About this course:
The purpose of this course is to examine the most common types of epilepsy and seizures across the lifespan, reviewing the incidence and prevalence, risk factors, clinical presentation, diagnostic criteria, and treatment modalities.
The purpose of this course is to examine the most common types of epilepsy and seizures across the lifespan, reviewing the incidence and prevalence, risk factors, clinical presentation, diagnostic criteria, and treatment modalities.
At the conclusion of this exercise, the nurse will be prepared to:
- Identify the appropriate terms and definitions related to seizures and epilepsy.
- Consider the impact of epilepsy on healthcare in the US and worldwide.
- Formulate an understanding of the pathophysiology of seizures.
- Identify precipitating factors for seizures and epilepsy.
- Discuss the assessment and diagnosis of seizures and epilepsy.
- Discuss the management of a patient with seizures and epilepsy.
- Explore the self-management and education needed for patients with seizures and epilepsy.
Epilepsy is a brain condition resulting in recurrent seizures. Seizures are disruptions in electrical communication between neurons. The term epilepsy is used if there are two or more seizures that are not caused by stimulation more than 24 hours apart, or after one seizure if the patient is at high risk for further seizure activity (Epilepsy Foundation, 2020a). Epilepsy is one of the most common neurological disorders in the US and is associated with multiple conditions that affect mental and physical health. Epilepsy can shorten a person’s life and significantly alter their well-being and ability to participate in activities of daily life (The Centers for Disease Control and Prevention [CDC], 2017).
Approximately 65 million people across the world suffer from epilepsy, with 3.4 million adults and nearly 500,000 children affected in the US. There are 150,000 new cases of epilepsy in the US annually, and 1 in 26 will develop epilepsy during their lifetime. Approximately one-third of those with epilepsy have uncontrollable seizures, with no current effective treatment modalities. While many cases of epilepsy have known causes, over 60% have no known cause (Epilepsy Foundation, 2020a).
Types of Seizures
A seizure type is a useful grouping of characteristics of seizures for purposes of communication in clinical care, research, or education. Physicians, pharmacists, researchers, or other stakeholders can use the typing of seizures to refine treatment, determine efficacy of medications, consider eligibility for procedures, or determine the severity of the patient’s diagnosis. Furthermore, a consistency of language among caregivers provides insight to the patient's condition and needs. The basic classifications of seizures are focal onset, generalized onset, and unknown onset (Fisher et al., 2017). The origin of the seizure, or where it starts in the brain explains what may occur during the seizure and the projected effects of the seizure as well as the appropriate treatment course for the seizure based on symptoms (Epilepsy Foundation, 2017c).
Focal Onset Seizures
Focal onset seizures originate within one hemisphere of the brain and may be localized or more widely distributed. For each seizure type, the ictal onset is consistent and exhibits specific patters that involve the ipsilateral and/or contralateral hemisphere. Signs and symptoms occurring during the seizure aids in the identification of the precise area, lobe, or hemisphere involved in the seizure onset and further dissemination (ILAE, 2020).
The seizure will further be classified according to the level of awareness, which is important to determine for daily life functioning and safety. If a seizure includes impaired awareness (patient loses awareness of their surroundings), then it is classified as such. The initial sign/symptom is the most important as it identifies the region of the brain the seizure originates, even if the seizure has other features. Focal seizures can be classified as follows:
- Aware or impaired awareness AND
- Motor onset OR
- Nonmotor onset which has the following subsets:
- Focal sensory seizure- a sensation present at onset such as tingling, flashing of lights, buzzing, odor, taste, dizziness, hot/cold feeling, or lightheadedness.
- Focal cognitive seizure- involves an alteration of cognitive function or thoughts.
- Focal emotional seizure-involves alterations in mood or emotions.
- Focal autonomic seizure-involves the autonomic nervous system and may begin with palpitations, epigastric sensations, pallor/flushing, erection, hypoventilation, urge to urinate or defecate, lacrimation, or pupillary dilation/constriction.
- Focal behavioral arrest seizure-involves a decrease in amplitude or arrest of ongoing motor activity during the seizure (ILAE, 2020).
Focal seizures can affect a large area of the brain and engage bilateral networks that include both the cortical and subcortical structures, which results in tonic-clonic seizure and loss of consciousness. This seizure would be classified as a focal to bilateral tonic-clonic seizure (ILAE, 2020).
