Can We Meet the Challenge? Raymond Tallis FRCP FMedSci SIG Meeting1.
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Transcript of Can We Meet the Challenge? Raymond Tallis FRCP FMedSci SIG Meeting1.
Can We Meet the Challenge?Raymond Tallis FRCP FMedSci
SIG Meeting 1
CommonDifferentUnder-researchedService challenges
SIG Meeting 2
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Unpleasant experience
Physical consequences
Psychosocial consequences
Underlying cause
SIG Meeting
CommonDifferentUnder-researchedService challenges
SIG Meeting 4
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5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age
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SIG Meeting 5
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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
CommonDifferentUnder-researchedService 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)
•Cleary, Tallis, Shorvon Lancet 2004
p <0.0001
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
CommonDifferentUnder-researchedService 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
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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 Meeting 15
CommonDifferentUnder-researchedService challenges
SIG Meeting 16
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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 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
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 Meeting 21
Need comprehensive, thoughtful, expert assessment AND reassessment
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To make epilepsy the least important thing in
the patient’s life
SIG Meeting
Need to have expertise in epilepsyNeed 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/rapportEducation, support and advice Act as resource of informationMonitoring of medicationTelephone helplineLink 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.
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Epilepsy in older adults is:
More common More important More to gain Much to be done
SIG Meeting