Risk of Unnatural Mortality in People With Epilepsy

Characteristics of deceased subjects transported to a postmortem imaging center due to unusual death related to epilepsy

OBJECTIVE

Patients with epilepsy have high risk of experiencing uncommon causes of death. This study aimed to evaluate patients who underwent unusual deaths related to epilepsy and identify factors that may contribute to these deaths and may also include sudden unexpected death in epilepsy (SUDEP).

METHODS

We analyzed 5291 cases in which a postmortem imaging (PMI) study was performed using plane CT, because of an unexplained death. A rapid troponin T assay was performed using peripheral blood samples. Clinical information including the cause of death suspected by the attending physician, body position, place of death, medical history, and antiseizure medications was evaluated.

RESULTS

A total of 132 (2.6%) patients had an obvious history of epilepsy, while 5159 individuals had no history of epilepsy (97.4%). Cerebrovascular disease was the cause of death in 1.6% of patients in the group with epilepsy, and this was significantly lower than that in the non-epilepsy group. However, drowning was significantly higher (9.1% vs. 4.4%). Unspecified cause of death was significantly more frequent in the epilepsy group (78.0% vs. 57.8%). Furthermore, the proportion of patients who demonstrated elevation of troponin T levels without prior cardiac disease was significantly higher in the epilepsy group (37.9% vs. 31.1%). At discovery of death, prone position was dominant (30.3%), with deaths occurring most commonly in the bedroom (49.2%). No antiseizure medication had been prescribed in 12% of cases, while 29.5% of patients were taking multiple antiseizure medications.

SIGNIFICANCE

The prevalence of epilepsy in individuals experiencing unusual death was higher than in the general population. Despite PMI studies, no definitive cause of death was identified in a significant proportion of cases. The high troponin T levels may be explained by long intervals between death and examination or by higher incidence of myocardial damage at the time of death.

PLAIN LANGUAGE SUMMARY

This study investigated unusual deaths in epilepsy patients, analyzing 5291 postmortem imaging cases. The results showed that 132 cases (2.6%) had a clear history of epilepsy. In these cases, only 22% cases were explained after postmortem examination, which is less than in non-epilepsy group (42.2%). Cerebrovascular disease was less common in the epilepsy group, while drowning was more common. Elevated troponin T levels, which suggest possibility of myocardial damage or long intervals between death and examination, were also more frequent in the epilepsy group compared to non-epilepsy group.

Can family members reliably assess mood and suicidal ideation in individuals with epilepsy?

BACKGROUND

Routine detection of depression, anxiety and suicidal ideation in people with epilepsy (PWE) remains suboptimal. We investigated the level of agreement between PWE and their proxies when evaluating these psychiatric symptoms.

METHODS

From October 2021 to March 2022, we conducted a cross-sectional anonymous survey at Vilnius University Hospital Santaros Klinikos (Vilnius, Lithuania). Persons accompanying PWE completed different scales measuring symptoms of depression and anxiety and evaluated suicidal ideation among PWE (defined as a non-zero score of the suicide item of the Beck depression inventory (BDI) or as a score > 1 of the item 4 of the Neurological Disorders Depression Inventory for Epilepsy, NDDI-E). Agreement between PWE and their proxies was measured using the Wilcoxon test for paired samples and Pearson's correlation analysis.

RESULTS

The study included 140 PWE (mean age 41.0 ± 18.1, 71 (50.7 %) female) and 140 proxies (mean age 49.0 ± 15.01, 105 (75.0 %) female, 57 (40.7 %) were parents, 51 (36.4 %) - spouses, 15 (10.7 %) - partners, 11 (7.9 %) - children and 6 (4.3 %) - siblings of PWE). There were no statistical differences in paired scores of the BDI, Hospital Anxiety and Depression scale, Generalized Anxiety Disorder scale-7, and the NDDI-E (p > 0.05). Proxies reported statistically higher scores on the Geriatric Depression Scale (Z =  - 2.026, p = 0.043) than PWE. The correlation between PWE and proxy evaluations for all instruments was moderate (varying from r = 0.500 to r = 0.688, p < 0.001). For most psychometric scales proxies became less accurate with higher scale scores for anxiety and depression and tended to underestimate the level of such symptoms (correlation between scale results and signed (PWE - proxy) mismatch varied from r = 0.368 to r = 0.641, p < 0.001). The measure of proxy-PWE agreement on suicidal ideation was low (Cohen's Κ = 0.192, p = 0.025); proxies missed 63 % (NDDI-E) to 70 % (BDI) of cases of suicidal ideation.

CONCLUSION

Companions of PWE provided comparable reports of participant anxiety and depression on a group level but tended to underestimate psychiatric symptoms as their scale scores became higher. Proxies significantly underreported suicidal ideation in those people who did express it. While proxy reporting should not be used interchangeably on an individual level, its use in group studies may be useful and ought to be investigated further.

Disordered activity? A review of the quality of epilepsy care provided to adults presenting to hospital with a seizure

The National Confidential Enquiry into Patient Outcome and Death reviewed the quality of care provided to adults who presented to hospital following an epileptic seizure. Clinical and organisational changes are highlighted that aim to improve patient care and outcomes.

