Counseling about sudden unexpected death in epilepsy (SUDEP): A global survey of neurologists' opinions

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.

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.

Parental Counseling About Sudden Unexpected Death in Epilepsy: Why, When, Where, What, Who, and How?

Effect of Counselling of Parents of Children With Epilepsy Focusing on Sudden Unexpected Death in Epilepsy Kumari S, Garg D, Sharma S, Pemde HK. Epilepsy Res . 2022;186:106992. doi:10.1016/j.eplepsyres.2022.106992 . PMID: 35970090. Objectives: To characterize the effects of sudden unexpected death in epilepsy (SUDEP) counselling on epilepsy-related childcare behaviour and practices, and emotional distress, measured by the Depression, Anxiety and Stress scale-21 (DASS-21), among parents of children with epilepsy (CWE), and to obtain feedback about SUDEP counselling. Methods: We conducted a single-arm, pre- and post-intervention study design. We enrolled 120 parents of CWE. At enrolment, we collected clinical and demographic data, assessed 18 epilepsy-related childcare and behaviour and practices and the DASS-21 score. Parents underwent a three-phase counselling, comprising SUDEP information via written material, followed by an informative video, and then a detailed face-to-face counselling session with treating clinicians. Changes in epilepsy-related childcare behaviour and practices, and DASS-21 scores were reassessed at one month. Qualitative feedback was obtained about SUDEP counselling. Results: At one month, 84.2% of parents reported a change in >2 epilepsy-related childcare behaviour and practices. Significant improvement compared to baseline was observed in reported administration of anti-seizure medications at fixed time (100% versus 57.5%; p < 0.0001), regular exercise (87.5% versus 60%; p < 0.0001), supervision of activity as advised (56.7%-39.2%; p = 0.0096), having a seizure action plan (97.5% versus 20%; p < 0.0001), rescue medications (95% versus 25.8%; p < 0.0001), providing information of child’s epilepsy to schools (100% versus 62%; p < 0.0001), providing an emergency contact number in schools (100% versus 58%; p < 0.0001), and a seizure action plan in their child’s school (54% versus 8%; p < 0.0001). There was no significant change in DASS-21 scores at one month. Parents expressed a preference for face-to-face interaction, in combination with other audiovisual modes, for SUDEP counselling, and being counselled when they were comfortable with their child’s diagnosis of epilepsy. Significance: SUDEP disclosure among Indian parents of CWE was associated with significant improvement in self-reported epilepsy-related childcare behaviour and practices, without increase in depression, stress or anxiety.

Sudden unexpected death in epilepsy

PURPOSE OF REVIEW

Sudden unexpected death in epilepsy (SUDEP) is a leading cause of death in patients with epilepsy. This review highlights the recent literature regarding epidemiology on a global scale, putative mechanisms and thoughts towards intervention and prevention.

RECENT FINDINGS

Recently, numerous population-based studies have examined the incidence of SUDEP in many countries. Remarkably, incidence is quite consistent across these studies, and is commensurate with the recent estimates of about 1.2 per 1000 patient years. These studies further continue to support that incidence is similar across the ages and that comparable factors portend heightened risk for SUDEP. Fervent research in patients and animal studies continues to hone the understanding of potential mechanisms for SUDEP, especially those regarding seizure-induced respiratory dysregulation. Many of these studies and others have begun to lay out a path towards identification of improved treatment and prevention means. However, continued efforts are needed to educate medical professionals about SUDEP risk and the need to disclose this to patients.

SUMMARY

SUDEP is a devastating potential outcome of epilepsy. More is continually learned about risk and mechanisms from clinical and preclinical studies. This knowledge can hopefully be leveraged into preventive measures in the near future.

An evidence-based approach to provide essential and desirable components to develop surveys on Sudden Unexpected Death in Epilepsy (SUDEP) for doctors: A focused review

Sudden Unexpected Death in Epilepsy (SUDEP) is a major concern for people with epilepsy, their families, their care givers, and medical professionals. There is inconsistency in the SUDEP counselling doctors provide, compared to what is recommended in clinical guidelines. Numerous national and international surveys have highlighted how epilepsy professionals, usually doctors, deliver SUDEP risk counselling, particularly, when they deliver it and to whom. These surveys help understand the unmet need, develop suitable strategies, and raise awareness among clinicians with the eventual goal to reduce SUDEPs. However, there is no standardised survey or essential set of questions identified that can be used to evaluate SUDEP counselling practice globally. This focused review analyses the content of all published SUDEP counselling surveys for medical professionals (n=16) to date covering over 4000 doctors across over 30 countries and five continents. It identifies 36 question themes across three topics. The questions are then reviewed by an expert focus group of SUDEP communication experts including three doctors, an expert statistician and SUDEP Action, an UK based charity specialising in epilepsy deaths with a pre-set criterion. The review and focus group provide ten essential questions that should be included in all future surveys inquiring on SUDEP counselling. They could be used to evaluate current practice and compare findings over time, between services, across countries and between professional groups. They are provided as a template to download and use. The review also explores if there is a continued need in future for similar surveys to justify this activity.

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.

Sudden unexpected death in epilepsy (SUDEP): Definition, epidemiology, and significance of education

People with epilepsy (PWE) may die suddenly and unexpectedly and without a clear under-lying pathological etiology; this is called SUDEP (sudden unexpected death in epilepsy). The pooled estimated incidence rate for SUDEP is 23 times the incidence rate of sudden death in the general population with the same age. Empowering healthcare professionals, PWE, and their care-givers with the appropriate knowledge about SUDEP is very important to enable efficient preventive measures in PWE. In the current narrative review, following a brief discussion on the definition, epidemiology, and risk factors for SUDEP, the authors discuss the importance of appropriately educating healthcare professionals, PWE, and their caregivers about SUDEP.