The provision of care to adults with an intellectual disability in the UK. A Special report from the intellectual disability UK chapter ILAE

Awareness of social care needs in people with epilepsy and intellectual disability

BACKGROUND

Nearly a quarter of people with intellectual disability (ID) have epilepsy with large numbers experiencing drug-resistant epilepsy, and premature mortality. To mitigate epilepsy risks the environment and social care needs, particularly in professional care settings, need to be met.

PURPOSE

To compare professional care groups as regards their subjective confidence and perceived responsibility when managing the need of people with ID and epilepsy.

METHOD

A multi-agency expert panel developed a questionnaire with embedded case vignettes with quantitative and qualitative elements to understand training and confidence in the health and social determinants of people with ID and epilepsy. The cross-sectional survey was disseminated amongst health and social care professionals working with people with ID in the UK using an exponential non-discriminative snow-balling methodology. Group comparisons were undertaken using suitable statistical tests including Fisher's exact, Kruskal-Wallis, and Mann-Whitney. Bonferroni correction was applied to significant (p < 0.05) results. Content analysis was conducted and relevant categories and themes were identified.

RESULTS

Social and health professionals (n = 54) rated their confidence to manage the needs of people with ID and epilepsy equally. Health professionals showed better awareness (p < 0.001) of the findings/recommendations of the latest evidence on premature deaths and identifying and managing epilepsy-related risks, including the relevance of nocturnal monitoring. The content analysis highlighted the need for clearer roles, improved care pathways, better epilepsy-specific knowledge, increased resources, and better multi-disciplinary work.

CONCLUSIONS

A gap exists between health and social care professionals in awareness of epilepsy needs for people with ID, requiring essential training and national pathways.

Who cares? A scoping review on intellectual disability, epilepsy and social care

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.

A review of the pharmacotherapeutic considerations for managing epilepsy in people with autism

INTRODUCTION

Autism, like other neurodevelopmental disorders (NDDs), has a strong association with epilepsy. There are known common genetic pathways in both autism and epilepsy. There are also specific genetic syndromes associated with both complex epilepsy and the autism phenotype.

AREAS COVERED

This review explores the evidence for common genetic etiologies and pathophysiological pathways in relation to both epilepsy and autism. Autism with comorbid epilepsy are associated with a high prevalence of medical and psychiatric comorbidities. This paper discusses how this influences assessment, treatment, and outcomes. The evidence for the treatment of specific seizure types in the context of NDDs is also examined alongside clinical commentary.

EXPERT OPINION

Despite the strong association, there is a limited evidence base to support the efficacy and tolerability of anti-seizure medications specifically in autism, with no Level 1 evidence or National Guidance available. Autism and epilepsy should be approached under a NDD model with cautious introduction and titration of anti-seizure medication. Alongside this, there is evidence to support a move toward precision medicine in specific genetic syndromes such as Tuberous Sclerosis Complex and other genetic seizure disorders. The first-line treatments that should be considered for focal seizures include carbamazepine, lamotrigine, and levetiracetam.

UK framework for basic epilepsy training and oromucosal midazolam administration

BACKGROUND

UK wide Oromucosal Midazolam is used as an emergency treatment in community for seizures administered by family/carers with the right training. The Joint Epilepsy Council (JEC) UK which produced the training guidelines disbanded in 2016.

PURPOSE

Provide standards for basic epilepsy education and rescue medication (Midazolam) administration.

METHODS

The Epilepsy Nurses Association (ESNA), The International League against Epilepsy, British Chapter (ILAE) and the Royal college of Psychiatrists (RCPsych), used the Delphi process to update guidelines for the administration of oromucosal midazolam including developing a voluntary on-line test for carers. During 2017-2019 a facilitator worked with two ESNA committees to update the existing guidance and another to develop a question-bank. Both committee outputs were circulated to the ESNA membership, then ILAE and RCPsych for review. Patient-facing organizations and charities' opinions were solicited. All feedback was assimilated. A private provider was contracted to deliver the test.

RESULTS

A consensus process involving two task and finish groups of 19 people each compared, reflected, debated, and engaged with stakeholders across three stages. The updated ratified guidelines were circulated nationally. The Delphi process highlighted many regions and individuals had local assessment tools and procedures in place, while others (around 50%) had no assessment provision. 278 carers with a 95% pass-rate and 100% positive feedback have undertaken the online test (10/2020).

CONCLUSION

The UK-wide care provision gap in basic epilepsy-training and safe rescue medication administration is now addressed. A two-yearly update to the guidelines and test is planned.

Aquatic exercise for people with intellectual disabilities: findings from a systematic review

Background: There is a need for promoting exercise practice among people with intellectual disabilities (ID). Aquatic exercise (AE) could be a viable option in this regard. Objective: To identify and critically analyze the best available evidence concerning the effects of AE in the physical and mental health of people with ID. Methods: A systematic review of randomized controlled trials (RCTs) and comparative studies was performed after searching within several databases up to March 2021. Results: A total of 4 RCTs and 3 comparative studies were found. Their methodological quality ranged from high to low. Aquatic interventions had positive effects on cardiorespiratory, muscular fitness and balance. Mixed effects were seen on parameters related to obesity and cognition. Scant information regarding feasibility and intervention fidelity was provided. In general, interventions details were not discussed in deep. Conclusion: Preliminary evidence shows that aquatic exercise can be prescribed to people with ID in order to improve their physical health. The impact of aquatic exercise on motor skills, cognitive function and mental health remains unclear. Further research on this topic should provide a detailed description of the interventions carried out, including information on the feasibility and intervention fidelity.

