ABC of Epilepsy E-Book

W. Henry Smithson

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 126

Veröffentlichungsjahr: 2012

Beschreibung

ABC of Epilepsy provides a practical guide for general practitioners, and all those working in primary care, on the diagnosis, treatment and management of epilepsy, and for the continued monitoring and long term support of what is still a relatively poorly understood neurological disorder.

This brand new title in the ABC series is highly illustrated throughout and presents what epilepsy is, its classification, and how to diagnose it. It covers anti-epileptic drugs and non-drug treatments, as well as self-management and living with epilepsy.

Edited by a general practitioner and neurologist team, the ABC of Epilepsy reflects current NICE guidelines and is ideal for all GPs, primary health care professionals, practice nurses and specialist nurses, and non-specialist medical staff who play an increasing role in monitoring and managing of epilepsy patients.

Leseprobe

Table of Contents

Title Page

Contributors

Foreword

Preface

Copyright

Chapter 1: What is Epilepsy? Incidence, Prevalence and Aetiology

What is epilepsy?

Epidemiology

The aetiology of epilepsy

Prognosis

Chapter 2: Describing and Classifying the Condition

The classification of epilepsy

Chapter 3: Making the Diagnosis—Taking a History, Clinical Examination, Investigations

Making the diagnosis

Taking a history

Clinical examination

Investigations

Common misdiagnoses

Diagnostic considerations in special groups

Chapter 4: Managing the Drug Treatment of Epilepsy

General principles

Starting treatment

Continuing treatment

Choosing an antiepileptic drug

Monitoring antiepileptic drug levels

Withdrawing antiepileptic drugs

Chapter 5: Non-drug Treatments Including Epilepsy Surgery

Epilepsy surgery

Psychological interventions

Biofeedback

Vagal nerve stimulation

Ketogenic diet

Chapter 6: Prolonged or Repeated Seizures

Treatment of prolonged or repeated generalised convulsive seizures

Treatment of non-convulsive status

Prevention of status epilepticus

Chapter 7: Special Groups—Women, Children, Learning Disability and the Elderly

Children

Women

People with a learning disability

Older people

Chapter 8: Monitoring and Review—How to Manage the Condition Long Term

People with learning disability

Children

Key principles of review

The role of primary care

The role of secondary care

The role of intermediate care

Chapter 9: Living with Epilepsy—Information, Support and Self-Management

Self-management

Support

Sudden unexplained death in epilepsy

Providing information

Training resources

Acknowledgements

Appendix: Epilepsy Charities

Index

Contributors

Jan Bagshaw

Clinical Nurse Specialist, Community Epilepsy Services, Rochdale, UK

Colin D. Ferrie

Consultant Paediatric Neurologist, Leeds General Infirmary, Leeds, UK

Alice Hanscomb

Independent Trainer and Leadership Consultant, Director of Hanscomb Training & Consultancy, High Wycombe, UK

Mike P. Kerr

Professor of Learning Disability Psychiatry, Cardiff University; Welsh Centre for Learning Disabilities, Cardiff, UK

W. Henry Smithson

General Practitioner and Acting Head, Academic Unit of Primary Medical Care, Medical School, University of Sheffield, Sheffield, UK

Matthew C. Walker

Foreword

Twenty years ago my partner, a young barrister, telephoned to say he was in hospital following a seizure whilst driving. Four months later he was seen by a neurologist, diagnosed and advised to take medication. Two months later he was discharged back to his GP, but died three months later suddenly and unexpectedly in his sleep. At no point was any information given about epilepsy or SUDEP (sudden unexpected death in epilepsy), and no one offered a helpline. Research and recognized good practice has advanced in leaps and bounds since my first encounter with epilepsy, and the editors, Henry and Matthew, are two of a small number of doctors who have made this happen.

I am honoured to write this foreword and must congratulate the editors and contributors on this wonderful book. Readers of this book will not only benefit from the expertise of researchers who are clinical leaders in the field, but will gain from the insight of professionals who have improved the lives of people with epilepsy and their families.

