Sudden unexpected death in epilepsy (SUDEP): what do patients think?

Emerging Trends in Neuropalliative Care: A Palliative Approach to Epilepsy and Seizure Management in Adults

Management of severe (drug-resistant) epilepsy and epilepsy in other serious illnesses is multidimensional and requires consideration of both physical symptoms and psychosocial distress that require individualized treatment. Palliative care offers a holistic approach to disease that focuses on all dimensions of suffering to maintain quality of life. Integration of a palliative care mind- and skillset in the management of severe epilepsy and epilepsy in other serious illnesses can provide person-centered care and support for families and caregivers.

Epilepsy professionals' views on sudden unexpected death in epilepsy counselling: A tale of two countries

BACKGROUND AND PURPOSE

Sudden unexpected death in epilepsy (SUDEP) is a leading cause of epilepsy mortality. All international guidance strongly advocates for clinicians working with people with epilepsy (PWE) to discuss SUDEP. Clinician views working with PWE in the UK and Norway on SUDEP counselling are compared.

METHODS

A cross-sectional online mixed methodology survey of 17 Likert and free-text response questions using validated themes was circulated via International League against Epilepsy/Epilepsy Specialist Nurses Association in the UK and International League against Epilepsy/Epilepsinet in Norway using a non-discriminatory exponential snowballing technique leading to non-probability sampling. Quantitative data were analysed using descriptive statistics and Mann-Whitney, Kruskal-Wallis, chi-squared and Fisher's exact tests. Significance was accepted at p < 0.05. Thematic analysis was conducted on free-text responses.

RESULTS

Of 309 (UK 197, Norway 112) responses, UK clinicians were more likely to have experienced an SUDEP (p < 0.001), put greater importance on SUDEP communication (p < 0.001), discuss SUDEP with all PWE particularly new patients (p < 0.001), have access and refer to bereavement support (p < 0.001) and were less likely to never discuss SUDEP (p < 0.001). Significant differences existed between both countries' neurologists and nurses in SUDEP counselling with UK clinicians generally being more supportive. UK responders were more likely to be able to identify bereavement support (p < 0.001). Thematic analysis highlighted four shared themes and two specific to Norwegians.

DISCUSSION

Despite all international guidelines stating the need/importance to discuss SUDEP with all PWE there remain hesitation, avoidance and subjectivity in clinicians having SUDEP-related conversations, more so in Norway than the UK. Training and education are required to improve communication, engagement and decision making.

Sudden unexpected death in epilepsy disclosure causes anxiety in patients with epilepsy: a Chinese questionnaire survey

Background and objective

Sudden unexpected death in epilepsy (SUDEP) has been regarded as a leading cause of premature death in patients with epilepsy (PWE). Although patients, relatives and caregivers have the right to be informed of SUDEP, neurologists prefer not to release the facts for fear of associated anxiety. In the study, a Chinese questionnaire survey was carried out to elucidate effect of SUDEP disclosure on anxiety in PWE and variables determining the anxiety of patients and provided suggestions for SUDEP disclosure.

Methods

A survey study in China was conducted. We recruited 305 PWE from 3 tertiary epilepsy centers who attended outpatient clinic from December 2021 to February 2022. Two hundred and thirty-two PWE completed the screening evaluation, survey and Hamilton anxiety rating scale (HAMA) twice with 171 PWE completing third HAMA at follow-up. HAMA scores at baseline, T1, T2 were compared using analysis of variance and dependent samples t-test. The variables related to anxiety were screened out by univariate analysis and used for multivariate logistic regression.

Result

We found 127 (54.7%) among the 232 participants experienced anxiety after SUDEP disclosure. HAMA scores at T1 were significantly higher than at baseline and T2, while there was no statistical difference between baseline and T2. Medical insurance, seizure severity, and whether the PWE supported SUDEP being disclosed to their relatives and caregivers only were associated with the occurrence of anxiety.

Conclusion

SUDEP disclosures may cause short-term acute anxiety, but have no long-term effects in PWE. Acute anxiety caused by SUDEP disclosure may be more common in PWE with NCMI and severe seizures. Meanwhile, compared with indirect SUDEP disclosure to their relatives and caregivers, direct SUDEP disclosure to PWE reduces the risk of anxiety. Recommendations are provided to avoid anxiety caused by SUDEP disclosure.

Sudden unexpected death in epilepsy: What Saudi people with epilepsy want to know-A cross-sectional study

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is a significant cause of mortality in people with epilepsy (PWE), with an incidence of 1 per 1000 members of the population. In Saudi Arabia, no data are available that inform local clinical practitioners about the attitudes of PWE regarding SUDEP. The aim of this study was to investigate the perspectives of Saudi PWE toward SUDEP and to assess their knowledge of SUDEP.

METHODS

A cross-sectional questionnaire-based study was conducted at the neurology clinics of King Abdul-Aziz Medical City, Riyadh and Prince Sultan Military Medical City, Riyadh.

RESULTS

Of the 377 patients who met the inclusion criteria, 325 completed the questionnaire. The mean age of the respondents was 32.9 ± 12.6 years. Of the study subjects, 50.5% were male. Only 41 patients (12.6%) had heard about SUDEP. Most patients (94.5%) wanted to know about SUDEP, of whom 313 (96.3%) wanted to receive this information from a neurologist. A total of 148 patients (45.5%) thought that the appropriate time to receive information about SUDEP was after the second visit, whereas only 75 (23.1%) wanted to learn about SUDEP during the first visit. However, 69 patients (21.2%) thought that the appropriate time to be informed about SUDEP was when seizure control had become more difficult. Almost half (172, 52.9%) of the patients thought that SUDEP could be prevented.

SIGNIFICANCE

Our findings suggest that most Saudi PWE do not know about SUDEP and want to be counseled about their risk of SUDEP by their physicians. Therefore, education of Saudi PWE about SUDEP must be improved.

SUDEP: Living with the knowledge

OBJECTIVE

To understand how knowledge of sudden unexpected death in epilepsy (SUDEP) impacted the lives of adult persons with epilepsy (PWE) and primary caregivers of both adults and children with epilepsy.