Mortality in children with epilepsy: Cohort study using the clinical practice research datalink

OBJECTIVE

To estimate Mortality Rate (MR) in UK children with epilepsy (CWE) compared to children without epilepsy (CWOE), describe causes of death, determine Mortality Rate Ratios (MRRs) for cause-specific mortality, and to analyse the contribution of co-morbidities (respiratory disease, neoplasm, and congenital disorders) to mortality rate.

METHOD

Retrospective cohort study of children born between 1998 and 2017, using linked data from the Clinical Practice Research Datalink Gold (Set 18). Epilepsy diagnoses were identified using previously validated codes. Causes of death were defined as natural or non-natural. Epilepsy-related deaths in CWE were those where underlying or contributing cause of death was epilepsy, status epilepticus, seizures, ill-defined/unknown cause or sudden death. We used Cox proportional hazard analysis to investigate associations of epilepsy and mortality.

RESULTS

There were 1,191,304 children followed for 13,994,916 person-years (median: 12) if which 9665 (0.8%) had epilepsy. Amongst CWE, 3.4% died. MR of CWE was 4.1 (95%CI 3.7-4.6)/1,000 person-years. CWE had an increased adjusted all-cause mortality (MRR 50.9,95%CI 44.8-57.7) compared to CWOE. Amongst the 330 deaths in CWE, 323 (98%) were natural, 7 (2%) non-natural, 80 (24%) epilepsy-related. MRR of non-natural deaths was 2.09 (95%CI 0.92,4.74, p = 0.08).

SIGNIFICANCE

Amongst CWE, 3.4% died during the study period. All-cause mortality rate in CWE was 4/1,000 person-years representing a fifty-fold increased mortality risk, after taking into account sex and socioeconomic status, compared to similarly aged children who did not have epilepsy. Causes of death mostly were not seizure-related. Non-natural death in CWE was uncommon.

Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study

BACKGROUND AND OBJECTIVES

People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea.

METHODS

We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs).

RESULTS

Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis.

DISCUSSION

This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.

Sudden unexpected death in epilepsy

PURPOSE OF REVIEW

Sudden unexpected death in epilepsy (SUDEP) is a leading cause of death in patients with epilepsy. This review highlights the recent literature regarding epidemiology on a global scale, putative mechanisms and thoughts towards intervention and prevention.

RECENT FINDINGS

Recently, numerous population-based studies have examined the incidence of SUDEP in many countries. Remarkably, incidence is quite consistent across these studies, and is commensurate with the recent estimates of about 1.2 per 1000 patient years. These studies further continue to support that incidence is similar across the ages and that comparable factors portend heightened risk for SUDEP. Fervent research in patients and animal studies continues to hone the understanding of potential mechanisms for SUDEP, especially those regarding seizure-induced respiratory dysregulation. Many of these studies and others have begun to lay out a path towards identification of improved treatment and prevention means. However, continued efforts are needed to educate medical professionals about SUDEP risk and the need to disclose this to patients.

SUMMARY

SUDEP is a devastating potential outcome of epilepsy. More is continually learned about risk and mechanisms from clinical and preclinical studies. This knowledge can hopefully be leveraged into preventive measures in the near future.

Mortality after a first-ever unprovoked seizure

OBJECTIVE

Although increased mortality associated with epilepsy is well understood, data in patients after their first-ever seizure are limited. We aimed to assess mortality after a first-ever unprovoked seizure and identify causes of death (CODs) and risk factors.

METHODS

A prospective cohort study was undertaken of patients with first-ever unprovoked seizure between 1999 and 2015 in Western Australia. Two age-, gender-, and calendar year-matched local controls were obtained for each patient. Mortality data, including COD, based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes, were obtained. Final analysis was performed in January 2022.

RESULTS

One thousand two hundred seventy-eight patients with a first-ever unprovoked seizure were compared to 2556 controls. Mean follow-up was 7.3 years (range = .1-20). Overall hazard ratio (HR) for death after a first unprovoked seizure compared to controls was 3.06 (95% confidence interval [CI] = 2.48-3.79), with HRs of 3.30 (95% CI = 2.26-4.82) for those without seizure recurrence and 3.21 (95% CI = 2.47-4.16) after a second seizure. Mortality was also increased in patients with normal imaging and no identified cause (HR = 2.50, 95% CI = 1.82-3.42). Multivariate predictors of mortality were increasing age, remote symptomatic causes, first seizure presentation with seizure cluster or status epilepticus, neurological disability, and antidepressant use at time of first seizure. Seizure recurrence did not influence mortality rate. The commonest CODs were neurological, most relating to the underlying cause of seizures rather than being seizure-related. Substance overdoses and suicide were more frequent CODs in patients compared to controls and were commoner than seizure-related deaths.

SIGNIFICANCE

Mortality is increased two- to threefold after a first-ever unprovoked seizure, independent of seizure recurrence, and is not only attributable to the underlying neurological etiology. The greater likelihood of deaths related to substance overdose and suicide highlights the importance of assessing psychiatric comorbidity and substance use in patients with first-ever unprovoked seizure.