Generalized Onset Seizure
The second group, a generalized onset seizure, will have the following classifications:
- Tonic-clonic and variants
- Epileptic spasms
- Nonmotor onset
- Typical absence
- Atypical absence
- Myoclonic absence
- Absence with eyelid myoclonia
The generalized seizure will have an originating point and rapidly engaging networks that are distributed bilaterally and can include cortical and subcortical structures, but not necessarily the entire cortex. Each individual seizure may appear localized, but the location and lateralization are not consistent from one seizure to the next (ILAE, 2020).
Unknown Onset Seizure
The third classification is unknown onset seizure and is used when there is no distinct categorization for the seizure with focal or generalized classifications. Seizures with an unknown onset can be further classified as motor or nonmotor. Often this classification is used until a distinction is made to the other classifications. For instance, if a patient comes into the emergency department after having a seizure, there may be inadequate information to place it into the proper category. After a thorough workup and diagnostics, a further classification may be made and update from the unknown onset classification (ILAE, 2020).
Lennox-Gastaut syndrome (LGS) is a severe kind of childhood epilepsy characterized by multiple types of seizures, particularly tonic and atonic seizures. LGS is considered an epileptic encephalopathy meaning the frequent seizure activity and abnormal electroencephalograph (EEG) activity degrades cognitive function and behavioral problems. The affected child suffers from behavioral problems that includes hyperactivity, aggression, or agitation; autism is common. Intellectual and behavioral problems make life difficult to manage for these individuals. The seizures usually begin in preschool years but may not be diagnosed for years. LGS seizures are difficult to manage and continue through the life of the patient. Children may not exhibit all the features of LGS and require close follow-up to ensure an accurate diagnosis. Onset of the disease past 10 years of age is rare. Emotional or developmental problems are usually recognized in the patient prior to LGS and there is a higher number of boys diagnosed than girls, but no racial differences are noted. One in four people suffering from LGS has no known cause. The condition is diagnosed b
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- Multiple seizure types starting in childhood but emerging over time.
- Characteristic EEG pattern with diffuse or widespread background slowing and slow spike-wave bursts in wakefulness with generalized paroxysmal fast activity found in sleep.
- Cognitive impairment, behavioral problems, or developmental delay may be present prior to the onset of seizures. They increase in severity over time with onset of seizure activity (Epilepsy Foundation, 2019c).
Dravet syndrome is another rare and drug resistant type of epilepsy beginning in the first year of life in an infant who is otherwise healthy. Onset is typically a prolonged seizure occurring with fever and on one side of the body, losing control of motor activity in their arm, face, foot, or other body part. The infant is developmentally normal prior to the onset of seizures with a decline afterwards and by late childhood they develop a crouched walk; these patients typically walk in a stooped posture due to nonphysiologic tightening of particular ligaments and muscles. Most cases of Dravet syndrome are due to a severe SCN1A gene mutation and the child develops varying degrees of developmental disability. In most cases, the mutation is not present in the parents and is considered a new or random mutation in the child. Seizures are typically tonic-clonic or clonic on one side of the body. The seizures are typically longer than five minutes and can result in status epilepticus. They recur every few weeks in infancy and early childhood. While the initial seizure is most often triggered by fever, subsequent seizures can be triggered by flashing lights, emotional stress or excitement. The child usually develops up to the age of two, but then lose developmental milestones and progress slower as they age. The child with Dravet syndrome may have a low motor tone, unsteady gait, crouched walking as they age, growth or nutritional problems, and problems with the autonomic nervous system which may affect the heart, lungs, stomach or intestines. This syndrome has mistakenly been linked to vaccines as children develop it near routine times for vaccines, but there has been no proven linkage in numerous research studies. Dietary therapy, vagus nerve stimulation, and combination medication therapies are used to control seizures (Epilepsy Foundation, 2019b).
Types of Epilepsy
Epilepsy classification involves three levels: the seizure type, the epilepsy type, and epilepsy syndrome. In order for clinicians to make the most appropriate diagnosis, a comprehensive history is obtained from the individual and family. Diagnostic testing such as imaging and EEG are considered. The etiology and the classification of epilepsy should be considered along the way and may change as further information is acquired. The classes are:
- Generalized epilepsy-patients have generalized seizure types and may have interictal and or ictal EEG findings. There is a generalized epileptiform to the EEG patterns. This classification includes childhood absence epilepsy, juvenile myoclonic and absence epilepsy or epilepsy with generalized tonic-clonic seizures.
