Quality of life after epilepsy surgery

OBJECTIVE

To assess the relation between seizure status and quality of life after surgery for drug resistant epilepsy, using a previously validated quality of life model developed for use in epilepsy.

METHODS

A retrospective postal survey was made on 94 patients who underwent surgery for epilepsy between 1986 and 1994, and 36 patients who after investigation during the same period were found to be unsuitable for surgery. A health related quality of life model was used containing validated measures of anxiety, depression, self esteem, mastery, impact of epilepsy, affect balance, stigma, overall health status, and overall quality of life, to examine the relation between postoperative seizure status and quality of life.

RESULTS

Overall 47.9% of patients were seizure free after surgery. On all measures seizure free patients scored significantly better than either patients deemed unsuitable for surgery or those having more than 10 seizures per year after surgery. Patients having less than 10 seizures per year obtained intermediate scores. There was no difference between the groups unsuitable for surgery or having more than 10 seizures per year postoperatively. Employment rates were significantly different between groups, 80% of seizure free and 53% of patients having less than 10 seizures per year in gainful employment postoperatively, compared with 28% and 27% of patients having greater than 10 seizures per year or those who were unsuitable for surgery.

CONCLUSIONS

Within broad categories, postoperative quality of life is clearly related to seizure outcome, but the study emphasises the importance of long term follow up in defining the tangible psychosocial effects of freedom from seizures.

The Neurotoxicity Scale--II. Results of a patient-based scale assessing neurotoxicity in patients with epilepsy

The Neurotoxicity Scale was devised as a patient-based report scale to assess the adverse effects of antiepileptic drugs on cognitive function. In a previous report we reported the clinical validity of the scale, tested in a double-blind randomized study, using a benzodiazepine in normal volunteers. In the present study, the clinical sensitivity, construct validity and reliability of the scale was tested in patients with epilepsy. Patients (n = 189), selected from both participating centres, representative for the patients with chronic epilepsy were included in the study. Reliability was tested with Cronbachs alpha and yields an almost maximal score (.95). Clinical sensitivity was compared with the previous normal volunteer study and was evaluated as satisfactory. Construct validity showed a five-factor structure, explaining 66.5% of the variance, with 'fatigue and slowing' as the dominant factor. In line with the assumptions for this scale and with the results obtained in normal volunteers, the scale appears to be unsuitable for differential assessment of type or severity of drug-induced impairment. The most valid primary outcome measure is the overall score that renders a global ('all or nothing') evaluation indicating that a subject experiences cognitive impairment and associates this with the antiepileptic treatment. Other factors that may impair cognitive function, such as seizure frequency do not influence this score. The scale has therefore maximal applicability as a screening instrument in outpatient practice and in early (phase II, IIIa) drug trials.

Factors influencing compliance with antiepileptic drug regimes

Failure to comply with drug regimes is prevalent amongst patients with epilepsy and the consequence of this is often an increased risk of further seizures. This paper describes the level of, and influences upon, non-compliance with antiepileptic drug (AED) treatment. A postal questionnaire was sent to an unselected, community-based population of patients with epilepsy. This instrument included questions about patients' AED treatment, any related side-effects, and AED-taking behaviour. Univariate analysis showed that factors associated with compliance were patient age, how important patients felt it was to take drugs as prescribed, whether patients reported feelings of stigma, whether on mono- or polytherapy, whether they were experiencing any side-effects because of AEDs, whether patients had a regular arrangement to see their GP about epilepsy and how easy they found their GP to talk to. Multivariate analysis showed that the strongest predictors of non-compliance were feeling it was not very or not at all important to take AEDs as prescribed, being a teenager, being aged under 60 and being on monotherapy. Further implementation of educational programmes for people with epilepsy would help to improve levels of compliance thereby reducing the risk of unnecessary seizures.

Patients' experiences of injury as a result of epilepsy

PURPOSE

The increased risk of mortality among people with epilepsy is well documented; people with epilepsy are more likely than the general population to die as a result of an accident. Data about incidence of nonfatal accidents and associated factors are not so readily available, even though such accidents are more common than fatal injuries. We report the proportion of people who sustain various injuries during a seizure and the key variables predicting injury.

METHODS

Questionnaires were mailed to an unselected, community-based population of patients with epilepsy. The questionnaire included clinical and demographic details, previously validated scales of psychosocial well-being, and questions about seizure-related injuries.

