion is a secondary generalised seizure.
2. Generalised seizures
A. Absence
A brief episode of unconsciousness with little or no motor accompaniment. (petit mal).
B. Myoclonic
Usually single, sudden, uncontrollable jerks.
C. Clonic
D. Tonic
E. Tonic-clonic
An epileptic attack in which there is loss of consciousness and generalised tonic then clonic muscle contractions.
F. Atonic
An attack in which there is generalised loss of muscle tone, and the patient falls down. Consciousness is not lost.
NB there is an increased incidence of sudden unexpected death (x6) not entirely due to status epilepticus.
Drugs of choice for the treatment of epilepsy
|
1st choice |
Probable second choice |
Last resort |
|
|
Partial +/- SGTCs* |
Carbamazepine |
Phenytoin |
Phenobarbitone |
|
Primary Generalised |
Sodium valproate |
Lamotrigine |
Phenobarbitone |
|
Absence |
sodium valproate |
Lamotrigine |
|
|
Myoclonic |
sodium valproate |
Lamotrigine |
*SGTCs=Secondary generalised tonic clonic seizures
Counselling points for patients with epilepsy
1. Poor compliance is the most common cause for treatment failure
2. Patient must not run out of medication
3. Continue antiepileptics throughout illness, take an extra tablet if vomiting
occurs soon after taking a tablet.
4. Medication should be taken regularly, as missed doses may provoke seizures
5. Encourage the use of a seizure diary.
6. Counsel patients on the use of contraceptives
7. Alcohol
8. Encourage patient to report side effects
9. British epilepsy Association
Reasons for referral
a. To confirm the diagnosis
b. Choice of treatment is changing all the time therefore up to date opinion is required
c. Advice about driving, employment, schooling etc..
Most common complaint of patients is lack of information
d. Patients with special circumstances
e.g. pregnancy(see later)
e. Patients with continuing seizures
Diagnosis must be reconsidered
20% of patients with drug-resistant epilepsy have emotional attacks or non epileptic attacks.
Use of video telemetry and EEG are invaluable
Anti epileptics and oral contraceptives
The effectiveness of both combined and progestogen only contraceptives may be considerably reduced by interaction with drugs that induce hepatic enzyme activity.
Anticonvulsants that induce hepatic enzyme activity:-
Loss of efficacy does not appear to be a problem with:-
However with the introduction of all anticonvulsants the patient should be asked to report any changes in the menstrual cycle
Family Planning association advises that in women who are unable to use an alternative form of contraception that a 50microgram pill be used.
If breakthrough bleeding occurs despite this either increase the dose of oestrogen or use a different form of contraception
Some feel that an additional form of contraception should be used, others feel that this is only necessary when adjustments are made in the anticonvulsant dose.
Depo-provera
No problems reported by the manufacturers
| The risk of major malformations, minor anomalies and dysmorphic features is x2-3 higher in infants of mothers with epilepsy who receive treatment with epileptic drugs compared with the risk in infants of mothers without epilepsy |
| A possibility exists that some of the risk is caused by a genetic pre-disposition for birth defects inherent in certain families and therefore genetic counselling may be required |
| Possibilities for prenatal diagnosis of major malformations should be discussed. High resolution scanning can be done at 16-22 weeks gestation. |
| The effects of tonic-clonic seizures are not well studied but they may injure the mother and may result in miscarriage |
| All women contemplating pregnancy should take folic acid 5mg/day |
| I thepatient has been seizure free for at least 2 years, withdrawal of anticonvulsant should be considered |
| If anticonvulsant treatment is necessary then a switch to monotherapy may be necessary |
| The lowest dose and plasma level should be used. |
Monitoring tests required with patients with antiepileptic drugs
Drugs/Drug group Monitoring required
| Drugs/Drug group | Monitoring required |
| Carbamazepine | Check blood levels only if there are continuing seizures or side- effects or to check compliance. FBC an LFTs before treatment and then regularly. |
| Phenytoin | Check blood levels only if there are continuing seizures or side-effects or to check compliance. FBC an LFTs before treatment and then regularly. Check folic acid levels every six months |
| Barbiturates | Check blood levels only if there are continuing seizures or side-effects or to check compliance |
| Valproate | FBC an LFTs before treatment and then regularly. Blood concentrations are not clinically useful |
| Lamotrigine Gabapentin Vigabatrin Clobazam |
No routine motoring is required |
If a patient is well controlled there is no reason to check levels and if they are checked do not increase dose just to get it within the therapeutic range!!!
The law and medical fitness to drive--a study of doctors' knowledge.
Doctors' knowledge on laws and recommendations regarding fitness to drive in
certain medical conditions by a questionnaire survey. The results show the poor
knowledge of doctors on several aspects of fitness to drive.
Postgrad Med J 1992 Aug
Regulations updated in 1994
Licence may be granted for 1,2 or 3 years provided
a) Free from any epileptic attack during the period of 1 year prior to the date of issue
OR
b) Nocturnal attacks only for 3 years
AND
c) Driving is not likely to be a source of danger to others
Licence may be changed to a 'till 70' if 6 years seizure free.
