Medical outcome in epilepsy patients of young adulthood—A 5-year follow-up study

Similar Profile and Magnitude of Cognitive Impairments in Focal and Generalized Epilepsy: A Pilot Study

Introduction: Cognitive impairments in epilepsy are not well-understood. In addition, long-term emotional, interpersonal, and social consequences of the underlying disturbances are important to evaluate.

Purpose: To compare cognitive function including language in young adults with focal or generalized epilepsy. In addition, quality of life and self-esteem were investigated.

Patients and Methods: Young adults with no primary intellectual disability, 17 with focal epilepsy and 11 with generalized epilepsy participated and were compared to 28 healthy controls. Groups were matched on age (mean = 26 years), sex, and education. Participants were administered a battery of neuropsychological tasks and carried out self-ratings of quality of life, self-esteem, and psychological problems.

Results: Similar impairments regarding cognitive function were noted in focal and generalized epilepsy. The cognitive domains tested were episodic long-term memory, executive functions, attention, working memory, visuospatial functions, and language. Both epilepsy groups had lower results compared to controls (effect sizes 0.24–1.07). The total number of convulsive seizures was predictive of episodic long-term memory function. Participants with focal epilepsy reported lower quality of life than participants with generalized epilepsy. Lowered self-esteem values were seen in both epilepsy groups and particularly in those with focal epilepsy. Along with measures of cognitive speed and depression, the total number of seizures explained more than 50% of variation in quality of life.

Conclusion: Interestingly, similarities rather than differences characterized the widespread cognitive deficits that were seen in focal and generalized epilepsy, ranging from mild to moderate. These similarities were modified by quality of life and self-esteem. This study confirms the notion that epilepsy is a network disorder.

Illness identity in young adults with refractory epilepsy

INTRODUCTION

Refractory epilepsy is an intrusive condition with important implications for daily functioning in emerging and young adulthood. The present study examined the degree to which refractory epilepsy is integrated in one's identity, and examined how such a sense of illness identity was related to health-related quality of life (HRQOL).

METHODS

A total of 121 18- to 40-year-old patients with refractory epilepsy (56.2% women) completed self-report questionnaires assessing the four illness identity states of acceptance, enrichment, engulfment, and rejection (Illness Identity Questionnaire (IIQ)); HRQOL (Quality of Life in Epilepsy Inventory - 31); and seizure frequency and severity (Liverpool Seizure Severity Scale (LSSS)). Illness identity scores were compared with a sample of 191 patients with a nonneurological chronic disease (congenital heart disease). Hierarchical regression analyses were conducted to assess the predictive value of illness identity for HRQOL when simultaneously controlling for demographic and clinical features.

RESULTS

Patients with refractory epilepsy scored higher on rejection and engulfment and lower on acceptance when compared with patients with congenital heart disease. Further, seizure severity and number of medication side-effects were positively related to engulfment and negatively to acceptance. Finally, when simultaneously controlling for various demographic and clinical variables, illness identity significantly predicted HRQOL (with engulfment being the strongest and most consistent predictor).

CONCLUSION

The extent to which patients with refractory epilepsy succeed in integrating their illness into their identity may have important implications for HRQOL. Clinicians should be especially attentive for signs that patients feel engulfed by their epilepsy.

Patterns of antiepileptic drug prescription in Sweden: A register-based approach

OBJECTIVES

To determine drug utilization pathways from the incident healthcare visit due to epilepsy and three years onward.

MATERIAL AND METHODS

Anti-epileptic drug utilization was calculated using individual information on inpatient- and outpatient care utilization and drug sales. Throughout, we used national register information pertaining to pharmaceutical sales linked to diagnosis-related healthcare utilization. Information on pharmaceutical sales was collected for the 2007-2013 period.

RESULTS

For the entire studied period, a majority of new patients with epilepsy were initiated on anti-epileptic drug treatment with a monotherapy (98%); most of these patients remained on that first treatment (64%). The three most frequently prescribed drugs accounted for 72% of the initiated AED treatments. Patients with epilepsy (ICD-10: G40/41) were most commonly prescribed carbamazepine, lamotrigine and valproate. The most common second-line monotherapy was levetiracetam. About 12% of new patients with epilepsy who were initiated on AED treatment during the period eventually switched to an add-on therapy. The proportion of patients who were initiated on treatment with carbamazepine or valproate decreased, and the proportion of patients who remained on their initial monotherapy increased between 2007 and 2013.

CONCLUSIONS

A limited number of anti-epileptic drugs accounted for the treatment of a majority of new patients with epilepsy (carbamazepine, lamotrigine and valproate accounted for more than 70%). Add-on therapies showed the same pattern, as the most frequently prescribed add-on regimens were the same ones that accounted for most of the monotherapies. There was a tendency towards fewer patients being initiated on AED treatment with either carbamazepine or valproate.