METHODS

The principles of fundamental qualitative description guided this descriptive and exploratory qualitative study to document patients' and caregivers' perceptions and experiences. A purposeful sample of individuals (18 years or older) diagnosed with epilepsy or primary caregivers of PWE completed a single in-depth, semi-structured, one-to-one telephone interview. Categories of findings were developed using directed content analysis.

RESULTS

A total of twenty-seven participants completed the study. This consisted of eight adult females and six adult males with epilepsy, ten female caregivers, and three male caregivers of PWE. All participants had become aware of SUDEP at least 12 months before their interview. Most were not informed about SUDEP by their treating neurologist and instead learned about SUDEP via alternative sources (e.g., the internet). All participants believed that knowledge of SUDEP outweighed the risks of being informed about it. Anxiety/fear related to SUDEP disclosure was generally not long-lasting. Caregivers of PWE were more directly impacted by SUDEP disclosure than adult PWE. Caregivers were more likely to make lifestyle/management changes due to learning about SUDEP (e.g., increased supervision and co-sleeping). Participants agreed that follow-up clinical support should be provided after SUDEP disclosure.

CONCLUSIONS

Disclosure of SUDEP risk may have more significant impacts on caregivers of PWE than adult PWE in the form of lifestyle changes and epilepsy management. After SUDEP disclosure, follow-up support should be offered to PWE and their caregivers, which should be incorporated into future guidelines.

Adapted Evidence-Based Clinical Practice Guidelines for Diagnosis and Treatment of Epilepsies in Children: A Tertiary Children's Hospital Update

HYPOTHESIS AND/OR BACKGROUND

We recently updated and merged the adapted clinical practice guidelines (CPGs) for the diagnosis and treatment of children with epilepsy of a tertiary-level hospital. Medical knowledge is always evolving. As a result, it is critical to revisit the clinical standards on a frequent basis to ensure that the best services are offered to the target receivers. The purpose of this article was to update and merge the CPGs at Alexandria University Children Hospital (AUCH) for the diagnosis (2014) and treatment (2016) of children with epilepsy to unify and standardize the practice for better care and outcome.

METHODS

This review and update CPG project was initiated by assembling a Guideline Review Group (GRG). The GRG conducted focus group discussions and decided to search any published updates of the recommendations of the previously identified high-quality and evidence-based CPG developed by the SIGN (Scottish Intercollegiate Guidelines Network) and to merge the two previous local CPGs under one comprehensive CPG for full management of epilepsy in children. The high quality of the selected source CPG from SIGN was based on quality assessment of CPGs undertaken previously using the Appraisal of Guidelines for Research and Evaluation II Instrument. The GRG followed the Checklist for the Reporting of Updated Guidelines (CheckUp), which is the CPG tool recommended by the Enhancing the Quality and Transparency of health Research Network for reporting of updated CPGs in addition to the RIGHT-Ad@pt Checklist for Adapted CPGs. The finalized updated CPG draft was sent to the external reviewer group topic experts.

RESULTS

The group updated 10 main categories of recommendations from one source CPG (SIGN). The recommendations included (1) epilepsy diagnosis; (2) recognition, identification, and referral; (3) pharmacological treatment of epilepsy and epilepsy syndromes; (4) nonpharmacological treatment of epilepsy and epilepsy syndromes; (5) managing pharmacoresistant epilepsy; (6) management of epilepsy in special groups; (7) medications; (8) children and caregiver education and support; (9) comorbidities and mortality; and (10) transitional care from pediatric to adult care services.

CONCLUSIONS

The finalized CPG provides evidence-based guidance to health care providers in AUCH for the diagnosis and management of epilepsy in children. The study also established the significance of a collaborative clinical and methodological expert group for the update of CPGs, as well as the usability of the "CheckUp" and "RIGHT-Ad@pt" CPG Tools.

Telemedicine for Individuals with epilepsy: Recommendations from International League Against Epilepsy Telemedicine Task Force

Worldwide, People with Epilepsy (PWE) are confronted with several barriers to face-to-face consultations. These obstacles hamper appropriate clinical follow-up and also increase the treatment gap for Epilepsy. Telemedicine holds the potential to enhance management as follow-up visits for PWE are focused on more on clinical history and counselling rather than physical examination. Besides consultation, telemedicine can also be used for remote EEG diagnostics and tele-neuropsychology assessments. In this article, the Telemedicine Task Force of the International League Against Epilepsy (ILAE) outlines recommendations regarding optimal practice in utilizing in the management of individuals with epilepsy. We formulated recommendations for minimum technical requirements, preparing for the first tele-consultation and the specificities for follow-up consultations. Special considerations are necessary for specific populations, including paediatric patients, patients who are not conversant with tele-medicine and those with intellectual disability. Telemedicine for individuals with epilepsy should be vigorously promoted with the aim of improving the quality of care and ultimately reduce the wide clinician access related treatment gap across several regions of the globe.

SUDEP Risk Counseling: What We Don't Do in the Shadows

Counseling About Sudden Unexpected Death in Epilepsy (SUDEP): A Global Survey of Neurologists’ Opinions

Asadi-Pooya AA, Trinka E, Brigo F, Hingray C, Karakis I, Lattanzi S, Valente KD, Contreras G, Turuspekova ST, Kishk NA, Aljandeel G, Farazdaghi M, Lopez YC, Kissani N, Triki C, Krämer G, Surges R, Mesraoua B, Yu HY, Daza-Restrepo A, Alsaadi T, Al-Asmi A, Kutlubaev MA, Pretorius C, Jusupova A, Khachatryan SG, Ranganathan LN, Ashkanani A, Tomson T, Gigineishvili D. Epilepsy Behav. 2022;128:108570. PMID: 35093831. doi:10.1016/j.yebeh.2022.108570

Objective:

To investigate the opinions and attitudes of neurologists on the counseling about sudden unexpected death in epilepsy (SUDEP) worldwide.

Methods:

Practicing neurologists from around the world were invited to participate in an online survey. On February 18th, 2021, we emailed an invitation including a questionnaire (using Google-forms) to the lead neurologists from 50 countries. The survey anonymously collected the demographic data of the participants and answers to the questions about their opinions and attitudes toward counseling about SUDEP.