RESULTS

Of patients who had had at least one seizure during the previous year, 24% sustained at least one head injury, 16% sustained a burn or scald, 10% a dental injury, and 6% some other fracture. Seizure type, seizure severity, and seizure frequency were key predictors of having sustained at least one of these four seizure-related injuries. Key predictors of burn/scald were seizure severity, seizure frequency and sex; those of head injury were seizure severity and type; that of dental injury was seizure severity; and those of some other fracture were seizure severity, duration of epilepsy, and three or more drug-related adverse effects.

CONCLUSIONS

These data help identify significant risk factors associated with seizure-related injuries and so facilitate sensible patient counseling about how the risks of such injuries can be minimized.

Quality of life of people with epilepsy: a European study

PURPOSE

To study the impact of epilepsy and its treatment on people with epilepsy in Europe. We therefore aimed to collect data from as many countries as possible.

METHODS

Clinical and demographic details and information about psychosocial functioning was collected using self-completed questionnaires mailed to members of epilepsy support groups.

RESULTS

Quality of life data was collected from >5,000 patients living in 15 countries in Europe. Over a third of all respondents had frequent seizures, and a fifth believed that their seizures were not well enough controlled by antiepileptic medication. Reported levels of side effects from medication were high. A significant number of respondents reported changing their medication because of side effects or poor control. Respondents reported that epilepsy and its treatment had a significant impact on a number of different aspects of their daily lives. Half of all respondents felt stigmatised by their epilepsy. There were significant differences by seizure type and frequency in the way respondents scored on measures of the perceived impact of their condition, the stigma associated with it and their health status as measured by a generic scale, the SF36.

CONCLUSIONS

This study confirms the findings of previous smaller-scale studies that reducing side effects and achieving better control of seizures are key to improving the quality of life of people with epilepsy, as is reducing the stigma and handicap associated with it.

Current issues in the management of epilepsy: the impact of frequent seizures on cost of illness, quality of life, and mortality

Cost of illness, quality of life (QOL), and sudden unexpected death in epilepsy are disease-related issues that have become increasingly prominent. Because new treatments for epilepsy are now becoming widely available, it is useful to attempt to determine the clinical factors most closely correlated with high disease management costs, excess mortality, and reduced QOL as a basis for considering whether new antiepileptic drugs (AEDs) or AED regimens may favorably influence these aspects of the chronic condition. Findings of recent studies in these diverse areas of epilepsy research indicate that a common clinical factor, seizure frequency, is closely associated with poorer outcomes with respect to cost of illness, QOL, and mortality. To the extent that newer AEDs can provide clinically significant reductions in seizure frequency among patients currently not optimally controlled with AEDs, a meaningful incremental benefit in each of these areas is a reasonable hypothesis. Prospective studies to assess the impact of better seizure control on these important outcomes are warranted.

Validation of the Wechsler Memory Scale-Revised in a sample of people with intractable temporal lobe epilepsy

PURPOSE

The Wechsler Memory Scale-Revised (WMS-R) is used routinely for presurgical assessment of memory for patients considering elective resection of the temporal lobe and/or hippocampus for the relief of intractable temporal lobe epilepsy (TLE). We investigated the validity of the WMS-R in a population of people with TLE.

METHODS

The sample consisted of 138 patients with a diagnosis of TLE in which the epileptogenic focus was clearly and exclusively lateralized to either the right or left hemisphere. They underwent a complete neuropsychological examination as a routine part of their investigation for epilepsy surgery. Psychometric scores included in this study were: Wechsler Adult Intelligence Scale-Revised (WAIS-R) I.Q. scores, National Adult Reading Test Revised (NART-R) predicted-I.Q. scores, and WMS-R Memory Index and subtest scores.

RESULTS

Multiple univariate analyses were performed. The group with left temporal focus had significantly lower Verbal Memory Index, Logical memory (both immediate and delayed), and Digit Span scores. Visual/Verbal discrepancy scores incorrectly identified most patients with right temporal focus. Analyses of a total group of people with epilepsy (i.e., mixed temporal, frontal, occipital and unknown foci) as compared with the normative sample indicated that the patient group scored significantly lower across all memory index scores and most memory subtests.

CONCLUSIONS

Our results confirm that the WMS-R is capable of lateralizing to left hemispheric impairment but is more problematic in the assessment of right hemispheric impairment. The Visual/Verbal Memory Index discrepancy has questionable validity. People with epilepsy performed less well on the WMS-R than did the normative sample. The need for reliable and valid nonverbal tests of memory is therefore warranted.