- Focal epilepsy-patients have focal type seizures and may have interictal or ictal EEG findings that normally accompany focal seizure types. Focal epilepsies may be unifocal, multifocal, or hemispheric.
- Combined generalized and focal epilepsy-patients have both generalized and focal seizure types and interictal or ictal EEG findings that accompany each seizure type. Dravet and Lennox Gastaut syndrome are in this classification.
- Unknown epilepsy-this term may be used during the diagnostic process until further determination is made. EEG can be normal or uninformative (ILAE, 2020).
Epilepsy etiology can include genetic, structural, metabolic, immune, infectious, or unknown origins. The following are examples of each etiology group:
- Genetic - chromosomal or gene abnormalities.
- Structural - malformations of cortical development, vascular malformations, hippocampal sclerosis, traumatic brain injury, or tumors.
- Metabolic - creatinine disorders, folic acid responsive seizures, glucose transporter 1 (GLUT1) deficiency, or cerebral folate deficiency.
- Immune - Rasmussen syndrome or antibody mediated etiologies.
- Infectious - bacterial meningitis, cerebral malaria, cerebral toxoplasmosis, CMV, HIV, or tuberculosis (ILAE, 2020).
Pathophysiology of Seizures
The pathophysiology of seizures can be quite complex; however, a simplistic explanation is a distortion of the normal balance between excitation and inhibition in the brain. The pathophysiology of focal seizures is different from those of generalized seizures, yet the overall cellular excitability from the imbalance of excitation and inhibition is increased with both. The imbalance can occur due to a variety of alterations at many levels of brain function, from genetic or cellular signaling to broad neuronal circuits. Causes of the imbalances can be genetic or acquired. Genetic causes can occur at the circuit level, the receptor level, or abnormal ionic channel functioning such as potassium channel mutations. Acquired cerebral injuries can alter the circuit function as well, such as a prolonged fever or head trauma that causes alterations of hippocampal circuitry, leading to seizure activity. The developing brain in an infant or child is especially prone to seizures with all the physiological changes taking place. However, seizures in children are less likely to cause structural damage than seizures in adults. Since the brain is involved in all bodily functions, multiple areas of the body can be affected during seizure activity (Ko, 2020; Stafstrom & Carmant, 2015).
Recent published information related to the genetic origin of epilepsy indicates that monogenic or polygenic mutations can result in epilepsy. Additionally, there can be multiple gene defects that lead to a state of altered excitability within the nervous system leading to seizure activity. As more knowledge expands, syndrome-specific treatment and interventions will be targeted (Stafstrom & Carmant, 2015).
Over the years, seizure classification and terminology have evolved. Fisher et al. (2017) notes the following changes from 1981 to 2017:
- Change in terminology from "partial" to "focal."
- Change in seizure types to focal, generalized, or unknown onset.
- Seizures of unknown onset can have features that are classified.
- Awareness is a new term used as a classifier of focal seizures.
- Old terms dyscognitive, simple partial, complex partial, psychic, and secondarily generalized were eliminated from terminology related to seizure activity.
- New terms for focal seizure types include automatisms, autonomic, behavior arrest, cognitive, emotional, hyperkinetic, sensory, and focal to bilateral tonic-clonic seizures. Atonic, clonic, epileptic spasms, myoclonic, and tonic seizures can be either focal or generalized.
- New generalized seizure types include absence with eyelid myoclonia, myoclonic absence, myoclonic-tonic-clonic, myoclonic-atonic, or epileptic spasms (Fisher et al., 2017).
Some seizure types appear in multiple categories within the new classification system. While the pathophysiology of seizure types may differ for the focal onset versus the generalized onset, the use of the terms atonic, clonic, myoclonic, and tonic are used for both categories (Fisher et al., 2017).
Many people find that seizures occur in patterns or in response to a stimulus. Seizures are often triggered by precipitating factors that are environmental, physical, clinical, or emotional. These triggers may vary from patient to patient, but common themes are physical or emotional stress, alcohol consumption or drug use, illness (particularly with increased temperatures or hypoglycemia), menstruation, or sleep deprivation. Missing doses of antiepileptic drug (AED) or taking medications that interfere with the function of AEDs can also trigger a seizure. Further triggers in those with epilepsy include strobe lights or video games. Patients and caregivers/parents should be counseled to maintain a record or journal of seizure triggers as these can be helpful in lessening the likelihood that a seizure will be triggered in the future (Epilepsy Foundation, 2014c).