Results:

In total, 1123 neurologists from 27 countries participated; 41.5% of the respondents reported they discuss the risk of SUDEP with patients and their care-givers only rarely. Specific subgroups of patients who should especially be told about this condition were considered to be those with poor antiseizure medication (ASM) adherence, frequent tonic-clonic seizures, or with drug-resistant epilepsy. The propensity to tell all patients with epilepsy (PWE) about SUDEP was higher among those with epilepsy fellowship. Having an epilepsy fellowship and working in an academic setting were factors associated with a comfortable discussion about SUDEP. There were significant differences between the world regions.

Conclusion:

Neurologists often do not discuss SUDEP with patients and their care-givers. While the results of this study may not be representative of practitioners in each country, it seems that there is a severe dissociation between the clinical significance of SUDEP and the amount of attention that is devoted to this matter in daily practice by many neurologists around the world.

The regulation of driving with non-epileptic seizures must be made clearer

Patients with epilepsy have their authorisation to drive restricted under detailed guidelines, but the rules for those with non-epileptic seizures are far less clear. We surveyed specialist clinicians in Australia and found little agreement as to whether such guidelines existed for non-epileptic seizures or what they might be. A number of possible interpretations of the Australian fitness to drive guidelines are explored, and these are often vague in themselves, as well as uncertain in their scope. This means clinicians making momentous driving decisions for their patients with non-epileptic seizures are doubly challenged, first in interpreting what guidelines exist, and second in what they mean. The International League Against Epilepsy proposed specific guidelines for driving with non-epileptic seizures, which reflect the range of presentations of non-epileptic seizures in a decision-making algorithm. We believe a specific algorithm such as this is essential in removing one level of uncertainty and responsibility for clinicians, and restoring equity for patients with non-epileptic seizures.

Sudden unexpected death in epilepsy: A pilot study on neurologists' knowledge and experience in the Eastern Mediterranean region

Background- Sudden unexpected death in epilepsy (SUDEP) is an important concern in patients with epilepsy who are otherwise healthy. Current knowledge of SUDEP and attitudes of neurologists in the Eastern Mediterranean Region (EMR) towards discussing SUDEP with their patients remain unknown. Objective- We aimed at assessing knowledge, attitudes and factors affecting SUDEP discussion practices of neurologists practicing in the EMR. Methodology- An electronic and paper-based survey was sent to 350 neurologists practicing in the EMR. They were questioned about the frequency, timing, and factors affecting their willingness to initiate SUDEP discussion. We also included questions about perceived patient reactions towards SUDEP discussions and neurologists' preferred way to provide SUDEP information to their patients. Results- We received 132 responses from the 350 surveys sent out (response rate 37.7%). Our results showed that only 1.5% of the neurologists discussed SUDEP with "most" of their patients and their caregivers while 55.3% "rarely" or "never" discussed it. Factors such as additional epilepsy training and more years of clinical experience did not significantly affect the frequency of SUDEP discussion (p = 0.329, p = 0.728). A significant negative association between the number of patients seen per year and the frequency of SUDEP discussion was seen (P= 0.046). Based on their selection of known risk factors, 81% of neurologists were considered as having insufficient knowledge of SUDEP. The top three perceived reactions by the neurologists on SUDEP discussion were distress (74.2%), anxiety (70.5%) and depression (65.9%). Most neurologists initiated SUDEP discussion by themselves and preferred brochures/pamphlets, websites and training sessions to provide SUDEP information. Conclusion- Neurologists in the EMR rarely discuss SUDEP, and have limited knowledge about its risk factors. Upon discussing SUDEP, they overwhelmingly receive negative reactions but not always. Based on our findings, we believe an unintended knowledge gap exists on part of the neurologists. This, coupled with a lack of trained epilepsy nurses and patient education material in regional languages can also be attributed to poor SUDEP discussion practices in the EMR.

Recommendations for risk management and better living with epilepsy. Phenomenological study of the experience of patients, relatives, and bereaved families

OBJECTIVE

To understand the lived experience of people with epilepsy (PWE) and their relatives, the risks associated with epilepsy, the information received from healthcare professionals, and the reaction to this information.

METHODS

Qualitative phenomenological study conducted between 2016 and 2018. Individual semi-directive in-depth interviews were performed based on a triangulation of sources in three study groups: PWE, relatives of PWE, and bereaved families. Interviews were analyzed continuously, using a semiopragmatic method until data saturation.

RESULTS

Interviews with PWE (N = 16), relatives of PWE (N = 8), and bereaved families (N = 10) led to several observations: (i) The stigmatizing representations of epilepsy and its constraints lead to a feeling of abnormality which determines the behavior of patients and their relatives; (ii) The global uncertainty surrounding epilepsy is an obstacle to the delivery of clear and personalized information by professionals, and, consequently, to empowerment; (iii) The communication skills of the physician have an impact on the lived experiences of patients and relatives; (iv) Better knowledge on direct mortal epilepsy-related risk could influence the perception of danger to oneself, and help find a balance between overprotection and trivialization. The experience of the patients and relatives led them to formulate concrete recommendations: (i) for the general public: to run information campaigns in order to limit stigmatization; (ii) for caregivers: to provide personalized and detailed information without minimizing the risks, in order to enable patients to "live by setting these risks"; (iii) for patients: to have a trusted person who is informed and trained in seizure management, to join patient associations.

CONCLUSION

Our study points out that stigma, uncertainty, and lack of clarity of information are all barriers to patient empowerment. In order to provide prompt and personalized information on how to live with epilepsy while managing the risks, physicians need to develop person-centered communication skills. Future research is also required for the development of tools to facilitate this communication.

Reducing Sudden Unexpected Death in Epilepsy: Considering Risk Factors, Pathophysiology and Strategies

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.

Patients' knowledge about epilepsy-related risks, morbidity, and mortality: A multicenter cohort study from Germany

INTRODUCTION

Patient education is a central component of quality care. Enhancing patient knowledge can improve patients' quality of life and facilitate successful self-management. We sought to identify patients' knowledge levels and knowledge gaps regarding epilepsy-related risks, morbidity, and mortality.

METHODS

Adult patients with epilepsy presenting to the university hospitals in Frankfurt, Greifswald, and Marburg between February 2018 and May 2020 were asked to participate in this questionnaire-based study.

