Managing Seizures and Epilepsy Across the LTC Continuum. Speaker Disclosures. Objectives

Transcription

1 Managing Seizures and Epilepsy Across the LTC Continuum NADONA/LTC June 9, 2013 Speaker Disclosures Dr. Haimowitz has disclosed that he has no relevant financial relationship(s). Objectives Discuss the prevalence of epilepsy and seizures across the LTC continuum Identify the unique clinical issues involved with assessing and managing residents with epilepsy in various LTC settings Discuss the role of pharmacologic management in managing the resident with epilepsy/seizures Discuss the care planning process for long-term success in managing epilepsy 1

2 Case Study An 89 year old female is admitted to your facility with a history of seizure disorder and is on multiple anticonvulsant medications. It is not clear when and how she acquired the diagnosis. Her medical history is significant for CVA, MI, CHF, diabetes, and she has renal failure resulting from IV antibiotic treatment for an episode of sepsis. She has a past surgical history significant for repair of a fractured hip that occurred during a severe motor vehicle accident that she was involved in many years ago. What clues are given in this case that would potentially explain why she has a seizure disorder diagnosis? Seizures & Epilepsy Third most common neurological disorder in the elderly (CVA, dementia) Incidence increases with age Widely variable Pathophysiologic findings Clinical manifestations Treatments Prognosis Seizures and Epilepsy are not interchangeable terms More than one seizure must occur before a diagnosis of epilepsy is made Specific Causes Not found in 50% of cases Usually secondary to an identified cause in adults Stroke/ Vascular Disease (25% of cases of 65 yrs of age) Head Trauma Developmental/ Congenital Disorders Infection Neoplasm Degenerative disorders (Alzheimer s Disease) 2

3 Some Common Causes of Secondary Seizures Metabolic Endocrine CNS Disorders Vascular Hyponatremia Hypocalcemia Hypoxia Hypo/hyperglycemia Renal Failure Hypo/hyperthyroid Neoplasm/Trauma Arrhythmias Stroke/Intracerebral hemorrhage Hypotension Some Common Causes of Secondary Seizures Infections Other Systemic Conditions Sepsis Encephalitis (Viral) Meningitis (Bacterial) Brain Abscess Sickle Cell Crisis Hypertensive Encephalopathy Systemic Lupus Erythematosus High Fever (any cause) Some Common Causes of Secondary Seizures Drug Induced Theophylline Meperidine Tricyclic Antidepressants Phenothiazines Lidocaine Quinolones Penicillins SSRI s Isoniazid Antihistamines Cyclosporine Interferons Cocaine Lithium Amphetamines ETOH Withdrawal Benzodiazepine Withdrawal Barbiturate Withdrawal 3

4 Differential Diagnosis for a First Seizure Classification Metabolic disorder CNS pathology Medications Infection Sleep disorders Psychiatric disorders Condition Electrolyte imbalance, hypo/hyperglycemia, hyponatremia, hyperthyroidism AD, CV, head trauma, hypoxia, infection, intracerebral bleed, migraine, subdural hematoma Alcohol, amphetamines, herbal remedies Urosepsis Restless leg syndrome, REM behavior disorders Catatonia, tardive dyskinesia, extrapyramidal disorders, panic disorders High Risk Populations Epilepsy Foundation of America Remission Definition: 5 or more years seizure free on medication 70% of those with epilepsy can be expected to enter remission. 10% of new patients fail to gain control of seizures despite optimum medical management. 75% of people who are seizure free on medication for 2 to 5 years can be successfully withdrawn from medication. Epilepsy Foundation of America 4

5 Clinical Manifestations Two-thirds of elderly patients with seizures do not have convulsions Those caused by vascular disease frequently present only with a lapse of consciousness Typically last a very short time (2-5 minutes) Change in mental status Postictal state may last >24 hours, sometimes for several days or a week Some Features of Postictal State Confusion Disorientation Falling Headache Hyperactivity Incontinence Language difficulties Temporary paralysis Wandering Clinical Manifestations Autonomic Symptoms (Pre-seizure) Pallor Diaphoresis Olfactory or gustatory sensations Urge to defecate Dizziness Vertigo Nausea Excessive salivation Sensory Symptoms Buzzing/ringing auditory hallucinations Visual hallucinations 5