Patients' experiences of and satisfaction with care for their epilepsy

PURPOSE

To determine condition-specific satisfaction with care, we studied patients' experience of general practitioner (primary physician) and hospital clinic care for their epilepsy and their views about the provision of information concerning the management of their condition.

METHODS

A postal questionnaire was sent to an unselected, community-based population of patients with epilepsy. In addition to clinical and demographic details and previously validated scales of psychosocial well-being, the instrument contained a series of questions about patients' experiences and views of the care they received for epilepsy from both general practice and the hospital services.

RESULTS

Doctors' interpersonal skills were the most influential factors affecting both patient satisfaction overall and the likelihood that doctors might discuss with patients certain clinical and social issues surrounding the management of the patient's condition. A sizable proportion of patients reported that they received insufficient information about epilepsy, both from hospital doctors and general practitioners.

CONCLUSIONS

Patients with epilepsy place great importance on having a doctor who is approachable, communicative, and knowledgeable and on receiving adequate information about their condition. Clinicians may need to be made more aware of the importance of accessibility and sensitivity to the nonclinical needs of their patients. Such easily implemented changes in the delivery of care would improve services in the United Kingdom for people with epilepsy.

The associations of psychopathology in epilepsy: a community study

There is a plethora of studies documenting the association between psychosocial disadvantage and epilepsy but a paucity of studies explaining the precise nature of that relationship. Previous studies have been hampered by methodological problems including small sample size and selection bias. This study examined the aetiology of psychopathology in epilepsy in a cross-sectional community study. A significant proportion of patients were anxious and depressed and many reported side effects of their medication. Stepwise multiple regression techniques were employed to examine the relationship between clinical, demographic and psychosocial variables. Results indicated that psychosocial variables were the best predictors of each other but when these were taken into account, patient perceived seizure severity was an important predictor variable in understanding the relationship between epilepsy and psychosocial functioning.

The development, reliability and validity of a disease specific quality of life model for adults with growth hormone deficiency

OBJECTIVE

Adults with GH deficiency frequently complain of lack of energy, fatigue, social isolation and problems with sexual relationships resulting in a low perceived quality of life. Previous studies of quality of life (QOL) in GH deficient adults have involved small numbers of patients and used measures not specifically designed for this patient population. We have devised a health related QOL model specifically designed for use in adults with GH deficiency and to assess the impact of future GH replacement therapy.

DESIGN

Six measurements were chosen for inclusion in the model. Two were adapted for use after clinical interviews with 12 adult GH deficient patients: the Impact and the Life Fulfilment scales. The others were the Nottingham Health Profile, the Hospital Anxiety and Depression Scale, the Self-Esteem Scale and the Mental Fatigue Questionnaire. The reliability of the 6 measures was assessed by 2 methods: test re-test correlation and internal consistency (Cronbach's alpha). The validity of the Impact and Life Fulfilment scales was assessed by correlation with the other 4 scales.

PATIENTS

Questionnaires were completed by 32 adults with hypothalamic pituitary disorders and GH deficiency (11 male, mean age 35.1 years), with a stimulated maximum serum GH response less than 10 mU/l (mean 2.96). Two had previously received GH injections in childhood. The questionnaires were also completed by 32 age and sex matched control subjects.

RESULTS

The 6 scales had test re-test correlations of 0.70-0.92 indicating reliability over time. The Impact and Life Fulfilment Scales and the Mental Fatigue Questionnaire had Cronbach's alpha scores of greater than 0.6 indicating their potential for use in clinical trials. The Impact and Life Fulfilment scales correlated significantly with many physical and psychological domains from the other 4 scales indicating these were valid in the assessment of health related QOL in GH deficient adults. Compared to the controls the patients with GH deficiency were significantly psychosocially disadvantaged in terms of depression, self-esteem, mental fatigue and life fulfilment.

CONCLUSION

The results of the reliability and validity studies indicate that this health related quality of life model for use with adults with GH deficiency is a potentially valid and reliable tool that could be used to assess the effect of GH treatment.