Influence of comorbidity on mortality in patients with epilepsy and psychogenic nonepileptic seizures

OBJECTIVE

This study aims to determine the contribution of comorbidities to excess psychogenic nonepileptic seizures (PNES) mortality.

METHODS

A retrospective cohort study was conducted of tertiary epilepsy outpatients from St. Vincent's Hospital Melbourne, Australia with an 8:1 comparison cohort, matched by age, sex, and socioeconomic status (SES) to national administrative databases between 2007 and 2017. Privacy-preserving data linkage was undertaken with the national prescription, National Death Index, and National Coronial Information System. Forty-five comorbid disease classes were derived by applying the Australian validated RxRisk-V to all dispensed prescriptions. We fitted Cox proportional hazard models controlling for age, sex, SES, comorbidity, disease duration, and number of concomitant antiseizure medications, as a marker of disease severity. We also performed a parallel forward-selection change in estimate strategy to explore which specific comorbidities contributed to the largest changes in the hazard ratio.

RESULTS

A total of 13 488 participants were followed for a median 3.2 years (interquartile range = 2.4-4.0 years), including 1628 tertiary epilepsy outpatients, 1384 patients with epilepsy, 176 with PNES, and 59 with both. Eighty-two percent of epileptic seizures and 92% of typical PNES events were captured in an epilepsy monitoring unit. The age-/sex-/SES-adjusted hazard ratio was elevated for epilepsy (4.74, 95% confidence interval [CI] = 3.36-6.68) and PNES (3.46, 95% CI = 1.38-8.68) and remained elevated for epilepsy (3.21, 95% CI = 2.22-4.63) but not PNES (2.15, 95% CI = .77-6.04) after comorbidity adjustment. PNES had more pre-existing comorbidities (p = .0007), with a three times greater median weighted Rx-RiskV score. Psychotic illness, opioid analgesia, malignancies, and nonopioid analgesia had the greatest influence on PNES comorbid risk.

SIGNIFICANCE

Higher comorbidity appears to explain the excess PNES mortality and may represent either a wider underrecognized somatoform disorder or a psychological response to physical illness. Better understanding and management of the bidirectional relationship of these wider somatic treatments in PNES could potentially reduce the risk of death.

Epilepsy-associated death in the Southwestern Ontario: A clinicopathological correlation study

Patients with epilepsy are at elevated risk for premature mortality, of which sudden unexpected death in epilepsy (SUDEP) is one of the leading causes. SUDEP incidence varies significantly depending on the population and the methods used to document the cause of death. We performed retrospective case review at the London Health Sciences Centre for the period of 2000 to 2018. Clinical information, scene investigations, general pathology findings, toxicology, and neuropathology findings were obtained, examined, and confirmed by two neuropathologists and one epileptologist. The characteristics were compared and summarized. We also evaluated the impact of 2010 revision of Ontario Coroner Act Regulation, which significantly limited whole brain examination. Among the 12,206 cases reviewed, we identified 152 cases with a known history of epilepsy. Ninety-seven cases (64%) were classified as SUDEP. There were significantly more SUDEP decedents found dead unwitnessed at night in prone position, than non-SUDEP. Generalized seizures were strongly associated with SUDEP. A male predominance was observed in SUDEP group between 15 and 35 years old. Near half of the brains examined were "unremarkable." There was no difference in neuropathology findings between SUDEP and non-SUDEP groups. After implementation of the 2010 revision of Ontario Coroner Act Regulation, fixed whole brain examination was reduced from 88% to 7% of the epilepsy-related death investigation. Except a lower diagnosis rate of "inflammatory/infectious changes," there were no significant differences in neuropathology findings. This is the first detailed clinical-pathological study on epilepsy-related death based on a Canadian cohort. This study reinforces the previously reported findings in SUDEP and highlights the importance of clinicopathological correlation for accurate classification of epilepsy-related death.

Psychiatric comorbidities and all-cause mortality in epilepsy: A nationwide cohort study

Background

People with epilepsy (PWE) having comorbid psychiatric conditions may be at greater risk of death. We aimed to determine the association between psychiatric disorders and all-cause mortality among PWE after adjustment for somatic comorbidities.

Methods

Based on data from the National Health Insurance Fund, a Cox survival analysis was done within a retrospective open cohort of all PWE (≥12 years) in Lithuania between January 2014 and June 2020. Cox models comparing mortality between PWE with or without psychiatric comorbidities were adjusted for sex, age, hospitalizations, and the epilepsy-specific comorbidity index.

Results

Of 47,964 PWE (age Md = 49, IQR = 34–62 years, 60.3% male, follow-up Md = 4.4, IQR = 2.1–6.1 years), 10,290 (21.5%) died during the study. The diagnosis of any psychiatric disorder (n = 26,137, 54.5%) was associated with increased mortality when adjusted for only sex and age (HR = 1.13, 95% CI = 1.09 to 1.18). After including the epilepsy-specific comorbidity index, the number of hospitalizations and hospital days in the analysis, only self-harm (HR = 1.55, 95% CI = 1.40 to 1.71) and substance use disorders (HR = 1.39 95% CI = 1.32 to 1.47), but not any psychiatric comorbidities (HR = 0.92 95% CI = 0.88 to 0.96) were related to elevated all-cause mortality. Mood, anxiety and behavioral disorders were associated with lower odds of mortality; however, they were rarely documented.

