Strategies for improving adherence to antiepileptic drug treatment in people with epilepsy

Dysphagia in Epilepsy Patients: The Silent Enemy

Purpose of Review

Dysphagia, or difficulty swallowing, affects several individuals globally and can contribute to a reduced quality of life and partial medication adherence, especially in patients with epilepsy. There is also a lack of awareness and understanding of dysphagia among both health care providers and patients. This review examines the interplay between dysphagia and epilepsy treatment and the potential for optimizing diagnosis and intervention.

Recent Findings

Dysphagia, although a prevalent condition, is often underdiagnosed or misdiagnosed. Managing dysphagia involves patient and caregiver education on medication management techniques, lifestyle changes, and collaboration with a multidisciplinary health care team. There are also several modalities to screen and evaluate for dysphagia by using technology, using questionnaires, and asking probing questions. In patients with epilepsy, dysphagia can make swallowing certain formulations of antiseizure medications (ASMs) difficult or impossible-so, there is a need for tailored management strategies if discontinuing the medication is not feasible. Alternative formulations such as soluble, liquid, granular, or powder alternatives have been recognized as valuable options in addressing partial adherence due to dysphagia.

Summary

Patients with dysphagia may have varying symptoms, making it challenging for clinicians to accurately identify the condition. To address this issue, various questionnaires and assessments have been developed to uncover swallowing difficulties. Administration of alternate ASM formulations must consider options available for each individual.

Quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town: a facility-based cross-sectional study

BACKGROUND

Epilepsy is one of the most common neurologic disorders affecting approximately 51 million people globally and is associated with significant cases of age-standardized DALYs (182.6 per 100 000 people). The quality of health care services offered to people suffering from epilepsy often fails to meet standards in Ethiopia or internationally. This study was designed to assess the quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town, 2024.

METHOD

A facility-based cross-sectional study was conducted among 392 adult epileptic patients attending public hospitals in Arba Minch Town. Data entry was performed via Epi-data 3.1 software, and the data were analyzed via SPSS version 24 software. Binary logistic regression analysis was used to evaluate the associations between quality of care and sociodemographic, disease-related, and treatment-related factors. Multivariate logistic regression analysis was applied to identify factors independently associated with quality of care.

RESULTS

Three hundred ninety-two adults with epilepsy participated in this study, for a response rate of 92.7%. More than one-half of the 237 (60.5%) patients were males, with a median age of 31 ± 12 years (interquartile range). Fewer than one-half (44.1%) of the patients adhered to antiepileptic medicines. The overall proportion of patients receiving quality care was 213 (54.3%). The seizure control rate was also low, at 130 (33.2%). Patients aged 18-29 years [AOR = 30.8 (95% CI, 8.22-35.616, p < 0.000)] and aged 30-39 years [AOR = 18.4 (95% CI, 5.016-67.613, p < 0.000)], and a seizure frequency of less than three [AOR = 2.318 (95% CI, 1.028-5.225, p < 0.043)] were positively associated with quality of care. Whereas, having poor knowledge about epilepsy [AOR = 0.107 (95% CI, 0.0.057-0.202, p < 0.000)] was negatively associated with quality care.

CONCLUSION

The quality of care provided to adult epilepsy patients at Arba Minch was low. In addition, patient knowledge, medication adherence, and the seizure control rate were also suboptimal. Therefore, addressing identified factors by involving all relevant stakeholders (health professionals, hospitals, zonal health departments, regional health bureaus, and patients) is critical for improving the quality of care. In addition, researchers willing to study this topic should use strong designs that can determine causal determinants of quality care.

Barriers and Facilitators to Accessing Care and Adhering to Medications in People With Epilepsy in India: Healthcare Workers' Perspectives

Introduction Exploring the barriers and facilitators that people with epilepsy face in accessing care and adhering to medications could enable a better understanding of how India's epilepsy treatment gap could be addressed. Furthermore, there is a paucity of research on the topic, and we could not find any studies exploring these barriers from the perspective of healthcare workers. Aim The study aimed to explore the barriers and facilitators to accessing care and adhering to medications faced by people with epilepsy in India. Methodology Purposive sampling was used to recruit healthcare workers at a private hospital and a non-governmental organization in Pune, India. A total of 13 participants were interviewed, with all of these interviews being audio-recorded. Findings were transcribed and then analyzed by thematic analysis. Findings Several barriers to accessing care were identified, with misconceptions surrounding epilepsy being the most frequently mentioned barrier. Facilitators to accessing care mentioned by participants included higher symptom severity and a higher level of education. Several barriers to medication adherence were discussed, with misconceptions and finances being key themes in participants' responses. Finally, four key themes arose from exploring facilitators to adherence, namely the low cost of medicines, counselling, a good doctor-patient relationship, and a higher education level. Discussion The barriers and facilitators in this study were similar to the barriers and facilitators identified in similar studies. However, some key differences were seen too. For example, this study found financial difficulties to be a key barrier to adherence, but a similar study in South India did not find financial difficulties to be a barrier. Several recommendations can be made based on the findings of this study on how to address India's epilepsy treatment gap. Conclusion People with epilepsy in India face several barriers and facilitators to accessing care and adhering to medications. India's epilepsy treatment gap is a complex and multifactorial issue and will therefore be challenging to address.