Assessment and Diagnosis
Diagnosing seizures can be a challenge for healthcare providers. There are many disorders that can cause behavioral changes, which can be confused with seizures or epilepsy. As the treatment of seizures requires an accurate diagnosis, determining the type of seizure or epilepsy is vital. Healthcare providers will need clear descriptions of seizure activity including the timing, potential triggers, symptoms, longevity, or any other descriptors that can aid in diagnosis. Most patients will initiate the diagnostic process with a primary healthcare provider, and then are subsequently referred to a neurologist or epilepsy specialist known as an epileptologist. The epileptologist is most often used for high risk cases such as pregnancy and childbirth or uncontrolled seizures. It is crucial to identify any underlying cause for the seizures, and the location within the brain where the seizures are being generated if possible. A detailed medical history, blood tests, electroencephalogram (EEG), and brain imaging, including a computer tomography (CT) scan, magnetic resonance imaging (MRI), or positron emission tomography (PET) scans are needed to properly diagnose the seizure patient (Epilepsy Foundation, 2013a; Mayo Clinic, 2019b).
The initial history should include questions such as:
- Can you give me a description of what happened?
- Is there a family member or witness to the seizure or event that can give further descriptions, including information on loss of consciousness?
- What events led up to the event or seizure?
- Was there any drug or alcohol use prior to the event or seizure?
- Were you sleep-deprived leading up to the event or seizure?
- What was the setting of the event or seizure?
- Had you just stood up or changed positions prior to the event or seizure?
- Was there a warning?
- How long did it last?
- Were there any after-effects following the event or seizure?
- Were you tired or confused after the event or seizure?
- Has there been more than one event or seizure?
- Have you ever seen a healthcare provider for this condition before?
- If so, what tests have been run, and when?
- Were you prescribed any medication for the condition? If so, what? And what effect did it have (Epilepsy Foundation, 2013a; Mayo Clinic, 2019b)?
Since patients may have other diagnoses in addition to seizures, there may be further testing needed. The gold standard for diagnosing a seizure is video EEG monitoring. Additional tests that may be ordered include MRI of the brain or CT angiogram of the head and neck, carotid ultrasound, conventional angiography, PET scan or a cardiac Holter monitor. These tests may be used to rule out or confirm other diagnoses such as transient ischemic attacks (TIAs), stroke, vasculitis, vascular malformations, or cardiac arrhythmias. An overnight sleep study (polysomnography) may be ordered to diagnose parasomnias (abnormal movements during sleep) or obstructive sleep apnea. A movement disorder physiologic study may be done to identify myoclonus or tremor (Epilepsy Foundation, 2013a; Mayo Clinic, 2019a, 2019b).
Blood tests may be performed to evaluate for infection, blood glucose abnormalities, electrolyte imbalances, or genetic conditions. A lumbar puncture may be performed if the healthcare provider suspects that an infection could be the source of the seizure. A full neurological examination should be completed to assess behavior, mental, and motor functioning, and determine if there are other deficits related to the nervous system (Epilepsy Foundation, 2013a; Mayo Clinic, 2019b).
During an EEG, electrodes are attached to the patient’s scalp using a paste-like substance. The electrical activity (impulses) of the brain are recorded by the electrodes. With epilepsy, it is common to have changes in the normal brain activity, which is evident by alterations in the wave patterns on the EEG results, even when a seizure is not occurring. A video EEG is the preferred diagnostic method as it can provide insight into the patient's response and behavior during the seizure; it involves a simple camera recording of the patient during the EEG. It is possible to perform ambulatory EEGs (without video) in which the patient wears the EEG at home; this provides recordings of the patient's brain activity over several days. A high-density EEG gives a more precise determination of the areas of the brain affected by seizures. With this EEG, the electrodes are placed much closer together than a regular EEG, typically 0.5 cm apart. There is no specific patient preparation for an EEG unless instructed by the healthcare provider, such as sleep deprivation in an attempt to trigger a seizure (Mayo Clinic, 2019a). See Figure 1 for an example of a typical EEG strip.