Conclusions

Our results suggest that psychiatric comorbidities increase all-cause mortality among PWE through their association with coexisting somatic conditions as only substance use disorders and self-harm were independently related to elevated all-cause mortality. Future clinical interview-based studies should explore the relationship between mortality in epilepsy and psychiatric comorbidities while adjusting for somatic comorbidities.

Knowledge and attitudes towards epilepsy: A survey of people with epilepsy

PROBLEM

Many studies focus on knowledge and attitudes of unaffected people towards epilepsy and people with epilepsy (PWE). The perspective of PWE themselves is much less explored.

METHODS

We invited PWE in Germany to answer a questionnaire on their knowledge and attitudes towards epilepsy and PWE.

RESULTS

The questionnaire was completed by 230 PWE (median age: 40 years; min./max.: 19/83; 66 % female). Of PWE, 22 % thought that PWE are more helpful, and 10 % thought that PWE are friendlier than other people. Nevertheless, reservations about relationships and friendships with other PWE existed: of the participants, only 74 % would definitely go on a date with another PWE, and 90 % would definitely include another PWE they liked into their circle of friends. Swimming was judged as more dangerous for PWE than for healthy people by 71 % of PWE. Of PWE, 86 % correctly assumed it was not useful to hold a person having a seizure to the ground. Putting a solid object in the mouth was considered not useful by 85 % of PWE. Of PWE, 20 % would definitely administer an available emergency medication if another PWE had a seizure. For 67 % of PWE, certain preconditions should have to be fulfilled such as an available document with instructions. Of PWE, 11 % stated they would not administer an available emergency medication if another PWE had a seizure.

CONCLUSION

Although positive attitudes of PWE towards other PWE exist, we also found some reservations calling for psychosocial support. Most PWE had sufficient knowledge about risks of certain activities and about measures to be taken during a seizure. Nevertheless, a small group of PWE showed knowledge gaps. Thus, educational support still seems essential.

Suicidality and antiepileptic drugs in people with epilepsy: an update

INTRODUCTION

Almost 15 years after the Food and Drug Administration (FDA) issued an alert about an increased suicidality risk with antiseizure medications (ASMs), there is still considerable debate on this subject.

AREAS COVERED

This is a review of the role of ASMs in the context of suicide in epilepsy.

EXPERT OPINION

After an explosion of research shortly after the FDA warning was released, only a limited number of studies were published in more recent years and they did not overcome the limitations of previous studies. Overall, available literature does not support an obvious causal relationship between ASMs and suicide. On the contrary, studies are highlighting the complex relationship between suicide and epilepsy, strengthening the bidirectional relationship and the multifactorial origin.

Sudden unexpected death in epilepsy

PURPOSE OF REVIEW

Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms.

RECENT FINDINGS

The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision.

SUMMARY

Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.

The risk of all-cause and cause-specific mortality in people prescribed mirtazapine: an active comparator cohort study using electronic health records

BACKGROUND

Studies have reported an increased risk of mortality among people prescribed mirtazapine compared to other antidepressants. The study aimed to compare all-cause and cause-specific mortality between adults prescribed mirtazapine or other second-line antidepressants.

METHODS

This cohort study used English primary care electronic medical records, hospital admission records, and mortality data from the Clinical Practice Research Datalink (CPRD), for the period 01 January 2005 to 30 November 2018. It included people aged 18-99 years with depression first prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine (5081), a different SSRI (15,032), amitriptyline (3905), or venlafaxine (1580). Follow-up was from starting to stopping the second antidepressant, with a 6-month wash-out window, censoring at the end of CPRD follow-up or 30 November 2018. Age-sex standardised rates of all-cause mortality and death due to circulatory system disease, cancer, or respiratory system disease were calculated. Survival analyses were performed, accounting for baseline characteristics using inverse probability of treatment weighting.

RESULTS

The cohort contained 25,598 people (median age 41 years). The mirtazapine group had the highest standardised mortality rate, with an additional 7.8 (95% confidence interval (CI) 5.9-9.7) deaths/1000 person-years compared to the SSRI group. Within 2 years of follow-up, the risk of all-cause mortality was statistically significantly higher in the mirtazapine group than in the SSRI group (weighted hazard ratio (HR) 1.62, 95% CI 1.28-2.06). No significant difference was found between the mirtazapine group and the amitriptyline (HR 1.18, 95% CI 0.85-1.63) or venlafaxine (HR 1.11, 95% CI 0.60-2.05) groups. After 2 years, the risk was significantly higher in the mirtazapine group compared to the SSRI (HR 1.51, 95% CI 1.04-2.19), amitriptyline (HR 2.59, 95% CI 1.38-4.86), and venlafaxine (HR 2.35, 95% CI 1.02-5.44) groups. The risks of death due to cancer (HR 1.74, 95% CI 1.06-2.85) and respiratory system disease (HR 1.72, 95% CI 1.07-2.77) were significantly higher in the mirtazapine than in the SSRI group.