Natural course of treated epilepsy and medico-social outcomes. Turku studies. Part II

Introduction. Population-based data on the prognosis of childhood-onset epilepsy were almost nonexistent in the 1960s. This prompted me to start an epidemiological prospective study on children with epilepsy.

Aim. To study the medical and social outcome of children with epilepsy.

Methods. The most important personal data on the natural course and outcome were reviewed and compared with the relevant data of other investigators.

Results and discussion. The natural course of treated epilepsy is remitting, uninterrupted by relapse (in 48%); a remitting-relapsing course (interrupted by relapses, in terminal remission) (19%); worsening course (early or late remission followed by drug-resistant epilepsy) (14%); and never in ≥5-year remission (drug resistance) (19%) The medical and social outcomes based on my unique, five decades followed cohort show that most subjects are in 10-year remission without medications, which is the definition of resolved epilepsy. Normal or subnormal IQ, non-symptomatic etiology, and low seizure frequency both in the first year of AED treatment and prior to medication appear to be clinical predictors of cure in childhood-onset epilepsy. Subjects with 1-year remission during the first five years form onset of treatment have more than 10-fold chance for entering 5-year terminal remission vs those who have no 1-year remission during the first five years. Even about one fourth of difficult-to-treat subjects become seizure free on medication and more than half of them enter one or more 5-year remissions. Epilepsy has a substantial impact on quality of life even in those who are seizure free off medication for many years and particularly those not in remission or in remission but still on medication.

Conclusions. The prognosis is excellent for medical and social outcome. The successful outcome is confirmed by several longitudinal studies from recent decades. Good response to early drug therapy does not necessarily guarantee a favorable seizure outcome, and even a late good response may still predict a successful prognosis. Our life-cycle study is being continued and targets to answer the question whether or not childhood-onset epilepsy is a risk factor for premature and/or increased incidence of mental impairment and dementia.

Retigabine as add-on treatment of refractory epilepsy--a cost-utility study in a Swedish setting

OBJECTIVES

To calculate comparative incremental cost-effectiveness ratios (cost per quality-adjusted life year, QALY) and net marginal benefits for retigabine as add-on treatment for patients with uncontrolled focal seizures as compared to add-on lacosamide treatment and no add-on treatment, respectively.

MATERIALS & METHODS

Calculations were performed using a validated decision-tree model. The study population consisted of adult patients with focal-onset epilepsy in published randomized placebo-controlled add-on trials of retigabine or lacosamide. Healthcare utilization and QALY for each treatment alternative were calculated. Probabilistic sensitivity analysis was performed using the specification of this model as a basis for Monte Carlo simulations. 2009 prices were used for all costs.

RESULTS

Results were reported for a 2-year follow-up period. Retigabine add-on treatment was both more effective and less costly than lacosamide add-on treatment, and the cost per additional QALY for the retigabine no add-on (standard) therapy comparison was estimated at 2009€ 15,753. Using a willingness-to-pay threshold for a QALY of € 50,000, the net marginal values were estimated at 2009€ 605,874 for retigabine vs lacosamide and 2009€ 2,114,203 for retigabine vs no add-on, per 1,000 patients. The probabilistic analyses showed that the likelihood that retigabine treatment is cost-effective is at least 70%.

CONCLUSIONS

The estimated cost per additional QALY, for the retigabine vs no add-on treatment comparison, is well within the range of newly published estimates of willingness to pay for an additional QALY. Thus, add-on retigabine treatment for people with focal-onset epilepsy with no/limited response to standard antiepileptic treatment appears to be cost-effective.

Review of therapeutic options for adjuvant treatment of focal seizures in epilepsy: focus on lacosamide

Epilepsy is one of the most common serious neurological conditions worldwide, with an age-adjusted incidence of approximately 50 per 100,000 persons per year in developed countries. Antiepileptic therapy can result in long-term remission in 60-70% of patients, but many patients will require combination treatment to achieve optimal seizure control, as monotherapy is ineffective at controlling seizures in 30-53% of patients. Despite the increase in available treatment options, patient outcomes have not improved significantly and there is still a need for more effective therapies. Drugs used in the treatment of focal-onset seizures are a diverse range of compounds, and in most cases their mechanism of action is unknown or poorly defined. This review discusses the efficacy and safety of the newer adjuvant antiepileptic therapies that may improve outcomes in patients unresponsive to monotherapy, including clobazam, vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine, levetiracetam, oxcarbazepine, pregabalin, zonisamide and eslicarbazepine, with focus on lacosamide. Lacosamide has been shown to exert its anticonvulsant effects predominantly by enhancement of the slow inactivation of voltage-gated sodium channels. Lacosamide is indicated for use as adjuvant treatment of focal-onset seizures in patients with epilepsy, and there is some evidence that it may also be of use in patients with status epilepticus and cancer patients with epilepsy. The efficacy of lacosamide has been assessed in three randomized, double-blind, placebo-controlled clinical trials, all of which have shown lacosamide to be effective at reducing seizure frequency and increasing 50% responder rates in patients with focal-onset seizures. Long-term lacosamide treatment is generally well tolerated and is not associated with significant drug interactions; the availability of an intravenous form of the drug also makes it particularly useful for a broad range of patients.