RESULTS

A total of 238 patients (52% women), with a mean age of 39.2 years (range: 18-77 years), participated in this study. Spontaneously, the majority of patients (51.3%) named driving a car, and other traffic-related accidents as possible causes of morbidity and mortality, and 23.9% of patients reported various causes of premature death, such as suffocation, drowning, and respiratory or cardiac arrest due to seizures. Falls due to epilepsy (19.7%) and injuries in general (17.6%) were named as further causes of morbidity and mortality. The vast majority were aware that alcohol (87.4%), sleep deprivation (86.6%), and risky activities in daily life (80.3%) increased the risk of seizure occurrence or increased morbidity and mortality. Regarding overall mortality, 52.1% thought that people with epilepsy were at greater risk of premature death, whereas 46.2% denied this fact to be true. Only 29.4% were aware of status epilepticus, and 27.3% were aware of sudden unexpected death in epilepsy (SUDEP). Driving ability, working ability, and seizure risk were named as major or moderate concerns among patients, but the risk of premature mortality was not a major concern. One-quarter of all patients (26.9%) indicated that they were not counseled about any risk factors or causes of morbidity or mortality by their physicians.

CONCLUSIONS

A lack of knowledge concerning premature mortality, SUDEP, and status epilepticus exists among adult patients with epilepsy. A substantial number of patients indicated that these issues were not discussed adequately by their physicians.

Using an animated video to promote an informed discussion on SUDEP with adolescents

PURPOSE

The purpose of this study was to create and test an animated video to teach adolescent patients about Sudden Unexpected Death in Epilepsy (SUDEP).

METHOD

Thirty-nine patients and thirteen parents watched the SUDEP video and completed at least one survey. Patients with epilepsy aged 14+ and their parents were recruited to watch the video during neurology clinic visits. Parents of minors provided verbal permission for their child to view the video. Participants were asked to complete pre- and post-video surveys. Data analysis included Fischer's exact tests for comparative data and percentages for categorical variables.

RESULTS

After watching the SUDEP video, 100% of parents and patients agreed that the video provided helpful knowledge, and 100% of parents and 96% of patients agreed that patients with epilepsy should know about SUDEP. Half of the parents surveyed, and 20% of patients, felt increased concerns after watching the video. Patients rated their understanding of SUDEP significantly higher after watching the video (p < 0.001).

CONCLUSION

Participants in this study thought that it was important for patients with epilepsy to know about SUDEP, and all agreed that the animated SUDEP video provided helpful knowledge. While some parents endorsed increased concerns after watching the video, the majority of parents still agreed to allow their child to watch the video. Adolescent education on SUDEP using a family-centered approach may be an important method of encouraging harm-reducing behaviors that can be lifesaving for patients with epilepsy. The standard of practice for SUDEP disclosure should continue to be face-to-face discussion with providers, and we propose this video as a tool to elevate and inform those discussions.

[SUDEP in brief - knowledge and practice recommendations on sudden unexpected death in epilepsy]

Sudden unexpected death in epilepsy (SUDEP) is the sudden and unexpected death of an epilepsy patient, which occurs under benign circumstances without evidence of typical causes of death. SUDEP concerns all epilepsy patients. The individual risk depends on the characteristics of the epilepsy and seizures as well as on living conditions. Focal to bilateral and generalized tonic-clonic seizures (TCS), nocturnal seizures and lack of nocturnal supervision increase the risk. Most SUDEP cases are due to a fatal cascade of apnea, hypoxemia and asystole in the aftermath of a TCS. Two thirds of SUDEP cases in unsupervised epilepsy patients with TCS could probably be prevented. Wearables can detect TCS and alert caregivers. SUDEP information is desired by most patients and relatives, has a favorable impact on treatment adherence and behavior and has no negative effects on mood and quality of life.Recommendations of the committee on patient safety of the German Society of Epileptology: the ultimate treatment goal is seizure freedom. If this cannot be achieved, control of TCS should be sought. All epilepsy patients and their relatives should be informed about SUDEP and risk factors. Patients and relatives should be informed about measures to counteract the elevated risk and imminent SUDEP. The counselling should be performed during a face-to-face discussion, at the time of first diagnosis or during follow-up visits. The counselling should be documented. Wearables for TCS detection can be recommended. If TCS persist, therapeutic efforts should be continued. The bereaved should be contacted after a SUDEP.

SUDEP education among U.S. and international neurology trainees

We evaluated baseline sudden unexpected death in epilepsy (SUDEP) knowledge and counseling practices among national and international adult neurology trainees with a 12-question online survey. The survey was emailed to all 169 U.S. neurology residency program directors and select international neurology/epilepsy program leaders. Program leaders were asked to distribute the survey link to adult neurology trainees. There were 161 respondents in the U.S. and 171 respondents outside the U.S. The latter were from 25 Latin American, European, Asian, and African countries. More than 90% of all trainees reported familiarity with SUDEP definition. Familiarity with SUDEP risk factors and mitigation measures ranged from 56% to 67% across these groups, with international trainees slightly more familiar with risk factors (67% vs. 61% in U.S.) but less familiar with mitigation measures (56% vs. 63% in U.S.). Approximately half of national (49%) and international (54%) trainees rarely or never counseled patients on SUDEP. Less than half of national (44%) and international (41%) trainees were educated about SUDEP. Many U.S. and adult neurology trainees remain unfamiliar with SUDEP risk factors and mitigation measures. Sudden unexpected death in epilepsy counseling falls below recommended standards. We suggest that worldwide neurology training programs' leaderships consider improving SUDEP education targeted at adult neurology trainees.

Implementation Science to Improve Quality of Neurological Care

Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.

Sudden Unexpected Death in Epilepsy: A Personalized Prediction Tool

Objective

To develop and validate a tool for individualized prediction of sudden unexpected death in epilepsy (SUDEP) risk, we reanalyzed data from 1 cohort and 3 case–control studies undertaken from 1980 through 2005.

Methods

We entered 1,273 epilepsy cases (287 SUDEP, 986 controls) and 22 clinical predictor variables into a Bayesian logistic regression model.

