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Bosch AT, Sander JW, Thijs RD. Antiseizure Medications and Sudden Unexpected Death in Epilepsy: An Updated Review. CNS Drugs 2024; 38:807-817. [PMID: 39112912 PMCID: PMC11377662 DOI: 10.1007/s40263-024-01112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 09/06/2024]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is responsible for most epilepsy-related deaths. It is mainly related to unwitnessed nocturnal convulsions, either focal to bilateral or generalised tonic-clonic seizures (TCS). Targeted preventive strategies are currently lacking as underlying mechanisms are largely unknown. Antiseizure medications (ASMs) modulate SUDEP risk through seizure reduction, but it is yet undetermined whether individual ASMs or other medications could also influence the internal SUDEP cascade. Seizure detection devices (SDD) may offer an alternative strategy by preventing TCS from being unwitnessed. Here, we critically evaluated the current evidence on the influence of ASMs, non-epilepsy concomitant drugs and SDD on SUDEP occurrence. We found no robust evidence for the effect of starting ASMs on SUDEP beyond TCS control, but we found some indications of a protective effect for polytherapy. We found no signs that specific ASMs exert a risk for SUDEP. One study suggested a possible protective effect of levetiracetam requiring further investigation. Only a few small studies addressed the association between non-epilepsy concomitant drugs and SUDEP, with no consistent effect for psychotropic medications and one more extensive study suggesting a lower risk among statin users. We only found indirect evidence indicating a protective effect for enhancing nocturnal supervision without explicitly addressing the impact of SDD on SUDEP occurrence. Further work is needed to explore the potential of ASMs and other interventions to modulate SUDEP risk, and they should accurately account for TCS frequency, polypharmacy and markers of non-adherence.
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Affiliation(s)
- Anemoon T Bosch
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, SL9 0RJ, UK
- Neurology Department, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands.
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK.
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Pace A, Watkins L, Fiott D, Bassett P, Laugharne R, James C, Shankar R. Identifying co-morbidities and risk in people with epilepsy: The Maltese experience. Epilepsy Behav 2024; 155:109795. [PMID: 38643661 DOI: 10.1016/j.yebeh.2024.109795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/24/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND People with epilepsy are at increased risk of multiple co-morbidities that may influence risk of adverse outcomes including impact on quality of life and premature mortality. These risk factors include potentially modifiable clinical characteristics associated with sudden unexpected death in epilepsy (SUDEP). For services to tackle risk, the clinical complexity of the target epilepsy population needs to be defined. While this has been comprehensively studied in large, economically developed countries little knowledge of these issues exist in small economically developed countries, like Malta (population: 500,000). METHODS This was a single centre study focused exclusively on patients attending Gozo General Hospital (GGH) Malta. STROBE guidance for reporting cross sectional studies was used to design and report the study. This was a retrospective review of standard care and SUDEP and seizure risks provided to all adults (over 18 years) with epilepsy attending GGH (2018-2021). RESULTS The review identified 68 people and 92% were compliant with their anti-seizure medication. A fifth (21%) had an intellectual disability. Despite only one patient having a psychotic illness, 19% were on antipsychotic medication. Only 18% of patients had a specific epilepsy care plan, 6% nocturnal surveillance and none had received advice on SUDEP. DISCUSSION Patient outcomes may be improved with increasing rates of personalized epilepsy care plans, appropriate nocturnal surveillance and reducing the prescription of antipsychotic medication as it is associated with greater risk of mortality. Issues such as stigma and shame appear to play a significant role in small communities and their access to care.
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Affiliation(s)
| | - Lance Watkins
- University of South Wales, Pontypridd, UK; Swansea Bay University Health Board, Port Talbot, UK; Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK
| | | | | | - Richard Laugharne
- Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK; Cornwall Intellectual Disability Equitable Research (CIDER), Cornwall Partnership NHS Foundation Trust Truro, UK
| | | | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK; Statsconsultancy Ltd, Bucks, UK.
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Zhou SM, McLean B, Roberts E, Baines R, Hannon P, Ashby S, Newman C, Sen A, Wilkinson E, Laugharne R, Shankar R. Analysing patient-generated data to understand behaviours and characteristics of women with epilepsy of childbearing years: A prospective cohort study. Seizure 2023; 108:24-32. [PMID: 37060628 DOI: 10.1016/j.seizure.2023.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/02/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Women with epilepsy (WWE) are vulnerable in pregnancy, with increased risks to mother and baby including teratogenic risks, especially from valproate. The free EpSMon mobile-phone app allows self-monitoring to afford patient-centred feedback on seizure related risks, such as sudden death in epilepsy (SUDEP) to its users. We sought to generate insights into various seizure related risks and its treatments in WWE of childbearing age (16 to 60 years ) using EpSMon. METHODS The study utilizes a prospective real-world cohort of 5.5 years. Patient reported data on demographics, medication taken, diagnoses, seizure types and recognised biological, psychological, and social factors of seizure related harm were extracted. Data was stratified according to frequent and infrequent users and those scoring lower and higher risk scores. Multivariate logistic regression and different statistical tests were conducted. FINDINGS Data from 2158 WWE of childbearing age encompassing 4016 self-assessments were analysed. Overall risk awareness was 25.3% for pregnancy and 54.1% for SUDEP. Frequent users were more aware of pregnancy risks but not of SUDEP. Repeated EpSMon use increased SUDEP awareness but not pregnancy risks. Valproate was used by 11% of WWE, ranging from 6.5% of younger to 31.5% of older women. CONCLUSIONS The awareness to risks to pregnancy, SUDEP and valproate is low. Valproate is being used by a significant minority. It is imperative risk communication continues for WWE based on their individual situation and need. This is unlikely to be delivered by current clinical models. Digital solutions hold promise but require work done to raise implementation and acceptability.
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Affiliation(s)
- Shang-Ming Zhou
- Centre for Health Technology, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
| | - Brendan McLean
- Cornwall Intellectual Disability Equitable Research (CIDER), Peninsula School of Medicine, University of Plymouth, Truro, TR4 9LD, UK; Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, UK
| | - Elis Roberts
- School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth PL4 8AA, UK
| | - Rebecca Baines
- Cornwall Intellectual Disability Equitable Research (CIDER), Peninsula School of Medicine, University of Plymouth, Truro, TR4 9LD, UK
| | | | | | | | - Arjune Sen
- Nuffield Department of Clinical Neurosciences, University of Oxford, OX39DU, UK
| | | | - Richard Laugharne
- Cornwall Intellectual Disability Equitable Research (CIDER), Peninsula School of Medicine, University of Plymouth, Truro, TR4 9LD, UK; Psychoanalytica St Germans, UK; Cornwall Intellectual Disability Equitable Research (CIDER), Cornwall Partnership NHS Foundation Trust Truro TR4 9LD UK
| | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), Peninsula School of Medicine, University of Plymouth, Truro, TR4 9LD, UK; Psychoanalytica St Germans, UK; Cornwall Intellectual Disability Equitable Research (CIDER), Cornwall Partnership NHS Foundation Trust Truro TR4 9LD UK.