Effects of a specialized inpatient treatment program on epilepsy-related impairments of patients with epilepsy and intellectual disability as rated by relatives and professional caregivers

INTRODUCTION

The aim of the study was to determine the impact of a comprehensive inpatient treatment program for persons with epilepsy and intellectual disability (ID) on the concerns of relatives and caregivers, quality of life (QoL), and global health and clinical aspects, assessed by a questionnaire for relatives and caregivers.

METHODS

We performed an open, controlled pre/post study in inpatients with epilepsy and ID or acquired brain damage treated for at least 14 days in a tertiary referral center for epilepsy. Questionnaires were administered to relatives/professional caregivers shortly before admission and 6 months after discharge for the treatment group (TG). The control group (CG) was recruited from the waiting list; questionnaires were answered at the time of application for treatment and 3-6 months later. The questionnaire was the GEOS-43G, the German version of the Glasgow Epilepsy Outcome Scale (GEOS-35), which was extended by eight additional questions from the GEOS-90. Furthermore, QoL, global health, and clinical aspects were assessed using a short questionnaire. Generalized estimation equations (GEEs) were used for statistical analyses.

RESULTS

One-hundred and eight subjects were evaluable in the TG, and 90 in the CG. Concerns about seizures, injuries/risks, medical treatment, diagnostic issues, and the GEOS-43G total score decreased significantly in the TG in contrast to the CG. For the TG, improvements were also significant for global QoL, global health, efficacy, tolerability of AEDs, and for seizure frequency. Caregivers reported larger improvements compared to relatives.

CONCLUSION

The evaluation of the relatives and caregivers in our study indicates that inpatient treatment in a specialized center with a dedicated multi-professional program led to significant improvements regarding the concerns of relatives or caregivers, and in the QoL and related aspects in persons with epilepsy and ID. This shows that specialized inpatient treatment may be helpful for persons with epilepsy and ID.

The provision of epilepsy care across Europe 2017: A 17-year follow-up survey

OBJECTIVE

To assess the resources available in the provision of epilepsy care across Europe and the developments since the International League Against Epilepsy (ILAE) survey published in 2003 (data collected in 2000).

METHODS

An updated online version of the European Epilepsy Services Inventory was distributed to all European chapters of the ILAE (N = 47) and responses were obtained from 33 chapters (response rate 70%). To assess trends and allow comparisons with the survey published in 2003, the responding countries were divided into 4 groups (Western, Central, Southern, and Eastern). Responses from European Union (EU) member states are reported as a subgroup (N = 23), since the current survey is a part of the EU-funded European Study on the Burden and Care of Epilepsy (ESBACE, www.esbace.eu).

RESULTS

The total number of physicians involved in epilepsy care had increased since 2000, with the largest increase seen for neurologists. The gap between the best- and the least-provided areas with regard to the competence of the providers had diminished. However, the density of comprehensive multidisciplinary epilepsy teams had not changed to any greater degree. The main problems reported by the chapters were to a large extent the same as in 2000 and included lack of specialists and specialist care, lack or underuse of epilepsy surgery, and problems regarding financing and resource allocation. Several chapters also highlighted problems with healthcare structure and organization.

SIGNIFICANCE

Although there have been some improvements concerning the availability of care for people with epilepsy in Europe over the last 17 years, there are still a number of problem areas with little improvement or where there are important regional differences.

Awareness, attitudes, skills and training needs of psychiatrists working with adults with intellectual disability in managing epilepsy

PURPOSE

Comorbid epilepsy is found in 22.5% of people with intellectual disability (ID). Responding to the continuing lack of clarity to the role of the ID psychiatrist in the United Kingdom with regards to epilepsy care, the Royal College of Psychiatrists (RCPsych) published the College Report (CR) 203 in May 2017. This proposed a three-tiered model of competency in ID epilepsy care, with minimum acceptable standards described as Bronze and greater expertise as Silver and Gold. This article documents the perceptions of ID psychiatrists as to their skills and training needs, and the perceived impact of CR203 on the profession.

METHODS

An e- questionnaire, matching the standards on CR203 and encouraging comments was designed, reviewed and approved by the RCPsych ID executive faculty. The survey was sent by email to all UK-registered RCPsych ID Faculty members via the RCPsych communications.

RESULTS

Of the expected 332 ID psychiatrists in the UK, 141 responses were received (42.4%). Key findings included that ID psychiatrists as a group have an interest in epilepsy but Bronze standards were frequently unmet, with variation across the UK. There was a noted lack of agreement on role among ID psychiatrists again linked to geographical variation. Regional disparity correlated to population density and proximity to tertiary neurological centres.

CONCLUSION

There are significant implications on training, both pre- and post- accreditation for the ID psychiatry speciality. The CR203 standards appear to be steps in the right direction to help define the role ID psychiatrists have in the delivery of epilepsy care.