CONCLUSIONS

Mortality was higher in people prescribed mirtazapine than people prescribed a second SSRI, possibly reflecting residual differences in other risk factors between the groups. Identifying these potential health risks when prescribing mirtazapine may help reduce the risk of mortality.

Epilepsy-Related Mortality in Children and Young Adults in Denmark: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Mortality is increased in epilepsy, but the important issue is that a proportion of epilepsy-related death is potentially preventable by optimized therapy and needs therefore to be identified. A new systematic classification of epilepsy-related mortality has been suggested by Devinsky et al. in 2016 to identify these preventable deaths. We applied this classification to an analysis of premature mortality in persons with epilepsy younger than 50 years.

METHODS

The study was a population-based retrospective cohort of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. Information on all deaths was retrieved from the Danish Cause of Death Registry, autopsy reports, death certificates, and the Danish National Patient Registry. The primary cause of death in persons with epilepsy was evaluated independently by three neurologist, one neuro-pediatrician, and two cardiologists. In case of uncertainty a pathologist was consulted. All deaths were classified as either epilepsy- or not-epilepsy-related, and the underlying causes or modes of death were compared between persons with and without epilepsy.

RESULTS

During the study period 700 deaths were identified in persons with epilepsy, and 440 (62.9%) of these were epilepsy-related, hereof, 169 (38%) directly related to seizures and 181 (41%) due to an underlying neurological disease. SUDEP accounted for 80% of deaths directly related to epilepsy. Aspiration pneumonia was the cause of death in 80% of cases indirectly related to epilepsy.Compared with the background population, persons with epilepsy had a nearly four-fold increased all-cause mortality (adjusted mortality hazard ratio of 3.95 [95% CI 3.64-4.27], p<0.0001) and a higher risk of dying from various underlying causes including alcohol-related conditions (hazard ratio of 2.91 [95% CI 2.23-3.80], p<0.0001) and suicide (hazard ratio of 2.10 [95% CI 1.18-3.73], p=0.01).

DISCUSSION

The newly proposed classification for mortality in persons with epilepsy was useful in an unselected nationwide cohort. It helped classifying unnatural causes of death as epilepsy-related or not, and it helped identifying potentially preventable deaths. The leading causes of premature mortality in persons younger than 50 years were related to epilepsy and were thus potentially preventable by good seizure control.

Mortality among People with Epilepsy: A Retrospective Nationwide Analysis from 2016 to 2019

We estimated age-adjusted mortality and investigated the dominant causes of death as well as comorbidities among people with epilepsy (PWE) in Lithuania, a country with frequent deaths from external causes. From 2016 to 2019, the age-adjusted rate of death among PWE in Lithuania was compared with mortality data in the general population. Each year of analysis, individuals who were diagnosed with epilepsy comprised a retrospective cohort. The standardized mortality ratio (SMR) of PWE varied from 2.93 (95% CI 2.78 to 3.07) to 3.18 (95% CI 3.02 to 3.34). PWE died at least one decade earlier than expected in the general population. The dominant causes of death were cardiovascular diseases (their proportion ranged from 44.8% to 49.3%), cancer (16.7% to 21.3%) and external causes of death (8.5% to 10.9%). The proportion of the latter decreased over time (r = −0.99, p = 0.01), whereas the SMR for external causes of death remained relatively constant. Epilepsy was the underlying cause of death in 163 cases (2.6%), and noted as a condition contributing to death in 1010 cases (15.9%). Cerebrovascular and cardiological conditions and dementia were the most frequent comorbidities among PWE before their death. Epilepsy-unrelated causes of death are relevant contributors to mortality among PWE. There is a need for PWE-oriented societal interventions to reduce the frequency of external deaths beyond the trend in the general population.

Unnatural-cause mortality patterns of Northern Finnish men and women diverge in adolescence - A 52-year follow-up

The Finnish population has a long life expectancy but ranks high in unnatural deaths on the European scale. Mortality has historical regional discrepancy in Finland, as Northern Finns are overrepresented in both natural and unnatural deaths. This study aimed to characterize the age- and sex-related trends in unnatural mortality among Northern Finns. Altogether 12 143 individuals, constituting >95% of births in Northern Finland in 1966, were followed up for a median of 52 years. The mortality patterns of this population were studied using death record data. Crude annual mortality rates were calculated and graphed for 10-year age strata (all-cause, natural-cause, and unnatural-cause mortality, as well as accident, suicide, and homicide mortality). Cox regression was used to analyze the sex discrepancy in mortality. A total of 874 deaths (7.2%) occurred during the follow-up period. Women had 47% and 73% lower risks of any death and unnatural death than men, respectively. From the second decade of life onwards, the unnatural mortality of men was 3-5 times that of women. Accident and suicide mortality rates of men were 2-13 and 2-3 times those of women, respectively. Homicides were rare among either sex. We conclude that Northern Finnish women have a substantially lower risk of all-cause mortality and unnatural mortality than men. To aid the development of preventive strategies, future studies should aim to identify the underlying factors behind unnatural mortality. Primarily, emphasis should be placed on the increased mortality of men from the second decade of life onwards.