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Newman H, Rudra S, Burrows L, Tromans S, Watkins L, Triantafyllopoulou P, Hassiotis A, Gabrielsson A, Shankar R. Who cares? A scoping review on intellectual disability, epilepsy and social care. Seizure 2023; 107:35-42. [PMID: 36958062 DOI: 10.1016/j.seizure.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/25/2023] Open
Abstract
PURPOSE Nearly a quarter of people with Intellectual disability (PwID) have epilepsy. Many have seizures across their lifetime. In the UK supporting their epilepsy linked risks and needs, particularly in professional care settings and in the community, requires significant social care input. Therefore, the interface between social and health care services is important. This study aim is to identify key intersectional areas of social provision for PWID and epilepsy. METHODS A scoping review of the literature was performed in accordance with PRISMA guidance with suitable search terms. The search was completed in CINAHL, Embase, Psych INFO, SCIE, and Cochrane electronic databases by an information specialist. A quality assessment was completed for the included studies where appropriate. The included studies were analysed qualitatively to identify key themes and provide a narrative description of the evidence by two reviewers. RESULTS Of 748 papers screened, 94 were retrieved. Thirteen articles met the inclusion criteria with a range of methodologies. A thematic analysis generated four key categories for significant social care involvement i.e., staff training and education; emergency seizure management; holistic approach to care; and nocturnal monitoring and supervision. CONCLUSIONS PwID with epilepsy have support needs that require fulfilling by various aspects of special care provision, many within the social ambit. Inspite of evidence of these needs and recurrent calls to work jointly with social care providers this has not happened. There is limited research into social care role in epilepsy management in PwID which needs addressing.
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Affiliation(s)
- Hannah Newman
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Livewell southwest, Plymouth,UK
| | - Sonya Rudra
- Central and North London NHS Foundation Trust, London, UK
| | - Lisa Burrows
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Samuel Tromans
- University of Leicester, Leicester, UK; Leicestershire Partnership NHS Trust, Leicester, UK
| | - Lance Watkins
- Swansea Bay University Health Board, Port Talbot, UK; University of South Wales, Pontypridd, UK
| | | | | | | | - Rohit Shankar
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Cornwall Partnership NHS Foundation Trust, Truro, UK.
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Shlobin NA, Sander JW. Reducing Sudden Unexpected Death in Epilepsy: Considering Risk Factors, Pathophysiology and Strategies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00691-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
Sudden Unexpected Death in Epilepsy (SUDEP) is the commonest cause of epilepsy-related premature mortality in people with chronic epilepsy. It is the most devastating epilepsy outcome. We describe and discuss risk factors and possible pathophysiological mechanisms to elucidate possible preventative strategies to avert SUDEP.
Recent Findings
Sudden death accounts for a significant proportion of premature mortality in people with epilepsy compared to the general population. Unmodifiable risk factors include a history of neurologic insult, younger age of seizure-onset, longer epilepsy duration, a history of convulsions, symptomatic epilepsy, intellectual disability, and non-ambulatory status. Modifiable risk factors include the presence of convulsive seizures, increased seizure frequency, timely and appropriate use of antiseizure medications, polytherapy, alcoholism, and supervision while sleeping. Pathophysiology is unclear, but several possible mechanisms such as direct alteration of cardiorespiratory function, pulmonary impairment, electrocerebral shutdown, adenosine dysfunction, and genetic susceptibility suggested.
Summary
Methods to prevent SUDEP include increasing awareness of SUDEP, augmenting knowledge of unmodifiable risk factors, obtaining full seizure remission, addressing lifestyle factors such as supervision and prone positioning, and enacting protocols to increase the detection of and intervention for SUDEP. Further studies are required to characterize precisely and comprehensively SUDEP risk factors and pathophysiological drivers and develop evidence-based algorithms to minimize SUDEP in people with epilepsy.
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Autonomic manifestations of epilepsy: emerging pathways to sudden death? Nat Rev Neurol 2021; 17:774-788. [PMID: 34716432 DOI: 10.1038/s41582-021-00574-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/24/2022]
Abstract
Epileptic networks are intimately connected with the autonomic nervous system, as exemplified by a plethora of ictal (during a seizure) autonomic manifestations, including epigastric sensations, palpitations, goosebumps and syncope (fainting). Ictal autonomic changes might serve as diagnostic clues, provide targets for seizure detection and help us to understand the mechanisms that underlie sudden unexpected death in epilepsy (SUDEP). Autonomic alterations are generally more prominent in focal seizures originating from the temporal lobe, demonstrating the importance of limbic structures to the autonomic nervous system, and are particularly pronounced in focal-to-bilateral and generalized tonic-clonic seizures. The presence, type and severity of autonomic features are determined by the seizure onset zone, propagation pathways, lateralization and timing of the seizures, and the presence of interictal autonomic dysfunction. Evidence is mounting that not all autonomic manifestations are linked to SUDEP. In addition, experimental and clinical data emphasize the heterogeneity of SUDEP and its infrequent overlap with sudden cardiac death. Here, we review the spectrum and diagnostic value of the mostly benign and self-limiting autonomic manifestations of epilepsy. In particular, we focus on presentations that are likely to contribute to SUDEP and discuss how wearable devices might help to prevent SUDEP.
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McCabe J, McLean B, Henley W, Harris C, Cheatle K, Ashby S, Shankar R. Sudden Unexpected Death in Epilepsy (SUDEP) and seizure safety: Modifiable and non-modifiable risk factors differences between primary and secondary care. Epilepsy Behav 2021; 115:107637. [PMID: 33317940 DOI: 10.1016/j.yebeh.2020.107637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The SUDEP and Seizure Safety Checklist ("Checklist") is a risk factors Checklist based around a person with epilepsy (PWE) demographics, seizure, physical, psychological, and lifestyle issues. The Checklist provides a cumulative picture of current risk when applied to a PWE. This study compares and contrasts risk factors of PWE in primary versus secondary care. METHODS The Checklist was applied to all PWE registered in four primary care practices in central Cornwall UK (pop: 120,000). Individual, modifiable, non-modifiable, and total risk factors and scores were compared between PWE open to secondary care and those not. Statistical tests were used to calculate significance of individual risk factors in primary or secondary care, to compare the total risk scores between care settings and to find the frequency differences of each risk factor between primary practices. RESULTS People with total and non-modifiable risk scores were higher in secondary care (both p < 0.001). However, modifiable risk scores were higher in primary care (p < 0.001). Psychiatric concerns were the most prevalent modifiable risk factor in primary care. There were significant differences in the risk profiles between all four primary care practices. CONCLUSION This study highlights that there is a lack of clarity on who is referred to secondary care and when. There needs to be an evidence-based system to allow for a bidirectional flow of PWE considering their fluctuating risk. The Checklist can be a decision support tool to enable this.