User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review

BACKGROUND

There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies.

OBJECTIVE

This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point?

METHODS

Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically.

RESULTS

A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies.

CONCLUSIONS

The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.

Nonadherence to antiseizure medications: what have we learned and what can be done next?

INTRODUCTION

Nonadherence to antiseizure medications (ASMs) is associated with increased mortality, morbidity, health care utilization, and costs.

AREAS COVERED

This article reviewed 18 randomized controlled trials published between Jan 2010 and Feb 2024 on Medication Adherence Enhancing Intervention (MAEI) for people with epilepsy. The adequacy of reporting intervention development process was assessed using the GUIDance for the rEporting of intervention Development (GUIDED). The adequacy of the intervention description was assessed using the Template for Intervention Description and Replication (TIDieR) checklist. The interventions were categorized as educational (n = 7), behavioral (n = 5), or mixed (n = 6). The impact of MAEIs on adherence is mixed with majority of studies either reporting no difference between intervention and control groups (n = 6) or improvement in the intervention group (n = 7). The shortcomings in the reporting of MAEIs development, MAEIs description, and MAEIs impact measurement were discussed.

EXPERT OPINION

Future research needs to accomplish the following tasks: 1) develop and test valid epilepsy-specific self-report measures for assessing adherence; 2) optimize intervention design; and 3) increase transparency in reporting all stages of research.

The Role of Pharmacists' Interventions in Increasing Medication Adherence of Patients With Epilepsy: A Scoping Review

OBJECTIVES

Epilepsy is a chronic disease that requires long-term treatment and intervention from health workers. Medication adherence is a factor that influences the success of therapy for patients with epilepsy. Therefore, this study aimed to analyze the role of pharmacists in improving the clinical outcomes of epilepsy patients, focusing on medication adherence.

METHODS

A scoping literature search was conducted through the ScienceDirect, PubMed, and Google Scholar databases. The literature search included all original articles published in English until August 2023 for which the full text was available. This scoping review was carried out by a team consisting of pharmacists and neurologists following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews and the Joanna Briggs Institute guidelines, including 5 steps: identifying research questions, finding relevant articles, selecting articles, presenting data, and compiling the results.

RESULTS

The literature search yielded 10 studies that discussed pharmacist interventions for patients with epilepsy. Five articles described educational interventions involving drug-related counseling with pharmacists. Two articles focused on similar pharmacist interventions through patient education, both verbal and written. Three articles discussed an epilepsy review service, a multidisciplinary intervention program involving pharmacists and other health workers, and a mixed intervention combining education and training with therapy-based behavioral interventions.

CONCLUSIONS

Pharmacist interventions have been shown to be effective in improving medication adherence in patients with epilepsy. Furthermore, these interventions play a crucial role in improving other therapeutic outcomes, including patients' knowledge of self-management, perceptions of illness, the efficacy of antiepileptic drugs in controlling seizures, and overall quality of life.

Cross-Cutting mHealth Behavior Change Techniques to Support Treatment Adherence and Self-Management of Complex Medical Conditions: Systematic Review

Background

Mobile health (mHealth) interventions have immense potential to support disease self-management for people with complex medical conditions following treatment regimens that involve taking medicine and other self-management activities. However, there is no consensus on what discrete behavior change techniques (BCTs) should be used in an effective adherence and self-management-promoting mHealth solution for any chronic illness. Reviewing the extant literature to identify effective, cross-cutting BCTs in mHealth interventions for adherence and self-management promotion could help accelerate the development, evaluation, and dissemination of behavior change interventions with potential generalizability across complex medical conditions.

Objective

This study aimed to identify cross-cutting, mHealth-based BCTs to incorporate into effective mHealth adherence and self-management interventions for people with complex medical conditions, by systematically reviewing the literature across chronic medical conditions with similar adherence and self-management demands.

Methods

A registered systematic review was conducted to identify published evaluations of mHealth adherence and self-management interventions for chronic medical conditions with complex adherence and self-management demands. The methodological characteristics and BCTs in each study were extracted using a standard data collection form.

