Transcript Presentation of epilepsy Focus

Seizures and
Epilepsy
PRESENTED BY
GERRY BROPHY
Training in Care Solutions
The brain is made up of billions of neurons, or
nerve cells. These are the electrically
charged units that, as they communicate with
each other, organize electrical energy to
make the brain work.
A neuron has three parts—
a cell body, an axon, and dendrites.
The enzymes and genetic material which directs the neuron are
contained in the cell body.
The cell body is surrounded by thin, branch-like projections, or
dendrites.
The axon is a long, thin, tail-like extension from the cell body,
insulated by a sheath of myelin. It carries an electrical charge to
the axon terminal, where it activates the release of neurotransmitting chemicals.
A. Primary Generalized Seizure
B. Partial Seizure
C. Partial Seizure with Secondary Generalization
Definitions: Clinical
 An epileptic seizure :
 is an intermittent stereotypical, usually unprovoked,
disturbance of consciousness, behaviour, emotion, motor
function or sensation that on clinical grounds results from
cortical neuronal discharge
 Epilepsy is a condition in which seizures recur, usually
spontaneously
Definition of Epilepsy by cause
 Idiopathic
 Symptomatic
 Drugs
 Alcohol
 Birth Trauma
 Brain Tumour
 CVA (stroke)
 Infection
How Many People Have Epilepsy?
 Epilepsy is the most serious neurological disorder affecting
people of all ages.
 It is believed that, as an absolute minimum, 0.5% of the
population have Epilepsy, this equates to 1 person in every
200, (350,000 people).
 20% of children, onset being before the age of 5 years.
 30% are sufferers between the ages of 6 and 25 years
 50% the onset is after the age of 25.
What causes seizures to happen
 In most people with epilepsy, seizures are spontaneous
events without a clear cause?
 However, in a few people, seizures can also be
triggered by specific stimuli such as flashing lights of
certain frequencies.
 Lack of sleep exhaustion, boredom, anxiety, abrupt
stopping of anti-epileptic medication, to much
alcohol, recreational drugs, computer screens and
games and also a bang to the head or accident can all
cause them.
What types of seizures
do you know?
Classification of Seizures
 Partial-onset seizures
 Simple partial
 Complex partial
 Secondary generalised tonic-clonic
Classification of Seizures cond.
 Generalised-onset seizures
 Typical absence
 Atypical absence
 Myoclonic
 Atonic
 Primary generalised tonic-clonic
 Clonic
 Tonic
Partial-onset seizures
 Commence at any age
 Usually have an aura which reflects seizure origin and
initial spread.
 Awareness may be retained (simple partial), partially
preserved or lost (complex partial)
 Can be secondary generalised tonic clonic
 Common patterns e.g. clustering
Generalised-onset Seizures
 Childhood, adolescence, young adults
 No warning
 Abrupt loss of consciousness (except myoclonus)
 Occur in normal e.g. typical absence or
diffusely abnormal brain e.g. tonic drop attacks
 Common pattern; soon after wakening
Seizures involving
altered consciousness
or behaviour
Simple partial seizures
 Twitching,
 numbness,
 sweating,
 dizziness or nausea;
 disturbances to hearing, vision, smell or taste; a
strong sense of deja vu.
Complex partial seizures
 Plucking at clothes.
 Smacking lips.
 Swallowing repeatedly or wandering around.
 The person is not aware of their surroundings or of
what they are doing.
Atonic seizures
 Sudden loss of muscle control
 Causing the person to fall to the ground.
 Recovery is quick.
Tonic-clonic Seizures
 Can be primary or secondary generalised
 Distinction has implications for management
Myoclonic seizures
 Brief forceful jerks which can affect the whole body or
just part of it.
 The jerking could be severe enough to make the
person fall.
Absence seizures
 The person may appear to be daydreaming or
switching off.
 They are momentarily unconscious and totally
unaware of what is happening around them.