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Affiliation(s)
- Joanne McCabe
- University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Brendan McLean
- Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall, UK
| | - William Henley
- Health Statistics Group, Institute of Health Research, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Craig Harris
- Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall, UK
| | - Katie Cheatle
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, UK
| | - Samantha Ashby
- SUDEP Action, 18 Newbury Street, Wantage, Oxfordshire, UK
| | - Rohit Shankar
- University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, UK; Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, UK.
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Abstract
Sudden unexpected death in epilepsy (SUDEP) remains an important cause of epilepsy-related mortality, especially in patients with refractory epilepsy. The exact cause is not known, but postictal cardiac, respiratory, and brainstem dysfunctions are implicated. SUDEP prevention remains a big challenge. Except for low-quality evidence of preventive effect of nocturnal supervision for SUDEP, no other evidence-based preventive modality is available. Other potential preventive strategies for SUDEP include reducing the occurrence of generalized tonic-clonic seizures using seizure detection devices, detecting cardiorespiratory distress through respiratory and heart rate monitoring devices, preventing airway obstruction (safety pillows), and reducing central hypoventilation using selective serotonin reuptake inhibitors and adenosine and opiate antagonists. However, none of the above-mentioned modalities has been proven to prevent SUDEP. The present review intends to provide insight into the available SUDEP prevention modalities.
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Aksoy D, Karakaya SB, Türkdoğan D, Karaketir ŞG, Save D. Awareness of sudden unexpected death in epilepsy among parents of children with epilepsy in a tertiary center. Epilepsy Behav 2020; 111:107125. [PMID: 32623029 DOI: 10.1016/j.yebeh.2020.107125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is the second leading neurological cause of potential years of lifelost after stroke. Despite growing numbers of studies on social aspects of epilepsy, there is a paucity of research on the awareness of SUDEP among the parents of children with epilepsy (CWE), especially in Turkey. In this study, we aimed to evaluate the knowledge of parents of the CWE regarding SUDEP in the tertiary setting. MATERIAL AND METHODS A total of 146 parents (108 female) aged 19 to 55 years (median age:34) of CWE were included at Marmara University, School of Medicine, Department of Pediatric Neurology outpatient clinic between May 2018 and September 2018. A total of 30 multiple-choice questions and a written survey were administered, which consisted of three sections. In the first section, the sociodemographics of parents and CWE were questioned. In the second section, the severity of epilepsy was evaluated. In the third section, the knowledge level and awareness of parents of CWE were assessed. RESULTS Of 146 parents, only 16.6% previously heard about SUDEP, while 45% of them heard from their relatives. The presence of prior knowledge of SUDEP was associated with the presence of prolonged postictal confusion and longer duration of epilepsy (p < 0.05). Ninety-seven (66%) parents desired to be informed about SUDEP, while 76 (54.7%) of them agreed that this information should be given at the time of diagnosis. The degree of anxiety in parents regarding death of epilepsy-related causes was significantly related with prolonged postictal confusion (p < 0.001) and using three or more antiepileptic drugs (p = 0.005). CONCLUSION Our data suggest that knowledge about SUDEP among parents with CWE found inadequate in Turkey. There should be much effort to inform parents and caregivers in epilepsy clinics on SUDEP, which may help to reduce the associated risk factors.
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Affiliation(s)
- Dilşat Aksoy
- Marmara University, School of Medicine, Istanbul, Turkey
| | | | - Dilşad Türkdoğan
- Marmara University, School of Medicine, Department of Pediatric Neurology, and Epilepsy Research and Implementation Centre, Istanbul, Turkey.
| | | | - Dilşad Save
- Marmara University, School of Medicine, Department of Public Health and Epilepsy Research and Implementation Centre, Istanbul, Turkey
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Pensel MC, Nass RD, Taubøll E, Aurlien D, Surges R. Prevention of sudden unexpected death in epilepsy: current status and future perspectives. Expert Rev Neurother 2020; 20:497-508. [PMID: 32270723 DOI: 10.1080/14737175.2020.1754195] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Sudden unexpected death in epilepsy (SUDEP) affects about 1 in 1000 people with epilepsy, and even more in medically refractory epilepsy. As most people are between 20 and 40 years when dying suddenly, SUDEP leads to a considerable loss of potential life years. The most important risk factors are nocturnal and tonic-clonic seizures, underscoring that supervision and effective seizure control are key elements for SUDEP prevention. The question of whether specific antiepileptic drugs are linked to SUDEP is still controversially discussed. Knowledge and education about SUDEP among health-care professionals, patients, and relatives are of outstanding importance for preventive measures to be taken, but still poor and widely neglected.Areas covered: This article reviews epidemiology, pathophysiology, risk factors, assessment of individual SUDEP risk and available measures for SUDEP prevention. Literature search was done using Medline and Pubmed in October 2019.Expert opinion: Significant advances in the understanding of SUDEP were made in the last decade which allow testing of novel strategies to prevent SUDEP. Promising current strategies target neuronal mechanisms of brain stem dysfunction, cardiac susceptibility for fatal arrhythmias, and reliable detection of tonic-clonic seizures using mobile health technologies.Abbreviations: AED, antiepileptic drug; CBZ, carbamazepine; cLQTS, congenital long QT syndrome; EMU, epilepsy monitoring unit; FBTCS, focal to bilateral tonic-clonic seizures; GTCS, generalized tonic-clonic seizures; ICA, ictal central apnea; LTG, lamotrigine; PCCA, postconvulsive central apnea; PGES, postictal generalized EEG suppression; SRI, serotonin reuptake inhibitor; SUDEP, sudden unexpected death in epilepsy; TCS, tonic-clonic seizures.
