Epilepsy: top tips
Greg Rogers, Clinical Champion for Epilepsy, 2013 - 2015
I am sure most of us have witnessed the dramatic scene of a person suffering an epileptic attack, it is distressing for the patient, their family and friends and for those around. Epilepsy however often remains an area which we as GPs approach with less confidence than we do other long term conditions. Epilepsy was chosen as a clinical priority, partly in response to numerous reports which provided evidence of the need to improve services for epilepsyi. The All Party Parliamentary Groupii reports that whilst only around 50% of the population with epilepsy are currently seizure free, it is usually possible to achieve seizure freedom rates of 70%. This highlights that there is a 20% treatment gap.
Seizure freedom reduces the standardised mortality rate to nearing that of the general population. Uncontrolled epilepsy has a high cost in terms of social and physical well being as well as generating unnecessary expense to the NHS. In the recent CCG- Outcome Indicator Set, epilepsy ranked the fifth highest long term ambulatory conditioniii to require unplanned admission to hospital. It is not surprising then to discover that amongst the findings are:
• 400 avoidable deaths a year from epilepsy
• 69,000 people living with unnecessary seizures
• 74,000 people taking drugs they do not need
• £189 million needlessly spent each year
My hope is to offer support and help for GPs to feel more conversant with this long term disease to reduce the impact of epilepsy on those affected by it. The following are my top five tips to help bring this about:
1. Seizure freedom: If a person has ongoing seizures, with or without loss of awareness and has not been reviewed and given a management plan by specialist care, offer referral to the local epilepsy service.
2. Psychosocial support: General practice is about holistic care. Reducing the psychosocial consequences of epilepsy can be identified by GPs being aware of the increased likelihood of depression and anxiety in this group. The pros and cons of SSRI treatment and referral to the local counselling services can be offered. Sign posting to the voluntary services and support for this can be found on Epilepsy Action’s website.
3. Women and girls with epilepsy: The MHRA have altered the guidance for sodium valproate following new further evidence of its teratogenicityiv and advise that all women at risk should have a discussion with an epilepsy specialist involving assessment of the risk/benefit.
4. Knowledge of Epilepsy: Undergraduate and postgraduate education on epilepsy can be scanty and one of the best ways to remedy this is through eLearning. An ideal package can be accessed here.
5. Epilepsy in the elderly, especially those with dementia: The prevalence of active epilepsy in the elderly population is up to 1.5%, but among nursing home residents may exceed 5%v. Atypical presentations may also include altered mental status, periods of staring, unresponsiveness, brief losses of consciousness, inattention, memory lapses or confusion. Should major seizures occur, their characteristics are similar to those in younger people – important markers being lateral tongue biting, waking in an ambulance or in hospital, or significant injuries.
This list is not definitive, but by applying these five top tips, we should see the lives of people greatly affected by epilepsy begin to improve.
For more information please refer to the RCGP Epilepsy Resources page.
iA Critical Time for epilepsy in England, Epilepsy Action, January 2013
iiWasted Money, Wasted Lives: The human and economic costs of epilepsy in England, All Party Parliamentary Group on Epilepsy, 2008
iiiCCG Outcomes Indicator Set: Emergency Admissions, The NHS Information Centre for health and social care, March 2013
ivMedicines related to valproate: risk of abnormal pregnancy outcomes, Medicines and Healthcare Products Regulatory Agency, 22 January 2015
vEpilepsy in the Elderly, Ann Johnston, Phil EM Smith, 2010, http://www.medscape.com/viewarticle/733423_1