Living with epilepsy accompanied by cognitive difficulties: young adults' experiences

OBJECTIVE

Epilepsy can sometimes be followed by memory impairment. This can result from the underlying cause of epilepsy or from recurrent seizures, or can be a side effect of antiepileptic drugs or a symptom of another disease such as depression. The aim of the study described here was to explore the experience of living with epilepsy and subjective cognitive decline.

METHOD

To better understand the deeper meaning of the phenomenon, a qualitative design was chosen. Fourteen adults aged 18-35 took part in focus group interviews. The participants were divided into four groups, two groups of women and two groups of men, and the interviews were conducted according to a semistructured protocol. Transcripts were analyzed in accordance with the content analysis guidelines.

RESULTS

Four themes emerged: "affecting the whole person," "influencing daily life," "affecting relationships," and "meeting ignorance in society."

CONCLUSIONS

Cognitive decline has a heavy impact on young adults with intractable epilepsy. In contrast to seizures, the cognitive decline is persistent. The themes reflected different hardships faced by the participants. The consequences of living with epilepsy and cognitive impairment concerned education, employment, social life, self-esteem, and hope for the future. The participants were already using strategies to cope with their cognitive decline, but may benefit from help in developing new strategies to better adjust to their memory problems. Development of more educational programs for both people with epilepsy and their relatives could improve their difficult situations. With help, people can learn to adjust their goals in life and live a fulfilling life despite the disease.

Patients' perceptions of living with epilepsy: a phenomenographic study

AIM

The study aimed to describe how patients with epilepsy perceive living with epilepsy.

BACKGROUND

Epilepsy signifies a medical diagnosis as well as a social label. Persons living with epilepsy have more psychosocial problems compared with the general population, and stigma is often experienced. Few studies address patients' life situations as a whole, and there are no studies on how patients perceive living with epilepsy.

DESIGN

This was a qualitative interview study where 19 outpatients were purposively chosen and interviewed.

METHOD

A phenomenographic approach was used for interviewing and for analysing the interviews.

RESULTS

Living with epilepsy was perceived in two different ways depending on the person's feelings towards the condition. A positive feeling signified 'Living with epilepsy means living a normal life - gaining and maintaining control' with the descriptive categories: 'Accepting the person with epilepsy', 'Taking responsibility' and 'Appreciating the good things'. A negative feeling signified 'Living with epilepsy means living with focus on the condition - conflict and avoidance or resigning to fate' with the descriptive categories: 'Struggling with feelings of stigma, prejudices and loss of control' and 'Giving up hope of recovery, accepting loss of control'.

CONCLUSION

The findings indicate that patients' perceptions of living with epilepsy are closely related to their feelings towards the condition. There is a need for further exploration of the relationship between perceptions of epilepsy as a phenomenon, perceptions of living with epilepsy and feelings related to the condition. Relevance to clinical practice.  The findings demonstrated how important feelings and perceptions are to how patients with epilepsy regard themselves. This knowledge is essential for nurses when helping patients to better understand underlying reasons for their reactions to various situations. Forming interventions to help patients with epilepsy to find coping strategies that enhance self-esteem and self-value is another area of relevance.

Self-esteem and sense of coherence in young people with uncomplicated epilepsy: a 5-year follow-up

OBJECTIVE

It is not clear how the psychosocial well-being of young people with epilepsy is affected by growing up with the condition. We studied self-esteem and sense of coherence in a group of young adults with epilepsy and compared the results with those obtained 5 years earlier.

METHODS

The participants (n = 97) answered questionnaires regarding self-esteem, sense of coherence, and medical characteristics.

RESULTS

Self-esteem and sense of coherence both decreased during the 5-year study period. Self-esteem was correlated to epilepsy-related variables. Participants who were seizure free scored higher on sense of coherence, but there was no association between seizure frequency and sense of coherence among participants who still experienced seizures.

CONCLUSION

We found that there was a decline in both sense of coherence and self-esteem over time for young adults with epilepsy. Growing up with epilepsy can lead to impairment of sense of coherence. Sense of coherence does not significantly correlate with epilepsy-related factors, but mirrors the phenomenon of epilepsy. Self-esteem is associated with such epilepsy-related factors as seizure frequency.