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Affiliation(s)
| | | | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Nydalen, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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Maguire MJ, Jackson CF, Marson AG, Nevitt SJ. Treatments for the prevention of Sudden Unexpected Death in Epilepsy (SUDEP). Cochrane Database Syst Rev 2020; 4:CD011792. [PMID: 32239759 PMCID: PMC7115126 DOI: 10.1002/14651858.cd011792.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review, published in 2016, Issue 7. Sudden Unexpected Death in Epilepsy (SUDEP) is defined as sudden, unexpected, witnessed or unwitnessed, non-traumatic or non-drowning death of people with epilepsy, with or without evidence of a seizure, excluding documented status epilepticus and in whom postmortem examination does not reveal a structural or toxicological cause for death. SUDEP has a reported incidence of 1 to 2 per 1000 patient-years and represents the most common epilepsy-related cause of death. The presence and frequency of generalised tonic-clonic seizures (GTCS), male sex, early age of seizure onset, duration of epilepsy, and polytherapy are all predictors of risk of SUDEP. The exact pathophysiology of SUDEP is currently unknown, although GTCS-induced cardiac, respiratory, and brainstem dysfunction appears likely. Appropriately chosen antiepileptic drug treatment can render around 70% of patients free of all seizures. However, around one-third will remain drug-resistant despite polytherapy. Continuing seizures place patients at risk of SUDEP, depression, and reduced quality of life. Preventative strategies for SUDEP include reducing the occurrence of GTCS by timely referral for presurgical evaluation in people with lesional epilepsy and advice on lifestyle measures; detecting cardiorespiratory distress through clinical observation and seizure, respiratory, and heart rate monitoring devices; preventing airway obstruction through nocturnal supervision and safety pillows; reducing central hypoventilation through physical stimulation and enhancing serotonergic mechanisms of respiratory regulation using selective serotonin reuptake inhibitors (SSRIs); and reducing adenosine and endogenous opioid-induced brain and brainstem depression. OBJECTIVES To assess the effectiveness of interventions in preventing SUDEP in people with epilepsy by synthesising evidence from randomised controlled trials of interventions and cohort and case-control non-randomised studies. SEARCH METHODS For the latest update we searched the following databases without language restrictions: Cochrane Register of Studies (CRS Web, 4 February 2019); MEDLINE (Ovid, 1946 to 1 February 2019); SCOPUS (1823 to 4 February 2019); PsycINFO (EBSCOhost, 1887 to 4 January 2019); CINAHL Plus (EBSCOhost, 1937 to 4 February 2019); ClinicalTrials.gov (5 February 2019); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, 5 February 2019). We checked the reference lists of retrieved studies for additional reports of relevant studies and contacted lead study authors for any relevant unpublished material. We identified any grey literature studies published in the last five years by searching: Zetoc database; ISI Proceedings; International Bureau for Epilepsy (IBE) congress proceedings database; International League Against Epilepsy (ILAE) congress proceedings database; abstract books of symposia and congresses, meeting abstracts, and research reports. SELECTION CRITERIA We aimed to include randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs; prospective non-randomised cohort controlled and uncontrolled studies; and case-control studies of adults and children with epilepsy receiving an intervention for the prevention of SUDEP. Types of interventions included: early versus delayed pre-surgical evaluation for lesional epilepsy; educational programmes; seizure-monitoring devices; safety pillows; nocturnal supervision; selective serotonin reuptake inhibitors (SSRIs); opiate antagonists; and adenosine antagonists. DATA COLLECTION AND ANALYSIS We aimed to collect data on study design factors and participant demographics for included studies. The primary outcome of interest was the number of deaths from SUDEP. Secondary outcomes included: number of other deaths (unrelated to SUDEP); change in mean depression and anxiety scores (as defined within the study); clinically important change in quality of life, that is any change in quality of life score (average and endpoint) according to validated quality of life scales; and number of hospital attendances for seizures. MAIN RESULTS We identified 1277 records from the databases and search strategies. We found 10 further records by searching other resources (handsearching). We removed 469 duplicate records and screened 818 records (title and abstract) for inclusion in the review. We excluded 785 records based on the title and abstract and assessed 33 full-text articles. We excluded 29 studies: eight studies did not assess interventions to prevent SUDEP; eight studies were review articles, not clinical studies; five studies measured sensitivity of devices to detect GTCS but did not directly measure SUDEP; six studies assessed risk factors for SUDEP but not interventions for preventing SUDEP; and two studies did not have a control group. We included one cohort study and three case-control studies of serious to critical risk of bias. The 6-month prospective cohort study observed no significant effect of providing patients with SUDEP information on drug compliance and quality of life, anxiety and depression levels. The study was too short and with no deaths observed in either group to determine a protective effect. Two case control studies reported a protective effect for nocturnal supervision against SUDEP. However due to significant heterogeneity, the results could not be combined in meta-analysis. One study of 154 SUDEP cases and 616 controls reported an unadjusted odds ratio (OR) of 0.34 (95% CI 0.22 to 0.53; P < 0.0001). The same study demonstrated the protective effect was independent of seizure control, suggesting that nocturnal supervision is not just a surrogate marker of seizure control. The second case-control study of 48 SUDEP cases and 220 controls reported an unadjusted OR of 0.08 (95% CI 0.02 to 0.27; P < 0.0001). The third case-control study of residential care centre patients who were already receiving physical checks more than 15 minutes apart throughout the night did not report any protective effect for additional nocturnal supervision (physical checks < 15 minutes apart; use of listening devices; dormitory setting; and use of bed sensors). However the same study did ascertain a difference between centres: the residential centre with the lowest level of supervision had the highest incidence of SUDEP. The case-control studies did not report on quality of life or depression and anxiety scores. AUTHORS' CONCLUSIONS We found limited, very low-certainty evidence that supervision at night reduces the incidence of SUDEP. Further research is required to identify the effectiveness of other current interventions - for example seizure detection devices, safety pillows, SSRIs, early surgical evaluation, educational programmes, and opiate and adenosine antagonists - in preventing SUDEP in people with epilepsy.
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Affiliation(s)
- Melissa J Maguire
- Leeds General InfirmaryDepartment of NeurologyGreat George StreetLeedsUK
| | - Cerian F Jackson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
- The Walton Centre NHS Foundation TrustLiverpoolUK
- Liverpool Health PartnersLiverpoolUK
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Torrance R, Yoon CH, Torrance AB, Tasker RC. Incorporating Ethically Relevant Empirical Data From Systematic Review of Reasons: A Case Study of Sudden Unexpected Death in Epilepsy. AJOB Empir Bioeth 2020; 11:91-103. [PMID: 32160128 DOI: 10.1080/23294515.2020.1737981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In this report we use a case study of risk of sudden unexpected death in epilepsy (SUDEP) to illustrate the contribution of systematic literature reviews of disease-specific ethical issues (DSEI). In particular, we show how ethically-relevant empirical data from such reviews can be used in the examination of the reasons for and against a particular normative approach to our DSEI. That is, we have attempted to offer a normative recommendation in response to the question of whether or not the risk of SUDEP should be disclosed to all patients. This case study functions as a form of empirical bioethics by providing a means of assessing empirical claims underlying reasons. As a result of this process, we are then able to provide clear and transparent, if not definitive, justification for a normative recommendation in response to a question of interest.
