Comprehensive management of epilepsy in persons with mental retardation

Comparative Efficacy of Levetiracetam for Epilepsy in School-Aged Children with Intellectual Disability and Normal Intelligence

Choosing optimal anti-seizure medication (ASM) is very important in pediatric patients with epilepsy who attend school, especially children with an intellectual disability (ID). Levetiracetam (LEV) has proven to be an effective, safe, generally well-tolerated, broad-spectrum ASM in children. In the context of increasing use of LEV in school-aged children with epilepsy and ID, we evaluate relevant clinical data, including efficacy, safety, and tolerability in children with epilepsy and an intellectual disability (ID) or normal intelligence (NI). We performed a retrospective chart review of children and included 298 pediatric patients with epilepsy who were treated with LEV with NI (147) and ID (151). After 6 months, 96% of NI and 83% of ID subjects had a seizure reduction rate greater than 50% (p = 0.031). The tolerability of LEV was generally good, with 75% retention rates at 2 years in both groups and only minor side effects (under 15%). The retention rates of patients with NI and ID were 76% and 74%, respectively (p = 0.597). Thus, LEV showed considerable efficacy with minimal side effects and high retention rates and is an easily maintained and safe treatment option for pediatric epilepsy with ID. However, better-designed research studies are needed to clearly elucidate the efficacy and safety of LEV in children with epilepsy and ID.

Development of the Epilepsy Risk Awareness scale (ERA scale) for people with epilepsy

PURPOSE

Quality of life in people with epilepsy depends on balancing protection from risks and avoiding unnecessary restrictions. The Epilepsy Risk Awareness Checklist (ERAC) was developed to summarise an individual's safety, health care and quality of life and to facilitate communication between professionals. Although effective, the existing Checklist required quantification and shortening to increase its utility, particularly as a longitudinal tool for measuring and communicating changes over time.

METHODS

5 clinical experts, 3 people with epilepsy and 5 carers assessed the importance of each item on the ERAC questionnaire in a two-round Delphi survey. The refined Epilepsy Risk Awareness scale (ERA scale) was piloted in 30 patients to obtain an overall and sub-scale score for personal safety, health care, and quality of life domains, and was compared with the validated Seizure Severity Scale and Epilepsy Self-Management Scale.

RESULTS

ERAC was shortened from 69 to 48 items to take 15-20min for completion. Pilot results showed good internal consistency for the overall ERA scale, for the Personal Safety and Health Care subscales, but less for the Quality of Life subscale. There was strong association between ERA scale and the Epilepsy Self-Management Scale, but little relationship with Seizure Severity Scale scores, which focus on individual seizures. User ratings were high.

CONCLUSIONS

The ERA scale has been shortened and quantified to provide an objective measure of the risks and safety profile in people with epilepsy. The scale will be further tested for intra-rater variability and utility.

A qualitative study of carers' and professionals' views on the management of people with intellectual disability and epilepsy: a neglected population

Little attention has been paid to the specific needs of people with intellectual disability and epilepsy despite evidence of increased prevalence of epilepsy, increased risk of complex epilepsy, and heightened use of health services among this group. In an attempt to address this gap, an online international survey was undertaken inviting health professionals and caregivers, both paid and family members, to share their views on the adequacy and quality of available treatment. This paper reports on the responses obtained from 113 individuals from the UK and Ireland. Findings revealed that professionals and carers differ in their expectations of treatment and with regard to maximizing communication during consultations. In addition, findings suggested that the potential of consultations to provide information for carers, as well as to allay concerns, may not be realized. Rescue medications were viewed favorably; however, respondents expressed less satisfaction with routine medications. These findings may reflect a failure by professionals to appropriately transfer knowledge of these treatments.

Dental management of special needs patients who have epilepsy

Patients who have developmental disabilities and epilepsy can be safely treated in a general dental practice. A thorough medical history should be taken and updated at every visit. A good oral examination to uncover any dental problems and possible side effects from antiepileptic drugs is necessary. Stability of the seizure disorder must be taken into account when planning dental treatment. Specific considerations for epileptic patients include the treatment of oral soft tissue side effects of medications and damage to the hard and soft tissue of the orofacial region secondary to seizure trauma. Most patients who have epilepsy can and should receive functionally and esthetically adequate dental care.