Medical Advice
Must be quite clear
1. Patient must be told he has epilepsy and that the law will prevent him from driving.
2. Emphasise to the patient that he must inform the DVLA.
3. Continued driving is illegal and may invalidate insurance cover.
4. Doctor has no legal responsibility to inform the DVLA
Must keep a written record
Confidentiality
A doctor should observe the code of professional conduct
GMC recognises that confidentiality may be breached where in the public interest failure to do so may place the patient or some other person at risk of serious harm or death.
In the first place the doctor must advise the patient to inform the DVLA
Subsequently he should challenge the patient and inform him that the doctor will have to inform the DVLA and WHY. This must be documented
If the patient does not inform the DVLA then the doctor should now do so.
If the doctor is aware that the DVLA had revoked the licence but the patient continues to drive the doctor may inform the police
Withdrawal of anticonvulsants.
There is a 40-50% risk of seizure recurrence in the succeeding 2 years
Most commonly as drugs are reduced and for six months after they have been stopped
Therefore under these circumstances it is advisable that the patient does not drive whilst the dose is being reduced and for six months after. But this is not enforced by the DVLA not is it a legal requirement.
Patients should also be aware that if they do have a seizure they will then be barred for a year after their last seizure
Isolated seizure
Defined as one or several seizures occurring in less than 24 hours
Patient must inform the DVLA
The licence will normally be revoked for one year or seizure free for 12 months.
If the seizure has been provoked e.g. drug abuse then the cause may be more relevant
Vocational drivers
Must be free
1. Epileptic attacks for >10years
AND
2. Have not taken anticonvulsants for 10 years
AND
3. Do not have a continuing structural cause.
Some references regarding epilepsy and general practice
BJGP review Thapar: Care of patients with epilepsy in the community. BJGP Jan 1996
Literature study using Medline and Epidata
Specific problems and difficulties of managing patients with epilepsy in the community can be categorized as :
1. Lack of systematic follow up
Many reviews suggest that patients are not regularly followed up by either their
GP or the hospital. The reasons for this haven't been explored and the
effectiveness of systematic follow up needs to be researched.
2. Inappropriate polypharmacy
Studies show that between 35 to 60% of patients are on more than one drug
Optimum seizure control can be achieved for 70-80% of patients.
Polypharmacy increases side effects, may not be efficacious, reduces compliance
and makes monitoring more difficult
3. Pt non compliance
50-70% of patients are compliant with med. from pt reporting and blood
monitoring
Patients often decide to not comply due to stigma associated with treatment.
Need to discuss compliance and the possibility of stopping treatment with
patients.
4. Failure of GP - pt communication
Studies have shown communication to be suboptimal. Many patients feeling they
require more in formation than is given by their GPs
5. Low levels of pt knowledge
One study suggested that patients with epilepsy had the same knowledge about
their condition than controls!!
Barriers to effective community care
1. Oganisational barriers
Computer searches fast but may be inaccurate e.g. some patients are taking
anticonvulsants for conditions other than epilepsy
Notes review and interview, more time consuming
Call recall is often difficult and defaulters may be the most in need of follow
up
Practice based epilepsy specialist nurses are advocated but a costly resource.
2.GP related barriers.
Reports suggest that most GPs feel that epilepsy is a complex disorder to
manage.
3. Patient related barriers
Stigma felt by patients is often greater than the stigma enacted upon them by
others.
Stigma increases with the severity of the illness
Stigma increases withdrawal and reduces attendance at special epilepsy clinics
Some patients do not have confidence in their GPs management of patients.
Initiatives to improve care for patients with epilepsy in the community
Local initiatives
Very little work on:
Practice based clinics
Epilepsy specialists nurses working in GP practices
Liaison nurses, between prim and sec care but also as an information base for
GPs
Guidelines have been produced in certain regions e.g. by the Irish RCGP
National initiatives
Two recent initiatives sponsored by Wellcome
1. Epilepsy task force
multidisplinary group and patients group-s
Aims
to raise public awareness
lobby for appropriate primary and secondary care provision
establish guidelines and minimum standards for hospital OPD services
2. Epilepsy liaison nurse programme
Ran for a year in areas where there were specialised clinic
Helped GPs manage their patients
Helped GPs set up clinics and audit their care
Have not been fully evaluated
Epilepsy monitoring and advice recorded: GP's views, current practice and
pt's preferences GP study of 37 GPs and 283 patients with epilepsy. BJGP
1996,46,11-14 Risdale et al
The majority (61%) of pt preferred their care to be supervised by their GPs
GPs reported that patients should be reviewed every 6 months (median 14 months)
GPs felt that a record should be made in the notes of the following in all
patients:
| Information | % of notes with information recorded |
| Driving regulations | 46 |
| Drug side effects | 9 |
| Self help groups | 3 |
35% of patients reported not getting enough advice.
A general practice records audit of the process of care for people with epilepsy.
Jacoby A Br J Gen Pract 1996 Oct 46
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