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Affiliation(s)
- Robert Torrance
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Chang-Ho Yoon
- Faculty of Medical and Health Sciences, Auckland University, Auckland, New Zealand
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Smart C, Page G, Shankar R, Newman C. Keep safe: The when, why and how of epilepsy risk communication. Seizure 2020; 78:136-149. [PMID: 32122784 DOI: 10.1016/j.seizure.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Risk communication between clinicians and people with epilepsy (PWE) and their families is under researched. There is limited guidance about when and how to have these discussions. This paper explores the current evidence on quality of risk related conversations in epilepsy and suggests a concept of an evidence-based guideline for person centred structured risk communication. METHODS A literature search of four electronic database, Ovid Medline, Ovid Embase, PUBMED, and CINAHL, was conducted by two independent reviewers using relevant search terms following the principals of the PRISMA guidance. No limits were applied. Supplementary searches included using backwards and forwards citation searching. A predesigned inclusion and exclusion criteria was administered to the identified results. RESULTS From 376 results identified, 17 studies met the final criteria of which ten were quantitative, five qualitative and two mixed methods. Perspectives of PWE and clinicians were represented. Extracted data was clustered into three domains: communication initiation (e.g. timing, individual tailoring); communication methods (preference for face to face with neurologists); and communication content (acknowledging the anxiety produced by risk communication, the benefits of being self-aware, normalising risk etc.). No papers focused on conversation structure (e.g. helpful phrases), or the best locations to hold conversations. CONCLUSION More research is needed to develop structured communication of risk. An attempt has been made to put current evidence into this format. Clearer guidance will enhance clinicians' confidence in communicating person centred epilepsy risk with PWE and their families thus improving outcomes.
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Mahr K, Bergmann MP, Kay L, Möller L, Reif PS, Willems LM, Menzler K, Schubert-Bast S, Klein KM, Knake S, Rosenow F, Zöllner JP, Strzelczyk A. Prone, lateral, or supine positioning at seizure onset determines the postictal body position: A multicenter video-EEG monitoring cohort study. Seizure 2020; 76:173-178. [PMID: 32109735 DOI: 10.1016/j.seizure.2020.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Most patients who die from sudden unexpected death in epilepsy (SUDEP) are found in the prone position. We evaluated whether changes in body position occur during generalized convulsive seizures (GCSs). METHOD GCSs in patients undergoing video-EEG-monitoring between 2007 and 2017 at epilepsy centers in Frankfurt and Marburg were analyzed in relation to changes in body position. RESULTS A total of 494 GCSs were analyzed among 327 patients. At seizure onset, positions included supine (48.2 %), right lateral (19.0 %), left lateral (15.6 %), sitting or standing (14.0 %), and prone (3.2 %). Between seizure onset and the start of generalization, 57.5 % of participants altered body positions. During four seizures, patients adopted a prone position, while, in five seizures, patients moved from a prone position. Patients who experienced GCS onset while in a nonprone position had a 2.1 % risk of entering the prone position by the end of their seizure. In contrast, 56.2 % of those in an initial prone position remained so at the end of the GCS, with an odds ratio for maintaining that position of 60.2 (95 % confidence interval: 29.1-124.3; p < 0.001). The likelihood of ending up in the prone position post-GCS did not vary among patients with different nonprone starting positions (p = 0.147). CONCLUSIONS Seizures in prone position occur during sleep and the highest risk for postictal prone positioning appears to be being in the prone position at GCS onset. Epilepsy patients should therefore be advised to go to sleep in a supine or lateral position to reduce their SUDEP risk.
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Affiliation(s)
- Katharina Mahr
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marc-Philipp Bergmann
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Lara Kay
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Leona Möller
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Katja Menzler
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susanne Knake
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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Shankar R, Ashby S, McLean B, Newman C. Bridging the gap of risk communication and management using the SUDEP and Seizure Safety Checklist. Epilepsy Behav 2020; 103:106419. [PMID: 31648927 DOI: 10.1016/j.yebeh.2019.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/05/2019] [Indexed: 01/17/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a tragic condition and, despite varied risk levels among the population with epilepsy, is the cause of significant premature mortality. In the last 20 years, though awareness of SUDEP has increased among epilepsy professionals, little has changed with regard to the death rates per se, in rates of informing people with epilepsy (PWE) of their person-centered SUDEP risks, or in the awareness levels of nonepilepsy clinicians, such as, primary care practitioners and hospital doctors. The challenges to make aware and inform PWE have been multifold, in particular, 'when', 'what', and 'how' to tell about SUDEP. Current guidance recognizes that to improve SUDEP rates, it is important to engage proactively with PWE. There is a need to bring shared responsibility between clinicians and PWE to help mitigate the risk of SUDEP. To enable this, a meaningful evidence-based person-centered conversation is essential. The SUDEP and Seizure Safety Checklist ("Checklist") was created to facilitate this. This paper showcases the background, concept, development, implementation, feasibility and validity studies undertaken, challenges, barriers, and limitations of the eight-year Checklist project, which has moved from a single clinic to an international presence. It outlines the need to further reform SUDEP risk communication recognizing the differences between a basic risk message at time of diagnosis as advocated by current good practice guidance and the need for a more person-centered discussion on a regular basis for which the Checklist can be a key catalyst. This article is part of the Special Issue "Prevent 21: SUDEP Summit - Time to Listen".