Living environment of persons with severe epilepsy and intellectual disability: a prospective study

We studied a population with intellectual disability (ID) and epilepsy and analyzed aspects of the living environment. Using an epilepsy impact score (EPIEK, the Epilepsy Impact Scale Kempenhaeghe), we found that epilepsy is more severe in younger persons than in older persons until about age 60 years. Individuals with more adaptive behavior had less severe epilepsy. Compared with persons with ID, the subjects in this study had fewer sensory problems and many more mobility problems, and more often saw a general practitioner. We concluded that people with severe epilepsy and ID have, in some ways, the same needs as people with only ID, and yet, in other ways (development of adaptive skills and aspects of living environment), distinctly different needs.

Epilepsy, intellectual disability, and living environment: a critical review

Epilepsy occurs at a higher incidence and is more prevalent in people with an intellectual disability than in the general population. Nonetheless, we have insufficient knowledge of the extra needs of people with epilepsy and intellectual disability, of their families, and of the living environment. The lack of information about specific needs of the living environment may, in particular, be important. A Medline search revealed that scant attention has been paid to the specific needs for patients with epilepsy and intellectual disability, and only a few studies have focused specifically on this topic. The majority of studies have been focused on medical treatment issues and the organization and availability of health and social services. There is an indication that people with epilepsy and intellectual disability lack skills training appropriate to their intellectual potential. And although several reviews have emphasized the need for information on living environment and quality of life, we did not find such studies in our search.

Adjunctive lamotrigine for refractory epilepsy in adolescents with mental retardation

Epilepsy is a major comorbid condition in adolescents with mental retardation and is often characterized by multiple seizure types that are refractory to treatment. This study (n = 22) describes a subanalysis of data from a larger multicenter study of adjunctive lamotrigine therapy in patients with mental retardation and refractory epilepsy and focuses on the outcome measures of seizure reduction, safety and tolerability, and impact on behaviors in adolescents with mental retardation and refractory epilepsy. The study kept baseline antiepileptic drugs constant and titrated lamotrigine over 8 weeks to the target dose, followed by an 8-week maintenance phase and then a 12-week optimization phase during which all antiepileptic drugs and lamotrigine could be altered as clinically indicated. Sixty percent of subjects had a 50% decrease in seizures by the end of the maintenance phase and a mean 39% reduction in seizure frequency by the end of the maintenance phase (25% by end of study) compared with baseline. Global improvements were observed in most patients, with statistically significant improvements in the Aberrant Behavior Checklist and the Habilitative Improvement Scale, which is predictive of less need for supportive care in activities of daily living and thus enhanced potential for greater independence. Lamotrigine-associated improvements in behavior can be attributed to improved control of seizures, a reduction in concomitant antiepileptic drugs, and/or direct mood-stabilizing and behavior-enhancing properties independent of the antiseizure effects of the drug. The results of this study suggest that lamotrigine is an important treatment option in adolescents with mental retardation and comorbid epilepsy.

Impact of new-generation agents on antiepileptic drug prescribing patterns in a residential ICF-MR facility

OBJECTIVE

Describe the impact of newer antiepileptic drugs (AEDs) on prescribing practices in a large, residential intermediate-care facility for the mentally retarded (ICF-MR), with onsite clinical pharmacist support services, over a 15-year period.

DESIGN

All residents at the facility receiving AEDs for management of seizure disorder were included in this retrospective assessment. Number and type of AEDs used per individual were recorded and analyzed over the 15-year interval. Current prescribing practices were evaluated regarding rational polytherapy prescribing trends.

SETTING

400-bed residential ICF-MR for the severe to profoundly mentally retarded.

PATIENTS/PARTICIPANTS

All individuals residing at the ICF-MR facility receiving AED therapy for a seizure disorder. Residents were primarily in the severe to profound range of developmental disability, with multiple medical comorbidities.

INTERVENTIONS

Clinical pharmacists actively participate in all treatment teams and monthly neurology clinic to promote and encourage rational pharmacotherapy.

MAIN OUTCOME MEASURES

Prescribing trends related to AED therapy were followed over a 15-year period. Comparisons were made regarding monotherapy and polytherapy at multiple-year intervals, with specific emphasis on how the newer generation AEDs have affected use of older medications.

RESULTS

Overall trend from 1988 suggests more monotherapy and less use of barbiturates. Introduction of a new generation of AEDs has not affected the overall trend toward one- or two-drug regimens over the period in review.

CONCLUSION

The relative stability of the number of AEDs per resident during the introduction of a new generation of AEDs suggests that as new drugs are added, ineffective or problem-prone drugs are discontinued.

