Epidemiologic aspects: lost in transition

Transition of Care in Epilepsy

Transition of care is the planned, coordinated movement from a child and family environment of pediatrics to a patient centered adult care setting. Epilepsy is a common neurological condition. While seizures remit in a proportion of children, in around 50% of children seizures persist into adulthood. Also, with advances in diagnostics and therapeutics, more children with epilepsy survive into adulthood, and need services of adult neurologists. Clinical guidelines from the American Academy of Pediatrics, American College of Family Physicians and American College of Physicians called for "supporting the healthcare transition from adolescence to adulthood", but this occurs in a minority of patients. There are several challenges to implementing transition of care at the level of the patient and family, pediatric and adult neurologist and with systems of care. Transition needs vary based on the type of epilepsy and epilepsy syndrome and presence of co-morbidities. Transition clinics are essential to effective transfer of care, but implementation remains extremely variable, with a variety of clinics or program structures in countries around the world. There is a need to develop multidisciplinary transition clinics, enhance physician education and establish national guidelines for this important process to be put into practice. Further studies are also needed to develop best practices and assess outcomes of well executed transition programs on epilepsy.

Current Pharmacologic Strategies for Treatment of Intractable Epilepsy in Children

Epileptic encephalopathy (EE) is a devastating pediatric disease that features medically resistant seizures, which can contribute to global developmental delays. Despite technological advancements in genetics, the neurobiological mechanisms of EEs are not fully understood, leaving few therapeutic options for affected patients. In this review, we introduce the most common EEs in pediatrics (i.e., Ohtahara syndrome, Dravet syndrome, and Lennox-Gastaut syndrome) and their molecular mechanisms that cause excitation/inhibition imbalances. We then discuss some of the essential molecules that are frequently dysregulated in EEs. Specifically, we explore voltage-gated ion channels, synaptic transmission-related proteins, and ligand-gated ion channels in association with the pathophysiology of Ohtahara syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. Finally, we review currently available antiepileptic drugs used to treat seizures in patients with EEs. Since these patients often fail to achieve seizure relief even with the combination therapy, further extensive research efforts to explore the involved molecular mechanisms will be required to develop new drugs for patients with intractable epilepsy.

Challenges in the Transition of Care Process for Patients with Dravet and Lennox–Gastaut Syndromes

Epileptic encephalopathies such as Dravet syndrome (DS) and Lennox–Gastaut syndrome (LGS) present unique challenges in the transition of care not only for the providers but also for the patients and families. Some of these challenges include the complexity of disease process, differences in medication management between children and adults, high incidence of comorbidities such as psychosocial issues, a lack of structured transition process from pediatric to adult care, and the lack of parental knowledge and reluctance to transition to an adult provider. Improving transition readiness and transfer of care are essential to long-term management and continuity of care. Studies show that patients/families who possess transition readiness skills have better health outcomes. Furthermore, participation in a structured transition intervention has been shown to improve transition readiness and utilization of ambulatory care in the adult setting. Reported benefits of implementation of transition planning include increased self-esteem, improved health literacy, fewer emergency room visits, decreased hospitalizations and comorbidities, and fewer school absences. Nevertheless, there is a lack of evidenced-based, family/patient-centered transition model of care. This review's primary goal is to provide an overview of challenges in the transition of care and recommendations for an ideal transition for patients with DS and LGS.

Fifty-year follow-up of childhood epilepsy - Social, psychometric, and occupational outcome

OBJECTIVE

The objective of this study was to explore and describe the experience of a childhood diagnosis of epilepsy and its consequences for the experiences of daily life over a span of 50 years.

METHODS

A descriptive mixed method design was chosen. Data were collected through a survey returned by 86 persons (59% response rate) who had received diagnoses of epilepsy as children. The survey contained questions about education, vocation, family status, and included the 14-item Hospital Anxiety and Depression Scale (HAD). Additionally, interviews (n = 11) were conducted and analyzed by interpretative description.

RESULTS

Few persons reported that the childhood diagnosis of epilepsy had affected their choice of education, work, or leisure activities. However, 20% reported that the diagnosis had caused problems in school or at work and had restricted their activities of daily living. Sixty-six percent of the participants were married, and 68% had children; of those, 12 (20%) reported that one or more of the children had also had seizures. Almost all reported no anxiety (82%) and no depression (90%). The results of the interviews revealed a balancing act between 'Controlling and managing the situation' and 'Not being restricted by the condition'.

SIGNIFICANCE

This long-term follow-up over a 50-year life-span of persons who received childhood diagnoses of epilepsy suggests that the consequences for education, work, and leisure activities were few. Most of the participants had developed strategies to manage their situation.

Intractable Generalized Epilepsy: Therapeutic Approaches

PURPOSE OF REVIEW

To summarize recent developments in therapeutic options, both medical and surgical, for patients with drug-resistant generalized epilepsy syndromes, which continue to be a multifaceted challenge for patients and physicians.