Diagnoses of Epilepsy
 Blood tests.
These are done to check the general health of the
person and help exclude a metabolic cause for the
epilepsy.
 CAT scan or MRI scan
These help to exclude structural cause for the epilepsy
and seizures.
 EEC (Electroencephalogram)
This test measures the electrical activity of the surface
of the brain at the time of the test.
Prevalence of epilepsy in people
with Learning Disability
 Up to 30% of people with LD have epilepsy
 About 30% of people with epilepsy have LD
 More common in people with severe to profound LD
50%+
Current antiepileptic drugs
 Phenobarbitone 1912
 Primidone
1952
 Carbamazepine 1963
 Clonazepam
1974
 Vigabatrin
1989
 Gabapentin
1993
 Topiramate
1995
 Oxcarbazepine 2000
 Pregabalin
2004
Phenytoin
1938
Ethosuximide
1960
Sod. Valproate 1974
Clobazam
1982
Lamotrigine
1991
Piracetam
1993
Tiagabine
1998
Levetiracetam 2000
Zonisamide
2005
A Common Sense Approach
Issues Specific to Learning Disability
 Communication
 Care situation
 Co-morbidity
Communication
 People with Learning Disabilities are more
likely than the general population to have
communication difficulties.
 This can make information gathering and
history taking difficult.
Communication
 Various reasons:
• “Physical” e.g. dysarthria due to cerebral palsy,
deafness, cleft palate.
• “Psychological” e.g. specific deficits due to autism,
mute due to anxiety/ depression.
• “Pathological” e.g. due to the severity of
intellectual impairment – i.e. lacks ability to
understand and communicate.
Communication
 May have no verbal communication, but may
communicate through:
• Signing – e.g. Makaton
• Pointing – e.g. to word cards
• Picture boards / communication passports
• Gesture
• Carers
• Facial expression
• Behaviour
 So don’t make assumptions - ask!
Communication
 May have verbal communication but :
• Do not properly understand questions
• Cannot adequately describe symptoms
• Cannot understand concept of time
• Cannot see this as important/ relevant
• Wishes to avoid talking about epilepsy
• Finds talking about other subjects more interesting
Carers
 Clients now find themselves in a variety of care
settings:
 Family home
 Their own homes – with professional support - from





minimal to 24 hours
Shared tenancies
Group homes
Nursing Homes
Continuing NHS Care
Private Care Homes
Epilepsy Care Plans
 These should include:
 Contact details for all involved
 Details of Medication
 Summary of Seizure Types
 Annual/ monthly Seizure Charts
 Rescue Medication protocol
 An epilepsy history
 A section to record any contact the patient has with GP/
hospital/ nurse, etc
Carers - Training
Carers need to be trained in the following areas:
 Epilepsy Awareness
 Administration of Rescue medication


Rectal diazepam
Buccal Midazolam
 First Aid and Basic Life Support
 Moving and Handling
 But also may need to be individualised for specific
patients/ circumstances
Co-morbidity - Physical
 Genetic conditions predisposing to physical illness
• Downs Syndrome - hypothyroidism, leukaemia, heart
defects, diabetes
• Tuberous Sclerosis - kidney and cerebral tumours
 Physical condition of which LD is a feature
• Cerebral Palsy – scoliosis, prone to urinary or respiratory
infections
• Encephalitis – epilepsy
 Developmental disorders of which physical disorder is a
feature
• Autism - epilepsy
Co-morbidity - Difficulties
 Investigations:
 May not tolerate investigations (or presumed they will
not tolerate investigations)
 May have non specific abnormal results (associated with
aetiology of Learning Disability but not necessarily of
seizures)
 Consent issues – MCA 2005
Co-morbidity - Difficulties
 Medications:
 Drug interactions
 Side effects
•
•
AEDs - Cognitive/ Behavioural/ Physical
Psychotropics - lower seizure threshold
 Compliance
 Consent
 Formulations
•
PEG feeding, swallowing problems
Practical difficulties in LD and
epilepsy
 Diagnostic difficulties
 Difficulties getting accurate information from carers
 Lack of carer education / experience of epilepsy
 Mistaking stereotypes with seizure activity
 Client tolerance of investigations
 Non Epileptic Attack Disorder (NEAD)
Management Difficulties
 Increased rates of side-effects
 Patients may not be able to report side effects
 Other behaviours and psychiatric disorder may be
masked by high levels of sedation
 Informed consent about care plan may be impossible
Medical Emergencies
 Status Epilepticus or Recurrent seizures (i.e. more
than 2/3 without apparent recovery in-between)
 Unusually prolonged seizure (Depends upon
individual)
 Not responding to Stesolid (Rectal valium)
 Not known to have epilepsy
Medical Emergencies
 Cluster of seizures without signs of stopping (Recurrent
seizures with recovery period between).