Results

A total of 122 studies were reviewed; the majority involved people with type 2 diabetes (28/122, 23%), asthma (27/122, 22%), and type 1 diabetes (19/122, 16%). mHealth interventions rated as having a positive outcome on adherence and self-management used more BCTs (mean 4.95, SD 2.56) than interventions with no impact on outcomes (mean 3.57, SD 1.95) or those that used >1 outcome measure or analytic approach (mean 3.90, SD 1.93; P=.02). The following BCTs were associated with positive outcomes: self-monitoring outcomes of behavior (39/59, 66%), feedback on outcomes of behavior (34/59, 58%), self-monitoring of behavior (34/59, 58%), feedback on behavior (29/59, 49%), credible source (24/59, 41%), and goal setting (behavior; 14/59, 24%). In adult-only samples, prompts and cues were associated with positive outcomes (34/45, 76%). In adolescent and young adult samples, information about health consequences (1/4, 25%), problem-solving (1/4, 25%), and material reward (behavior; 2/4, 50%) were associated with positive outcomes. In interventions explicitly targeting medicine taking, prompts and cues (25/33, 76%) and credible source (13/33, 39%) were associated with positive outcomes. In interventions focused on self-management and other adherence targets, instruction on how to perform the behavior (8/26, 31%), goal setting (behavior; 8/26, 31%), and action planning (5/26, 19%) were associated with positive outcomes.

Conclusions

To support adherence and self-management in people with complex medical conditions, mHealth tools should purposefully incorporate effective and developmentally appropriate BCTs. A cross-cutting approach to BCT selection could accelerate the development of much-needed mHealth interventions for target populations, although mHealth intervention developers should continue to consider the unique needs of the target population when designing these tools.

Interventions to Improve Medication Adherence in Children With Epilepsy: A Systematic Review

Low medication adherence remains a major challenge in the treatment of epilepsy, particularly in children. In recent years, several approaches and interventions have been employed to promote medication adherence in children with epilepsy (CWE). In this study, we aimed to summarize the evidence on these interventions. In this systematic review, major medical electronic databases were searched for relevant literature from January 2005 till July 2023, including PsycINFO, Medline (via PubMed), Google Scholar, Taylor & Francis databases, and CENTRAL by the Cochrane Library. We planned to include observational studies (with a control arm) and clinical trials involving children/adolescents (<19 years) with epilepsy and/or their caregivers/families who underwent any intervention to improve adherence to anti-seizure medications. Out of 536 articles searched, eight (six randomized trials and two non-randomized intervention studies) were included in the systematic review. A total of 2,685 children/adolescents along with their caregivers participated in these studies. Six studies used educational and two used behavioral interventions to improve adherence to anti-seizure medications. Four studies showed variable levels of adherence improvement, ranging from 2-20% up to 73.9% post-intervention. To conclude, the findings suggest the potential for educational interventions to promote medication adherence in CWE. The class of evidence was II to III among the included studies, as per American Academy of Neurology guidelines.

Stakeholder perceptions of community pharmacist population health management of people living with epilepsy

OBJECTIVE

To identify the predisposing, enabling, and reinforcing factors influencing the integration of community pharmacists in population health approaches to epilepsy care.

METHODS

Key informant interviews were conducted with 32 stakeholders, including five people living with epilepsy (PWE), ten caregivers of PWE, seven epileptologists, one neurologist, one epilepsy nurse, and eight community pharmacists in Washington State and Oregon from September 2019 to February 2020. Interviews were audio recorded, transcribed, and analyzed using a rapid content analysis approach guided by the PRECEDE-PROCEED Model to identify predisposing, enabling, and reinforcing factors influencing integration of community pharmacists in population health approaches to epilepsy care.

RESULTS

Four predisposing, four enabling, three positive reinforcing factors, and two negative reinforcing factors emerged as influencing integration of community pharmacists in a population health approach to epilepsy care across all stakeholder groups. Predisposing factors included patient advocacy, medication adherence, medication monitoring, and medication education. Enabling factors were a shared vision, collaboration structure, efficient communication, and pharmacist attributes (knowledge, experience, and attitude). Positive reinforcing factors included a team approach, easy to access support, and medication adherence. Negative reinforcing factors were duplicate or conflicting care and limited time and resources.

SIGNIFICANCE

This study identified several predisposing, enabling, and reinforcing factors influencing integration of community pharmacists in population health approaches to epilepsy care based on stakeholder perceptions. Community pharmacists may consider these factors when implementing services for patients with epilepsy.

