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Managing epilepsy in primary care

A Gaitatzis
MRCP
Clinical Research Fellow in Neurology

P Hosking
RGON MSc
Epilepsy Nurse Specialist

Department of Clinical and Experimental Epilepsy
University College London Institute of Neurology
National Hospital for Neurology and Neurosurgery
London
National Society for Epilepsy
Buckinghamshire

Epilepsy is the most common chronic neurological condition, affecting five to ten per 1,000 of the population at any time.(1) It is a condition characterised by recurrent (two or more) epileptic seizures, unprovoked by any immediately identified cause.(2) Its management in primary care is discussed here. In the second part of this series the different drug therapies used in epilepsy treatment will be considered.
An epileptic seizure is produced by abnormal synchronised discharge of neurons in the cortex of the brain. It consists of sudden and transitory abnormal phenomena, which may include alterations of consciousness, as well as motor, sensory, autonomic or psychic events, perceived by the patient or an observer. 
Seizures are classified into partial and generalised, according to their origin and manifestations as assessed clinically and by electroencephalogram (EEG).(3) A separate classification exists for the various types of epilepsy and epilepsy syndromes, which is based on seizure type, age of onset, EEG and imaging findings.(4)
Depending on its severity and response to treatment, epilepsy may have deleterious effects on a person's quality of life. This is because epilepsy and its treatment:

  • May affect cognitive, psychological and social development.
  • May pose lifestyle restrictions.
  • May be complicated with other co-occurring ­disorders and treatment side-effects.
  • May be associated with increased mortality and risk of sudden death.

There is also a significant burden on the family and/or carers of people with epilepsy. In the UK, people with epilepsy make greater use of health services and have higher levels of morbidity than people without epilepsy, irrespective of age, sex and social class.(5,6)
 
Managing epilepsy
The management of patients with epilepsy is based on an accurate diagnosis of epilepsy and the identification - if possible - of the epileptic syndrome responsible for the patient's ailment. A misdiagnosis may lead to iatrogenic complications and has potentially devastating implications on employment and quality of life.
In the UK, care of people with epilepsy is shared between primary and secondary care. Tertiary centres provide assessment of patients with uncertain diagnoses, evaluation of candidates for epilepsy surgery, and long-term care and rehabilitation facilities. The specific roles and responsibilities of healthcare professionals in these settings depend on the type of shared care model developed locally. Healthcare professionals in primary care, however, are in a privileged position to care for and support these patients and their families in the community over their professional lifetime.
It is estimated that epilepsy will generate 100 GP consultations and more than 120 telephone contacts per year, given an average GP list size of 1,800 patients. This work will involve administrative staff, doctors and practice nurses. Primary care plays an important role in the initial diagnosis and management, as well as in continuity of care.(7) All patients presenting with a first seizure should be referred immediately to a hospital specialist with an interest in epilepsy, who should undertake further investigations, such as EEG and magnetic resonance imaging (MRI), to help identify the type and cause of epilepsy.
The role of the GP is to take the history from the patient and a witness, make an initial tentative diagnosis, provide information for the patient, make initial referral, and initiate treatment if required (ie, if there is a long delay for assessment by the specialist). Continuing care needs to be established, and a review plan has to be agreed between patient, specialist and GP. The GP should address concerns by patients and their carers, review seizure control and medication (prescribing, effectiveness, compliance and side-effects), and provide information and advice. Patients need to be re-referred to the specialist for issues such as inadequate seizure control, consideration of drug withdrawal (usually after a five-year remission) and for preconceptual counselling.
 
The epilepsy specialist nurse
Liaison between the two levels of care can be facilitated by the epilepsy specialist nurse (ESN). The ESN has a vital role in improving healthcare services by facilitating continuity of care and access to the specialist, and taking patient views into account (see Table 1).

[[NIP04_table1_41]]
 
Treating epilepsy
The cornerstone of epilepsy treatment is the use of antiepileptic drugs (AEDs). The different types of drugs available for various patients groups will be described in part two of this series, scheduled to appear in the next issue of Nursing in Practice.

[[NIP04_pp_41]]

References

  1. Bell GS, Sander JW. The epidemiology of epilepsy: the size of the problem. Seizure 2001;10(4):306-16.
  2. Hopkins A, Shorvon S. Definitions and epidemiology of epilepsy. In: Hopkins A, Shorvon S, Cascino GD, editors. Epilepsy. London: Chapman & Hall Medical; 1995. p. 1-24.
  3. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981;22:489-501.
  4. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989;30:389-99.
  5. Gaitatzis A, Majeed A, O'Sullivan C, Sander JW. Disease-specific consultation rates in general practice in England and Wales. Epilepsia 2001;42 Suppl:80.
  6. Sander JW, Gaitatzis A, O'Sullivan C, Majeed A. Socio-demographic differences in use of health services in people with epilepsy: a prospective cohort study. Epilepsia 2001;42 Suppl 2:132.
  7. Smithson WH. Epilepsy in primary care. In: Duncan J, Sisodiya SM, Smalls JE, editors. Epilepsy 2001 - from science to patient. Oxford: International League Against Epilepsy; 2001. p. 441-5.

Resources
British Epilepsy Association
W:www.epilepsy.org.uk
Epilepsy Foundation (US)
W:www.epilepsy foundation.org
National Society for Epilepsy
W:www.epilepsynse.org.uk
International Bureau of Epilepsy
W:www.ibe-epilepsy.org
American Epilepsy Society
W:www.aesnet.org
Scottish Intercollegiate Guidelines Network
W:www.sign.ac.uk
International League Against Epilepsy
W:www.ilae-epilepsy.org
Driving Regulations
DVLA
W:www.dvla.gov.uk/at_a_glance/chl/neurological.htm