Lamotrigine as adjunctive therapy in patients with refractory epilepsy and mental retardation

This study evaluated the effects of lamotrigine as adjunctive therapy for refractory epilepsy in patients with mental retardation. Patients with epilepsy and mental retardation having uncontrolled seizures despite treatment with other antiepileptic drugs were eligible (n=67). The open-label study comprised a Baseline Phase, an Escalation Phase during which lamotrigine was titrated to a target dose, an 8-week Maintenance Phase during which doses of lamotrigine and concomitant antiepileptic drugs were maintained, and a 12-week Optimization Phase during which doses of lamotrigine and other antiepileptic drugs could be adjusted. Almost half (44%) of patients experienced a 50% reduction in seizure frequency during the Maintenance Phase after addition of lamotrigine; 15% of patients became seizure-free. A similar pattern of results was reported for the Optimization Phase. Investigator-rated clinical status was improved relative to baseline in 66 and 74% of patients at the end of the Maintenance and Optimization Phases, respectively. Most patients experienced improvements in seizure frequency, duration, and intensity during the Maintenance Phase (62 to 72%) and the Optimization Phase (65 to 74%). Many patients were rated as having improved social functioning during the Maintenance Phase (42%) and the Optimization Phase (46%). The Aberrant Behavior Checklist score for lethargy and the mean Habilitative Improvement Scale score were improved at the ends of the Maintenance and Optimization Phases relative to baseline (P< or =0.04). One limitation of this study is its open-label design, which limits the ability definitively to attribute the clinical improvements to lamotrigine. Adjunctive lamotrigine in patients with refractory epilepsy and mental retardation appears to decrease seizure frequency and improve behavior while permitting a reduction in dose of concomitant antiepileptic drugs.

Topiramate in patients with learning disability and refractory epilepsy

PURPOSE

Management of seizures in learning disabled people is challenging. This prospective study explored the efficacy and tolerability of adjunctive topiramate (TPM) in patients with learning disability and refractory epilepsy attending a single centre.

METHODS

Sixty-four patients (36 men, 28 women, aged 16-65 years) were begun on adjunctive TPM after a 3-month prospective baseline on unchanged medication. Efficacy end points were reached when a consistent response was achieved over a 6-month period at optimal TPM dosing. These were seizure freedom or > or =50% seizure reduction (responder). Appetite, behaviour, alertness, and sleep were assessed by caregivers throughout the study.

RESULTS

Sixteen (25%) patients became seizure free with adjunctive TPM. There were 29 (45%) responders. A further 10 (16%) patients experiencing a more modest improvement in seizure control continued on treatment at the behest of their family and/or caregivers. TPM was discontinued in the remaining nine (14%) patients, mainly because of side effects. Final TPM doses and plasma concentrations varied widely among the efficacy outcome groups. Many patients responding well to adjunctive TPM did so on < or =200 mg daily. Mean carer scores did not worsen with TPM therapy.

CONCLUSIONS

TPM was effective as add-on therapy in learning-disabled people with difficult-to-control epilepsy. Seizure freedom is a realistic goal in this population.

Treatment of seizures in patients with learning disabilities

People with learning disabilities commonly have seizures. Combined electroencephalogram and video investigations improve diagnostic accuracy, while neuroimaging may indicate a role for surgery. When epilepsy is diagnosed, individually tailored care is necessary. Rational antiepileptic drug use is advocated, with emphasis upon the newer agents due to their better tolerability and ease of use. Regular clinical review will prevent over-medicating. Although an optimistic approach can now be adopted, future developments require a more solid evidence base together with a rationality to all aspects of care, including drug therapy, carer education, closer collaboration among specialists, and mutual skill awareness of all involved.

Epilepsy and learning disabilities--a challenge for the next millennium?

People with learning disabilities often have seizures in addition to other disorders. Precise diagnosis may be difficult, but accuracy can be improved using electroencephalographic and video investigations. Following the establishment of a diagnosis of epilepsy, individually tailored care is necessary taking into account other health, behavioural and therapeutic issues. Neuroimaging may indicate a need for surgery which should not be automatically excluded as a treatment option. Rational antiepileptic drug use is advised, with emphasis upon the newer agents due to their better tolerance and ease of use. A programme of regular review will prevent over-medicating. Drug therapy may be withdrawn in a seizure-free patient. Realistic goals should be established for each individual coupled with an optimistic approach to care. However, future developments require a solid evidence base combined with rationality in all aspects of management. The community learning disability epilepsy nurse specialist is the key health-care professional who can ensure that a learning disabled individual with epilepsy is able to take full advantage of all available services. Education, closer collaboration and the mutual recognition of skills will ensure more cohesive and comprehensive care for this disadvantaged patient population.