can we meet the challenge? raymond tallis frcp fmedsci sig meeting1
TRANSCRIPT
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Can We Meet the Challenge?Raymond Tallis FRCP FMedSci
SIG Meeting 1
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CommonDifferentUnder-researchedService challenges
SIG Meeting 2
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Unpleasant experience
Physical consequences
Psychosocial consequences
Underlying cause
SIG Meeting
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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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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
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CommonDifferentUnder-researchedService challenges
SIG Meeting 7
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Presentation
Type of seizure
Differential diagnosis
Aetiology
Co-morbidity
Functional consequences
Clinical pharmacology
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Pre-stroke seizures
Post-stroke seizures
SIG Meeting 9
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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
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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
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CommonDifferentUnder-researchedService challenges
SIG Meeting 12
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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
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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
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CommonDifferentUnder-researchedService challenges
SIG Meeting 16
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Accurate diagnosis
Comprehensive management
SIG Meeting
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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
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Muddling non-seizures with seizure
Muddling seizures with non-seizure
SIG Meeting 19
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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
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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
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Need comprehensive, thoughtful, expert assessment AND reassessment
SIG Meeting 22
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To make epilepsy the least important thing in
the patient’s life
SIG Meeting
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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
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Shared care Role of GPSIs The annual review Hospital-based epilepsy service Specialist epilepsy nurse
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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
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Building good relationships/rapportEducation, support and advice Act as resource of informationMonitoring of medicationTelephone helplineLink between primary and secondary care
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Research study conducted for Epilepsy Action
April – May 2005
SIG Meeting 28
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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
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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
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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
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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
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Accurate diagnosis Full information Appropriate drug treatment Ready access to review of diagnosis and
treatment Ready access to further information and
advice
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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