Results

Cross-validated individualized model predictions were superior to baseline models developed from only average population risk or from generalized tonic-clonic seizure frequency (pairwise difference in leave-one-subject-out expected log posterior density = 35.9, SEM ± 12.5, and 22.9, SEM ± 11.0, respectively). The mean cross-validated (95% bootstrap confidence interval) area under the receiver operating curve was 0.71 (0.68–0.74) for our model vs 0.38 (0.33–0.42) and 0.63 (0.59–0.67) for the baseline average and generalized tonic-clonic seizure frequency models, respectively. Model performance was weaker when applied to nonrepresented populations. Prognostic factors included generalized tonic-clonic and focal-onset seizure frequency, alcohol excess, younger age at epilepsy onset, and family history of epilepsy. Antiseizure medication adherence was associated with lower risk.

Conclusions

Even when generalized to unseen data, model predictions are more accurate than population-based estimates of SUDEP. Our tool can enable risk-based stratification for biomarker discovery and interventional trials. With further validation in unrepresented populations, it may be suitable for routine individualized clinical decision-making. Clinicians should consider assessment of multiple risk factors, and not focus only on the frequency of convulsions.

Probable Sudden Unexpected Death in Dogs With Epilepsy (pSUDED)

Sudden unexpected death in human epileptic patients (SUDEP) is defined as death related to recurrent unprovoked seizures, death occurring unexpectedly, and suddenly in a patient with reasonable state of health, without an obvious medical cause of death, trauma, asphyxia, or intractable status epilepticus, and in post mortem examination no obvious reason for death can be found. “Probable SUDEP” (pSUDEP) is defined as SUDEP not confirmed pathologically. The adapted abbreviation for dogs is used in the following: “pSUDED” (probable sudden unexpected death in dogs with epilepsy). The aim of the present monocentric retrospective study using an online questionnaire was to evaluate the occurrence of pSUDED. Data of canine patients presented with seizures between 01/1998 and 05/2018 were retrospectively analyzed and classified according to their etiology (n = 1,503). Owners were contacted by telephone to participate in answering a validated questionnaire. A total of 509 owners were reached, and 373 owners completed the questionnaire. In addition to signalement (e.g., breed), special attention was paid to the frequency and presentation of seizures and seizures in the context of death. Fifty-one percent (191/373) of the dogs were dead at the endpoint of the study. A large proportion of the dogs was euthanized (149/191) because of seizure severity or health problems unrelated to seizures. Idiopathic epilepsy (IE) was diagnosed in 19/34 dogs which died unexpectedly. Of these seven animals had to be excluded for further investigation of pSUDED because of status epilepticus or aspiration pneumonia as a result of the seizures. In 12 dogs with IE the last seizure event occurred between 6 h and ~3 months before death. pSUDED was suspected in these dogs and an occurrence rate of 4.5–10% was calculated. pSUDED appears in a similar occurrence rate as human SUDEP and should be considered as a possible complication in epileptic dogs. The results of this study suggest that dogs with IE but especially those with brachycephalic syndrome and cluster seizures have an increased risk to die of pSUDED. Owners of dogs with seizures should be educated about the risk of sudden death in dogs with epilepsy.

Epilepsy-Work-Up and Management in Children

Pediatric epilepsy is a highly variable condition due to age-related expression of syndromes that require specific diagnosis, evaluations, and treatments. Children with epilepsy differ from their adult counterparts in many important ways, mostly related to the age-related expression of specific epilepsy syndromes. This results in many important considerations related to the epilepsy diagnosis, classification, evaluations to determine an etiology, as well as treatment guidelines. A good understanding of these factors will help to establish an accurate epilepsy diagnosis, which in turn will guide appropriate testing and treatment decisions. In this way, patients will have improved seizure outcomes, and families will be educated appropriately and provided with the most accurate prognostic information available. The purpose of this article is to review the diagnosis, work-up, and management of pediatric epilepsy.

Awareness of sudden unexpected death in epilepsy among parents of children with epilepsy in a tertiary center

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.

Incorporating Ethically Relevant Empirical Data From Systematic Review of Reasons: A Case Study of Sudden Unexpected Death in Epilepsy

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.

Keep safe: The when, why and how of epilepsy risk communication

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.

Bridging the gap of risk communication and management using the SUDEP and Seizure Safety Checklist

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".

SUDEP: A global perspective

The potential for an epileptic seizure to end life has been known throughout history, although the cause of many such deaths is still not understood. Over the last 25 years there has been increasing interest in the phenomenon of Sudden Unexpected Death in Epilepsy (SUDEP) leading to an upswing in the investigation of epilepsy-related mortality. Families bereaved by epilepsy have played an important role in promoting awareness and research, with the UK leading the way on community and political action to tackle epilepsy-related mortality; SUDEP has now become a global conversation with clinicians, scientists, and the community working together to identify strategies that can reduce deaths. The evolution in the approach to epilepsy-related deaths and the impact on epilepsy care are discussed. This paper is for the Special Issue "Prevent 21: SUDEP Summit - Time to Listen".

Why we urgently need improved epilepsy therapies for adult patients

PURPOSE

Up to a third of patients with epilepsy suffer from recurrent seizures despite therapeutic advances.

RESULTS

Current epilepsy treatments are limited by experiential data from treating different types of epilepsy. For example, we lack evidence-based approaches to efficacious multi-drug therapies or identifying potentially serious or disabling adverse events before medications are initiated. Despite advances in neuroscience and genetics, our understanding of epilepsy pathogenesis and mechanisms of treatment-resistance remains limited. For most patients with epilepsy, precision medicine for improved seizure control and reduced toxicity remains a future goal.

CONCLUSION

A third of epilepsy patients suffer from ongoing seizures and even more suffer from adverse effects of treatment. There is a critical need for more effective and safer therapies for epilepsy patients with frequent comorbitidies, including depression, anxiety, migraine, and cognitive impairments, as well as special populations (e.g., women, elderly). Advances from genomic sequencing techniques may identify new genes and regulatory elements that influence both the depth of the epilepsies' roots within brain circuitry as well as ASD resistance. Improved understanding of epilepsy mechanisms, identification of potential new therapeutic targets, and their assessment in randomized controlled trials are needed to reduce the burden of refractory epilepsy. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.

Patients' knowledge on epilepsy and SUDEP improves after a semi-structured health interview

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.