A CT scan can be used to obtain cross-sectional images of the brain to evaluate for structural abnormalities that may be causing the seizures, such as tumors, cysts, or bleeding. A CT scan is a three-dimensional computer-generated image based on x-ray images. An example of an image from a CT scan of the head can be seen below in Figure 2a. Similarly, an MRI can detect lesions or abnormalities in the brain with the use of powerful magnets and radio waves. A more in-depth MRI, called a functional MRI (fMRI), can measure the changes in blood flow within the brain, as seen in Figure 2c. An fMRI may be used prior to surgery to locate critical functions precisely, such as movement or speech, so the surgeon can avoid injury to those areas during surgery. PET scans can be used to detect brain function abnormalities. A small amount of radioactive tracer material is typically injected to help with visualization of chemical activity in certain tissues, as seen in Figure 2b. If the MRI, EEG, or other tests could not determine exactly where the seizures are originating, a single-photon emission CT (SPECT) scan might be conducted. This test uses a radioactive tracer to provide a detailed, three-dimensional map of the blood flow through the brain during seizures (Mayo Clinic, 2019a).
In addition to the aforementioned diagnostic testing, healthcare providers may order statistical parametric mapping (SPM), Curry analysis, or magnetoencephalography (MEG) to determine exactly where the seizures are originating. SPM is a method where tissue metabolism is assessed, as areas of the brain have an increased metabolic rate during seizures, to determine where the seizure originates. Curry analysis combines EEG data and an MRI of the brain to determine where the seizures are occurring. MEG measures the magnetic fields that are created through electrical brain activity to locate the areas of seizure onset (Mayo Clinic, 2019a).
Once an accurate diagnosis is established, through identifying the seizure type and location of origin, proper treatment can be initiated. Some people may have a single seizure that is determined to be associated with an underlying condition; once this condition has been treated, the patient should not have any further seizures. On the other hand, ongoing seizures may be diagnosed as epilepsy (Epilepsy Foundation, 2013a; Mayo Clinic, 2019a).
Management of Epilepsy/Seizures
Since seizures have multiple etiologies not associated with epilepsy, the treatment modalities will vary as well. Treatment for seizures that are not due to epilepsy will be focused on finding the underlying condition and correcting it, while simultaneously halting the seizure activity. During a seizure, medications may be administered intravenously (IV). Typical IV medications for seizures includes benzodiazepines, such as lorazepam (Ativan) and diazepam (Valium). The patient with an acute seizure diagnosis may be initiated on an IV benzodiazepine via continuous infusion t until the underlying cause of the seizure can be determined and corrected. A patient with a diagnosis of epilepsy may be given IV benzodiazepines to stop a seizure but is not typically placed on a continuous infusion or repeated oral doses of a benzodiazepine. Oxygen therapy should be used as indicated. Patients having a seizure should never be restrained and nothing should be put in their mouth that could cause further injury such as a bite guard (Epilepsy Foundation, 2014b, 2020b; Medscape, n.d.).
Similarly, rescue treatments are those needed in special situations during seizure activity outside of a hospital or clinical setting. Many epilepsy patients have emergency medications to be administered by others during an acute seizure (not routine medications that are taken daily) such as diazepam (Valium) or other benzodiazepines to quickly stop the seizure. These drugs may be prescribed for emergency use with clear instructions on administration by family or friends outside of the clinical setting. Emergency care may still be needed, depending on the situation. Rescue medications may be used for seizures that are unusual or last longer than typical events, cluster seizures (multiple short seizures), or with breakthrough seizures that may occur during medication changes or with an acute illness. Diazepam (Valium) can be given rectally, or a dissolvable tablet can be placed under the tongue or between the cheek and gum for quick absorption. Benzodiazepines are not generally used on a daily basis due to their risk of abuse or dependence, particularly to the elderly (Epilepsy Foundation, 2020b)
The most important consideration is safety during seizures. Caregivers should be instructed to provide a safe environment during a seizure. Patients should be gently helped to the floor, placed on their side (preferably right), and their airway kept clear. Clothing around the neck should be loosened, and something soft, such as a pillow, should be placed under their head. The caregiver should stay with the patient and observe any behaviors that can be reported to the healthcare provider later for the support of the treatment plan. 911 should be called if the seizure lasts more than five minutes, if the patient does not return to their typical mental and physical state, if they are injured or pregnant, if there are repeated seizures, if the seizure is the first one for the patient, if there is any difficulty in breathing, or if the seizure occurs in water (Epilepsy Foundation 2020b).