 Suspected serious secondary injury (e.g. from fall during
tonic stage).
 You are concerned and need further advice .
 Remember - if in doubt do too much rather than too little
EMERGENCY FIRST AID
 Tonic-Clonic seizures
 The person loses consciousness, the body stiffens, then
falls to the ground.
 This is followed by jerking movements. A blue tinge
around the mouth is likely. This is due to irregular
breathing.
 Loss of bladder and/or bowel control may occur.
 After a minute or two the jerking movements should
stop and consciousness may slowly return.
First Aid
 Don’t panic .
 Once a seizure has started there is nothing you can do




to stop it.
If you can get to the person quickly enough try to
gently lower them to the ground.
Remember to look after your back and if the person is
writhing violently it may be best to stand away and let
the person fall.
If you get injured you will be of no use to the person
having a seizure.
Make a note of the time.
First Aid
 Once the person is on the floor try to loosen any
clothing such as belts, ties buttons etc. This is to
ensure an adequate blood and oxygen flow.
 Do not restrain the person in any way. The violent
contractions of the muscles could results in bone
breakage.
 If possible remove any objects that could cause further
injury to the person. Move chairs and tables out of the
way as well as knives and forks.
First Aid
 Try to put something soft under their head to prevent
any head injuries e.g. cushions or blankets or even your
coat.
 Never put anything in the mouth or try to remove the
tongue from between the teeth. If they are going to
bite their tongue or lips they will have already done so.
 When the seizure has finished. Check the airway and
breathing, put the person gently in the recovery
position.
First Aid
 After the seizure the person may simply fall asleep
where they are. They may be confused and dazed but
will almost certainly want to sleep.
 Stay with the person and accompany them to their bed
or the nearest sofa. Let the person sleep and check on
them regularly.
 Record the seizure.
Don't...
 Restrain the person
 Put anything in the person’s mouth
 Try to move the person unless they are in danger
 Give the person anything to eat or drink until they are
fully recovered
 Attempt to bring them round
Call for an ambulance if...
 You know it is the person’s first seizure
 The seizure continues for more than five minutes
 One tonic-clonic seizure follows another without the
person regaining consciousness between seizures
 The person is injured during the seizure
 You believe the person needs urgent medical attention
Recording a seizure.
 There is no agreed standard for the recording of
epileptic seizures.
 Partial seizures .i.e. absences may be difficult to spot
and therefore record accurately.
 Generalised seizures are easier to record but activity
before the seizure took place may be of greater
importance in identifying and preventing triggers than
other details.
Recording a seizure
 If someone has regular seizures it maybe possible to
break the recording down.
 For example first try to identify what time of day the
seizures are most likely to occur .i.e. their duration.
 Then concentrate on what the person is doing
immediately preceding a seizure to try and establish if
there are obvious triggers.
 Finally concentrate on what actually takes place during
the seizure. For example; colour changes, movements,
breathing, and condition after the seizure.