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Affiliation(s)
- Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro TR4 9LD, UK; Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro TR1 3HD, UK.
| | | | | | - Craig Newman
- Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth PL4 8AA, UK
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16
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Gutiérrez-Viedma Á, Sanz-Graciani I, Romeral-Jiménez M, Parejo-Carbonell B, Serrano-García I, Cuadrado ML, Aledo-Serrano Á, Gil-Nagel A, Toledano R, García-Morales I. Patients' knowledge on epilepsy and SUDEP improves after a semi-structured health interview. Epilepsy Behav 2019; 99:106467. [PMID: 31421520 DOI: 10.1016/j.yebeh.2019.106467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients' education is the most relevant contributor to patient self-management of epilepsy. We aimed to assess the acquisition of knowledge after a semi-structured interview. METHODS We performed a quasi-experimental prospective study with a cohort of patients with epilepsy admitted for prolonged video electroencephalogram (VEEG). We measured patients' baseline knowledge with a 10-item true-false test (test A). Then, a qualified nurse carried out a semi-structured interview. We measured acquired knowledge with another 10-item true-false exam (test B), prior to VEEG discharge and after a 3- to 5-month follow-up, and we compared the difference between the scores in test A and test B. Finally, we conducted a satisfaction and suitability survey on the interview at follow-up. RESULTS Thirty-two patients participated, half were women. Their median age was 39.5, and the median length of schooling was 14 years. The median time since epilepsy onset was 13 years, 75% had suffered tonic-clonic seizures. The median score on test A was 7, while the median score on test B was 8.5 (p < 0.001) both at VEEG discharge and after follow-up. After the interview, 84.4% of participants reported that they were very satisfied with the information received; 87.5% stated that they had not previously heard about SUDEP (sudden unexpected dead in epilepsy); and 93.8% considered it important to receive detailed information about SUDEP. CONCLUSIONS Patient education through a semi-structured comprehensive interview improves knowledge of patients with epilepsy about their disease. The calm atmosphere and the qualified nursing working at VEEG units make them an appropriate setting for talking about epilepsy and its risks, including SUDEP.
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Affiliation(s)
- Álvaro Gutiérrez-Viedma
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Plaza de Ramón y Cajal s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain.
| | - Isabel Sanz-Graciani
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - María Romeral-Jiménez
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - Beatriz Parejo-Carbonell
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - Irene Serrano-García
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Unidad de Metodología de Investigación y Epidemiología Clínica, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - María-Luz Cuadrado
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Plaza de Ramón y Cajal s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - Ángel Aledo-Serrano
- Unidad de Epilepsia, Servicio de Neurología, Hospital Ruber Internacional, Calle La Masó 38, 28034 Madrid, Spain
| | - Antonio Gil-Nagel
- Unidad de Epilepsia, Servicio de Neurología, Hospital Ruber Internacional, Calle La Masó 38, 28034 Madrid, Spain
| | - Rafael Toledano
- Unidad de Epilepsia, Servicio de Neurología, Hospital Ruber Internacional, Calle La Masó 38, 28034 Madrid, Spain; Unidad de Epilepsia, Servicio de Neurología, Hospital Ramón y Cajal, Carretera de Colmenar Viejo 100, 28034 Madrid, Spain
| | - Irene García-Morales
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Plaza de Ramón y Cajal s/n, 28040 Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain; Unidad de Epilepsia, Servicio de Neurología, Hospital Ruber Internacional, Calle La Masó 38, 28034 Madrid, Spain
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[Sudden unexpected death in epilepsy (SUDEP) : Epidemiology, cardiac and other risk factors]. Herzschrittmacherther Elektrophysiol 2019; 30:274-286. [PMID: 31489492 DOI: 10.1007/s00399-019-00643-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is one of the most frequent epilepsy-related causes of death. The incidence of SUDEP is estimated to be approximately 1.2/1000 person-years (PY); however, it varies considerably depending on disease-specific and demographic factors. The estimated incidence of SUDEP in children seems to be significantly lower (0.22/1000 PY) than in adults but recent studies in children (>12 years) indicated a similar incidence to that of adults. Based on these estimations, approximately 700 SUDEP cases would be expected in Germany annually but no reliable data or epidemiological studies on SUDEP are available. Various risk factors and predictors for SUDEP have been investigated, e.g. age, seizure frequency, number of antiepileptic drugs, non-compliance and comorbidities, with sometimes contradictory results. This is understandable given that the exact mechanisms of SUDEP are unclear; however, it is very likely that the frequency of (nocturnal) generalized tonic-clonic seizures is the most important risk factor. Nocturnal monitoring of seizures (using devices) or the presence of another person at night may represent important factors to reduce the risk of SUDEP. Thus, seizure control and seizure monitoring are, according to current knowledge, the most important factors to avoid SUDEP. Some recent studies have contributed to a better understanding of possible pathomechanisms of SUDEP; however, further research is needed to identify predictive clinical factors and biomarkers and in particular to prevent SUDEP.
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18
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Elmali AD, Bebek N, Baykan B. Let's talk SUDEP. ACTA ACUST UNITED AC 2019; 56:292-301. [PMID: 31903040 DOI: 10.29399/npa.23663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/21/2019] [Indexed: 01/17/2023]
Abstract
Sudden unexplained death in epilepsy (SUDEP) is a devastating complication of epilepsy which was under-recognized in the recent past despite its clear importance. In this review, we examine the definition of SUDEP, revise current pathophysiological theories, discuss risk factors and preventative measures, disclose tools for appraising the SUDEP risk, and last but not least dwell upon announcing and explaining the SUDEP risk to the patients and their caretakers. We aim to aid the clinicians in their responsibility of knowing SUDEP, explaining the SUDEP risk to their patients in a reasonable and sensible way and whenever possible, preventing SUDEP. Future studies are definitely needed to increase scientific knowledge and awareness related to this prioritized topic with malign consequences.
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Affiliation(s)
- Ayşe Deniz Elmali
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
| | - Nerses Bebek
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
| | - Betül Baykan
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
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19
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The neurology-psychiatry interface in epilepsy. Ir J Psychol Med 2018; 38:9-15. [PMID: 33715646 DOI: 10.1017/ipm.2018.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.
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20
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Saxena A, Jones L, Shankar R, McLean B, Newman CGJ, Hamandi K. Sudden unexpected death in epilepsy in children: a focused review of incidence and risk factors. J Neurol Neurosurg Psychiatry 2018; 89:1064-1070. [PMID: 29632029 DOI: 10.1136/jnnp-2017-317702] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/21/2018] [Accepted: 03/12/2018] [Indexed: 11/04/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) in children, although rare, needs critical attention given the tragic nature and devastating consequences for families and caregivers. True incidence is unknown and risk factors are not completely understood, more so in children compared with adults. A focused narrative review of available studies on paediatric SUDEP was undertaken to comprehend its risk factors and to develop strategies to recognise and where possible modify SUDEP risk and ultimately reduce incidence. We reviewed 16 population-based studies from various settings. We found overlapping risk factors from different studies. The prime risk factor is uncontrolled seizures. This review supports the view that children entering adolescence with optimal seizure control could be a key aspect in reducing adult mortality related to SUDEP. Ideally, clinicians would want to be able to predict prospective, individualised SUDEP risk, which is challenging due to a myriad of risk factors and an inherent non-homogeneous paediatric epilepsy population. Nevertheless, an adequate evidence base exists as evidenced by this review to support information giving and communication to support young people with epilepsy and their families in being active partners in recognising and reducing their SUDEP risk. More work particularly in the form of prospective studies and registries are needed to further clarify true incidence which may have been previously underestimated and to update risk factors.
