Transcript Slide 1
Can We Meet the Challenge? Raymond Tallis FRCP FMedSci SIG Meeting 1 Common Different Under-researched Service challenges SIG Meeting 2 Unpleasant experience Physical consequences Psychosocial consequences Underlying cause SIG Meeting 3 Common Different Under-researched Service challenges SIG Meeting 4 210 200 190 180 Incidence/100,000 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 50-54 55-59 60-64 65-69 SIG Meeting 70-74 75-79 80-84 85+ 5 456,000 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 SIG Meeting 6 Common Different Under-researched Service challenges SIG Meeting 7 Presentation Type of seizure Differential diagnosis Aetiology Co-morbidity Functional consequences Clinical pharmacology SIG Meeting 8 Pre-stroke seizures Post-stroke seizures SIG Meeting 9 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) p <0.0001 •Cleary, Tallis, Shorvon Lancet 2004 SIG Meeting 10 Approximately 10% of patients with ischaemic stroke will have developed post- stroke seizures by 5 years (Burn, et al. 1997, Oxford Community Stroke Project) SIG Meeting 11 Common Different Under-researched Service challenges SIG Meeting 12 Percentage of patients remaining in the trial over time (52 weeks). Rowan et al. Neurology 2005; 64:1868-1873. SIG Meeting 13 When to start? Which drug? What dose? Adverse reactions? Interactions? Monitoring? Compliance? Withdrawal? SIG Meeting 14 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! SIG Meeting 15 Common Different Under-researched Service challenges SIG Meeting 16 Accurate diagnosis Comprehensive management SIG Meeting 17 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 SIG Meeting 18 Muddling non-seizures with seizure Muddling seizures with non-seizure SIG Meeting 19 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] SIG Meeting 20 Epileptic event Possible misdiagnosis Partial motor status Extra pyramidal movement disorder Sensory seizures Transient ischaemic attack Complex partial seizures Organic or functional psychosis Epileptic vertigo (due to temporal lobe attacks) Brain stem vestibular disease/nonspecific dizziness Todd’s Palsy Stroke/TIAs Any kind of seizures ’Falls’ SIG Meeting 21 Need comprehensive, thoughtful, expert assessment AND reassessment SIG Meeting 22 To make epilepsy the least important thing in the patient’s life SIG Meeting 23 Need to have expertise in epilepsy Need to have expertise in special aspects of epilepsy in older people Need to have expertise in other problems that older people may have SIG Meeting 24 Shared care Role of GPSIs The annual review Hospital-based epilepsy service Specialist epilepsy nurse SIG Meeting 25 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 SIG Meeting 26 Building good relationships/rapport Education, support and advice Act as resource of information Monitoring of medication Telephone helpline Link between primary and secondary care SIG Meeting 27 Research study conducted for Epilepsy Action April – May 2005 SIG Meeting 28 9 out 10 geriatricians see elderly people with seizures Most geriatricians think the prevalence of seizures is lower than it in fact is SIG Meeting 29 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 SIG Meeting 30 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 SIG Meeting 31 Training and education (geriatricians, neurologists) [NB National Meeting 2nd March] Professional bodies: Special Interest Groups Flag up nationally: DoH (New Commissioning arrangements?) Voluntary Bodies SIG Meeting 32 Accurate diagnosis Full information Appropriate drug treatment Ready access to review of diagnosis and treatment Ready access to further information and advice SIG Meeting 33 Do not settle for second class care. SIG Meeting 34 Epilepsy in older adults is: More common More important More to gain Much to be done SIG Meeting 35