Can We Meet the Challenge? Raymond Tallis FRCP FMedSci SIG Meeting1

 Common  Different  Under-researched  Service challenges SIG Meeting2

3  Unpleasant experience  Physical consequences  Psychosocial consequences  Underlying cause SIG Meeting

 Common  Different  Under-researched  Service challenges SIG Meeting4

Age Incidence/100,000 SIG Meeting5

6  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

 Common  Different  Under-researched  Service challenges SIG Meeting7

 Presentation  Type of seizure  Differential diagnosis  Aetiology  Co-morbidity  Functional consequences  Clinical pharmacology SIG Meeting8

 Pre-stroke seizures  Post-stroke seizures SIG Meeting9

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 < SIG Meeting10

 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 Meeting11

 Common  Different  Under-researched  Service challenges SIG Meeting12

Percentage of patients remaining in the trial over time (52 weeks). Rowan et al. Neurology 2005; 64: SIG Meeting13

14  When to start?  Which drug?  What dose?  Adverse reactions?  Interactions?  Monitoring?  Compliance?  Withdrawal? SIG Meeting

 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 Meeting15

 Common  Different  Under-researched  Service challenges SIG Meeting16

17  Accurate diagnosis  Comprehensive management SIG Meeting

 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 Meeting18

 Muddling non-seizures with seizure  Muddling seizures with non-seizure SIG Meeting19

 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 Meeting20

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’ SIG Meeting21

Need comprehensive, thoughtful, expert assessment AND reassessment SIG Meeting22

23 To make epilepsy the least important thing in the patient’s life SIG Meeting

 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 Meeting24

 Shared care  Role of GPSIs  The annual review  Hospital-based epilepsy service  Specialist epilepsy nurse SIG Meeting25

 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 Meeting26

 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 Meeting27

Research study conducted for Epilepsy Action April – May 2005 SIG Meeting28

 9 out 10 geriatricians see elderly people with seizures  Most geriatricians think the prevalence of seizures is lower than it in fact is SIG Meeting29

 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 Meeting30

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 Meeting31

 Training and education (geriatricians, neurologists) [NB National Meeting 2 nd March]  Professional bodies: Special Interest Groups  Flag up nationally: DoH (New Commissioning arrangements?)  Voluntary Bodies SIG Meeting32

 Accurate diagnosis  Full information  Appropriate drug treatment  Ready access to review of diagnosis and treatment  Ready access to further information and advice SIG Meeting33

Do not settle for second class care. SIG Meeting34

35 Epilepsy in older adults is:  More common  More important  More to gain  Much to be done SIG Meeting