Epilepsy is the most serious common neurological condition. The impact of the epilepsies, however, remains underestimated. Epilepsy represents more than recurrence of seizures because it is associated with significant co-morbidities. Mortality rates have increased over the last 20 years when mortality rates have fallen across other conditions. In the UK, 70% of the population with epilepsy could be seizure free with optimal treatment, but only 52% achieve freedom from seizures.

This book is essential reading for any professional likely to come across epilepsy in their day-to-day practice.

Jane Hanna OBE

Director, Epilepsy Bereaved

Preface

The purpose of this addition to the ABC series is to provide a source of up-to-date information to enhance and broaden the management of a complex and challenging condition. Most current epilepsy texts have taken a predominantly biomedical perspective aimed at the specialist, but of less relevance to generalists involved in the management of people with epilepsy. We have addressed this gap by providing a practical approach to care throughout the patient pathway.

As a first step, it is critical to ensure that the diagnosis is correct and complete. Drug treatment should then be matched to the type of epilepsy and to the patient. However, there are other treatment modalities, and it is important to identify which people are suitable for these. Most importantly, the condition should be reviewed in a timely and supportive way. Epilepsy management is not just related to seizures, but encompasses numerous psychosocial challenges, which are often neglected. Patients need to be fully informed so that they can share in management decisions with clinicians to ease the burden of living with the condition.

This book is aimed at non-specialist physicians, general practitioners, practice and community nurses, clinicians in Accident and Emergency departments, doctors and nurses in training and those involved with the social aspects of care which is so important to many of those with epilepsy.

The editors have substantial experience in different aspects of care: one is an academic general practitioner with an interest in the condition who chaired the first NICE guideline group and was foundation chair of the UK International League against Epilepsy GP Society, and the other an academic neurologist with an international reputation in the field of translational epilepsy research and the management of people with drug resistant epilepsy.

The editors would like to record their thanks for expert contributions from other epilepsy specialists, epilepsy nurses and the voluntary sector. Thanks are also due to the National Institute for Health and Clinical Excellence for allowing us to use NICE Guideline CG20 as a resource that underpins much of this book.

Lastly we would like to thank Adam Gilbert (Commissioning Editor) and Kate Newell (Senior Development Editor) at Wiley Blackwell for their guidance and patience in the conception and delivery of this book.

W. Henry Smithson

Matthew C. Walker

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Library of Congress Cataloging-in-Publication Data

ABC of epilepsy / edited by W. Henry Smithson and Matthew Walker. — 1st ed.

p.; cm.—(ABC series)

Includes bibliographical references and index.

ISBN 978-1-4443-3398-5 (pbk. : alk. paper)

I. Smithson, Henry. II. Walker, M. C. (Matthew Charles) III. Series: ABC series (Malden, Mass.)

[DNLM: 1.Epilepsy. WL 385]

616.85′3—dc23

2011045228

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Chapter 1

What is Epilepsy? Incidence, Prevalence and Aetiology

W. Henry Smithson1 and Matthew C. Walker2

1Academic Unit of Primary Medical Care, Medical School, University of Sheffield, UK

2UCL Institute of Neurology, University College London and National Hospital for Neurology and Neurosurgery, London, UK

Overview

Epilepsy is not a single condition but a term to describe a tendency to have recurrent unprovoked seizuresIt is the commonest serious neurological condition with an incidence of about 50 cases per 100 000 per year and prevalence estimated at 5–10 cases per 1000About 50% of cases have no identifiable cause, but the majority of new cases in adults is symptomatic and so investigations are needed to identify the underlying cause

Epilepsy is not one entity but more a fascinating group of conditions with many different manifestations depending on the part of the brain that is affected, the age of the individual, any underlying cause and the way that seizure activity spreads. It is one of the oldest recorded medical conditions. The first known written reference to it is in a Babylonian cuneiform dating back more than 3000 years, and epilepsy was considered a form of possession by a demon or departed spirit. Five hundred years later the same concept is present in Greek texts; indeed the word ‘epilepsy’ derives from the Greek for ‘to possess’ or ‘to take hold of’. The Ancient Greeks considered that only the gods could knock someone unconscious, make their body thrash around uncontrollably, and afterwards bring them around with no apparent ill effects. Even today, seizures can be frightening to see, and lead to unnecessary prejudice and misunderstanding.