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Affiliation(s)
- Anurag Saxena
- The Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | | | | | | | - Craig G J Newman
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Khalid Hamandi
- Wales Epilepsy Unit, Department of Neurology, University Hospital of Wales, Cardiff, UK
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21
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Watkins L, Shankar R. Reducing the Risk of Sudden Unexpected Death in Epilepsy (SUDEP). Curr Treat Options Neurol 2018; 20:40. [DOI: 10.1007/s11940-018-0527-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Shankar R, Henley W, Boland C, Laugharne R, McLean BN, Newman C, Hanna J, Ashby S, Walker MC, Sander JW. Decreasing the risk of sudden unexpected death in epilepsy: structured communication of risk factors for premature mortality in people with epilepsy. Eur J Neurol 2018; 25:1121-1127. [PMID: 29611888 DOI: 10.1111/ene.13651] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Good practice guidelines highlight the importance of making people with epilepsy aware of the risk of premature mortality in epilepsy particularly due to sudden unexpected death in epilepsy (SUDEP). The SUDEP and Seizure Safety Checklist ('Checklist') is a structured risk communication tool used in UK clinics. It is not known if sharing structured information on risk factors allows individuals to reduce SUDEP and premature mortality risks. The aim of this study was to ascertain if the introduction of the Checklist in epilepsy clinics led to individual risk reduction. METHODS The Checklist was administered to 130 consecutive people with epilepsy attending a specialized epilepsy neurology clinic and 129 attending an epilepsy intellectual disability (ID) clinic within a 4-month period. At baseline, no attendees at the neurology clinic had received formal risk advice, whereas all those attending the ID clinic had received formal risk advice on multiple occasions for 6 years. The Checklist was readministered 1 year later to each group and scores were compared with baseline and between groups. RESULTS Of 12 risk factors considered, there was an overall reduction in mean risk score for the general (P = 0.0049) but not for the ID (P = 0.322) population. Subanalysis of the 25% of people at most risk in both populations showed that both sets had a significant reduction in risk scores (P < 0.001). CONCLUSION Structured discussion results in behavioural change that reduces individual risk factors. This impact seems to be higher in those who are at current higher risk. It is important that clinicians share risk information with individuals as a matter of public health and health promotion.
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Affiliation(s)
- R Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK.,Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, UK
| | - W Henley
- Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, UK
| | - C Boland
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | - R Laugharne
- Cornwall Partnership NHS Foundation Trust, Truro, UK.,Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, UK
| | | | - C Newman
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | - M C Walker
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - J W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, Buckinghamshire, UK.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
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23
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Shankar R, Newman C, Gales A, McLean BN, Hanna J, Ashby S, Walker MC, Sander JW. Has the Time Come to Stratify and Score SUDEP Risk to Inform People With Epilepsy of Their Changes in Safety? Front Neurol 2018; 9:281. [PMID: 29755403 PMCID: PMC5934492 DOI: 10.3389/fneur.2018.00281] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/10/2018] [Indexed: 11/24/2022] Open
Abstract
Recent publication of the American Academy of Neurology SUDEP guidance highlighted the importance to American clinicians of making people with epilepsy aware of SUDEP risk. It is the first guideline to do this in the United States. It follows precedent set out in the UK by National Institute of Clinical Excellence in 2004. While a significant achievement, the lack of clarity of how to deliver this guidance in an enduring and person-centered manner, raises concerns on how its long-term effectiveness in risk mitigation. Shared decision-making with an emphasis on delivering person-centered communication to foster self-management strategies is increasingly recognized as the ideal model of patient–clinician communication in chronic diseases such as epilepsy. The tension between delivering evidence-based risk information, yet, tailoring it to the individual is complex. It needs to incorporate the potential for change not only in seizure factors but also other health and social factors. Safety advice needs to be dynamic and situation sensitive as opposed to a “one off” discussion. As a significant minority of people with epilepsy have drug-resistant seizures, the importance of keeping the advice contextual at different intervals of the person’s life cannot be overstated as many of them are managed in primary care. We present some exploratory work, which identifies the need to improve communication at a primary care level and to review risks regularly. Regular reviews using a structured risk factor checklist as a screening tool could identify, sooner, people who’s health issues are worsening and justify referrals to specialists.
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Affiliation(s)
- Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, United Kingdom.,Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, United Kingdom
| | - Craig Newman
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom
| | | | | | | | | | - Matthew C Walker
- NIHR University College London, Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom
| | - Josemir W Sander
- NIHR University College London, Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom.,Chalfont Centre for Epilepsy, Buckinghamshire, United Kingdom.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
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24
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Knowledge of sudden unexpected death in epilepsy (SUDEP) among 372 patients attending a German tertiary epilepsy center. Epilepsy Behav 2018; 80:360-364. [PMID: 29454605 DOI: 10.1016/j.yebeh.2017.11.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is evidence that the sudden unexpected death in epilepsy (SUDEP) risk can be reduced by good seizure control, nocturnal supervision, and by early cardiopulmonary resuscitation if cardiorespiratory arrest occurs in the aftermaths of generalized tonic-clonic seizures (GTCS). These measures, however, may critically depend on the knowledge of patients and relatives on SUDEP. Here, we assessed the basic knowledge on SUDEP of people with epilepsy at a tertiary epilepsy center in Germany. METHODS Adult patients with epilepsy and relatives or caregivers of patients with epilepsy aged 16years or older attending our outpatient clinic from January to March 2014 were given the opportunity to participate in a (assisted or unassisted) written survey. In the anonymized questionnaire, people were asked if they had already heard about SUDEP, by what means and if they wish to learn (more) about SUDEP. Furthermore, age, sex, epilepsy duration, highest degree of education, number of GTCS during the last year, and estimation of subjective impairment by their disease were assessed. Statistics were done using mixed linear or logistic regression models. RESULTS A total of 372 patients' questionnaires were included in this survey. More than 87% of the participants had never heard of SUDEP before. Whereas about 50% of the participants wanted to learn more about SUDEP, about 40% did not. Only the age at survey was significantly associated with both being informed and the desire of learning more about SUDEP: Younger patients had more often heard (p=0.022) and wanted to know more about SUDEP (p=0.020). Thirty-nine patients were considered at high risk for SUDEP. Of these, only 6 patients (15%) knew about SUDEP prior to this survey, but 18 patients (46%) wanted to learn more about this fatal complication. CONCLUSION Our data suggest that the level of information on SUDEP among people with epilepsy is poor in Germany regardless of sex, school education, or epilepsy severity. Additionally, a considerable proportion of people with epilepsy seems to prefer not getting detailed information on SUDEP. More efforts are required to understand the potential barriers of the education of patients and relatives on sudden death with the ultimate goal of decreasing the risk of SUDEP.