The clinical course of epilepsy and its psychosocial correlates: findings from a U.K. Community study

As part of a large community-based study, we retrospectively examined the clinical course of epilepsy in an unselected population of people who had a recent history of seizures or were receiving antiepileptic drugs (AEDs). Clinical information was collected from medial records, and information about psychosocial functioning was obtained by means of postal questionnaires sent to identified subjects. The response rate to the postal questionnaire was 71%. There were some deficiencies in the recording of clinical data, which is not unusual since data were taken from records held by primary physicians rather than from hospital clinics. Nevertheless, findings regarding the clinical course of epilepsy corresponded to those of earlier studies. Fifty-seven percent of the sample had had at least a 2-year seizure-free period and 46% of subjects were currently in a remission of at least 2-year duration. There was a clear relationship between current seizure frequency and levels of anxiety and depression, perceived impact of epilepsy, perceived stigma, and marital and employment status. The relationship of seizure frequency and other clinical variables to psychosocial function was explored by multivariate analysis techniques. The amount of variation in scores on the various measures of function accounted for by the clinical variables was small. The most important predictor was current seizure activity, which was the first variable to enter the regression analyses for six of the eight measures of psychosocial function considered. Age at epilepsy onset also emerged as a significant predictor for depression, stigma, and marital status. In individuals with epilepsy in remission, there was little evidence that psychosocial functioning was associated with length of remission, a finding which may in part reflect the nature of this study population. The results indicate that there are several more important predictors of psychopathology and social dysfunction in epilepsy and suggest several implications for treatment interventions.

Non-epileptic attack disorders in children and adolescents: a single case study

Previous research into non-epileptic attack disorder (NEAD) has focused on the individual. We report a teenager with non-epileptic seizures which highlights the importance of the family in the development and maintenance of such attacks. The authors propose that in children and adolescents the focus of therapeutic intervention should be the individual within the context of the family.

Advances in methods for assessing the impact of epilepsy and antiepileptic drug therapy on patients' health-related quality of life

We studied 31 previously validated and newly developed generic and epilepsy-specific scales to evaluate their usefulness for assessing the impact of epilepsy and anti-epileptic drug (AED) therapy on health-related quality of life (HRQOL). Included were the MOS SF-36 Health Survey, additional measures of mental health, cognition, epilepsy-specific perception of control, behavioural problems, distress, worries and experiences, the Liverpool Epilepsy Impact and Seizure Severity scales, and a patient-completed symptom checklist. Questionnaires were completed twice by 136 patients on AED therapy in a multicentre study in the UK. Validity was assessed in relation to disease severity, defined as time since last seizure, and to patient-reported symptoms. Statistical analyses to estimate the contribution of HRQOL information of each scale relative to that of others were conducted. The 171-item questionnaire could be completed by out-patients with epilepsy with good data quality. With few exceptions, generic and epilepsy-specific measures satisfied psychometric tests of hypothesized item groupings and scale score reliability (internal consistency and test-retest reliability) and differentiated well between groups of patients differing in time since last seizure and in symptom impact, regardless of time since last seizure. However, scales differed widely in their validity in discriminating between groups of patients known to differ clinically. The SF-36 Role Physical scale best discriminated among groups differing in disease severity. The epilepsy-specific Mastery, Impact, Experience, Worry, Distress, and Agitation scales were among the 10 best measures in discriminating among groups differing in disease severity. Generic measures, especially measures of social and role functioning and mental health, were best at differentiating groups of patients differing in symptom impact. Recommendations are offered for concepts and specific scales most likely to be useful in future studies of the HRQOL burden of epilepsy and the HRQOL benefits of AED therapy.

Health-related quality-of-life issues: optimizing patient outcomes

Quality of life has emerged as an important health care outcome for patients with chronic illnesses requiring long-term therapy. Disease-specific quality-of-life instruments have been developed as outcome measures for several chronic diseases, and the number of studies that have used quality of life as an outcome measure has increased dramatically in the past 10 years. Quality-of-life measures have not been widely applied in epilepsy, however. Because seizure severity is an important measure of quality of life, seizure severity scales that quantify seizure severity in the evaluation of medical and surgical treatments of epilepsy have been developed for use in clinical trials. The development of a health-related quality-of-life model for epilepsy, including previously validated scales, and its application to the assessment of treatment effects in a clinical trial are described.

Epilepsy, pseudoseizures and perceived family characteristics: a controlled study

Previous research in the area of pseudoseizures has focused upon their phenomenology and the characteristics of the individual with pseudoseizures. This study set out to examine the role of pseudoseizure behaviour in fulfilling a function within the family context. Pseudoseizure patients, patients with epilepsy and healthy controls completed questionnaires measuring the following variables--anxiety and depression, locus of control, self-esteem, family characteristics and perceived seizure severity. People with pseudoseizures perceived their families as displaying less commitment and support to each other (family Cohesion scale) and less emphasis on ethical issues and values (family Moral-religious scale) than both the epilepsy and the control groups. People with pseudoseizures reported levels of family interest in political, social and recreational activities (family Intellectual-cultural scale) similar to people with epilepsy, both these group scores being lower than the control group. The two patient groups also reported higher depression scores than controls, yet only the epilepsy group had lower self-esteem than the controls. These initial findings support a role of family involvement in therapy for people with pseudoseizures and may lead to a better understanding of the aetiology of pseudoseizures, as well as clarifying characteristics which may well aid the differentiation of pseudoseizures from epilepsy.