Let's talk SUDEP

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.

A decision tree to determine fitness to drive in epilepsy: Results of a pilot in two Australian states

OBJECTIVE

Certification by treating physicians of fitness to drive in people with epilepsy creates a conflict of interest that may result in unsafe decisions, damage the doctor-patient relationship, expose the physician to legal liability and prevent optimal treatment. Ideally, the treating physician should provide objective clinical information to the driver licensing authority (DLA), which then determines fitness or otherwise. However, DLAs in Australia do not employ medical staff and the national standards are complex. Fitness is determined by the treating physician, according to published national standards. The purpose of this study was to determine the feasibility of using a decision tree to determine fitness, according to the Australian standards.

METHODS

A decision tree was constructed to use clinical data to determine whether a patient met the national standard to drive a private motorcar, failed to meet it or required further assessment. A form was designed to collect the necessary clinical data from the treating physician. A computerized version of the decision tree was then used in a pilot in two Australian states in parallel with the existing certification system. Four hundred thirty-nine drivers with declared epilepsy and their treating physicians were invited to participate when their annual driver licence review was due.

RESULTS

Two hundred fifty-three (58%) forms were returned. All patients were considered fit to drive by their physician. Seventy-six percent had not had a seizure for over two years. In 88.1%, there was agreement between the decision tree and treating physician, with 3.6% identified by the decision tree as requiring review. Although considered fit by their physician, 6.3% did not meet the national standard to drive.

SIGNIFICANCE

The decision tree model is a practical alternative to fitness certification by treating physicians. This Australian pilot can serve as a model for applying objective standards to driving assessments in other jurisdictions, using local driving standards. It has the potential to improve road safety by avoiding the negative effects of certification by treating physicians and can cope with complex standards. It is now in use in two states of Australia.

Automated detection of sudden unexpected death in epilepsy risk factors in electronic medical records using natural language processing

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability.

METHODS

Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic-clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F-measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three "boilerplate" standard text phrases from away notes and repeated performance.

RESULTS

We observed high performance in home test data (F-measure range = 0.86-0.90), and low to high performance in away test data (F-measure range = 0.53-0.81). After removing three boilerplate phrases, away performance improved (F-measure range = 0.79-0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data.

SIGNIFICANCE

Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling.

What information about sudden unexpected death in epilepsy (SUDEP) is available on YouTube?

OBJECTIVE

We sought to assess and analyze the information available about sudden unexpected death in epilepsy (SUDEP) and the general perception of this condition by the public on YouTube.

METHODS

We evaluated all consecutive videos containing references to 'sudden unexpected death in epilepsy' and 'SUDEP' on YouTube. Data were extracted after applying the inclusion and exclusion criteria. Various characteristics of the videos including the type of content, uploading source, likes, dislikes, and comments received were classified and analyzed.

RESULTS

A total of 113 videos were included, with the majority uploaded by individual users (51.3%) followed by activist groups (40.7%). The primary content from individual users created videos were tribute to family members who died because of SUDEP (43.1%) and personal narration (36.2%), whereas educational/scientific information (55%) and advertisements (45%) to raise SUDEP awareness comprised the videos from professional societies and activist groups. More than three-fourths of the comments to the videos were in response to individual user uploaded videos, and mainly comprised of positive statement conveying empathy or describing personal encounters.

CONCLUSION

Substantial information is available regarding SUDEP on YouTube; however, the viewer engagement remains limited. Individual user-created videos about SUDEP are the most popular and viewer engaging. Incorporating personal/anecdotal experiences in addition to scientific information in the video content might further improve the viewer engagement.

To reveal or conceal? Adult patient perspectives on SUDEP disclosure

OBJECTIVE

The study aimed to evaluate adult patient or caregiver feelings and viewpoints about sudden unexpected death in epilepsy (SUDEP) awareness.

BACKGROUND

The decision to discuss SUDEP with patients and families has created much debate. Many healthcare providers (HCPs) are hesitant to discuss SUDEP because of the perception of evoking unnecessary fear in patients while others argue that informing patients about SUDEP may enhance patient compliance, improve seizure control, and aid in saving lives. This study quantifies patient viewpoints regarding their right to information, requirements of disclosure, and initial responses of fear and patient motivation toward behavioral change.

DESIGN/METHODS

This was a prospective random sample survey of adult patients with epilepsy or their caregivers. Every third eligible adult patient with epilepsy or caregiver was given a one-page SUDEP information sheet promoted by the Epilepsy Foundation of America. Participants were then asked if they were interested in completing an eight-item questionnaire assessing their perception of the information.

RESULTS

Ninety-four of ninety-six subjects completed the survey (98%). One hundred percent (n = 94) of responders felt they had a right to be informed about SUDEP, and 95% felt that their HCP should be required to inform them. Respondents also indicated that SUDEP awareness motivated them for better medication adherence (89%) and management of lifestyle factors that lower seizure threshold (88%). Thirty percent endorsed increased fear. However, 100% of those patients or caregivers who endorsed fear still felt it was their right to be informed. Patients who endorsed fear were also more likely to be interested in nonpharmacologic treatment options as a result of SUDEP disclosure.

CONCLUSIONS

Patients and caregivers feel it is their right to be informed about SUDEP, irrespective of evoked fear. The vast majority of participants endorsed a requirement for HCPs to disclose related information. While some participants endorsed fear, most agreed that SUDEP awareness motivated them to better manage factors that trigger seizures. Patient education regarding SUDEP may play a key role in encouraging modifying lifestyle factors that lower seizure threshold and facilitate more aggressive interventions in patients with pharmacoresistant epilepsy.