6 Clinical Manifestations Aura Typical of seizures starting in or involving the temporal lobe A feeling of déjà vu Feelings of impending doom, fear, euphoria, or an odd sensation in the stomach Rarely, the aura may also be pleasant Clinical Manifestations Vocalizations Commonly seen with seizure activity Not intelligible language Consist of repetitive phrases then become incorporated into the seizure activity Vocalization may have originally been a response to the oncoming seizure activity help me Two Types of Seizures Generalized Abnormal electrical activity in both brain hemispheres Partial Abnormal electrical activity confined to a small area of the brain 18 6

7 Generalized Seizures Tonic-Clonic Also termed a Grand Mal seizure or Convulsion Usually starts with a cry Results from abrupt movement of air across the glottis from sudden tonic muscle contraction Body becomes diffusely stiff, often with arching of the back Breathing is suspended, sometimes with cyanosis Urinary incontinence is common After seconds tonic activity gives way to clonic rhythmic jerking of all 4 extremities Stridorous breathing takes over with foaming and gasping Postictal stupor lasting 2 to 8 hours or longer Generalized Seizures Tonic-Clonic: Following the postictal state Severe headache Sore muscles Inability to concentrate for a day or more Severe memory loss that gradually improves over a period of weeks Generalized Seizures Absence Synonymous with the term Petit Mal Seizure Generally described as a momentary lapse of awareness Victim has no awareness of the event and may not realize that time is passing (often lose their place reading or lose their train of thought) No Aura No postictal symptoms Usually begin in childhood and are first noticed by teachers May occur several times per day without causing any progressive neurologic disease 7

8 Generalized Seizures Atonic and Tonic Brief motor events Sudden increase or decrease in muscle tone Often cause falls and injury Usually occurs in those with diffuse central nervous system disease Generalized Seizures Myoclonic Brief episodes of sudden motor contraction Often flexion of the upper extremities but can be any extremity Appear as muscle jerks No loss of consciousness Can occur in clusters and convert to a generalized tonic-clonic seizure Partial seizures Simple partial seizures Patient is awake and aware but may be confused Complex partial seizures Consciousness impaired but not completely lost May include amnesia, confusion, repetitive behaviors and staring Most common type in elderly patients 8

9 Features of Partial Seizures Altered mental status (e.g., disorientation, lapse of consciousness, memory disturbance, tuning out, unexplained confusion, staring) Chewing Disrobing Dizziness Falling Fear Incontinence Language difficulties Lip smacking Physical injuries (e.g., bruises, cuts, falls, fractures, tongue-biting) Staring Swallowing Temporary paralysis Evaluation of Possible Seizure Step 1: Determine if event really was seizure May be difficult Staff should report description of condition rather than diagnosis Take into account treatment goals Step 2: Obtain information about precipitating events Step 3: Obtain a medical history/physical exam Step 4: Diagnostic Studies EEG Brain Imaging (CT, MRI, PET scan) Metabolic screen Toxic screen Screen for endocrine disorders (don t cause seizures but will worsen clinical course) Lumbar puncture not useful unless hemorrhage, infection, or immunologic disease is suspected 27 9

10 Medications That May Lower Seizure Threshold Antibiotics (esp quinolones) Anticholinesterases Antidepressants (esp tricyclics and high dose buproprion) Antipsychotics Baclofen Cyclosporine Hypoglycemic agents causing hypoglycemia Levodopa Opioid analgesics (esp fentanyl and meperidine) Tramadol Management of Seizures 29 Initial Treatment Protect resident from harm Evaluate environment for hazardous objects Observe resident for progression (SPS to CPS or generalized seizure) Move to private area if appropriate Be calm, comforting and reassuring 10

11 Recommendations for Generalized Seizures with Convulsions Gently place resident into reclining position on floor/other flat surface Place soft/flat item under resident s head Turn to one side to prevent choking and to keep airway clear If seated, turn head to one side to drain any fluids Do not force anything into resident s mouth Do not give po until seizure resolved and resident alert Do not try to restrain jerking movements Antiepileptic Drugs (AEDs) 7.7% of new admissions on AEDs 60% with seizure indication Other indications include neuropathic pain, behavioral disturbances, migraines, bipolar disorder AEDs Most common in LTC are phenytoin, carbamazepine, and phenobarbital These, plus valproate, are first-generation AEDs May promote osteoporosis Phenobarbital highest incidence of side effects (avoid) Second-generation AEDs fewer side effects, greater cost, broader nonseizure indications 11