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Watkins L, Shankar R, Sander JW. Identifying and mitigating Sudden Unexpected Death in Epilepsy (SUDEP) risk factors. Expert Rev Neurother 2018; 18:265-274. [PMID: 29425076 DOI: 10.1080/14737175.2018.1439738] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Sudden Unexpected Death in Epilepsy (SUDEP) is a significant cause of death for people with chronic epilepsy. Good practice guidance in the UK and the USA expect SUDEP to be discussed with the individual. The event rarity, methodological variance and lack of robust research into the pathological mechanisms, associated risk factors, and management strategies have created a challenge on how and what to discuss. There are some significant associations which allows for risk assessment and mitigation. Areas covered: The current understanding of static and modifiable risk factors for SUDEP and how to manage these more effectively are reviewed. Longitudinal risk may be assessed using standardised risk assessment tools which help in communicating risk. Technological advancement allows measurement of physiological parameters associated with seizures and risk of SUDEP using small wearable devices. Further evidence is needed to demonstrate such technologies are efficacious and safe. Expert commentary: Risk reduction should be an important part of epilepsy management and we suggest a Gold Standard of Care which healthcare professionals and services should aim for when approaching SUDEP risk management. A Minimum Standard of Care is also proposed that is practical to implement, that all people with epilepsy should expect to receive.
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Affiliation(s)
- Lance Watkins
- a Neath Port Talbot CLDT, Mental Health & Learning Disability Delivery Unit , Abertawe Bro Morgannwyg University Health Board , Morriston , Swansea
| | - Rohit Shankar
- b Department of Intellectual Disability Neuropsychiatry , Cornwall Partnership NHS Foundation Trust , Truro , UK.,c Exeter Medical School, Knowledge Spa , Royal Cornwall Hospital Truro , Cornwall , UK
| | - Josemir W Sander
- d UCL Institute of Neurology , NIHR University College London Hospitals Biomedical Research Centre , London , UK.,e Chalfont Centre for Epilepsy , Buckinghamshire , UK.,f Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , Netherlands
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Determining factors of electrocardiographic abnormalities in patients with epilepsy: A case-control study. Epilepsy Res 2016; 129:106-116. [PMID: 28043059 DOI: 10.1016/j.eplepsyres.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/28/2016] [Accepted: 12/16/2016] [Indexed: 11/21/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in young patients with epilepsy (PWE). Although its mechanisms are still poorly understood, they may include cardiorespiratory dysfunction. Standard 12-lead electrocardiograms (ECGs) were obtained from 62 consecutive patients (aged 18-66y) with a definite diagnosis of epilepsy, without seizures at the day of ECG, and 57 healthy controls matched for sex, age and body mass index (BMI). All ECGs were evaluated by a blinded board-certified cardiologist. Patients with symptomatic focal epilepsy represented 90.3% (N=56), of whom 56.4% (N=35) had temporal lobe epilepsy, with a mean duration of 22.02±14.96years of epilepsy. We observed more prolonged P-wave (p<0.0001) and PR interval (p=0.01) in patients than in controls. Additionally, longer QT intervals (p<0.01), pathologic QT dispersion (p<0.01) and left atrial overload (p<0.01) were more common in PWE. Multiple linear regression analysis evidenced age, gender and polytherapy as factors associated with altered ECG. Therefore, routine ECG should be requested in PWE, especially for males, increasing age and in polytherapy. Findings such as longer PR and QT interval, and pathologic QT dispersion, may reflect cardiac structural changes and/or autonomic nervous system dysfunction and indicate a risk for SUDEP.
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Mclean B, Shankar R, Hanna J, Jory C, Newman C. Sudden unexpected death in epilepsy: measures to reduce risk. Pract Neurol 2016; 17:13-20. [DOI: 10.1136/practneurol-2016-001392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2016] [Indexed: 11/04/2022]
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Kommajosyula SP, Randall ME, Tupal S, Faingold CL. Alcohol withdrawal in epileptic rats - Effects on postictal depression, respiration, and death. Epilepsy Behav 2016; 64:9-14. [PMID: 27723498 DOI: 10.1016/j.yebeh.2016.09.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 01/08/2023]
Abstract
Patients with epilepsy are at risk of sudden unexpected death in epilepsy (SUDEP). The most common series of events in witnessed cases of SUDEP is a generalized convulsive seizure followed by terminal apnea. Risk factors for SUDEP include prolonged postictal depression (PID), as well as alcohol abuse. The present study examined these issues in a genetic epilepsy model that exhibits generalized convulsive audiogenic seizures (AGSz) but rarely exhibits seizure-induced death, the genetically epilepsy-prone rats (GEPR-9s). We evaluated the effect of ethanol withdrawal (ETX) in GEPR-9s on respiration patterns, duration of PID, and the incidence of seizure-induced death. Audiogenic seizures were induced in GEPR-9s and in normal Sprague-Dawley rats, which were subjected to a 4-day binge ethanol protocol, 18-24h after the last ethanol dose. Following the tonic seizures, all GEPR-9s exhibited PID, characterized by loss of the righting reflex and respiratory distress (RD), which were absent during ETX seizures in the normal rats. During ETX, GEPR-9s exhibited significant increases in the duration of PID and RD, compared with vehicle-treated GEPR-9s. A significant increase in the incidence of death following seizure in GEPR-9s subjected to ETX was observed, compared with that in vehicle-treated GEPR-9s and normal rats subjected to ETX. Death in GEPR-9s was preceded by prolonged seizures because, in part, of the emergence of post-tonic generalized clonus. These results indicate that ETX induced significant increases in the duration of PID and RD, which contributed to the greater incidence of mortality in GEPR-9s compared with that in vehicle-treated GEPR-9s and normal rats. These experiments observed an elevated risk of sudden death associated with alcohol withdrawal in a genetic epilepsy model that had previously been identified as a risk factor in human SUDEP.
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Affiliation(s)
- Srinivasa P Kommajosyula
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, P.O. Box 19629, Springfield, IL 62794-9629, United States
| | - Marcus E Randall
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, P.O. Box 19629, Springfield, IL 62794-9629, United States
| | - Srinivasan Tupal
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, P.O. Box 19629, Springfield, IL 62794-9629, United States
| | - Carl L Faingold
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, P.O. Box 19629, Springfield, IL 62794-9629, United States.
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