Maintenance Treatment- Pharmacological
Epilepsy patients are typically placed on an AED such as phenytoin (Dilantin) and/or phenobarbital (Luminol). Most seizures can be controlled on a single AED or a combination. Table 2 below offers information on the most common AEDs and their associated nursing implications.
Primary teaching with all AEDs is to take medications at the same time every day and maintain a routine, either with or without food as appropriate. Consistency is vital to maintain a therapeutic blood level and control seizure activity. Medications should never be stopped without the healthcare provider's direction, and many must be tapered to avoid withdrawal symptoms or increased seizure activity. In addition to the list above, other AEDs include:
- Clobazam (Sympazan)
- Valproic acid (Depakene, Valprosid)
- Eslicarbazepine Acetate (Aptiom)
- Ethosuximide (Zarontin)
- Ezogabine (Patiga)
- Felbamate (Felbatol)
- Gabapentin (Neurontin)
- Lacosamide (Vimpat)
- Lamotrigine (Lamictal)
- Levetiracetam (Keppra)
- Midazolam (Nayzilam)
- Oxcarbazepine (Trileptal)
- Perampanel (Fycompa)
- Pregabalin (Lyrica)
- Primidone (Mysoline)
- Rufinamide (Inovelon)
- Tiagabine Hydrochloride (Gabitril)
- Vigabatrin (Sabril)
- Zonisamide (Zonegran)
Further information on these treatments can be found at the Epilepsy Foundation website (2014b).
Cannabis use in the treatment of epilepsy has also been studied. Medicinal properties of cannabis have been largely credited to the two most biologically active phytocannabinoids, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) (Mouhamed, et al., 2018). CBD was isolated in 1940, and THC was isolated in 1964. In the 1990s, the human endocannabinoid system was discovered, and the cannabinoid receptors, CB1 and CB2, were cloned (Rosenberg et al., 2015). Mouhamed and colleagues (2018) assessed treatment with THC to be too broad for therapeutic purposes but found positive findings when they reviewed five trials published between 2013 and 2018 studying the use of CBD in the treatment of drug-resistant epilepsy in children or young adults. These studies showed a more significant reduction in the frequency of atonic and partial seizures, followed by reductions in tonic/tonic-clonic seizures, with minimal reports of adverse effects. Of note, these studies did not utilize CBD as a replacement to the subjects' AED, but as an adjunct. In 2018, the FDA approved cannabidiol (Epidiolex) for the treatment of seizures associated with Lennox-Gastaut syndrome and Dravet syndrome in patients who are two years of age and older. This is the first FDA-approved drug that contains a purified substance derived from marijuana. The efficacy of cannabidiol (Epidiolex) was evaluated through three randomized, double-blind, placebo-controlled clinical trials involving 516 patients with either Lennox-Gastaut syndrome or Dravet syndrome. Within these studies, when cannabidiol (Epidiolex) was taken alongside with other medications, it was shown to be effective in reducing the frequency of seizures when compared with placebo. The most common side effects include sedation, sleepiness, fatigue, weakness, malaise, and lethargy. Less common side effects include elevated liver enzymes, decreased appetite, diarrhea, skin rash, and insomnia. Aside from cannabidiol (Epidiolex), there are no other FDA-approved drug products for epilepsy that contain CBD (FDA, 2020a). Seizures/epilepsy is one of the most common qualifying medical conditions within the states that have legalized the use of medical cannabis/marijuana (Leafly, 2020). Fenfluramine (Pondamin) is currently in clinical trials but is not available publicly at this time. Fenfluramine (Pondamin) was formerly used as an appetite suppressant to treat obesity (Epilepsy Foundation, 2019b).
Nonpharmacological and Self-Management
Patients and their families should be given tools to manage this disorder, including:
- a medication list and schedule,
- a healthcare contact list with phone numbers and other contact information for all healthcare providers and local EMS,
- an online seizure diary or physical journal that maintains information about seizure activity and potential triggers, and
- a dietary diary or menus.
It is important to empower patients with tools that can prepare them for adverse events, prevent future events, and develop plans that ensure preparedness in all situations (Epilepsy Foundation, 2013b). The Epilepsy Foundation (2013a) offers an online diary and a mobile application to document details about an individual's seizure experience. The online resource is called My Seizure Diary and is a self-management tool and medication list to track health history, manage medication and other therapies, recognize triggers through tracking, and even communicate with the healthcare provider (Epilepsy Foundation, 2013a). Seizure alert devices are also available; they help with alerting family members that a seizure is occurring. This can be particularly helpful in children to alert caregivers or family members of impending seizure activity. Service animals can also be trained to alert patients of impending seizure activity or alert caregivers when a seizure occurs, maintaining protection of the patient as well as activating an alert for help (Epilepsy Foundation, 2017b, 2018).