12 Major Epileptic Drugs Potential Adverse Events and Other Effects/ Issues Generic Name Trade name Prominent Side Effects Carbamazepine Tegretol Diplopia Fatigue Hyponatremia Tremor Cardiotoxicity Other Effects Mood Stabilizer Other issues Enzyme Inducer Gabapentin Neurontin Fatigue Myoclonus Pedal edema Sedation Wt gain Lamotrigine Lamictal Insomnia Nausea Headache Tremor Anxiety Treatment of Pain No drug interactions Mood Stabilizer Risk for Stevens Johnson Syndrome Levetiracetam Keppra Mood Change Irritability/lethargy Oxcarbazepine Trileptal Depression Tremor Sedation Rash Hyponatremia Mood Stabilizers No drug interactions Major Epileptic Drugs Potential Adverse Events and Other Effects/ Issues Generic Name Phenobarbitol Trade Name Prominent Side Effects Other Effects Fatigue Depression Sedation Phenytoin Dilantin Fatigue Ataxia Hirsuitism Gingival hypertrophy Topiramate Topamax Anorexia Glaucoma Renal Stones Paresthesia Word-finding difficulty Joint pain Treatment of Pain Other issues Enzyme inducer Enzyme inducer Headache Tx Enzyme Mood Stabilizer inducer Valproate Depakene Weight gain Alopecia Tremor Edema Parkinsonism Zonisamide Zonegran Anorexia Dizziness Renal stones Headache Tx Mood Stabilzer Mood Stabilizers Enzyme inhibitor Monitoring Drug levels for first-generation AEDs Not well-established for second-generation (compliance?) Seizure frequency Watch for side effects and adverse reactions 12

13 Goals of Therapy Seizure-free with no adverse events associated with medications Occurs in >60% of people on medication Monotherapy is recommended to minimize risk of adverse events Stopping AEDs No specific guidelines Reconfirm that diagnosis correct (prophylactic for stroke/head injury) Unclear if gradual reduction if seizure-free for 3-5 yrs relevant in elderly Taper by no >20% every 4-6 weeks Documentation Develop treatment plan Note risk of seizures on problem list Address: assessment diagnosis of clinical problems development, communication, and implementation of care plan evaluation of response to treatment revision of care plan as needed 13

14 Role of Medical Director Staff education (med risks/benefits, reason for use, AED monitoring) Collaboration with consultant pharmacist Ensure process for staff training in seizure recognition, description and documentation Review of facility policy/procedures Applying the Care Process Following a good care process is critical for seizure management in this setting There are four phases to a care process Recognition Assessment/Root cause analysis Treatment Monitoring Quality Assurance Program for Recognizing and Managing Seizures Recognition: Identifying history of, risk factors for, or signs and symptoms suggestive of seizures Assessment: Clarifying nature, causes, and impact of seizures on resident Treatment: Selecting and providing appropriate interventions Monitoring: Reviewing response to treatment and deciding whether to continue, change, or stop interventions 14

15 A1550 Coding Instructions Check all conditions related to MR/ DD status present before age 22. When age of onset if not specified, assume that the condition meets this criterion AND is likely to continue indefinitely. C1600 Importance May indicate delirium or other serious medical complications. May be reversible if detected and treated in a timely fashion. E0200 Coding Instructions Type of behavior(s) resident exhibits Frequency of behavior during the lookback period 15

16 E0900 Wandering Presence & Frequency Coding Instructions Code the number of days in the look-back period that the resident wandered. Do not code the number of episodes of wandering. MDS 3.0 Section I Active Diagnoses 16

17 Case Study An 89 year old female is admitted to your facility with a history of seizure disorder and is on multiple anticonvulsant medications. It is not clear when and how she acquired the diagnosis. Her medical history is significant for CVA, MI, CHF, diabetes, and she has renal failure resulting from IV antibiotic treatment for an episode of sepsis. She has a past surgical history significant for repair of a fractured hip that occurred during a severe motor vehicle accident that she was involved in many years ago. What clues are given in this case that would potentially explain why she has a seizure disorder diagnosis? Does your process give opportunities for evaluation and treatment change? Access to clinical tools Clinical guidance Practice management Timely communications and publications Grassroots advocacy Networking, connection and collegiality Member benefits continually grow and evolve Summary Late-onset seizures significant issue in LTC Especially common after strokes or dementia Can be under-recognized and under-treated Individualize evaluation and treatment based on cause/severity, goals of care and life expectancy Monitor and document Use MDS for care planning 17

18 Thank You! Contact Information Daniel Haimowitz MD FACP CMD at 18