People with epilepsy and their relatives want more information about risks of injuries and premature death

For most people with chronic diseases such as epilepsy, thorough knowledge of the disease is important in order to reduce feelings of insecurity and to enable better management of everyday life. Whether and when to inform patients and their families about all the risks associated with epilepsy is a matter of controversy. Using a web-based survey, patients with epilepsy (PWE) (n=1183) and carers, family members, or guardians of PWE, who could either answer on behalf of the patients (CBP) (n=676) or on their own behalf (CAR) (n=231) were asked whether they wanted information about the risk of epilepsy-related injuries and premature death and also whether they had received such information. Ninety percent or more of PWE, CBP, and CAR reported that they wanted such information, and 50% of CAR, 81% of CBP, and 70% of PWE had received some information about seizure-related injuries. Regarding risk of unexpected death, 31% of PWE, 35% of CBP, and 28% of CAR had received information on this issue. Those with tonic-clonic seizures were most eager to obtain information on these matters, and those best informed about epilepsy-related risks were males and the youngest part of the cohort. The wish for more information or the likelihood of having already received information was independent of the individual's seizure situation. This study demonstrates that there is a considerable gap between what the patients want regarding information and what they are actually given by healthcare providers.

Effects of microRNA-129 and its target gene c-Fos on proliferation and apoptosis of hippocampal neurons in rats with epilepsy via the MAPK signaling pathway

This study aims to investigate the effect of microRNA-129 (miR-129) on proliferation and apoptosis of hippocampal neurons in epilepsy rats by targeting c-Fos via the MAPK signaling pathway. Thirty rats were equally classified into a model group (successfully established as chronic epilepsy models) and a normal group. Expression of miR-129, c-Fos, bax, and MAPK was detected by RT-qPCR and Western blotting. Hippocampal neurons were assigned into normal, blank, negative control (NC), miR-129 mimic, miR-129 inhibitor, siRNA-c-Fos, miR-129 inhibitor+siRNA-c-Fos groups. The targeting relationship between miR-129 and c-Fos was predicted and verified by bioinformatics websites and dual-luciferase reporter gene assay. Cell proliferation after transfection was measured by MTT assay, and cell cycle and apoptosis by flow cytometry. c-Fos is a potential target gene of miR-129. Compared with the normal group, the other six groups showed a decreased miR-129 expression; increased expression of expression of c-Fos, Bax, and MAPK; decreased proliferation; accelerated apoptosis; more cells arrested in the G1 phase; and fewer cells arrested in the S phase. Compared with the blank and NC groups, the miR-129 mimic group and the siRNA-c-Fos group showed decreased expression of c-Fos, Bax, and MAPK, increased cells proliferation, and decreased cell apoptosis, fewer cells arrested in the G1 phase and more cells arrested in the S phase. However, the miR-129 inhibitor groups showed reverse consequences. This study suggests that miR-129 could inhibit the occurrence and development of epilepsy by repressing c-Fos expression through inhibiting the MAPK signaling pathway.

Knowledge of sudden unexpected death in epilepsy (SUDEP) among 372 patients attending a German tertiary epilepsy center

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.

Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society

OBJECTIVE

To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epilepsy populations and address the question of whether risk factors for SUDEP have been identified.

METHODS

Systematic review of evidence; modified Grading Recommendations Assessment, Development, and Evaluation process for developing conclusions; recommendations developed by consensus.

RESULTS

Findings for incidence rates based on 12 Class I studies include the following: SUDEP risk in children with epilepsy (aged 0-17 years) is 0.22/1,000 patient-years (95% confidence interval [CI] 0.16-0.31) (moderate confidence in evidence). SUDEP risk increases in adults to 1.2/1,000 patient-years (95% CI 0.64-2.32) (low confidence in evidence). The major risk factor for SUDEP is the occurrence of generalized tonic-clonic seizures (GTCS); the SUDEP risk increases in association with increasing frequency of GTCS occurrence (high confidence in evidence).

RECOMMENDATIONS

Level B: Clinicians caring for young children with epilepsy should inform parents/guardians that in 1 year, SUDEP typically affects 1 in 4,500 children; therefore, 4,499 of 4,500 children will not be affected. Clinicians should inform adult patients with epilepsy that SUDEP typically affects 1 in 1,000 adults with epilepsy per year; therefore, annually 999 of 1,000 adults will not be affected. For persons with epilepsy who continue to experience GTCS, clinicians should continue to actively manage epilepsy therapies to reduce seizures and SUDEP risk while incorporating patient preferences and weighing the risks and benefits of any new approach. Clinicians should inform persons with epilepsy that seizure freedom, particularly freedom from GTCS, is strongly associated with decreased SUDEP risk.

Experiences with premorbid SUDEP discussion among participants in the North American SUDEP Registry (NASR)

The North American SUDEP Registry (NASR) is a repository of clinical data and biospecimens in cases of sudden unexpected death in epilepsy (SUDEP), a leading cause of epilepsy-related deaths. We assessed whether bereaved families were aware of SUDEP before their family member's death and their preferences for SUDEP disclosure. At enrollment, next-of-kin of SUDEP cases completed an intake interview, including questions assessing premorbid SUDEP discussions. Only 18.1% of the 138 next-of-kin recalled a previous discussion of SUDEP with a healthcare provider or support resource. Of the 112 who did not recall such a discussion, 72.3% wished it was discussed, 10.7% were satisfied it was not discussed, and 17% were unsure. A history of status epilepticus predicted SUDEP discussion. Rates of SUDEP discussion were not significantly higher among SUDEPs after 2013 (the approximate study midpoint) compared with those before then. Our study suggests that SUDEP remains infrequently discussed with family members of persons with epilepsy. Nearly three-quarters of family members wished they had known of SUDEP before the death. However, some were indifferent or were satisfied that this discussion had not occurred. We must balance more systematic education of patients and families about SUDEP while respecting individual preferences about having this discussion.

Practice Guideline Summary: Sudden Unexpected Death in Epilepsy Incidence Rates and Risk Factors: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society

OBJECTIVE

To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epilepsy populations and address the question of whether risk factors for SUDEP have been identified.

METHODS

Systematic review of evidence; modified Grading Recommendations Assessment, Development and Evaluation process for developing conclusions; recommendations developed by consensus.

RESULTS

Findings for incidence rates based on 12 Class I studies include the following: SUDEP risk in children with epilepsy (aged 0-17 years) is 0.22/1,000 patient-years (95% CI 0.16-0.31) (high confidence in evidence). SUDEP risk increases in adults to 1.2/1,000 patient-years (95% CI 0.64-2.32) (low confidence in evidence). The major risk factor for SUDEP is the occurrence of generalized tonic-clonic seizures (GTCS); the SUDEP risk increases in association with increasing frequency of GTCS occurrence (high confidence in evidence).