Dietary therapy is suggested by many healthcare providers. Diets such as the classic ketogenic diet, a high-fat, low-carbohydrate, moderate-protein diet, can help with seizure control in many patients. These diets are used in conjunction with medications and not instead of. The ketogenic diet ratio is the ratio of fat to carbohydrate and protein grams combined. Carbohydrates and proteins are restricted, and typically there is a 3:1 or 4:1 ratio of fat to carbohydrates/proteins. A specific number of calories may be prescribed by the healthcare provider or dietician, and the calories will be focused on foods that are high in fat such as heavy whipping cream, butter, mayonnaise, and olive or canola oil. This diet is usually started in the hospital with extensive dietary teaching for the family and may begin with an 18-24 hour fast except for water. This can speed up ketosis. The patient and/or family must monitor for carbohydrates in all foods and medications. Children who go on this diet may decrease their seizures by up to 50%, and another 10-15% become seizure-free on the diet. They will continue to take their medications; however, the diet may allow them to decrease the dose required. Side-effects of this diet can be kidney stones, high cholesterol in the blood, constipation, slowed growth, or bone fractures. Dietary supplements are typically needed as this type of diet does not provide sufficient intake of all micronutrients needed. Calcium, vitamin D, and selenium are likely needed as dietary supplements. Other diets that have shown success are the low glycemic index diet, the medium chain triglyceride (MCT) ketogenic diet, and the modified Atkins diet (Epilepsy Foundation, 2017a).
Other treatment options that should be considered when medication and diet do not control seizures or cause intolerable side effects include surgery or implantable devices. Surgeons may elect to remove the part of the brain that is causing seizures. Neuromodulation is electrical stimulation using a small implanted device that sends electrical currents to the affected area of the brain. There are various devices available, and each works differently, but generally, the stimulation releases substances that change how the cells act and take them back to their normal state (Epilepsy Foundation, 2017b, 2018).
Pregnancy can bring unique challenges to managing epilepsy. Women are affected by epilepsy different than men, partially due to hormonal changes, menstrual cycles, and menopause. Estrogen increases the electrical activity of the brain and progesterone has the opposite effect. Medications are often adjusted due to the different life phases of women, and pregnancy delivers not only challenges to manage medications, but also protection of the unborn child. Over 90% of women with a history of epilepsy have healthy babies, yet 10% may have birth defects. The risk of seizure activity during pregnancy increases by 25% and many require medication adjustments. In most cases, women with a history of epilepsy do not have difficulty becoming pregnant, yet the use of valproic acid (Depakene, Valprosid) can contribute to polycystic ovarian disease, making becoming pregnant more difficult (Epilepsy Foundation, 2014a).
When considering pregnancy, women with epilepsy should plan ahead, as planned pregnancies have opportunities for the greatest outcomes. The healthcare team (often a neurologist and/or epilepsy specialist and obstetrician) can develop a treatment plan ahead of time that provides the optimal opportunities for the mother and baby. Unfortunately, approximately 50% of all pregnancies in the US are unplanned. Baseline pre-pregnancy AED drug levels should be obtained and ongoing monitoring throughout the pregnancy should take place as hormonal changes cause fluctuating medication levels. A prenatal vitamin and folic acid supplement are needed to support nutritional deficiencies and decrease the risk of neural tube defects that are associated with some medications, particularly in the first trimester. Suggested daily dose of folic acid is a multivitamin with 0.4 mg folate, as well as an additional 2 mg folate supplement. The mother should pay close attention to seizure triggers and ensure healthy living with a healthy diet and exercise. There are no reported increases in seizures during delivery; however, if a seizure occurs, medications are given to control it immediately. A Caesarean section might be performed if the mother is at risk of seizure or experiences a prolonged seizure during labor (Epilepsy Foundation, 2014a).