What is epilepsy?

An epileptic seizure is a clinically discernible event, which results from the synchronous and excessive discharge of a group of neurons in the cerebral cortex. The manifestation of a seizure depends on where in the brain it starts and how far and fast it spreads. Epileptic seizures usually have a sudden onset, spread in a matter of seconds or minutes and, in most instances, are brief. The seizure can be divided into a prodrome (the occasional recognition that a seizure will occur, sometime hours or days beforehand), the seizure, which may include an aura (symptoms present at the beginning of a seizure), and lastly the post-ictal state (a period after the seizure during which the patient is usually confused). The mechanisms underlying seizure initiation and spread are still poorly understood, but involve the aberrant synchronisation of excitatory neurons, abnormal neuronal firing (e.g. burst firing) and a failure of inhibition. Seizures can therefore result from the ingestion of or withdrawal from drugs that affect neuronal activity (e.g. mefloquine, alcohol, benzodiazepines).

It is important to distinguish between seizures and epilepsy. Epilepsy is the tendency to have recurrent, unprovoked seizures. Seizures can result from specific precipitants such as fever in young children; soon after stroke; metabolic disturbances, for example hypoglycaemia; drug abuse/withdrawal; or acute head injury. These seizures are termed acute symptomatic seizures. Following such seizures, the chance of an unprovoked seizure is usually quite low and so the person would not be considered as having epilepsy. Similarly a single seizure is not usually considered sufficient to make a diagnosis of epilepsy. To make a diagnosis of epilepsy, there has to be a likelihood of having recurrent, unprovoked seizures. The seizure risk should be assessed when we are considering starting treatment, allowing someone to drive a car, fly a plane etc.

The tendency to have recurrent, unprovoked seizures results from alterations in brain excitability either as a result of genetic or environmental factors (or a combination of both). Epilepsy can therefore result from a number of underlying causes, and is thus best considered a symptom of an underlying brain disorder. The difficulties in attaching a threshold to the diagnosis of epilepsy have led to difficulties in epidemiological studies. For example, if someone is treated with antiepileptic drugs (AEDs) for a couple of seizures but has been seizure free for 10 years, would you consider them as having epilepsy?

Epidemiology

Given the variability in the definition of epilepsy, the incidence in the UK has been estimated to be approximately 50 cases per 100 000 people per year. No consistent national or racial differences have been found. However, the incidence is higher in low-income countries (probably due to the increased incidence of infective brain diseases), and in rural communities. The incidence of epilepsy has a bimodal distribution with a peak in the first two decades of life (epilepsy secondary to genetic and congenital aetiologies) and a second peak in later life, over 60 years of age, due to late seizures after stroke and tumours (Figure 1.1). The incidence in children is decreasing, possibly due to better perinatal care, whilst the incidence in the elderly is increasing, possibly due to better survival of people following strokes.

Figure 1.1 Incidence of epilepsy with age. Source: After Hauser et al. (1993)

Most prevalence studies of active epilepsy have found rates between 5 and 10 per 1000 persons in the population, regardless of location. Lifetime prevalence rates are much higher, and it is estimated that 2–5% of the population at age 70 years will have had epileptic seizures at some point in their lives (Figure 1.2); this is slightly higher in men than women. Epilepsy is more common in certain populations such as people with cerebral palsy and people with autism and/or learning difficulties.

Figure 1.2 Cumulative prevalence of epilepsy. Source: After Hauser et al. (2011)

The aetiology of epilepsy