RECOMMENDATIONS

Level B: Clinicians caring for young children with epilepsy should inform parents/guardians that in 1 year, SUDEP typically affects 1 in 4,500 children; therefore, 4,499 of 4,500 children will not be affected. Clinicians should inform adult patients with epilepsy that SUDEP typically affects 1 in 1,000 adults with epilepsy per year; therefore, annually 999 of 1,000 adults will not be affected. For persons with epilepsy who continue to experience GTCS, clinicians should continue to actively manage epilepsy therapies to reduce seizures and SUDEP risk while incorporating patient preferences and weighing the risks and benefits of any new approach. Clinicians should inform persons with epilepsy that seizure freedom, particularly freedom from GTCS, is strongly associated with decreased SUDEP risk.

Unravelling the mysteries of sudden unexpected death in epilepsy

INTRODUCTION

Sudden unexpected death in epilepsy (SUDEP) is the most frequent cause of premature death in epileptic patients. Most SUDEP events occur at night and frequently go unnoticed; the exact pathophysiological mechanisms of this phenomenon therefore remain undetermined. Nevertheless, most cases of SUDEP are attributed to an infrequent yet extremely severe complication of epileptic seizures.

DEVELOPMENT

We conducted a systematic literature search on PubMed. Our review article summarises scientific evidence on the classification, pathophysiological mechanisms, risk factors, biomarkers, and prevention of SUDEP. Likewise, we propose new lines of research and critically analyse findings that are relevant to clinical practice.

CONCLUSIONS

Current knowledge suggests that SUDEP is a heterogeneous phenomenon caused by multiple factors. In most cases, however, SUDEP is thought to be due to postictal cardiorespiratory failure triggered by generalised tonic-clonic seizures and ultimately leading to cardiac arrest. The underlying pathophysiological mechanism involves multiple factors, ranging from genetic predisposition to environmental factors. Risk of SUDEP is higher in young adults with uncontrolled generalised tonic-clonic seizures. However, patients apparently at lower risk may also experience SUDEP. Current research focuses on identifying genetic and neuroimaging biomarkers that may help determine which patients are at high risk for SUDEP. Antiepileptic treatment is the only preventive measure proven effective to date. Night-time monitoring together with early resuscitation may reduce the risk of SUDEP.

SUDEP: What do adult patients want to know?

PURPOSE

The purpose of this descriptive qualitative study was to understand the range of adult patients' views on whether and how to discuss the issue of SUDEP with patients with epilepsy and to clarify the optimal timing and formulation of this information.

METHOD

The principles of fundamental qualitative description informed all design decisions. Twenty-three patients aged 18-65years participated in the study. Nineteen participants completed a single one-on-one telephone interview, whereas four participants shared their experiences in a focus group. Directed content analysis was used to code, categorize, and synthesize the interview data.

RESULTS

Of the 42 patients invited to participate, 23 participated in the study. There was consensus among all study participants that all individuals diagnosed with epilepsy should be informed about SUDEP. Many participants believed that the best time to be told about SUDEP was at diagnosis. The majority of participants suggested that the discussion about SUDEP should take place face to face, in a verbal discussion, followed by written information to take home. Several participants suggested that the information about SUDEP should not be shared separately but rather incorporated into the general information they received about epilepsy. Nearly all the participants felt that the information about SUDEP should come from the neurologist.

CONCLUSION

Participants of this study wanted neurologists to inform patients about the risk of SUDEP, with the optimal timing and setting of SUDEP counseling determined on a case-by-case basis.

Sudden Unexpected Death in Epilepsy (SUDEP): Are All Your Patients Informed?

Sudden unexpected death in epilepsy (SUDEP) is a devastating direct epilepsy-related cause of death. Although its occurrence has some risk factors, it is unanticipated and very traumatic to the families of affected patients. Effective preventive measures for SUDEP are lacking; therefore, efforts are directed at modifiable risk factors. The majority of caregivers of patients with epilepsy and SUDEP wish they would have known more about the topic before the terminal event. SUDEP is a difficult topic for physicians and clearly even more challenging to discuss with patients and caregivers. The pathophysiology of SUDEP is controversial, but awareness should be raised despite individual opinions. During the last decade SUDEP has received substantial attention, and efforts are being made to increase worldwide awareness. The American Epilepsy Society and Epilepsy Foundation Joint Task force, National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network recommend educating patients about SUDEP. Education will potentially help meet treatment goals, promote better patient-physician rapport, decrease anxiety and fear, serve as a filter for inaccurate information, and lessen grief and blame in the families of patients affected by SUDEP. This article will cover a literature review on SUDEP, epidemiology, risk factors, proposed mechanism, potential interventions, physician practices and suggested measurements, and public websites designed to increase SUDEP awareness.

Epilepsy: addressing the transition from pediatric to adult care

Adolescence is a period of rapid change, both physical and psychosocial for any young person. It can be challenging when they have ongoing health problems and when their care needs to be transitioned to the adult health care system. Transition should be a planned process of addressing the medical and associated comorbid conditions from pediatric to adult care in a coordinated manner. In most cases, the young person and their family are well known to the pediatrics services and have built a relationship based on trust and often friendship over many years. Understandably, there is significant apprehension about moving from this familiar setting to the unknown adult services. Apart from having a sound knowledge of specific childhood epileptic conditions and associated comorbid disorders, it is important that both the pediatric and adult epilepsy teams are motivated to provide a successful and safe transition for these patients. It is essential that transition is seen as a continual process and not as a single event, and good preparation is the key to its success. It is also important that general practitioners are closely engaged to ensure successful transition. An overview of how to effectively address transition in epilepsy, different models of transition, transition of relevant epilepsies, and their management is discussed.

Patient Education: Identifying Risks and Self-Management Approaches for Adherence and Sudden Unexpected Death in Epilepsy

Patient education in epilepsy is one part of quality epilepsy care and is an evolving and growing field. Health outcomes, patient satisfaction, safety, patient/provider communication, and quality of life may all be affected by what people are taught (or not taught), what they understand, and how they use this information to make decisions and manage their health. Data regarding learning needs and interventions to address medication adherence and sudden unexpected death in epilepsy education can be used to guide clinicians in health care or community settings.