Alcohol-Specific Mortality in People With Epilepsy: Cohort Studies in Two Independent Population-Based Datasets

Objectives: The risk of dying by alcohol-specific causes in people with epilepsy has seldom been reported from population-based studies. We aimed to estimate the relative risk of alcohol-specific mortality in people with epilepsy, and the extent to which problematic alcohol use was previously identified in the patients' medical records.

Method: We delineated cohort studies in two population-based datasets, the Clinical Practice Research Datalink (CPRD GOLD) in England (January 01, 2001–December 31, 2014) and the Secure Anonymised Information Linkage (SAIL) Databank in Wales (January 01, 2001–December 31, 2014), linked to hospitalization and mortality records. People with epilepsy were matched to up to 20 persons without epilepsy on gender, age (±2 years) and registered general practice. We identified alcohol-specific death from Office for National Statistics (ONS) records using specified ICD-10 codes. We further identified prescriptions, interventions and hospitalisations related to alcohol use.

Results: In the CPRD GOLD, we identified 9,871 individuals in the incident epilepsy cohort and 185,800 in the comparison cohort and, in the SAIL Databank, these numbers were 5,569 and 110,021, respectively. We identified a five-fold increased risk of alcohol-specific mortality in people with epilepsy vs. those without the condition in our pooled estimate across the two datasets (deprivation-adjusted HR 4.85, 95%CI 3.46–6.79).

Conclusions: People with epilepsy are at increased risk of dying by an alcohol-specific cause than those without the disorder. It is plausible that serious alcohol misuse could either contribute to the development of epilepsy or it could commence subsequent to epilepsy being diagnosed. Regardless of the direction of the association, it is important that the risk of dying as a consequence of alcohol misuse is accurately quantified in people affected by epilepsy. Systematically-applied, sensitive assessment of alcohol consumption by healthcare professionals, at opportunistic, clinical contacts, with rapid access to quality treatment services, should be mandatory and play a key role in reduction of health harms and mortality.

Precision Medicine: Academic dreaming or clinical reality?

Precision medicine can be distilled into a concept of accounting for an individual's unique collection of clinical, physiologic, genetic, and sociodemographic characteristics to provide patient-level predictions of disease course and response to therapy. Abundant evidence now allows us to determine how an average person with epilepsy will respond to specific medical and surgical treatments. This is useful, but not readily applicable to an individual patient. This has brought into sharp focus the desire for a more individualized approach through which we counsel people based on individual characteristics, as opposed to population-level data. We are now accruing data at unprecedented rates, allowing us to convert this ideal into reality. In addition, we have access to growing volumes of administrative and electronic health records data, biometric, imaging, genetics data, microbiome, and other "omics" data, thus paving the way toward phenome-wide association studies and "the epidemiology of one." Despite this, there are many challenges ahead. The collating, integrating, and storing sensitive multimodal data for advanced analytics remains difficult as patient consent and data security issues increase in complexity. Agreement on many aspects of epilepsy remains imperfect, rendering models sensitive to misclassification due to a lack of "ground truth." Even with existing data, advanced analytics models are prone to overfitting and often failure to generalize externally. Finally, uptake by clinicians is often hindered by opaque, "black box" algorithms. Systematic approaches to data collection and model generation, and an emphasis on education to promote uptake and knowledge translation, are required to propel epilepsy-based precision medicine from the realm of the theoretical into routine clinical practice.

Polypharmacy in patients with epilepsy: A nationally representative cross-sectional study

OBJECTIVE

The objective of the study was to characterize the prevalence of polypharmacy and central nervous system (CNS)-acting medications in patients with epilepsy, and particular types of medications.

METHODS

This was a retrospective cross-sectional study using data from the nationally representative National Health and Nutrition Examination Survey (NHANES). We included patients who reported taking at least one prescription medication in order to treat seizures or epilepsy during NHANES survey years 2013-2016. We assessed the number and types of drugs and predictors of total number of medications using a negative binomial regression. We then assessed prevalence of polypharmacy (≥5 medications), CNS polypharmacy (≥3 CNS-acting medications) and additional CNS-acting medications, and drugs that lower the seizure threshold (i.e., bupropion and tramadol), and extrapolated prevalence to estimated affected US population.

RESULTS

The NHANES contained 20,146 participants, of whom 135 reported taking ≥1 antiseizure medication (ASM) for seizures or epilepsy representing 2,399,520 US citizens using NHANES's sampling frame. Patients reported taking a mean 5.3 (95% confidence interval (CI): 4.3-6.3) prescription medications. Adjusting for race, sex, and uninsurance, both age and number of chronic conditions predicted increased number of medications (incident rate ratio (IRR) per decade: 1.16, 95% CI: 1.04-1.28; IRR per chronic condition: 1.19, 95% CI: 1.11-1.27). Polypharmacy was reported by 47% (95% CI: 38%-57%) of patients, CNS polypharmacy by 34% (23%-47%), benzodiazepine use by 21% (14%-30%), opioid use by 16% (11%-24%), benzodiazepine plus opioid use by 6% (3%-14%), and 6% (2%-15%) reported a drug that lowers the seizure threshold. Twelve percent (7%-20%) took an opioid with either a benzodiazepine or gabapentinoid.