Development of a novel scale to assess life fulfillment as part of the further refinement of a quality-of-life model for epilepsy

We have been involved in developing a health-related quality-of-life model for use as an outcome measure in epilepsy. As part of the further development of this model, we have developed a measure of life fulfillment. This scale is based on methods previously described by Krupinski in 1980. The value of Krupinski's approach is the opportunity for patients to weight the numerous aspects of their quality of life and assess the discrepancy between their actual and desired circumstances. The life fulfillment scale has been shown to be reliable (alpha = 0.7) and valid. The scale is currently being applied to several clinical studies in epilepsy. We believe that the scale provides a valuable contribution to our health-related quality-of-life model.

Towards a comprehensive neuropsychological service in the United Kingdom for adult patients being considered for epilepsy surgery

We report the findings of two one-day meetings concerned with the current practice of clinical neuropsychologists involved in epilepsy surgery in Britain. Nine centres participated in the survey, the aim of which was to examine the strengths and current weaknesses in the services provided nationally and move toward further development. Each centre was asked to provide information via a questionnaire on three definitive areas: patient and family expectations and psychological health; neuropsychological protocol pre- and post-surgery; the intra-carotid sodium amytal protocol. Results of the survey revealed diverse practices across the three areas. Implications and recommendations for a uniformed approach have been made and a standard approach to assessing outcome is being further investigated by the epilepsy surgery group. However, the authors argue that a review of the whole of neuropsychological services for epilepsy and surgery is required.

Stress in midwifery: a comparison of midwives and nurses using the Work Environment Scale

Previous research into midwifery has identified a number of potential sources of stress without attempting to understand the variables that might contribute to it. The study sample was drawn from a population of registered nurses and midwives and compares the work environment of 29 midwives with 180 nurses, using the Work Environment Scale Questionnaire. Significant differences were found between midwives and nurses for involvement, supervisor support, autonomy, work pressure and clarity of roles. These results have the potential for forming the basis of future research.

The initial development of a health-related quality of life model as an outcome measure in epilepsy

Patients with refractory epilepsy, despite no fixed physical deficit, are often socially and psychologically handicapped. Currently available outcome measures for epilepsy do not adequately address these manifestations or their influence on well-being and quality of life. A patient-based health-related quality of life (HRQL) model for epilepsy including physical, social and psychological domains was constructed. It contains previously validated measures of anxiety, depression, happiness, overall mood, self-esteem, mastery, social satisfaction and general health and a specifically designed seizure severity scale with patient- and carer-based components. The psychometric properties of this model were evaluated in the context of the trial of a potential new antiepileptic drug. All the scales, except the Social Problems Questionnaire, have acceptable internal consistency (alpha 0.69-0.85) in this patient population. Construct validity is indicated by the ability of the scales to differentiate between groups of patients predicted to have different levels of psychosocial function. Treatment effects were detected by the patient (P = 0.017) and carers (P = 0.035) subscales of the seizure severity scale, the happiness (P = 0.003) and the mastery (P = 0.003) scales. Despite obvious deficiencies preliminary analyses are encouraging. This model provides a framework for investigating the complex interaction between the physical, social and psychological manifestations of epilepsy. The model has potential as an outcome measure for use in longitudinal studies and as a measure of disability for use in cross-sectional studies designed to compare quality of life in different populations of people with epilepsy.

Detecting the faking of amnesia: performance differences between simulators and patients with memory impairment

This study attempted to establish criteria for distinguishing patients with genuine memory problems from those who are attempting to simulate amnesia. The performance of simulators and genuine amnesics was compared under distraction conditions in which subjects had to count backwards between presentation and recall, and under no-distraction conditions in which the retention interval was unfilled. Genuine amnesics performed significantly worse than controls under distraction conditions, but did not perform significantly worse than controls under no-distraction conditions. However, those attempting to fake amnesia performed significantly worse than controls under no-distraction as well as under distraction conditions. They also exaggerated the memory deficit overall relative to genuine amnesics. It is suggested that these two criteria might be used successfully in clinical settings to assist in the detection of simulators.