Medications to prevent seizures must be continued during pregnancy, as harm can come to the baby and mother with seizure activity. Seizures can cause falls, auto accidents, premature labor, or miscarriage in the woman, and decreased oxygen delivery and/or heartrate in the baby. Potential birth defects related to AEDs include neural tube defects such as spina bifida, cleft lip/palate, skeletal defects, urologic defects, or heart malformations. Thus, utilization of medications that are safest for both mother and baby are crucial. The lowest risk AEDs include carbamazepine (Tegretol), lamotrigine (Lamictal), and levetiracetam (Keppra). At this time, there are many unknowns about AED use in pregnancy, but it is undeniable that the risk increases with higher dosages and multiple medications within the treatment plan. It is important for pregnant mothers to take the minimum effective dose of a single medication to control seizures whenever possible (Epilepsy Foundation, 2016).
Regarding breastfeeding, most studies monitoring children up to six years of age found they had equal or higher IQs when compared to children who were bottle fed born to mothers taking AEDs. It is suggested that the mother take her AED immediately after breastfeeding to decrease the amount of medication in the breastmilk (Epilepsy Foundation, 2016).
It should be noted that the rate of seizures is highest in the first few years of life, then tapers off through the fifties, then rises again later in life. Seizures increase with other age-related diseases like Parkinson's, but also increase with renal failure, electrolyte or glucose disturbances, drug intoxication or withdrawal, trauma, degenerative diseases like Alzheimer's, infectious diseases such as meningitis or encephalitis, and strokes. Treating the elderly can be challenging due to their sensitivity and reactions to AEDs. Gabapentin (Neurontin) and lamotrigine (Lamictal) have advantages for the geriatric population as they have few interactions with other drugs. Gabapentin (Neurontin) is approved as a single therapy for seizures with high efficacy. Generally, carbamazepine (Tegretol) or phenytoin (Dilantin) may decrease the effectiveness of other drugs that seniors are often taking such as warfarin (Coumadin). If warfarin (Coumadin) is taken with one of these medications, the prothrombin time (PT) must be checked frequently and the dose adjusted accordingly. They also lower folate and vitamin D, which is very important in managing osteoporosis and decreasing fractures in older women. The four primary enzyme-inducing AEDs include carbamazepine (Tegretol), phenytoin (Dilantin), phenobarbital (Luminol), and primidone (Mysoline). These four stimulate the metabolism and decrease the serum concentration of other AEDs, as well as numerous other medications, such as digoxin (Lanoxin) and furosemide (Lasix). They may also increase the risk of toxicity of other medications as well, such as amiodarone (Pacerone) and erythromycin (Erythrocin) (Epilepsy Foundation, n.d.)
Gabapentin (Neurontin) and lamotrigine (Lamictal) are not metabolized in the same manner and do not cause these interactions. Other potential adverse effects to AEDs for seniors include:
- Increased risk of falls due to ataxia from the medications,
- Risk of bradycardia or other arrhythmias from carbamazepine (Tegretol),
- Risk of hyponatremia with carbamazepine (Tegretol) or oxycarbazepine (Trileptal),
- Thrombocytopenia, parkinsonism, dementia, and hearing deficits with valproic acid (Depakene, Valprosid) (Epilepsy Foundation, n.d.).
Of note, seniors have an increased sensitivity to benzodiazepines and metabolize the drugs slower than other populations. There is an overall risk to cognitive functioning, delirium, falls, fractures, and accidents in and out of the home with these drugs (Fick et al., 2019).
A febrile seizure is a fairly common seizure disorder in pediatric patients that is associated with fever, without other intracranial abnormalities or infections. Febrile seizures can be classified into three groups: simple, complex, and symptomatic. Children with a genetic predisposition can be more susceptible to febrile seizures. Viruses, bacteria, or vaccines can be causative agents of febrile seizures. Simple febrile seizures last less than 15 minutes, are generalized, occur once within a 24-hour period, and have no focal component. A complex febrile seizure lasts more than 15 minutes, have a focal component, and occur more than once in a 24-hour period. A symptomatic febrile seizure is a seizure occurring due to fever in a child that has a preexisting neurological abnormality. Acute management of a febrile seizure is to maintain a patent airway, ensure effective breathing, administer oxygen therapy as needed, protect from injury, place in semi-prone position and preferably on the right side, loosen the clothing, and treat the fever with antipyretics such as acetaminophen (Tylenol) or ibuprofen (Motrin). According to the duration and severity, rectal diazepam can be given for any seizure over five minutes in length, or IV diazepam (Valium), lorazepam (Ativan), or phenobarbital (Luminol) for a patient seizing longer than 15 minutes (Schellack & Schellack, 2019).
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