CONCLUSIONS

Polypharmacy is common in patients with epilepsy. Patients taking ASMs frequently reported also taking other CNS-acting medications (i.e., opioids, benzodiazepines, seizure threshold-lowering medications), and medication combinations with black box warnings. Central nervous system polypharmacy poses health risks. Future research is needed to explore drivers of polypharmacy and strategies to help mitigate potentially harmful prescription use in this high-risk population.

Prediction of seizure freedom after epilepsy surgery - Critical reappraisal of significance of intracranial EEG parameters

OBJECTIVE

To analyze the significance of intracranial electroencephalography (iEEG) parameters such as seizure onset patterns (SOP) and size of seizure onset zone (SOZ) with respect to prediction of seizure freedom after resective epilepsy surgery.

METHODS

All patients who underwent iEEG with subdural electrodes between January 2006 and December 2015 in our epilepsy-center were included. Various iEEG parameters were retrospectively analyzed regarding their predictive value to post-operative seizure freedom. Furthermore, associations of specific SOPs with underlying histopathology and brain regions of the SOZ were examined.

RESULTS

Eighty-one patients (34 female) with 324 seizures were assessed. Low-voltage fast activity (37%) and sharp activity <13 Hz (30%) were the most frequent SOPs. Focal SOZ (≤2 cm) was the only iEEG parameter independently associated with 1-year post-operative seizure freedom (OR 4.1, 95% CI 1.433-11.679). While no SOP was linked to specific histopathologies, some associations between SOPs and anatomical regions of SOZ were found.

CONCLUSIONS

A circumscribed SOZ, but no specific SOP was predictive for seizure freedom after epilepsy surgery.

SIGNIFICANCE

Intracranial EEG may be helpful to predict post-operative seizure freedom. Multicenter studies with larger numbers of patients are required to reliably assess the significance of specific SOPs for successful resective epilepsy surgery.

Mortality in patients with psychogenic nonepileptic seizures

Objective

To investigate the hypothesis that patients diagnosed with psychogenic nonepileptic seizures (PNES) on video-EEG monitoring (VEM) have increased mortality by comparison to the general population.

Methods

This retrospective cohort study included patients evaluated in VEM units of 3 tertiary hospitals in Melbourne, Australia, between January 1, 1995, and December 31, 2015. Diagnosis was based on consensus opinion of experienced epileptologists and neuropsychiatrists at each hospital. Mortality was determined in patients diagnosed with PNES, epilepsy, or both conditions by linkage to the Australian National Death Index. Lifetime history of psychiatric disorders in PNES was determined from formal neuropsychiatric reports.

Results

A total of 5,508 patients underwent VEM. A total of 674 (12.2%) were diagnosed with PNES, 3064 (55.6%) with epilepsy, 175 (3.2%) with both conditions, and 1,595 (29.0%) received other diagnoses or had no diagnosis made. The standardized mortality ratio (SMR) of patients diagnosed with PNES was 2.5 (95% confidence interval [CI] 2.0–3.3). Those younger than 30 had an 8-fold higher risk of death (95% CI 3.4–19.8). Direct comparison revealed no significant difference in mortality rate between diagnostic groups. Among deaths in patients diagnosed with PNES (n = 55), external causes contributed 18%, with 20% of deaths in those younger than 50 years attributed to suicide, and “epilepsy” was recorded as the cause of death in 24%.

Conclusions

Patients diagnosed with PNES have a SMR 2.5 times above the general population, dying at a rate comparable to those with drug-resistant epilepsy. This emphasizes the importance of prompt diagnosis, identification of risk factors, and implementation of appropriate strategies to prevent potential avoidable deaths.

The Secure Anonymised Information Linkage databank Dementia e-cohort (SAIL-DeC)

Introduction

The rising burden of dementia is a global concern, and there is a need to study its causes, natural history and outcomes. The Secure Anonymised Information Linkage (SAIL) Databank contains anonymised, routinely-collected healthcare data for the population of Wales, UK. It has potential to be a valuable resource for dementia research owing to its size, long follow-up time and prospective collection of data during clinical care.

Objectives

We aimed to apply reproducible methods to create the SAIL dementia e-cohort (SAIL-DeC). We created SAIL-DeC with a view to maximising its utility for a broad range of research questions whilst minimising duplication of effort for researchers.

Methods

SAIL contains individual-level, linked primary care, hospital admission, mortality and demographic data. Data are currently available until 2018 and future updates will extend participant follow-up time. We included participants who were born between 1st January 1900 and 1st January 1958 and for whom primary care data were available. We applied algorithms consisting of International Classification of Diseases (versions 9 and 10) and Read (version 2) codes to identify participants with and without all-cause dementia and dementia subtypes. We also created derived variables for comorbidities and risk factors.