How much can medical management alone improve the outcome of adult drug-resistant epilepsy? An exploratory study on possibilities and limitations of combining multiple therapeutic actions

PURPOSE

Failure to control epileptic seizures with two medications, adequately chosen and dosed, indicates drug-resistant epilepsy (DRE). The chance of pharmacologically controlling seizures is low for patients with DRE and uncontrolled seizures who are not candidates for surgery, who have already undergone surgery, or who already had a vagus nerve stimulator (VNS) placed. Patients experiencing these conditions must instead rely on medical management of their seizures, and there is no breakthrough solution on the horizon. Medical care of DRE might be optimized by systematically considering factors that promote and inhibit breakthrough seizures. For example, seizure control could be enhanced through measures such as increasing the frequency of follow-up visits, tracking treatment plan compliance, treating sleep disorders, rational polypharmacy, adjusting drug administration to achieve higher levels when seizures are more likely and educating patients on seizure triggers. A systematic and simultaneous implementation of all of these measures is likely to yield a sizable, clinically relevant, improvement. This paper presents an exploratory study on the effects of implementing such an approach, specifically evaluating this method's impact on seizure frequency.

METHODS

I performed a retrospective chart review of 659 consecutive adult patients with epilepsy followed up at the University of Utah and at the Salt Lake City VA Medical center using the multimodal approach described above. I identified 27 patients who had DRE and uncontrolled seizures and in whom a medical management optimization protocol was implemented. I measured these patients' seizure frequency at the beginning and the end of the study period and compared the results with those of a matching control group of 48 patients.

RESULTS

The optimization protocol did not increase the number of seizure-free patients with DRE; however, it was effective in minimizing seizure frequency in patients whose seizures remained uncontrolled. Among these patients, the median seizure frequency dropped by 64% in the optimization group but did not change in the control group.

CONCLUSIONS

Despite the high occurrence of DRE, there is no accepted protocol for the related medical management. This paper describes an effective approach that can be implemented in a clinically relevant and readily achievable manner.

Systematic review of real-world studies evaluating the impact of medication non-adherence to endocrine therapies on hard clinical endpoints in patients with non-metastatic breast cancer

Breast cancer, one of the most common malignancies, is associated with significant economic and health burden both at the patient and societal level. Although medication non-adherence to endocrine breast cancer therapies is common, so far only limited systematic evidence has been available on its quantitative consequences, as previous systematic reviews focused mainly on factors contributing to medication non-adherence. The objective of this review was to explore the implications of medication non-adherence to endocrine therapies on hard clinical outcomes in breast cancer based on real-world studies. A systematic literature review was conducted on PubMed; empirical evidence on hard clinical endpoints (i.e., survival, disease-free survival, metastasis and recurrence) were extracted from uni- or multivariate statistical analyses from retrospective or prospective cohort studies. Of the 2,360 identified records, 12 studies met the inclusion criteria. Two studies identified significant positive association between medication non-adherence and the risk of distant metastasis, three articles between medication non-adherence and the recurrence of breast cancer, two studies between medication non-adherence- and non-persistence and of worse disease-free survival and eight articles between medication non-adherence and mortality. There was only one study where the positive association between medication adherence and survival did not apply to all subgroups. The strong evidence on the negative health consequences of non-adherence to breast cancer treatments indicates the need for the regular monitoring of medication adherence. Furthermore, explicit inclusion of adherence enhancing interventions into health policy agenda would be warranted to improve medication adherence also at a system level.

Pandemics and Burden of Stroke and Epilepsy in Sub-Saharan Africa: Experience from a Longstanding Health Programme

Eighty percent of people with stroke live in low- to middle-income nations, particularly in sub-Saharan Africa (SSA) where stroke has increased by more than 100% in the last decades. More than one-third of all epilepsy-related deaths occur in SSA. HIV infection is a risk factor for neurological disorders, including stroke and epilepsy. The vast majority of the 38 million people living with HIV/AIDS are in SSA, and the burden of neurological disorders in SSA parallels that of HIV/AIDS. Local healthcare systems are weak. Many standalone HIV health centres have become a platform with combined treatment for both HIV and noncommunicable diseases (NCDs), as advised by the United Nations. The COVID-19 pandemic is overwhelming the fragile health systems in SSA, and it is feared it will provoke an upsurge of excess deaths due to the disruption of care for chronic diseases such as HIV, TB, hypertension, diabetes, and cerebrovascular disorders. Disease Relief through Excellent and Advanced Means (DREAM) is a health programme active since 2002 to prevent and treat HIV/AIDS and related disorders in 10 SSA countries. DREAM is scaling up management of NCDs, including neurologic disorders such as stroke and epilepsy. We described challenges and solutions to address disruption and excess deaths from these diseases during the ongoing COVID-19 pandemic.