RECENT FINDINGS

Newer generation pharmaceutical options are now available, such as brivaracetam, rufinamide, lacosamide, perampanel, and cannabidiol. Less restrictive dietary options appear to be nearly as effective as classic ketogenic diet for amelioration of seizures. The latest implantable devices include responsive neurostimulation and deep brain stimulation. Corpus callosotomy is an effective treatment for some seizure types, and newer and less invasive approaches are being explored. Resective surgical options have demonstrated success in carefully selected patients despite generalized electrographic findings on electroencephalogram. The current literature reflects a widening range of clinical experience with newer anticonvulsant medications including cannabinoids, dietary therapies, surgical approaches, and neurostimulation devices for patients with intractable generalized epilepsy.

Transition From Pediatric to Adult Neurologic Care

PURPOSE OF REVIEW

With advances in medical care, the number of youths surviving with medically complex conditions has been steadily increasing. Inadequate transition planning and execution can lead to gaps in care, unexpected emergency department visits, and an increase in health care costs and patient/caregiver anxiety. Many barriers that prevent adequate transition have been identified, including insufficient time or staff to provide transition services, inadequate reimbursement, resistance from patients and caregivers, and a dearth of accepting adult providers.

RECENT FINDINGS

Transition is distinct from transfer of care. Transition is a planned multistage process, while transfer refers to a point in time where responsibility of care shifts from one provider to another. Key differences exist between the pediatric and adult models of care. A successful transition should empower the patient to understand and take responsibility in managing his or her condition; foster independent functioning to the extent that is possible; integrate educational, legal, and community resources in the care plan; and identify appropriate adult health care providers at the time of transfer. Different models have been proposed to streamline the transition process, with improvement in patients' knowledge of their condition, self-efficacy, and confidence.

SUMMARY

Neurologists have a key role in supporting their patients in the transition to adulthood. This article reviews basic tenets and provides tools to assist in navigating the complex transition process. These tenets are intended to improve quality of care and decrease clinician burden and remain an active area of research.

Cognitive Outcome in Childhood-Onset Epilepsy: A Five-Decade Prospective Cohort Study

OBJECTIVES

Little is known about the very long-term cognitive outcome in patients with childhood-onset epilepsy. The aim of this unique prospective population-based cohort study was to examine cognitive outcomes in aging participants with childhood-onset epilepsy (mean onset age=5.3 years) five decades later (mean age at follow-up=56.5 years).

METHODS

The sample consisted of 48 participants with childhood-onset epilepsy and 48 age-matched healthy controls aged 48-63 years. Thirty-six epilepsy participants were in remission and 12 continued to have seizures. Cognitive function was examined with 11 neuropsychological tests measuring language and semantic function, episodic memory, and learning, visuomotor function, executive function, and working memory.

RESULTS

The risk of cognitive impairment was very high in participants with continuing seizures; odds ratio (OR)=11.7 (95% confidence interval [CI] (2.8, 49.6), p=.0008). They exhibited worse performances across measures of language and semantic function, and visuomotor function compared to participants with remitted epilepsy and healthy controls. In the participants with remitted epilepsy, the risk of cognitive impairment was somewhat elevated, but not statistically significant; OR=2.6 (95% CI [0.9, 7.5], p=.08).

CONCLUSIONS

Our results showed that the distinction of continued versus discontinued seizures was critical for determining long-term cognitive outcome in childhood-onset epilepsy. Few participants in remission exhibited marked cognitive impairment compared to age-matched peers. However, a subgroup of participants with decades long active epilepsy, continuous seizure activity and anti-epileptic drug (AED) medication, showed clinically significant cognitive impairment and are thus in a more precarious position when entering older age. (JINS, 2017, 23, 332-340).

Transition to adult medical care for adolescents with epilepsy

INTRODUCTION

During transition to adult medical care, the adolescent with epilepsy is especially prone to emotional, mental, physical, and social developmental difficulties, leading to stigma and poor psychosocial and socioeconomic outcome in the long term.

OBJECTIVES

The aim of this review is twofold: to describe the psychosocial and medical transition from adolescence to adulthood and to evaluate the most effective model for transitional services in adolescents with epilepsy.

METHODS

We searched PubMed for quantitative and qualitative data about transition from adolescence to adulthood in patients with epilepsy.

RESULTS

A total of 49 articles were retrieved. We reviewed personal, psychosocial, and medical issues during transition and their long-term individual and societal consequences. Identifying risk factors for poor transition can lead to appropriate interventions for patients and their family. Although the concept of multidisciplinary transition care for adolescents with epilepsy is widely recognized, only a few transition clinics have been established. There is lack of evidence for their quality and cost-effectiveness.

CONCLUSION

In addition to medical problems, more attention should be paid to the risk of psychosocial problems during transition from pediatric to adult care. The implementation of transition care for adolescents with epilepsy is considered beneficial; however, its effectiveness should be further investigated.