Results

From 4.4 million unique participants in SAIL, 1.2 million met the cohort inclusion criteria, resulting in 18.8 million person-years of follow-up. Of these, 129,650 (10%) developed all-cause dementia, with 77,978 (60%) having dementia subtype codes. Alzheimer's disease was the most common subtype diagnosis (62%). Among the dementia cases, the median duration of observation time was 14 years.

Conclusion

We have created a generalisable, national dementia e-cohort, aimed at facilitating epidemiological dementia research.

Epilepsy Benchmarks Area IV: Limit or Prevent Adverse Consequence of Seizures and Their Treatment Across the Life Span

Epilepsy represents a complex spectrum disorder, with patients sharing seizures as a common symptom and manifesting a broad array of additional clinical phenotypes. To understand this disorder and treat individuals who live with epilepsy, it is important not only to identify pathogenic mechanisms underlying epilepsy but also to understand their relationships with other health-related factors. Benchmarks Area IV focuses on the impact of seizures and their treatment on quality of life, development, cognitive function, and other aspects and comorbidities that often affect individuals with epilepsy. Included in this review is a discussion on sudden unexpected death in epilepsy and other causes of mortality, a major area of research focus with still many unanswered questions. We also draw attention to special populations, such as individuals with nonepileptic seizures and pregnant women and their offspring. In this study, we review the progress made in these areas since the 2016 review of the Benchmarks Area IV and discuss challenges and opportunities for future study.

Hopelessness in persons with epilepsy: Relationship with demographic, clinical, and social variables

Persons with epilepsy show a higher risk of suicidal ideation and behavior than the general population. Hopelessness, as a feature of demoralization, is considered an emerging risk factor for suicidal ideation. Psychopathological comorbidity, mainly depression, has to be taken into account to predict suicidal attempts but the relationship between suicidality and epilepsy has been also reported independently from depressive disorders. The aim of the study was to investigate hopelessness in a sample of persons suffering from epilepsy without comorbidity with psychiatric disorders and its association with demographic, social, and clinical variables, putatively predictive of suicidal behaviors. Beck Hopelessness Scale (BHS) has been used as measure of suicidal ideation in 72 consecutive outpatients afferent to a third level epilepsy center. Exclusion criterion was psychiatric comorbidity evaluated by clinical approach and quantified by Clinical Global Impression (CGI) Scale. Clinical (focus localization, age at onset, number of drugs), demographic, social variables, and intellectual level were considered. Age, age at onset, gender, intellectual level, socioeconomic status, duration of illness and therapy, number of drugs, seizure frequency, and localization of the epileptic focus and side involved were found associated with BHS score increase. In a sample of persons with epilepsy, without psychiatric comorbidity, our data show an association between factors related to the biological pathophysiology and the clinical course of the disease with the sociodemographic status, as a risk factor for suicidal ideation.

[Suicidality in epilepsy: epidemiology and clinical risk factors]

The results of studies on the prevalence of suicidal behavior in patients with epilepsy are discussed in the article. The reasons for the high incidence of suicides among patients with epilepsy are given, with special attention paid to social, demographic, clinical and pathopsychological risk factors. Existing gaps in our knowledge about suicidal behavior in patients with epilepsy are analyzed.

Risk factors for self-harm in people with epilepsy

OBJECTIVE

To estimate the risk of self-harm in people with epilepsy and identify factors which influence this risk.

METHODS

We identified people with incident epilepsy in the Clinical Practice Research Datalink, linked to hospitalization and mortality data, in England (01/01/1998-03/31/2014). In Phase 1, we estimated risk of self-harm among people with epilepsy, versus those without, in a matched cohort study using a stratified Cox proportional hazards model. In Phase 2, we delineated a nested case-control study from the incident epilepsy cohort. People who had self-harmed (cases) were matched with up to 20 controls. From conditional logistic regression models, we estimated relative risk of self-harm associated with mental and physical illness comorbidity, contact with healthcare services and antiepileptic drug (AED) use.

RESULTS

Phase 1 included 11,690 people with epilepsy and 215,569 individuals without. We observed an adjusted hazard ratio of 5.31 (95% CI 4.08-6.89) for self-harm in the first year following epilepsy diagnosis and 3.31 (95% CI 2.85-3.84) in subsequent years. In Phase 2, there were 273 cases and 3790 controls. Elevated self-harm risk was associated with mental illness (OR 4.08, 95% CI 3.06-5.42), multiple general practitioner consultations, treatment with two AEDs versus monotherapy (OR 1.84, 95% CI 1.33-2.55) and AED treatment augmentation (OR 2.12, 95% CI 1.38-3.26).

CONCLUSION

People with epilepsy have elevated self-harm risk, especially in the first year following diagnosis. Clinicians should adequately monitor these individuals and be especially vigilant to self-harm risk in people with epilepsy and comorbid mental illness, frequent healthcare service contact, those taking multiple AEDs and during treatment augmentation.